Introduction:

Heart-Healthy Goals. The goals of a heart-healthy diet are to eat foods that help obtain or maintain healthy levels of cholesterol and fatty molecules called lipids. You can achieve this by:

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

Any diet should also help keep blood pressure and weight under control.

General Recommendations

In 2006, the American Heart Association (AHA) issued revised diet and lifestyle recommendations. The current guidelines recommend:

• Balance calorie intake and physical activity to achieve or maintain a healthy body weight. (Controlling weight, quitting smoking, and exercising regularly are essential companions of any diet program. Try to get at least 30 minutes, and preferably 60 - 90 minutes, of daily exercise.)
• Eat a diet rich in a variety of vegetables and fruits. Vegetables and fruits that are deeply colored (such as spinach, carrots, peaches, and berries) are especially recommended as they have the highest micronutrient content.
• Choose whole-grain, high-fiber foods. These include fruits, vegetables, and legumes (beans). Good whole grain choices include whole wheat, oats/oatmeal, rye, barley, brown rice, buckwheat, bulgur, millet, and quinoa.
• Eat fish, especially oily fish, at least twice a week (about 8 ounces/week). Oily fish such as salmon, mackerel, and sardines are rich in the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Consumption of these fatty acids is linked to reduced risk of sudden death and death from coronary artery disease.
• Limit daily intake of saturated fat (found mostly in animal products) to less than 7% of total calories, trans fat (found in hydrogenated fats, commercially baked products, and many fast foods) to less than 1% of total calories, and cholesterol (found in eggs, dairy products, meat, poultry, fish, shellfish) to less than 300 mg per day. Choose lean meats and vegetable alternatives (such as soy). Select fat-free and low-fat dairy products. Grill, bake, or broil fish, meat, and skinless poultry.
• Use little or no salt in your foods. Reducing salt can lower blood pressure and decrease the risk of heart disease and heart failure.
• Cut down on beverages and foods that contain added sugars (corn syrups, sucrose, glucose, fructose, maltrose, dextrose, concentrated fruit juice, honey).
• If you consume alcohol, do so in moderation. The AHA recommends limiting alcohol to no more than 2 drinks per day for men and 1 drink per day for women.

Women

The AHA guidelines for women are similar to the general dietary recommendations. However, the AHA suggests that women with existing heart disease consider taking omega-3 fatty acid supplements (850 - 1,000 mg/day of EPA and DHA). For women with high triglyceride levels, higher doses (2 - 4 g/day) may be appropriate. The AHA recommends against women taking antioxidant vitamin supplements (C, E, beta-carotene) or folic acid supplements for prevention of heart disease.

In addition, women who are pregnant or breastfeeding should avoid eating fish that is high in mercury content (shark, swordfish, mackerel, and tile fish). Choose fish and shellfish that are lower in mercury content and eat about 12 ounces/week. (The AHA recommends a higher weekly fish amount for women than for men. However, women of childbearing age should limit tuna to 6 ounces a week to reduce the risks for mercury contamination.)

Children

Atherosclerosis, the build-up of plaque in the arteries, begins in childhood. Experts stress the importance of heart-healthy dietary guidelines for children and adolescents to help prevent the development of heart disease later in life. Children should eat foods that are low in saturated fat, trans fat, and cholesterol. These foods include:

• Fruits and vegetables
• Whole grains
• Low-fat and nonfat dairy products
• Beans, fish, and lean meats

[For more information, see In-Depth Report #23: Cholesterol; Report #3: Coronary artery disease and angina; Report #14: High blood pressure; and Report #53: Weight control and diet.]

Fats and Oils

Some fat is essential for normal body function. Fats can have good or bad effects on health, depending on their chemistry. New research suggests that the type of fat is more important than the total amount of fat when it comes to reducing heart disease.

All fats, good or bad, are high in calories compared to proteins and carbohydrates. In order to calculate daily fat intake, multiply the number of fat grams eaten by nine (one fat gram is equal to 9 calories, whether it's oil or fat) and divide by the number of total daily calories desired. One teaspoon of oil, butter, or other fats equals about 5 grams of fat. All fats, no matter what source they are from, add the same calories. The American Heart Association recommends that fats and oils have less than 2 grams of saturated fat per tablespoon.

Try to replace saturated fats and trans fatty acids with unsaturated fats from plant and fish oils. Omega-3 fatty acids, which are found in fish and plant sources, are a good source of unsaturated fats. Generally, two servings of fish per week provide a healthful amount of omega-3 fatty acids.

All fats and oils found in foods are made up of chains of molecules called fatty acids. There are three major chains: saturated fatty acid (found mostly in animal products) and two unsaturated fatty acids -- monounsaturated and polyunsaturated fatty acids (found in plant products). The oils and fats that people and animals eat are nearly always mixtures of these three chains, but one type of fatty acid usually predominates in specific oils or fats.

Harmful Fats (Saturated Fats and Trans Fatty Acids). Reducing consumption of saturated fats and trans fatty acids is the first essential step in managing cholesterol levels through diet.

• Saturated Fats. Saturated fats are found predominantly in animal products, including meat and dairy products. They are strongly associated with higher cholesterol levels, and they may be even more dangerous in women than in men. High-fat meals are associated with sudden surges in triglyceride levels and other lipids along with impaired blood flow in the arteries to the heart. (Tropical oils such as palm, coconut, and cocoa butter are also high in saturated fats.) The American Heart Association recommends limiting saturated fat consumption to less than 7% of total calories per day.

Click the icon to see an image of saturated fats.

• Trans Fatty Acids. Trans fatty acids are manufactured fats created during a process called hydrogenation, which is aimed at stabilizing polyunsaturated oils to prevent them from becoming rancid and to keep them solid at room temperature. They are particularly dangerous for the heart and may pose a risk for certain cancers. These partially hydrogenated fats are even worse than saturated fats. Studies report that high consumption of these fats reduces HDL ("good cholesterol") levels, has harmful effects on the linings of the arteries, and may increase the risk for type 2 diabetes. Hydrogenated fats are used in stick margarine and in many fast foods and baked goods, including most commercially produced white breads. (Liquid margarine is not hydrogenated and is recommended.) The FDA ordered that food labels list the amount of trans fatty acids in food products beginning in January 2006. The American Heart Association recommends limiting daily consumption of trans fats to less than 1% of total daily calories.

Click the icon to see an image of trans fatty acids.

Beneficial Fats and Oils (Polyunsaturated and Monounstaurated Fats). Some fat is essential for health, and fat is essential for healthy development in children. Public attention has mainly focused on the possible benefits or hazards of monounsaturated (MUFA) and polyunsaturated (PUFA) fats.

• Polyunsaturated fats are found in safflower, sunflower, corn, and cottonseed oils and fish.
• Monounsaturated fats are mostly present in olive, canola, and peanut oils and in most nuts. (Canola is the least saturated of all the fats.) Studies report that replacing carbohydrates with monounsaturated fats improves glucose control after meals and reduces triglycerides in people with type 2 diabetes. Oils are more calorie-dense, however, and such patients should be wary of weight gain.

Essential Fatty Acids. Researchers are most interested in the smaller fatty-acid building blocks contained in both oils, which may have more specific effects on lipids. Three important fatty acids are the essential fatty acids omega-3, omega-6, and omega-9.

Omega-3 fatty acids are found in fish oil (docosahexaenoic and eicosapentaenoic acids) and plants (alpha-linolenic acid).

Click the icon to see an image of omega-3 fatty acids.

• Docosahexaenoic (DHA) and Eicosapentaenoic (EPA) Acids. DHA and EPA are found in fish oils, and evidence suggests that they have significant benefits for the heart, including reducing sudden death from heart disease, inflammation, blood clotting factors, blood pressure, and improving triglyceride and HDL levels. Results from a study presented at the 2005 meeting of the American Heart Association suggested that daily EPA supplements plus statin therapy can protect against heart attack, angina, and coronary artery disease. However, although fish and fish oil are good for the heart, patients who have an implantable defibrillator should not take fish oil supplements. A 2005 study suggested that these supplements may make heart rhythm problems worse in some patients.
• Alpha-linolenic Acid. Alpha-linolenic acid is a plant precursor of DHA, which means the body can convert it to DHA. Sources include canola oil, soybeans, flaxseed, and certain nuts and seeds (walnut, flax, chia, and sometimes pumpkin seed). Some, but not all, studies suggest that oils or foods containing alpha-linolenic acid may also be heart-protective. Supplements or foods containing alpha-linolenic acid may also protest the heart. For example studies have reported heart protection from flaxseed supplements and also from nuts, such as almonds, macadamia, and walnuts. Nuts are high in calories, however.

Omega-6 polyunsaturated fatty acids are found in corn, safflower, soybean, and sunflower oil. PUFA oils containing omega-6 fatty acids constitute most of the oils consumed in the US. Some omega-6 fatty acids are important for health. However, high intake of these fats may be associated with weight gain in the abdomen (the so-called apple shape), a risk factor for heart disease. High consumption is also associated with a higher risk for certain cancer and some chronic diseases.

Click the icon to see an image of different types of weight gain.

Omega-9 monounsaturated fatty acids are contained in canola and olive oil, which help protect the heart.

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

Fat Substitutes. Fat substitutes added to commercial foods or used in baking, deliver some of the desirable qualities of fat, but they do not add as many calories. They cannot be eaten in unlimited amounts. They are considered most useful for helping keep down total calorie count.

• Plants substances known as sterols, and their derivatives called stanols, reduce cholesterol by blocking its absorption in the intestinal tract. Margarines containing sterols (Benecol, Take Control) are available. Benecol is derived from pine bark and Take Control from soybeans. These products do not appear to block absorption of fat-soluble nutrients or vitamins, as olestra does. They may be hydrogenated and include some trans fatty acids, however.
• Olestra (Olean) passes through the body without leaving behind any calories from fat. Studies suggest that it helps improve cholesterol levels and may help overweight people lose weight. Early reports of cramps and diarrhea after eating food containing olestra have not proven to be significant. Of greater concern is the fact that even small amounts of olestra deplete the body of certain vitamins and nutrients that may help protect against serious diseases, including cancer. The FDA requires that the missing vitamins be added back to olestra products, but not other nutrients.
• Beta-glucan is a soluble fiber found in oats and barley. Products using this substance (Nu-Trim) may reduce cholesterol and have additional health benefits.

A number of other fat-replacers are also available. Although studies to date have not shown any significant adverse health effects, their effect on weight control is uncertain, since many of the products containing them may be high in sugar. People who learn to cook using foods naturally lacking or low in fat eventually lose their taste for high-fat diets, something that may not be true for those using fat substitutes.

Dietary Cholesterol

The story on cholesterol found in the diet is not entirely straightforward. The body produces cholesterol naturally or obtains it through meals. Animal-based food products contain cholesterol. High amounts occur in meat, dairy products, egg yolks, and shellfish. (Plant foods, such as fruits, nuts, grains, do not contain cholesterol.) The American Heart Association recommends no more than 300 mg of dietary cholesterol per day for the general population and no more than 200 mg daily for those with high cholesterol.

Click the icon to see an image of foods that contain cholesterol.

Carbohydrates

Carbohydrates are either complex (as in starches) or simple (as in fruits and sugars). One gram of carbohydrates equals four calories. The current general recommendation is that carbohydrates should provide 50 - 60% of the daily caloric intake. Many studies report that people can protect their heart and circulation by eating plenty of fruits and vegetables.

Complex Carbohydrates. Complex carbohydrates found in whole grains and vegetables are preferred over those found in starch-heavy foods, such as pastas, white-flour products, and potatoes. Most complex carbohydrates are high in fiber, which is important for health. Whole grains are extremely important for people with diabetes or at risk for it.

Click the icon to see an image of complex carbohydrates.

Simple Carbohydrates (Sugar). Experts recommend that no more than 10% of daily calories should come from sugar. (Currently, Americans eat nearly half a pound of sugar a day on average, and sugar intake constitutes 25% of a day's calories.) Sugars are usually one of two types:

Click the icon to see an image of simple carbohydrates.

• Sucrose. Source of most dietary sugar, found in sugar cane, honey, and corn syrup.
• Fructose. Found in fruits and vegetables. Although fructose does not appear to be have any different effects in the body than sucrose, most of the fruits and vegetables that contain it are vital for good health.

High levels of sugar consumption -- whether fructose or sucrose -- have been associated with higher triglycerides and lower levels of HDL cholesterol, the so-called good cholesterol. The high consumption of sugar is most likely one of the factors in the current obesity epidemic. Soda, other sweetened beverages, and fruit juice are major contributors to childhood obesity.

Fiber-Rich Foods

Fiber is an important component of many complex carbohydrates. It is almost always found only in plants. (One exception is chitosan, a dietary fiber made from shellfish skeletons.) Fiber cannot be digested but passes through the intestines, drawing water with it, and is eliminated as part of feces content. High-fiber diets (up to 55 grams a day) can be very helpful. Different fiber types may have specific benefits:

• Insoluble fiber (found in wheat bran, whole grains, seeds, nuts, legumes, and fruit and vegetable peels) may help achieve weight loss. Consuming whole grains on a regular basis may lower the risk for heart disease and heart failure, improve factors involved with diabetes, and lower the risk for type 2 diabetes. (Wheat bran taken as a supplement has not been associated with any benefits. The whole grain may be needed for good health.) High consumption of nuts (such as almonds, macadamia, and walnuts) may be highly heart protective, independent of their fiber content.
• Soluble fiber (found in dried beans, oat bran, barley, apples, citrus fruits, and potatoes) may help achieve healthy cholesterol levels and possibly reduce blood pressure as well.
• Soluble fiber supplements, such as those that contain psyllium or glucomannan, may also be beneficial. Psyllium is taken from the husk of a seed grown in India and is very effective for lowering total and LDL cholesterol. It is found in laxatives (Metamucil), breakfast cereals, and other products. Triglyceride and sodium levels need to be watched, however. People who increase intake of soluble fiber should also drink more water to avoid constipation.

Click the icon to see an image of soluble and insoluble fiber.

Protein

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

Fish. Fish is probably the best source of protein. Evidence suggests that eating moderate amounts of fish (twice a week) may improve triglyceride and HDL levels and help lower the risks for death from heart disease, dangerous heart rhythms, blood pressure, a tendency for blood clots, and the risk for stroke.

Click the icon to see an image of stroke.

The most healthy fish are oily fish, such as salmon, mackerel, trout, or sardines, which are high in omega-3 fatty acids. A 2006 Journal of the American Medical Association (JAMA) study suggested that modest consumption of oily fish can reduce the risk of heart-related death by 36% and death from all causes by 17%. On average, three capsules of fish oil (preferably as supplements of DHA-EPA) are about equivalent to eating one serving of fish.

Most guidelines recommend eating fish at least twice a week. Doctors may recommend that people with heart disease or high triglyceride levels consume extra quantities or take DHA-EPA supplements.

Women of childbearing age or nursing mothers should avoid fish that contains high amounts of mercury (such as shark, swordfish, golden bass, and king mackerel) and limit intake of tuna to 6 ounces/week. They should, however, try to eat at least 12 ounces/week of a variety of lower mercury-containing fish and shellfish (such as catfish, salmon, haddock, perch, tilapia, trout, crab, shrimp, and scallops). According to the JAMA study, the benefits of fish intake (especially from low-mercury fish) outweigh the potential risks.

Soy. Soy is an excellent food. It is rich in both soluble and insoluble fiber, omega-3 fatty acids, and provides all essential proteins. Soy proteins have more vitamins and minerals than meat or dairy proteins. They also contain polyunsaturated fats, which are better than the saturated fat found in meat. The best sources of soy protein are soy products (tofu, soy milk, soybeans). Soy sauce is not a good source. It contains only a trace amount of soy and is very high in sodium.

For many years, soy was promoted as a food that could help lower cholesterol and improve heart disease risk factors. But an important 2006 American Heart Association (AHA) review of studies found that soy protein and isoflavone supplement pills do not really have any effects on cholesterol or heart disease prevention. The AHA still encourages patients to include soy foods as part of an overall heart healthy diet but does not recommend using isoflavone supplements.

Meat and Poultry. For heart protection, choose lean meat. Saturated fat in meat is the primary danger to the heart. The fat content of meat varies depending on the type and cut. It is best to eat skinless chicken or turkey. However, the leanest cuts of pork (loin and tenderloin), veal, and beef are nearly comparable to chicken in calories and fat as well as their effect on LDL and HDL levels. However, even chicken and lean meat do not improve cholesterol levels and, in terms of heart health, fish is a more desirable choice.

Dairy Products. The best dairy choices are low-fat or fat-free products. Substituting low-fat dairy products can help lower blood pressure and lower the incidence of factors related to type 2 diabetes and heart disease (insulin resistance, high blood pressure, obesity, and unhealthy cholesterol).

Vitamins

Antioxidant Vitamins E, C, and A. Vitamins E, C, and A are most studied for their health effects because they serve as antioxidants. Antioxidants are chemicals that act as scavengers of particles known as oxygen-free radicals (also sometimes called oxidants). High intake of foods rich in these vitamins (as well as other food chemicals) have been associated with many health benefits, including prevention of heart problems.

Research on the effects of vitamin supplements on heart disease and diabetes, however, has been mixed. Although some research initially observed favorable effects from vitamin E in preventing blood clots and preventing build-up of plaque on blood vessel walls, most studies have found no heart protection from either vitamin E or C supplements.

Click the icon to see an image of phytochemicals.

B Vitamins (Folic Acid). Deficiencies in the B vitamins folate (known also as folic acid), B6, and B12 have been associated with a higher risk for heart disease in some studies. Such deficiencies produce higher blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease, stroke, and heart failure. Researchers have been studying whether vitamin B supplements can reduce homocysteine levels and, consequently, heart disease risks.

While major studies have indicated that B vitamin supplements help lower homocysteine levels, they have no effect on heart disease outcomes. Some experts think that homocysteine may be a marker for heart disease rather than a cause of it.

Click the icon to see an image of sources of folate.Click the icon to see an image of sources of B12.

Minerals

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

• Potassium. Evidence indicates that a potassium-rich diet can lower systolic blood pressure by 1.8 m Hg and diastolic blood pressure by 1 mm Hg. Some evidence suggests that a potassium-rich diet can reduce the risk of stroke by 22 - 40%. Expert guidelines now support the use of potassium supplements or enough dietary potassium to achieve 3,500 mg per day for people who have no risk factors for excess potassium levels. This goal is particularly important for people who have a high sodium intake. [People who take potassium-sparing diuretics (such as spironolactone), have chronic kidney problems, or take digoxin should not take potassium supplements without talking to their doctors.] The best source of potassium is from the fruits and vegetables that contain them. Potassium-rich foods include bananas, oranges, pears, prunes, cantaloupes, tomatoes, dried peas and beans, nuts, potatoes, and avocados.
• Magnesium. Some studies suggest that magnesium supplements may cause small but significant reductions in blood pressure. However, a clinically significant benefit on blood pressure has not yet been proven. The recommended daily allowance of magnesium is 320 mg. People who live in soft water areas, who use diuretics, or who have other risk factors for magnesium loss may require more dietary magnesium than others.
• Calcium. Calcium regulates the tone of the smooth muscles lining blood vessels. Studies have found that people who consume enough dietary calcium on a daily basis have lower blood pressure than those who do not. The effects of extra calcium on blood pressure, however, are mixed, with some studies showing higher pressure with calcium supplementation.

Click the icon to see an image of sources of calcium.

Salt Restriction

Consuming less than 2,300 mg (about one teaspoon) of sodium (salt) each day is helpful for lowering blood pressure. Some people over age 50, or who have high blood pressure, may need to reduce sodium intake to less than 1,500 mg daily. This lowering of blood pressure may also help protect against heart failure and heart disease. Experts disagree on the overall benefits of salt restriction for everyone. Still, the following people should take particular measures to restrict salt:

• People at Risk for Salt-Sensitivity. About half of people with hypertension have blood pressure that reacts significantly to salt. Such people are known as salt-sensitive. Among those at highest risk for salt sensitivity are African-Americans, people with diabetes, and elderly people.
• Overweight People. Overweight individuals may absorb and retain sodium differently from people with normal weights. One study reported that high sodium intake was associated with an increased risk of heart disease and all-cause mortality in overweight, but not in normal weight, people. Reducing sodium can also help reduce the risk of stroke in people who are overweight.

Simply eliminating table and cooking salt can be beneficial. Salt substitutes containing mixtures of potassium, sodium, and magnesium (such as Cardia) are available, but they are expensive. If you are thinking of using a salt substitute, talk to your doctor first.

About 75% of the salt in the typical American diet comes from processed or commercial foods, not from food cooked at home, so the benefits of table-salt substitutes are likely to be very modest. Some sodium is essential to protect the heart, but most experts agree that the amount is significantly less than that found in the average American diet. If people cannot significantly reduce the amount of salt in their diets, adding potassium-rich foods might help to restore a healthy balance.

Water, Alcohol, and Caffeine

Water. Many heart risk factors, especially those associated with blood clotting, are increased with dehydration. In one study, drinking five or more glasses of water a day was significantly associated with a lower risk for fatal heart events than drinking two or fewer glasses a day.

Alcohol. A number of studies have found heart protection from moderate alcohol intake (one or two glasses a day). The benefits reported include higher HDL levels, blood clot prevention, and anti-inflammatory properties plus lower rates of heart failure and heart attack. Although red wine is most often cited for healthful properties, any type of alcoholic beverage appears to have similar benefit.

On the negative side, an estimated 10% of hypertension cases are caused by alcohol abuse. Men with high blood pressure should limit their intake to an average of no more than one or two drinks a day, and women (especially those at risk for breast cancer) and lighter people should only have one drink a day. (A “drink” is equivalent to a 12-ounce bottle of beer, a 4-ounce glass of wine, or a 1.5-ounce shot of hard liquor.) Overuse of alcohol can also lead to many heart problems. Pregnant women, people who can't drink moderately, and people with liver disease should not drink at all. People who are watching their weight should be aware that alcoholic beverages are very high in calories.

Caffeinated Beverages.

• Tea. Although it contains caffeine, tea, both black and green, is often cited for its health benefits. Green tea especially is rich in chemicals that may offer protection against damaging forms of LDL. A 2006 study of Japanese adults who drank high amounts of green tea (3 or more cups a day) found that green tea consumption was associated with reduced risk of death from heart disease. Green tea did not, however, appear to offer any protection against cancer.
• Coffee. Coffee, like red wine, contains phenol, which helps prevent oxidation of LDL cholesterol. However, unfiltered coffee (Turkish coffee, Scandinavian boiled or French pressed coffee, and espresso) contains an alcohol called cafestol, which may raise cholesterol and triglyceride levels. Filtered coffee does not contain this residue. Coffee drinking is associated with small increases in blood pressure, but the risk it poses is very small in people with normal blood pressure. Moderate coffee consumption (1 - 2 cups a day) poses no heart risks and long-term coffee consumption does not appear to increase the risk for heart disease in most people, even if they consume large daily amounts.