SPECIAL ARTICLE Dietary Control of Serum Cholesterol in Clinical Practice By NORMAN JOLLIFFE, M.D.,t ETHEL MASLANSKY, M.S., FLORENCE RUDENSEY, R.N., B.S., MARTHA SIMON, M.S., AND ALICE FAULKNER, M.S. THE RELATION of lipids in the diet to blood lipids and their significance in the etiology of atherosclerosis is subject to con- siderable differences of opinion. The Central Committee for Medical and Community Pro- grams of the American Heart Association, through the Board of Directors, revised a recommendation made to them in 1957,1 and now considers that "reduction or control of fat consumption under medical supervision with reasonable substitution of polyunsatu- rated for saturated fats is recommended as a possible means of preventing atherosclerosis and decreasing the risk of heart attacks and strokes. " 2 The purpose of this article is to help implement the recommendation of the American Heart Association by providing the necessary practical dietetic information for the practising physician and cardiologist in the dietary control of serum cholesterol and other lipid fractions in those instances in which they consider dietary control "in- dicated. " Diets for the control of hypercholesteremia have been conveniently divided into two major types: the "Prudent Diet Pattern" and the "Therapeutic Vegetable Oil Diet Pattern." Prudent Diet Pattern The "Prudent Diet" pattern was devised by the senior author in 1956 and used experi- mentally on a few subjects. It was put into effect on a larger scale in 1957 when the Diet and Coronary Heart Disease Study Project of the Department of Health, City of New From the Bureau of Nutrition, Department of Health, New York, New York. f Deceased. Circulation, Volume XXIV, December 1961 York, was initiated.3 The "Prudent Diet' is one recommended for use to the general public and furnishes the family an adequate, well- balanced diet pattern for all normal adults and, with modification of the milk allotment, for children after infancy.4 5 This diet pat- tern is nutritionally adequate and meets the specific nutrient requirements of the Recom- mended Dietary Allowances of the Food and Nutrition Board of the National Research Council. It is palatable and consists of ac- ceptable American foods commonly available in every community. In addition, it is made up of foods listed in the normal diet pattern recommended by the U. S. Department of Agriculture in their Home Economics Re- search Report Number 3. In practice,3 we have found that this diet pattern furnishes approximately 30 per cent of its calories as fat, which for a caloric intake of about 2,300 (the maintenance level for the average normal weight urban man in his 50's) will supply about 75 Gm. of total fat. Of this total, about 20 Gm. are saturated fatty acids, 25 Gm. monounsaturated, and 30 Gm. polyunsatu- rated, yielding a polyunsaturated fatty acid/ saturated fatty acid ratio (the P/S ratio) of 1.5. Theoretically, if our subjects followed our prescription rigidly, this ratio would be about 1.8 to 2.0. For a 1,800 caloric diet (the maintenance level for the average nor- mal weight urban woman in her 50's) this diet will supply a total of about 60 Gm. of total fat, of which 16, 20, and 24 Gm. are saturated, monounsaturated, and polyunsat- urated, respectively. We have devised a prudent diet pattern 1415 by guest on May 21, 2018 http://circ.ahajournals.org/ Downloaded from by guest on May 21, 2018 http://circ.ahajournals.org/ Downloaded from by guest on May 21, 2018 http://circ.ahajournals.org/ Downloaded from
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SPECIAL ARTICLE
Dietary Control of Serum Cholesterol in Clinical PracticeBy NORMAN JOLLIFFE, M.D.,t ETHEL MASLANSKY, M.S., FLORENCE RUDENSEY,
R.N., B.S., MARTHA SIMON, M.S., AND ALICE FAULKNER, M.S.
THE RELATION of lipids in the diet toblood lipids and their significance in the
etiology of atherosclerosis is subject to con-siderable differences of opinion. The CentralCommittee for Medical and Community Pro-grams of the American Heart Association,through the Board of Directors, revised arecommendation made to them in 1957,1 andnow considers that "reduction or control offat consumption under medical supervisionwith reasonable substitution of polyunsatu-rated for saturated fats is recommended asa possible means of preventing atherosclerosisand decreasing the risk of heart attacks andstrokes. " 2 The purpose of this article is tohelp implement the recommendation of theAmerican Heart Association by providingthe necessary practical dietetic informationfor the practising physician and cardiologistin the dietary control of serum cholesteroland other lipid fractions in those instancesin which they consider dietary control "in-dicated. "
Diets for the control of hypercholesteremiahave been conveniently divided into two majortypes: the "Prudent Diet Pattern" and the"Therapeutic Vegetable Oil Diet Pattern."
Prudent Diet PatternThe "Prudent Diet" pattern was devised
by the senior author in 1956 and used experi-mentally on a few subjects. It was put intoeffect on a larger scale in 1957 when the Dietand Coronary Heart Disease Study Projectof the Department of Health, City of New
From the Bureau of Nutrition, Department ofHealth, New York, New York.
f Deceased.
Circulation, Volume XXIV, December 1961
York, was initiated.3 The "Prudent Diet' isone recommended for use to the general publicand furnishes the family an adequate, well-balanced diet pattern for all normal adultsand, with modification of the milk allotment,for children after infancy.4 5 This diet pat-tern is nutritionally adequate and meets thespecific nutrient requirements of the Recom-mended Dietary Allowances of the Food andNutrition Board of the National ResearchCouncil. It is palatable and consists of ac-ceptable American foods commonly availablein every community. In addition, it is madeup of foods listed in the normal diet patternrecommended by the U. S. Department ofAgriculture in their Home Economics Re-search Report Number 3. In practice,3 wehave found that this diet pattern furnishesapproximately 30 per cent of its calories asfat, which for a caloric intake of about 2,300(the maintenance level for the average normalweight urban man in his 50's) will supplyabout 75 Gm. of total fat. Of this total, about20 Gm. are saturated fatty acids, 25 Gm.monounsaturated, and 30 Gm. polyunsatu-rated, yielding a polyunsaturated fatty acid/saturated fatty acid ratio (the P/S ratio) of1.5. Theoretically, if our subjects followedour prescription rigidly, this ratio would beabout 1.8 to 2.0. For a 1,800 caloric diet(the maintenance level for the average nor-mal weight urban woman in her 50's) thisdiet will supply a total of about 60 Gm. oftotal fat, of which 16, 20, and 24 Gm. aresaturated, monounsaturated, and polyunsat-urated, respectively.We have devised a prudent diet pattern
for two types of individuals, (a) the "Pru-dent Diet" for those of normal weight with-out a weight problem and whose normalappetite can be depended upon to regulatetheir total caloric intake; (b) the "PrudentReducing Diet" for overweight subjects whomust be reduced and then maintained at thelower desirable weight. This diet requires thatthe quantity of food be prescribed in termsof common household measurements. At theend of weight reduction, it can be convertedto the prudent diet by the addition of 45Gm. of vegetable oils and, if desired, 10 Gm.of a linoleate-rich margarine* as well asbread, fruit, cereals, and vegetables inamounts needed to add sufficient calories tomaintain weight at the reduced desired level.The "Prudent Diet" pattern is practical
in that it can be followed indefinitely by themajority of motivated subjects. It has beeneffective in lowering the serum cholesterol inthe majority of our subjects: about 80 percent of those with control levels in the uppertertile (270 mg. per cent and over), 60 percent of those in the middle tertile (230 to269 mg. per cent), and 30 per cent of thosein the lowest tertile (under 230 mg. per cent).It is thus effective in lowering the serumcholesterol in about 60 per cent of people
*The senior author has proposed to the Food andDrug Administration that, in the interest of easyconsumer identification, a margarine, shortening, orother product composed chiefly of fats and oils beallowed to carry on their label the term " linoleate-rich" or some other appropriate term provided thatthe product contains over 25 per cent of cis-cislinoleic acid (or its biologic equivalent) and a P/Sratio of at least 1.25. Margarines meeting thesespecifications generally available at the present timeinclude (1) Emdee, made by Pitman-Moore Company,available in drug stores, at a recommended price of$1.00 per pound, (2) Mazola Margarine, made byCorn Products Company, available at grocery storesat a recommended price of 41c per pound, (3)Fleischman's Sweet (Unsalted) Margarine (wrappedin a green label), made by Standard Brands, Tinc.,available in the frozen-food section of grocery stores,and selling at a recommended price of 49c per pound.These same companies may make other brands ofmargarines that do not meet these requirements andare not recommended for the prudent diet.
with serum cholesterol levels above 230 mg.per cent. The effectiveness of this compositelowering of all subjects is shown in figure 1,which represents the course of the serumcholesterol of 97 men of normal weight aged50 to 59 years during the control period andat the end of 6 months on the diet.3 6 Thereis a fall in cholesterol from the control levelof 253 to 224 mg. per cent after 6 months(t = 5.16, significant beyond the 1-per centlevel). The figure further demonstrates thefall in cholesterol by tertiles. In the highestthird, 34 men dropped from 298 to 253 mg.per cent; in the middle third, 32 men droppedfrom 249 to 224 mg. per cent, while in thelowest third, 31 men dropped from 207 to 191mg. per cent after 6 months on the "PrudentDiet." The fall in each tertile is significantbeyond the 1-per cent level. Those patientswith positive diagnoses of coronary arterydisease responded like those with no coronaryartery disease but with similar control cho-lesterol levels.The number of subjects have now been
extended to about 300 men7 and the periodof observation has been extended up to 3years, with the serum cholesterol levels show-ing no tendency to rise with time with mostsubjects except when the subject, either de-liberately or carelessly, broke the diet. It issurprising how many subjects, after a fallin serum cholesterol as a result of the "Pru-dent Diet," deliberately break the diet to seeif a rise in cholesterol results. It does.The instructions for the "Prudent Diet
Pattern" designed for people of normalweight without a weight control problem fol-low:
1. Consume adequate amounts of high-gradeprotein foods at each meal. The sources forthese include cottage cheese (preferablyskim-milk cottage cheese), fat-free milk,chicken, turkey, veal, leaner cuts of beef,mutton, lamb, pork, fish, seafood, and eggwhites. All visible fat should be removed fromthe meats and poultry.Remember, there are 21 meals each week.
canned fish or seafood in at least five mealseach week. Lunch is a good time for this.Do not be limited to the leaner fish but in-clude fat fish as well, as they are good sourcesof polyunsaturated fatty acids. Bake, roast,broil, or boil meats and poultry. Fish, veal,and chicken may be fried in a vegetable oilrich in polyunsaturated fatty acids (corn,cottonseed, safflower, soybean, sunflower). Useveal or poultry in four meals each week oroftener. Use 3-oz. servings for women, 4-oz.servings for men, of beef, lamb, mutton, andpork-a combined total of not more than 12oz. for women and 16 oz. for men each week.For the other eight meals each week use cot-tage cheese or egg whites, an occasional serv-ing of liver, or additional servings of fish,seafood, or poultry. Unless otherwise in-structed, you may use up to four whole eggseach week. You may also use whole milk forcoffee but otherwise restrict the use of milkto non-fat varieties, such as fresh or recon-stituted skim milk, fat-free buttermilk, orevaporated skim milk. When instructed, youmay emulsify a vegetable oil rich in poly-unsaturated fatty acids with your skim milkby use of a high-speed electric mixer.8
2. A total of 11/2 oz. (45 ml.) of vegetableoil rich in polyunsaturated fatty acids shouldbe consumed daily. Most patients prefer touse about 1/2 oz. in food preparation and con-sume a minimum of 1 oz. of the oil at thetable each day. This may be used in saladdressings and on vegetables, emulsified inmilk, or added to cereals or soups. In addi-tion, you may use a 10-Gm. pat of a recom-mended margarine rich in liquid vegetable oildaily as a table spread. When a solid fat ispreferred in cooking or baking, use a recom-mended margarine rich in liquid vegetableoil, preferably one with a P/S ratio of 1.5or higher. Never use the conventional par-tially hydrogenated types of margarines,cooking fats, or butter. Do not reuse and donot heat it to the smoking point.
3. Do not eat the following: butter, cream,whole milk, and ice cream; conventional par-tially hydrogenated margarine, shortening,Circulation, Volume XXIV, December 1961
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Figure 1of normal weight, 50 to 59 yearsdiet to 6 months. Total and
and lard; foods containing these in largeamounts, such as most cakes and pastries. Inplace of butter and ordinary or partially hy-drogenated margarine, use a recommendedmargarine rich in liquid vegetable oil; inplace of shortening, use either a vegetable oilrich in polyunsaturated fatty acids or a rec-ommended margarine or shortening rich inliquid vegetable oil*; in place of cream usean emulsion of a vegetable oil rich in poly-unsaturated fatty acids.
4. Balance the diet by consuming adequateamounts of vegetables, fruits, nuts, bread,and cereals.More than 4 years' experience with more
than 600 men and their wives shows the fol-lowing to be the most common difficulties en-countered by our subjects in adhering to the"Prudent Diet": 1. Giving up pastries witha high content of saturated fat, such as Dan-ish pastry, coffee cake, pound cake, "plain"cake, cookies, and pies. This prohibition is areal deprivation for many people and causesthe most frequent difficulty. These productsneed not be prohibited for the person whosewife is willing to make them with vegetable
*Solid shortenings rich in liquid vegetable oil arenot, at this writing, available for use by the generalpublic.
oil or a recommended margarine or shortening-one containing a P/S ratio of about 1.5 orhigher. These shortenings, in the form of aliquid vegetable oil containing an emulsifier,are on the market and available to the com-mercial baker, and produce in many instancespastry products with eating qualities similarto those made with conventional solid short-enings. At this time, the Food and DrugAdministration has not permitted industryclearly to identify these products for the con-sumer.
If the government regulatory agencieswould permit factual labeling of this improvedtype of product by the distributors, the com-mercial bakers, in cooperation with the man-ufacturers of shortening, could make this typeof baked goods readily available and identi-fiable at the point of sale. This might be asvaluable to the public health as the bakers'contribution in cooperating with the bread-enrichment program. Recipes for the use ofvegetable oils in cooking and baking have beendeveloped by the major vegetable oil com-panies and may be obtained gratis from them.Since most modern housewives, however, donot or will not do their own pastry baking,persons following this diet are limited to an-gel food cake, sponge cake, Holland honeycake, almond macaroons, and the few otherlow-fat baked goods that are commerciallyavailable. 2. Limiting the size of portion andthe frequency of serving of all flesh prod-ucts, especially beef, mutton, and pork, whichcontain the greatest amount of saturated fats.Many men in our affluent society have becomeaccustomed to consuming 8-, 10-, and 12-ounceportions of these products. In a balanced diet,containing adequate calories, no normal per-son needs servings of animal flesh greater than3 or 4 ounces daily, especially when skim milkand cottage cheese are also included. 3. Pro-hibition of ice cream is a deprivation for manypersons, although this ranks well below thefirst two complaints listed. Here, water icesand sherbets are the best substitutes in statesprohibiting imitation ice cream. In thosestates where this product is legal, frozen des-serts imitating ice cream in appearance, taste,
and consistency can be made with liquid vege-table oils in place of butter fat. This latterproduct is permitted in the prudent diet ofthe persons without a weight problem. 4. Res-taurant meals may present difficulty for somepeople but this difficulty is more apparentthan real. In restaurants where the food isprepared to order, no problem exists. In res-taurants and cafeterias, where the food isprepared on a large scale, the entree chosenshould be fish, seafood, or poultry, whichshould be boiled, broiled, or baked. The des-sert should be limited to fruit. 5. Prohibitionof hard cheeses of all varieties is a minor dif-ficulty for a few people. For those who musthave hard cheese occasionally, one ounce maybe substituted for 2 ounces of the beef, mut-ton, or pork allowance. 6. The prohibition ofbutter, cream, and whole milk has presentedno difficulties. Butter is one of the easiestfoods to replace in the dietary, since so manysubstitutes are available, e.g., the recom-mended margarines, mayonnaise, and cottagecheese spreads moistened with skim milk orskim milk filled with vegetable oil. For theoccasional subject with a peptic ulcer, emul-sifying the vegetable oil in skim milk is satis-factory.
The Prudent Reducing Diet (for PersonsWho Are Overweight)
People who are overweight due to excess fator those who have been overweight and areattempting to maintain their lowered weightmust, as a rule, be given diets in which theamount of food is detailed in standard por-tions. For these people, we have devised a"Prudent Reducing Diet" and a "PrudentMaintenance Diet." The "Prudent ReducingDiet" is, in general, the "Prudent Diet" pat-tern without the vegetable oils and recom-mended margarines permitted those personswithout a weight problem. This gives a P/Sratio of about 0.75.To this basic pattern sufficient bread, ce-
reals, fruit, and vegetables are added to makeup the desired caloric level, usually about1,600 for men and 1,200 for women. Whenweight reduction is completed, the vegetableoil and recommended margarine allotments
are added and the amount of bread, cereals,fruits, and vegetables are adjusted so that the"Prudent Reducing Diet" is now convertedto the "Prudent Maintenance Diet."The effects of these reducing diet patterns
on serum cholesterol levels have been de-scribed.9' 10 Of a starting group of 211 men,50 to 59 years old, 111 (52.6 per cent) ad-hered so rigidly to the prescribed reducingdiet as to achieve a Performance Index"' of85 or better during the first 10 weeks of ob-servation. Their average control serum cho-lesterol dropped from 261 to 225 mg. per centby the end of 6 weeks (fig. 2) and remainedlevel thereafter (t = 6.78, highly significant).Of the 111 men, 97 reduced to desirable lev-els, 75 of these have been maintained on the"Prudent Maintenance Diet" for at least 6months, and 56 of these maintained for atleast 1 year with the average serum cholesterolremaining level.
Therefore, with respect to effect on serumcholesterol, strict adherence to the "PrudentReducing Diet" yields results similar to thoseobtained by the use of the "Prudent Diet"with normal weight men. Further, mainte-nance of weight after successful weight reduc-tion by use of the "Prudent MaintenanceDiet" serves to maintain the lowered serumcholesterol level and prevents the rebound ex-perienced by the more usual type of reducingand maintenance diets.10When the subjects are divided into tertiles,
the results are similar to those obtained by useof the "Prudent Diet" among men of normalweight. In the highest third, the average of307 mg. per cent fell to 254 mg. per cent; 251mg. per cent in the middle third fell to 222mg. per cent; 207 mg. per cent in the lowestthird fell to 198 mg. per cent. The lower limitreached by each tertile corresponds veryclosely to its counterpart in the men of normalweight. The major point of difference lies inthe time necessary to achieve the low value-6 weeks on the reducing diet as compared to5 to 6 months on the prudent diet.
Therapeutic Diet PatternA "Therapeutic or Vegetable Oil Diet"
pattern becomes important whenever theCirculation, Volume XXIV, December 1961
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Figure 2One-hundred eleven obese men, 50 to 59 years old,on prudent reducing diet to 10 weeks. Total andtertiles.
"Prudent Diet" pattern fails to lower theserum cholesterol and other serum lipid frac-tions to desirable levels.
It is advisable to start immediately on the"Therapeutic Vegetable Oil Diet" pattern ifthe subject has essential hypercholesteremiaor exhibits xanthelasma, xanthoma tendino-sum, or a serum cholesterol level above 400mg. per cent.The "Therapeutic Vegetable Oil Diet" pat-
terns devised by Kinsell et al.,'2 Brown andPage,'3 and Ahrens et al.'4 are all based uponthe common principle of reducing to the bar-est minimum the amount of saturated fattyacids derived from ruminant animal flesh,dairy products, egg yolks, and all types ofhydrogenated margarines and shortenings. Inaddition, 2 to 4 ounces (60 to 120 Gm.) of avegetable oil rich in polyunsaturated fattyacids, such as corn, cottonseed, safflower, soy-bean, and sunflower, are added daily. Proteinsources are primarily non-fat milk, skim-milkcottage cheese, selected nuts, egg whites, fish,and seafood. The more liberal of these dietsmay contain small amounts of chicken or tur-key, while the ruminant animal meats arelimited to such special occasions as Christmasand anniversaries. Unlike the "Prudent Diet "pattern, these diets, in our opinion, are dras-
tic and should be used only under medicalsupervision. A polyvitamin capsule containingsupplementary amounts of all the essentialvitamins and iron should be routinely em-ployed, since the "Therapeutic Diet" pattern,like many other diets where more than 25 percent of the calories are derived from one food,is likely to be low in an essential micronu-trient.
Tables that list the fatty acid compositionof common dietary fats in terms of saturatedfatty acids, monounsaturated fatty acids, andpolyunsaturated fatty acids per 100 Gm. havebeen published15 and are useful for physiciansor clinics who wish to offer a wide menu range.It is usually preferred, in those subjects inwhom a "Therapeutic Diet" pattern is indi-cated, to start with the high ratios and liber-alize to lower ones as clinical and laboratoryprogress occurs.
Ordinarily, for different calorie levels, donot change the basic diet pattern, but makethe changes only in the amounts of bread,cereals, vegetables, and fruits. To insure suf-ficient amounts of vegetable oil, it is even moreimportant than in the "Prudent Diet " toincorporate the oil in cooking, in saladdressings, emulsified in skim milk, and addedto vegetables and cereals.*In the high ratio diets, the use of walnuts
is very important, as this food supplies largeamounts of polyunsaturated fatty acids, chieflylinoleic, and provides a P/S ratio of 8.75. Thelimited supply of this food, however, has madeus restrict its routine use to diets with P/Sratios of 2.5 to 3.0 or higher. For example,the daily inclusion of 2 ounces of walnuts inour 2.5 to 3.0 diet, with a cut of about 400calories in bread, fruits, and vegetables issufficient to raise the P/S ratio to about 3.0to 3.5. The measured amount of walnuts, whenused, can be used at the table, combined insalads, or on protein dishes, or used as snacks.Menu plans for the "Therapeutic Vegetable
*Recipes using vegetable oils in cooking may beobtained from the New York City Department ofHealth. Most of these recipes may be found inAppendix D of the second edition of "Clinical Nu-trition.''l
Oil Diet" pattern at 2.5 to 3.0 and 4.0 to 5.0P/S ratio, each at two calorie levels are avail-able in recipes given by the New York CityDepartment of Health.
Low-Fat DietsLow-fat diets are occasionally indicated
rather than the "Prudent" or "Therapeutic"patterns. The chief indication for the use oflow-fat diets to control serum lipid levels arefound among a few hyperglyceridemic-hyper-cholesteremic patients as defined by Brownand Page.16 These investigators report thattwo of nine such patients responded by anincrease in serum triglyceride and cholesterollevels when placed on their vegetable oil dietpattern. The determination of serum trigly-cerides, however, is difficult and is not avail-able in most hospitals or clinical laboratories.We recommend, in the absence of such facili-ties, that this type of diet be used in the rela-tively rare instances when the "Prudent" or" Therapeutic " type of diet elevates the serumcholesterol.A qualitative low-fat diet that will meet
most purposes can be adapted from the "Pru-dent Maintenance Diet " pattern by thesimple omission of the vegetable oil and rec-ommended margarine and the isocaloric sub-stitution of fruits, vegetables, bread, andcereals. The low-fat diets so constructed willyield 10 to 12 per cent of total calories as fat.At the 2,300-calorie level, it will provide 20to 30 Gm. of fat and 15 Gm. at the 1,800-calorie level, each with a P/S ratio of about0.75.Another method is to use the low-fat menus
provided by Keys and Keys.17
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3. JOLLIFFE, N., RINZLER, S., AND ARcHaE, M.: TheAnti-Coronary Club; -micluding a discussion ofthe effects of a prudent diet on the serum
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F)
We have seen that there is no absolute truth apart from mathematical principles;in all natural phenomena the principles from which we start, like the conclusions whichwe reach, embody only relative truths. The experimenter's stumbling block, then, con-sists in thinking that he knows what he does not know, and in taking for absolute, truthsthat are only relative. Hence, the unique and fundamental rule of scientific investigationis reduced to doubt, as great philosophers, moreover, have already proclaimed.-CLAUDEBERNARD. An Introduction to the Study of Experimental Medicine. New York, TheMaeMillan Company, 1927, p. 49.
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ErratumIn the article by Jolliffe et al., December 1961
issue, the graphs for figures 1 aind 2 on pages 1417and 1419 are interchanged. The legends for thesefigures are correct as labeled.
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