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The Problem
• Most don’t meet dietary recommendations1
• Diet is the single most significant RF for
disability and premature death2
• Nutrition minimally addressed in care2
• Much of what presented as fact is myth3
1. USDA 2016 2. Devries et al. Amer J of Med 2014 3. Lesser et al. Am Fam Phys 2015
Common Food Myths
• Shop the perimeter of the grocery store
• Fat is bad for you
• Carbs are bad for you
• Low Fat is good for you
• Dairy is an important dietary category
Overview
• Review of guidelines
– nutrients vs. foods
• Explore common problems and barriers
• Motivating change
• Resources
2015-2020 Dietary Guidelines
• Big changes:
• “Added sugar” less than 10% of daily calories
• Lifted restriction on total fat and cholesterol
• Notable absences:
• Did not recommend cut back on red and processed
meats
Motives of USDA
• Potential Conflict of Interest
– Promote Nutrition and Health
– Agriculture Advocacy
• “…help improve the stability and strength of the
agricultural economy”
• Strong Food Lobby
Fats
• Saturated Fat
• Trans Fat
• Polyunsaturated fat
– Omega-3
– Omega-6
• Monounsaturated fat (Omega-9)
Saturated Fats and Cholesterol
• Saturated fats– If replaced with carbohydrate no clear benefit1
– May not all be equal2
– Plant based vs. animal based saturated fats have different properties based on chain length
• Cholesterol – Produced only by animals
– Dietary cholesterol, particularly from eggs, does not increase significant risk for CAD3
1. Siri-Tarino et al. Am J Clin Nutr. 2010 2. Hunter et al. Am J Clin Nutr. 2010 3. Rong et al. BMJ 2013
Omega-3 vs. Omega-6 Fatty Acids
• Omega 3:6 ratio thought to be close to 1:1 in Paleolithic human
diet
• Western diet is about 1:15 to 1:20-40
• Omega-6 thought to be pro-inflammatory when consumed in large
amounts
– Activation of arachidonic acid pathway
– Prothrombotic
– Vasospasm and vasoconstriction
– Pro-arrythmia
Simopoulos. Biomed Pharmacother 2002
Carbohydrates
• Simple sugars vs. complex
carbohydrates
– The misnomer
• Body converts starches quickly
to glucose
• Need to limit simple sugars
and starches
Glycemic Index and Load
• Measure of how quickly food is digested
– Serum glucose rise compared to 50gm white bread
– www.glycemicindex.com
• High GI foods cause rapid rise in glucose
• Glycemic load
– Considers amount of digestible carbohydrate
– Watermelon and carrots vs. potatoes
Carbohydrates
• Glycemic Index and Load
– Whole grain ≠ low glycemic index/load
• Low Glycemic Load
– Lower total cholesterol and LDL1
– Decreased rates of CAD2
– Biomarkers lower3
– Improved DM control4 with less hypoglycemia5
1. Thomas et al. Cochrane Database Syst Rev. 2007 2. Beulens et al. J Am Coll Cardiol 2007 3. Schwingshackl et al. Nutr Metab
Cardiovasc Dis 2013 4. Wang et al. Prim Care Diabetes 2015 5. Thomas and Elliot Cochrane Databse Syst Rev 2009
Whole Grains
• Coarse ground grains have lower glycemic index
than products with finer flour
• Fiber and some health benefits preserved regardless
of GI/GL
• Decrease in CVD
Glycemic Index and Weight Loss
• Two groups randomized to same caloric intake with varied GI
– Higher weight loss in low GI group
• Summary of high GI:
– Eat more
– Hungry more often
– Harder to loose weight
• (even if eat the same amount of food)
– More likely to have chronic disease
Protein
• Higher protein content relative to carbohydrates
– Decreased CVD
– Decreased LDL and TG
– Increased HDL
• Quality of protein is important
• Plants based sources are best
– Less weight gain1
– Improved morbidity/mortality
1. Mozaffarian et al. NEJM 2011
Plant Based Diets
• Reduced mortality1
• Decreased CAD2
• Decreased premenopausal breast cancer risk3
• Decreased blood pressure, lipids4
1. Pan, A. et al. Arch Intern Med 2012 2. Bernstein et al. Circulation 2010
3. Farvid et al In J Cancer 2014 4. Appel, L. J. et al. JAMA 2005
Pan, A. et al. Arch Intern Med 2012;0:archinternmed.2011.2287v1-9.
Dose-response relationship between red meat intake and risk of all-cause mortality in the Health Professionals Follow-up Study (A)
and the Nurses' Health Study (B)
Fruits and Vegetables
30% risk reduction in acute MI with
daily consumption
– Interheart study1
30% risk reduction of CVD and
ischemic stroke
– Nurse’s Health and Health
Professional Follow-up studies2
40% risk reduction for CVD
– PREDIMED study3
1. Yusuf et al. Lancet 2004 2. Hung et al. J Natl Cancer Inst 2004 3. Buil-Cosiales et al. Br J Nutr. 2016
Fiber and Health
• Soluble vs. insoluble fiber
• Foods:
– Whole grains
– Vegetables
– Fruits
– Legumes
• Health effects
– Reduction of CVD events
(14%) and death (27%)1
– Improve insulin sensitivity2
– LDL reduction3
– Decrease blood pressure3
– Decreased breast cancer risk4
1. Periera et al. Arch Intern Med 2004 2. Schulze et al. Am J Clin Nutr 2004 3.
Hartley et al. Cochrane Database Syst Rev 2016 4. Aune et al. Ann Oncol 2012
Food Sources of Fats
• Polyunsaturated fat
– Omega-3
• Cold water fish, fortified eggs, grass-fed animals, flax seed, canola oil,
walnuts, soy, sea grown algae
– Omega-6
• Safflower, corn, cottonseed, and mixed veg oil
• Monounsaturated fat– Olive oil, nuts and nut butters (almond, cashew), avocado, canola oil
Nuts
• Mediterranean diet with nuts1
• Improved age related cognitive decline
• Decreased mortality with tree nuts and peanuts2
• Overall 27-31%
• CVD 30-48%
• Lower body weight3
• Decreased diabetes3
1. Valis-Pedret et al. JAMA Intern Med 2015 2. Luu et al. JAMA Intern
Med 2015 3. Sabate and Ang Am J Clin Nutr 2009
Mozaffarian D et al. N Engl J Med 2011;364:2392-2404.
Relationships Between Specific Food and Beverage Consumption and Weight
Milk: Does Not Necessarily do the Body Good
• What we get from milk: calcium, protein, fat, carbohydrate
• Can have large amount of saturated fat and calories
• Not independently associated with weight gain1
• Decreases risk of metabolic syndrome2
• Up to 75% of people around the world can not fully digest
cow milk
• Many other sources of calcium
1. Mozaffarian D et al. N Engl J Med 2011 2. Babio et al. J Nutr 2015
Beverages
• Satiety response diminished1
• Liquid calories more closely associated with obesity2
• Potential for large number of calories
• Often high glycemic index
• Water preferable
– NutritionSource.org
1.DiMegilo and Mattes Int J Obes Relat Metab Disord 2000 2. Zheng et al. J Hum Nutr Diet 2015
Artificial Sweeteners
• Increased Metabolic syndrome risk when
consume > 5 beverages/week1
• Associated with increased DM2
• Some evidence to suggest that individuals eat
more when consume sweeteners without
calories
1. Ferreira-Pego et al J Nutr 2016. 2. Imamura et al. Br J Sports Med 2016
Mediterranean Diet
• Emphasis on fruits and vegetables
• Plant proteins and fish over other animal proteins
• Whole grains (coarsely ground)
– Low glycemic index
• Healthy fats
– High omega-3 and monounsaturated fats
– Low omega-6 and saturated fats
Lyon Diet Heart Study
• Mediterranean vs. “prudent western” diet
• Secondary prevention of CVD
– 70% reduction in CV death
– 60% reduction of all cause mortality
de Lorgeril et al. Circulation 1999
Mediterranean Diet
• Greater adherence1
– Lower overall mortality
• Reduced coronary artery disease deaths
• Reduced cancer deaths
• Decreased risk of breast cancer2
– Predimed Study: 70% risk reduction in group with Mediterranean
diet with added olive oil
• Decreased hip fracture3
1. Trichopoulou et al NEJM 2003 2. Toledo et al. JAMA Int Med 2015
3. Byberg et al. Bon Miner Res 2016
Mediterranean Diet
• Compared to old AHA diet in Metabolic Syndrome1
– Lower insulin and hsCRP
– Improved endothelial function
– Higher resolution of metabolic syndrome
• 55% vs. 23%
• Decreased rates of diabetes2
1. Esposito et al JAMA 2004 2. Esposito et al. Endocrine 2016
Key Concepts
• Plant Based Whole Foods Diet
• Fruits and Vegetables
• Glycemic Index
• Fatty Acids
• Start with the big targets– Sweet beverages as an example
Mindless Eating: Brian Wansink
• Many things effect what we eat:
– Labels, surroundings, plate size, meal
companions, proximity to food, variety of
choices
• Decreased portion, package and tableware
size lead to decreased consumption1
1. Hollands et al. Cochrane Database Syst Rev 2015
Satiety and Intuitive Eating
• Associated with lower BMI1,2 and better psychological health1
• Caloric density not related to satiety
• Identify emotional eating patterns
1. Van Dyke and Drinkwater, Public Health Nutr 2014 2. Cole et al. Mil Med 2016
Kids and Food
• Palatability– Infants
– “No thank you bite”
– Kids in the kitchen/garden
– What parents eat
– What is available
• Availability– Water in lunchroom associated with decreased BMI
• Cooking classes
– Community
– Online
• Chop Chop Magazine
The Skill of Cooking
• Community Partnerships
– Dietetics programs
– Grocery stores
– Culinary schools
Medical School Education
• Focus on food and patient advice
• Teach Motivational Interviewing
• Culinary Medicine
• Inter-professional Education
Nutrition CME
• Healthy Kitchens Healthy Lives
• Food as Medicine, Center for Mind-body Medicine
• University of Arizona
• Tulane University
• American College of Lifestyle Medicine
Resources for Consumers
• Harvard School of Public Health
– www.nutritionsource.org
• Ending The Food Fight, David Ludwig
– www.endingthefoodfight.com
• Mindless Eating: Why We Eat More Than We Think, Brian Wansink
– www.mindlesseating.org
• The Hunger Within, Marilyn Migliore
• Many apps and websites
– My Fitness Pal, Sparkpeople, etc.
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