Identifying Ornish-Friendly Foods TALKING POINTS Ask participants: “How many people read food labels?” Ask participants: “What do you look for when reading food labels?” INSTRUCTOR: Allow participants to answer. Most responses will be calories, sodium, fat, saturated fat, cholesterol, and sugar. Well today we are going to simplify the label reading process. We will only need to look at two areas on the food label to tell if a food is Ornish friendly. NOTE TO THE HEALTH PROFESSIONAL: Plan to do a grocery store tour the same day of this lecture or within a week of this presentation to reinforce the label reading guidelines and to provide “hands on” experience. Refer to “Tips for a Successful Grocery Store Tour” in the Staff Program Manual. Identifying Ornish-Friendly Foods 1

Today we will: Read a nutrition label Identify “Ornish friendly” foods Identify whole grains and full-fat soy foods Record these foods on the Nutrition PAL Form TALKING POINTS: The objectives for today’s lecture are to learn how to read nutrition labels and identify if a food is Ornish friendly or not. We will practice reading labels, selecting whole grain Ornish friendly foods, review full fat soy foods, and determine where these certain examples should be listed on the weekly food diary and nutrition PAL form.

Avoid These Foods Meats Milk Products Egg Yolks Oils & Fats Nuts & Seeds Caffeine Other TALKING POINTS: Just to review, foods not included in the Nutrition Spectrum Reversal Program are of course all animal products and any foods made with animal products (with the exception of fat-free dairy and egg whites); regular and low fat dairy products, egg yolks, added fats and oils, high fat plant foods such as olives, coconuts, avocados, nuts and seeds, caffeinated foods and beverages, and any foods that contain hydrogenated and partially hydrogenated oils.

Gain These Benefits Decreased death rate from heart disease and certain cancers Decreased obesity Decreased risk of coronary artery disease Decreased blood pressure Decreased risk for osteoporosis TALKING POINTS: By eliminating these foods from our eating style, we are significantly limiting our intake of saturated fat and cholesterol. Research has shown that vegetarians have lower death rates from heart disease and cancer, as well as decreased rates for many other disease states.

ENJOY These Foods… *Limited Whole grains Vegetables Fruits Legumes Non-fat milk products* Egg whites Fat-free sweets* Alcohol* TALKING POINTS: As you learn this new way of eating, it is important to focus on the large variety and abundance of food choices you are including versus those you have excluded. The Nutrition Spectrum Reversal Program is abundant in whole grains foods, vegetables, fruits, plant based protein foods such as beans, peas, soy foods as well as egg whites. Fat-free dairy products are encouraged as these foods are great sources of protein and calcium. They are limited to 2 servings a day because they are also a source of cholesterol. Sweets and alcohol also have a place in the Reversal Eating Style but they are limited because they are refined carbohydrates that can increase triglycerides. They are also a source of empty calories that contain little nutritional value. Other grains and starches, primarily high in simple carbohydrates should be limited. Individuals with diabetes, elevated triglycerides or elevated body weight often need to further limit or eliminate refined carbohydrates and should work with their RD to customize to their needs. Starchy vegetables are included in the other grain and starch category but are higher in nutrient content than other refined grain products and can be chosen more often than simple, refined carbohydrates. *Limited

More Benefits You’ll Enjoy Improved blood sugar control Weight loss Decline in acid reflux Increase in energy and empowerment Increase in disease-fighting compounds TALKING POINTS: Fiber, vitamins, minerals, and phytochemicals are prevalent in plant based foods and are responsible for a multitude of benefits. Whole grains, fruits and vegetables contain fiber that has been shown to help improve blood sugar control in people with diabetes. Fiber also help to fill you up quicker and contains no calories, thus assisting in weight loss. Replacing high-fat and caffeinated beverages with low-fat foods and caffeine free foods and beverages also helps to reduce acid reflux. Plant based foods are good sources of antioxidants as well as phytonutrients that help fight off and may prevent certain diseases such as cancer.

How can I tell if a food is Ornish friendly? TALKING POINTS: We know what kinds of natural foods, like fruits and vegetables, are part of the Nutrition Spectrum Reversal Program but how do we tell if a product purchased in a grocery store or health food store meets the Reversal guidelines for being low fat and vegetarian? It’s important to realize that you can’t just rely on the name of the product or the outside packaging of the product. Many products, such as some of those seen here in this slide, appear to look vegetarian and healthy but upon further investigation, they do not meet the Dr. Dean Ornish Program for Reversing Heart Disease guidelines. Let’s go through some simple steps on how to read a food label.

General Nutrition Facts Label Format TALKING POINTS: Nutrition labeling is required for most foods. Exceptions include food served for immediate consumption (cafeterias, sidewalk vendors, etc), ready-to-eat food that is prepared primarily on site (bakery and deli items), foods shipped in bulk, and plain coffees, teas, some spices, and other foods with no significant nutritive value. The nutrition label on this slide shows the required information featured on all nutrition labels. The Food and Drug Administration has required food manufacturers to list the amount of trans fat in their product since January 1, 2006. This is found under saturated fat and also shows up in the ingredient list as hydrogenated or partially hydrogenated oils. Trans-fats are typically unsaturated fats that have gone through a chemical change to make them more like a saturated fat. Trans fats help improve the shelf life of baked goods but have proven to be detrimental to our heart health. All nutrition labels give the nutrition content based on the serving size listed. The calories, fat, protein etc. listed on the food label is for that serving size, not the amount in the entire package. To make label reading simple, we will be looking at 2 areas. The first is grams of total fat, displayed near the top of the nutrition facts. We will only be concerned with the grams of fat, not the % daily value.

Ingredient List Format Greatest Amount Ingredients: Water, organic diced tomatoes (organic diced tomatoes, organic tomato juice, sea salt, citric acid, calcium chloride), organic tomato paste, organic beans (organic kidney beans, organic black beans, organic pinto beans, organic navy beans), organic onions, corn starch, organic corn, organic cane sugar, organic dehydrated onions, organic chili powder, organic canola oil, sea salt, organic spice, organic dehydrated garlic, organic cilantro. TALIKING POINTS: The second section we will be looking at is the ingredient list. As you can see, ingredients are listed in descending order. Major ingredients are listed first and lesser ingredients are listed at or near the end of the list. This becomes important as we determine if a food is Ornish friendly. The organic canola oil that appears in this ingredient list is considered a minor ingredient because of its place near the end of the list. The ingredient list is not always located with the Nutrition Facts label. It may be on the bottom or sides of the package. Least Amount

Acceptable Unacceptable Mainly Unsaturated Mainly Saturated Canola oil Corn oil Diglycerides Lecithin Monoglycerides Nut oils Olive oil Peanut oil Safflower oil Sesame oil Sunflower oil Soybean oil Mainly Saturated Beef fat/tallow/lard Butter or margarine Chicken fat Coconut oil Cream Hydrogenated oils/trans fatty acids Partially hydrogenated oils Mayonnaise Palm/palm kernel oil Shortening Whole milk and low-fat dairy Egg yolks TALKING POINTS: This slide displays other fats and oils that one might find in an ingredient list. If fats and/or oils appear in an ingredient list, we say that food contains added fat. The left column shows certain oils that are mainly unsaturated fats (remember that no oil is saturated fat free). These oils can be a part of an Ornish friendly food depending on where they are located in the ingredient list. More about that later. The right column lists fats that are mainly saturated. These fats and oils must be avoided in food products. It does not matter where they are located in the ingredient list. If a food product contains even one of these fats or oils, the product goes back on the shelf. It is not Ornish friendly. It is because of this “rule” that we do not have to be concerned with the cholesterol, saturated fat, and trans fat sections of the food label. We will not be selecting any foods with saturated fat, animal protein or fat, and trans fat in the ingredient list, thus assuring a very low intake of cholesterol and saturated fat and eliminating trans fat from our foods. Just as a reminder, this “added fat rule” applies only to packaged foods that you purchase in a store. Remember that we will not be adding fats or oils to foods prepared at home or in restaurants, with the exception of nonstick cooking spray.

Does it have 3g or less of TOTAL FAT? Fat Gram Rule Does it have 3g or less of TOTAL FAT? Yes Read label further No TALKING POINTS: Let’s go through the steps for identifying Ornish friendly foods. The first thing we look at when we pick up a product is the GRAMS OF TOTAL FAT. We ask, “Does this product have 3 grams of fat or less per serving?” If the answer is NO, the item goes back on the shelf – it is not Ornish friendly. This rule assures us that we will only be consuming low-fat foods. Soy is the one exception to this rule and we will talk about that in a few slides. If the answer is yes, it doesn’t mean the product is Ornish friendly yet. We must read the label further to find the source of the fat – natural or added. 11

Does the FAT occur naturally? Source of Fat Rule Does the FAT occur naturally? No Yes TALKING POINTS: Next we look at the ingredient list to determine if there is a fat or animal source present. If yes, ask yourself: “does it occur naturally or has it been added by the manufacturer?” If fat occurs naturally in a food, you will see a gram amount in the total fat gram section of the Nutrition Facts. However, when you look at the ingredient list, there is no fat or oil listed. Remember that our magic number for fat is 3 grams or less. A good example is oatmeal. Oatmeal has 3 grams of fat per serving and the ingredient is solely 100% whole grain oats. The fat occurs naturally in the oats. These types of low fat foods with naturally occurring fats can be enjoyed as outlined in the Reversal Food Guide Pyramid. If fat does not occur naturally in the food, that means the manufacturer has added oil or fat to that product. If the fat that appears in the ingredient list is part of the unacceptable fats (mainly saturated fats and oils) – that product goes back on the shelf – it is not Ornish friendly. If the fat is part of the “acceptable” oils, we are one step closer to saying it is an Ornish friendly food but we are not done yet! Is it an acceptable fat? No Enjoy Yes 12

Is this food Ornish-friendly? TALKING POINTS: Here again is a typical food label. Is it Ornish Friendly? ANSWER: No because this particular food is 7 grams of fat per serving. There is no need to look at anything else, including the ingredient list, because the fat grams exceed the 3 grams of fat or less rule.

Is this food Ornish-friendly? TALKING POINTS: Here is an example of a low-fat tortilla chip. Is this food Ornish Friendly? ANSWER: Yes. You cannot tell if the food is Ornish friendly without looking at the ingredient list. The food is less than 3 grams of fat per serving however you must look at the ingredient list to determine if the food is Ornish friendly Some examples are “Guiltless Gourmet Original Baked and Unsalted Tortilla Chips” and “Guiltless Gourmet Original Baked Blue Corn Chips”

Is this food Ornish-friendly? Ingredients: Stone Ground Yellow Corn, Expeller Pressed Hi-Oleic Canola Oil, Salt, Lime TALKING POINTS: Now that we have read the ingredient list, are these low-fat chips Ornish Friendly? ANSWER: YES. It is Ornish friendly. The oil (expeller pressed canola oil) in the ingredient list is one of the “acceptable” oils.

Is this food Ornish-friendly? Total Fat: 1 gram Ingredients: Stone Ground Corn, Salt TALKING POINTS: Yes – this food is Ornish friendly. There is only one gram of fat per serving. The ingredients are corn and salt – no fats or oils. Where is the one gram of fat coming from? ANSWER: the fat occurs naturally in corn. When fat appears as grams of total fat but there is not fat or oil listed in the ingredient, we say that food has naturally occurring fat. Where would you record this food on your food dairy and PAL forms? INSTRUCTOR: Allow participants to answer>. ANSWER: These tortilla chips are not a whole grain therefore they do not belong in the whole grain category. They would only be listed under “Other Grains” on the weekly food diary.

Is this food Ornish-friendly? NUTRITION FACTS: Serving Size 1 bagel (85g; approx 3 oz.) Servings Per Container 4 Amount Per Serving Calories 230 Calories from Fat 10 % Daily Value Total Fat 1g 2% Sat Fat 0g Cholesterol 0g Sodium 380mg 16% Total Carb 46gm 15% Dietary Fiber 5g 19% Sugars 7g 7g Protein 10g 130g INGREDIENTS: Enriched high-gluten flour (flour, malted barley flour, niacin, reduced iron, thiamine mononitrate, riboflavin, folic acid), water, whole wheat flour, honey, wheat germ, wheat bran, sugar, malt, salt, cornmeal, yeast, ascorbic acid Is it whole grain? TALKING POINTS: Here is another example – is this food Ornish friendly? INSTRUCTOR: Allow participants to give thoughts and answers. ANSWER: This food is Ornish friendly. It has 1 gram of fat and there are no oils listed in the ingredient list. Again the 1 gram of fat is most likely from the wheat products. Is this Ornish friendly food a whole grain? ANSWER: This food is not a whole grain because a whole grain or whole wheat flour is not listed as the very first ingredient. In order for a food to be a true whole grain – whole wheat flour or other whole grain such as whole grain oats must be the first ingredient. So even though this is an Ornish friendly food, there are better options to provide a person with more nutrients. The ideal choice is a food with whole grain as their first ingredient.

Is this food Ornish-friendly? INGREDIENTS: 100% Durum Whole Wheat Flour Total Fat: 3 grams Is it whole grain? TALKING POINTS: Is this food Ornish Friendly? INSTRUCTOR: Allow participants to give thoughts and answers ANSWER: This food is Ornish friendly – it has 3 grams of fat and no added oils in the ingredient list. Is it a whole grain? ANSWER: Yes – this Ornish friendly food is also a whole grain because it lists 100% whole wheat flour as the first ingredient. It would be recorded under the whole grain section on the weekly food diary as well as the whole grain column on the nutrition PAL form.

Full-Fat Soy Foods AN EXCEPTION Greater than 3 grams of fat per serving Naturally occurring fat derived from the soybean No added fat/oil added by the manufacturer Examples: Soymilk (1 cup; >3 grams of fat) Tofu (1/2 cup) Dry roasted soy nuts (1/4 cup) TALKING POINTS: There is one exception to the rule that foods must be 3 grams of fat or less per serving – soy foods. The Nutrition Spectrum Reversal Program allows for one serving of a full fat soy food a day. We talked about full fat soy foods in the Introduction to Nutrition Lecture. They are a good source of protein and omega-3 fatty acids. Full fat soy foods are classified as those soy foods that have more than 3 grams of fat per serving. This fat occurs naturally in the soybean meaning no added fat or oil will appear in the ingredient list. Let’s take a look at an example.

Is this food Ornish-friendly? Nutrition Facts Serving Size 1 cup (240mL) Amount per Serving Calories 100 Calories from Fat 30 % Daily Value* Total Fat 3.5g 5%    INGREDIENTS: Filtered Water, Whole Organic Soybeans, Naturally Milled Organic Evaporated Cane Juice, Calcium Carbonate, Natural Vanilla Flavor, Sea Salt, Carrageenan, Vitamin A Palmitate, Vitamin D2, Riboflavin (B2), Vitamin B12 TALKING POINTS: This example uses a popular soy milk – Silk. It has 3.5 grams of fat per serving. As you can see, this exceeds our 3 grams of fat or less rule. However, because this is a soy product, derived from the soybean, and there is no added oil or fat in the ingredient list, we can consume one serving per day. One serving of a full fat soymilk is 8 ounces or 1 cup. Where would we record this serving on the nutrition PAL form?

TALKING POINTS: Full-fat soy foods are recorded on the full fat soy food line on the weekly food diary as well as the full fat soy food column of the PAL form. Remember that only one serving of a full fat soy food a day should be consumed. All soy foods less than 3 grams of fat fall under the “Other Protein Foods” category. Lets take a look at an example.

Is this food Ornish-friendly? NUTRITION FACTS: Serving Size 1 burger (71g) Servings Per Container 4 Amount Per Serving Calories 90 Calories from Fat 10 Total Fat 1g Saturated Fat 0g Cholesterol Sodium 350mg Total Carbohydrate 6g Dietary Fiber 4g Sugars Protein 13g INGREDIENTS: water, soy protein concentrate, wheat gluten, contains less than 2% of natural flavor, salt, maltodextrin, dried onion, yeast extract, sesame oil, defatted wheat germ, caramel color, hydrolyzed corn, soy and wheat gluten, soy sauce (water, soybeans, wheat, salt), autolyzed yeast extract, natural and artificial flavor (contains cottonseed), methylcellulose, disodium guanylate, disodium inosinate, succinic acid  TALKING POINTS: This is a soy based vegetarian burger from a popular vegetarian food line known as Boca. Is this food Ornish Friendly? INSTRUCTOR: Allow participants to answer and give reason for answer. Have them take you through the steps in determining if a food is Ornish friendly. ANSWER: This is an Ornish friendly food – it is 1 gram of fat. Oil does appear in the ingredient list, however the sesame oil is a minor ingredient (contains 2% or less than = minor ingredient). How would you record it on your food diary and PAL form? INSTRUCTOR: Have participants give answers. Soy based vegetarian burgers and meat analogs do not meet the criteria for a full-fat soy food. They are a processed form of soy and if they contain >3 grams of fat, it more than likely comes from added oils from the manufacturer. Soy cheese would also be considered an “other” protein. Most soy cheeses contain less than 3 grams of fat and have oil in the ingredient list.

TALKING POINTS: This Ornish friendly Boca Burger counts as an “Other Protein Food” and the amount consumed should be recorded in this particular section of the weekly food diary. The serving for this food would be included in the “Other Protein Foods” on the PAL form as well. The serving for this food would go one more place on the PAL form - the “Low fat foods ≤3 gm fat” column. This column is for Ornish friendly foods that have an acceptable oil appearing in the bottom half of the ingredient list. Remember – you are allowed to consume no more than 3 servings a day of these types of food.

Fat-Free Foods With Added Oil In the Ingredient List AN EXCEPTION 0 grams of fat per serving but contain an acceptable oil within the ingredient list Acceptable oil can be located anywhere in the list of ingredients Each serving consumed needs to be “counted” as a packaged food with added fat. Limit to 0 to 3 servings per day. TALKING POINTS: A food product can be labeled as “fat free” as long as it contains less than ½ gram of fat per serving. Therefore, some products labeled as fat free may contain a source of added fat by the manufacturer. Remember to check the list of ingredients to see if a fat or oil has been added and to see if its an Ornish-friendly ACCEPTABLE fat or oil. All fat free foods (foods with 0 grams of fat per serving) that contain ACCEPTABLE fats or oils can Be included in the reversal eating style in moderation, regardless of where the acceptable added fats or oils fall in the ingredient list. Servings of any fat free foods with trace amounts of added oils are still limited to 0-3 servings per day. By following this serving limit, you will continue to maintain an eating style that is with the 10% daily fat guidelines. This guideline applies only to fat free food products (foods with 0 grams of fat per serving). Other packaged foods (food with 1 to 3 grams of fat per serving) that contain added fats or oils need to have the acceptable oil. As a reminder, any Ornish friendly food with added oil should be limited to no more than 3 servings per day. Let’s take a look at an example.

ACCEPTABLE Fat-Free Food INGREDIENTS: water, vegetable mono and diglycerides, salt, rice starch, gelatin, lactose, coloring yellow number 5 and 6, vegetable datem, Potassium sorbate, soy lecithin, lactic acid, artificial flavors, vitamin A (palmitate) TALKING POINTS: These first two products, Promise Ultra fat free spread and I Can’t Believe It’s Not Butter fat free spread, are examples of foods that fit the revised nutrition guidelines. They contain acceptable oils in their ingredient lists and both contain 0 grams of fat per serving.

UNACCEPTABLE Fat-Free Food Nutrition Facts Serving Size 1 tbsp (15mL)    Calories 25 Calories from Fat 0   % Daily Value*   Total Fat 0 g 0%      Saturated Fat 0g 0%   Cholesterol 0g 0%   Sodium 0g 0%  INGREDIENTS: water, sugar, corn syrup solids, partially hydrogenated soybean and/or cottonseed oil**, natural and artificial flavors, dipotassium phosphate, sodium caseinate (a milk derivative)***, titanium dioxide, sodium stearoyl lactylate, polysorbate 60, carrageenan, beta-carotene color TALKING POINTS: These last two products, I Can’t Believe It’s Not Butter spray and Coffee-Mate fat-free French Vanilla Non-Dairy Creamer, are examples of foods that do not fit the guidelines. They contain unacceptable oils, butter and partially hydrogenated oils. Note: Fat-free toppings such as fat free Cool-Whip and fat free Reddi-Whip still do not fit the reversal nutrition guidelines because they contain hydrogenated oils or other unacceptable fats such as cream.

TALKING POINTS: Fat-free foods with an acceptable added-fat are recorded in the low-fat food section on the weekly food diary as well as the low fat food column of the PAL form. Limit servings to no more than 3 per day.

Packaged Fat-Free Dairy Products AN EXCEPTION 0 grams of fat per serving, but contain a fat or oil of any kind within the ingredient list Fat or oil can be located anywhere in the list of ingredients Examples: fat-free cream cheese, fat-free cheese, fat-free cottage cheese, fat-free mayonnaise etc. Limit to no more than 2 servings per day TALKING POINTS: Over the past several years, manufacturers have added trace amounts of fat or oil to many fat-free dairy products. In some cases, the type of fat added is a saturated fat in trivial amounts. Examples of these products include fat-free sour cream, fat-free cream cheese, fat-free cheese products and fat-free cream based dressings. Fat-Free Dairy Guideline: All “fat-free” dairy products are acceptable, regardless of the type of fat added. All fat-free dairy products are still limited to no more that 2 servings per day. Due to the trivial amounts of these added fats and the restriction of no more than 2 servings per day, overall fat consumption is minimal and still falls within the reversal nutrition guidelines. Examples of fat-free dairy products that fit the guidelines include: fat-free cheese slices, fat-free shredded cheese, fat-free cream cheese, fat-free sour cream, fat-free yogurt, fat-free cottage cheese, fat-free mayonnaise and fat-free milk. Let’s take a look at an example.

ACCEPTABLE Fat-Free Dairy Food INGREDIENTS: protein concentrated skim milk, skim milk, contains less than 2% of sodium tripolyphosphate, sugar, pasteurized milk and cream, salt, artificial color, xanthan gum, carrageenan, potassium sorbate and calcium propionate as preservatives, cheese culture, sodium phosphate, artificial flavor, carob bean gum, vitamin a palmitate TALKING POINTS: Under the updated guidelines for fat free dairy products, the fat free cream cheese, shown in this example, would be an acceptable product, even though milk and cream are in the ingredient list. This holds true for only fat free dairy products such as milk, cheese, yogurt, cream cheese, cottage cheese, and sour cream. A maximum of 2 servings a day of fat free dairy products is allowed.

Let’s Go Shopping TALKING POINTS: Open up the floor for questions. Let’s practice. INSTRUCTOR: Pass out packages or labels from both Ornish friendly and non-Ornish foods. Have participants take turns, if time permits, practicing reading food labels. REMINDER TO HEALTH PROFESSIONAL: The grocery store tour should be done after this lecture is presented (see “Tips to a Successful Grocery Store Tour” in the Staff Program Manual).