Reducing Sugar and Salt: Healthoutfit

 
A Harvard Medical School Special Health Report

Reducing Sugar and Salt:
Strategies for minimizing risks to your health

                                                                                                             In this report:
                                                                                                             Sodas and juice
                                                                                                             Salt and sodium
                                                                                                             What the labels mean
                                                                                                             Self-defense: Sugar-
                                                                                                             reducing strategies
                                                                                                             Recipes
                                                                                                             SPECIAL SECTION
                                                                                                             Blood pressure matters

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REDUCING SUGAR AND SALT
SPECIAL HEALTH REPORT
                                                                      Contents
Medical Editor                                                        A brief history of sugar and salt . . . . . . . . . . . . . . . . . . . . . .2
Teresa Fung, ScD, RD.
Adjunct Professor of Nutrition,                                       The lowdown on sugar. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
Harvard School of Public Health
Editor                                                                Rise and fall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
P.J. Skerrett                                                         Insulin resistance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Copy Editor                                                           Glycemic index: The type of carbohydrate matters . . . . . . . . . . . . . 8
Robin Netherton                                                       Factors that affect a food’s glycemic index . . . . . . . . . . . . . . . . . . 8
Art Director
Nieves Jenkins
                                                                      Glycemic load: Measuring the full effect . . . . . . . . . . . . . . . . . . . . 8
Creative Director                                                     Beyond the glycemic load . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Judi Crouse                                                           Sodas and juice . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Illustrators                                                          Reducing sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Scott Leighton, Jason Laramie
Published by Harvard Medical School                                   Salt and sodium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Anthony L. Komaroff, M.D., Editor in Chief                            Sodium in excess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Edward Coburn, Publishing Director                                    Sodium reduction helps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
                        In association with
                                                                      A salt step-down in the works . . . . . . . . . . . . . . . . . . . . . . . . . . 17
          Belvoir Media Group, LLC, 800 Connecticut Avenue, Nor-
          walk, CT 06854-1631. Robert Englander, Chairman and         SPECIAL SECTION: Blood pressure matters . . . . . . . . . . . 18
          CEO; Timothy H. Cole, Executive Vice President, Editorial
          Director; Philip L. Penny, Chief Operating Officer; Greg    Understanding the numbers . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
King, Executive Vice President, Marketing Director; Ron Goldberg,
Chief Financial Officer; Tom Canfield, Vice President, Circulation.   A call to action . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
Copyright ©2012 by Harvard University. Written permission is          Sugar . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
required to reproduce, in any manner, in whole or in part, the
material contained herein. Submit reprint requests in writing to:     Salt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
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Web Site                                                              Say no to liquid calories . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
For the latest information and most up-to-date publication
list, visit us online at www.health.harvard.edu.
                                                                      What about artificial sweeteners? . . . . . . . . . . . . . . . . . . . . . . . 25
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                                                                      Other strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
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Dear Reader,

            Salt and sugar are two of the most humdrum items in kitchen cupboards. But they have been
            centers of controversy in academic debates and arguments over public health policies as ex-
            perts dispute the hazards of taking in too much of these nutrients and the benefits of cutting
            back. In just the last few years, the evidence of how much harm these tasty flavor enhancers
            can do has become undeniable.
            It’s not the spoonful of sugar at breakfast or the dash of salt at the dinner table that are the big
            worries. Instead, it’s the sugars added to sweetened beverages, juices, desserts, and cereals, and
            the salt hidden in prepared foods. We need zero added sugar because we get all the sugar we
            need from what’s naturally in food, and because the body can make blood sugar from almost
            any carbohydrate-containing food. Yet added sugars now provide almost 20% of the average
            American’s daily calories. We need only a scant amount of sodium—less than one gram a day
            (about 1/30th of an ounce)—to survive. But because it is in so many of the processed foods we
            have come to rely on, we take in an average of about 3.5 grams of sodium a day.

            Why are the excesses of sugar and salt an issue? Added sugars provide so-called empty calo-
            ries, energy with no other nutritional value. There is mounting evidence that they are helping
            fuel the astronomical rise in obesity and diabetes in the United States and around the world.
            Too much salt can lead to high blood pressure and related health problems like stroke, heart
            disease, and kidney failure.

            We can’t blame salt and sugar for tasting good. They are, after all, key stimulators of our taste
            buds, and for sound evolutionary reasons. Sugar’s sweetness represents caloric energy, the fuel
            of life. And every cell in the body needs the sodium in salt. But the consequences of overdoing
            them are visible all around us.

            This report aims to help you make your own decisions by explaining the serious health risks
            associated with taking in too much sugar and salt and offering ways to reduce their use with-
            out sacrificing taste.

            Sincerely,

            Teresa Fung, Sc.D.,RD
            Adjunct Professor of Nutrition, Harvard School of Public Health

Harvard Health Publications | Harvard Medical School | 10 Shattuck Street, Second Floor | Boston, MA 02115
     This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
A brief history of sugar and salt

S    ugar and salt are inexpensive ingredients that are
     ubiquitous in the food supply. That hasn’t always
been the case.
                                                                               As a result, two commodities that were once hard
                                                                          to come by are now almost impossible to avoid. “In
                                                                          recent years,” researchers commented in the jour-
     Sugar started out as a hard-to-come-by ingredient.                   nal Nature in 2012, “sugar has been added to virtu-
Throughout most of human history, it was available                        ally every processed food, limiting consumer choice.
only when fruit ripened or bees had been busy. But                        Nature made sugar hard to get; man made it easy.”
once the technology of extracting sugar from plants                            Why is this a problem? As described more fully in
evolved—first from sugar cane and then from beets—                        the following chapters, too much of a good thing can
sugar not only became abundant but also helped                            be hazardous to health. The average American takes in
direct the course of history, leading in the New World                    more than 350 calories a day from added sugars, often
to colonies, plantations, and the scourge of slavery.                     in soda, energy drinks, and other sweetened bever-
     Salt was once so difficult to get that it was used                   ages. Those empty calories are contributing to the obe-
as currency. In some early economies it was worth its                     sity problem in the United States. About one-third of
weight in gold. The word salary comes from the Latin                      American children and more than two-thirds of adults
“salarium,” which means salt money. It is thought to                      are overweight or obese. Excess weight is strongly
refer to part of the pay given to Roman soldiers to buy                   linked to the development of diabetes, heart disease,
salt. Cities were built around salt deposits; wars have                   some cancers, osteoarthritis, and more. Too much salt
been fought over it.                                                      is a key contributor to high blood pressure (hyperten-
     Today, sugar and salt are produced in vast quan-                     sion). By age 65, more than half of Americans have
tities. According to estimates by the U.S. Department                     high blood pressure; after age 75, three-quarters have
of Agriculture and the U.S. Geological Survey, in 2011                    it. People with high blood pressure are more prone to
the world produced nearly 200 million tons of sugar                       having a stroke or heart attack or developing heart
and 320 million tons of salt.                                             failure or kidney failure.
                                                                               It only makes sense that cutting back on added
                                                                          sugars can help cut calories. And a compelling study
 Table 1 Comparing salt and sodium
                                                                          published in The New England Journal of Medicine
    By weight, table salt (sodium chloride) is about 40% sodium.          estimated that if Americans as a whole cut back salt
    This table can help you convert between teaspoons of salt and
    milligrams of sodium.                                                 intake by ½ teaspoon a day (about 1,200 milligrams
          SALT                   SALT                  SODIUM
                                                                          of sodium; see Table 1, left), that small change would
      (TEASPOONS)            (MILLIGRAMS)           (MILLIGRAMS)          prevent up to 99,000 heart attacks, 66,000 strokes, and
            ¼                     1,450                   600             92,000 premature deaths each year.
            ½                     2,900                  1,200
                                                                               Becoming aware of how much sugar and sodium
                                                                          you consume, and finding ways to adjust them health-
            ¾                     4,250                  1,800
                                                                          fully, are good strategies for your health. In the following
             1                    5,800                  2,300
                                                                          pages we’ll show you how to do that.

2          Reducing Sugar and Salt                                                                                 w w w.h ealt h .ha r va r d.e du

          This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
The lowdown on sugar

A    ll sugars, from refined white sugar to honey and
     agave nectar, are a type of carbohydrate. Carbo-
hydrates are chemical compounds that contain only
                                                                          exchange, turning simple and complex carbohydrates
                                                                          into glucose. If needed, our bodies can even turn pro-
                                                                          tein and fat into blood sugar.
three elements—carbon, hydrogen, and oxygen—in a                               When you eat a bowl of white rice, a slice of
dizzying array of combinations. Sugars and other car-                     whole-grain bread, or an orange, the body breaks
bohydrates are the main nutrient in bread, pasta, cere-                   down digestible carbohydrates into sugar molecules.
als, beans, vegetables, and dairy foods.                                  Glucose is rapidly passed into the bloodstream and
     Once upon a time, the only sugars we consumed                        delivered to cells from the brain to the toes. Leftover
were those naturally in the foods we ate. Today, much                     glucose can be linked into long chains called glycogen
of the sugar in our food supply has been put there                        and stored in the liver for later use, or converted into
by humans. The USDA began to use the term “added                          fat and stored in fat cells. The speed with which a car-
sugars” in 2000 to help consumers identify foods that                     bohydrate-containing food becomes blood sugar can
have added calories with no added nutrition. Added                        influence weight and long-term health.
sugars—white sugar, brown sugar, maple syrup, honey,
molasses, high-fructose corn syrup, and more—now
represent 16% of the total calories we consume. In                        Rise and fall
other words, about one-sixth of our calories have no                      Picture a roller coaster track—plenty of ups and
nutritional value. Added sugar has been linked to an                      downs, some high and steep, others low and gentle.
overall decline in the quality of the U.S. diet, as well                  That’s essentially what your blood sugar and insulin
as to weight gain and increases in obesity and heart                      levels look like over the course of a day. Meals and
disease. The latest Dietary Guidelines for Americans                      snacks cause highs that drop to lows later on. Learning
took aim at sugars added to foods during processing                       to eat in a way that makes your blood sugar levels look
in food plants, in the kitchens of restaurants, and even                  more like a kiddie coaster than a wild, breathtaking
at our breakfast tables.                                                  ride can make a difference to your health.
     Chemists initially divided carbohydrates into two                         Because every cell in the body depends on
groups: simple and complex. Simple carbohydrates                          instant access to just the right amount of blood sugar,
included sugars like glucose (sometimes called dex-                       Goldilocks-like mechanisms are in place to make sure
trose), fructose (fruit sugar), lactose (milk sugar),                     that blood sugar doesn’t rise too high or fall too low.
and sucrose (table sugar). Complex carbohydrates                          Sometimes, though, they can be overwhelmed.
were made up of interlocking chains of sugar mole-                             A rise in blood sugar stimulates the pancreas to
cules, like those found in starch and fiber. Simple ver-                  release insulin into the bloodstream. This hormone tells
sus complex is a perfect division for chemists, but it                    cells to absorb glucose; without insulin, they can’t take
doesn’t at all explain how carbohydrates affect health.                   it in. The higher the blood sugar level, the more insu-
     Our bodies rely on just one type of sugar—glu-                       lin released. As cells sponge up glucose, the amount of
cose. But we never need to eat glucose, or any sugar                      glucose in the bloodstream begins to drift downward,
for that matter, since the body can turn many kinds                       followed by the amount of insulin (see Figure 1, page
of food into glucose. Think of glucose as the univer-                     4). As blood sugar approaches the lowest safe level, the
sal currency of the body’s carbohydrate economy, and                      pancreas begins releasing another hormone, called glu-
the organs of the digestive system as a 24/7 currency                     cagon. It tells the liver to start breaking down glycogen

ww w. h ealt h . h ar v ar d . e du                                                                        Reducing Sugar and Salt        3
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Carbs matter                                                                 Here’s where the type of carbohydrate comes into
                                                                                                     play. A meal or snack containing foods that the body
                             Carbohydrates contribute about half of all calories
                             to a typical American diet. A worrisome half of these                   immediately converts into glucose (like white bread
                             “carbohydrate calories” come from eight sources, none                   or white rice) causes a rapid, high spike in blood
                             of which even remotely qualifies as a health food. All                  sugar. That’s followed by an equally high spike in insu-
                             are chock-full of rapidly digested carbohydrates.                       lin (see Figure 1, below). But a big jolt of insulin can
                                 1. Soft drinks, sodas, and fruit-flavored drinks                    quickly drive blood sugar down to or below the safe
                                 2. Cake, sweet rolls, doughnuts, and pastries                       zone. If there isn’t any more digestible carbohydrate
                                 3. Pizza                                                            in the stomach or intestines, the gut and brain send
                                 4. Potato chips, corn chips, and popcorn                            out signals that get you looking for something more to
                                 5. Rice
                                                                                                     eat—while at the same time the liver is breaking down
                                                                                                     glycogen and pumping glucose into the bloodstream.
                                 6. Bread, rolls, buns, English muffins, and bagels
                                                                                                          Easily digested carbohydrates are abundant in
                                 7. Beer
                                                                                                     the American diet (see “Carbs matter,” left). They are
                                 8. Frozen potatoes and French fries                                 thought to contribute to weight gain because they trig-
                                                                                                     ger hunger signals relatively soon after eating. In addi-
and release the resulting glucose into the bloodstream.                                              tion, the glut of insulin that follows a high spike in blood
This provides a steady supply of blood sugar for the                                                 sugar prompts the body to convert glucose into fat.
brain and other cells. That release of stored glucose is                                                  A meal or snack of slowly digested carbohydrates
why you can go for hours, or even days, without eating                                               (like whole grains or beans) smooths out the blood
and your cells still have a steady supply of fuel.                                                   sugar–insulin roller coaster. The digestive system takes

Figure 1 Blood sugar roller coaster

                                                 Easily Digested Carbohydrate                                                               Slowly Digested Carbohydrate

                                                                               Insulin                                                                                  Insulin
                                                                               Blood Glucose                                                                            Blood Glucose
    Change in blood sugar, insulin

                                                                                                       Change in blood sugar, insulin

                                            0        1       2          3            4         5                                        0      1      2          3            4         5
                                                                 Time (hour)                                                                              Time (hour)

How blood sugar and insulin rise and fall in the bloodstream depends on the type of carbohydrate that is being digested.
Source: Eat, Drink, and Be Healthy (Free Press, 2005)

4                                    Reducing Sugar and Salt                                                                                                    w w w.h ealt h .ha r va r d.e du

                                     This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
longer to break down these carbohydrates into sugar                       levels for longer periods. Over time, this can damage
molecules (see Figure 1, page 4). That means blood                        nerves, blood vessels, and other tissues. It also makes
sugar rises more slowly and hits a lower peak, as does                    the pancreas produce more and more insulin after
insulin. This is good for health (see “Insulin resis-                     every meal or snack in an effort to help cells to absorb
tance,” below). It also means it takes longer to get hun-                 blood sugar. As an overworked pancreas wears out,
gry again.                                                                insulin production slows. This causes blood sugar to
    Among people with diabetes, high levels of blood                      skyrocket after eating and to remain high for longer
sugar and insulin contribute to many of the compli-                       periods. These are signs of type 2 diabetes (once called
cations of this disease, such as nerve damage, loss                       adult-onset diabetes and non-insulin-dependent dia-
of vision, kidney disease, sexual dysfunction, and                        betes). In 1980, about six million Americans had dia-
wounds that won’t heal. Routine high blood sugar and                      betes. Today, it affects more than 25 million, one-third
insulin can also pose problems for seemingly healthy                      of whom don’t know they have it.
individuals. They can tip people toward developing                            Insulin resistance isn’t just a blood sugar problem.
diabetes. Research suggests they may also contribute                      It has also been linked with a variety of other prob-
to other chronic conditions, including breast cancer,                     lems, including high blood pressure, high blood lev-
colon cancer, and polycystic ovary syndrome. While                        els of triglycerides (a type of fat), low blood levels of
smoothing out your blood sugar and insulin levels                         high-density lipoprotein (HDL, “good” cholesterol),
may help you prevent these conditions, the proven                         heart disease, and possibly some cancers.
benefits are preventing heart disease and diabetes and                        High blood sugar and insulin levels also contrib-
controlling weight.                                                       ute to the buildup of fat around the waist. This belly
                                                                          fat (technically called abdominal fat or visceral fat)
                                                                          appears to pose more of a health problem than fat that
Insulin resistance                                                        accumulates around the hips and thighs. It has been
In a healthy body, liver and fat cells immediately                        linked to high blood pressure, high cholesterol, high
respond to insulin’s “open up for sugar” signal and                       blood sugar, and heart disease (see “Do you have met-
begin to pull in glucose from the bloodstream. In a                       abolic syndrome?” page 6). Belly fat offers a snapshot
growing number of people, the response to this essen-                     that can tell you how healthy you are. Simply measur-
tial signal becomes muted. This resistance to insulin                     ing the waist can be useful because many people gain
causes two key problems. It keeps blood sugar at high                     abdominal fat as they go through midlife, even those

      Is high-fructose corn syrup a special problem?
      For centuries, Americans satisfied their craving for sugar           Yet some people have vilified high-fructose corn syrup as
      with sucrose (table sugar) from sugar cane and sugar beets,          one of the key culprits behind the obesity epidemic. It’s
      honey, maple sugar, and molasses. Beginning in the 1970s,            an easy argument to make, since its adoption by the food
      more and more of what sweetens our foods and beverages               industry parallels the trajectory of obesity rates. And while
      has come from corn, most of it in the form of high-fructose          it’s true that the body processes fructose in a different way
      corn syrup. Found in everything from sugared sodas to baby           than it processes glucose, both refined sugar and high-
      food, high-fructose corn syrup now makes up more than                fructose corn syrup contain about the same amounts of
      half of the added sugar we now consume.                              fructose.
      Chemically, high-fructose corn syrup is very similar to              So far, there isn’t any solid evidence that high-fructose corn
      sucrose. Every molecule of sucrose contains one molecule of          syrup is worse than any other added sugar. What’s impor-
      glucose and one of fructose. High-fructose corn syrup is pure        tant is keeping your intake of all added sugars in check. The
      glucose mixed with pure fructose in almost equal propor-             American Heart Association recommends keeping your in-
      tions (about 55% fructose and 45% glucose). So it’s likely           take of added sugars under 100 calories a day (24 grams, or
      that table sugar and corn sweeteners have similar effects on         6 teaspoons) for women and under 150 calories (36 grams,
      blood sugar, insulin, and metabolism.                                or 9 teaspoons) for men.

ww w. h ealt h . h ar v ar d . e du                                                                        Reducing Sugar and Salt          5
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who are not gaining weight. A waistline that expands
    Do you have metabolic syndrome?
                                                                                       more than two or three inches over the years should
    Metabolic syndrome, a cluster of conditions that occur
                                                                                       trigger a warning that you need to reevaluate your
    together, increases the risk of heart disease, stroke, and
    diabetes. One of its key features is a large waist. If you                         diet and physical activity levels. To see how your waist
    have one, you’re more likely to have the other character-                          measurement stacks up, see Figure 2, below.
    istics.                                                                                Four main factors contribute to insulin resistance.
    You have metabolic syndrome if you have three or more                              One of them can’t be controlled, but the other three can.
    of these five traits:                                                                  ■ Genes. Insulin resistance is more common
        1. Waist circumference more than 35 inches in                                  among Native Americans, Pacific Islanders, and other
           women or 40 inches in men                                                   people of Asian heritage than it is among those of
        2. Fasting blood triglyceride level of 150 milligrams/                         European descent. Although you can’t change your
           deciliter (mg/dL) or higher                                                 genes, you can beat a genetic predisposition to insulin
        3. HDL (“good”) cholesterol of less than 40 mg/dL in                           resistance by staying lean, being physically active, and
           men or less than 50 mg/dL in women                                          eating a healthful diet.
                                                                                           ■ Weight. The further you stray from a healthy
        4. Systolic blood pressure (the top number of a read-
           ing) of 130 mm Hg or higher, or diastolic pressure
                                                                                       weight, the harder it is for your body to handle glu-
           (the lower number) of 85 mm Hg or higher                                    cose. One way to determine if your weight is in the
                                                                                       healthy range is to determine your body mass index
        5. Fasting blood sugar level of 100 mg/dL or higher.
                                                                                       (BMI). This is a measure of weight for height. You can
    (Note: You are considered to have a trait if you receive
    treatment for it, even if your numbers are normal with
                                                                                       find your BMI in Table 2, page 7, or calculate it online
    this treatment.)                                                                   at www.health.harvard.edu/BMI.
    Source: National Heart, Lung, and Blood Institute                                      ■ Exercise. During exercise, muscles extract glu-
                                                                                       cose from the blood more efficiently, and with less

Figure 2 Check your belly

                 Waist circumference                                                                  Waist-to-hip ratio

                                                   Just below the
                                                   bottom rib

                                                    Narrowest
                                                    part of midriff
                                                        Waist circumference can be
                                                        measured in several places.
                                                        Many researchers favor using
                                                        the top of the hip bone as
                                                        a landmark, so the tape                                                  Hips are usually
                                                        measure goes over the navel                                              measured at the
                                                                                                                                 widest circumference,
                                                                                                                                 around the buttocks

           Waist circumference associated                                                        Minimum waist-to-hip ratio associated
           with increased health risks:                                                          with increased health risks:
           For men: More than 40 inches (102 cm)                                                 For men: 0.9–1.00
           For women: More than 35 inches (88 cm)                                                For women: 0.85

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help needed from insulin, than muscles do at rest.                              ■ Dietary fat. Although the mix of fats in the diet
The effect lasts for several hours afterward. Being a                      plays a small role in insulin resistance, it can make a
couch potato doesn’t do much to clear glucose from                         difference. A high intake of trans fat (from margarines
the bloodstream. People who aren’t very active have                        and prepared foods) and a low intake of polyunsatu-
higher fat-to-muscle ratios than active people, even if                    rated fat (from vegetable oils and fatty fish) contribute
their BMIs are in the healthy range.                                       to insulin resistance.

  Table 2 Finding your BMI
  The body mass index (BMI) is an index of weight by height. The definitions of normal, overweight, and obese were established after researchers
  examined the BMIs of millions of people and correlated them with rates of illness and death. These studies identified the normal BMI range as
  that associated with the lowest rates of illness and death.

          HEIGHT                                                       BODY WEIGHT IN POUNDS
           4’10”                      91–115            119–138                 143–162                 167–186                    191+

           4’11”                      94–119            124–143                 148–168                 173–193                    198+
            5’0”                      97–123            128–148                 153–174                 179–199                    204+
            5’1”                      100–127           132–153                 158–180                 185–206                    211+
            5’2”                      104–131           136–158                 164–186                 191–213                    218+
            5’3”                      107–135           141–163                 169–191                 197–220                    225+
            5’4”                      110–140           145–169                 174–197                 204–227                    232+
            5’5”                      114–144           150–174                 180–204                 210–234                    240+
            5’6”                      118–148           155–179                 186–210                 216–241                    247+
            5’7”                      121–153           159–185                 191–217                 223–249                    255+
            5’8”                      125–158           164–190                 197–223                 230–256                    262+
            5’9”                      128–162           169–196                 203–230                 236–263                    270+
           5’10”                      132–167           174–202                 209–236                 243–271                    278+
           5’11”                      136–172           179–208                 215–243                 250–279                    286+
            6’0”                      140–177           184–213                 221–250                 258–287                    294+
            6’1”                      144–182           189–219                 227–257                 265–295                    302+
            6’2”                      148–186           194–225                 233–264                 272–303                    311+
            6’3”                      152–192           200–232                 240–272                 279–311                    319+
            6’4”                      156–197           205–238                 246–279                 287–320                    328+
            BMI                       19–24              25–29                   30–34                   35–39                     40+
                                      NORMAL          OVERWEIGHT           CLASS I OBESITY         CLASS II OBESITY        CLASS III OBESITY
 You can calculate your own BMI with the following formula:
 1. Take your weight in pounds and multiply it by 703.
 2. Measure your height in inches and multiply it by itself.
 3. Divide the number from step two into the number from step one. The answer is your BMI. If your BMI is less than 20 you are
    underweight; between 20 to 24.9, you are at a normal, healthy weight; between 25 to 30, you are overweight; and above 30,
    you are obese.

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              This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
Glycemic index:                                                         ■   High glycemic index (70 or higher): White bread,
The type of carbohydrate matters                                          white rice, potatoes, rice cakes, most crackers,
Classifying carbohydrates as simple versus complex                        bagels, cakes, doughnuts, croissants, waffles, most
does little to tell us which carbohydrate-containing                      packaged breakfast cereals.
foods release their sugars in a flash and which yield                     Choosing foods low on the glycemic index can
them more like those timed-release cold capsules you                  help you avoid big blood sugar highs and lows.
see on television commercials.
     To find a better way, Canadian nutrition researcher
David Jenkins and his colleagues did something revo-                  Factors that affect a food’s
lutionary in the early 1980s—they measured how dif-                   glycemic index
ferent types of carbohydrate-containing foods affected                Glycemic index isn’t a set, unvarying value like molecu-
blood sugar compared with pure glucose. They called                   lar weight. Processing and cooking methods, as well as
this comparison the glycemic index.                                   what you eat with the food, all affect how rapidly your
     Measuring glycemic index is a painstaking process                body breaks down its carbohydrates and how quickly
that requires a volunteer to consume an amount of a                   your bloodstream absorbs the liberated glucose.
test food—whole oats, pear, black beans, ice cream,                       ■ Grinding grain dramatically increases how fast
and so on—that contains 50 grams of carbohydrate.                     digestive enzymes can attack the starch and break it
His or her blood sugar is then measured at regular                    apart. Wheat flour has more surface area to attack than
intervals over the next two hours. On another day,                    wheat berries. Most wheat flour has also been stripped
the same volunteer does the same thing, but this time                 of its bran—the protective, hard-to-digest, fibrous
consumes 50 grams of glucose. Then the values for the                 outer coat that slows the action of digestive enzymes.
food and glucose are compared, by dividing the rise in                Steel-cut oats, which are sliced oat grains, have a lower
blood sugar sparked by the test food by the rise due to               glycemic index than regular oatmeal, which is made of
glucose.                                                              smashed oat grains.
     The higher the glycemic index, the faster and                        ■ The more indigestible fiber a food contains, the
more strongly the food affects blood sugar. The lower                 lower its glycemic index. That’s because fiber carries
the glycemic index, the lower and slower the rise in                  along partly digested food and protects it from diges-
blood sugar.                                                          tion. This spreads out the absorption of glucose into
     Since the concept was created, researchers have                  the bloodstream.
measured the glycemic index of several thousand                           ■ Fats slow the digestive process. Eating fat with a
foods. As you can see in Table 3, page 9, the glycemic                carbohydrate-rich food can temper the rise in blood sugar.
index clearly shows that not all complex carbohydrates                    ■ Lemon juice, vinegar, and other acidic ingredients
are good, and not all simple ones are bad. Cornflakes,                also delay the rise in blood sugar after you eat a carbo-
chemically a complex carbohydrate, have a high gly-                   hydrate-rich food.
cemic index—in the 80s—meaning they quickly and
strongly boost blood sugar. Fructose, the simplest of
sugars, has a very low glycemic index—23—meaning                      Glycemic load:
it has little effect on blood sugar. It’s useful to think of          Measuring the full effect
foods in three categories:                                            The glycemic index of a food tells only part of the
   ■ Low glycemic index (55 or less): Most fruits and veg-            story. How much of the food is consumed also affects
      etables, beans, minimally processed grains, pasta,              blood sugar and insulin levels. That’s why research-
      low-fat dairy foods, and nuts.                                  ers at the Harvard School of Public Health developed
   ■ Moderate glycemic index (56 to 69): Sweet potatoes,              the concept they call glycemic load. It is calculated by
      corn, white rice, pasta, some breakfast cereals                 multiplying a food’s glycemic index by the number of
      such as Cream of Wheat and Mini Wheats.                         grams of carbohydrate consumed and dividing by 100.

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Table 3 Glycemic index and glycemic load values for commonly eaten foods
  The glycemic index and glycemic load offer information about how a food affects blood sugar and insulin. The lower the glycemic index or glycemic
  load, the less the food affects blood sugar and insulin levels. Scientists have calculated glycemic index and glycemic load for more than 2,500 foods. A
  sample is provided in the table below. The University of Sydney in Australia maintains a free searchable database of glycemic index and glycemic load
  values at www.glycemicindex.com. The healthiest choices are those with a glycemic index below 55 and a glycemic load below 10.

                                                                                                     GLYCEMIC            CARBOHYDRATE                 GLYCEMIC
  FOOD                                                                    SERVING SIZE               INDEX (%)             (in grams)                  LOAD*
  WHITE RICE                                                                  5 ounces                    89                     48                        43
  CRANBERRY JUICE                                                               1 cup                     68                     35                        24
  SPAGHETTI, COOKED                                                             1 cup                     49                     48                        24
  CORNFLAKES                                                                    1 cup                     93                     25                        23
  SNICKERS BAR                                                           1 bar (2 ounces)                 68                     34                        23
  JELLY BEANS                                                                 1 ounce                     80                     28                        22
  POTATOES (WHITE), BOILED                                                      1 cup                     78                     26                        20
  GRAPE-NUTS CEREAL                                                            ½ cup                      75                     22                        16
  COCA-COLA                                                                  12 ounces                    63                     26                        16
  CHEERIOS                                                                      1 cup                     74                     20                        15
  SHREDDED WHEAT CEREAL                                                      2 biscuits                   67                     20                        13
  OATMEAL (ROLLED OATS)                                                         1 cup                     58                     22                        13
  BANANA (RIPE)                                                              1 medium                     51                     25                        13
  RAISIN BRAN CEREAL                                                            1 cup                     61                     19                        12
  ORANGE JUICE                                                                  1 cup                     46                     26                        12
  CORN TORTILLA                                                              2 medium                     46                     22                        11
  WHITE BREAD                                                                  1 slice                    75                     14                        10
  STRAWBERRY JAM                                                           1 tablespoon                   51                     20                        10
  WHOLE-WHEAT BREAD                                                            1 slice                    74                     13                        10
  PIZZA HUT SUPER SUPREME PIZZA                                                2 slices                   36                     24                         9
  ENGLISH MUFFIN                                                              1 muffin                    77                     11                         8
  ALL-BRAN CEREAL                                                              ½ cup                      42                     21                         8
  BLACK BEANS                                                                   1 cup                     43                     23                         7
  APPLE (GOLDEN DELICIOUS)                                                   1 medium                     39                     16                         6
  ENGLISH MUFFIN, WHOLE GRAIN                                                 1 muffin                    43                     11                         5
  PUMPERNICKEL (DARK RYE BREAD)                                                1 slice                    41                     12                         5
  MILK, SKIM                                                                    1 cup                     37                     13                         5
  RED LENTILS                                                                   1 cup                     21                     18                         4
  TABLE SUGAR (SUCROSE)                                                     1 teaspoon                    65                      4                       2.6
  FRUCTOSE                                                                  1 teaspoon                    15                      4                       0.6
  *Glycemic load is calculated by multiplying grams of carbohydrate by glycemic index and dividing by 100.
  Source: Atkinson FS, Foster-Powell K, Brand-Miller JC. “International tables of glycemic index and glycemic load values: 2008,” Diabetes Care (2008), Vol. 31, No.
  12, pp. 2281–83.

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              This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
Take spaghetti, for example. It has a glycemic                                  little carbohydrate per serving. Take watermelon as
index of 46. An average serving delivers 31 grams of                                an example. It has a high glycemic index (80), which
carbohydrate: 46 times 31 divided by 100 equals 14.                                 might make you stay away from it. Yet as its name
    As with the glycemic index, putting foods into                                  implies, watermelon is mostly water; a cup of water-
three categories can help determine good choices and                                melon cubes contains just six grams of carbohydrates.
portion sizes:                                                                      So the glycemic load is small, under 5.
  ■ Low glycemic load (10 or lower): Lentils and beans                                   Sugary soda has a moderate glycemic index
    (kidney, garbanzo, black, etc.); fiber-rich fruits and                          because it contains a fair amount of fructose, which
    vegetables; nuts and seeds; whole grains like bar-                              has relatively little effect on blood sugar. But it also
    ley, wheat berries, and the like.                                               delivers plenty of carbohydrates, so it has a high gly-
  ■ Medium glycemic load (11 to 19): Steel-cut oatmeal;                             cemic load.
    whole-wheat pasta and some breads; fruit juices                                      Following a diet with a low glycemic load will help
    without extra sugar; brown rice; sweet potatoes.                                you to make healthier food choices. And because the
  ■ High glycemic load (20 or higher): Soda, energy drinks,                         foods are typically higher in fiber and nutrients, you
    and other sugar-sweetened beverages; candy;                                     will feel satisfied longer, which can help control weight.
    white rice; French fries and baked potatoes; sug-
    ary breakfast cereals.
    Because glycemic load includes information on                                   Beyond glycemic load
how much carbohydrate is consumed, it is better                                     The glycemic index and glycemic load are guides to
than glycemic index alone at capturing what’s going                                 choosing carbohydrate-containing foods, not strict
on in your bloodstream after you eat a carbohydrate-                                rules. It’s also important to evaluate the other nutri-
containing food.                                                                    ents in a food. Some carbohydrate-rich foods deliver
    Some foods have a high glycemic index but very                                  far more than just sugar. Fruits and vegetables offer

Figure 3 Sugar intake through sweetened drinks

                         300                                                                                         Male                  Female
                                                                                  273
                                                                                                  252
                         250

                         200
                                  178
                                                                                         171
     Calories per day

                                                                                                                   159
                         150                                     141                                     138

                                           103                           112
                         100                                                                                              86
                                                  71      70                                                                          70

                          50                                                                                                                   42

                           0
                                     All            2–5             6–11           12–19           20–39            40–59          60 and over
                                                                             Age (years)

In the United States, average consumption of sugar from sweetened beverages peaks in the teen years.
Source: CDC/NCHS, National Health and Nutrition Examination Survey, 2005–2008.

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                    This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
fiber, vitamins, minerals, and plenty of active phyto-                    Given how much soda, fruit beverages, and other soft
chemicals. The same is true for intact or slightly pro-                   drinks Americans consume, almost half of the added
cessed grains.                                                            sugar in the U.S. diet comes from soft drinks and fruit
    The biggest value of the glycemic load may be                         juices. Among youths, sugar intake from sugar-sweet-
for deciding among various options. When picking                          ened beverages represents nearly 15% of their daily
a snack or planning a meal, choosing foods with low                       intake of calories (see Figure 3, page 10).
glycemic loads is better for your insulin-making cells                         A number of studies have linked sugar-sweetened
and your overall health than choosing those with high                     drinks to weight gain and an increased risk of type 2
glycemic loads.                                                           diabetes. The most recent, a trio of reports published
                                                                          in The New England Journal of Medicine, link regu-
                                                                          lar consumption of sugar-sweetened beverages to the
Sodas and juice                                                           development of obesity in children, adolescents, and
Sprinkling 10 to 12 teaspoons of sugar on a bowl of                       adults. Other studies have found that men and women
cereal would make it much too sweet to eat. Yet accord-                   who regularly drank sugar-sweetened beverages were
ing to the Harvard School of Public Health’s Nutrition                    at increased risk of stroke and heart disease, even
Source, that’s how much sugar is in a 12-ounce can of                     after other unhealthful lifestyle or dietary factors were
many popular soft drinks. (See www.hsph.harvard.                          accounted for.
edu/nutritionsource/healthy-drinks/how-sweet-is-it                             Sugar-sweetened beverages generally deliver pure
for a list of the amount of sugar in popular beverages.)                  calories without any of the healthful nutrients you

      What about fruit juice?
      Fruit juice is different from sodas and other sugar-                 And keep in mind that not all juices are equal. Grapefruit
      sweetened beverages, right? It depends on how much you               juice, for example, changes the way some people absorb
      drink. As an accompaniment to your breakfast, or as the              and metabolize certain drugs. It can make it hard for the
      occasional thirst quencher, 100% juice—not juice-flavored            body to absorb some drugs, leading to lower blood levels.
      sugar water—can be part of a healthy diet. Real juice                This happens with the allergy medication fexofenadine (Al-
      gives you some vitamins, minerals, and maybe a bit of                legra); digoxin, which is used to treat heart failure; losartan
      fiber.                                                               (Cozaar), used to control blood pressure; and the antican-
      Keep in mind that 100% fruit juice can deliver a lot of              cer drug vinblastine. Grapefruit juice can boost blood levels
      calories. Twelve ounces of orange juice delivers about 150           of other drugs, sometimes to dangerous heights. Drugs
      calories, the same as a similar amount of sugar-sweetened            in this category include calcium-channel blockers such as
      soda. If juice is part of your morning routine, use a small          felodipine (Plendil), nifedipine (Procardia), and nisoldipine
      glass that holds 6 ounces.                                           (Sular), which are used to control high blood pressure; car-
                                                                           bamazepine (Carbatrol, Tegretol), used to control epilepsy;
      The main problem with drinking juice to quench thirst is             some widely used cholesterol-lowering medications such
      that many people don’t eat less to adjust for the extra cal-         as lovastatin (Mevacor), atorvastatin (Lipitor), and simvas-
      ories in it. That’s a surefire recipe for gradual weight gain.       tatin (Zocor); cyclosporine, an immunosuppressant taken
      It’s also easy to confuse 100% juice with “juice drinks,”            mainly by people who have had an organ transplant; and
      which are little more than juice-flavored sugar water.               buspirone (BuSpar), used to fight alcohol abuse, depres-
      If you use juice to quench your thirst, dilute it with regular       sion, panic disorder, and a variety of other problems.
      or sparkling water. Start with two parts juice to one part           Something in grapefruit juice also appears to create condi-
      water and gradually work your way to one part juice to               tions that help form kidney stones. In the Nurses’ Health
      three or four parts water. Or skip the juice altogether and          Study and the Health Professionals Follow-up Study, every
      add a squeeze of lemon or lime to plain or sparkling water.          8 ounces of grapefruit juice consumed a day increased
      Vegetable juices are usually lower in calories than fruit            the chances of developing kidney stones by 44%. While
      juices, but check the label to be sure—and don’t forget to           more research is needed to confirm this finding, it’s a good
      make note of the sodium content.                                     reason to limit your intake of grapefruit juice.

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              This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
might get from real fruit juices or, better yet, fruit—               insulin levels. When this happens several times a
vitamins, minerals, other phytochemicals, and in                      day—in addition to the blood sugar boosts that occur
some cases even some fiber. That’s a problem for sev-                 after eating—it can cause problems. Among women
eral reasons:                                                         participating in the Nurses’ Health Study, those who
  ■ Weight gain. Many people treat “liquid calories”                  drank one soda a day nearly doubled their risk of dia-
from sugar-sweetened beverages as somehow different                   betes. Among people who are insulin resistant, taking
from “food calories,” and don’t make up for the calo-                 in lots of easily digested carbohydrates raises the blood
ries in soda or juice by eating less. Drinking one can                level of triglycerides, a kind of fat-carrying particle that
of soda a day doesn’t seem like a big deal, and prob-                 increases the risk of heart disease.
ably isn’t if you cut back on calories elsewhere and eat
plenty of fruits and vegetables. But if you don’t adjust
your diet, the extra 120 to 150 calories a day from a                 Reducing sugar
sugar-sweetened beverage could easily translate into                  Now that you know more about added sugars and how
higher numbers on the scale and extra fat around the                  they can affect health, it’s time to learn where they are
belly.                                                                and how you can cut back. Strategies for doing this are
  ■ Exhausting insulin. The rapidly digested sugars in                described in “Self-defense: Sugar-reducing strategies,”
soda and fruit juices quickly boost blood sugar and                   beginning on page 23.

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Salt and sodium

T    o a chemist, salt is what you get when positive and
     negative ions enter each other’s orbit. To the rest of
us, salt is sodium chloride, the white crystals left over
                                                                                        The current Dietary Guidelines for Americans
                                                                                    places the healthy upper limit for sodium at 2,300 mg a
                                                                                    day, or about 1 teaspoon of salt. That drops to no more
when seawater evaporates.                                                           than 1,500 mg a day for African Americans, individuals
     The human body needs sodium for many essen-                                    with high blood pressure (hypertension), diabetes, or
tial tasks. Nerves need it to transmit impulses. Muscle                             kidney disease, and anyone over age 51. The American
fibers, including those in the heart and blood vessels,                             Heart Association says that everyone should try to keep
need it to contract and relax. Sodium helps the body                                sodium intake under 1,500 mg a day.
maintain a proper fluid balance. But it doesn’t take                                    Too much salt has been linked to health problems
much sodium to accomplish these jobs. The Yano-                                     for centuries. About 5,000 years ago, Emperor Huang
mamo people of the Amazon rainforest get by on just                                 Di Neijin of China wrote: “If too much salt is used for
200 milligrams (mg) of sodium a day (the amount in                                  food, the pulse hardens.” In the modern era, Dr. Lewis
1/10th teaspoon of salt). By comparison, the average                                Dahl from the Brookhaven National Laboratory began
American gets 17 times more than that—3,400 mg a                                    proposing in the 1950s that diets high in sodium con-
day (about 1½ teaspoons of salt; see Figure 4, below).                              tributed to high blood pressure. His hypothesis was
                                                                                    challenged by other researchers, and the sodium con-
                                                                                    troversy has raged ever since.
                                                                                        The long-running debate over whether cutting
Figure 4 The rise of sodium consumption                                             back on salt in the diet has meaningful effects on
                                                                                    health has been mostly laid to rest. A large body of
                                                                                    research accumulated over the past two decades shows
                        4,500
                                                                                    clear benefits from consuming less salt—not just for
                        4,000                           1971–1974                   lowering blood pressure but also for reducing the risk
                                                        2003–2006
                        3,500                                                       of stroke and heart problems (see “Self-defense: Con-
      Sodium (mg/day)

                        3,000                                                       quering your salt habit,” page 28).
                        2,500
                        2,000
                        1,500
                                                                                    Sodium in excess
                                                                                    The human body has sophisticated mechanisms
                        1,000                                                       for making sure enough sodium is always available.
                          500                                                       Chalk that up to two facts: every cell in the body needs
                            0                                                       sodium, and sodium was scarce throughout most of
                                       Men            Women                         human evolution. Now that sodium is abundant, those
                                    ages 20–74       ages 20–74                     mechanisms may be working against us.
                                                                                        Most Americans get far more sodium than they
                                                                                    need. It’s hard not to. Prepared foods are loaded with
The American diet has become saltier since the seventies.
According to dietary surveys, average dietary sodium intake rose
                                                                                    table salt. An 8-ounce serving of macaroni and cheese
considerably from the early 1970s to the early 2000s.                               or an order of fast food fries can serve up as much as
Source: Institute of Medicine.                                                      1,000 mg of sodium (see Table 4, page 14).

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                        This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
In healthy individuals, the kidneys respond to                                     to relax and contract with ease. It may also overstimu-
excess sodium by flushing it out in the urine. When                                    late the growth of heart tissue.
this process doesn’t work properly and extra sodium                                         About one-quarter of people with normal blood
is retained, the kidneys hang on to water. Some of                                     pressure and nearly 50% of people who have high
that water makes its way into the bloodstream. As                                      blood pressure are salt sensitive, meaning consuming
the amount of fluid flowing through blood vessels                                      too much sodium elevates their blood pressure and
increases, the pressure inside them increases, forcing                                 puts them at risk for complications. Dozens of studies
the heart to work harder. In addition, excess sodium                                   have shown that blood pressure rises with higher lev-
makes blood vessels less flexible, blunting their ability                              els of sodium in the diet—and that curbing salt intake

Table 4 Hidden salt in commercially prepared food
                                                                                                                                           % OF RECOMMENDED
  FOOD                                                                        SERVING                        SODIUM (MG)
                                                                                                                                          DAILY LIMIT (2,300 MG)
  Kung Pao chicken with rice                                                    2 cups                             2,610                               113
  Ham sandwich with mustard                                                    9 ounces                            2,340                               102
  Lasagna                                                                       2 cups                             2,060                                90
  Sauerkraut, canned                                                             1 cup                             1,560                                68
  Tuna salad sub sandwich                                                      6 inches                            1,293                                56
  Baked beans, canned                                                            1 cup                             1,106                                48
  Chicken noodle soup, canned                                                    1 cup                             1,106                                48
  Macaroni and cheese, canned                                                    1 cup                             1,061                                46
  Pasta sauce                                                                    1 cup                             1,030                                45
  Corned beef brisket                                                          3 ounces                             964                                 42
  Burger King Whopper                                                              1                                900                                 39
  Chicken pot pie                                                               1 small                             857                                 37
  Dill pickle                                                                1 (3 ounces)                           833                                 36
  Chicken bouillon                                                           4-gram cube                            743                                 32
  Ham                                                                           2 slices                            739                                 32
  Vegetable juice cocktail                                                       1 cup                              653                                 28
  KFC Biscuit                                                                      1                                560                                 24
  Cottage cheese                                                                ½ cup                               457                                 20
  American cheese                                                               1 slice                             442                                 18
  McDonald's French fries                                                     Super size                            390                                 17
  Waffle, frozen                                                                   1                                383                                 17
  Raisin Bran cereal                                                             1 cup                              361                                 16
  Green beans, canned                                                            1 cup                              354                                 15
  Cheese pizza                                                                  1 slice                             336                                 15
  Sources: U.S. Department of Agriculture, Agricultural Research Service. 2012. USDA National Nutrient Database for Standard Reference, Release 25. Nutrient Data
  Laboratory Home Page, www.ars.usda.gov/ba/bhnrc/ndl and the Center for Science in the Public Interest (see www.cspinet.org/salt).

14       Reducing Sugar and Salt                                                                                                          w w w.h ealt h .ha r va r d.e du

        This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
lowers blood pressure. The landmark DASH-Sodium                           nology, and Medicine in London described other
trial is perhaps the best example of these (see “The                      harmful effects attributed to high salt consumption
DASH diet,” below).                                                       beyond raising blood pressure. High sodium intake
     Writing in the Journal of Human Hypertension,                        increases the mass of the left ventricle (the heart’s
researchers at the Imperial College of Science, Tech-                     main pumping chamber), which makes the heart work

      The DASH diet
      DASH stands for Dietary Approaches to Stop Hypertension, a           Further analysis of the trial’s results found that the DASH
      diet developed by nutritionists to lower blood pressure. Put         diet reduced blood pressure in virtually all groups tested re-
      to the test in two large clinical trials—the first described in      gardless of such factors as age, sex, race, and hypertension
      The New England Journal of Medicine in 1997—the DASH                 status. Its effects were most pronounced, though, in African
      diet passed with flying colors. For many people who follow           Americans and people with high blood pressure. In fact, the
      it, the diet is enough to keep blood pressure in the normal          results were so promising that federal dietary guidelines
      range without medicine.                                              now recommend that all Americans—not just those with
                                                                           high blood pressure—follow the DASH diet.
      Key features of the DASH diet include plenty of fruits,
      vegetables, and whole grains; several servings daily of              A follow-up study, the DASH-Sodium trial, compared a typi-
      low-fat dairy products; some fish, poultry, dried beans, nuts,       cal American diet (the control diet) with the DASH diet at
      and seeds; and minimal red meat, sweets, and sugar-laden             different sodium levels (3,300, 2,400, or 1,500 mg per day).
      beverages. This mix of foods provides ample calcium,                 People with high blood pressure who ate the DASH diet at
      potassium, magnesium, vitamins, and fiber while limiting             the lowest sodium level had an average systolic pressure
      saturated fat, cholesterol, and sodium. Compared with the            reading 11.5 mm Hg lower than participants eating the
      typical American diet, the DASH eating plan has a relatively         control diet at the highest sodium.
      higher calcium content and less salt, total fat, saturated fat,      Still more support for DASH came from the Harvard-based
      and cholesterol. It also has 173% more magnesium, 150%               Nurses’ Health Study. Among nearly 90,000 female nurses
      more potassium, 240% more fiber, and 30% more protein.               whose diets, other habits, and health were followed for 24
      The blood pressure–reducing ability of the DASH diet can’t           years, those whose eating patterns most closely resembled
      be attributed to any single nutrient.                                the DASH diet had fewer heart attacks and strokes and
      In the original DASH study, 459 volunteers were randomly             were less likely to have died of heart disease compared with
      assigned to one of three diets. One was based on what most           women reporting average American diets.
      Americans eat, with 37% of calories from fat. The second             Combining a structured weight-loss program with the DASH
      was a similar regimen with fruits and vegetables added.              diet can drop your blood pressure even more than DASH
      The third was a “combination” diet—the DASH diet—con-                alone, according to a study of 144 overweight or obese peo-
      taining 27% of calories from fat, plus plenty of fruits and          ple with high blood pressure who weren’t taking any blood
      vegetables, whole grains, low-fat or nonfat dairy products,          pressure–lowering drugs. About a third of them followed
      and small amounts of meat, fish, poultry, and nuts.                  the DASH diet along with a weight-management program.
      After following the DASH plan for eight weeks, participants          Another third did DASH alone, and the other third followed
      with high blood pressure experienced average reductions              their regular diet. The weight-management program relied
      of 11.4 millimeters of mercury (mm Hg) in systolic pressure          on a strategy known as “appetite awareness training,”
      (the top number of a blood pressure reading) and 5.5 mm              which teaches people to identify their natural hunger and
      Hg in diastolic pressure (the bottom number). These results          fullness cues to help them learn when and how much to eat.
      are comparable to the effects of some blood pressure                 The program also included supervised exercise sessions that
      drugs. Participants with borderline high blood pressure also         featured biking, walking, or jogging for 45 minutes (includ-
      experienced improvements, suggesting that the DASH diet              ing a warm-up and cool-down) three times a week.
      may keep some people from developing high blood pres-                After four months, average blood pressure readings for the
      sure in the first place. The second diet, which was higher           DASH-plus-weight-management group dropped by 16.1/9.9
      in fats but also rich in fruits and vegetables, also lowered         mm Hg, compared with 11.2/7.5 mm Hg for the DASH-only
      blood pressure, although not as much as the DASH plan.               group and 3.4/3.8 mm Hg for the control group. The blood
      All reductions occurred without people changing their salt           pressure reductions seen in the weight-management group
      intake, alcohol consumption, or weight—factors known to              were similar to what doctors would expect from a high dose
      influence blood pressure.                                            of a blood pressure drug.

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              This Harvard Health Publication was prepared exclusively for Penny McIntosh - Purchased at http://www.health.harvard.edu/
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