Plant-based Eating: Enhancing Health Benefits, Minimizing Nutritional Risks
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Learning Objectives
At the end of the session, the participants will be able to:
1. Know there is no single definition of a plant-based diet.
2. Discuss health aspects of vegetarian and vegan diets and quality of evidence supporting health claims.
3. Assess nutritional adequacy/status of vegetarians and/or vegans throughout the life cycle and provide strategies for meeting dietary recommendations for vitamin B12, DHA calcium, and zinc.
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Plant-based Eating: Enhancing Health Benefits, Minimizing Nutritional Risks
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and Cooperative Extension professionals to research
and to each other through engaging online learning opportunities
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MFLN Intro
Sign up for webinar email notifications at militaryfamilies.extension.org/webinars
3. Dr. Kathy Kolasa
•Volunteer faculty at the Brody School of Medicine
and consultant to Vidant Health hospital system
•Co authored module on Medical Nutrition Therapy
for the American Board of Preventive Medicine
lifestyle Medicine curriculum.
•Past President of the Society for Nutrition Education
and Behavior
Today’s Presenters
3
Dr. Roman Pawlak
•Associate Professor, Department of Nutrition
Science, East Carolina University
•Worked on Vegetarian Nutrition Evidence Analysis
Project for the Academy of Nutrition & Dietetics
•Authored eight books in five languages
•Research interests: Vitamin B12, vegetarian diets
4. Roman Pawlak, PhD, RD
East Carolina University
Department of Nutrition Science
Kathryn Kolasa, PhD, RDN, LDN
Brody School of Medicine
Department of Family Medicine
Plant-based Eating:
Enhancing Benefits,
Minimizing Nutritional Risks
8. DISCLOSURES
Pawlak R.
I have been a vegetarian for the last 34 years
with the last 16 years being a practical vegan
(vegan at home but using cheese and yogurt
while traveling overseas) due to my religious,
ethical, and health reasons.
Kolasa K.
I usually follow a DASH eating approach to
manage weight and blood pressure – since 8
9. By the end of the session,
participants will be able to identify:
Health benefits associated with
vegetarian diets
Nutritional risks associated with
vegetarian diets
Practical applications
9
10. 10
POLL
The Vegan way of eating is the healthiest:
Strongly agree
Agree
Neither agree or disagree
Disagree
Strongly disagree
13. Plant-based Nutrition –
No single definition
A whole-food, plant-based diet is centered on whole, unrefined,
or minimally refined plants; based on fruits, vegetables, tubers,
whole grains, and legumes; excluding or minimizing meat
(including chicken and fish), dairy products, and eggs—using
plant based proteins, as well as highly refined foods like
bleached flour, refined sugar, and oil (from forksoverknives.org).
– Interest and ability of our patients to follow
varies
13
14. Plant-based Nutrition –
No single definition
• USDA Healthy Vegetarian Eating Pattern defined in 2015-2020
Dietary Guidelines (Appendix 5) and reflex eating patterns
reported by self-identified vegetarians in NHANES. Dairy and
eggs are included because consumed by most. Can be vegan
if all dairy choices are fortified soymilk or other plant based
dairy subs and eggs eliminated (https://health.gov)
• Other terms used
– Lacto-ovo-vegetarian: no flesh but may have eggs/dairy
– Vegan: no flesh, eggs, dairy, honey
– Pesco: allows fish/seafood
– Semi: occasional beef, pork, poultry
14
15. What are the health
benefits of following a
plant-based diet?
Share in the chat pod.
What are the health
benefits of following a
plant-based diet?
Share in the chat pod.
15
18. Effects of Vegetarian Diets on Blood Lipids:
A Systematic Review and Meta-Analysis of
Randomized Controlled Trials
Wang et al. J Am Heart Assoc. 2015;4:e002408
“Vegetarian diets significantly lowered blood concentrations of TC,
LDL-C, and HDL-C. The pool estimated changes were:
– TC: - 0.36 mmol/L (95% CI 0.55 to 0.17; P<0.001),
– LCL-C: - 0.34 mmol/L (95% CI 0.57 to 0.11; P<0.001),
– HDL-C: - 0.10 mmol/L (95% CI 0.14 to 0.06; P<0.001), …
Vegetarian diets did not significantly affect blood
triglyceride concentrations with a pooled estimated mean
difference of - 0.04 mmol/L (95% CI 0.05 to 0.13; P=0.40).”
TC: - 0.36 mmol/L (95% CI 0.55 to 0.17; P<0.001),
LCL-C: - 0.34 mmol/L (95% CI 0.57 to 0.11; P<0.001),
HDL-C: - 0.10 mmol/L (95% CI 0.14 to 0.06; P<0.001), …
18
19. Vegetarian Diets and Blood Pressure:
A Meta-Analysis
Yokoyama et al. JAMA Internal Medicine, 2014;174:577-587
Comparison of systolic BP between vegetarians and
non-vegetarians in observational studies
19
20. Vegetarian Diets and Blood Pressure:
A Meta-Analysis
Yokoyama et al. JAMA Internal Medicine, 2014;174:577-587
Comparison of diastolic BP between vegetarians
and non-vegetarians in observational studies
20
21. Vegetarian diets and glycemic control in diabetes: a
systematic review and meta-analysis
Yokoyama et al. Cardiovasc Diagn Ther 2014;4(5):373-382
Mean change in HgA1c
“Consumption of
vegetarian diets
is associated
with improved
glycemic control
in type 2
diabetes.”
21
22. Adherence to a Vegetarian Diet and Diabetes
Risk: A Systematic Review and Meta-Analysis of
Observational Studies
Lee & Park, Nutrients, 2017;9:603; doi:10.3390/nu9060603
“This meta-
analysis
indicates that a
vegetarian diet
is inversely
associated with
diabetes risk.”
22
23. 28.8 27.3 26.3 25.7
23.6
0
5
10
15
20
25
30
35
Type of Vegetarian Diet, Body Weight, and
Prevalence of Type 2 Diabetes
Tonstad S., et al Diabetes Care 2009;32:791–796
Mean BMI by diet group
> 40 lbs 23
24. “Measurable clinical improvements take place in
short order in response to substantial lifestyle
change. Often, participants were able to decrease
or discontinue antidiabetic, hypolipidemic, and
antihypertensive medication. Reductions in
important markers of coronary risk, such as serum
lipid levels, were significant and rapid.”
Coronary Risk Reduction Through Intensive Community-Based
Lifestyle Intervention: The Coronary Health Improvement
Project (CHIP) Experience
Diehl. Am J Cardiol 1998;82:83T–87T
24
25. Coronary Risk Reduction Through Intensive Community-Based
Lifestyle Intervention: The Coronary Health Improvement
Project (CHIP) Experience
Diehl. Am J Cardiol 1998;82:83T–87T
Measurable clinical improvements take place in short
order in response to substantial lifestyle change
Participants were able to decrease or discontinue
antidiabetic, hypolipidemic, and antihypertensive
medication.
Reductions in important markers of coronary risk, such
as serum lipid levels, were significant and rapid
25
28. A Whole-Food Plant-Based Diet Reversed
Angina without Medications or Procedures
Massera et al. Case Reports in Cardiology, 2015; ID 978906
A 60-year-old man presented with typical angina and had a positive stress test.
He declined both drug therapy and invasive testing. He chose to adopt a whole-food
plant-based diet.
Patient’s functional capacity
Sept.
2012
Able to
walk 1 to
2 blocks
Jan.
2013
Able to
walk
1 mile
Oct.
2013
Jog 2
miles
Sept.
2014
Jog 4+
miles
“His clinical
improvement
continued and at
our most recent
visit, two years
after initial
presentation, he
was able to jog
more than 4 miles
without incident.”
“A whole-food
plant-based diet
helped reverse
angina without
medical or invasive
therapy. It appears
prudent that this
type of lifestyle be
among the first
recommendations
for patients with
atherosclerosis.”
28
29. A Whole-Food Plant-Based Diet Reversed
Angina without Medications or Procedures
Massera et al. Case Reports in Cardiology, 2015; ID 978906
• Chicken
• Fish
• Low fat dairy
• Some vegetables
• Some fruits
• Some nuts
Diet afterDiet before
• Vegetables
• Fruits
• Whole grain products
• Potatoes
• Legumes
• Nuts
29
31. • Experimental group (N = 28)
low-fat (6.8% of energy) vegetarian diet
stopping smoking
stress management training
moderates exercise
• Control group (N = 20)
Can lifestyle changes reverse
coronary heart disease?
The lifestyle heart trial
Ornish D. et al., Lancet 1990;336:129-133
31
32. Changes in symptoms among
the experimental group
Changes in symptoms
among the control group
Can lifestyle changes reverse
coronary heart disease?
The lifestyle heart trial
Ornish D. et al., Lancet 1990;336:129-133
32
33. Intensive lifestyle changes for
reversal of Coronary Heart Disease
Ornish et al. JAMA 1998;280:2001-2007
30
35
40
45
50
55
60
Diameter
stenosis(%)
Control
Treatment
Baseline 1 year 5 years
40.7
41.3
38.5 37.3
42.3
51.9
“More regression of coronary atherosclerosis occurred
after 5 years than after 1 years in the experimental group.”
33
34. Intensive lifestyle changes for
reversal of Coronary Heart Disease
Ornish et al. JAMA 1998;280:2001-2007
Diet adherence and change in percentage
diameter stenosis
Most adherence
Middle
adherence
Least
adherence
-6.81
-3.02
-0.37
n = 6 n = 7 n = 6
Changesindiameterstenosis
baselineto5years(%)
“The experimental
group’s marked
reduction in
frequency, severity,
and duration of
angina after 1 year
was sustained at
similar levels after 5
years.”
34
35. Intensive lifestyle changes for
reversal of Coronary Heart Disease
Ornish et al. JAMA 1998;280:2001-2007
“These ambulatory patients were able to make and maintain
comprehensive changes in diet and lifestyle for 5 years and showed
even more regression of coronary atherosclerosis after 5 years than
after 1 years as measured by percent diameter stenosis. In contrast,
patients following more conventional lifestyle recommendations showed
even more progression of coronary atherosclerosis after 5 years than
after 1 year, and had more then twice as many cardiac events as
patients making comprehensive lifestyle changes.”
35
36. Vegetarian
diets
Reduce risk of
cataract
Reduce risk of
diabetic
complications
Decrease risk
of diverticular
disease
Prevent relapse of
Crohn’s disease
Possible
reduce risk of
kidney failure
Possible reduce
risk of dementia/
Alzheimer’s
Reduce risk of
some cancers
Possible
reduced risk of
gallstones
36
38. 38
POLL
Which of the following constitute nutritional
risks for vegetarians?
Protein
Vitamin D
Iron
Vitamin B12
Essential fatty acids
39. Is Vitamin B12 Deficiency a Risk Factor for
Cardiovascular Disease in Vegetarians?
Pawlak R. Am J Prev Med 2015;48(6):e11–e26
39
40. Is Vitamin B12 Deficiency a Risk Factor for
Cardiovascular Disease in Vegetarians?
Pawlak R. Am J Prev Med 2015;48(6):e11–e26
41. DHA Status of Vegetarians
Sanders T. Prostaglandins, Leukotrienes and Essential Fatty
Acids, 81, 137–141
Fatty acids Vegans Omnivores
MUFA 11.1±0.5 11.5±0.2
18:2n-6 LA 24.8±1.8 12.0±0.4
18:3n-3 ALA 2.2±0.16 1.3±0.05
20:5n-3 EPA ND 0.2±0.02
22:6n-3 DHA ND 0.3±0.03
Intake of essential fatty acids
41
42. DHA Status of Vegetarians
Sanders T. Prostaglandins, Leukotrienes and
Essential Fatty Acids, 81, 137–141
Proportion of DHA in RBC, platelets & plasma lipids
42
43. Proportion of DHA in RBC, platelets & plasma lipids
DHA Status of Vegetarians
Sanders T. Prostaglandins, Leukotrienes and
Essential Fatty Acids, 81, 137–141
43
44. Pawlak et al. Am J Lifestyle Med. https://doi.org/10.1177/1559827616682933
Among female vegetarians,
•% of ferritin <12 μg/L or <12 ng/mL ranged from 12%
to 79%.
•% of hemoglobin < 120 g/L ranged from 6% to 30.3%.
Among males,
•% of ferritin <12 μg/L ranged from 1.7% to 29%.
•% of hemoglobin < 115 g/L was 0% and < 140 g/L was
15.3%.
44
45. Practical applications
As they pertain to health reasons for following a Plant Based Diet ----
not all the other reasons why individuals are
increasingly choosing plant based diets
(e.g. environment, animal rights, ethical or religious issues, cost, peer
pressure)
45
46. Help your patient understand how a plant
based diet impacts chronic conditions:
• Research indicates that plant-based diets improve cardiovascular
disease risk factors including:
– Blood pressure (strong)
– Serum Triglycerides and LDL-C (without significantly altering HDL-C
or TG) (strong)
– Blood glucose and Hg A1c (fair*)
– Weight status (BMI) (strong)
– Risk of IHD (fair*)
– Reverse atherosclerosis (fair*)
Ratings by Pawlak, 2016 46
47. Help your patient understand how a plant
based diet impacts chronic conditions:
• Research ALSO indicates that plant-based diets decrease risk of
– Most types of cancer (fair*)
– Cataract (weak*) almost no study of whole food plant
based diet
– Diverticular disease (weak*)
– Crohn’s disease (weak*)
– Overall and disease specific mortality (fair*)
*rating primarily because of limited data—need quality studies
Ratings by Pawlak, 2016 47
48. Take evidence based approach: 2015 DGA
Assess where your patient’s diet currently is and help them move
to one that meets their health needs and personal goals
1. Follow a healthy eating pattern across the lifespan
2. Focus on variety, nutrient density, and amount
3. Limit calories from fats; reduce sodium and
4. Shift to healthier food and beverage choices
5. A healthy eating pattern include: variety of vegetables from all groups (dark green,
red & orange, legumes, starchy); fruits, especially whole; grains—at least half are
whole; fat free or low fat dairy and/or fortified soy beverages; variety of protein foods
from seafood, lean meats and poultry, eggs, legumes, nuts, seeds, soy products; &
oils limits sat fats and trans fats, trans fats & added sugar and sodium (DGAC,
2015)
48
49. • Use the 5 A’s approach to counsel a patient for dietary
change: Ask, Advise, Agree/Assess, Assist, Arrange
• The 5A’s approach recommended in 2002 by U.S.
Preventive Services Task Force as an evidence based
approach to behavioral counseling (Whitlock, 2002);
adopted in 2011 by CMS as an evidence based approach
for intensive behavioral therapy for obesity benefit
• Use SMART Goals; Small Change
– Specific, significant, stretching
– Measurable, meaningful, motivational
– Attainable, achievable, agreed upon, action oriented
– Realistic, relevant, reasonable, rewarding, results
oriented
– Trackable, timely, tangible
Patient Centered Counseling:
Use 5 A’s
49
50. S.K. Agrees to Work Toward
Plant Based Eating Approach
• SK who is overweight, meets the criteria for metabolic
syndrome; follows a “good southern food” diet—she is seeking
life balance and reduced risk for chronic disease
• ADVISE: brief overview of health benefits of whole plant
based eating approach and description of DASH,
Mediterranean and USDA Vegetarian approaches; risks and
benefits of meat
• AGREE:
– Replace sausage biscuit with yogurt and berries for breakfast 2
days/week,
– Bring soy meal replacement shake for lunch,
– Think about appointment with RDN and/or on-line weight class,
– Likes the sound of Mediterranean so she will complete
Mediterranean diet screening tool to determine what changes she
needs to make (Rumawas, 2009; Kolasa, 2010)
– To join her daughter in eating plant based foods at dinner instead of meat
50
51. Risks and Benefits of Red Meat Consumption
• Growing consensus that consumption of red meat, especially
processed, increases risks for chronic diseases including
increased risks for
– At 3.5 oz/day: Stroke (11%), breast cancer (11%),
cardiovascular mortality (15%) colorectal cancer (17%),
advanced prostate cancer (19%),
– At 1.7 oz/day: total prostate cancers (4%), cancer mortality
(8%), breast (9%)< colorectal (18%), pancreatic cancer
(19%), stroke (13%), diabetes (32%),
– ?components in meat (e.g. saturated fat), environmental
contaminants (e.g. PCBs), residues (e.g. hormones,
antibiotics), substances created in cooking (PAHS, HAAs),
additives (e.g. large amts of sodium, nitrates/nitrites)
• Wolk A. Potential hazards of eating red meat. J Internal Med. 2016; DOI:
10.1111/joim.12543
51
52. Risks and benefits of red meat consumption
• 2015 Dietary Guidelines for Americans
– Beef, veal, pork, lamb and mutton contribute essential amino
acids, vitamins (including B12) and minerals (including iron
and zinc).
– Recommendation is for “meats, poultry and eggs” .. In a
2,000 calorie diet, 26 ounces per week. Suggest eating lean
meats. Does not restrict “RED”. May include processed
meats and poultry as long as total intake of sodium, calories
from sat fat and added sugar are within limits.
• In 2007 World Cancer Research Institute suggested people
who eat red meat consume less than 18 oz a week, very little if
any to be processed (cured, smoked, salted, with added
chemicals—ham, sausages, bacon, franks, salami)
52
53. Will their health goals be met by –
DASH: A plant-based diet
(Evidence Level A) to promote lower blood pressure,
lower cholesterol, healthy weight
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
• 10 servings fruit and vegetables (need not be fresh)
• 8 servings grains
• 3 servings low fat dairy
• Less than 6 ounces of meat, fish, poultry
• 4-5 servings nuts/week
• 31 grams fiber, 2,400 mg sodium, 4700 mg potassium, 500 mg
magnesium, 1,240 mg calcium
2016 US News & World Reports: Best and Healthiest Diet Plan
53
54. Will their health goals be met by –
DASH: A plant-based diet
(Evidence Level A) to promote lower blood pressure,
lower cholesterol, healthy weight
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/
EVIDENCE OF BENEFIT CONTINUES TO GROW SINCE INTRODUCTION IN 1997
•Blood pressure: meta analysis of 24 RCTs net effect of -7.62mm Hg systolic
and -4.22 mm Hg diastolic—replacement for one medication
•Weight loss and Blood Pressure in African Americans; up to 35 pounds
•Lower LDL-C about 0.3 to 0.4 mmol
•Lower TG about 14-18 md/dL
•Depending on other factors raises HDL-C up to 10 mg/dL
•Improves insulin resistance; lowers FBG 8-15 mg/dL
•Reduces bone turn-over—prudent for bone health
•Improves heart failure if also have high blood pressure
•Reduced risk of kidney stones
•Possible reduced risk of depression
54
55. • An abundance of food from plant sources
• Emphasis on a variety of minimally processed and, wherever
possible, seasonally fresh and locally grown foods
• Olive oil as the principal fat, replacing other fats and oils
• Total fat ranging from less than 25 percent to over 35 percent of
energy, with saturated fat no more than 7 to 8 percent of energy
(calories).
• Daily consumption of low to moderate amounts of cheese and
yogurt
Will their health goals be met by the - Mediterranean: A plant-based diet
(Evidence Level B in U.S.) to promote lower blood pressure, lower
cholesterol, healthy wt, lower cancer risk, anti-inflammatory
55
56. • Twice-weekly consumption of low to moderate amounts of fish
and poultry (recent research suggests that fish be somewhat
favored over poultry); up to 7 eggs per week (including those
used in cooking and baking).
• Fresh fruit as the typical daily dessert
• Red meat a few times per month
• Regular physical activity at a level which promotes a healthy
weight, fitness and well-being.
• Moderate consumption of wine, normally with meals; about one
to two glasses per day for men and one glass per day for
women.
• http://www.oldwayspt.org/mediterranean-diet-pyramid
Will their health goals be met by the - Mediterranean: A plant-based diet
(Evidence Level B in U.S.) to promote lower blood pressure, lower
cholesterol, healthy weight, lower cancer risk, anti-inflammatory
56
58. Bottom line for those choosing plant-
based diet
• Plant-based diets composed of a variety of grains (preferably whole
grains), fruits, and vegetables (including legumes), nuts and seeds
provide adequate amounts and quality of protein, fats, carbohydrates
and dietary fiber.
• Help patients plan nutritionally adequate diets
• Such diets do not provide adequate amounts of direct sources of
vitamin B12 or long chain essential fatty acids (EPA & DHA).
• Help patients recognize supplemental need for B12, EPA & DHA
58
59. Balance benefits of fish with risks
• Need 1 - 6-oz serving oily fish
• If eat >2 servings, eat a variety to avoid accumulated
exposure
• <12 yrs old and pregnant women can safely eat 12 oz/wk;
avoid shark, tilefish, swordfish, king mackerel, golden bass,
albacore tuna, local catches from contaminated waters
• Modest fish intake reduces CHD death by 36% or 9-18%
effect on total mortality (statins effect is 15%)
– www.noaa.gov
59
60. Be aware of symptoms of B12 deficiency – pediatric
population
HematologicAnthropometric Other
Anorexia
Lethargic
Lack of responses to
stimuli/interaction with
people
Hopotonic
Muscular weakness
Involuntary movements
Slow/abnormal EEG
Delays in speech
development
Developmental delays/fall
in growth curves
Weight < 10th
percentile
Height < 10th
percentile
Head circumference <
10th
percentile
Unable to sit alone
Unable to walk
Involuntary movements
Hyperpigmentation
Abnormal fine and gross
motor function
Elevated MMA
Elevated Hcy
Low or “normal” B12
Low Hg and hematocrit
Pancytopenia
Low or subnormal RBC
Low or subnormal WBC
Low or subnormal platelets
60
61. Be aware of symptoms of B12 deficiency –
adults/elderly population
HematologicNeurological General
Fatigue
Disorientation
Numbness and tingling
Tingling
Paresthesia
Burning pain in lower
limbs
Tremors
Restless leg syndrome
Sleeping difficulties
Gait
Cognitive decline
Short term memory
lapses
Depression
Onset of irrelevant speech
Slurring of speech
Low or “normal” B12
Low Hb and hematocrit
Pancytopenia
Low or subnormal RBC
Low or subnormal WBC
Low or subnormal
platelets
Elevated MMA (>271
nmol/L)
Elevated Hcy (>10µmol/L)
61
62. Need to consider supplements of these nutrients
• If young adults include foods/beverages fortified with
vitamin B12 might not need supplements
• For most, vitamin B12 supplement needed with the
dose being age, medical condition and life stage
dependent; varying from 250 to 1,000 µg
• Algal EPA & DHA supplements are prudent to ingest
with a combined dose of ~500 mg/d
• Calcium if inadequate intake from food—enough to
meet the DRI
Bottom line for those choosing plant-
based diet
62
63. Calcium and Bone Health vs. CVD?
• Calcium recognized in 2015 DGA as under-consumed
• Mrs. JH
– Has family history heart disease
– Diagnosed with osteopenia. Instructions on her bone density
report: “hormonal therapy, dietary supplementation and weight
bearing exercise may prevent further bone loss. Maintain an
intake of 1,500 mg calcium daily with 600 IU vitamin D.”
– She follows a plant based diet and gets only 500 mg calcium
from food. She is supplementing with 1,000 mg calcium
carbonate.
Individuals truly unable to meet their Dietary Reference Intake
(DRI) for calcium through diet should use the lowest dose of
supplement necessary to meet DRI; split doses into multiple
smaller doses per day.
63
64. What are some good
plant-based sources of
calcium?
Share in the chat pod.
What are some good
plant-based sources of
calcium?
Share in the chat pod.
64
65. Calcium content in selected products (mg/3.5 oz.)
(USDA. National Nutrient Database for Standard References. https://ndb.nal.usda.gov/)
Calcium Content
65
66. Assist patient with resources
vrg.com
https://oldwayspt.org/system/files/atoms/files/Vegetarian-
Vegan%2520brochure.pdf 66
67. Use with permission from: http://plantbaseddietitian.com/current-former-veg/#post/0 67
69. Connect with MFLN Nutrition & Wellness Online!
MFLN Nutrition @MFLNNW
MFLN Nutrition and Wellness
MFLN Nutrition and Wellness
NW SMS icons
69
70. MFLN Intro
70
We invite MFLN Service Provider Partners
to our private LinkedIn Group!
https://www.linkedin.com/groups/8409844
DoD
Branch Services
Reserve
Guard
Cooperative Extension
71. Evaluation & Continuing Education Credits
MFLN Nutrition & Wellness is offering 1.0 CPEU
for today’s webinar.
Please complete the evaluation at:
•https://vte.co1.qualtrics.com/jfe/form/SV_dmAm0
71
72. MFLN Nutrition & Wellness
Upcoming Event
The low FODMAP diet for irritable bowel
syndrome: From evidence to practice
• Thursday, March 29, 2018
• 11:00 am – 12:00 pm Eastern
• https://learn.extension.org/events/3300
For more information on MFLN Nutrition & Wellness go to:
https://militaryfamilies.extension.org/nutrition-and-wellness
72
74. References 1/9
• Academy of Nutrition and Dietetics. Nutrition Terminology Reference Manual (eNCPT): Dietetics Language for
Nutrition Care 2014. http://ncpt.webauthor.com. Accessed August 7, 2015.
• Academy of Nutrition and Dietetics, 2016; Definition of Terms.
http://www.eatrightpro.org/resources/practice/patientcare/scope-of-practice. Accessed March 24, 2016.
• Academy of Nutrition and Dietetics. Nutrition Care Manual. www.nutritioncaremanual.org. Accessed April 2,
2016.
• Alexander, S, C., Cox, M, E., Turner, C, L., Lyna, P., Ostbye, T., Tulsky, J, A., Dolor, R, J., & Pollak, K, I.
(2011). Do the Five A’s work when physicians counsel about weight loss? Family Medicine.43, 179-184.
• Appleby, P.N., Allen, N.E., & Key, T.J. (2011). Diet, vegetarianism, and cataract risk. American Journal Clinical
Nutrition., 93, 1128–1135.
• Appleby, P.N., Davey, G.K., & Key, T.J. (2002). Hypertension and blood pressure among meat eaters, fish
eaters, vegetarians and vegans in EPIC-Oxford. Public Health Nutrition, 5, 645-654.
• Barnard, N.D., Katcher, H.I., Jenkins, D.J., Cohen, J., & Turner-McGrievy, G. (2009). Vegetarian and vegan diets
in type 2 diabetes management. Nutrition. Reviews., 67, 255–263.
• Bradley, D, W., Murphy, G; Snetselaar,L,G., Myers, E, F., & Qualls, L, G. 2013. The incremental value of
Medical Nutrition Therapy in weight management. Managed Care. 40-45
• Bueche, J., Charney, R., Pavlinac, J,. Skipper, A., Thompson, E., & Myers E. (2008), Nutrition Care Process.
Part II. Journal American Dietetic Association. 108, 1287-1293.
74
75. References 2/9
• Chiba, M., Abe, T., Tsuda,H., Sugawara , T., Tozaw, H., Fujiwara, K., & Imai, H. (2010). Lifestyle related disease
in Crohn’s disease: relapse prevention by a semi-vegetarian diet. World Journal Gastroenterol. 16, 2484-2495.
• CMS. Intensive behavioral therapy for obesity (IBTO) https://www.cms.gov/Outreach-and-Education/Medicare-
Learning-Network-MLN/MLNMattersArticles/downloads/MM7641. March 7, 2012. Accessed April 1, 2016.
• Committee on Nutrition Services for Medicare Beneficiaries. (2000) Nutrition services in ambulatory settings. In
The role of nutrition in maintaining health of the elderly. 212-224, National Academy of Sciences. www.nap.edu
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83
You could say that virtually all diets consumed in the US are plant based…
But of course that’s not what most people are thinking when they say Plant Based Diet
Plant based eating patterns are on the rise in the U.S. for health, cost, animal welfare and environmental concerns. (www.healthyeating.org)
There is no legal or universally accepted definition of plant based nutrition or diet. It is a phrase that is often used by the proponents of a vegetarian and/or vegan eating approach. However, many nutritionists would state that the DASH and Mediterranean Eating Approaches described in the Dietary Guidelines for Americans are plant based and that plant based does not necessarily mean “plant only”.
Dr. Wayne Dysinger offered this definition of whole food plant-based nutrition in the ACPM Lifestyle Medicine Course: ““Whole food plant-based nutrition is a diet that maximizes the intake of whole plant foods and minimizes the intake of processed and animal-derived foods. The daily diet is organized around foods-as-grown: vegetables, fruits, whole grains, beans, chickpeas, split peas, lentils, mushrooms, herbs, spices and small amounts of seeds and nuts. The regular consumption of industrial: sugars, animal products, refined grains and oils is avoided”
There are many reasons an individual may want to move toward a plant based diet: health, peer pressure, health of the planet, ethical and religious considerations----
In this webinar we are focusing on the health related issues.
Plant based eating patterns are on the rise in the U.S. for health, cost, animal welfare and environmental concerns. (www.healthyeating.org)
There is no legal or universally accepted definition of plant based nutrition or diet. It is a phrase that is often used by the proponents of a vegetarian and/or vegan eating approach. However, many nutritionists would state that the DASH and Mediterranean Eating Approaches described in the Dietary Guidelines for Americans are plant based and that plant based does not necessarily mean “plant only”.
Dr. Wayne Dysinger offered this definition of whole food plant-based nutrition in the ACPM Lifestyle Medicine Course: ““Whole food plant-based nutrition is a diet that maximizes the intake of whole plant foods and minimizes the intake of processed and animal-derived foods. The daily diet is organized around foods-as-grown: vegetables, fruits, whole grains, beans, chickpeas, split peas, lentils, mushrooms, herbs, spices and small amounts of seeds and nuts. The regular consumption of industrial: sugars, animal products, refined grains and oils is avoided”
There are many reasons an individual may want to move toward a plant based diet: health, peer pressure, health of the planet, ethical and religious considerations----
In this webinar we are focusing on the health related issues.
Almost with no exceptions studies have shown a lower systolic BP among vegetarians, compared to non-vegetarians. Similarly, studies have shown that adopting vegetarian diets as a treatment option resulted in lowering of systolic BP.
Almost with no exceptions studies have shown a lower diastolic BP among vegetarians, compared to non-vegetarians. Similarly, studies have shown that adopting vegetarian diets as a treatment option resulted in lowering of diastolic BP.
This data is an example of the high vitamin B12 deficiency incidence in different studies. The deficiency incidence varied from 20% (using an inadequate deficiency criteria of MMA &gt;376 nmol/L) to 92% among vegans.
This data is an example of the high vitamin B12 deficiency incidence in different studies. The deficiency incidence varied from 20% (using an inadequate deficiency criteria of MMA ?376 nmol/L) to 92% among vegans.
Some studies showed so low intake of EPA and DHA among vegetarians that it was undetectable.
Studies that assessed EPA and DHA status among vegetarians and non-vegetarians without exception showed lower status among the former, with vegans having the lowest levels.
My recent reviews shows that iron status is a major problem for both adults and children (next slide).
Should you recommend for everyone or just those interested…. Evidence of benefit:
The data are limited and some quite old…. So this picture may be incomplete
Should you recommend for everyone or just those interested…. Evidence of benefit:
The data are limited and some quite old…. So this picture may be incomplete
Need to take an evidence based approach. Dietary Guidelines for Americans is national nutrition policy and over the years has recognized the evidence supporting healthy vegetarian and Mediterranean eating patterns. Those interested in the environment can also find these acceptable
No data to support Paleo
The five 2015-2020 guidelines are:
1) Follow a healthy eating pattern across the lifespan
2) Focus on variety, nutrient density, and amount
3) Limit calories from added sugars and saturated fats and reduce sodium
4) Shift to healthier food and beverage choices
5) Support healthy eating patterns for all
-recognizes evidence to support healthy
vegetarian and healthy Mediterranean eating
patterns
Need to take an evidence based approach. Dietary Guidelines for Americans is national nutrition policy and over the years has recognized the evidence supporting healthy vegetarian and Mediterranean eating patterns. Those interested in the environment can also find these acceptable
No data to support Paleo
The five 2015-2020 guidelines are:
1) Follow a healthy eating pattern across the lifespan
2) Focus on variety, nutrient density, and amount
3) Limit calories from added sugars and saturated fats and reduce sodium
4) Shift to healthier food and beverage choices
5) Support healthy eating patterns for all
-recognizes evidence to support healthy
vegetarian and healthy Mediterranean eating
patterns
S.K was counseled by a health coach following the 5As approach. As part of the ADVISE step gives a brief overview of strategies known to be effective in managing metabolic syndrome and preventing kidney stones. SK says she is thankful for the advice, doesn’t see herself following a diet right now but is interested in moving toward a plant based way of eating. She agrees to study the breakfast menu at her favorite drive thru restaurant and replace her sausage biscuit with a fruit and yogurt parfait at least two days a week. She will also bring a soy meal replacement shake from home two days a week for lunch and make an effort to select items marked as “healthy choice” from the vending machine. SK agrees to think about making an appointment with the dietitian and attending an orientation for the on-line weight management class. The health coach provides her with a Mediterranean diet screener which she agrees to complete it and identify foods she and her teens like. She will substitute plant based foods for her animal based food products for the dinners she shares with her daughters who have expressed a desire to “eat less meat”.
Wolk says review of meta-analyses etc suggest it is plausible
High heat (heterocyclic amines or HAAS); BBQ/charring (polycyclic aromatic hydrocarbons or PAHs)
Wolk says review of meta-analyses etc suggest it is plausible
High heat (heterocyclic amines or HAAS); BBQ/charring (polycyclic aromatic hydrocarbons or PAHs)
First DASH papers published in 1997. Lots of papers about benefits since. Little known about sustained benefits of lifestyle interventions.
ENCORE 16 week intervention and then one year follow up.
Hinderliter et al. The long term effects of lifestyle change on blood pressure: one year follow up of the ENCORE Study. Am J HTN&gt; 2014;27(5):734-741.
Study was of overweight hypertensive men and women; at 1 year the blood pressure effect continued, there was some back sliding on weight loss ; so chage in diet to DASH pattern effect persisted longer than reduced calories and exercise did not persist as well either.
First DASH papers published in 1997. Lots of papers about benefits since. Little known about sustained benefits of lifestyle interventions.
ENCORE 16 week intervention and then one year follow up.
Hinderliter et al. The long term effects of lifestyle change on blood pressure: one year follow up of the ENCORE Study. Am J HTN&gt; 2014;27(5):734-741.
Study was of overweight hypertensive men and women; at 1 year the blood pressure effect continued, there was some back sliding on weight loss ; so chage in diet to DASH pattern effect persisted longer than reduced calories and exercise did not persist as well either.
KEY MESSAGES: (1) The Mediterranean eating approach includes a large amount of food from plant sources. Because a patient feels full they may consume fewer calories than when following a more traditional Western diet. (2) Although this plan emphasizes eating minimally processed, fresh and locally grown foods, patients should be told they can also use canned, frozen and dried fruits and vegetables. (3) This approach may be slightly higher in fat than previously recommended by the American Heart Association, but the emphasis is on using healthy fats like olive and canola oil. (4) Moderate amounts of lower fat cheeses and low or no fat yogurt are recommended for their calcium. (5) Although data do not support the use of supplemental omega 3 fatty acids for cardiovascular health, the American Heart Association recommends two fish meals per week. (6) This approach include a moderate consumption of wine with meals. Note that a serving of wine is 5 ounces.
KEY MESSAGES: (1) The Mediterranean eating approach includes a large amount of food from plant sources. Because a patient feels full they may consume fewer calories than when following a more traditional Western diet. (2) Although this plan emphasizes eating minimally processed, fresh and locally grown foods, patients should be told they can also use canned, frozen and dried fruits and vegetables. (3) This approach may be slightly higher in fat than previously recommended by the American Heart Association, but the emphasis is on using healthy fats like olive and canola oil. (4) Moderate amounts of lower fat cheeses and low or no fat yogurt are recommended for their calcium. (5) Although data do not support the use of supplemental omega 3 fatty acids for cardiovascular health, the American Heart Association recommends two fish meals per week. (6) This approach include a moderate consumption of wine with meals. Note that a serving of wine is 5 ounces.
2015 -2020 Dietary Guidelines included dietary plans for healthy vegetarian/vegan diets built on actual diets consumed as reported in NHANES survey
The media and professional literature have been filled with discussions about the role of calcium in prevention of bone disease as well as increasing risk for heart disease. Patients expect advice even while the evidence is unclear. Calcium is recognized in 2015 DGA as under-consumed. Let’s look briefly at two cases and how they might be addressed with the current information.
Mrs JH has family history heart disease; diagnosed with osteopenia. Instructions on her bone density report: “hormonal therapy, dietary supplementation and weight bearing exercise may prevent further bone loss. Maintain a intake of 1,500 mg calcium daily with 600 IU vitamin D” She follows a plant based diet and gets only 500 mg calcium from food. She is supplementing with 1,000 mg calcium carbonate.
Mr KP has PMR and has been treated with corticosteroid. He follows the DASH eating plan most days. He read he is at risk for osteoporosis and he self prescribed 500 mg/day.
Vegans, who exclude dairy products have several plant foods to choice from to ensure adequate Ca intake.
Identify good patient education materials
In addition, we would like to invite our MFLN Service Provider partners (such as DoD, branch services, Guard and Reserve service providers and Cooperative Extension professionals) to continue the discussion in our private and moderated LinkedIn group.
Please click the link to join the group or send us an email.
We look forward to hearing from you!