Eight Steps to a Heart-Healthier Diet (Part 1: Steps One to Four)

By Janis Jibrin, M.S., R.D., and Tracy Gensler, M.S., R.D.

Step One: Fill your plate with fruits and vegetables.
Step Two: Make more of your grains whole.
Step Three: Nosh on nuts.
Step Four: Slash sodium.


Enjoy spaghetti with red sauce and a glass of wine? Bean burritos? Grilled fish? Zucchini, spinach, or any other vegetable sautéed in olive oil and garlic? Then heart-healthy eating is for you. “It’s come a long way from the low-fat diets of a decade or so ago. Now you can tailor your diet to include foods you love—the choices are nearly endless,” says Janet M. de Jesus, M.S., R.D., a nutritionist with the National Heart, Lung, and Blood Institute in Rockville, MD.


If your diet isn’t so stellar right now, no worries! We’ll help you craft a way of eating that you really enjoy and that fits into your lifestyle. And instead of changing your entire diet overnight—an approach that generally backfires—we’re giving you eight steps. Which will allow you to ease into a heart-protective diet gradually and make changes that really stick.


So, with the first four steps, you’ll be doing the following:

  • Working your way up to at least five servings of fruits and vegetables daily
  • Making at least 50 percent of your grains whole grains
  • Eating an ounce of nuts daily
  • Reducing sodium to 2,300 mg daily


Come back next month to complete your heart-healthy eating plan. That’s when you’ll

  • Switch over to healthier sources of fats.
  • Eat healthier sources of protein.
  • Take in two dairy (or soymilk) servings daily.
  • Set a daily “treat” calorie limit.

And all through the program, you’ll be watching portion sizes. We’ll help you, by recommending specific servings sizes—and number of servings—for each food group you’ll be working on. So, it’s not a “diet” in the traditional sense, but if you follow our portion recommendations, those of you who need to lose weight will naturally cut calories.


Fatal, but not fated


About every 39 seconds, someone in this country dies of heart disease—it’s the leading killer of Americans. 1   What’s so heartbreaking—literally—is that most of these deaths could have been prevented. The World Health Organization estimates that a whopping 80 percent of heart disease deaths are because of poor diet, lack of exercise, smoking and excessive alcohol intake. 2   And even among nonsmokers, lack of exercise and an unhealthy diet may be responsible for a staggering 74 percent of heart disease cases, according to the long-running Harvard Nurses’ Health Study. 3


Ideally, prevention begins in childhood and young adulthood. “However, it’s never too late. Even if you already have heart disease, switching to a healthy lifestyle may slow disease progression and reduce risk of heart attack,” says Dr. Jarett Berry, assistant professor of internal medicine at UT Southwestern Medical Center. “But don’t become complacent; even if you don’t have heart disease, if you have risk factors, such as obesity, high LDL cholesterol and high blood pressure, you’re paving the way for heart disease later in life,” he warns. Berry’s recent study 4 found that a 55-year-old man with no risk factors for heart disease has just a five percent chance of dying from heart disease through age 80. But with two risk factors, the likelihood jumps to 30 percent. (For women the risk is six percent versus 21 percent, respectively.)


Start making the changes outlined here (and in the upcoming “Part Two”) watch your cholesterol, body weight and other heart risk factors improve.


Steps One – Four:

Step One:  Fill your plate with fruits and vegetables.


Why: “If you’re a fruit and vegetable eater, you’re already combating heart disease as well as other chronic diseases,” notes de Jesus. The research backs her up: For instance, Harvard University studies tracking men and women for decades show that people who eat at least five servings of fruit and vegetables daily reduce their risk of having a heart attack or stroke by 28 percent compared to those consuming less than 1 1/2 servings daily. 5
How come? For one, fruits and vegetables fill you up on very few calories, which help manage weight, which, in turn, reduce heart disease risk. Though light in calories they contain upwards of 100,000 phytonutrients (beneficial plant compounds). For instance, the allicin in garlic not only lowers LDL—the “bad” cholesterol carrier—but it helps prevent it from becoming oxidized. (Oxidized LDL is more likely to clog arteries.) Anthocyanins, which give blackberries, blueberries, cherries, purple grapes, strawberries, raspberries and eggplant skin their red, blue and purple tones help make blood less likely to clot (which in turn can reduce risk of heart attacks and stroke). This compound also raises HDL levels, the “good” cholesterol carrier, which whisks this substance out of your body 6,7.
Old-fashioned vitamins and minerals also pull their weight when it comes to preserving your heart. For instance, fruits and vegetables are rich in potassium, a mineral that helps reduce blood pressure, and many are good sources of the antioxidant vitamin C. They all contain fiber, also linked with lowering heart disease risk.

How: Aim to get two servings of fruit and at least three servings of vegetables daily. A serving is a half-cup raw or cooked and comes to about 25 calories. That loosely translates to a medium-sized fruit, such as an orange or medium apple, or half a large fruit, such as a banana or large mango. And because salad greens are so low calorie, 2 cups of salad greens equal a half-cup of chopped vegetables.


Getting your “five a day” isn’t so hard:

Breakfast: 1/2 cup berries topping your cereal (1 fruit serving)
Lunch: 1 cup baby carrots (2 vegetables servings) with your lunch, followed by an orange (1 fruit serving)
Dinner: a side of spinach sautéed in olive oil and garlic (1 vegetable serving)


Although all fruits and vegetables are nutritious, make sure to include berries, citrus, eggplant, tomatoes and the “cruciferous” vegetables (e.g., arugula, broccoli, Brussels sprouts, cauliflower, kale, mustard greens) as they’re especially linked to heart protection. Include a wide variety of types and colors, as each specializes in its own brand of phytonutrients, vitamins and minerals.


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Step Two: Make more of your grains whole.


Why: Oatmeal has grabbed the spotlight as the heart-healthy whole grain, but really all whole grains deserve top billing. People who eat more whole grains—about three servings daily—have a 30 to 50 percent reduction in heart disease risk over those eating little to none. 8,9   Credit goes to similar heart-healthy compounds in fruits and vegetables: vitamins, minerals, phytonutrients and fiber. But white rice, white flour and other refined grains are stripped of most nutrients. (“Enriched” refined grains have some B vitamins and iron added back, but no phytonutrients or fiber.)
Oatmeal, barley and psyllium offer a special cholesterol-lowering advantage because they’re particularly rich in a type of fiber called “soluble” or “viscous” fiber. 10   This type of fiber forms a thick gel in the gut, trapping bile acid, a substance produced by your body to help break down fat in the diet. Bile acid is made from cholesterol, so when it hitches a ride out of the body with viscous fiber (instead of being reabsorbed as it normally is), the body draws from your blood cholesterol to make more bile acid, thus lowering LDL. In addition, viscous fiber traps some of the fat and cholesterol from the diet, sending it out of the body before it can be absorbed.
And all whole grains appear to have a weight loss advantage over refined grains. Their fiber makes them more satiating, meaning you feel fuller, longer for the calories.


How: Have five grain servings per day if your daily calorie level ranges from 1,500 to 1,800. Above 1,800 calories per day, start with six grain servings, and tack on more as your calorie needs increase. A serving is about 80 calories, which is approximately a half-cup of cooked pasta, rice or other grain, and a medium slice of bread. Cereals vary so widely in calories that you must check the label to figure out how much you get for 80 calories.


Although legumes (such as black beans, lentils and pinto beans), sweet potatoes, potatoes and peas aren’t grains, they are so close nutritionally, that they fall in the grain group as well. Therefore, you should consider 1/2 cup each serving. Beans are especially heart healthy—we’ll incorporate them more formally into your diet next month, in part two of this plan.


You can distribute your grain servings however you like. For five daily servings, we often recommend having two at breakfast (which makes a nice bowl of cold or hot cereal), two at lunch (so you can have a sandwich), and one at dinner.


Now figure out what percent of your grains are whole grains—aim to reach at least 50 percent. If you’re already there, raise it to 75 percent. It’s difficult to maintain a solid 100 percent if you eat out much—restaurants rarely have 100 percent whole grain bread or pasta, and many serve only white rice.


Tricky food labels can make it difficult to know if you’re getting a whole-grain product. For instance, “multigrain” does not necessarily mean whole grain. Think about it—the bread, cereal or other product can be made of a multitude of refined grains! But the ingredient list doesn’t lie; and to help you decipher it, here’s your guide:


Whole grains:
Barley *
Brown rice
Oats, oatmeal, steel-cut oats
Rye berries
Wheat berries
Whole corn
Whole rye
Whole semolina
Whole spelt
Whole wheat
Wild rice

* Pearled barley has some of the bran removed, but that’s OK because it’s still high in fiber and nutrients.
Not whole grains
All-purpose flour
Degermed cornmeal
Enriched flour
Rice flour
Rye flour
Semolina **
Spelt **
Unbleached flour
Wheat flour

** Even without the word “whole,” sometimes these grains are whole. You can’t be sure unless the product is billed as “100% whole grain” on the label.


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Step Three: Nosh on nuts.


Why: You might think it’s, well, a little nuts to recommend that you eat such a high calorie food on this plan. After all, calorie control is key to a healthy heart. But research shows that nut eaters actually tend to be leaner than people who don’t eat nuts. 12   How come? Nuts are particularly satiating. In other words, 100 calories of nuts will keep you going a lot longer than 100 calories of soda or doughnuts. And research is indicating that we may not absorb nuts all that well, so some off those calories leave the body.
But the most compelling reason to make nuts a staple is because the nuts that are lower in saturated fat (such as almonds, walnuts, hazelnuts, pecans, certain pine nuts, and pistachio nuts) can help lower LDL and are linked with reduced risk of heart disease. 13   And it’s no wonder; nuts are chock-full of heart-protective compounds. However, not all nuts meet the low saturated fat requirements, including Brazil nuts, macadamia nuts, cashew nuts and certain varieties of pine nuts. All nuts contain healthy fats, like monounsaturated fat and omega-3s (which we’ll tell you all about next month). In addition to phytonutrients, vitamins and minerals, many nuts are rich in the amino acid arginine. In the body, it converts to nitric oxide, which helps relax the blood vessels and lower blood pressure. Eating nuts can reduce inflammation; chronic inflammation is not only a trigger for heart disease but for cancer and other chronic diseases.


How: The amount of nuts you can eat depends partly on the number of calories you can get away with and still maintain a healthy weight (or lose weight, if you need to). A good place to start is with an ounce—about 3 tablespoons—of unoiled, unsalted nuts per day (or 1 1/2 tablepoons peanut butter, almond butter or other nut butter—again, unsalted is healthier). This comes to about 150 calories. If you’re adding that amount to your diet, make sure to cut 150 calories elsewhere. (Potato chips, soda and other junk food would be a good place to start!)


Here are some of our favorite ways to eat nuts:


Breakfast: If cereal and nonfat milk tend to be your breakfast staples, topping your bowl with nuts not only adds satisfying crunch, but the healthy fat helps keep you feeling fuller longer throughout the morning. You get the same effect if you throw in a tablespoon or two of almonds, almond butter or peanut butter into a banana/yogurt breakfast smoothie.


Lunch and Dinner: Roasted, unsalted nuts add texture and taste to salads, grain pilafs, fruit salads and many other dishes. (Roast in the toaster oven or oven in a single layer at about 300° for 4 to 8 minutes, watching carefully that they don’t burn.) Crushed nuts make a wonderful coating for baked fish and chicken, and can even serve as a mock piecrust. And, of course, peanut butter and almond butter are classics with thinly sliced banana, apple or pear in a sandwich.


Snack: Plain nuts, roasted nuts, nuts with dried fruit, nuts topping yogurt and fresh fruit, a teaspoon or two of nut butter on apple, or banana slices—nuts are a natural snack food.

Although almonds, peanuts and walnuts are the most well-researched when it comes to heart protection 13, all nuts are nutritious. So go ahead and mix it up with pistachios, pecans and any other types. Seeds, such as pumpkin and sunflower seeds, are also nutrient powerhouses, so include them as well.


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Step Four: Slash Sodium


Why: Although you might read about the occasional study indicating that sodium isn’t such a big deal when it comes to blood pressure, the vast weight of the evidence indicates it is. A diet moderate in sodium may help manage healthy blood pressure levels —a major risk factor in analyzing your risk of heart disease. Excess sodium raises blood pressure by hanging onto fluid, increasing blood volume, which taxes the heart. And, according to a review of 13 studies published in the British Medical Journal, excess sodium can also cause arteries to stiffen, another cause of high blood pressure. 14  This review also linked excess sodium with higher risk of stroke.


How: We’ll be honest with you, capping sodium at 2,300 milligrams (mg) per day—the recommended upper limit for people without heart disease or high blood pressure—is really tough. 15   And if you do have these conditions, you’re supposed to limit sodium to 1,500 mg; nearly impossible to achieve unless you prepare all your meals at home.


That’s because packaged, processed foods, and most restaurant foods, are absolutely teeming with sodium. Order a burger and you’ve asked for somewhere between 1,000 and 3,000 mg of sodium—and that’s without the fries! Many of the boxed flavored rice brands run 700 to 1,000 mg sodium for just one serving. And even healthy foods, like lentil, black bean and minestrone soup run you about 600 to 800 mg for just half a can.


That said, getting down to 2,300 mg is definitely doable if you consistently follow the strategies below. “Even if you’re in the group that should be maxing out at 1,500 mg, start by making 2,300 mg your goal. Take it step-by-step, allowing your taste buds to get used to lower sodium foods,” recommends de Jesus. Here’s how:

  • Buy raw. As much as possible, buy raw fruits, vegetables, meat, poultry and fish, and prepare them yourself. That way, you’re starting out with virtually no sodium.
  • Buy “no salt added.” Frozen vegetables, canned beans, canned tomatoes and many other canned vegetables now come in no-salt-added versions.
  • Compare labels and choose lower sodium foods. When you can’t get a no-salt-added product, buy the one lowest in sodium. There are tremendous differences; for instance, jarred spaghetti sauce ranges from about 200 to 600 mg sodium per half cup; bread (who knew bread had so much sodium?) from 0 mg to 340 mg sodium per slice; salad dressing 35 mg to 620 mg sodium per 2 tablespoons.
  • Cook without salt, but use a salt shaker at the table. Think about it—when you cook, you can easily add a teaspoon of salt (2,325 mg sodium)—usually more—to a chili, soup, pasta or other dish serving four people. That’s at least 580 mg sodium per serving—on top of all the other sodium in the meal.But skip the salt and add a dash to the serving on your plate (a generous dash is 1/8 teaspoon) and you’ve cut sodium in half. And you won’t miss it, because the impact of those salt crystals hitting the tongue is stronger than even more salt dissolved into a dish. In a study at the Monell Chemical Senses Center, participants ate a low-sodium diet (1,600 milligrams per day) and were told they could use a salt shaker liberally. Adding salt at the table raised sodium levels only 20 percent to about 1,920 mg daily—still nice and low.However, you do need salt when making certain baked goods; otherwise, the dough won’t rise properly. That’s OK. If the rest of your meal is low in sodium, you’ve more than offset the amount in the baked good.
  • Choose lower sodium options at restaurants. If it’s a chain with nutrition info posted online, pick out lower sodium options—if they exist! In restaurants without nutrition information, ask the server if there are any dishes that are not preseasoned, like grilled salmon or chicken, and request them salt-free. Skip soups and make your own salad dressing with olive oil and vinegar, instead of prepared dressings. (Ask the server if the kitchen can toss fresh herbs into your salad to pump up taste).

For more tips on reducing sodium see New Strategies for Slashing Salt.

And coming up next…


You’ve definitely had your hands full with steps one – four. As you’re making these changes, keep motivation up by remembering why you’re doing this—to look and feel better, to stay alive and active longer for your family, or for whatever personal reasons you may have.


Ready for the rest of the plan? Check out Part 2: Steps Five to Eight.


1 Roger, VL, et al. Heart disease and stroke statistics—2012 update: a report from the American Heart Association.Circulation, 2012;125:e2-e220
2 WHO Fact sheet No. 317, downloaded February 9, 2012 from http://www.who.int/mediacentre/factsheets/fs317/en/index.html
3 Nurses Health:  Hu, F.B and Willett, W. C. Optimal diets for prevention of coronary heart disease. JAMA, November 27, 2002—Vol. 288, No. 20
4 Berry, JD, et al. Lifetime risks of cardiovascular disease, N Engl J Med 2012; 366;321-9
5 Hung, HC et al. Fruit and vegetable intake and risk of major chronic disease. J Natl Cancer Inst. 2004; 96:1577–84.
6 Mazza, G. Anthocyanins and heart health. Ann Ist Super Sanità, 2007; Vol. 43, 4: 369-374
7 Noda, Y, et al. Antioxidant activity of nasunin, an anthocyanin in eggplant peels. Toxicology Vol. 148, Issues 2–3, 7 August 2000, 119–123
8 Jonnalagadda, SS, et al. Putting the whole grain puzzle together: health benefits associated with whole grains–summary of American Society for Nutrition 2010 Satellite Symposium. J. Nut r. 141: 1011S–1022S, 2011
9 Liu, S, et al. Whole-grain consumption and risk of coronary heart disease: results from the Nurses’ Health Study. Am J Clin Nutr. 1999;70:412–9.
10 Queenan, KM, et al. Concentrated oat β-glucan, a fermentable fiber, lowers serum cholesterol in hypercholesterolemic adults in a randomized controlled trial. Nutrition Journal, 26 March 2007, 6:6
11 Esfahani, A, et al. Symposium on Dietary management of disease. Session 4: CVD, diabetes and cancer. A dietary portfolio for management and prevention of heart disease. Proceedings of the Nutrition Society / Volume 69 / Is 1, 39–44
12 Tey, SL. Nuts improve diet quality compared to other energy-dense snacks while maintaining body weight. Journal of Nutrition and Metabolism Article ID 357350, Vol. 2011, 1–11
13 Kris-Etherton, P. The role of tree nuts and peanuts in the prevention of coronary heart disease: multiple potential mechanisms. J. Nutr. September 2008, 138: 1746S–1751S
14 Pasquale, S, et al. Salt intake, stroke, and cardiovascular disease: meta-analysis of prospective studies. BMJ, 2009; 339:b4567
15 U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010


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