Plant-based diet for treating heart disease

Coronary artery before and after plant-based diet (C. Esselstyn 2001)

Coronary artery before (left) and after (right) plant-based diet (Esselstyn CB Jr: Preventive Cardiology 2001;4: 171-177)

Few people realise that a plant-based diet not only prevents heart disease but can also reverse it. Choosing whole grains, fruits and vegetables and avoiding simple sugars, and saturated and trans fats, as in meat and dairy products, has been shown to result in regression of coronary atherosclerosis after 1 and 5 years in some studies (1) (2) and to continue for over 12 years in other studies (3).

In contrast, standard medical interventions for cardiac patients, such as coronary artery bypass, bypass grafts, atherectomy, angioplasty or stenting, treat only the symptoms, not the disease.  It is therefore not surprising that patients who receive these interventions alone often experience progressive disease, graft shutdown, restenosis, more procedures, progressive disability, and ultimately death from disease (4).

Caldwell Esselstyn MD persuaded 18 cardiac patients to continue with a plant-based diet for over 12 years. Adherent patients experienced no extension of clinical disease, no coronary events, and no interventions. This finding is all the more compelling when we consider that the original compliant 18 participants experienced 49 coronary events in the 8 years before the study (4).

Some patients believe that there is no need to change their diet if they have had heart surgery, stents inserted and/or are taking drugs like statins and aspirin.

A recently published international study (5) indicated that individuals (more than 31,000 men and women of an average age of 66 in this study) who chose whole grains, fruits, vegetables, nuts, and fish over meat, eggs and refined carbohydrates had a 35% reduction in cardiac death rates over 5 years. That’s a 35% reduction in addition to the decrease from surgery and optimal medical management. And these men and women were older, where you’d expect diet to be able to reverse less.

So it is never too late to make simple changes to your diet and lifestyle to improve your long-term health, whether you have medically-managed heart disease or not.

If you have heart disease, you can eat a wonderful variety of delicious, nutrient-dense foods:

  • All vegetables except avocado. Leafy green vegetables, root vegetables, vegetables that are red, green, purple, orange, and yellow – every colour of the rainbow
  • All legumes—beans, peas, and lentils of all varieties.
  • All whole grains and products, bread and pasta, that are made from them—as long as they do not contain added fats.
  • All fruits

You need to avoid:

  • Red meat, poultry and fish
  • Dairy products
  • Oils of all kinds (even olive oil)

 

For recipe ideas, tips and information about following a plant-based diet please sign up for my free newsletter and check out my website.

You can also find me on Facebook, Twitter and LinkedIn.

 

References

(1) Ornish, D. et al (1998). Intensive lifestyle changes for reversal of coronary heart disease. JAMA, Vol 280, No. 23, 2001-2007

(2) Ornish, D. et al (1990). Can lifestyle changes reverse coronary heart disease?  The Lancet, 21 July 1990, Vol 336, No. 8708, 129-133

(3) Esselstyn, C. (2001).  Resolving the coronary artery disease epidemic through plant-based nutrition.  Preventive Cardiology, 4, 171-177

(4) Esselstyn, C.  Updating a 12-Year Experience With Arrest and Reversal Therapy for Coronary Heart Disease (An Overdue Requiem for Palliative Cardiology).  Article on Caldwell Esselstyn’s website.

(5) Dehghan, M. et al. Relationship Between Healthy Diet and Risk of Cardiovascular Disease Among Patients on Drug Therapies for Secondary Prevention: A Prospective Cohort Study of 31 546 High-Risk Individuals From 40 Countries. Circulation, 4 December 2012, 126: 2705-2712

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Towards a new paradigm for public health

Food-Vegetables-01In 1990, physician and health economist Christopher Murray at Harvard University and medical demographer Alan Lopez at the World Health Organisation embarked on the first ever attempt to measure the global burden of disease and developed the now-famous Disability Adjusted Life Year (DALY) metric that made it possible to combine estimates of mortality and morbidity burden around the world. DALY is the sum of years lived with disability [YLD] and years of life lost [YLL].

Since then, there have been estimates in 1999 to 2002 and 2004. But the latest iteration of the project, Global Burden of Disease 2010, has been on a different scale, involving nearly 500 researchers from more than 300 institutions in 50 countries. It is the largest ever systematic effort to describe the global distribution and causes of a wide array of major diseases, injuries, and health risk factors.

Twenty years ago, the project assessed the burden of 107 diseases and injuries and ten selected risk factors for the world and eight major regions over one calendar year. Now, thanks to advances in technology, the availability of data, and the participation of experts around the world, as well as the leadership of a core group of researchers, the scope has increased to 291 diseases and injuries in 21 regions, for 20 age groups, and an estimation of trends from 1990 to 2010. Global Burden of Disease 2010 also includes an assessment of 67 risk factors.

The results, published yesterday in seven articles in The Lancet, are set to shake up health priorities across the world.

In summary, the analysis shows that infectious diseases, maternal and child illness, and malnutrition now cause fewer deaths and less illness than they did twenty years ago. As a result, fewer children are dying every year, but more young and middle-aged adults are dying and suffering from disease and injury, as non-communicable diseases, such as cancer and heart disease, become the dominant causes of death and disability worldwide. Since 1970, men and women worldwide have gained slightly more than ten years of life expectancy overall, but they spend more years living with injury and illness.

There were 52.8 million deaths in 2010 compared with 46.5 million deaths in 1990. Of these, 12.9 million were from ischaemic heart disease and stroke, or one in four deaths worldwide, compared with one in five in 1990. Cancer claimed 8 million lives in 2010 compared with 5.8 million in 1990; trachea, bronchus and lung cancer accounted for 20% of these. Twice as many people died of diabetes in 2010 – 1.3. million – than in 1990, which is higher than deaths from tuberculosis or malaria (1.2 million each). Deaths from HIV/AIDS increased from 0.30 million in 1990 to 1.5 million in 2010, reaching a peak of 1.7 million in 2006. The fraction of global deaths due to injuries (5.1 million deaths) was marginally higher in 2010 (9.6%) compared with two decades earlier (8.8%). This was driven by a 46% rise in deaths worldwide due to road traffic accidents (1.3 million in 2010) and a rise in deaths from falls.

The contributions of risk factors to regional and global burden of diseases and injuries has shifted substantially between 1990 and 2010, from risk factors that mainly cause communicable diseases in children to risk factors that mainly cause non-communicable diseases in adults.

The proportion of overall disease burden attributable to childhood underweight – the leading risk factor worldwide in 1990 – had more than halved by 2010, making childhood underweight the eighth risk worldwide, behind six behavioural and physiological risks, and household air pollution from solid fuels. Other risks for child mortality, such as non-exclusive and discontinued breastfeeding, micronutrient deficiencies, and unimproved water and sanitation, have also fallen. However, child and maternal undernutrition risks collectively still account for almost 7% of disease burden in 2010, with unimproved water and sanitation accounting for almost 1%.

Of the non-communicable disease risks, high blood pressure, high body-mass index, high fasting plasma glucose, alcohol use, and dietary risks have increased in relative importance. This overall shift has arisen from a combination of the ageing population, substantial achievements in lowering mortality of children aged younger than 5 years, and changes in risk factor exposure.

These broad global patterns mask enormous regional variation in risks to health. In sub-Saharan Africa, risks such as childhood underweight, household air pollution from solid fuels, and suboptimal breastfeeding continue to cause a disproportionate amount of health burden, despite decreasing. The shift to risk factors for non-communicable disease was clear in east Asia, North Africa and Middle East, and Latin America.

For people aged 15 to 49 years, the leading risk factor worldwide was alcohol use, followed by tobacco smoking including second-hand smoke, high blood pressure, high body-mass index, diet low in fruits, drug use, and occupational risk factors for injuries. Risk factor rankings in this age group stayed broadly similar between 1990, and 2010, with the exception of iron deficiency, which dropped from the fourth leading risk factor in 1990, to ninth in 2010.

High blood pressure, tobacco smoking including second-hand smoke, alcohol use, and diet low in fruits were all in the top five risk factors for adults aged 50 to 69 years and adults older than 70 years, in both 1990, and 2010, accounting for a large proportion of disease burden in both age groups. Globally, high blood pressure accounted for more than 20% of all health loss in adults aged 70 years and older in 2010, and around 15% in those aged 50 to 69 years. Tobacco smoking including second-hand smoke accounted for more than 10% of global disease burden in each of these age groups in 2010.

Globally, the sum of years lived with disability and years of life lost (DALY), was influenced most by dietary risk factors and physical inactivity – together these were responsible for 10% of the global disease burden in 2010.

Of the individual dietary risk factors, the largest attributable burden in 2010 was associated with diets low in fruits (4.9 million deaths), followed by diets high in sodium (4.0 million deaths), low in nuts and seeds (2.5 million deaths), low in whole grains (1.7 million), low in vegetables (1.8 million deaths), and low in seafood omega-3 fatty acids (1.4 million deaths). Physical inactivity and low physical activity accounted for 3.2 million deaths.

This impressive analysis of global health issues by Christopher Murray and colleagues provides much reason for hope but also challenges the current medical paradigm and global healthcare system.

It shows clearly that the focus of global health authorities in recent decades on reducing infection and malnutrition has paid off – life expectancy has increased almost everywhere. This focus needs to continue to minimise incidence of diseases like tuberculosis, malaria and HIV/AIDs.

It also reveals, however, that the leading causes of death in the modern developed world are conditions which cannot be controlled by vaccinations, antibiotics, improved sanitation or insecticides. The data provide evidence that the risk factors for non-communicable diseases like heart disease, cancer and diabetes, are predominantly related to poor diet and lifestyle.

The large attributable burden for dietary risk factors such as diets low in fruits, vegetables, whole grains, nuts and seeds, and seafood omega-3 fatty acids might come as a surprise to some. The large burden is caused by both high exposure, e.g., low intake of fruits and vegetables in many regions – and large effect sizes.

Given the crucial role of dietary and lifestyle factors in determining long-term health, the answer to alleviating the suffering created by these chronic non-communicable diseases does not lie in the current medical model, with its preoccupation with drugs and surgery. Our doctors are trained to relieve symptoms not to address the underlying causes of chronic disease. Powerful commercial interests in the food, pharmaceutical and health sectors drown out the voices of those who can see that the solution is really very simple.

Widespread consumption of plant-based diets, rich in vegetables, fruit, whole grains, beans, nuts and seeds, together with not smoking and more physical activity, would transform people’s lives and radically reduce healthcare costs. It is not rocket science.

Dr Murray, I salute you and your colleagues for a first rate piece of work. May the truths you have exposed become part of mainstream understanding as quickly as possible and lead to a sea change in our approach to health and well-being.

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References

Murray et al (2012). Global Burden of Disease 2010. The Lancet, 13 December 2012.

Alzheimer’s Disease, metabolic disorders and the role of diet

Accumulating evidence for the role of metabolic disorders such as insulin resistance, diabetes, obesity and hypertension in increasing the risk of Alzheimer’s disease and vascular dementia, is reviewed in a new paper published this month in the Archives of Neurology.

alzheimersbrain

In the same journal, compelling evidence is presented that higher pre-diagnosis total cholesterol, low-density lipoprotein cholesterol, and diabetes are associated with faster cognitive decline in patients with incident Alzheimer’s disease.

A cohort of 156 patients with incident Alzheimer’s Disease (mean age 83 years) were followed for up to 10 years.  Changes in a composite score of cognitive ability were monitored from diagnosis onwards.

“These findings indicate that controlling vascular conditions may be one way to delay the course of Alzheimer’s, which would be a major development in the treatment of this devastating disease as currently there are few treatments available to slow its progression,”

said Yaakov Stern, Ph.D., a professor at the Taub Institute for the Research on Alzheimer’s Disease and the Aging Brain and director of the Cognitive Neuroscience Division of the Gertrude H. Sergievsky Center at Columbia University Medical Center, and senior author of the paper.

“Preventing heart disease, stroke and diabetes – or making sure these conditions are well managed in patients diagnosed with them – can potentially slow the disease progression of Alzheimer’s,” said Dr. Stern.

Diets high in fruit, vegetables, fibre and unsaturated fats, and low in sugar, salt and saturated fat are known to reduce the risk of a range of chronic conditions, such as diabetes, heart disease and stroke.  This means eating more plant-based foods and less processed and animal-based foods.

wholegrainsandveg

Stabilising blood sugar is crucial.  This may be done by eating a diet with a low glycaemic load, that is, one that includes moderate quantities of complex carbohydrates which release glucose slowly into the bloodstream.  Whole grains, such as whole-wheat bread, brown rice, quinoa, millet and buckwheat are valuable for helping to ensure smooth regulation of blood sugar.  In contrast, highly refined carbohydrates, such as white bread, white rice, white pasta and table sugar, create a roller-coaster of blood sugar highs and lows, which if left unchecked, can ultimately give rise to insulin resistance and eventually to diabetes.  Potatoes release sugar into the bloodstream almost as fast as table sugar and thus should be eaten sparingly, unless you are lean and exercise regularly.  Consuming protein with carbohydrates at every meal has also been found to help regulation of blood sugar.

Increasing the quantity of vegetables and fruit in the diet is also vital.  Blood sugar levels are easier to maintain if vegetables are emphasized more than fruit, as some fruit contains a lot of sugar.  A minimum of 5 portions of fruit and vegetables per day is recommended.  For easy tips for increasing the amount of fruit and vegetables in your diet please click here.

Unsaturated fats found in plant oils, such as olive oil and the oils of nuts and seeds, and in oily fish, are beneficial for preventing heart disease and other vascular health conditions.  For practical suggestions for ways to incorporate more healthy unsaturated fats in your diet please click here.

For information and practical tuition in how to put all these recommendations together to create fabulous food that protects you from diabetes, heart disease and Alzheimer’s Disease, please come to a Cooking for Health course, run by nutrition expert, Dr Jane Philpott.

Over-eating when eating out

Recently, I gave the menu of a well-known chain restaurant to a group of students and asked them to select what they would eat if they were dining there. 

 

They selected a starter (garlic bread with cheese), a main course (traditional lasagne with a salad), a dessert (ice cream) and a drink (a can of coke). 

 

Using the restaurant’s own nutritional information, they calculated the nutrient content of what they had chosen (Table 1).  The results left the students open-mouthed.

 

Their menu selection had provided:

 

n 106% of the guideline daily amount of calories (assuming 2000 kcal per day);

n 141-171% of the guideline daily amount of protein (depending on whether they were male or female);

n 61% of the guideline daily carbohydrate;

n 109% of the guideline daily amount of total fat;

n 192% of the guideline daily amount of saturated fat

n 52% of the guideline daily amount of salt. 

 

It is worth noting that the dietary reference value for salt in the UK is 6 g per day, compared with 2.3 g per day in the USA.

 

Thus, one meal out would have provided more than the entire day’s requirement for calories; enough protein to last for one and a half days; and enough saturated fat to last for two days.

 

Most people have no idea of the nutrient content of the food they are eating, nor of the potentially damaging effects on their health of a dietary excess of sugar, saturated fat and salt. 

 

Given that at least one–third of household expenditure on food and drink is spent on food eaten outside the home in the UK, food manufacturers and caterers have a real opportunity to contribute to an improvement in public health whilst also making a profit themselves. 

 

There is now convincing research evidence to suggest that increasing the amount of fruit, vegetables and whole grains in the diet, whilst decreasing the amount of sugar, saturated fat and salt, helps to protect the body from chronic conditions such as obesity, type 2 diabetes, heart disease and various cancers.

 

A two-day professional training course is offered, tailored to equip caterers, and those involved in encouraging healthier catering practices, with information and practical tools to achieve healthier eating in the population.

 

By the end of the course, participants will:

  • Understand the basic principles of nutrition
  • Be aware of the importance of food in the maintenance of health and well-being
  • Appreciate the role of lifestyles and culture in influencing diet
  • Recognise the potential benefits for both caterers and customers of providing a choice of healthier options
  • Know more about ingredient selection and methods of food production and processing that can be used to create healthier options, whilst being attractive and convenient to modern tastes and lifestyles
  • Be able to apply appropriate and relevant skills and knowledge when advising catering businesses or when planning, preparing, promoting and serving healthier foods

For further information on the course content and the course tutor, Dr Jane Philpott, please click http://cookingforhealth-uk.com/healthier-catering.php.

 

 

Table 1

Menu item

Calories per portion

Protein g per portion

Carbohydrate g per portion

Total fat g per portion

Saturated fat g per portion

Salt g per portion

 

Starter

 

568

 

29.8

 

35.6

 

34

 

16.5

 

1.15

 

Main course

 

934

 

 

42.2

 

74.4

 

33.1

 

14.6

 

1.84

 

Dessert

 

 

475

 

5.5

 

18.8

 

18.1

 

11.1

 

0.15

 

Drink

 

 

139

 

0

 

35

 

0

 

0

 

0

 

 

 

 

 

 

 

 

Total

 

 

2116

 

77.5

 

163.8

 

85.2

 

42.2

 

3.14

 

Gov guideline

 

 

2000 kcal

 

45 g/day (women)

55 g/day (men)

 

267 g per day

 

78 g per day

 

22 g per day

 

6 g per day

 

% of guidelines

 

 

106%

 

171% (women)

141% (men)

 

 

61%

 

109%

 

192%

 

52%

 

 

 

Recipe for quinoa, apricot and walnut porridge

Quinoa (pronounced KEEN-wah) is a species of the broad-leaf goosefoot family (Chenopodium quinoa) grown as a crop primarily for its edible seeds. It is not a grass. Its leaves are also eaten as a leafy vegetable, much like amaranth, but the commercial availability of quinoa greens is currently limited.Quinoa originated in the Andean region of South America, where it has been an important food for 6,000 years. The Incas, who held the crop to be sacred, referred to quinoa as “chisaya mama” or “mother of all grains”, and it was the Inca emperor who would traditionally sow the first seeds of the season using ‘golden implements’.

quinoa-crop

Quinoa has come to be highly appreciated for its nutritional value, as its protein content is very high (14 to 20 per cent). Unlike wheat or rice (which are low in lysine), quinoa contains a balanced set of essential amino acids for humans, making it an unusually complete food.  It is a good source of dietary fibre and phosphorus and is high in copper, magnesium and iron. Quinoa is gluten free and considered easy to digest. In its natural state quinoa has a coating of bitter-tasting saponins, making it unpalatable. Most quinoa sold commercially in North America and Europe has been processed to remove this coating.

Quinoa is as versatile as rice, cooks rapidly (10 to 15 minutes) and can be used in creamy porridges, soups, salads, stir-fries and stews.

RECIPE

Quinoa, apricot and walnut porridge

Serves 1

Ingredients

50g quinoa
200ml rice milk
4 organic dried apricots (chopped)
15g walnuts (chopped)

Method

Wash the quinoa thoroughly and place in pan. Add rice milk and chopped apricots and simmer gently for 20 to 30 minutes, until the quinoa is soft. Mix in the chopped walnuts and serve.

For more recipes ideas, information about diet and health, and practical tuition in cooking with whole foods, come along to a Cooking for Health course on Cooking with Whole Foods, in Somerset, UK, with nutrition consultant and cookery teacher Dr Jane Philpott.

Blood pressure of people with metabolic syndrome is more sensitive to salt intake

A study of 1900 Chinese people has revealed that the blood pressure of people with metabolic syndrome is more sensitive to salt intake.  Thus reduction of salt intake could be an especially important component in reducing blood pressure in patients with multiple risk factors for metabolic syndrome.  These are the conclusions of authors of an article published Online First in a forthcoming edition of The Lancet, written by Dr Jing Chen, Tulane University School of Medicine, New Orleans, LA, USA.    

salt_shaker

Metabolic syndrome is a combination of medical disorders that increase the risk of developing diabetes and cardiovascular disease.  It affects 1 in 5 people and prevalence increases with age.  Symptoms and features are:

  • Fasting hyperglycemia — diabetes mellitus type 2 or impaired fasting glucose, impaired glucose tolerance, or insulin resistance;
  • High blood pressure;
  • Central obesity (also known as visceral, male-pattern or apple-shaped adiposity), overweight with fat deposits mainly around the waist;
  • Decreased HDL cholesterol;
  • Elevated triglycerides

metabolic-syndrome

The study analysed 1906 Chinese participants without diabetes, aged 16 or more, who were selected to receive a low-sodium diet for 7 days followed by a high-sodium diet (six-fold higher than the low-sodium phase) for an additional 7 days.  Participants were excluded from the analysis if metabolic risk factor information was missing or if they did not complete their dietary interventions.  Blood pressure was measured at baseline and on days 2,5,6 and 7 of each intervention.  Metabolic syndrome was defined as the presence of  three of more of: abdominal obesity, raised blood pressure, high triglyceride concentration, low HDL cholesterol, or high glucose.  High salt sensitivity was defined as a decrease in mean arterial blood pressure of more than 5 mm Hg during low-sodium or an increase of more than 5 mm Hg during high-sodium intervention.

The researchers found that 283 of 1881 patients with complete data had metabolic syndrome.  In both the high-sodium and low-sodium phase, the blood pressure of patients with metabolic syndrome was more sensitive to changes in salt intake.  Compared with those with no risk factors, participants with four or five risk factors had a three-and-a-half times higher risk of salt sensitivity during the low-sodium phase and a three-fold higher risk of high salt sensitivity during the high-sodium phase.

The authors conclude that “the results suggest that the metabolic syndrome enhances blood pressure response to sodium intake.  Reduction in sodium intake could be an especially important component in reducing blood pressure in patients with multiple risk factors for metabolic syndrome.”

Epidemiological evidence suggests a lower prevalence of the metabolic syndrome is associated with dietary patterns rich in whole grains, fruit, vegetables and unsaturated fats.  For information and practical tuition in preparing such food, why not come along to a Cooking for Health course, which are held  throughout the year in Somerset, UK. 

 

 

 

 

 

 

 

Mediterranean diet may help prevent prostate cancer

Recently reviewed evidence relating diet and prostate cancer suggests that a traditional Cretan Mediterranean style diet based on a variety of plant foods (fruits, vegetables, wholegrain cereals, nuts and legumes), olive oil as the main source of fat, moderate to low intake of dairy foods, moderate to high intake of fish and moderate intake of wine, mostly with meals, may be helpful in reducing prostate cancer risk.

mediterranean_food

A recent meta-analysis of prospective cohort studies using a score to assess adherence to a Mediterranean diet found that stronger adherence was associated with reduced all cause, cardiovascular and cancer mortality, as well as decreased incidence of Parkinson’s and Alzheimer’s diseases [i].

Two intervention studies have supported the benefits of a Mediterranean style diet on metabolic risk factors [ii] [iii].  In a Spanish study, men and women with elevated levels of cardiovascular risk factors were randomised to either of two ‘Mediterranean’ diets and provided with either olive oil and nuts, or to a control low fat diet.  After 3 months the Mediterranean diet groups had lower mean plasma glucose, systolic blood pressure and total/HDL cholesterol ratio than the control group [ii].  Italian adults with the Metabolic Syndrome were randomised to a ‘Mediterranean’ diet or a ‘prudent’ diet, both with similar macronutrient (carbohydrate, protein, fat) composition.  The ‘Mediterranean’ diet was associated with greater improvements in markers of vascular risk and endothelial function than the control group [iii].  In both studies the ‘Mediterranean’ diet groups received more nutrition education than the control groups.

The Lyon Heart Study demonstrated that a modified Cretan diet low in butter and meats, and high in fish, fruits and enriched with alpha-linolenic acid from canola oil was more effective than a ‘prudent’ diet in the secondary prevention of coronary events and overall mortality [iv]. 

Simopoulos [v] notes that the traditional Greek diet resembles the Paleolithic diet in terms of fibre, antioxidants, saturated and monounsaturated fat, thus is consistent with human evolution.  While traditional diets must reflect regionally available foods, the dietary principles of the traditional Greek diet may be applied in many countries.  The evidence suggests that a traditional Greek or Cretan style diet is consistent with what humans have evolved to consume and may protect against common chronic diseases, including prostate cancer.

For information and practical tuition in how to incorporate the dietary principles of the Mediterranean diet into your own cooking, why not come along to a Cooking for Health course, run throughout the year in Somerset, UK.

Jane Philpott

References

[i] Sofi, F., Cesari, F., Abbate, R., Gensini, G F., Casini, A. Adherence to Mediterranean diet and health status: meta-analysis.  BMJ 2008: 337: a1344.

[ii] Estruch, R., Martinez-Gonzalez, M A., Corella, D. et al.  Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomised trial.  Ann Intern. Med. 2006: 145: 1-11.

[iii] Esposito, K., Marfella, R., Ciotola, M. et al.  Effect of a Mediterranean-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome: a randomised trial.  J Am Med Assoc 2004; 292: 1440-6.

[iv] de Lorgeril, M., Salen, P. Modified Cretan Mediterranean diet in the prevention of coronary heart disease and cancer.  In Simopoulos A,P., Visioli, F. eds.  Mediterranean Diets.  World Review Nutr. Diet. Basel: Karger, 2000: 1-23.

[v] Simopoulos, A P. The traditional diet of Greece and cancer.  Eur J Cancer Prev 2004; 13:219-30.