Alternate approach to low fat—low saturated fat—low cholesterol diet

the dietary change probably must be long term if not lifelong, in duration (7). N~t only is introducing a rigid food pattern a problem but also guilt or ~nxi­ By emphasizing quantities rather than ety is engendered when foods knowmgly types of animal foods, this approach o~­ rich in fat or cholesterol are consumed. fers variety, decreased waste, economIC advantages, and lowered saturated fa.t The food not only must be palatable, but guilt or anxiety over eating cemain foods and cholesterol intakes. must not be developed. Thus to be sucThe concept was developed by a multicessful, long term dietary change should disciplinary group composed of a pr~v.ate be individualized. A single dietary prepraoticing pediatrician, the Nulntlon Section of the Arizona State Department scription has not and probably will not succeed for the majority. of HeaIth, Departments of ,P ediatrics and It is our belief ,that, ra.ther than subFamily and Community Medicine of th.e mitting 'a universal dietary recommendaUniversity of Arizona College of MedItion ,to ,t he population, an alternate s~lu­ cine, ,a nd a representative of the food lion ,to the problem exists. By employmg indu~try. the Recommended Dietary Allowances Through increasingly intensive educa(RDAs) for protein (8), an a1te~native tional effonts and lay press coverage of approach has been developed which althis subjeot, the general public is becomlows for individual taste and yet remeing aware of the possible relationship of dies a basic problem, namely, the excesexcessive dietary cholesterol and 3Jtherosive consumption of saturated fat and sclerosis. With the high prevalence of the cholesterol. The concept of limiting prodisease accompanied by public awaretein intake is new to mOSlt consumers. ness not suppor,ted by effeotive remedial Praotically, this concept might ·b e preprograms, the general public is consented to the individual in .the following cerned and anxious. manner. First, the importance of protein The low fat-low srutura.ted fat-10w cho- in the diet is stressed. Second, the lesterol dietary recommendations, as cur- amount of protein for the individual as rently used, ,tend to alter the types of stated in ,the RDA is emphasized as adefoods consumed by reducing some and quate (8). Third, the disadvantage~ of substituting others rather than arbitrarily consuming excessive .a mounts of ammal forbidding all animal fat sources. For ex- protein and thus animal products are ample, it is recommended to reduce the enumerated as follows: intake of beef, pork, lamb, egg yolks, or1. Many animal products are associgan meats, shellfish, and . dairy produots ated wi.t h undesirably high amounts of rich in butter fat and increase consump- satura.ted fntand cholesterol. tion of low or nonfat dairy products, fish, 2. Undesirably rich sources of caloand poultry (4). It has been demon- ries may be consumed, as many ,animal strated ,that these types of recommenda- products are rich in fats. . tions are effective in lowering cholesterol 3. This is a wasteful form of obtamlevels and perhaps in reducing ischemic ing calories from an ecological viewcardiov.ascular disease in study populapoint. . tions (3). Long term free living adher4. These animal foods are expensive ence has 'n ot been examined. from .t he financial point of view. However, in this rigid dietary prescripOnce tlhe RDA for protein for each tion, serious problems become evident. member of ,the family is presented, then Individual taste which is influenced by the amounts of protein in the various family and ethnic backgrounds is not re- foods a re shown. For ease of calculation spected. Many people simply do not like by the consumer, approximation of the the foods that are usually prescribed, protein content of these foods ~s made. 1 and,even ,though their future health may Individualized dietary suggestIOns can be adversely affected, they cannot or will then be offered. The protein quantities in not adhere to a long .t erm conventional the animal foods (dairy products and dietary program. For long ,t erm success- meats) have been averaged as follows. ful adherence, i,t would seem that there Eight ounces of milk and one ounce of must be some immediate gratification, cheese (average of 17 types) have eight i.e., day~by-day eating must be enjoy- grams of protein and one o unce of meat able. Food is not medicine and should has seven grams of protein (an average not be treated as such. Individuals, if inMaterials are presented which include prote;n ,e' tensely motivated, may consume dis- I ·uirements for each family member. a~d a c~ cu ad ~ons to determine the total,fam,!y s pro~e'n/n. agreeable foods but how long will ~his other sheet nutrient needs. A purchaSIng list for 00 s IS compulsive aotivity last? To be effectIVe, also developed with the family.

Commentary Alternate Approach to Low Fat-Low Saturated FatLow Cholesterol Diet By Glenn M. Freidman, Anita Yanochik, Nancy West, Stanley Goldberg, and Dileep G. Bal Ischemic coronary and cerebral vascular disease, secondary to atherosclerosis, is .the major cause of morbidity and mor.tality in the United States and industrialized nations of ,t he world (1) . Among the risk faotors are excessive intakes of calories, satmated fat, and cholesterol. In susceptible segments of the popula,t ion, one or more of these factors contribute to eJeva.ted serum lipids (cholesterol and triglycerides) which have been implicated as basic to the disease process (2). This overabundance of these substances is related .10 our high intakes of animal products, e.g., dairy and meat products (3). The American Heart Association has recommended that, in order to reduce blood cholesterol levels ·to low risk ranges, the aduLt dietary intake of cholesterol should be kept to .a pproximately 300 milligrams or less per 24 hours (4) whereas the average adult American consumes an average greater ,t han 600 milligrams per 24 hours. Since cholesterol is only found in animal foods , t his is a reflection of our overemphasis on foods froman"imal sources. However, many of these animal foods are also rich sources of protein. Protein is consumed well in excess of needs by most Americans. Acoordingto the TenStrute Nutrition Survey, the mean protein intake for young people significantly exceeds the recommended dietary allowance for this nutrient (5). The advisabiHty of feeding unduly large amounts of protein ,to children has been seriously questioned (6). The approach developed in ·this paper offers an aLternative to the current low fat-low saturated fat-low cholesterol diet. THE AUTHORS are,' respectively, Pediatrician in private practice of medicine, Scottsdale, Ariz., and Adjunct Assistant Professor, Department of Pediatrics, University of Arizona College of Medicine; Chief, Nutrition Section, Arizona State Department of Health (address for correspondence: 1740 W. Adams St., Room 315, Phoenix, AZ 85007) : Executive Directo~, Dairy Council of Arizo,na: P~ofesso~ of .Ped,atrics, Department of Ped,atr,cs, UnIversIty of Arizona College of Medicine; and Assistant Professor, Nutrition and Epid.emiology,. Depar!ment of Family and CommunIty Me.dl.clne, University of Arizona College of Med,Cine.

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Journal of NUTRITION EDUCATION

VOL. 6, NO. I, JAN.-MARCH, 1974

of 54 meat ,types including beef, pork, veal, lamb, poultry, sea food) (9). An example is ,t hen developed utilizing the individual taste preferences. A ISO-pound father with an RDA of 56 grams of protein would be allowed to take only up to this amount of protein from animal sources. However, it is not implied tha
Table I Protein RDAs for Various Family Members Protein RDA

Family member Father (150 IbsJ Mother Child (I yrJ Child (4 yrs) Child (12 yrs)

56 gms 46 gms 23 gms 30 gms 44 gms

Total

199 gms

protein is recommended for Ithis family. The family consumes cheese, milk 'and meat. Thus the day's foods for the family might include two quarts of milk containing 64 grams of protein, four ounces of American cheese which would have 32 grams of protein, ,a nd 20 ounces of beef (raw) or 15 ounces cooked, containing 105 grams of protein, or a total of 201 grams of protein. These amounts (or equivalents) mu\.tiplied hy seven would equal the weekly shQPping list fDr animal prDducts. Thus, this concept is easily adaptable to food purchasing by manipulating the various animal prDtein sources listed above, depending upon individual tastes and food budgets. It would seem easier for some people to eat smaller quantLties of food which they enjoy, rather than learn an entirely new eaJting pattern. Since the calories from animal products are reduced, the remaining dietary suggestions include eating plant fODds such as legumes, cereals, and grains and frequent consumptionof green-yellDw vegetables and fruits. Foods w1th ,a IDW nutrient/calorie value, e.g., SQme snack foods, sof,t drinks, are used sparingly. This "prDtein ooncept" is applicable to the majority of animal products which are not very high in saturated fat or cholesterol. However, SDme protein-contain-

Table 2 Principles of the "Alternative" Diet I. Animal protein-no more than the RDA level

per day 2. Organ meats, shellfish-restrict consumption to weekly 3. Egg5--consume only singly and not daily 4. Fats-use liquid polyunsaturated vegetable oils and margarines in preference to animal fats; butter restricted to 1/8 lb. (112 stick) per week 5. Dairy foods-some daily 6. Yellow and green vegetables-include daily 7. Cereal and grain products daily.

ing animal produots are exceedingly rich in these substances, e.g., organ meats, eggs, and shellfish. Some special de-emphasis is necessary for these foods. Thus i-t is suggested that organ meats and shellfish be consumed only occasionally, say weekly, while eggs can be consumed only singly and only ,t hree ~o ,five a week. The protein Df these foods would alSo. be included in the animal protein calculation, e.g., six grams of protein per egg. Foods that are pure or predominan.t1y fa,t ,and without significant protein also deserve special mention, e.g., cooking and salad oils and butoter-fat prDducts. Liquid polyunsatur.ated vegetable oils are advised in preference to. animal fats for cooking or use in salads. Some butter may be used subject to. a maximum of VB pDund (1;2 stick) per family member per week. Margarine wDuld be preferred if greater quantities of fat are desired. However, daily consumption of dairy foods is encouraged because of their high calcium content. The final nutritional pattern will be one that is adequate but nOot excessive in animal protein, ,a nimal fat, Qr cholesterol. Table 2 summarizes !the principles of the diet. Table 3 illustrates the kinds of menus that might cOomprise the diet for a fa,ther. The quantities WDuld be adjusted appropriately for other family members. These Cand other) menus were calculated for calories, protein (animal and vegetable sDurces), fa,t, carbohydrate, calcium, iron, vitamin A, thiamin, riboflavin, niacin , vitamin B-6, magnesium, saturaJted .a nd polyunsaturated fat, and P / S ratio. In almost every case, ,t he RDAs are well met with the exception of iron for the mother; iot is very difficult to meet the 18 milligram iron allowance in any diet, and ,t he forthcoming increase in enrichment Df bread and flour should solve this problem. If this concept were to receive wide acceptance, it is po~~ble a significant lowering of our high natiQnal cholesterol levels (and, hopefully, a decrease in atherosclerosis) might be effected without an unduly restrictive diet which might be unacceptable. This concept would be applicable and advantageous ,to all segments of
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1. In a private pediatric office associated with .the Department of Pediatrics of the University of Arizona College of Medicine in a familiallongi,tudinal, atherosclerosis, risk factor, screening, and intervention program, and 2. In the community through the nutrition delivery sy&tem of the Arizona State Department of Health. In conclusion, we suggest this diet pa.ttern would be lower in dolla'r cost, an immediate advantage aiding C()mpliance; allow easier maintenance of a desirable weight for many people; and would not be wasteful in protein nor be excessive in £a.t or cholesterol, the latter hopefully producing the long term effects of decreasing cardiovascular disease. With appropriate nutrition education regarding ,this concept, we might hopefully induce ,a change in the public's nutritional behavior and move towards resolving one of our major dietary dilemmas. REFERENCES 1. HiIIeboe, H.E., Geographic Distribution of Arteriosclerotic Heart Disease, in Cowdry's Arteriosclerosis, Blumenthal, H. T., Ed., Charles C. Thomas, Springfield, III., 1967, p. 623. 2. Connor, W.E. ,and Connor, S.L., The key role of nutritional factors in the preven-

tion of coronary heart disease, Prevo Med., 1 :49, 1972. 3. "Report of Inter-Society Commission for Heart Disease Resources: Primary Prevention of the Atherosclerotic Disease Circulation," Vol. XLII, Dec. 1970. 4. Anon., Statement on Diet and Heart Disease, released by Committee on Nutrition, American Heart Assoc., 1973. 5. Anon., Ten-State Nutrition Survey, V Dietary; VIOl, 1968-70, U.S. Department of Health, Education and Welfare, DHEW Publication No. (HSM) 72-8133. 6. Holt, L.E., Jr., Protein economy in the growing child, Post Grad. Med., 27 (No. 6) :783, 1960. 7. Strong, J.P. and McGill, H.C., The natural history of coronary atherosclerosis, Amer. J. Path., 40 (No.1): 37,1962. 8. Anon., Recommended Dietary Allowances, 9th ed., National Academy of Sciences, National Research Council, Washington, D.C., to be published in 1974. 9. Anon., Nutritive Value of Foods, Home and Garden Bulletin #72, U.S. Department of Agriculture, Washington, D.C., 1971. ACKNOWLEDGEMENT We gmtefully acknowledge .the assistance of Morissa White and Kristie Kujawski who completed the laborious calculations for all diets while field students with the Arizona State Department of Health as part of their field study for the M.P.H. degree.

Table 3 Sample Menus Diet A. Breakfast Soft cooked egg, I Bread, whole wheat, 2 slices Margarine,2 pats Jelly, I tbsp. Grapefruit, !l2 Milk, whole, !l2 cup

Lunch Macaroni and cheese, I cup Bread, whole wheat, 2 slices Salad: Lettuce, 2 large leaves Tomato, I small Green pepper, I tbsp. Oil, safflower, I tbsp. Milk, whole, I cup Snacks: Banana, I Dry-roasted peanuts, 45 Raisins, !l4 cup Beer, 12 oz.

Supper Rice, white, enriched, I cup Chop Suey: Chicken, white, 2!12 oz. Bean sprouts, 1!l3 cup Mushrooms, I oz. Bamboo shoots, !l4 cup Oil, safflower, 2 tbsp. Soy sauce, I tbsp. Peas, !l2 cup Water chestnuts, 2

Diet B. Breakfast Pancakes, 4" diam., 6 Syrup, 2 tbsp. Grapefruit, !l2 Milk, I cup

10

I

Lunch Peanut butter sandwich: Bread, whole wheat, 2 slices Peanut butter, I tbsp. Carrot and raisin salad, !l2 cup Orange, I med. Milk, Whole, I cup Angel cake, 2" of 8" cake Snacks: Crackers, Rye-Krisp, 4 Cheese, cheddar, 2 oz. Beer, 12 oz.

Journal of NUTRITION EDUCATION

Supper Broiled salmon, 3!12 oz. Rice, white, enriched, 2h cup Broccoli, 2h cup Bread, whole wheat, 2 slices Margarine, I tbsp. Salad: Lettuce, 2 large leaves Tomato, I med. French dressing, I tbsp. Orange sherbet, I cup

Adapting the University Curriculum in Nutrition to National Needs By Cecilia A. Florencio E:ditors note: The University of the Philippines developed a four-year undergraduate degree program in Community Nutrition designed to prepare nutritionists who have: 1) greater appreciation and facility for nutrition work in the community and 2) more adequate preparation for carrying out both preventive and curative nutritional services.

The university must play a part far beyond ,the passive role of transmitting knowledge. It must assume the posture of a social critica.nd ran agent of change, never ceasing ,to create the environment that is conducive to national development and progress. To do this, the universities must develop curricular programs relevant to national needs and aligned with national priorities. The Department of Education and CuIture of ,the Philippines submits that univers~ties in ,the country have failed to provide education that is functional, useful, and applicable ,to Philippine conditions. This problem in Philippine education is attributed ,to [he fact that our curriculum did not develop naturally. Its growth does not reflect nor parallel the s,tages of development that our country has gone through. Philippine education in general,and education in nutrition as an example, has been patterned arter, if not copied from, ,the United States. Howson (1) has said "Educational tmnsplants are rejected as readily as human transplants unless one has studied the recipient as closely a.s the donor." A curriculum developed and proven useful in one country is not necessarily appropriate in another. The truth of this basic principle in education is 'Supported by the Philippine experience with the use of the U.S. nutrition curriculum for at least 30 years.

The Traditional Curriculum Every year, nine colleges and universities in Manila and the suburbs and three in the provinces graduate a ,total of about 200 students with the degree of Bachelor of Science in Nutrition or Dietetics. The nutrition depar,tments or sections in these insti,tutions are either under the College of Home Economics or Liberal Al'ts. Although ,there were many graduates before 1960, let us assume-just for the sake of argument-that we had our fint batch of 200 gr,aduates a year in 1960. This means that ,to da,te there are about THE AUTHOR is Chairman, Dept. of Food Science and Nutrition, University of the Philippines, Diliman, Quezon City, Philippines. VOL. 6, NO. I, JAN.-MARCH, 1974