Plant-based Eating: Enhancing Health Benefits, Minimizing Nutritional Risks
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- 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
- 6. DISCLOSURES Pawlak received a research grant from the Vegetarian Practice Group at the Academy of Nutrition and Dietetics 6
- 7. DISCLOSURES We received an honorarium from: 7
- 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
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- 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
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- 17. Vegetarian diets Improve blood lipid profile Reduce diastolic BP Improve blood glucose control Reduce systolic BP Reduce oxidative stress Decrease endothelial inflammation Help in maintaining normal BMI Protect against plaque formation 17
- 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
- 27. A case report 27
- 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
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- 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
- 68. CC0 by GDJ via Pixabay 68
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- 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 Accessed April 2, 2016. • Crowe, F.L., Appleby, P.N., Travis, R.C., & Key, T.J. (2013). Risk of hospitalization or death from ischemic heart disease among British vegetarians and nonvegetarians: results from the EPIC-Oxford cohort study. American Journal Clinical Nutrition, 97, 597-603. • Crowe, F.L., Appleby, P.N., Allen, N.E., & Key, T.J. (2011). Diet and risk of diverticular disease in Oxford cohort of European Prospective Investigation into Cancer and Nutrition (EPIC): prospective study of British vegetarians and non-vegetarians. British Medical Journal, 343:d4131 doi: 10.1136/bmj.d4131. • Dietary Guidelines Advisory Committee (GDAC). (2015). Scientific report of the 2015 Dietary Guidelines Advisory Committee: Advisory report to the Secretary of Health and Human Services and the Secretary of Agriculture. Retrieved from http://health.gov/dietaryguidelines/2015-scientific-report/pdfs/scientific-report-of-the-2015-dietary- guidelines-advisory-committee.pdf. Accessed March 31, 2016. • Doets EL, In 't Veld PH, Szczecińska A, Dhonukshe-Rutten RA, Cavelaars AE, van 't Veer P, Brzozowska A, de Groot LC. Systematic review on daily vitamin B12 losses and bioavailability for deriving recommendations on vitamin B12 intake with the factorial approach. Ann Nutr Metab. 2013;62:311-322. 75
- 76. References 3/9 • Eckel, R.H., Jakicic, J.M., Ard, J.D., de Jesus, J.M., Houston Miller, N., Hubbard, V.S., & Yanovski, S.Z. (2014). AHA/ACC guideline on lifestyle management to reduce cardiovascular risk: A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation, 129(suppl 2), S76-S99 • Eussen SJ, de Groot LC, Clarke R, Schneede J, Ueland PM, Hoefnagels WH, van Staveren WA. Oral cyanocobalamin supplementation in older people with vitamin B12 deficiency: a dose-finding trial. Arch Intern Med. 2005;165(10):1167-72. • Evatt ML, Terry PD, Ziegler TR, Oakley GP. Association between vitamin B12- containing supplement consumption and prevalence of biochemically defined B12 deficiency in adults in NHANES III (third national health and nutrition examination survey). Pub Health Nutr. 2009;13(1):25–31. • FAO. Protein quality evaluation. Bethesda, MD, USA 1989. • Ferdowsian HR, & Barnard ND. (2009). The effects of plant-based diets on plasma lipids. American Journal of Cardiology, 104, 947-956. • Food and Drug Administration. Food Labeling. http://www.fda.gov/Food/GuidanceComplianceRegulatoryInformation/GuidanceDocume nts/FoodLabelingNutrition/ucm152626.htm; http://www.fda.gov/Food/FoodSafety/Product- SpecificInformation/MedicalFoods/default.htm. Accessed April 16, 2016. • Gans, K. M., Sundaram, S. G., McPhillips, J. B., Hixson, M. L., Linnan, L., & Carleton, R. A. (1993). Rate your plate: an eating pattern assessment and educational tool used at cholesterol screening and education programs. Journal of Nutrition Education, 25(1), 29- 36. 76
- 77. References 4/9 Gorjipour F, Asadi Y, K Osguei N, Effatkhah M, Samadikuchaksaraei A. Serum level of homocysteine, folate and vitamin-B12 in epileptic patients under carbamazepine and sodium valproate treatment: a systematic review and meta-analysis. Iran Red Crescent Med J. 2013;15(3):249-253. • Gupta SK, Sawhney RC, Rai L, Chavan VD, Dani S, Arora RC, Selvamurthy W, Chopra HK, Nanda NC. Regression of coronary atherosclerosis through healthy lifestyle in coronary artery disease patients--Mount Abu Open Heart Trial. Indian Heart J. 2011;63(5):461-469. • Haddad, E. Lecture presentation. Loma Linda University, Feb. 26, 2013 • Hawkins, C., Rao, S.G., Vaccarino, V., & Ali, M.K. (2016). Effects of different dietary interventions on blood pressure: Systematic review and meta-analysis of Randomized Controlled Trials. Hypertension. 67,733-739. • Hollis, J.F., Gullion, C.M., Stevens, V.J., Brantley, .J., Appel, L,J., Ard, J.D., Champagne, C.M., Dalcine, A., Erlinger, T.P., Funk, K., Laferriere, D., Lin, P-H, Loria, C, M., Samuel-Hodge, C., Vollmer, W, M., Svetkey, L, P. & Weight Loss Maintenance Trial Research Group (2008). Weight loss during the intensive intervention phase of the weight-loss maintenance trial. American Journal Preventive Medicine. 35,118–126. • Hwang, C, Ross, V, & Mahadevan, U. (2014). Popular exclusionary diets for Inflammatory Bowel Disease: The search for a dietary culprint. Inflammatory Bowel Disease. 20, 732-741. • Institute of Medicine. Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein, and amino acids. Retrieved from: http://www.iom.edu/Reports/2002/Dietary−Reference−Intakes−for−Energy−Carbohydrate−Fiber−Fat−Fatty−Acids −Cholesterol−Protein−and−Amino−Acids.aspx. 77
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Editor's Notes
- Coral www.extension.org/militaryfamilies Webinar notifications www.extension.org/62831
- 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!