Nutrition pearls from integrative cardiologist, Steven Devries MD, Associate Professor of Medicine, Northwestern Feinberg School of Medicine, Executive Director of The Gaples Institute. Clinicians receive little nutritional training in medical school and residency. It’s time to fill that gap! We discuss the strength of the literature supporting dietary interventions for cardiovascular health and review practical tips to help patients achieve healthy eating patterns. Patients need to hear from us that nutrition matters!
Written & Produced by: Molly Heublein MD
Hosts: Matthew Watto MD, Paul Williams MD, Molly Heublein MD
Guest: Stephen Devries MD
Editor: Matthew Watto MD
Special thanks to Elena Gibson MS4 for writing our show notes
Nutrition Pearls Show Notes
The average medical student only gets 19 hours of nutritional teaching, primarily focused on biochemistry and nutritional deficiencies. Most residency programs have minimal teaching on nutrition. The ACGME guidelines (hundreds of pages) for training in internal medicine, pediatrics, and cardiology do not even include the words “nutrition”, “diet”, or “food”. -Dr Devries
The Lyon Diet Heart Study compared a control group and a Mediterranean diet group in secondary prevention of cardiovascular events among patients with prior myocardial infarction (MI). Participants were given the following recommendations: (1) eat more fruits and vegetables (2) replace refined grains with whole grains (3) decrease red meat consumption and increase fish and nut intake (4) use olive oil and canola-based margarine as cooking oil. Participants were not instructed to eat a specific amount of any food. In five years, there was a 72% risk reduction of cardiovascular events in the Mediterranean diet group compared to the control.
The PREDIMED Study assessed primary prevention of cardiovascular disease in a group eating a mediterranean diet with high olive oil intake compared to a low fat diet (Estruch 2018 PMID: 29897866). The study was originally published in 2013, and it was then retracted and republished in 2018 due to inconsistencies in randomization. The updated results revealed close to a 30% event reduction in the Mediterranean group compared to controls.
A JAMA article showed that suboptimal diet is responsible for 45% of cardiometabolic deaths (Micha 2017 PMID: 28267855)
If someone is told to eat less of one thing, they will eat more of something else (Remember the reduced fat diet pushed 10-20 years ago? Americans started eating more simple carbohydrates…Uh-oh!). Not all whole grains are made equally. The best are boiled whole. Ground grains like flour have a higher glycemic index.
Take a picture and show patients what healthy servings would look like on a plate.
Avoid naming a specific “diet label” such as Atkins or Mediterranean because these can mean many things. Break each aspect of the diet into specific recommendations e.g. eat more whole grains; avoid processed foods from a bag, box or can, etc.
Avoid focusing on percentages of nutrients or measurements of nutrients/servings (grams of fat, mg of sodium, cups of servings of vegetables). It’s more helpful teach basic concepts and principles of nutrition. Dr Devries admits that calorie counting may be useful initially to make patients aware of the caloric density in their food choices. He notes that calorie counting is unwieldy in the long-term.
When discussing the benefits of consuming monounsaturated and polyunsaturated fats, provide examples of foods. Monounsaturated fats are found in foods such as olive oil and avocados. Polyunsaturated fats include omega 3s and omega 6s. There are two types of omega 3s: marine omega 3s (EPA and DHA) and plant omega 3s (ALA). Marine omega 3s include fish sources, especially cold-water fatty fish such as salmon, mackerel, tuna, herring, and sardines. Examples of plant omega 3s include chia, flax, flaxseed oil, and walnuts. All other vegetable oils contain omega 6s (e.g. corn, sunflower, safflower, soy, and cottonseed). Although there is some thought that omega 6s are pro-inflammatory, this is very controversial and not completely understood. Omega 6s are also commonly used in processed foods, so they do not always keep great company.
Oils are more than just the sum of their fats. Canola Oil is high in alpha-linolenic acid (ALA), a plant source of omega 3. Olive oil has been shown to increase HDL quality (Pedret 2018. PMID: 29956886). Extra virgin olive oil contains a high polyphenol content. It’s been noted that lesser grades of olive oil (e.g. virgin olive oil or VOO) produce a smaller rise in HDL compared to extra virgin olive oil (EVOO). -Dr Devries
Tracking specific nutrient intake is difficult and often unnecessary. While the debate between 1500 vs 2300 mg sodium diets may be useful at a population health level, it is very difficult for patients to recognize these differences. Instead, talk about foods that are high in sodium and suggest healthier alternatives/substitutes.
Cost represents an important and prevalent barrier to healthy eating among patients. Many healthy foods such as avocados, extra virgin olive oil, and fish are not affordable. To address this at the micro/individual level, discuss affordable individualized ideas with patients. If a patient drinks soda, start by replacing soda with water. Dr Devries recommends offering more affordable healthy options like canned beans, canned fish, and frozen fruits and vegetables. It should be noted that frozen fruits and vegetables retain the vast majority of nutritional content.
Dr Devries points out that even if a patient can afford healthier foods, they might not know how to cook those foods. Therefore, ask patients about their familiarity and provide resources or referrals to help them with meal prep to improve the quality of their diet.
Dietary pattern is the most important, but calorie counting can be helpful in the early phases of dietary change to provide a baseline assessment of calorie distribution. Applications to track calories can be helpful. The Lose It app is one popular choice. Avoid a blind focus on calorie counting, since it is too tedious for most people to do consistently. Focus on eating healthy options because it is much more difficult to overeat with whole foods. Set goals for healthy eating choices and physical activity, NOT weight loss. These are changes the patient can make, and there are clear benefits to physical activity and healthy eating without weight loss (Ross Can J Cardiol 2008 PMC: 2794451). Remind patients that even though they haven’t lost weight, they have improved their health and cardiovascular risk in a way that can’t be measured in pounds.
No. For example, low carb or high protein diets don’t seem to have a clear benefit for health over other diets. A recent study (DIETFITS Randomized Clinical Trial) comparing healthy versions of low carb vs. healthy low fat found that people lost identical amounts of weight with both eating patterns (Gardner 2018 PMID: 29466592). Therefore, the QUALITY of the macronutrients is more important. Dr Devries points out that both muffins and apples are carbohydrates, but the type of carbohydrates and overall quality couldn’t be more different.
There is evidence of weight loss benefits (Harris 2018 PMID: 29419624). Animal studies show evidence of longevity benefits, but this hasn’t been studied in humans (Anton 2013 PMID: 23639403). Since extreme fasting diets are unrealistic, a focus on delaying breakfast by 1-2 hours or having dinner an hour earlier may be more practical. This so called intermittent fasting is a hot topic under study [ Mattson 2017 PMID: 27810402 ].
Providers should focus on instilling the value and importance of nutrition, even if it occurs in a very quick and basic way. Try these tactics:
The Gaples Institute for integrative cardiology: education and advocacy to make nutritional education a bigger part of healthcare.
Listeners will be aware of healthy food patterns for cardiovascular risk reduction and be able to translate these recommendations to patient counseling.
After listening to this episode listeners will…
Dr Devries reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
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This was such a good interview with easy suggestions to take to my patients! I also have a health blog and will be referencing the Gaples Institute! Thanks again for another useful hour!
Awesome - thanks so much!
Can you have someone explain the role and benefits of coconut oil and medium chain fatty acids? Coconut is high is saturated fats...but it’s mostly lauric acid which is supposed to be healthy fat?