#119 Nutrition Pearls, Heart Health, Bacon

October 15, 2018 | By Molly Heublein

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!

Credits

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 from Dr. Devries

1. The Mediterranean diet has been associated with significant benefits in cardiovascular and cardiometabolic health (Lyon Heart Study. Circulation. 1999 PMID: 16512956).
2. Dr Devries avoids prescribing a specific diet (e.g. Mediterranean, South Beach, etc.) and instead makes general recommendations for healthy eating that are easier to conceptualize and follow.
3. Recommendations for a healthy diet should include increases in fruits, vegetables, nuts, fish, plant-protein, and whole grains; And decreases in red meat, saturated fats and processed foods. -Dr Devries
4. Processed meats should NOT be a part of ANY DIET. They are the new trans fats, no amount is a good amount. They were labeled a carcinogen by WHO/IARC in 2015.
5. Examples of affordable healthy options include canned beans, canned fish, and frozen fruits and vegetables. -Dr Devries
6. Focus on setting goals for healthy dietary patterns and physical activity, NOT weight loss or “exercise”. Even making a small change like one more vegetable serving/day can help improve health. -Dr Devries
7. Dr Devries says, “We in primary care send a message about the importance of diet in health when we do or don’t bring it up”. Let’s spread the message that it matters!

Nutrition Pearls Show Notes

Medical Education & Nutrition

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

Mediterranean Diet – The Evidence

Secondary Prevention 1,2,3

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.

Primary Prevention

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.

Cardiometabolic Deaths

A JAMA article showed that suboptimal diet is responsible for 45% of cardiometabolic deaths (Micha 2017 PMID: 28267855)

Nutrition Pearls – Diet Counseling

THINGS TO DO

Discuss aspects of a healthy diet and make recommendations:

• Eat as many vegetables and fruits as you can
• Replace refined grains with whole grains
• Decrease red meat and replace with fish and non-animal proteins
• Consume healthy fats: olive oil (ideal cooking oil).  
• Avoid processed meats: Processed meats are the new trans fat, no amount is okay.  WHO labels these as carcinogens and proinflammatory (Bouvard. Lancet Oncol. 2015 PMID: 26514947)
• Limit foods rich in saturated fats and processed foods

Recommend replacements and describe specifics.

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.

Use a visual representation of portions.

Take a picture and show patients what healthy servings would look like on a plate.

Talk about Snacks

• Good Snacks: Nuts, fruit, small pieces of dark chocolate
• Dangerous Snacks: Foods high in carbohydrates/sugar (donuts, bagels, chips).  These are less satiating and cause blood sugar swings with a rebound in hunger.
• Nuts: Some argue against nuts because of the high caloric intake, but they have been shown to promote weight loss (Mozaffarian 2011 PMID: 21696306).

THINGS TO AVOID

Labels

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.

Percentages and Quantities

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.

Nutrition Pearls – Specific Nutrients

Fats

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.

More on Oils

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

Salt

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.

Top 3 sources of sodium intake in the US

1. Bread
2. Cold cuts
3. Pizza

Barriers to Healthy Eating & Nutrition

Cost

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.

Comfort

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.

Nutrition and Weight loss

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.

Q&A From Listeners

Do macronutrient balances matter?

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.

Intermittent fasting and Nutrition

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 ].

Nutrition Takeaways  

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:

• Identify one item that the patient can work on (e.g. cutting down soda intake, replacing one bag of chips a day with fruit, etc.)
• Convey to the patient that while medication is essential to treatment, it is not enough. Dr Devries notes that achieving health requires paying attention to diet and lifestyle choices.

Plugs/Resources

The Gaples Institute for integrative cardiology: education and advocacy to make nutritional education a bigger part of healthcare.

1. CME for clinicians: 3 hours of clinical and nutritional essentials (Currently $50 usually $75)  
2. FREE learning tool patients: This source features great nutrition information with clear photographic descriptions of healthy eating patterns. It’s free to the public!!

Goals and Learning Objectives

Goal

Listeners will be aware of healthy food patterns for cardiovascular risk reduction and be able to translate these recommendations to patient counseling.  

Learning objectives

After listening to this episode listeners will…

1. Describe some of the pivotal trials around dietary interventions for cardiovascular health.
2. Identify and explain healthy eating patterns
3. Recall the basics of dietary fats and oils
4. Counsel patients on dietary interventions and overcome barriers to healthier eating

Disclosures

Dr Devries reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Time Stamps

• 00:00 Disclaimer
• 00:35 Intro and guest bio
• 02:40 Guest one-liner, book recommendation, favorite failure, nontraditional career path
• 10:10 Nutrition and medical education
• 12:45 Evidence for how nutrition can improve health outcomes
• 15:33 How to describe a heart healthy or Mediterranean diet to patients
• 25:16 Discussion of fats and oils
• 31:44 Food deserts, healthy snacking options
• 37:15 Calorie counting and use of healthy eating apps
• 40:55 How to frame the discussion about a healthful eating pattern with patients
• 47:18 Macronutrient content. Does it matter?
• 52:50 Intermittent fasting
• 54:24 Free resource for patients to learn about nutrition

Links from the show

1. Kitchen Table Wisdom (book) by Rachel Naomi Remen
2. The Gaples Institute – A nonprofit advocating natural strategies balanced with conventional medicine.
3. De Lorgeril M, Renaud S, Mamelle N, Salen P, Martin JL, Monjaud I, Guidollet J, Touboul P, Delaye J. Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease. Lancet. 1994 Jun 11;343(8911):1454-9. Erratum in: Lancet 1995 Mar 18;345(8951):738. PubMed PMID: 7911176.
4. De Lorgeril M, Salen P, Martin JL, Monjaud I, Delaye J, Mamelle N. Mediterranean diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999 Feb 16;99(6):779-85. PubMed PMID: 9989963.
5. Willett WC. The Mediterranean diet: science and practice. Public Health Nutr.  2006 Feb;9(1A):105-10. Review. PubMed PMID: 16512956.
6. Estruch R, Ros E, Salas-Salvadó J, Covas MI, Corella D, Arós F, Gómez-Gracia E, Ruiz-Gutiérrez V, Fiol M, Lapetra J, Lamuela-Raventos RM, Serra-Majem L, Pintó X, Basora J, Muñoz MA, Sorlí JV, Martínez JA, Fitó M, Gea A, Hernán MA, Martínez-González MA; PREDIMED Study Investigators. Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Supplemented with Extra-Virgin Olive Oil or Nuts. N Engl J Med. 2018 Jun 21;378(25):e34. Doi: 10.1056/NEJMoa1800389. Epub 2018 Jun 13. PubMed PMID: 29897866.
7. Mozaffarian, Dariush et al.  Changes in Diet and Lifestyle and Long-Term Weight Gain in Women and Men. N Engl J Med 2011; 364:2392-2404.  June 23, 2011 DOI: 10.1056/NEJMoa1014296
8. Pedret A, Fernández-Castillejo S, Valls RM, Catalán Ú, Rubió L, Romeu M, Macià A, López de Las Hazas MC, Farràs M, Giralt M, Mosele JI, Martín-Peláez S, Remaley AT, Covas MI, Fitó M, Motilva MJ, Solà R. Cardiovascular Benefits of Phenol-Enriched Virgin Olive Oils: New Insights from the Virgin Olive Oil and HDL Functionality (VOHF) Study.  Mol Nutr Food Res. 2018 Aug;62(16):e1800456. doi: 10.1002/mnfr.201800456. Epub 2018 Jul 30. Review.
9. Harris L, Hamilton S, Azevedo LB, Olajide J, De Brún C, Waller G, Whittaker V,
   Sharp T, Lean M, Hankey C, Ells L. Intermittent fasting interventions for
   treatment of overweight and obesity in adults: a systematic review and
   meta-analysis. JBI Database System Rev Implement Rep. 2018 Feb;16(2):507-547. doi: 10.11124/JBISRIR-2016-003248. PubMed PMID: 29419624.
10. Anton S, Leeuwenburgh C. Fasting or caloric restriction for healthy aging. Exp
    Gerontol. 2013 Oct;48(10):1003-5. doi: 10.1016/j.exger.2013.04.011. Epub 2013 Apr 29. PubMed PMID: 23639403; PubMed Central PMCID: PMC3919445.
11. Gardner CD, Trepanowski JF, Del Gobbo LC, et al. Effect of Low-Fat vs Low-Carbohydrate Diet on 12-Month Weight Loss in Overweight Adults and the Association With Genotype Pattern or Insulin Secretion: The DIETFITS Randomized Clinical Trial. JAMA. 2018;319(7):667-679.