My father grew up in La Porte, Indiana. My grandmother was from the La Porte area, too, and my grandfather came from Georgia. A lot of my grandparents’ food choices were founded in their Southern heritage — diet choices that new research shows affect heart health in the long term.
I have a few childhood memories of visiting my grandparents. One involves eating a bologna sandwich, but this was no ordinary bologna sandwich. My grandmother fried the bologna in grease that she’d saved from prior fried meals. In fact, she pretty much fried the whole meal. As a kid with no bias toward healthy or appropriate foods, all I can remember is that the lunch tasted great. Not all the meals I ate with my grandparents were fried, though: I also remember picking fresh blueberries with my cousin to put in cereal for breakfast.
What Is Southern Cuisine?
Southern food and cuisine is diverse. All Recipes sums it up this way:
“Everyone knows that fried chicken and fluffy biscuits are Southern staples. But what about Country Captain (a stew-like chicken dish), Hoppin’ John (made with black-eyed peas), and Louisville Hot Brown (a gratinéed turkey sandwich)? There are so many culinary classics of the American South: smoked country ham and redeye gravy, chicken and dumplings, and crayfish étouffée are just a few more. And then there’s Brunswick stew: first made with squirrel meat (now mostly with chicken), Brunswick stew originated in Virginia or Georgia — depending on who’s telling the story. And for dessert? Don’t forget the pecan or sweet potato pie, or fresh peach cobbler!”
Regional food choices can teach us a lot about our health future, since different patterns of heart disease and its risk factors vary across different regions of the United States. One of those regions has been labeled the “stroke belt.”
The stroke belt spans the Southern United States and includes Indiana, Louisiana, Georgia, Alabama, South Carolina, Mississippi, Tennessee, South Carolina, Arkansas, Virginia, and Tennessee.
People in this area are far more likely to have a stroke — by as much as 34 percent — compared to people in other U.S. regions. In addition to stroke, these states also have much higher rates of heart attacks and heart failure.
Southern Lifestyle Choices and Heart Health
On the surface, there are clear reasons behind the epidemic of stroke and heart disease in the South. Rates of obesity and high blood pressure — risk factors for stroke and heart disease — are much higher there. As I have discussed in my prior columns, lifestyle choices often underlie the diseases we encounter as adults. To me, that link between lifestyle choices and health is both good and bad news. The bad news is that we put ourselves in situations that make it more likely that we’ll develop disease. But the good news is that we can do something about it and, in some cases, reverse heart disease by changing our lifestyle.
In the stroke belt, one of the poor lifestyle choices that’s most obvious is the high rate of cigarette smoking. The smoking habit has been associated with numerous diseases, including multiple cancers, stroke, heart attack, peripheral vascular disease, and premature aging. My father has told me that when he was growing up, it was hard for him to see out the windows of the car at times because of the cigarette smoke.
What is it about these lifestyle choices that are deeply founded in Southern culture? Specifically, what about Southern cuisine? Is this one of the reasons the stroke belt exists?
Although it seems logical to put the two together, that decision would be premature without data to support it, because community diseases are complex. They reflect not only diet, but other things as well, including:
- Socioeconomic status
- Family infrastructures and support
- Childhood environments
- Types of activities that increase burning off calories
- Cultural acceptability of lifestyle choices and norms
- Local occupations
- Access to health services and medical care
A Study That Links Diet, Stroke, and Heart Disease
Researchers from the University of Alabama at Birmingham, and Boston University, undertook a large study on diet and risks for stroke and heart disease to answer questions like these. Results were just published in the August issue of Circulation, the journal of the American Heart Association.
This national research effort, called Reasons for Geographic and Racial Differences in Stroke (REGARDS), looked at 17,418 patients age 45 and older. The patients initially enrolled between 2003 and 2007, and researchers have followed them medically since that time. The investigators in this study looked specifically at people’s diet choices, exercise, energy expenditure, alcohol use, obesity rates, heart disease risk factors, and socioeconomic status.
People who joined the clinical trial were asked to rank the frequency of their diet choices on a scale of one (never) to nine (every day). Diet patterns were then classified into five groups:
- Convenience Diet: loaded heavily with mixed dishes, pasta dishes, pizza, and Chinese and Mexican foods
- Plant-Based Diet: mostly vegetables, fruits, cereal, beans, fish poultry, yogurt, and fruit juice
- Sweets Diet: loaded with sugars, desserts, chocolate, sweetened breakfast cereals, and candy
- Southern Diet: lots of added fats, fried foods, organ and processed meats, eggs, and sugar-sweetened beverages
- Alcohol and Salad Diet: mostly beer, wine, liquor, leafy green vegetables, salad dressing, and tomatoes
Clearly, most people are not exclusively in one of these categories. I would like to say I consistently follow the plant-based pattern, but unfortunately, with my schedule, I spend a fair amount of time in the convenience pattern. For most people, our diets are a reflection of these many categories, and we hope to spend less time in the sweets pattern.
The authors anticipated that we are diverse, so they sorted each of the five categories into four groups, from lowest to highest consumption of a diet type.
Over a five-year follow-up period, patients who ate the most of a Southern diet had the highest rates of coronary artery disease. Of all the diet patterns, the Southern diet was remarkable for the amount of associated heart disease risk. The researchers took other factors into account, including:
- Whether a person got exercise
- How many calories they burned
- Whether they smoked
- Their body mass index (BMI)
- Whether they had high blood pressure, diabetes, or high cholesterol
- Their socioeconomic status
Here’s how the elevated risk associated with the Southern diet compared to risk linked to the other diets:
- The Southern diet increased risk of developing heart disease by a range of 37 to 200 percent.
- The plant-based diet lowered risk by 5 to 21 percent.
- The convenience diet lowered risk slightly, by 2 to 5 percent.
- The alcohol and salad diet increased risk by 3 to 17 percent.
- The sweet-based diet increased risk by 18 to 35 percent.
The magnitude of risk with the Southern diet was extraordinary. Compared to a sweet-based diet, a diet many consider to be the poorest in terms of food choices, the Southern diet raised risk 5 to 10 times.
How to Keep Heart Disease Risk Lower
The REGARDS trial teaches us a few key points.
1. Despite your activity level, weight, occupation, race, and gender, your dietary choices do matter. These choices can profoundly increase our heart disease risk.
2. Next, diets that are heavy on meats, added fats, and fried foods are harmful to your health and can explain some of the regional and cultural differences in heart disease risk we see in the United States.
3. Finally, a healthy diet includes plant-based foods. But one that also includes alcohol consumption can also be associated with harm to your heart. Drinking alcohol can increase blood pressure and directly injure the heart. I previously wrote a column about the effects of alcohol on our hearts, particularly as we age, and research which suggests that drinking less could improve your heart function and condition.