Christopher Scuderi D.O

Assistant Professor Community Health and Family Medicine University of Florida College of Medicine Jacksonville

Medical Director UF Health Family Medicine and Pediatrics New Berlin Disclosures

 I hated vegetables as a kid

 The truth is I hated them so much that, as a child, I would find novel ways to make them disappear

 The only vegetable I would eat was iceberg lettuce

Introduction question #1

 How often do you talk to your patients with chronic diseases about dietary changes as a therapeutic option?

 A. Never  B. Less than 20% of the time  C. 20-40% of the time  D. 40-80% of the time  E. 80-100% of all encounters

Introduction question #2

 When you do recommend dietary changes for your patients which one do you usually recommend?

 A. Atkins Diet  B. South Beach Diet  C. Paleolithic Diet  D. Weight Watchers  E. Mediterranean Diet  F. Plant-based Whole Foods Diet  G. Vegan Diet  H. Other Objectives

 1. Discuss importance of discussing dietary changes with each of our patients

 2. Review current diets in the literature and popular culture

 3. Evaluate plant-based diets role as an effective part of a treatment plan for common medical diseases

Adult obesity and diabetes in the US Childhood obesity in the US Current CDC data

 Childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years.

 The percentage of children aged 6–11 years in the United States who were obese increased from 7% in 1980 to nearly 18% in 2012. Similarly, the percentage of adolescents aged 12–19 years who were obese increased from 5% to nearly 21% over the same period.

 In 2012, more than one third of children and adolescents were overweight or obese.

http://www.cdc.gov/healthyyouth/obesity/facts.htm

Recent good news

 In 2014 the National Health and Nutrition Examination Survey showed:

 During 2011 to 2012 8% of children between the ages of two and five were obese down from 2003 to 2004 where almost 14% of children in that age group were considered obese.

 The study also found a slight decrease in the obesity rates of children ages six to 11, reporting that the rate had dropped from 18.8 in 2003-2004 to 17.7% in 2011-2012

https://jama.jamanetwork.com/article.aspx?articleid=1832542 Bad news from the same study

 Specifically, from 2003-2004 to 2011-2012, the obesity rates among:  12- to 19-year-olds increased from 17.4% to 20.5%  40- to 59-year-olds increased from 36.8% to 39.5%  Women older than 60 increased from 31.5% to 38.1%

 Overall, the report found that the childhood obesity rate (all children ages two to 19) has remained about constant over the last 10 years, at 17%

 In addition, the study found that 35% of adults ages 20 and above were considered obese in 2011-2012

https://jama.jamanetwork.com/article.aspx?articleid=1832542 Why the improvement in toddlers?

 Overall decreased calorie consumption:  7% less boys  4% less girls  Changes in federal subsidy programs encouraging consumption of more fruits, vegetables and healthy foods  Increase in rates of breast-feeding  Impact of “Let’s Move” and similar campaigns Are we helping?

 2009 disparities study demonstrated physicians discussed food choices with:  52% of their obese Caucasian patients  45% of obese African-Americans  42% of obese Latinos

 In another 2013 study:  Almost all the doctors opened a discussion about weight if the patient was obese  But with overweight patients (B.M.I. 25 to 29.9):  27% of normal-weight physicians discussed diet  Only 16% of physicians with a higher than normal B.M.I. discussed diet http://www.ahrq.gov/research/findings/nhqrdr/nhdr09/nhdr09.pdf In 2013 our patients felt:

http://www.gallup.com/poll/163772/americans-say-doctors-advise-health-habits.aspx Current popular diets

http://www.consultant360.com/articles/todays-diets-do-they-work-fact-versus-fiction 2013 Meta-analysis low carb diets

• Figure 2: Adjusted risk ratios for all-cause mortality associated with low-carbohydrate diets.

• Similar study from Annals of Internal Medicine from 2010 had similar results along with lower mortality for vegetable based low-carb diet http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0055030 Teresa T. Fung, Rob M. van Dam, Susan E. Hankinson, Meir Stampfer, Walter C. Willett, Frank B. Hu; Low-Carbohydrate Diets and All-Cause and Cause- Specific MortalityTwo Cohort Studies. Annals of Internal Medicine. 2010 Sep;153(5):289-298. Other diets lacking long-term evidence

 Gluten-free diet:  Celiac disease  No long-term trial demonstrations of weight loss

 Paleolithic diet:  Diet and lifestyles of our hunter/gatherer ancestors  Emphasizes abundant consumption of vegetables, fruits, nuts, and meats (including bone marrow and internal organs)  Prohibits dairy, legumes, and cereal grains, which did not become part of the human diet until the age of agriculture  No long-term trials showing efficacy yet  Short term trial showed calcium deficiency  Cereal use since 23,000 BC? www.choosemyplate.gov  Typical healthful plate

 ½ Plant foods  Vegetables and fruits

 ¼ Whole grains  whole-wheat flour  bulgur (cracked wheat)  oatmeal  whole cornmeal  brown rice

 ¼ Lean protein  Lean meats  Seafoods  Beans, nuts and soy products Difference between plant-based diet and vegan and vegetarian

 Vegan (total vegetarian diet)  Excludes animal products  Especially meat, seafood, poultry, eggs, and dairy products  Does not require consumption of whole foods  Does not restrict fat or refined sugar

 Raw food vegan  Same principles  Also excludes all foods cooked at temperature > 118’F

 Whole-foods plant-based low fat diet  Encourages plant foods in their whole form  Vegetables, fruits, legumes, seeds and nuts  Limits animal products  Total fat is restricted

Types of vegetarian diets Challenges of vegetarian diets

 Vegetarians may be at risk for deficiency in:  vitamins B12 and D  Iron  Calcium  Zinc  long chain omega-3 fatty acids

 Dietary deficiencies in vegetarians are not as common today as they were decades ago due to:  the availability of fortified products and meat substitutes  greater awareness of the need for balanced eating

Position of the American Dietetic Association: Vegetarian Diets. J Am Diet Assoc. 2009;109:1266-1282. Mediterranean diet

 Similar to whole-foods plant-based diet with some additions

 Encourages plant foods in their whole form  Especially vegetables, fruits, legumes, seeds and nuts  Allows small amount of:  Chicken  Dairy  Eggs  Red meat allowed one to two times per month

 Consumption of fish and olive oil is encouraged

AARP New American Diet  AARP New American Diet promotes the idea of “diet” as a noun—something to live on, rather than something to go on.  Emphasizes “food as medicine,” since food can impact every system of the body.  Diet focuses on consumption of:  Frequent small meals  Water  Whole grains  Healthy fats  Reduced intake of simple sugars and processed foods  Vegetables and fruits are recommended in high quantities  Fish, low-fat dairy, and moderate consumption of red meat are also prominent components

Whyte J. AARP New American Diet: Lose Weight, Live Longer. New Jersey: Wiley; 2013. Importance of plant-based diet

 In 2013 (JAMA) released the results of 96,000 patient study of Seventh-Day Adventists

 Members of the Seventh-Day Adventist Church have the longest life expectancy of all Americans.  6.7 years men  3.7 years women

 Their doctrines call for “clean, healthy living” that includes exercise and “a well-balanced vegetarian diet that avoids the consumption of meat, coupled with intake of legumes, whole grains, nuts, fruits and vegetables…”

 Vegetarians, pesco-vegetarians, and people who eat a Mediterranean diet were all associated with a lower mortality rate

 Vegetarian and plant-based diets were associated with reductions in risks for several major diseases, such as hypertension, diabetes and coronary artery disease

 The study also showed an increased risk of increased mortality from a diet high in sugar, meat (especially red meat and processed meat) and eggs http://media.jamanetwork.com/news-item/vegetarian-diets-associated-with-lower-risk-of-death/ Comparison of Vegetarian With Non-vegetarian Dietary Patterns With Respect to All-Cause and Cause-Specific Mortality From a Cox Proportional Hazards Regression Model Among Participants in the Adventist Health Study 2, 2002-2009

JAMA Intern Med. 2013;173(13):1230-1238. doi:10.1001/jamainternmed.2013.6473 Diabetes Risk in Seventh Day Adventist Study

Odds ratios with 95% confidence intervals for incident diabetes by dietary group adjusted for age, BMI, ethnicity, gender, educational level, income, TV watching, sleep, alcohol, physical activity and cigarette smoking.

S Tonstad et al, Vegetarian diets and incidence of diabetes in the Nutrition, Metabolism & Cardiovascular Diseases (2013) 23, 292e299 Vegetarian diets and hypertension  2014 JAMA meta-analysis :

 In the 7 controlled trials (a total of 311 participants; mean age, 44.5 years)  Consumption of vegetarian diets was associated with :  Lower mean systolic BP −4.8 mmHg and diastolic BP −2.2 mmHg, compared with the consumption of omnivorous diets

 In the 32 observational studies (a total of 21,604 participants; mean age, 46.6 years)  Consumption of vegetarian diets was associated with:  Lower mean systolic BP −6.9mmHg and diastolic BP −4.7mmHg compared with the consumption of omnivorous diets

Yoko Yokoyama, PhD, MPH etAl; Vegetarian diets and blood pressure, a meta-analysis JAMA Intern Med. 2014; 174(4):577- 587. doi: 10.1001/jamainternmed.2013.14547 From: Vegetarian Diets and Blood Pressure: A Meta-analysis

JAMA Intern Med. 2014;174(4):577-587. doi:10.1001/jamainternmed.2013.14547

Figure Legend:

Pooled Diastolic Blood Pressure (BP) Among Vegetarians in Observational StudiesEffects on diastolic BP are depicted as squares; error bars indicate 95% CIs. Meta-analysis yielded a pooled estimate of −4.7 mm Hg (95% CI, −6.3 to −3.1) for diastolic BP, which is depicted as a blue diamond. Arrows indicate that the 95% CI exceeds the left line. Vegan diets were defined as omitting all animal products; vegetarian diets may include some animal products as indicated by the terms lacto (dairy products) and ovo (eggs).

Does race matter in hypertension?

 As compared with non-vegetarians, African American vegetarian/vegans had a 44% lower odds of developing hypertension

 There was no significant difference in risk between pesco-vegetarians and non-vegetarians

Fraser,Gary; Katuli,Sozina; Anousheh,Ramtin; Knutsen,Synnove; Herring,Patti; Fan,Jing; Vegetarian diets and cardiovascular risk factors in black members of the Adventist Health Study-2 Public Health Nutr., 2014, FirstView, Supplement -1, 1- Risk of hospitalization or death from ischemic heart disease among British vegetarians and nonvegetarians: results from the EPIC-Oxford cohort study

No. of cases HR (95% CI) P2

Overall 1235 0.68 (0.58, 0.81) <0.001 Further adjusted 1235 0.72 (0.61, 0.85) <0.001 for BMI Sensitivity analysis Excluding first 2 1133 0.69 (0.58, 0.82) <0.001 years of follow-up Primary diagnosis 938 0.72 (0.60, 0.87) 0.001 of IHD

F Crowe Etal Risk of hospitalization or death from ischemic heart disease among British vegetarians and nonvegetarians: results from the EPIC-Oxford cohort studyAm J Clin Nutr March 2013 vol. 97 no. 3 597-603 Plant-based diet and weight Loss

 2013 study showed that patients who ate a plant-based diet without calorie restriction had nearly twice as much weight loss, compared to diets including meat.

 This was supported by another study from the Journal of the Academy of Nutrition and Dietetics, which compared three groups of patients eating a similar number of calories:  38 % of meat eaters were obese  18% of pesco-vegetarians  9% of vegetarians

N Rizzo Nutrition patterns of vegeterian and nonvegetarian patients; Journal of the Academy of Nutrition and Dietetics - December 2013 (Vol. 113, Issue 12, Pages 1610-1619, DOI: 10.1016/j.jand.2013.06.349) Is variety the spice of life?

 2013 study showed that the amount of fruits and vegetables consumed is more important than variety in lowering the risk of heart disease (1)

 If you can get both variety and a large number of fruits and veggies per day, that’s a bonus.

 A 2014 study in Britain linked 7 daily servings of fruits and vegetables to the lowest levels of mortality (2)

1.S Bhupatharinaju; Quantity and variety in fruit and vegetable intake and risk of coronary heart disease Am J Clin Nutr December 2013 vol. 98 no. 6 1514-1523 2. Oyebode O, et al. J Epidemiol Community Health 2014;0:1–7. doi:10.1136/jech-2013-203500 Nuts (superfood?)

 Another area where we easily can improve diet is by increasing how many times a week we eat nuts

 A 2013 New England Journal of Medicine study revealed that people:  Who ate nuts seven or more times per week had a 20% reduction in all cause mortality  Those who ate nuts at least one time per week had an 11% reduced in risk all cause mortality

Bao,Ying; Han,Jiali; Hu,Frank B.; Giovannucci,Edward L.; Stampfer,Meir J.; Willett,Walter C.; Fuchs,Charles S; Association of Nut Consumption with Total and Cause-Specific Mortality N.Engl.J.Med., 2013, 369, 21, 2001-2011, Massachusetts Me More bad news for meat

 A 2013 European study had two very clear points:

 Daily consumption of at least 5.6 ounces or more of red meat daily was associated with a 14% increased mortality

 Even worse off were folks who ate processed meats, such as salami, bacon. Those who ate at least 5.6 ounces a day of processed meats had a 44% increased mortality

Rohrmann et al.: Meat consumption and mortality -results from the European Prospective Investigation into Cancer and Nutrition. BMC Medicine 2013 11:63.

ADA 2014 Guidelines

 A variety of eating patterns (combinations of different foods or food groups) are acceptable for the management of diabetes. Personal preference (e.g., tradition, culture, religion, health beliefs and goals, economics) and metabolic goals should be considered when recommending one eating pattern over another

 In people with type 2 diabetes, a Mediterranean-style, MUFA-rich eating pattern may benefit glycemic control and CVD risk factors and can therefore be recommended as an effective alternative to a lower fat, higher-carbohydrate eating pattern

 For good health, carbohydrate intake from vegetables, fruits, whole grains, legumes, and dairy products should be advised over intake from other carbohydrate sources, especially those that contain added fats, sugars, or sodium

 People with diabetes and those at risk for diabetes should limit or avoid intake of sugar- sweetened beverages(from any caloric sweetener including high-fructose corn syrup and sucrose) to reduce risk for weight gain and worsening of cardiometabolic risk profile

http://care.diabetesjournals.org/content/37/Supplement_1/S14.full.pdf+html 2013 AHA Recommendations

 For Patients who would benefit from LDL-C lowering:

 Consume a dietary pattern that emphasizes intake of vegetables, fruits, and whole grains; includes low-fat dairy products, poultry, fish, legumes, nontropical vegetable oils and nuts; and limits intake of sweets, sugar-sweetened beverages and red meats

 Aim for a dietary pattern that achieves 5% to 6% of calories from saturated fat

 Reduce percent of calories from saturated fat

 Reduce percent of calories from trans fat

 In addition for patients with hypertension:  Consume no more than 2,400 mg of sodium/day;

http://circ.ahajournals.org/content/early/2013/11/11/01.cir.0000437740.48606.d1.full.pdf In summary

 We should be discussing dietary interventions with each patient

 Plant-based whole foods diets are beneficial in lowering mortality risk, and risks of common diseases

 7 servings a day seems to have the most benefit  5+2

 Fish consumption is also associated with improved mortality

Any questions?

 Thank you for your time

 Please email me if you have any further questions: [email protected]