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EVIDENCED-BASED DIETS AND THEIR ROLE IN HEALTHCARE

MERCY MEDICAL CENTER OUTPATIENT REGISTERED TERRI CLARK AND KRISTEN DECKER REGISTERED VS NUTRITIONIST

• 4 year degree, minimum + accredited internship program • Successful completion of certification exam + licensure within state • Accrediting body – Academy of and Dietetics FOUNDATIONS FOR PROPER NUTRITION

• Healthful eating of a variety of foods, focusing on whole foods and portion control • Individualization of nutrition plan based on patient goals and lifestyle • Nutrition Tracking and Food Logs OBJECTIVES AND OUTLINE

• Evidence-Based Overview • • Ketogenic and Low Diets • Low FODMAP Diet • Mercy Outpatient Nutrition Services • Resources for physicians and patients Meats & Sweets Less often Wine Poultry, Eggs, Cheese and Yogurt in moderation Moderate portions, daily to weekly

Fish and Seafood Mediterranean Often, at least twice a week Drink water Diet Pyramid Fruits, Vegetables, Grains (mostly whole), Olive oil, , Nuts, , Seeds, Herbs and Spices Base every on these foods

Be physically active; Enjoy with others

© 2009 Oldways Preservation and Exchange Trust • www.oldwayspt.org MEDITERRANEAN DIET POTENTIAL BENEFITS

• Improvement of the following conditions: • Depression, Alzheimer's and healthier function • High blood pressure • Lowering of blood and values • Decreased stroked risk and other cardiovascular risk factors • PATTERNS OF PLANT AND ANIMAL INTAKE AND CARDIOVASCULAR MORTALITY

• Adventist Health Study-2 assessed diets of 81,337 men and women from 2002-2007, using food frequency reports. (1) • An average of 9.9 years for follow up was noted among participants – in this time 2,276 deaths were identified as due to cardiovascular disease. • After controlling for several potential confounders, an 18 gram increase in animal protein intake (~1/4 total protein intake) was significantly associated with a higher risk of CVD mortality • There was no significant association found between plant protein intake and CVD mortality • “Healthy diets can be advocated to prefer lower amounts of protein from meat and higher intakes of protein from plant sources, such as nuts and seeds.” BENEFITS OF MEDITERRANEAN DIET

• Diets that emphasize whole, fresh foods and limit sugars, saturated and sodium may prevent and manage and cardiovascular diseases. (1) • The body of research on preventing -related chronic diseases also supports the benefits of a plant-based eating pattern. (2) • The healthfulness of a plant-based diet is emphasized with regards to the American Institute of Research guidelines. (3) DKK1

Ketogenic Diet Very Low Carbohydrate, High

• Ketogenic Diet guidelines are often specific and restrictive with , keeping totals to very low percentages of calories (often between 20-50 grams of total carbohydrate).

SAD (Standard American Diet) Ketogenic Diet Slide 9

DKK1 Decker, Kristen K., 1/14/2019 KETOGENIC DIET BASICS

• Healthy fats and low carbohydrate vegetables are meant to be the foundation: • Olive oil, , olives, , nuts and seeds • Leafy greens, cucumbers, celery, bell peppers, broccoli, , , squash • Saturated fats (butter, bacon, coconut oil, high fat meats) are allowed in moderation but not intended to be emphasized as the only source of fat • Grains, legumes/beans and fruits are essentially avoided during this lowest carbohydrate phase as well as any processed foods or drinks (cereals, breads, crackers, tortillas, pasta, soda, etc.) KETOGENIC DIET

• Benefits • Potential Side Effects • Potential medication weaning (blood • sugar management meds) • Lipid abnormalities (although some • Improvements in mood, sleep, alertness research supports improvements) • Weight loss • Low electrolytes • Improved blood pressure, lipid panel, • Gastrointestinal Hemoglobin A1C • Pancreatitis LOW CARBOHYDRATE DIETS

very low-carbohydrate/ ketogenic diet: 20 to 50 g/day or <10% of total kcal; • low-carbohydrate diet: <150 g/day or <26% of total kcal; • moderate-carbohydrate diet: >130 g/day or 26% to 45% of total kcal; • high-carbohydrate diet: >225 g/day or >45% of total kcal. LOW CARBOHYDRATE DIETS

• For weight loss, a lower carbohydrate goal of 50-150 grams per day generally results in faster and more sustainable weight loss, for many. • For comparison: The USDA dietary guidelines recommend 225-325 grams of carbohydrates per day on a 2,000 calorie diet, which is 45-65% of daily calories. • More research supports reducing the level to less than 100 grams daily to lower postprandial glucose response, reduce serum synthesis, increase HDL, promote satiety. (4) • For those initially using the ketogenic diet, transitioning to a low carbohydrate diet can be a great “end goal” and easier lifestyle to maintain long term. KETOGENIC AND LOW CARBOHYDRATE DIETS

COMMON AND EFFECTIVE USES: THE CHALLENGES:

• • Adherence • Reflux/ Heartburn • Accountability and support – dietitian, doctor, family, friends, • Polycystic Ovarian Syndrome online • Diabetes • Quality resources – websites, • Weight Loss recipes, products and substitutions RESEARCH SUPPORTING LOW CARBOHYDRATE DIETS

• Data from 1,141 obese patients, some with type 2 diabetes, showed that following a very low-carb diet for between 3-36 months resulted in significant improvements in: • Waist circumference, blood pressure, , glucose, A1C, insulin levels and C-reactive protein levels as well as an increase in heart-protective HDL cholesterol (5)

• A long-term study published in August 2010 (Annals of Internal Medicine) involving 115 participants, average age 58, mean BMI 34.6 and an A1C of 7.3% (5,8)

• Compared the effects of a high fat, low-carb (14% daily calories) diet and a low-fat, high-carbohydrate (53% calories) • The results showed that although weight loss was comparable in both groups, the low carb group benefited from greater reductions in use of glucose-lowering medication, blood pressure and triglycerides and larger increases in their HDL cholesterol. RESEARCH…

• 34 randomized adults who were overweight with an A1c greater than 6% in a 12-month study using a very low-carb/ketogenic diet (20 g to 50 g carbohydrate, excluding fiber) or a moderate- carbohydrate (45% to 50% of total kcal), calorie-restricted, low-fat diet with equal retention of 85%. (7) • Both groups received education and support separately throughout the study. • At 12 months, participants in the very low-carb/ketogenic diet group had: • Greater decreases in A1c (from 6.6% to 6.1%) compared with those in the moderate-carbohydrate group (6.9% to 6.7%) • Lost more weight (18# average loss vs. 3.75#) • Had larger reductions or discontinuation of glucose-lowering medications KETOGENIC AND LOW CARBOHYDRATE FINAL THOUGHTS

• Consistent across most low-carb studies is that • Kidney health also shouldn’t be a concern for despite the higher total and saturated fat content, most individuals with type 2 diabetes and individuals tend to benefit from lower normal renal function. It’s important to triglycerides, higher HDL cholesterol, lower C- remember that the low-carb diets studied in the reactive protein levels, and better glycemic scientific literature aren’t necessarily high-protein control – which all translate to lower CVD risk. diets but rather higher-fat diets. • Total LDL cholesterol values usually remain stable but shifts are usually seen in their particle size from the small and dense pattern B to the larger, less harmful pattern A., as explained in August 2005 issue of Nutrition and Metabolism (5) CONSENSUS?

• Ketogenic and low carb diets ARE effective for improvements in diabetes and heart disease risk factors, as well as weight loss • These diets are as or less effective than others if the focus is long term weight loss, as all diet and lifestyle changes must be continued to maintain results • They may not be advised for someone with renal disease or specific CVD markers • The beneficial role of a dietitian to educate and support patients throughout this process, in collaboration with physicians, is backed by research MERCY OUTPATIENT NUTRITION SERVICES 15 + YEARS AT MERCY (LOCATED IN WOMEN’S CENTER)

• Medical Nutrition • Bariatric Program • Mercy Weight Loss Program • Educational Speaking • Media NUTRITION CONSULTATIONS

• Motivational interviewing and assessing readiness for lifestyle changes • Goal setting • Self monitoring – food logs, water intake, activity, weekly weights • Structured meal plans, portion control and suggested products, as needed • Problem solving and additional resources The FODMaP Diet promoting gastrointestinal health with diet FODMaPs Fermentable , , and

• Slowly absorbed, highly osmotic, and rapidly fermented short- chain carbohydrates • Found in both natural and synthetic foods and beverages. • Education on elimination diet of foods high in FODMAPs, gain relief from GI symptoms and eventually add back in foods tolerated.

WHO BENEFITS ON THE FODMAPS DIET

Patients with Usual Symptoms -  Abdominal  Abdominal pain - Intolerance  Abnormal bowel habits - Non-Celiac Sensitivity  Constipation / diarrhea  Excessive gas  Lack of BM satisfaction  Passage of mucous  Fatigue LOW FODMAP DIETARY APPROACH

• Implemented by a FODMAP knowledgeable dietitian • Elimination Phase (2-6 week) • Reintroduction phase (2-4 months - to lifetime) RESEARCH SUPPORTING FODMAPS DIET

Over the past 10 years, the magnitude of evidence for the mechanisms and clinical efficacy of the low FODMAP diet has surpassed any other dietary intervention for IBS, except . Staudacher et al (2017) Gut. Effective treatment for many patients diagnosed with IBS and associated symptoms (75-85% of IBS patients experienced significant, sustainable relief of their IBS symptoms). Australian research at Monash University Numerous clinical studies have found evidence that a low FODMaP diet alleviate symptoms associated with digestive discomfort in people with IBS. Gibson PR, Shepherd SJ ;AmJ Gastroenterol.(2012) MERCY LOW FODMAPS CLASS

• Starting sometime in 2019 (hopefully this Spring) • Small Classes (2-4 participants) • 10 weeks in length with 4 group visits during this duration. • Cost? – unsure at this time. • Our goal is to give the patient a clear understanding of foods to eliminate and eventually re-introduce foods to provide variety of tolerated foods and to avoid nutritional deficiencies. MERCY BARIATRIC SURGERY PROGRAM AND NUTRITION SERVICES MERCY BARIATRIC SURGERY PROGRAM ROLE OF THE DIETITIAN

PRE OPERATIVELY POST OPERATIVELY • Meet Monthly • Educate appropriate post op diets • Promote Safe and Steady weight loss • Liquid, puree, soft, general through nutrition education / behavior • Ensure fluid and protein requirements are change met. • Emphasis on hydration • Encourage continued new eating habits • education • Ensure MVI / min supplements and • Encourage daily exercise Micronutrient deficiencies are avoided MERCY WEIGHT LOSS PROGRAM

• Started program in 2011 • Portions • Led by a dietitian with a focus on • Food Groups evidenced based nutrition • Mindful Eating • Duration: 12 Weeks • Meal Planning • Class Size: 6 to 2 participants • Stimulus Control • Location: Diabetes Center or Main Campus Hospital • Support Network • Cost: $199.00 (Self Pay) • Eating Out MERCY WEIGHT LOSS PROGRAM – STATISTICS

• 70% program retention rate • 285 start / 270 completed class • Average weight loss • 8.6 lbs. (3.7%) within 12 weeks • Several participants with 20+ lbs. lost. • ** What was most weight a participant lost? 32# ! ** MERCY WEIGHT LOSS PROGRAM – WHAT ARE PEOPLE SAYING…

• I now have the tools I need to be • I would recommend this program to successful with food choices and lifestyle anyone. I actually looked forward to the changes. class every week. • I lost enough weight to gain back • Changed a lot of habits to a healthier confidence in myself and to try a lot of lifestyle and lost approx. 27lbs! other things, but I think the support and • Make better choices, realize that weight how I was taught was what the big loss is lifetime of healthy eating, not a benefit. diet. MERCY WEIGHT LOSS PROGRAM HOW DID YOU HEAR ABOUT THE PROGRAM…

• Website (www.mercycare.org/weightloss) • Physician referrals / recommendations • Mercy Mailers and flyers • Word of Mouth MERCY DIETITIANS – OFFICE LOCATED IN THE WOMEN’S CENTER

• Experts in nutrition • We meet the patient’s where they are at • Focus on education and wellness • Timely appointments to help patient grasp concepts • Updated and evidence-based nutrition handouts / resources REFERRING A PATIENT EPIC PROCESS OUTLINE

• Plan  Meds/Orders  • Diagnoses: • Type in: Ambulatory referral for Nutrition • Obesity & morbid obesity Services • Diabetes • Details – open order • • Expected date – at least 1 week out from • Food Allergies current date • Irritable Bowel Syndrome • Reason for referral – MNT Medicare reimbursement, • Celiac Disease must be associated with diagnosis

Mercy Outpatient Nutrition Office: • 319-221-8610 RESOURCES

• Keto and Low Carb: • https://www.dietdoctor.com/low-carb/for-doctors • https://blog.virtahealth.com/low-carb-research-comprehensive-list/ • www.virtahealth.com • Mediterranean • https://oldwayspt.org/health-studies • https://oldwayspt.org/traditional-diets/mediterranean-diet • FODMAPs • www.katescarlata.com • http://www.katescarlata.com/low-fodmapgrocerylist/ REFERENCES

• 1. International Journal of Epidemiology, Volume 47, Issue 5, 1 October 2018, Pages 1603–1612, https://doi.org/10.1093/ije/dyy030

• 2. Franz MJ, MacLeod J, Evert A, et al. Academy of Nutrition and Dietetics nutrition practice guideline for type 1 and type 2 diabetes in adults: systematic review of evidence for medical nutrition therapy effectiveness and recommendations for integration into the nutrition care process. J Acad Nutr Diet. 2017;117(10):1659-1679

• 3. Collins K. New cancer prevention recommendations explained. American Institute for Cancer Research website. http://blog.aicr.org/2018/05/29/new-cancer-prevention-recommendations-explained/. Published May 29, 2018.

• 4. Tian Hu, Lu Yao, Reynolds K, Whelton, P, et al. The Effects of a Low-Carbohdyrate Diet vs. a Low-Fat Diet on Novel Cardiovascular Risk Factors: A Randomized Controlled Trial. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586572 Published September 7, 2015; Nutrients

• 5. Aglaée Jacob, MS, RD, CDE. Low-Carb Diets — Research Shows They May Be More Beneficial Than Other Dietary Patterns. Today’s Dietitian. August 2013 Issue. Vol. 15 No. 8 P. 12 https://www.todaysdietitian.com/newarchives/080113p12.shtml

• Hope Warshaw, MMSc, RD, CDE, BC-ADM, FAADE, and Toby Smithson, MS, RDN, LD, CDE, CCP. Ver y Low-Carbohydrate Diets. Today's Dietitian. November 2018 Issue. Vol. 20, No. 11, P. 28 https://www.todaysdietitian.com/newarchives/1118p28.shtml REFERENCES

• 6. Pasquale Mansueto, Aurelio Seidita, aAberto D’alcamo, and Antonio Carroccio. Nutrition in clinical practice Vol. 30No. 5 Oct. 2015. Role of FODMAPs in patients with IBS

• 7. Saslow LR, Daubenmier JJ, Moskowitz JT, et al. Twelve-month outcomes of a randomized trial of a moderate-carbohydrate versus very low-carbohydrate diet in overweight adults with type 2 diabetes mellitus or prediabetes. Nutr Diabetes. 2017;7:304.

• 8. Tay J, Thompson CH, Luscombe-Marsh ND, et al. Effects of an energy-restricted low-carbohydrate, high unsaturated fat/low saturated fat diet versus a high-carbohydrate, low-fat diet in type 2 diabetes: a 2-year randomized clinical trial. Diabetes Obes Metab. 2018;20(4):858-871.