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Food as Medicine
Nutrition to Prevent Chronic Disease
Lyndi Schwartz, MD, FACPProgram Director, Internal Medicine Residency
Kettering Medical CenterKettering, OH
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John 10:10
• “The thief does not come except to steal, and to kill and to destroy. I have come that they may have life, and that they may have it more abundantly.”
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Risk Factors for Chronic Disease Deaths
JAMA 2018
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45% of deaths due to heart disease, stroke, & diabetes are directly caused by poor diet.
Micha et alJAMA 2018
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I Corinthians 6:19,20
• “Or do you not know that your body is the temple of the Holy Spirit who is in you, whom you have from God, and you are not your own? For you were bought with a price; therefore glorify God in your body and in your spirit which are God’s.”
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What I’ll Cover• Consensus views on nutrition• What do Americans eat?• CV disease, insulin resistance,
cancer, & obesity: what does the science suggest we should eat?• Key points about macronutrients
(carbs, fats, protein)
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Making sense of Nutrition Studies: What does the overall skyline show?
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Healthful
Whole GrainsLegumesFruitsVegetablesNutsSeeds
Debatable
PoultryEggsDairyFish
Unhealthful
Processed meatRed meatAdded sugarRefined grainsUltraprocessed foods
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Healthful
Whole GrainsLegumesFruitsVegetablesNutsSeeds
Debatable
PoultryEggsDairyFish
Unhealthful
Processed meatRed meatAdded sugarRefined grainsUltraprocessed foods
Any meat that has been cured, smoked, fermented, or added
preservatives.
Bacon, hot dogs, bologna, sausage, salami, pepperoni, ham, cold cuts, deli
slices, chicken nuggets
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Healthful
Whole GrainsLegumesFruitsVegetablesNutsSeeds
Debatable
PoultryEggsDairyFish
Unhealthful
Processed meatRed meatAdded sugarRefined grainsUltraprocessed foods
Beef, pork, lamb, goat, veal, venison
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Healthful
Whole GrainsLegumesFruitsVegetablesNutsSeeds
Debatable
PoultryEggsDairyFish
Unhealthful
Processed meatRed meatAdded sugarRefined grainsUltraprocessed foods
Whole grains that have been stripped of most fiber and
nutrients.
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Whole Grains:
Whole wheat
Oats
Rye
Corn
Brown rice
Barley
Kamut
Spelt
Millet
Teff
Wild rice
Pseudograins:
Quinoa
Amaranth
Buckwheat
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Whole Grains:
Whole wheat
Oats
Rye
Corn
Brown rice
Barley
Kamut
Spelt
Millet
Teff
Wild rice
Pseudograins:
Quinoa
Amaranth
Buckwheat
Refined GrainLose 80% of fiber &
nutrients
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“Wheat bread”“Multigrain”
“7-Grain”
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Healthful
Whole GrainsLegumesFruitsVegetablesNutsSeeds
Debatable
PoultryEggsDairyFish
Unhealthful
Processed meatRed meatAdded sugarRefined grainsUltraprocessed foods
Industrially produced foods
• Physical, biological, or chemical processing
• Industrial/chemical additives (flavors, colors, sweeteners, emulsifiers etc)
• Highly palatable
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“...a diet higher in plant-based foods, such as vegetables, fruits, whole grains, legumes, nuts, and seeds, and lower in calories and
animal-based foods is more health promoting and is associated with less
environmental impact than is the current U.S. diet.”
Scientific Report of the 2015 Dietary Guidelines Advisory Committee
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“Eat food. Not too much. Mostly plants.”Michael Pollan
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What is a Plant-Based Diet?
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What About a Mediterranean Diet?
• Based on traditional dietary patterns in Mediterranean; varies by place
• Mediterranean diet scoring system:✓Get points for eating grains, beans,
fruits, vegetables, olive oil, fish, & small amount of wine
✓Lose points for eating dairy, poultry, & red meat
• Benefits for reduction of cardiovascular, cancer, diabetes risk✓Lyon Heart Study✓PREDIMED Study
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• More plants better outcomes
• More meats worse outcomes
• Fish, olive oil, alcohol - not the primary benefit
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Which of the following is the #1 source of calories among Americans ages 2 and up?
A.Sugar-sweetened beveragesB.DessertsC.Breads, bagels & rollsD.Cheese & cheese products
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Top Sources of Calories Among Americans > 2 Yrs Old
#1 Grain-based dessertsCake, cookies, pie, cobbler, sweet rolls, pastries, donuts
#2 BreadsWhite bread and rolls, mixed-grain bread, flavored bread, bagels
#3 Chicken and chicken mixed dishesFried and baked chicken parts, chicken strips/patties, stir-fries, casseroles, sandwiches, salads, other chicken dishes
#4 Soda/energy/sports drinksSodas, energy drinks, sports drinks, sweetened bottled water
#5 Pizza
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70% of our calories come from processed & ultraprocessed foods
58%
30%
12%
Ultraprocessed Foods Unprocessed or minimally processed foods Processed Foods
14% meats, milk, eggs
14% grains, Root vegetables,Legumes, vegetables, fruits(includes juices, refined grains)
• Added sweeteners• Vegetable oils• Animal fats• Foods made with these
(cheese, processed meats)
Industrially produced• Breads• Desserts• Salty snacks• Soft drinks• Pizza• Breakfast cereals• Meat products
etc
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Cardiovascular Disease
Insulin Resistance
Cancer Prevention
Obesity
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Cardiovascular Disease
Insulin Resistance
Cancer Prevention
Obesity
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Healthful
Whole GrainsLegumesFruitsVegetablesNutsSeeds
Debatable
PoultryEggsDairyFish
Unhealthful
Processed meatRed meatAdded sugarRefined grainsUltraprocessed foods
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• Grains• Legumes• Fruits• Vegetables• Nuts & Seeds• Small amounts of
meat/poultry/dairy/eggs• Few highly processed foods
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Red & Processed Meat – CV Risk
Wolk, Journal of Internal Medicine 2016
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Meatless Diets & Ischemic Heart Disease
Ischemic Heart Disease
Key et al(Am J Clin Nutr 1999, n>76,000)
↓ 24% (mortality)
Huang et al(Ann Nutr Metab 2012, n>124,000)
↓ 29% (mortality)
EPIC Oxford(Am J Clin Nutr 2013, n>44,000)
↓ 32% (incident cases)
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TMAO effects
↑ Uptake of cholesterol macrophages
↑ foam cell formation
↑platelet aggregation
↓ hepatic clearance of cholesterol
TMAO Increases
➢All-cause mortality➢CV mortality➢Major adverse CV
events➢CHF severity➢ 30-day adverse CV
events post ACS
Tang W et alN Eng J Med 2013
Koeth R et alNat Med, 2013
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Hazard ratio, CV mortality: 2.75 for >25% of kcal from
added sugar
RR Coronary heart disease: 1.98 for highest quintile of
refined carbohydrates
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Limits on Added Sugar(AHA recommendations)
Women: 6 tsp/100 Kcal/25gMen: 9 tsp/ 150 Kcal/ 37.5g
Johnson et al, Circulation 2009
6 Teaspoons added
sugars per day for women
9 Teaspoons added
sugars per day for men
15 Teaspoons of sugars in a
20 oz. coke
23 Teaspoons ACTUAL sugars consumed
by average American per day
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• Systemic review and meta-analysis, 95 studies worldwide
• Each 2.5 servings/day of fruits & vegetables decreases risk by • 8% for CHD• 16% for stroke• 10% for all cause mortality
• Benefits continued up to 10 servings/day
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• Nurses’ Health Study 1 & 2, Health Professionals Follow-Up Study; 4.8 million person-years of follow-up• Plant-based diet index (PDI): high in all plant foods, low in
animal foods• Healthy PDI: High in whole grains, fruits, vegetables, nuts, legumes,
vegetable oils• Unhealthy PDI: high in fruit juice, refined grains, fried potatoes &
chips, sugar-sweetened beverages, sweets/desserts
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Hazard ratio, CHD incidence• Overall plant-based diet: 0.92 (0.83-1.01)• Healthy plant-based: 0.75 (0.68-0.83)• Unhealthy plant-based: 1.32 (1.20-1.46)
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Plant Foods & Cardiovascular Health: Mechanisms?
• Replace disease-promoting foods
• Reduce LDL oxidation via polyphenols/antioxidants
• Improve endothelial function
• Reduce inflammation
• Beneficially alter gut microbiota
• Lower blood pressure via high potassium low sodium
• Decrease lipids
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Randomized Controlled Trials
Decrease in Total & LDL Cholesterol
Semi-veg diet, Lacto-ovo veg diet
10-15%
Vegan diet 15-20%
Veg w added fiber/soy/nuts
20-35%
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Cardiovascular Disease
Insulin Resistance
Cancer Prevention
Obesity
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Healthful
Whole GrainsLegumesFruitsVegetablesNutsSeeds
Debatable
PoultryEggsDairyFish
Unhealthful
Processed meatRed meatAdded sugarRefined grainsUltraprocessed foods
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Fat accumulation in skeletal muscle & liver cells (ectopic fat) is a primary cause of insulin resistance• Skeletal Muscle: decreased glucose uptake• Liver: decreased glycogen synthesis, increased
gluconeogenesis
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Fat accumulation in skeletal muscle & liver cells (ectopic fat) is a primary cause of insulin resistance• Skeletal Muscle: decreased glucose uptake• Liver: decreased glycogen synthesis, increased
gluconeogenesis
• Adiposity• Excess calories• Excess dietary fat• Inflammation• Oxidative stress• Mitochondrial
dysfunction
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•Replace carbs with protein → increasedrisk of DM2•22% increased risk for highest quintile of protein (109g/day)•Association attributed to animal protein
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Fructose from Sugar-Sweetened Foods/Drinks
“Empty Calories” →Weight gain
Fatty liver & increased fat in skeletal muscleObesity
Lipotoxicity → Insulin Resistance
De novo lipogenesis in liver
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Which type of foods most protective against type 2 diabetes?
A.Cruciferous vegetablesB.BerriesC.Whole GrainsD.Fish
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Whole Grains lower diabetes risk: effect of cereal fiber
• Improves postprandial glucose response
• Lowers calorie density• Increases satiety• Metabolized by gut bacteria to form
short-chain fatty acids
➢Increase GLP1➢Increase insulin sensitivity➢Regulate cytokines to decrease
inflammation➢Improve mitochondrial function
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• >500,000 adults followed for 7 yrs
• Daily fruit consumption: 12% lower risk of diabetes
• In those who had diabetes at baseline, 3x/wk fruit lowered• All-cause mortality by 17%• Microvascular complications by 28%• Macrovascular complications by 13%
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• Nurses’ Health Study 1 & 2, Health Professionals Follow-Up Study; 4.8 million person-years of follow-up
• Risk of type 2 diabetes➢Plant-based dietary pattern: 20% ↓ risk
➢Healthy plant-based pattern: 34% ↓ risk➢Unhealthy plant-based pattern: 16% ↑ risk
• Independent of body weight & other risk factors
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Plant-Based Diet for Type 2 Diabetes• RCT, 99 pts with DM2 x 74wks• Low-fat plant-based diet (no
calorie restrictions) vs conventional, reduced-calorie diet
• Better glycemic control with plant-based diet (a1c -0.40 vs -0.01, p+0.03) when med adjustments excluded
• Better lipid reduction & weight loss with plant-based diet
Barnard et al, AM J Clin Nutr 2009
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Cardiovascular Disease
Insulin Resistance
Cancer Prevention
Obesity
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Healthful
Whole GrainsLegumesFruitsVegetablesNutsSeeds
Debatable
PoultryEggsDairyFish
Unhealthful
Processed meatRed meatAdded sugarRefined grainsUltraprocessed foods
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Red & Processed Meat – Cancer Risk
Risk of colorectal cancer:
• 17% increase per 100g/day red meat
• 18% increase per 50g/day of processed meat
(Chan et al, Plos One 2011)
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What are the mechanisms?
• Nitrate Salts
• Heme iron
• Heterocyclic amines
• Polyaromatic hydrocarbons
• Advanced glycation end products
• N-Glycolylneuraminic acid (Neu5Gc)
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Fruits & Vegetables
• 7.5 servings/day confers significant, 14% reduction in total cancer risk
• Significant benefit for cruciferous vegetables & green-yellow vegetables
Aune et al, Int J Epidemiol 2017
14% risk reduction at 600g
(7.5 servings) per day
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Whole Grains• Every 3 servings/day
➢Decreases colorectal cancer risk by 17%➢Decreases total cancer mortality by 17%
• In stages I-III colon cancer, every 5 g daily increase in whole-grain fiber associated with 33% decrease in colorectal cancer mortality
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Fruits & vegetables: ↑ expression of genes used in cell defense & DNA repair
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Plant-based diet: ↓ expression of tumor-promoting genes
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Recommendations
Body FatnessBe as lean as possible within the normal range of body weight
Physical ActivityBe physically active as part of everyday life
Foods and Drinks that Promote Weight GainLimit consumption of energy-dense foods
Avoid sugary drinks
Plant FoodsEat mostly foods of plant origin
Animal FoodsLimit intake of red meat and avoid processed meat
Alcoholic DrinksLimit alcoholic drinks
Preservation, Processing, PreparationLimit consumption of salt
Avoid moldy cereals (grains) or pulses (legumes)
Dietary SupplementsAim to meet nutritional needs through diet alone
American Institute for
Cancer Research, AICR.org
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Genesis 1:29
• “And God said, ‘See, I have given you every herb that yields seed which is on the face of all the earth, and every tree whose fruit yields seed; and to you it shall be for food.”
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Cardiovascular Disease
Insulin Resistance
Cancer Prevention
Obesity
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What’s the best diet for healthy weight loss?
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What’s the best diet for healthy weight loss?
• Sustainable – not a temporary ‘diet’
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What’s the best diet for healthy weight loss?
• Sustainable – not a temporary ‘diet’• Optimizes overall health independent of
weight loss
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Low-Carb High-Fat DietsPossible Benefits Major Concerns
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“Eat food. Not too much. Mostly plants.”Michael Pollan
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More Plants…Healthier Weight
Prevalence Studies:People eating diets high in plant foods have healthier BMIs
Tonstad, Diabetes Care 2009Spencer, Int J Obesity 2003Wang, Int J Obesity 2009
Prospective Studies:Diets low in fiber & high in meat are strongly tied to weight gain
Vergnaud et al, AM J Clin Nutr 2010Halkjaer et al, Int J Obesity 2011Rosell M et al, Int J Obesity 2006
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• Increases satiety without extra calories
• Add 14g fiber/day → 10-18% lower calorie intake
• Whole grain fiber increases metabolic rate & promotes loss of calories in stool
• Promotes beneficial gut bacterial patterns & production of SCFAs
• Improves blood sugar response to food
• Reduces heart disease, diabetes, & cancer risk
Fiber: Not just for constipation anymore!
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Carbs, Protein, & Fat:The Bottom Line
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Protein
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Protein Needs vs Actual Intake
Fulgoni et al, Am J Clin Nutr 2008
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Problems With Excess Protein
• Obesity
• Diabetes
• Heart Disease
• High Blood Pressure
• High Cholesterol
• Kidney Stones
• Worsened Kidney Function
• Gout
• Cancers
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Among those 1 with > risk factor, replacing just 3% of animal protein lowered mortality by▪ 34% for processed red meat▪ 19% for eggs (including 17% decrease in cancer death)▪ 12% for unprocessed red meat▪ 8% for dairy▪ 6% for poultry & fish
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The package matters….
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What nutrient are 97% of Americans deficient in?
A.IronB.Omega 3 fatty acidsC.CalciumD.Fiber
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Fats
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The Skinny on FatsSaturated
• Highest in animal foods, tropical oils
• Increase LDL, atherosclerosis, insulin resistance
Monounsaturated
• Olives, avocados, nuts
• Decrease insulin resistance
Trans-Fats
• “Partially hydrogenated” oils
• Mostly manmade
• Ultra processed foods
• Highly atherogenic
Polyunsaturated
• Vegetable oils, nuts, seeds, fish (omega 3)
• Decrease insulin resistance, lower LDL
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The package matters!Protein & fat: animal vs plant sourcesCarbs: refined vs whole-food sources
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Then God said, “I give you every seed-bearing plant on the face of the whole earth and every tree that has fruit with seed in it. They will be yours for food.”-Genesis 1:29
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