Hot Topics In Clinical Hot Topics in Clinical Nutrition Associate Dean for GraduateNutrition and Continuing Robert Baron, MD MS Professor of Medicine Medical Education I would describe my diet as: 1. 2. Balanced, healthy 3. Not as healthy as I want it to be 4. Vegetarian 5. Pesco-vegetarian 6. Mediterranean 7. Low carbohydrate 8. Low glycemic index 9. Gluten-free 10. Paleo None of the above 36% Robert B. Baron MD MS 38% No Relevant Financial Relationships Disclosure 5% B a l a n c e d , h e a l . 11% N o t a s h e a l t h y . 3% V e g e t a r i a n P e s c o - v e g e t a r i . Why Do We Care About What We Eat? 2% M e d i t e r r a n e a n L o w c a r b o h y d r a . 0% 2% L o w g l y c e m i c i . 2% G l u t e n - f r e e 2% P a l e o US Leading Causes of Death, CDC N o n e o f t h e a b . 1. Heart Disease 32.6% 2. Cancer 3. Chronic lower respiratory disease 7.5% 4. Stroke 5. Accidents 6. Alzheimer 7. Diabetes 8. Influenza and pneumonia 2.9% 9. Nephritis, nephrotic syndrome’’’ & nephrosis 2.7% s disease 10. Intentional self-harm (suicide) 2.0% 30.9% 7.0% 6.4% 4.3% 3.7% 1 Robert B. Baron MD MS Hot Topics in Clinical Nutrition Why Do We Care About What We Eat? Lifestyle and Disease US Leading Causes of Death, CDC 1/3 of premature deaths in the U.S. are attributable 1. Heart Disease 32.6% to poor nutrition and physical inactivity. 2. Cancer 30.9% Over 50% of American adults do not get the 3. Chronic lower respiratory disease 7.5% recommended amount of physical activity. 4. Stroke 7.0% Only 10% of Americans eat a healthy diet 5. Accidents 6.4% consistent with federal nutrition recommendations. 6. Alzheimer ’’’s disease 4.3% Too high in calories, saturated and trans fat, 7. Diabetes 3.7% salt, and refined sugars. 8. Influenza and pneumonia 2.9% Too low in fruits, vegetables, whole grains, 9. Nephritis, nephrotic syndrome & nephrosis 2.7% calcium, and fiber. 10. Intentional self-harm (suicide) 2.0% Topics U.S. Calorie Intake Total calories and macronutrient balance Dietary Fiber Calorie consumption in the U.S. has US Dietary Guidelines increased 30% over the past 4 decades. Sodium Year Average Vegetarian Diets and Mediterranean Diets calories Antioxidants and B vitamins consumed Fish oil 1970 2,057 2008 2,674 Recommendations 2 Robert B. Baron MD MS Hot Topics in Clinical Nutrition Top calorie sources in U.S. Extra Calories From Eating Away 1. Grain-based desserts From Home 2. Yeast breads 3. Chicken and chicken-mixed dishes Calories/meal Calories/meal 4. Soda, energy drinks, and sports drinks at home at a restaurant 5. Pizza Normal Weight 550 825 6. Alcoholic beverages Overweight/Obese 625 900 7. Pasta and pasta dishes 8. Mexican mixed dishes 9. Beef and beef dishes 10. Dairy desserts Public Health Nutrition, 2013 Macronutrient Composition Dietary Fiber Macronutrient composition: the relative Plant matter proportions of fat, carbohydrate, and Not digested by human digestive enzymes protein in the diet Some can be digested by gut bacteria Bottom line: Includes a wide range of macronutrient composition is consistent with a healthy diet Cellulose, hemicellulose, pectins, gums, and in most clinical circumstances total calories mucilages, lignins “trumps” macronutrient composition Classified as soluble or insoluble achieving desired calorie intake will achieve most clinical goals IOM: Men 30-38 g/day. Women 21-25 g/day. 3 Robert B. Baron MD MS Hot Topics in Clinical Nutrition Dietary Fiber: Dietary Fiber: The Most Important Nutrient? The Most Important Nutrient? Heart: Lowers LDL, lowers triglycerides Meta-analysis of 22 cohort studies: Diabetes: Reduces blood sugar Every 7 grams of fiber associated with a 9% decrease in CV events Gut: Prevents constipation, hemorrhoids, diverticular disease One portion of whole grains and one portion of legumes, or from two to four Weight: Promotes satiety servings of fruits and vegetables. Threapleton DE, BMJ, 2013 Baron RB, BMJ 2013 Quantifying Dietary Fiber (per serving) Apple: 4.4 Shredded wheat 6.1 Principles of a Healthy Diet Blueberries: 3.6 Brown rice 1.5 White rice 0.3 Orange: 3.0 Peanuts 9.1 Grapes 0.8 Wide variety of foods Asparagus 1.4 Pear: 5.5 Kidney beans 6.8 Raspberries 8.0 High food quality Broccoli 1.1 White bread 0.7 Carrot 1.7 Wheat bread 1.9 Moderation (right quantity) Spinach 3.5 Wheat-bran cereal 7.4 Tomato 1.0 Cornflakes 0.9 Powdered psyllium 3.0 Oatmeal 4.8 4 Robert B. Baron MD MS Hot Topics in Clinical Nutrition “Basic Four” Food Groups (1956) Food Group Pyramid (1992) MyPlate (2010) MyPlate 5 Robert B. Baron MD MS Hot Topics in Clinical Nutrition Dietary Guidelines 2010 Too Many Refined Grains Enjoy food, but eat less Federal guidelines recommend six 1 ounce Make half your “plate” fruits and vegetables; servings per day for a 2000 calorie diet, and half consume beans, whole grains, nuts and seeds should be whole grain. Increase the intake of seafood & fat-free & low-fat milk and milk products The average person eats 8 servings of grains per day, and 7 of the 8 are refined. Drink water instead of sugary drinks Compare sodium in foods and choose the lower v Consume only moderate amounts of lean meats, poultry & eggs What is a serving of grain? Select whole grains 1/2 cup cooked rice or other cooked grain Look for “““whole ””” in the first ingredient 1/2 cup cooked pasta on the label. 1/2 cup cooked hot cereal, such as oatmeal Aim for total carbs/fiber = <10 for 1 six inch tortilla bread and <5 for cereals. 1 slice of bread (1 oz.); ½ bun 1 very small (1 oz.) muffin ½-1 cup ready-to-eat cereal (½ cup = ½ a baseball) 6 Robert B. Baron MD MS Hot Topics in Clinical Nutrition Way Too Much Added Sugar Salt and Public Policy The average person consumes 30 teaspoons of Coronary Heart Disease Policy Model to quantify sugar and sweeteners per day (over 15% of benefits of modest salt reduction in U.S. calories). Benefit through a reduction in systolic blood (Includes cane and beet sugar, high fructose corn pressure from 1-9 mm Hg in selected populations syrup, corn syrup, dextrose, honey) New cases of CHD decrease by 4.7 - 8.3 and The AHA recommends < 6 teaspoons (24 grams) stroke by 2.4 to 3.9 /10,000 of added sugar per day for women, and < 9 (36 grams) for men . Regulatory change leads to wide benefit and is cost-effective A 20 oz. soda has twice that. Bibbins-Domingo K, et al. NEJM 2010 Nutrition Action Health Letter, CSPI, March, 2013 Sodium reduction and BP control in individual patients Dietary Guidelines 2010 Reduce sodium intake to ≤100 meq/d Addressing Sodium: (2.4 g Na): 2-8 mm Hg in SBP 2,300 mg per day for general population DASH Diet: 6 mm alone; 1,500 mg for aged 51+, African Americans & hypertension, diabetes & kidney disease DASH diet plus sodium restriction: 14 mm Na 7 Robert B. Baron MD MS Hot Topics in Clinical Nutrition Sodium Salt in the US Diet But: 1/2 of U.S. would qualify for 1,500 mg recommendation Average current intake 3,400 mg per day (1.5 80% in processed or pre- teaspoon salt) prepared foods Institute of Medicine: May 2013: Limit everyone to 2,300 mg per day (1 teaspoon salt) Evidence doesn’t support lower recommendations Sources: Mattes et al. Top sodium sources in U.S. Sources of sodium in US 1. Yeast breads 2. Chicken and chicken-mixed dishes 3. Pizza 35% from cereal and cereal 4. Soda, energy drinks, and sports drinks products 5. Cold cuts 6. Condiments 26% from meat & meat products 7. Mexican mixed dishes 8% from milk & milk products 8. Sausage, franks, bacon and ribs 9. Regular chees 10. Grain-based desserts 8 Robert B. Baron MD MS Hot Topics in Clinical Nutrition Mediterranean Diet: Healthy fats and good carbs with a big side of fruits and vegetables Primary Prevention of Cardiovascular Disease with a Mediterranean Diet Eat about 1 ounce of nuts NEJM, Feb. 25, 2013 most days 7447 Men and women, type 2 diabetes or at least 3 CV risk factors. 4.8 years 1 ounce of nuts=1/4 cup or a small handful Compared 1) Mediterranean diet supplemented with 4 Tbsp/day of olive oil or 2) with 1 ounce of nuts/day; vs. 3) a low fat diet (the control) But be aware of the calories… Results: 288 cardiovascular events occurred: 3.8% in 1 ounce=160-200 calories the olive oil group, 3.4% in the nut group, and 4.4% in the control group. (P=0.015) 9 Robert B. Baron MD MS Hot Topics in Clinical Nutrition Vegetarian Diets: Vegetarian Diets Observational Study Vegans Adventist Health Study 2 Fruitarians 73,000 participants; 2570 deaths 5.8 years follow-up Lacto-vegetarians Compare: vegans, pesco-; lacto-ovo-; Lacto-ovo vegetarians and semi-vegetarians to non- Pesco-vegetarians vegetariants Pollo-vegetarians Outcome: lowest mortality in pesco- vegetarians and vegans (15-20%). Flexitarians (Semi-vegetarians) Orlich, JAMA IM, 2013 Baron, JAMA IM, 2013 Antioxidants: Antioxidants All-cause mortality Vitamin A 16% increase Meta-analysis of 47 high-quality Beta-carotene 7% increase randomized trials of antioxidants Vitamin E 4% increase 181,000 individuals Vitamin C 6% trend towards increase 25,000 deaths All p << 0.05 except vitamin C Bottom line: actively discourage anti-oxidant use Bjelakovic, JAMA, 2007 Bjelakovic, JAMA, 2007 10 Robert B.