What diet does and why it matters to primary care Jennifer Brunelli, MS, RD, LDN Carolina Panthers Sports Dietitian Manager/Owner, Sports RDpro LLC MyPlate 2005, 2010, 2015* Dietary Guidelines Recommend The 2015 DGA states that healthy eating patterns, including low‐fat or fat‐free dairy 3 Daily Servings of Dairy foods, are associated with reduced risk for Foods several chronic diseases, including cardiovascular disease (strong evidence) and for Those >9 years type 2 diabetes (moderate evidence). Research has also linked dairy intake to improved bone health, especially in children and adolescents.
!" #$%&' $%$% 3 Servings of Milk Deliver a Unique Nutrient Package
“… the amount of many potential Three alternatives to provide servings of sufficient calcium would milk provide too many provide calories and/or be a the same large amount to level of consume daily.” nutrients found in “…bioavailability of the these calcium in vegetable foods products has not been addressed and could pose a concern.”
2015 Dietary Guidelines Advisory Committee Report. Appendix E3.6 https://www.nationaldairycouncil.org/content/2018/three-servings-of-milk-deliver-a-unique-nutrient-package Visit nationaldairycouncil.org for flashcards on cow’s milk and dairy alternative beverages
https://www.nationaldairycouncil.org/content/2018/how-milk- compares-to-various-plant-based-alternative-beverages Nearly 9 in 10 Americans Fall Short on Dairy Recommendations
Americans* consume, on average, <2 cup equivalents of dairy foods/day. Adding just one more dairy serving a day could help close the gap. National Dairy Council. NHANES 2011-2014. *(2+ y)
2015-2020 Dietary Guidelines for Americans Dietary Intakes Compared to Recommendations. Percent of US Population Ages 1 & Older Who Are Below, At or Above Each Dietary Goal EATING DAIRY FOODS IS NOT LINKED TO HIGHER RISK FOR KEY CHRONIC DISEASES and in some cases may be linked to lower risk, according to a review of 20+ studies.
CVD HIGH BLOOD PRESSURE TYPE 2 DIABETES (includes heart attack and stroke)
Total dairy* and cheese Total dairy is associated with Total dairy, yogurt and cheese consumption is associated with lower risk for hypertension (high- consumption is associated with lower risk for stroke (moderate quality evidence) lower risk for T2D (moderate- to quality evidence) high-quality evidence) Cheese and yogurt consumption Total dairy, cheese and yogurt is not associated with higher risk A meta-analysis found eating consumption is not associated for hypertension (moderate- to approximately 3 ounces of with higher risk for CVD high-quality evidence) yogurt (80 g) per day, compared (moderate- to high-quality evidence) to none, is associated with Clinical trials continue to lower risk for T2D Total dairy, cheese and yogurt investigate how dairy products, consumption is not associated including low-fat dairy products, with higher risk for coronary might contribute to a healthy artery disease (moderate- to high- blood pressure in different quality evidence) populations *Dairy foods in these studies are whole, reduced fat, low-fat and fat-free milk, cheese and yogurt OPTIONAL Link to infographic: https://www.nationaldairycouncil.org/content/2019/dairy-foods-key-for-supporting-health Drouin-Chartier JP. Systematic Review of the Association between Dairy Product Consumption and Risk of Cardiovascular-Related Clinical Outcomes. Adv Nutr 2016 Plant-based in Perspective
2015-2020 Dietary Guidelines For Americans Dietary Patterns are Plant-Based and Incorporate Animal Foods
https://health.gov/dietaryguidelines/2015/resources/2015-2020_Dietary_Guidelines.pdf Fad Diets
How to spot a fad diet:
Promise a quick fix
Claims that sound too good to be true
Dramatic statements that are refuted by reputable scientific organizations
Lists of "good" and "bad" foods
Recommendations made to help sell a product
Elimination of one or more of the five food groups (fruits, vegetables, grains, protein, and dairy) Types of Fad Diets
Low carbohydrate
Keto, Atkins, Southbeach, Zone Low fat
Ornish, TLC, Engine 2 Elimination/ Food group restrictive
Whole 30, Paleo Magic foods
Cabbage Soup, Grapefruit Diet Paleo
Paleolithic diet
Emphasizes- lean meat, fish, shellfish, fruit, vegetables, eggs, nuts, and seeds
Excludes- grains, legumes, cereals, dairy, processed foods, refined sugars and added salt Paleo
Image source: Jen Christiansen (Scientific American) Paleo
Late Paleolithic Contemporary Dietary Era Diet Paleo Diet Guidelines for Americans Protein (%) 34% 38% 10-35% Carbohydrate (%) 45% 23% 45-65% Fat (%) 21% 39% 20-35% Calcium (mg) 1580 628 1000
Adapted from: Berggren et al. 2018. Nutrition and Health Info Sheet: The Paleo Diet- For Health Professionals. Paleo
Benefits
Includes nutrient-dense whole fresh foods and encourages limiting highly processed foods containing added salt, sugar, and unhealthy fats
No long-term research to support Limitations
Limitation of grains and dairy - limits key nutrients like fiber, vitamin D, calcium, thiamin, riboflavin and iron.
Limitation of salt and dairy - increases one’s risk for developing iodine deficiency Paleo
Metabolic and physiologic effects from consuming a hunter-gatherer (Paleolithic)-type diet in type 2 diabetes. European Journal of Clinical Nutrition (2015) 69, 944–948; doi:10.1038/ejcn.2015.39 Type 2 Diabetes
Dairy A meta-analysis showed association between total dairy product consumption and the risk of T2DM. The summary RR and 95% CI for high vs. low total dairy product consumption was 0.89 (0.84–0.94) (I2 = 48.81, p = 0.03).
Reference- Tian et al. 2017. Dietary Protein Consumption and Figure. (a) Total dairy products (b) whole milk (c) yogurt and type 2 diabetes RRs for the Risk of Type 2 Diabetes: A Systematic Review and Meta- the highest vs. the lowest intake in all subjects. The RR of each study is represented by a square, 95% CI are represented by the horizontal lines, and the diamond Analysis of Cohort Studies. Nutrients. represents the estimate and its 95% CI. Type 2 Diabetes
Whole Grains
A higher intake of wholegrain is associated with a lower risk of T2DM, as well as an improvement of its major risk factors (overweight/obesity, plasma glucose regulation, postprandial hyperinsulinemia, and insulin resistance) Schematic outline of plausible mechanisms of action by which wholegrain could influence glucose homeostasis and T2DM risk development. PYY: peptide YY; CCK: cholecystokinin; GIP: gastric inhibitory peptide; GLP-1: glucagon like peptide 1; FFA. Free fatty acids; TG triglycerides; and SCFA: short chain fatty acids, ↓ decrease, ↑ increase.
Reference- Della Pepa, Giuseppe et al. “Wholegrain Intake and Risk of Type 2 Diabetes: Evidence from Epidemiological and Intervention Studies.” Nutrients vol. 10,9 1288. 12 Sep. 2018, doi:10.3390/nu10091288 Ketogenic Diet
KETO MACRONUTRIENTS Fat Protein Carb History- 1st used in 1921 to treat epilepsy Extremely low carbohydrate diet 10% Purpose- Force the body to use ketones for energy instead of blood glucose 30%
60% Ketogenic Diet Ketogenic Diet
Short-term side effects- nausea, vomiting, headache, fatigue, dizziness, insomnia, difficulty in exercise tolerance, and constipation, sometimes referred to as keto flu
Long-term side effects- hepatic steatosis, hypoproteinemia, kidney stones, and vitamin and mineral deficiencies
Complications often lead to emergency room visits and admissions for dehydration, electrolyte disturbances, and hypoglycemia
Long-term compliance = low Ketogenic Diet
Does it work? Useful for some people with uncontrolled epilepsy Current Research - cancer and diabetic populations Obesity
Meta-analysis conducted by Bueno et al. (2013)- ketogenic diet was associated with < 1 kg of additional weight loss over high-carbohydrate, low-fat strategies
Meta-analysis conducted by Hall et al. (2016)- energy expenditure and fat loss was greater with low-fat diets compared with ketogenic diets Concern for general population - high fat content combined with restrictions on nutrient-rich fruits, vegetables and grains
Meta-analysis conducted by Aune el al. (2016)- whole grain intake was associated with a dose-dependent reduction in risk of coronary heart disease, cardiovascular disease, total cancer, and all-cause mortality Ketogenic Diet
Seidelmann, Sara B et al. 2018. Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis. The Lancet Public Health, Volume 3, Issue 9, e419 - e428 Whole 30
A popular 30-day nutrition challenge created by Doug and Melissa Hartwig and promoted on their website (whole30.com) and through their several best-selling books
Elimination Diet
Allowed- Meat, Seafood, Eggs, Fruits, Vegetables, Natural fats, Herbs, Spices, Seasonings
Eliminates- Sugar, Alcohol, Grains, Legumes, Dairy, Carrageenan, MSG, Sulfites, Baked Goods, Junk Food, Treats (even with approved ingredients) Whole 30
Unanswered Questions
No short or long term studies
Why 30 days?
How should people shift diet after 30 days?
Long-term effect of categorizing foods as good vs bad Intermittent Fasting
Any period of voluntary food restriction Protocols are varied and might include: Religious fasting Time restricted feeding Scheduled days of extreme caloric restriction followed by normal or high calorie days Intermittent Fasting
Research
Has not demonstrated that alternate-day fasting regimens produce superior weight loss in comparison to standard, continuous calorie restriction weight-loss plans
There are considerable observational data on various forms of religious fasting
Suggest that these regimens result in transitory weight loss
Mixed impacts on other biomarkers
Data are lacking regarding the impacts of intermittent fasting on other health behaviors, such as diet, sleep, and physical activity
There are limited data linking intermittent fasting regimens with clinical outcomes (diabetes, cardiovascular disease, cancer, or other chronic diseases, such as Alzheimer's disease) Intermittent Fasting
Future Studies Needed: Modified fasting regimens appear to promote weight loss and may improve metabolic health
Insufficient data to determine the optimal fasting regimen:
Length of the fasting interval
Number of fasting days per week
Degree of energy restriction needed on fasting days
Recommendations for dietary behavior on nonfasting days Large-scale randomized trials of intermittent fasting regimens in free-living adults are needed Studies should examine effects on not only weight, but also body composition Within Day Energy Balance Within Day Energy Balance
From Deutz R, Benardot D, Martin D, Cody MM. Relationship between energy deficits and body composition in elite female gymnasts and runners. Med Sci Sports Exerc.2000;32(3):659–68. Effects of Dieting
Negative Health Effect- increased risk of heart disease Negative impact on metabolism Missing key nutrients
Example- calcium
Increased risk for osteoporosis, stress fracture, and broken bones Can lead to eating disorders How to counsel patients
Determine the nutrition and obesity prevention and treatment messages you have the time and skill to provide to your patients Recognize the difference between advising patients on the basics and the in-depth counseling provided by an RDN
An RDN has the knowledge and skills needed to help individuals make changes that can affect outcomes Know when to refer to RDN
Could be one of the most important ways that health care professionals help patients learn about, implement and sustain behavior changes Questions?