Getting Excited about Food: Improving

Nutrition One Bite at a Time

Amy Locke, MD, FAAFP, ABIHM

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

Information Overload!

Marketing Food as Healthy

• Granola

• Yogurt

• Juice

• Low Fat

• Cholesterol Free

• Heart Healthy

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

MACRONUTRIENTS

The details

Fats

• Saturated Fat

• Trans Fat

• Polyunsaturated fat

– Omega-3

– Omega-6

• Monounsaturated fat (Omega-9)

Low Fat Diet vs. Standard Diet

Howard et al. JAMA 2006;295:655-666

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

Ailhaud et al. Prog Lip Res 2006

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

FOOD

The details

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

Relative Risk for CAD: Fruits and Vegetables

Joshipura et al. Ann Int Med; 2001; 134(12):1106-1114.

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

QUESTIONS

PUTTING IT ALL TOGETHER

What to eat?

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

ADDITIONAL CONSIDERATIONS

Setting the stage

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

MAKING RECOMMENDATIONS

RESOURCES

When you need help

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.

Recommended Practice Changes

1. Adequately assess patients’ current dietary habits

2. Assess patient specific barriers to optimal nutrition

3. Use motivational interviewing to move patients

towards healthier options