© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 7

NUTRITION POTPOURRI: FADS AND HOT TOPICS

AMY LOCKE, MD, FAAFPASSOCIATE PROFESSOR

CO-DIRECTOR, RESILIENCY CENTERUNIVERSITY OF UTAH

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

OVERVIEW

• Approaches to a healthy diet– Dietary patterns

• Nutrients vs. foods

• Diets and weight loss• Helping people make lifestyle change

PUTTING IT ALL TOGETHERDietary Patterns

AES POLLING QUESTION

What is the most important dietary change for weight loss?

A. Monitor caloriesB. Low fatC. High fatD. Low carbohydrateE. No one diet has proven superior

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

MEDITERRANEAN DIET

• Lyon Diet Heart Study– Secondary prevention of CVD

• 70% reduction in CV death• 60% reduction of all cause mortality

• Compared to old AHA diet in Metabolic Syndrome1

– Higher resolution of metabolic syndrome• 55% vs. 23%

• Decreased rates of diabetes2

1. de Lorgeril et al. Circulation 1999 2. Esposito et al JAMA 2004 3. Esposito et al. Endocrine 2016

MEDITERRANEAN DIET

• Lower overall mortality1

• The greater the adherence, the stronger the effect• Reduced coronary artery disease and 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

DASH DIET

• Dietary Approaches to Stop Hypertension• Improved cardiovascular risk factors1-3

– Decreased blood pressure– Weight loss– Managing and preventing diabetes

111. Siervo et al. Br. J Nutr 2015. 2. Saneei et al. NMCD 2014. 3. Shirani et al. Nutrition 2013.

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

NUTRITION SUMMARY

• Lots of vegetables and fruits• Whole grains

– Low glycemic load• Lean protein, emphasize plants• Healthy fats• Avoid sugary beverages and processed foods• Limit saturated fat and trans fat

• Appropriate quantity of foods• Moderate alcohol

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

– Increased by 21% with > 2 beverages/day3

– Substituting 1 serving/day with water decreases risk by 5%3

• 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 3. Huang et al. Am J Clin Nutr 2017

MODERATE ALCOHOL CONSUMPTION

• Reduction in CVD1

• Increased breast cancer risk2

– May be mitigated by adequate dietary folate3

• May be less beneficial outside of white race4

• Newer studies bringing benefits into question5

• Don’t recommend start drinking if nondrinker

1. Rimm et al BMJ. 1996 2. Chen et al. Ann Intern Med 2002 3. Zhang et al. JAMA 1999 4. Jackson et al. Am J Public Health 2015 5. Knott et al. BMJ 2015

DIETS AND WEIGHT LOSS

AES POLLING QUESTION

Which of the following has been shown to decrease success of weight loss?

A. Physician’s BMIB. Focus on food quality instead of caloriesC. Focus on high fat/low carb dietsD. Focus on diet over exercise

BARRIERS TO PROVIDING ADVICE

• Time • Priorities for the visit• Expertise/Feelings of inadequacy• Perception of efficacy • Lack of referral options• Stigma/negative physician attitudes

DEVELOPING A CUSTOMIZED PLAN

Detailed History

Review the options

Realistic short-and long-term

goalsEngage team Reassess

LIFESTYLE HISTORY

• Nutrition:• Physical Activity:• Sleep:• Stress: • Social Connection:• Screen time:

QUICK NUTRITION HISTORY

• Fruits and veggies• Eating out• Beverages• Snacks• 24 hr food recall

• Happy with food eaten?• Cooking skills• Time and money constraints

• Gluten free• FODMAPS• Ketogenic• Intermittent fasting• Paleo• Whole30

POPULAR DIETS

Global

Governmental

Agriculture, industry, market

Community Environment

Scociocultural

Individual

Barriers and Opportunities for

Healthy EatingAfshin et al. 2014

• Food knowledge• Cooking skill• Food prep interest• Taste preference• Family expectations• Recognition of satiety• Mindless eating

BARRIERS: NUTRITION• Ability to read food labels• Financial/food availability• Time management

– Hours worked– Child care– Other activities (i.e. TV)

• Emotional eating

ADDITIONAL CONSIDERATIONSSetting the stage

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

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

• Cooking classes– Community– Online

• Chop Chop Magazine

THE SKILL OF COOKING• Community Partnerships

– Dietetics programs– Grocery stores– Culinary schools

• Culinary Medicine

BUILDING THE TEAM

• The office• The health system• The community• The country

• Physician • APRN/PA• Nurse• Medical Assistants

THE OFFICE TEAM

• Pharmacist• Dietitian • Social Work• Psychology• Health Coach

MAKING RECOMMENDATIONS

TAILORING THE MESSAGE

• Fruits and veggies• Healthy fats

• Cut back on fast food• Limit sweet beverages

SOLUTIONS

• Meet patients where they are• Motivators? Goals?• Simple messages• Focus on what to eat

– (less on what not to eat)• Set a good example• Write a prescription

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

• Oldways, cultural food resource, www.oldwayspt.org• The Hunger Within, Marilyn Migliore• Many apps and websites

– My fitness pal, sparkpeople, etc.