Prudent Diet and Preventive Nutrition From Pediatrics to Geriatrics: Current Knowledge and Practical Recommendations
(Part 5 of a Multipart Series)
Enas A Enas, A Senthilkumar, Hancy Chennikkara, Marc A Bjurlin
Coronary Artery Disease in Asian Indians (CADI) Research Foundation, and University of Illinois, Chicago, USA
Prudent Diet for All Ages and the Entire Population
The traditional Mediterranean diet is characterized by abundant plant foods (vegetables, breads, pastas, beans, nuts, and seeds). Fresh fruit is the typical daily dessert, and olive oil is used as the principal source of fat. Dairy products (principally cheese and yogurt), fish, and poultry are consumed in low-to-moderate amounts. Red meat and egg are consumed in low amounts (0–4 eggs weekly). Wine is consumed in low-to-moderate amounts, normally with meals. This diet is typically high in total fat (35%–45%) but low in SAFA (7%–8% of energy). Greater adherence to the traditional Mediterranean diet is associated with a significant reduction in total mortality.377 The 6 beneficial components of this diet have recently been elucidated. They are vegetables, legumes, whole-grain cereal, fish, fruit, and nuts, which form the basis for the "prudent diet"377 (Table 10).199–203,225–227,231–236
According to the new paradigm, dietary pattern rather than individual nutrients appears to be more important. Recent research suggests the existence of a food synergy in which the beneficial effects of healthy foods are magnified when several different types of foods are consumed.213 Hu et al. have developed the concept of "prudent diet" (modified from the Mediterranean diet).30,378–380 The "prudent diet" has a higher intake of vegetables, fruits, legumes, whole grains, fish, and poultry, whereas the "western diet" is characterized by a higher intake of red meat, processed meat, refined grains, sweets, desserts, French fries, and high-fat dairy products.378,380 The "prudent diet" is associated with a 24% decreased risk of CVD compared to a 46% increased risk with the western diet.215,380
Consumers are bombarded on a daily basis with the Babel of nutritional breakthroughs.381 Food companies advertize their products, nutrition researchers publicize their latest results, and the media are more interested in a controversial story than in scientific facts.30 Trivial reports are often publicized as major breakthroughs by the media, and cause confusion among consumers. It is difficult for most journalists and consumers to tell the difference between a major research finding and a trivial report.381
The dangers of the current western diet and the contaminated vegetarian diet, and the remarkable benefits of the prudent diet need to be disseminated among cardiologists, physicians, and the public. This diet can be sustained lifelong but needs to be adapted to Indian ingredients and cooking methods. Several countries have developed dietary guidelines to reduce nutritional information anarchy. The Indian consensus on the prudent diet should incorporate scientific facts, and the cultural preferences appropriate for different parts of India. Such information needs to be adopted by the scientific community, and adapted by the food industry.
Current Knowledge on Preventive and Therapeutic Nutrition
Randomized, controlled clinical trials, meta-analysis, and systematic reviews are considered the ultimate tests of the benefits of therapeutic interventions. Such reviews have shown a 24% reduction in major coronary events in dietary trials lasting >2 years.382 The TC/HDL ratio is the single best lipid predictor of CVD. This ratio is determined by 3 partly opposing dietary factors—the proportion of energy from SAFA, which raises TC; the proportion of energy from total fat, which raises HDL; and the excess in total energy intake, which produces obesity and secondarily lowers HDL.20 The greatest reduction in CVD risk is achieved by LDL-lowering by reducing SAFA intake. Decreasing SAFA intake is best accomplished by reducing the intake of high-fat dairy products, and increasing fiber-rich foods. A diet incorporating lean beef, skinless chicken, and fatty fish has been shown to improve the lipid profile by 5%–10%.383
The preferred replacement for SAFA is MUFA or PUFA and not carbohydrates (Table 11). Replacing SAFA with carbohydrates decreases the LDL levels but makes LDL small, dense, and more dangerous by increasing the TG levels.30 Substituting carbohydrates with MUFA decreases the LDL level, and increases the HDL level. PUFA and MUFA increase insulin sensitivity, and decrease the risk of type 2 diabetes.45,384–386 Substantial evidence indicates that diets using MUFA and PUFA as the predominant form of dietary fat, an abundance of fruits and vegetables, and adequate n-3 fatty acids can offer significant protection against CAD, stroke and diabetes (Table 8). Adequate consumption of fruits and vegetables provides most of the necessary antioxidants, and are preferable to dietary supplements in the form of pills. Replacing a high glycemic with a low glycemic index, and reducing the glycemic load can reduce the risk of diabetes161 (Table 6).
Nuts, once deemed unhealthy because of their high fat content, have become an important part of diets designed to control weight, lower blood pressure and cholesterol, and achieve secondary prevention of CAD, besides adding variety, texture and flavor to dishes.145,211,215,387 Unless a beneficial effect is clearly demonstrated by well-designed scientific studies, the liberal use of butter, ghee, palm oil, and coconut (oil and milk) should be discouraged. However, in diets with a negligible intake of fish, meat, milk, and dairy fat, the modest use (<7% of energy) of such oils may be preferable to no fat at all.
Better food habits can help reduce the risk of diabetes, MI, stroke, and death. A healthy eating plan means choosing the right foods to eat, and preparing them in a healthy way. A healthy diet involves a decrease in the use of refined grains, tropical oils, egg yolks, animal, dairy, and hydrogenated fats, and an increase in the consumption of whole grains, vegetables, nuts, legumes, and fruits.7 Increasing the MUFA intake up to 20% of energy, as a replacement for SAFA and carbohydrates, may help prevent and treat the metabolic syndrome, diabetes, and CVD. Such a strategy can also significantly reduce the need for lipidoptimizing drugs. Since meat contains one-third MUFA and one-third cholesterol–neutral stearic acid, its consumption can also be incorporated into a healthy diet, provided lean cuts are used, and the quantity limited to 150 g/day.6
People eat specific foods because of their taste, easy availability and affordability, but are often unaware of the health benefits and risks. Dietary modifications remain the cornerstone of both the treatment and prevention of diabetes and CVD, the twin epidemics of the twenty-first century.234,388–391 A prudent diet together with regular physical activity, avoidance of smoking, and maintenance of a healthy body weight may prevent the majority of diabetes and CVD in the Indian population.30 Aggressive dietary interventions may reduce CVD events to a similar magnitude as that achieved with statins. Compared with medical or surgical interventions, nutritional intervention is low-risk, low-cost, and readily available.259 A variety of whole grains, not refined grains, as well as various types of fruits and vegetables should be the main form of carbohydrates.242 Prolonged cooking of vegetables should be avoided. It is important to realize that the vegetarian diet is healthy only when it is low in SAFA, and the predominant energy is from foods with a low glycemic index.215 The best way to counter the perils of contaminated vegetarianism is by substituting full-fat dairy products with low-fat dairy products. Cooking oils containing high SAFA should be replaced with those containing high MUFA. Deep-frying, especially with previously used oils, should be discouraged. Nuts are healthy, wholesome foods, and their use should be encouraged as a replacement for unhealthy calories. A diet rich in fish has multiple benefits, including raising HDL, and lowering TG levels, and preventing sudden death.383 Consumption of fish is preferable to taking a large number of fish oil capsules. There is increasing evidence that dietary and lifestyle modifications begun in childhood are likely to have benefits later in life.392 Therefore, these dietary guidelines are applicable to all Asian Indians >2 years of age, and not just those with diabetes or heart disease.
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