Earlier this year, I was invited to attend a journal club for cardiology fellows. The topic was nutrition and cardiovascular disease. One of the articles chosen for discussion was the study by Franco et al.1 The purpose of the study was to calculate the theoretical effectiveness of a Polymeal to decrease the risk of cardiovascular disease. The Polymeal evolved from the earlier concept of the Polypill proposed by Wald and Law.2 They advocated the development of a pill that contained 6 pharmacological agents that had been demonstrated to decrease cardiovascular risk factors. Wald and Law estimated that the combined effects of these agents would reduce cardiovascular disease by 80% if the Polypill were administered to the general population. Similarly, Franco et al selected 7 components for their Polymeal. Each of the 7 components had been demonstrated by prior research to reduce cardiovascular risk factors by 12% to 32%. The components of the meal were wine (150 mL/d), fish (4 times a week), dark chocolate (110 g/d), fruits and vegetables (400 g/d), garlic (2.7 g/d), and almonds (68 g/d). Franco et al estimated that regular consumption of the Polymeal by the general population would produce a 76% reduction in cardiovascular disease.

A vigorous discussion ensued regarding the validity of the assumptions underlying the authors' conclusions. The assumption that generated the greatest contention was that the individual components of the diet would have such combined multiplicative effects. It was generally agreed that dietary nutrients have interactive and complimentary effects and therefore do not operate in isolation. This limitation was also recognized by the Franco et al who argued that they simply applied the same principles to food as did Wald and Law to drugs. Given the ironic tone of the article, it is evident that the intent of Franco et al was to illustrate idiosyncrasies in the way we approach both dietary and medical treatment of cardiovascular disease. At the closing of the journal club, one of the attending cardiologists asked me, "If I were to tell my patients to make one change in their diet, what should it be?"

There are several insights that I took from this experience. First, the Polymeal approach highlights our current reliance on drugs to treat many of the health-related problems that could be treated with lifestyle changes, including dietary modifications. Although we do not have an ideal method to quantify their cumulative effects, it is evident that what we eat makes a difference in our risk for cardiovascular disease. On a contrary note, the Polymeal approach also highlights the trend toward treating foods as drugs. The current emphasis on assuring adequate intake of individual nutrients has resulted in people relying on nutritional supplements as the best means to achieve cardiovascular health. This carries the risk of people dropping whole food groups from their diet in favor of a pill containing single nutrients derived from those groups. There are likely many components of these foods that remain undiscovered and unappreciated for their health effects.

The closing question by the cardiologist struck me as symbolic of the present misconceptions regarding the way nutritional recommendations are commonly interpreted. There is a tendency to believe that a single dietary change is all that is needed to achieve health and well-being. The focus on making a single change can result in a new diet that is as bad as or worse than the original. The American Heart Association recommendation that fat comprise 30% or less of total calories provides an ideal example. This recommendation has been improperly implemented by both the public and health professionals. The response to this recommendation has been to focus on replacing high-fat foods with low-fat alternatives without regard to the other ingredients in the food or to the other American Heart Association nutrition recommendations. The food industry took full advantage of this trend and marketed a wide variety of low-fat and fat-free products that could be eaten guilt-free. These products, however, typically have been very high in sodium, high in carbohydrates, and equally high in calories. Subsequently, this recommendation has been unfairly criticized for having little effect on the growing incidence of obesity and related cardiovascular risks in the United States.3 More recently, we have witnessed the same unfortunate trend with respect to carbohydrates.

The nutrition guidelines of both the American Heart Association4 and the United States Department of Agriculture5 recommend the adoption of food patterns that include whole foods rather than specifying required amounts of individual nutrients. Following these recommendations provides macronutrients in proportions that the majority evidence shows are beneficial to cardiovascular health. Moreover, these recommendations provide adequate amounts of micronutrients such that supplementation is not necessary.

It will take concerted effort on the part of healthcare providers to overcome the powerful marketing forces of the food industry, the tendency to focus on making single dietary changes, and the growing reliance on nutritional supplements. It is imperative that we be at least as informed as our patients regarding the currently available nutrition information. The articles for this special issue of Journal of Cardiovascular Nursing were chosen to provide the most current information with respect to nutrients that can affect cardiovascular health and to demonstrate the essential role of nutrition in the health of our patients. I commend the authors for their comprehensive thoughtful treatment of each subject. I challenge you as the reader to interpret the information provided in this issue within the perspective outlined above.

Terry A. Lennie, PhD, RN

Guest Editor

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