a salad gold evidence-based approach to nutrition calm a...1/16/2020 1 romaine calm! a salad gold...

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Romaine Calm!A Salad Gold Evidence-Based Approach to

Nutrition

Joshua Liberman, MD, FACC

Preventive Cardiology, Ascension Wisconsin

Governor, President WI‐ACC

Disclosures

No Financial Conflicts of Interest

(But I am Plant‐based)

• All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self‐evident.

‐Arthur Schopenhauer 1788‐1860

• Nearly 70% of U.S. adults are classified as overweight or obese• 40 years ago: < 25%

• Over that same time frame, the prevalence of diabetes as a percentage of the U.S. population quadrupled

• Currently 8.3% of the U.S. population• Continuing to rise

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•33% of the world’s population is overweight or obese

• 23.2% overweight (24% men, 22.4% women)• 937 million people

• 9.8% Obese (7.7% men, 11.9% women)• 396 million

Kelly et al. Int J Obesity 2008: 32, 1-7.

By the year 2030, if trends continue, 57.8% of the world’s population will

be overweight/obese

Why? The Food We Eat Is Killing Us!

So What Should We Do About It?

Let’s Go on a Diet!!

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Community Confusion

• Low Fat?• Low Carb?•Smart Carb?•High Protein? • Low Protein?•Paleo?•Keto?•WheatBelly?•Organic?

•All Diets are equal• Equivalent adherence leads to equivalent weight loss

• Satiety, hunger, weight loss were all similar

Sacks FM et al. NEJM 2009; 360:859-73

Jensen, M.D., et al. Circulation. 2014; 129: S102-38

All diets are equal??

All diets are equal for the purpose of weight loss…

….but that doesn’t mean that all diets are equally healthy

Improvements in dietary intake have been conclusively linked to decreases in:

•Heart Attacks•Strokes•Cancer

•Breast•Prostate•Cancer

•Diabetes•Hypertension•Dementia

•Autoimmune Disease

Can lifestyle changes reverse coronary heart disease? The Lifestyle Heart Trial

• Prospective, randomized, controlled trial to determine whether comprehensive lifestyle changes affect coronary atherosclerosis after 1 year

• 28 patients were assigned to an experimental group

• 20 to a usual‐care control group.

• Without use of lipid‐lowering drugs

Lancet 1990 Jul 21;336(8708):129‐33.

The Lifestyle Heart Trial

Lancet 1990 Jul 21;336(8708):129‐33.

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Lancet 1990 Jul 21;336(8708):129‐33.


• 195 coronary lesions analyzed by quantitative coronary angiography.

• The average percentage diameter stenosis regressed from 40.0% to 37.8% in the experimental group

• Progressed from 42.7% to 46.1% in the control group.

• When only lesions >50% stenosed were analyzed:• Average % diameter stenosis regressed from 61.1% to 55.8% in the exp group

• Progressed from 61.7% to 64.4% in the control group.

• Overall: 82% of experimental‐group patients had an average change towards regression.

Lancet 1990 Jul 21;336(8708):129‐33.


• Only a 5% change in diameter?• Remember: Perfusion is a fourth power function of the radius

• Even small changes in coronary artery stenosis cause disproportionate changes in myocardial perfusion.

• Coronary flow reserve increased and arterial modeling improved in experimental group patients

• Using cardiac PET imaging, there was a more than 300%improvement in myocardial perfusion in the experimental group when compared to the randomized control group after five years.

Am J Cardiol 1992 Apr 1;69(9):845‐53Lancet 1990 Jul 21;336(8708):129‐33JAMA 1998;280(23):2001‐2007


Ornish D et al. Lancet 1990 Jul 21;336(8708):129‐33

• 91 % reduction in the frequency of angina

• 42% reduction in duration of angina

• 28% reduction in the severity of angina.

• In contrast, control‐group patients reported:• 165 % rise in frequency

• 95% rise in duration

• 39% rise in severity of angina

Dose‐Dependent Response

Ornish D et al. Lancet 1990 Jul 21;336(8708):129‐33.

The Lifestyle Heart Trial:5 Year Follow‐up

Ornish D et al. JAMA 1998;280(23):2001‐2007

•There was even more regression of coronary atherosclerosis after 5yrs in the experimental group.

• Coronary atherosclerosis continued to progress in the control group

• More than 2x as many cardiac events occurred in the control group during 5 year follow‐up.

• 25 cardiac events occurred in 28 experimental group patients (0.89 events/pt)

• 45 events in 20 control group patients (2.25 events/pt)

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Same Diet

Ornish D, et al. JAMA 1983;249:54‐59

• Randomized controlled trial• ~50 patients with at least one 50% coronary lesion and who had abnormal exercise radionuclide ventriculography

• LVEF failed to improve with exercise or +RWMAs

• Exercise radionuclide ventriculography revealed that experimental group patients showed improvements in their ejection fraction and regional wall motion when compared to the randomized control group after only 24 days.

• statistically significant

• Exercise duration increased 44%• Total work increased 55%

• Improved left ventricular regional wall motion during peak exercise

• 91.0% mean reduction in frequency of anginal episodes after only 24 days.

Ornish D, et al. JAMA 1983 247 () p

The patients improved so much that it was necessary to reduce or discontinue antihypertensive and cardiac medications in 78% of the experimental

group patients but in none of the randomized control group patients.

Demonstration project

Silberman, et al. Am J Health Prom; 2010 24(4):260‐6

• ~ 3,000 patients who went through this program at 24 hospitals and clinics in West Virginia, Nebraska, and Pennsylvania

• Significant improvement in virtually all metrics after 12wks and after 1 yr• LDL

• Weight (BMI decreased by 6.6%)

• Systolic blood pressure

• Diastolic blood pressure

• Hemoglobin A1c

• All of these improvements occurred even though medications were often reduced by their physicians during this time

• Depression scores were reduced by 47.4%

Esselstyn Jr, CB., et al. Journal of Family Practice 63(7) (2014): 356‐64

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So What is This Magical Diet?

The Ornish Diet

• Fruits, vegetables, grains, legumes, and soybean products without caloric restriction

• No animal products except egg white and one cup/day of non‐fat milk or yogurt.

• The diet contained approximately:• 10% of calories as fat (polyunsaturated/saturated ratio > 1)• 15‐20% protein• 70‐75% carbohydrates (predominantly complex)

• Cholesterol intake was limited to ≤ 5 mg/day

• Salt was restricted only for hypertensive patients• Caffeine was eliminated

• Alcohol was limited: no more than 2 units/day

The Ornish Program:General Idea

• Whole/Natural Plant‐Based Foods

• Avoidance simple sugars

• Emphasis on the intake of complex carbohydrates and other whole foods

• Moderate aerobic exercise

• Stress management training

• Smoking cessation

• Group psychosocial support

So….

Eat food. Mostly plants. Not too much.

Michael Pollan

The Omnivore’s Dilemma

Pollan M. The Omnivore’s Dilemma: A Natural History of Four Meals. New York, New York: Penguin, 1996

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“Mostly Plants”

In observational studies as well as clinical trials, populations or groups that eat primarily plant‐based diets have

significantly lower cholesterol levels and lower rates of death from heart disease

•Plant‐Based/Vegetarian Diets have been shown to:• Prevent and reverse atherosclerosis• Reduce mortality from ischemic heart disease

• Prevent or cure diabetes (Type 2)• Improve HTN

• Prevent and reverse early prostate cancer• Reduce risk of colon cancer• Reduce risk for breast cancer• Reduce hospitalization and death from diverticular disease

• Ameliorate symptoms of Parkinson’s• Promote weight loss

• Decrease cataract formation• Reduce Diverticulosis/itis

Esselstyn Jr, CB., et al. JFP 63(7) (2014): 356-64Ornish D et al. JAMA, 280 (1998), p. 2001 Orlich MJ et al. JAMA Int Med 2013 Jul 8; 173(13): 1230–1238.Trapp CB et al. Curr Diab Rep 2010 Apr;10(2):152-8 Barnard ND Am J Clin Nutr. 2009 May;89(5):1588S-1596S.Taylor EF et al .Br J Cancer 96:1139-46Crowe FL et al. BMJ. 2011 Jul 19;343 Baroni L et al. Nutr Neurosci. 2011 Jan;14(1):1-9Appleby PN et al. Am J Clin Nutr. 2011 May;93(5):1128-35.

Then why is everyone doing Keto or Paleo?

What’s all the Fuss about a “Keto” diet?

•A ketogenic diet is one diet that starves the body of glucose sources so that it’s forced to burn ketone bodies — products of fat metabolism — as fuel.

•Promotes weight loss

Bittman, M and Katz, DL. New York Times

Is Weight Loss Everything?

•Not everything that causes weight loss or apparent metabolic improvement in the short term is a good idea.

• Cholera• Weight Loss

• Lower Blood Sugar

• Lower lipids

• Heroin


High Protein Diets:Potential Benefits

• In short‐term trials, consumption of high‐protein diets have been shown to produce greater weight loss, loss of fat mass, and preservation of lean mass compared with the consumption of normal‐protein diets• Possibly due differences in appetite signaling & satiety

• Differential levels of ghrelin, leptin, and cholecystokinin• Appear to increase energy expenditure• Leading to reduced energy intake

Westerterp‐Plantenga MS et al. Br J Nutr. 2012;108(suppl 2):S105‐S112Leidy HJ et al. Am J Clin Nutr. 2015;101(6):1320S‐1329S.Adams SH. Adv Nutr. 2011;2(6):445‐456

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High Protein Diets:Potential Benefits

•High‐protein diets have been linked to improvements in CV risk factors:• Blood pressure• Blood lipid/lipoprotein profiles• Glycemic regulation

Santesso N, et al Eur J Clin Nutr. 2012;66(7):780‐8Dong JY et al. Br J Nutr. 2013;110(5):781‐789.Foster GD Ann Intern Med. 2010;153:147‐157.

So burgers or pepperoni are fine. They’re paleo, right?

There were no Paleolithic burgers, or pepperoni.

There was also no paleolithic bacon.


High Protein Diets:Potential Downfalls

•High consumption of dietary protein obviously leads to a decrease intake of other foods• usually carbohydrates

• And a decrease in carbohydrate foods with high fiber and other micronutrients may have a negative effect.

•Choices of dietary protein source will influence other macronutrients, micronutrients, and polyphenols in the diet, potentially leading to detrimental health effects.

Richter CK, et al Adv Nutr. 2015;6(6):712‐728.

High Animal Protein Diets

•Known evidence‐based measures of CV disease such as flow‐mediated vasodilation, LDL‐C and CRP worsened on a typical Atkins diet

•But improved significantly on a low‐fat, whole‐foods, plant‐based diet.

Miller M, et al. J Am Diet Assoc 2009;109:713–717.

High Animal Protein Diets

• Increased methionine and alanine intake associated with higher odds of elevated BP

• Higher proportions seen in animal products

• Whereas threonine and histidine were associated with lower BPs• Higher proportions seen in plants

• Why? Putative Mechanisms:• Advanced Glycation End products in red meat cooked at high temp. leads to increased angiotensin II

• Reactive oxygen species by impair vasodilation through nitric oxide quenching

Tuttle KR et al. Am J Kidney Dis 2012 Jun;59(6):803‐9

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High Protein Diets

US National Health and Nutrition Examination Survey (NHANES) data showed a significant increase in the risk of all cause death associated with higher protein

intake.

Levine ME et al. Cell Metab. 2014;19(3):407‐417.

Animal Protein

•One recent study showed that intake of animal protein had no relationship with mortality

• But….the major source of protein was fish

Budhathoki, S et al. JAMA Intern Med. Published online August 26, 2019

OK. I won’t do Keto or Paleo. What if I just eat a “moderate”

amount of red meat?

Animal Protein

•Several ecologic and observational studies havereported a positive correlation between overall animal protein intake and mortality due to CV disease and cancer• Higher animal protein intake was associated with higher CVD‐related mortality.

Carroll KK. Nutr Rev. 1978;36(1):1‐5Tominaga S, Kuroishi T. Int J Cancer. 1997;(suppl 10):2‐6.Song M et al. JAMA Intern Med. 2016;176(10):1453‐1463

Red Meat

1

1.1

1.2

1.3

1.4

1.5

1.6

1.7

1.8

1.9

Quintile 1 Quintile 2 Quintile 3 Quintile 4 Quintile 5

Red Meat and Health Outcomes

Cancer CV Mortality All Cause Mortality

An NIH/AARP study of 500,000 subjects reported that the consumption of red meat was significantly associated with increases in:• Total mortality

• CV mortality

• Cancer mortality

Sinha R et al Arch Intern Med 2009;169:562–571.

Red Meat

•Increases Risk of:•Atherosclerosis•Diabetes•Stroke•Cancer

• Colorectal• Bladder• Prostate• Endometrial• Breast An Pan et al. Am J Clin Nutr 10 August 2011

Larsson SC, et al. Am J Clin Nutr 2011; 94:417-421Chan DS et al., PLoS One. 2011;6(6):e20456Wang C et al. Med Oncol. 2011 May 24John EM et al. Nutr Cancer. 2011 May; 63(4):525-37Bandera EV et al. Cancer Causes Control. 2007 Nov;18(9):967-88Toniolo et al. Epidemiology 1994 Jul;5(4):391-7Giovanucci et al. J Natl Cancer Inst 1993 Oct 6;85(19):1571-9

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Red Meat

• Higher intake of processed meat is associated with an increased risk of stroke

• 23% increase in relative risk of stroke for those who had the highest intake of processed meat compared with those with the lowest intake

• Low‐fat deli turkey, ham, and bologna

Larsson SC, et al. Am J Clin Nutr 2011; 94:417-421

Red Meat

• For colorectal cancer, a 3 serving/week reduction in processed meats, led to a relative risk of 0.93 (95% CI 0.89‐0.95)

• Substitution of one serving of nuts, low‐fat dairy, and whole grains per day to replace one serving of red meat per day could be associated with a 16–35% lower risk of T2D.

Johnston BJ et al. Annals of Int Med 2019; Bouvard V et al. Lancet Oncol. 2015 Dec;16(16):1599‐60An Pan et al. Am J Clin Nutr published 10 August 2011

• The Harvard School of Public Health estimated that a moderate reduction in red meat consumption could hypothetically reduce mortality by 7.6% or approximately 200,000 deaths per year in the US.

• Based on all available meta‐analysis data and the prevalence of meat consumption

• 55% of US adults consuming at least 3.5 servings of red meat per week from the NHANES

https://www.hsph.harvard.edu/nutritionsource/2019/09/30/flawed‐guidelines‐red‐processed‐meat

Saturated Fat

Saturated Fat

• Estimated that replacement of 5% of energy from saturated fat by unsaturated fat would reduce risk of CAD by 42%

• 95% CI: 23, 56; P < 0.001

Hu, FH et al. NEJM 1997 337:1491-9

Saturated Fat and Cancer

•2001 meta‐analysis• Statistically significant positive relationship between saturated fat and ovarian cancer

•2003 meta‐analysis• Significant positive relationship in both control and cohort studies between saturated fat and breast cancer

•2007 review• Limited but consistent evidence for a positive relationship between animal fat and colorectal cancer

Nutrition and Cancer 40 (2): 87–91

Boyd NF et al. Br J Cancer 62(9): 1672-85

World Cancer Research Fund. 2007. pp. 139

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But our Ancestors Ate Paleo, Didn’t They?

Wait…Didn’t I Just Hear that Red Meat Was Fine?

• Controversial “Guideline” statement put out on 10/1/19 by Annals of Internal Medicine

• Published a cluster of 5 systematic reviews (3 were meta‐analyses and the other 2 were narrative reviews

• Lower consumption of red meat and or processed meats is associated lower total, CVD, and cancer mortality and incidence of type 2 diabetes.

• Uniformly, all the summary relative risks are <1 and the majority of the estimates are statistically significant

Wait…Didn’t I Just Hear that Red Meat Was Fine?

• Based on showing “minimal impact from the 3 serving/week reduction”, they concluded, as a self‐declared GUIDELINE

• “The panel suggests that adults continue current unprocessed red meat consumption (weak recommendation, low‐certainty evidence).”

• “The panel suggests adults continue current processed meat consumption (weak recommendation, low certainty evidence).”

Annals of Internal Medicine

Their Rationale:

1. The observed effects are very small

2. The quality of evidence is very low

3. Meat eaters enjoy meat and won’t change their behaviors

4. Environmental impact was considered “outside of the scope” of their guideline.

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Annals of Internal Medicine

1. “The observed effects are very small”1. Health benefits or risk would be much larger for individuals consuming >1

servings/day of red meat (among approximately 1/3 of US adults).

2. Based on their meta‐analyses of large cohorts, dietary patterns with a moderate reduction in red and processed meat consumption were associated with:

1. Lower total mortality by 13% (95% Confidence interval 8% to 18%)

2. CVD mortality by 14% (6% to 21%)

3. Cancer mortality by 11% (4% to 17%)

4. Type 2 diabetes risk by 24% (14% to 32%)

These risk reductions are substantial at both individual and population levels.

2. The quality of evidence is very low

3. Meat eaters enjoy meat and won’t change their behaviors

4. Environmental impact was considered “outside of the scope” of their guideline.

Annals of Internal Medicine & Controversy

• 2014: Saturated fat is not bad – Guidelines are wrong

• 2017: Sugar is not bad – Guidelines are wrong

• 2019: Bacon and Beef are not bad – Guidelines are wrong

Chowdhury R et al. Ann Intern Med. 2014;160(6):398‐406.Johnston BC et al. Ann Intern Med. 2017;166(4):257‐267Johnston BC et al. Ann Intern Med. 2019; October 1

What Does the Paleo Diet Get Right?

Cutting down on processed foods that have been highly modified from their raw state through various methods of preservation. So…What Is It About Plants?

Plant Power

• Intake of plant protein, but not animal protein, has been associated with favorable changes in:

• Blood pressure

• Waist circumference

• Weight

• Fasting insulin levels and insulin resistance

• Risk of DM II

Tielemans SM et al. Nutr Metab Cardiovasc Dis. 2014;24(11):1228‐1233.Shang X, et al. Clin Nutr. 2017;36(6):1540‐1548Chalvon‐Demersay T, et al. J Nutr. 2017;147(3):281‐292. Elliott P et al. Arch Intern Med. 2006;166(1):79‐87.van Baak MA, et al. Nutrients. 2017;9(12):E1326.

Plant Power

•Higher intake of plant protein is associated with a lower risk of T2DM

• vs increased risk of DM associated with animal protein.

Shang X, et al. Am J Clin Nutr. 2016;104(5):1352‐1365.Malik VS, et al Am J Epidemiol. 2016;183(8):715‐728.

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Plant Power

•Higher plant protein intake was associated with lower total and CVD‐related mortality

• Intake of plant protein was associated with:• Lower total mortality

• HR = 0.87 (95% CI, 0.78‐0.96) for quintile 5 vs. quintile 1

• Lower CV disease–related mortality• HRs, 0.84 [95% CI, 0.73‐0.96] to 0.70 [95% CI, 0.59‐0.83


Plant Power

•Higher plant protein intake was associated with lower total and CVD‐related mortality

• In a study of postmenopausal women in Iowa,higher vegetable protein intake was associated with 30% lower risk of CHD mortality compared with lower vegetable protein intake.

• In a combined analysis of the Nurses’ Health Study and the Health Professionals Follow‐up Study, Song et al revealed a similar inverse association with plant protein intake, wherein a 3% increase in energy from plant protein was associated with 10% lower risk of overall mortality and 12% lower risk of CV mortality.

Kelemen LE et al Am J Epidemiol. 2005;161(3):239‐249Song M et al. JAMA Intern Med. 2016;176(10):1453‐1463.

Plant Power

Higher intake of nuts and grains or

legumes was associated with

lower CVD‐related and all‐cause mortality

Papandreou C et al. Clin Nutr. 2019;38(1):348‐356Aune D, et al. BMJ. 2016;353:i2716.

Plant Power

• Replacement of red meat protein or processed meat protein with plant protein was associated with lower total, cancer‐related, and CVD‐related mortality

• Isocaloric substitution of 3% energy from plant protein replacing red meat protein was associated with:

• Lower total mortality (HR, 0.66; 95% CI, 0.55‐0.80)

• Lower cancer‐related mortality (HR, 0.61; 95% CI, 0.45‐0.82)

• Lower CVD‐related mortality (HR, 0.58; 95% CI, 0.39‐0.86) mortality

• Substitution for processed meat protein was associated with lower total (HR = 0.54; 95% CI, 0.38‐0.75) and cancer‐related (HR = 0.50; 95% CI, 0.30‐0.85) mortality.



Plant Power:So How Much IS That?

• For an average person with 2000 kcal/d of energy intake:• 3% of energy from plant protein would be approximately 260g for a protein‐rich food such as soy

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Plant Power

• Ornish et al found that a changing to a plant‐based diet caused beneficial changes in gene expression in 500 genes in only 3 months:

• Upregulating disease‐preventing genes

• Downregulating oncogenes that promote breast cancer and prostate cancer

• Downregulating genes that promote inflammation and oxidative stress, which often contribute to the cause and progression of coronary artery disease.

Ornish D et al. PNAS 2008 Jun 17; 105(24): 8369–8374.

Plant‐Based Eating

•Adventist Health Study 2• Large North American cohort study

• Approximately 96,000 cohort members were enrolled throughout the United States and Canada between 2002 and 2007.

• Recruitment for the study was done in Seventh‐day Adventist churches• Special effort to recruit black subjects (including African Americans and Caribbean Americans)

• An important group that has been underrepresented in scientific studies of diet and health.

• Approximately 27% of the cohort members were black in AHS‐2

• 65% of subjects were women.

• The mean age at enrollment was 57 y.

Orlich MJ et al. JAMA Int Med 2013 Jul 8; 173(13): 1230‐8


•Adventist Health Study 2• Dietary patterns were defined along a vegetarian continuum

• Categorized on the basis of their reported intakes of key food items of animal origin

• 7.7% of cohort members were vegan

• 29.2% were lacto‐ovo‐vegetarian• 9.9% were pesco‐vegetarian • 5.4% were semi‐vegetarian

• 47.7% were nonvegetarian.

Orlich MJ et al. JAMA Int Med 2013 Jul 8; 173(13): 1230‐8


•Adventist Health Study 2• Vegetarian dietary patterns were associated with:

• lower body mass index

• lower prevalence and incidence of diabetes mellitus• lower prevalence of the metabolic syndrome and its component factors

• lower prevalence of hypertension• lower risk of cancer• lower all‐cause mortality [HR = 0.88 (95% CI, 0.80‐0.97)]

Orlich MJ et al. JAMA Int Med 2013 Jul 8; 173(13): 1230‐8Rizzo NS et al. Diabetes Care 2011;34:1225–7Tonstad S et al. NutrMetab Cardiovasc Dis 2013;23:292–9Tantamango‐Bartley Y et al. Cancer Epidemiol Biomarkers Prev 2013;22:286–94.Pettersen BJ et al. Public Health Nutr 2012;15:1909–16.


•Adventist Health Study 2• Vegetarian dietary patterns were associated with:

• lower body mass index

• lower prevalence and incidence of diabetes mellitus• lower prevalence of the metabolic syndrome

• lower prevalence of hypertension• lower risk of cancer• lower all‐cause mortality [HR = 0.88 (95% CI, 0.80‐0.97)]

• Even after adjustment for other risk factors

Orlich MJ et al. JAMA Int Med 2013 Jul 8; 173(13): 1230‐8Rizzo NS et al. Diabetes Care 2011;34:1225–7Tonstad S et al. NutrMetab Cardiovasc Dis 2013;23:292–9Tantamango‐Bartley Y et al. Cancer Epidemiol Biomarkers Prev 2013;22:286–94.Pettersen BJ et al. Public Health Nutr 2012;15:1909–16.

PREDIMED TrialEstruch R et al. NEJM 2018; 378:e34

• 7447 participants• 55 to 80 years of age• 57% women• High CV risk, but with no CV

dz at enrollment

• One of three diets: • Mediterranean diet

supplemented with extra‐virgin olive oil

• Mediterranean diet supplemented with mixed nuts

• Low Fat control diet

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PREDIMED Trial

Estruch R et al. NEJM 2018; 378:e34

What is it about plants that makes them so healthy?

Polyunsaturated Fatty Acids

• With every 5% increase in energy from PUFAs, there is a 10% decrease in heart disease risk

• Replacing all saturated fat in your diet with PUFAs can reduce risk of heart disease by ~40%

• Much more effective than reducing overall fat intake

Czernichow S et al. Br. J Nutr 2010; 4:1-9Clarke R et al. BMJ 1997; 314:112-7Hodson L et al. Eur J Clin Nutr 2001; 55:908-15Mozaffarian D et al. PLoS Med 2010; 7:e1000252Hu FB et al. NEJM 1997p; 337:1491-9

Mono Unsaturated Fatty Acids

•Examples of foods high in MUFA are:

• Olives and olive oil• Peanuts and peanut oil• Cannolis and Canola oil• Avocados• Nuts:

• Almonds

• Pecans • Hazelnuts• Cashew nuts• Macadamia nuts

• Pistachio nuts

Canola Oil

•Omega‐9 Fatty Acids

•The major source of fat in Mediterranean diets

• Olive Oil (> 75% oleic acid)

Mono Unsaturated Fatty Acids

• For Diabetics, MUFA‐rich diets exert a positive influence in:

• Body weight

• Glucose profiles

• Serum lipid levels

Ros E. Am J Clin Nutr 2003;78:617S–625S.

Bos MB et al. Nutr Metab Cardiovasc Dis 2009Mensink RP, et al. Am J Clin Nutr. 2003;77:1146 –55Galgani JE, et al. Br J Nutr. 2008;100:471– 479.Riserus U, et al. Prog Lipid Res. 2009;48:44 –51.Jebb SA, et al. Am J Clin Nutr. 2010;92:748 –758.

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Dietary Fiber

Is Fiber Paleo?

•Our ancestors consumed a wide variety of ever‐changing plant foods that gave them up to 100 grams of fiber daily.

• The American Dietetic Association recommends a healthy diet include 20‐35 grams of fiber a day from plant foods

•We, on the other hand, eat an average of 15 grams of daily fiber

Dietary Fiber

• Lowers serum cholesterol levels

•Slows glucose absorption• Improves insulin sensitivity

• Lowers blood pressure•Promotes weight loss

• Inhibits lipid peroxidation•Anti‐inflammatory

• Increases excretion of bile acid, estrogen, and fecal procarcinogens and carcinogens by binding to them

Dietary fiber reduces the risk of death from cardiovascular, infectious, and

respiratory diseases.

Park Y et al. Arch Intern Med. 2011; 171:1061-8

Dietary fiber intake is associated with a significantly lowered risk of total death in

both men and women

22% decrease in risk of death


>40% lower risk of dying from cancer!


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Dietary Sources of Fiber

•Beans• 4‐8 grams in 1/2 cup

•Brown rice• 5.5 grams in 1 cup

• White rice has only 2 grams

•Fruits w/skin (apples and pears)

• 4‐5 grams

•Corn (on the cob)• 4 grams

•High fiber cereals• As much as 10 grams of fiber per serving

•Green peas• 4 grams in 1/2 cup

•2 slices of whole wheat bread

• 6 grams

•Broccoli• 5g in 1 cup

What is it about plants?

• What they have:• Monounsaturated Fats

• Polyunsaturated Fats

• Fiber

• What they don’t have:• Cholesterol

• Saturated Fat*

• Heme‐Iron

• TMAO

• AGEs

• Heterocyclic amines

• Carnitine/Taurine

Summary

• All truth passes through three stages. First, it is ridiculed. Second, it is violently opposed. Third, it is accepted as being self‐evident.

‐Arthur Schopenhauer 1788‐1860

•There is a growing convergence of scientific evidence that an optimal diet is mostly plant based

• Consists predominantly of fruits, vegetables, whole grains, legumes, and soy products.

• Low in refined carbohydrates, saturated fat, and trans fats

• High in complex carbohydrates with adequate omega‐3 fatty acids

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Plant‐Based Diets

The "Ornish diet" has been rated "#1 for Heart Health" by a panel of independent medical and nutrition experts at U.S. News & World Report

for eight years from 2011‐2019.

The Academy of Nutrition and Dietetics 2016 Position Paper

• “It is the position of the Academy of Nutrition and Dietetics that appropriately planned vegetarian, including vegan, diets are healthful, nutritionally adequate, and may provide health benefits in the prevention and treatment of certain diseases.

• These diets are appropriate for all stages of the life cycle, including pregnancy, lactation, infancy, childhood, adolescence, older adulthood, and for athletes.

• Plant‐based diets are more environmentally sustainable than diets rich in animal products because they use fewer natural resources and are associated with much less environmental damage.”

• https://www.eatrightpro.org/‐/media/eatrightpro‐files/practice/position‐and‐practice‐papers/position‐papers/vegetarian‐diet.pdf

Where Do I Begin?

I want to counsel my patients, but don’t know how or where to start

Counsel your Patient:Step 1

Educate Yourselves

Counsel your Patient:Step 2

Ask your patients what they eat

Counsel your PatientStep 3:

•Counsel your patient:

•Start slow

•Baby steps/Small Changes

•Make substitutions

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5 Simple Rules

Avoid Red Meat

Hamburgers, Meatloaf, Ground Beef, Steak

Avoid Pig

Pork, Bacon, Sausage, Ham

Avoid Processed Meats

Lunchmeat, Sausage, Ham, Salami, Bologna, Brats, Polish, Hot Dogs

Decrease Starch intake

Potatoes, Pasta, Noodles, Rice, Bread

Eat Whole Grain versions instead (but still decrease overall amount)

Avoid Restaurant food

Not just fast food

• The arc of the moral universe is long, but it bends toward justice.• Martin Luther King

• “The arc of achieving optimal health is long, but it bends toward veganism”• Joshua Liberman

•Eat food. Mostly plants. Not too much.

•Michael Pollan, The Omnivore’s Dilemma

The End

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