Give each group member these handouts during this session:
(Optional) List of Places Where Group Members Can Get Their Cholesterol Levels Checked - Prepare this list before the session. You may find information at your local health department, hospital, or clinic.
Ask the questions below, and give the correct answers if group members do not. Q: Who remembers why you should try to limit the amount of salt and sodium in your diet? A: You should cut back on salt and sodium to help prevent or lower high blood pressure. Q: Does anyone remember some ways to reduce the amount of salt you eat? A: To cut back on salt and sodium, you can:
Check the Nutrition Facts label to choose foods lower in sodium, such as light soy sauce (soy sauce with low sodium).
Use fewer high-sodium sauces and ingredients, such as patis (fish sauce), tuyo (salty dried fish), hibi (salty, dried shrimp), and bagoong (fermented fish paste).
Use herbs and spices instead of salt to season foods.
Eat more fruits, vegetables, and fat-free or low-fat milk products for snacks.
Choose low-sodium or unsalted nuts, pretzels, crackers, and popcorn.
Say: At the end of our last session, you made a pledge to choose foods lower in salt and sodium. Share with the group what you did. What problems did you have? How did you solve them? Note: Allow 5 minutes for group members to respond.
About This Session
Say: Today we are going to talk about high blood cholesterol as a risk factor for heart disease. You will learn what you can do to keep your blood cholesterol levels low. We will also do some group activities that show how much saturated fat is in some foods and how to cook with less saturated fat. We will also learn how to keep trans fat and cholesterol intake low.
Say: Last week, Lola’s family showed us that with courage and dedication, everyone can make changes so there will be less sodium in the foods they eat. Lola Idad encourages her family always to be thankful for and mindful of how they live their lives, including what they eat and how much. She often says, “Bilisan mo ang gawain. Hinay-hinay sa pagkain.” This means, “If it is work, do it fast; if it is food, eat it little by little.” With Lola’s help, her family is now on the journey to heart health. In addition to watching their sodium intake, the de la Cruz family is lowering the amount of saturated fat they eat. Throughout this session, we will see examples of how the members of this family have made heart healthy changes to their eating habits.
Facts About Blood Cholesterol Say: If a person’s blood cholesterol level is too high, he or she is more likely to get heart disease. Here are some facts about blood cholesterol:
About 107 million American adults have total blood cholesterol levels that are above the desirable level. Of these, 38 million have high total blood cholesterol levels, meaning that they are at higher risk for clogged arteries and heart attack.
Filipinas living in the United States have higher total cholesterol than Caucasian women.
In the United States, Asians and Native Hawaiians and other Pacific Islanders are less likely than most ethnic groups to have their blood cholesterol checked.
Cholesterol and Heart Disease Note: This section explains what cholesterol is, why the body needs it, how much cholesterol the body needs, and where cholesterol comes from.
Say: Cholesterol is a soft, waxy, fat-like substance found in the body. Your body uses cholesterol to produce hormones and some vitamins.
Show picture card 5.1.
Say: Cholesterol comes from two sources:
Your liver makes all the cholesterol your body needs to keep you healthy. When cholesterol is produced, it goes into the bloodstream. The cholesterol that travels in your bloodstream is called blood cholesterol.
Cholesterol also comes from the food you eat. Foods that come from animals have cholesterol. The cholesterol in the foods you eat is called dietary cholesterol. Other types of fat in foods that raise cholesterol are saturated fat and trans fat. Today we will learn how to lower your intake of these fats.
Say: When too much cholesterol is in the blood, it increases the risk of a heart attack, stroke, and other health problems.
Ask: Do any of you know someone who has high blood cholesterol? Note: Allow about 2 minutes for group members to respond.
Say: Several things affect your blood cholesterol level. You cannot change some of them, such as your age, whether you are a man or a woman, or your family history (having family members with high blood cholesterol). But you can change the types of food you eat, the amount of physical activity you do, and your weight.
Say: You can help prevent or lower high blood cholesterol by taking the following measures:
Eating a heart healthy diet low in saturated fat, trans fat, and cholesterol
Being active every day
Maintaining a healthy weight
Show picture card 5.2.
Cholesterol travels through the bloodstream in the form of packages called “lipoproteins.” These packages are made of fat and protein.
Low-density lipoproteins (or LDL) carry the cholesterol to your blood vessels, clogging them like rust in a pipe. This is why LDL cholesterol is often called the “bad” cholesterol.
Cholesterol also travels in the blood in high-density lipoproteins (or HDL). HDL helps to remove cholesterol from your body, like removing rust from a pipe. This is why HDL cholesterol is often called the “good” cholesterol.
Picture it this way:
The LDL person in the car (bad blood cholesterol) throws fat and cholesterol into the street (blood vessels).
The HDL person (good blood cholesterol) cleans up fat and cholesterol deposited by the LDL and puts it in the trash.
Just remember, the “L” in LDL is for Lousy, and the Lower it is, the better. The “H” in HDL is for Healthy, and the Higher it is, the better.
What Are Your Numbers?
Show picture card 5.3.
Ask: How do you find out if you have high blood cholesterol levels or too much fat in your blood?
Say: Your blood cholesterol levels are measured with a blood test. The test can be done at a doctor’s office or at a cholesterol screening (for example, at a health fair).
A lipid profile is the blood test done at the doctor’s office. It is a complete test to measure the levels of each type of fat in the blood. It measures total cholesterol, LDL cholesterol, HDL cholesterol, and triglycerides. (We will talk about triglycerides later.) You have to fast for 12 hours before this test. This test is recommended for adults aged 20 or older.
Screening sites may only test total cholesterol and sometimes HDL cholesterol. If you are an adult aged 20 or older, you may need to follow up with the doctor for a complete lipid profile.
Ask: Have you ever had your blood cholesterol checked? If you have, do you remember your levels?
Give group members the “Take Action To Control Your Cholesterol” handout. Review the cholesterol levels. Note: If participants should ask, explain that cholesterol is measured in milligrams per deciliter (mg/dL).
Show picture card 5.4.
Say: Here are what the total cholesterol numbers (mg/dL) mean:
Less than 200 = Desirable — Keep up the good work.
200-239 = Borderline high
Depending on your other risk factors, you may be at a higher risk for heart disease.
It is time to change your eating habits, increase your physical activity, and lose weight if overweight.
240 or more = High
You are at a higher risk for clogged arteries and a heart attack.
Ask your doctor what your risk is for heart disease.
Say: Here is what your HDL and LDL cholesterol numbers (mg/dL) mean:
LDL (bad) cholesterol: Keep it low!
Less than 100 = Optimal
100-129 = Near optimal
130-159 = Borderline high
160-189 = High
190 and more = Very High
HDL (good) cholesterol: The higher the better! Keep it 40 mg/dL or higher.
More Information: Heart Disease Risk and Your LDL Level
The goal for the LDL (bad cholesterol) level is different for each person. It depends on the risk factors you have. The number of risk factors – such as high blood pressure, low HDL, family history of heart disease, age and gender, and smoking – affects your LDL goal. The higher your LDL level and the more risk factors you have, the greater your chances of developing heart disease or having a heart attack. Your doctor can help you set a goal for your LDL level.
What Are Triglycerides?
Say: Have any of you heard of triglycerides? Note: Allow 2 minutes for group members to answer.
Say: Triglycerides are another type of fat in the blood. When you eat too many calories, drink alcohol, or smoke, your body makes more triglycerides. When your triglycerides are high, it puts you at increased risk for heart disease.
Say: A healthy triglyceride level is less than 150 mg/dL.
Say: People with high triglycerides often have low HDL cholesterol (good cholesterol). People with diabetes can also have high triglycerides and low HDL cholesterol.
Say: To have a healthy triglyceride level:
Maintain a healthy weight or lose weight if you are overweight.
Be physically active on all or most days of the week.
Eat a heart healthy diet that is low in saturated fat, trans fat, and cholesterol.
Limit candy, sweets, desserts, regular soda, juice, and other food and drinks high in sugar.
Avoid smoking cigarettes and drinking alcohol. Smoking raises triglycerides and lowers HDL cholesterol. Excess alcohol also raises triglycerides.
More Information: here's what your triglyceride number (mg/dL) means:
Less than 150 = Normal
150–199 = Borderline high You may be at an increased risk for heart disease. To lower your level, aim for a healthy weight, and be more physically active.
200–499 = High Weight control and physical activity are very important to lower your level. Watch out for other heart disease risk factors such as overweight and obesity, diabetes, low HDL, and high blood pressure.
500 or More = Very high See your doctor immediately! This level requires attention to prevent severe problems with your pancreas.
Ask: Do you know what your triglyceride level is? Note: Allow a few minutes for group members to respond.
Encourage group members to make an appointment to have their cholesterol and triglycerides checked.
Tell them to be sure to ask for their results and to write them on their wallet cards.
(Optional) Give group members a list of clinics and hospitals where they can get low-cost or free blood cholesterol testing.
The Metabolic Syndrome and Your Health
Now, we are going to learn about the metabolic syndrome. This disorder is made up of a group of five factors that affect heart health.
Many people have this health problem and don’t know they have it.
Say: As I name the five factors that make up the metabolic syndrome, hold up your fist. Raise one finger for each risk factor you have.
Show picture card 5.5.
Say: The five factors that make up metabolic syndrome are:
A low HDL (good) cholesterol level of below 50 for women and below 40 for men
A triglyceride level of 150 mg/dL or more
A blood pressure of 130/85 mmHg (The blood pressure level considered a factor for metabolic syndrome is 130/80. This level is different from the level that defines high blood pressure, 140/90.) or more (either number that is high counts as a risk)
A waist measurement greater than 35 inches (88 centimeters) for women and greater than 40 inches (102 centimeters) for men
Higher than normal fasting blood glucose (blood sugar) level of 100 or more
Ask: How many fingers (risk factors) do you have raised?
If you have three or more of these factors, you have the metabolic syndrome.
The metabolic syndrome raises your chances of developing heart disease, diabetes, and stroke.
People with the metabolic syndrome should lose weight and become physically active.
Say: If you think you have metabolic syndrome, talk to your doctor.
Healthy Arteries Activity
Note: This section uses the picture cards and an artery model to show how cholesterol can collect on the walls of the arteries and slow down and block the flow of blood. Blocked arteries can cause a heart attack or stroke.
Show picture card 5.6.
Say: Blood flows freely to all cells of the body when arteries are normal and healthy.
Say: When your LDL cholesterol is too high, cholesterol may become trapped in the walls of your arteries, causing them to harden. The opening of the arteries can become clogged and narrowed.
Pass the artery model around so that group members can look at it closely.
Ask: Have you ever seen someone fry food with lard and dump the hot lard down the sink?
Allow a moment for group members to respond. Then ask them why they should not do this.
Say: It is because the lard will clog the pipes. Foods high in saturated fat and trans fat will clog your pipes (arteries). So we want to treat our bodies just as well as we treat our pipes.
Facts About Saturated Fat, Trans Fat, Cholesterol, and Fiber
Say: Today, we will talk about the different types of fat and how they affect heart health.
There are two main types of fat–saturated fat and unsaturated fat. Most foods contain some of both types. The saturated fat plus the unsaturated fat in food make up the total fat found in food.
Saturated fat is found in foods that come from animals, such as high-fat meats, cheese, milk, and butter.
Another type of fat called trans fat also raises cholesterol. trans fat is found in a variety of baked goods (such as cookies, pies, and pastries), fried foods, stick margarine, and vegetable shortening. Choose light margarine (soft tub) instead of stick (hard) margarine, and look for trans-fat-free spreads in the grocery store.
Eating too much saturated fat and trans fat will raise your blood cholesterol level more than anything else you eat. This will raise your chances of developing heart disease.
Say: It is important to limit the amount of saturated fat and trans fat you eat, but you need some dietary fat to be healthy. Fats are necessary because they are used by the body to:
Store and provide energy.
Help carry vitamins A, D, E, and K throughout the body.
Ask: What types of fat do you use to cook your food? Note: Allow about 3 minutes for group members to answer. Write responses on the blackboard or on a large piece of paper taped to the wall.
Show group members a stick of butter (or a can of shortening or lard).
Butter, shortening, and lard are examples of foods high in saturated fat.
Saturated fat is usually solid at room temperature.
Saturated fat is usually found in foods from animals.
Show picture card 5.7.
Say: Here are foods that are high in saturated fat:
Whole milk and products made from whole milk (regular cheeses and cream cheese)
Ice cream and whipped cream
Fatty cuts of meat, such as chuck, regular ground beef, ribs, bacon, and sausage; canned meat, such as pork, corned beef, and vienna sausage
Skin of chicken, turkey, and pig
Oils such as coconut, palm, and palm kernel
Doughnuts, pastries, cakes, and cookies
Show picture card 5.8.
Say: Here are foods that are lower in saturated fat:
Lean meats such as loin, round, and extra lean ground beef
Fish and seafood (Shrimp and crawfish have more cholesterol than most other types of fish and seafood, but they are lower in total fat and saturated fat than most meats and poultry.)
Poultry without the skin
Fat-free and low-fat milk, cheese, and yogurt
Vegetable oil, such as canola, safflower, or sesame oil
Fruits and vegetables
Say: You want to limit the amount of saturated fat in your diet.
Say: Even though vegetables and fruits are low in saturated fat, any plant food prepared with oil high in saturated fat (for example, eggplant or banana that is deep fried in coconut or palm oil) may raise your cholesterol level.
Show group members a bottle of vegetable oil.
Say: Unsaturated fats are usually liquid at room temperature. As mentioned before, a few oils (coconut, palm, and palm kernel) are high in saturated fat.
(Optional)Say: The types of unsaturated fats are polyunsaturated and monounsaturated.
Say: The graph will quickly show you which products have the least saturated fat.
Ask: What four oils have the least saturated fat?
Say: Canola oil, safflower oil, sesame oil, and sunflower oil have the least saturated fat.
Say: Although polyunsaturated and monounsaturated fats are better for our health than saturated fat, we need to eat less of all types of fat. Fats are high in calories, and all fats have the same number of calories. Cutting back on calories helps us lose weight. We will talk about this in the next session.
Show picture card 5.9.
Say: Foods high in cholesterol can also raise your blood cholesterol and increase your risk of heart disease. Dietary cholesterol is found only in foods that come from animals. Foods that are highest in cholesterol are:
Organ meats, such as liver, kidneys, tripe, heart, and tongue
Show picture card 5.10.
Say: Foods that come from plants do not contain cholesterol. Foods that do not contain cholesterol include:
Say: Plant foods that are prepared with animal products (for example, tofu fried in lard) have cholesterol.
Say: Plant foods are generally lower in saturated fat and don’t have cholesterol. They also contain a type of dietary fiber (soluble) that is beneficial for lowering cholesterol.
Show picture card 5.11.
Say: Soluble fiber is found in foods such as oats, fruits, barley, vegetables, and cooked dry beans and peas. So, this gives you one more reason to eat a variety of fruits and vegetables in addition to some whole-grain cereals such as oatmeal.
Say: Fruits and vegetables that are a good source of soluble fiber are citrus fruits (oranges and grapefruit), guava, mango, apples, papaya, peaches, pears, pineapple, bananas, brussels sprouts, broccoli, and carrots. For great sources of soluble fiber, try to include a variety of cooked dry beans, cabbage, green beans, and oatmeal. Avoid canned beans that contain high amounts of salt and sodium. Prepare beans at home, flavoring them with garlic and spices instead of salt.
Point out on the Nutrition Facts labels where to find saturated fat, trans fat, and cholesterol.
Show picture card 5.12.
Say: For a healthier heart, use the Nutrition Facts labels to choose foods with a lower Percent Daily Value for saturated fat and cholesterol. If you have high cholesterol, you may need to aim for a lower percent for saturated fat and cholesterol. Try to keep trans fat as low as possible. A doctor or registered dietitian can help you with this.
Show group members where the Percent Daily Value is found on the Nutrition Facts label for whole milk.
Say: Look at the bottom of the handout. Look at the Percent Daily Value for whole milk and fat-free milk. Which is lower in saturated fat?
Say: Fat-free milk is lower in saturated fat. One cup of fat-free milk has none of the Percent Daily Value of saturated fat. One cup of whole milk has 25 percent, or one-fourth, of the Percent Daily Value of saturated fat.
Say: Trans fat is now listed on all Nutrition facts labels. It is listed on a line below saturated fat, as seen here. Compare labels to choose the food lowest in saturated fat, trans fat, and cholesterol.
Say: Now look at “Mila’s Breakfast Choices.” We are going to use the Nutrition Facts label to practice choosing foods that are lower in fat. First, I am going to tell you about a problem for many busy people. Then, we will use Nutrition Facts labels to find some solutions.
Mila has little time in the morning to prepare breakfast. She often has a bibingka (sweet rice cake) for breakfast, or leftovers, such as pork longanisa and fried rice. Look at the nutrition facts labels. Help Mila select some breakfast foods that are lower in saturated fat than her usual choices. It is also important to compare labels for trans fat and cholesterol amounts.
Pork longanisa, sweet, or chicken siopao (steamed bun with chicken filling)? Correct answer: chicken siopao
Ask for a volunteer to describe: Note: Write the answers on the blackboard or on a large piece of paper taped to the wall. Help the volunteer select some substitutes, if needed.
What he or she usually eats for breakfast
Which foods are higher in fat
What lower-fat foods can be chosen to replace them
(Optional) Mila Teaches Rose About Heart Healthy Cooking Role Play Note:Ask for two volunteers to be the actors in the role play. Give these two group members the “Mila Teaches Rose About Heart Healthy Cooking Role Play” handout. As the trainer, you can read the introduction. After the activity is completed, allow 5 minutes for discussion by asking the following questions.
What are some of the lessons we learned from this role play?
Is there any part of the role play that you can use in your own life?
2 tablespoons coconut oil = About 7 teaspoons (27.2 g)
From the can of shortening, spoon the amount of fat listed on the chart onto the plate labeled for that food.
Take the remaining plates, and place each food item (or a picture of the food) on the separate plates.
Put all the plates away until you are ready to do this activity.
Say: We are going to play a guessing game that will help you learn about the total fat content of several foods. Learning which foods are higher in fat and how to replace them with foods that contain less fat will help you make healthier choices. Decreasing your total fat intake can help you reduce your saturated fat, trans fat, and calorie intake.
Show group members the plates of foods (or pictures of food) that you prepared ahead of time.
Say: Guess how many teaspoons of fat are found in one serving of each of these foods. Write your guess on the “Guess the Fat Activity” handout. Note:Ask group members to tell you the amount of fat they guessed for the first food item. After group members have shared their guesses, tell them the actual number of teaspoons of fat the food contains. Tell them to write this amount on their handout, too. Bring out the plate of fat you made ahead of time for that food to show them how much it is. Then do this for the other foods.
Say: As you can see, it is easy to go over the limit for fat when we eat foods higher in fat, such as fried foods, some fast foods, hotdogs, coconut milk, chips, canned pork, corned beef hash, vienna sausages, bibingka (sweet rice cake), and ice cream. Eating foods lower in total fat will also help you reduce your saturated fat, trans fat, and cholesterol intake. To make it easier to cut back on fat, eat more foods that are lower in fat, such as fruits, vegetables, rice, whole-grain cereals and breads, beans, and fat-free or low-fat milk products.
Ask: How do you feel about the true amount of fat in the foods you guessed? Note: Allow 3 to 5 minutes for group members to talk about their reactions.
Say: There are lower-fat substitutes for some of the higher-fat foods that we eat often.
Review the following list.
Foods and Their Lower-Fat Substitutions
Regular cheese vs. Fat-free or low-fat cheese
Evaporated whole milk vs. Fat-free or low-fat milk or soy milk
Lard or coconut oil vs. Canola oil, safflower oil, or sesame oil
Lumpiang shangai (fried lumpia) vs. Lumpiang sariwa (fresh lumpia)
Vienna sausage vs. Low-fat vienna sausage
Sardines, canned in olive oil vs. Sardines, canned in tomato sauce
2 snack cakes vs. Fresh fruit, such as pineapple or fruit cocktail, in juice
12 ounces halo halo dessert (made with condensed milk) vs. 12 ounces halo halo dessert (made with fat-free or low-fat milk)
Say: You can also reduce the amount of fat you eat by simply eating foods higher-fat foods less often or in smaller amounts.
Cooking With Less Saturated Fat Activity
Note: This section provides information that will help group members cut back on the amount of saturated fat in their diets. This activity will help them understand that they can cut back on the fat without giving up their traditional foods.
Ask: Before we do this activity, can you tell me what you can do to cook with less saturated fat? Note: Allow 3 minutes for group members to respond. Write their answers on the blackboard or on a large piece of paper taped to the wall.
Say: The next activity shows how to prepare foods with less saturated fat.
Ask: How has saturated fat been reduced in this recipe?
Allow a moment for group members to respond. Add the following answers if they are not mentioned:
The skin from the chicken has been removed.
The chicken is boiled, not fried.
The dish uses olive oil, which has less saturated fat than lard, palm oil, or coconut oil.
The dish is flavored with vegetables, light soy sauce, and herbs, instead of salt.
The dish is cooked and simmered slowly in moist heat instead of fried in fat.
Say: Remember, foods that are lower in fat still contain calories. Check your portion sizes (including the side dishes, such as steamed rice). If you eat these foods in large quantities, you may gain weight. Note:Ask if there are any questions. Encourage group members to try this recipe at home this week.
Say: This week, Lola and her family remind us that the steps to a healthy heart also require discipline. Discipline means taking control of your eating habits. With courage and discipline, you can limit foods high in saturated fat, trans fat, and cholesterol.
Say: Please take a few moments to reflect on Lola’s advice and how it applies to your life. At the bottom of the handout, there is a space called “A Time To Reflect.” Use this section to record your feelings about this week’s session. Please write down your thoughts. Remember, this is for you and no one else.
Give each group member 2 to 3 minutes to write down some thoughts.
Say: You have learned a lot today about high blood cholesterol and how to eat less saturated fat, trans fat, and cholesterol. Now, let’s think about how you can apply what you have learned. Please think of one change you can make in your everyday life to keep your blood cholesterol in check.
Say: Be specific about what you plan to do, how you plan to do it, and when you will start. Here are some examples:
I will take the skin off the chicken, and I will throw the skin away.
I will bake the fish instead of frying it in lard or grease.
Say: Take the pledge for life with Lola Idad. Lola and her family have taken the pledge to practice heart healthy eating every day. Take a step toward eating less saturated fat, trans fat, and cholesterol. Pledge to do one thing on this list during the coming week.
Say: Would anyone like to share his or her pledge with the group? Note: Write down pledge ideas on the blackboard or on a large piece of paper taped to the wall. Note: If someone says they will use less oil in cooking, ask them to give you an example.
Say: We will discuss the results of your pledges next week. Remember to continue to work on your pledges to be physically active and eat less salt and sodium.
Say: Thank you for coming today. What did you think of today’s session? Note: Wait to see if group members respond.
Say: I am looking forward to seeing you at the next session. The next session will be about maintaining a healthy weight.
Note for Educator: Think about today’s session. What worked and what didn’t work? Have you decided to lower the amount of saturated fat in your diet and to know your numbers based on what was covered in today’s session?
Information on this page is taken from the English print version of “Healthy Heart, Healthy Family: A Community Health Worker's Manual.” U.S. Department of Health and Human Services, National Institutes of Health, National Heart Lung and Blood Institute, NIH Publication No. 08-3674, Originally Printed 1999, Revised May 2008.