"Nutrition Beyond the Food Guide Pyramid"
Nutrition Beyond the Food Guide Pyramid By Laura LaValle, RD, LD 1 According to the Surgeon General’s 1988 report, 2/3 of all deaths are associated with imbalances in diet and nutrition. Advances in modern medicine (technology, drugs, vaccines, etc.) are being offset by lifestyle and nutritional risk factors. Nutrition in America: Historical Perspective • From the 1st to the 19th centuries almost 100% of the food supply was obtained from sustainable agriculture, wildlife and livestock. • At the end of the 20th century, 60-70% of the food supply is processed. Industrialized Agriculture • Food is grown far from the point of sale – picked before fully matured – forced ripening through chemicals • Nutrient depletion of soil – fertilization necessary – wide variation in the mineral content of foods 1988 Dietary Recommendations: Surgeon General • Overriding concern was the increase in coronary heart disease • Based on report, recommended lowering total fat intake to <30% calories, saturated fat in diet USDA Food Guide Pyramid • Developed in the 1980’s, released in 1992. • Goals of the pyramid – – to give consumers a visual aid to help them know how to eat healthy – An aid to help plan diets that contain all needed nutrients and reduce disease risk primarily by reducing fat intake Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI 30, or ~ 30 lbs overweight for 5’4” woman) No Data <10% 10%-14% 15-19% 20% Source: Mokdad A H, et al. J Am Med Assoc 2001;286:10 Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI 30, or ~ 30 lbs overweight for 5’4” woman) No Data <10% 10%-14% 15-19% 20% Source: Mokdad A H, et al. J Am Med Assoc 2001;286:10 Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI 30, or ~ 30 lbs overweight for 5’4” woman) No Data <10% 10%-14% 15-19% 20% Source: Mokdad A H, et al. J Am Med Assoc 2001;286:10 Obesity Trends* Among U.S. Adults BRFSS, 1991, 1995 and 2000 (*BMI 30, or ~ 30 lbs overweight for 5’4” woman) 1991 1995 2000 No Data <10% 10%-14% 15-19% 20% Source: Mokdad A H, et al. J Am Med Assoc 1999;282:16, 2001;286:10. Obesity Trends* Among U.S. Adults BRFSS, 1991-2002 (*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” woman) 1991 1995 2002 No Data <10% 10%–14% 15%–19% 20%–24% ≥25% The results of the 1999 National Health and Nutrition Examination Survey (NHANES) indicate that an estimated 61 percent of U.S. adults are either overweight or obese. Health Conditions Associated with Obesity and Overweight • Hypertension • Angina • Dyslipidemia • congestive heart • Type 2 diabetes failure • insulin • stroke resistance/impaired • gallstones glucose tolerance • gout • coronary artery • osteoarthritis disease • apnea The Low-fat Craze of 1990’s and Food Manufacturing: •Processed “fat free” foods –carbohydrate loaded foods marketed as “fat free” –extra sugar and additives needed for flavoring of lower fat foods The Final Product:Fat-free Foods • High sugar • Processed • Higher sodium • Additives - e.g. artificial flavors • Artificial fats Emergence of Low Carb Diets and alternate pyramids • Re-emergence of Atkins diet • Food manufacturers and restaurants responded to desire for “low carb” foods • The Zone, South Beach • Harvard Healthy Eating Pyramid • Mediterranean Diet Pyramid Metabolic Syndrome • AHA guidelines – Elevated waist circum, Elev. Trig.(>150), Reduced HDL (< 40 or 50), Elev BP >(135/85), Elev. Fasting glu (>100) • 1 in 4 ages 25- 60 in U.S. are at risk, age 61 and over, have 40% probability of having the syndrome. • Visceral fat (belly fat) (Hamdy, Joslin Diabetes Center) • Insulin Resistance – (Reaven at Stanford first described Syndrome X) Insulin Resistance • Excess insulin – increases the permeability of cells to key ions (potassium and magnesium), induces secretion of angiotensin II = hypertension • Promotes fatty acids from liver (carried on VLDL) to be stored in fat cells and inhibits breakdown of fat from fat cells. Cells with too much fat produce fewer receptors. Leads to ↑ VLDL, ↑Trig, ↑ LDL,↓ HDL • Elevated bl. glu leads to ↑ glycation and increased free radicals which oxidizes LDL (very atherosclerotic) Harvard Health Eating Pyramid, (2001 Willett) Harvard’s Healthy Eating Pyramid 1. Foundation = exercise 2. Whole Grain Foods (at most meals). 3. Plant Oils. 4. Vegetables (in abundance) and Fruits (2 to 3 times). 5. Fish, Poultry, and Eggs (0 to 2 times) 6. Nuts and Legumes (1 to 3 times) 7. Dairy or Calcium Supplement (1 to 2 times) 8. Red Meat and Butter (Use Sparingly) 9. White Rice, White Bread, Potatoes, Pasta, and Sweets (Use Sparingly) 10. Multiple Vitamin - take one 11. Alcohol (in moderation) Healthy Eating Indexes Harvard study findings • Men who followed USDA’s Food Guide pyramid had 11% lower risk, women 3% lower risk of developing chronic disease • Harvard’s – men who followed Healthy Eating Pyramid had 40% lower risk, women 30% lower risk Mediterranean Diet • 7-10 whole fruits and vegetables/day • High Fiber foods – whole grains • Fish or other Omega 3 sources – 1 -2 svg/wk. • Protein - Lean red meat, skinless poultry, and low fat dairy • Nuts and Legumes • Alcohol – one glass of wine, beer or 1.5 oz. hard alcohol with dinner • No Trans fats Mediterranean Diet Leads to 23% risk of death from any cause* • Characteristics common to 16 countries: • High frt, veg, potato, beans, nuts, seeds and whole grain bread consumption • Olive oil • Fish and chix, moderate red meat • Wine – moderate intake with meals • Reliance on local fresh produce (organic) • Dairy – low to moderate, cheese and daily plain yogurt, no milk • Active Lifestyles *(Healthy Ageing: a Longitudinal Study in Europe) JAMA, 2004;292:1433 Physical Activity and Insulin Resistance • Katzmarsyk (Ontario) – study of 19,000 men age 20-79. • Men who were physically active had 50% reduced risk of death from CVD regardless of chol. level. • “It shouldn’t be called metabolic syndrome, it should be called physical inactivity syndrome.” What’s missing in American diets? • 6 out of the 10 leading causes of death are associated with dietary behavior. • Fruits and vegetables - consumption still under 5 a day (NHANES-II found 91% eating <5/d). Newer studies recommending >9/day, i.e. the DASH diet, newer pyramid designs • Fiber – from fruits, vegetables and whole grains (svgs still under 1 per day). • Vitamins and minerals – not getting RDA’s in typical diets • Omega 3 fats What are Americans getting too much of? • Refined carbs – Sugar and starches • Trans fats from hydrogenated oils • Refined and processed foods Fast Food • Primary source of trans fat and refined sugars • Young adults who ate fast food 3x/wk or more gained an extra 10 lbs and had a two fold increased risk of insulin resistance. * “Fast-food Habits, Weight Gain, and Insulin Resistance (The CARDIA Study): 15-Year Prospective Analysis”. Mark Pereira, et al. The Lancet, January 1, 2005. Trans Fat – What’s the problem? • Trans fat – occur in large amounts in hydrogenated oils, especially partially hydrogenated oils (fats used to extend shelf life of oils) • Occur naturally in some foods – ie beef and dairy • Replace essential fatty acids in building cell walls and influence prostaglandin production Trans fats: Man made vs. naturally occurring • Conjugated linoleic acid (CLA), found in red meat and dairy products, has been shown to have positive health benefits including. . . • May inhibit breast and colon cancer tumor growth, have anti-diabetic properties, enhance immune response and exerts positive effects on lean and fat body mass and growth. (MacDonald, H.B. Conjugated linoleic acid and disease prevention: a review of current knowledge. J. Am.Coll.Nutr.19: 111s-118s; 2000.) • American Dietetic Association identifies CLA as a component in dairy products and red meat that may alter cancer carcinogenesis. • No CLA in fat free dairy products Sources of Trans Fat Product Common Serving Size Total Fat g Sat. Fat g %DV for Sat. Fat Trans Fat g French Fried Potatoes± Medium 27 7 35% 8 (Fast Food) (147 g) Butter** 1 tbsp 11 7 35% 0 Margarine, stick† 1 tbsp 11 2 10% 3 Margarine, tub† 1 tbsp 7 1 5% 0.5 Mayonnaise†† 1 tbsp 11 1.5 8% 0 (Soybean Oil) Shortening± 1 tbsp 13 3.5 18% 4 Potato Chips± Small bag 11 2 10% 3 (42.5 g) Milk, whole± 1 cup 7 4.5 23% 0 Milk, skim† 1 cup 0 0 0% 0 Doughnut± 1 18 4.5 23% 5 Cookies± 3 6 1 5% 2 (Cream Filled) (30 g) Candy Bar± 1 10 4 20% 3 (40 g) Cake, pound± 1 slice 16 3.5 18% 4.5 (80 g) Man made trans fats • Compromised cell membranes and function • Decrease HDL • Increase LDL • Promote inflammation • Cause insulin resistance Essential Fatty Acids • Must be obtained in the diet • used to synthesize prostaglandins • enzyme function, ratio of omega-3 to omega-6 and the presence of certain nutrients determine the pathways – healthy vs. unhealthy prostaglandins Sources of Essential Fatty Acids • Omega 3 (Linolenic) • Omega-6 (linoleic) – flax oil – evening primrose oil – leafy green vegetables – safflower oil – salmon – tuna – borage oil – mackerel – sesame oil – sardines – canola oil – trout – cod liver oil – peanut oil – wild game – poultry – Some nuts (macadamia, – pork walnuts) – Avocado Prostaglandins •Hormones synthesized at the cellular level and used almost instantaneously •Difficult to study in controlled setting •over 30 prostaglandins have been identified •three general categories Prostaglandins • Prostaglandin E-1 and prostaglandin E-3 have health promoting activities – immune modulating – anti-inflammatory – anticoagulant (prevent platelet aggregation) – dilate arteries Prostaglandins • Prostaglandin E-2 (PGE-2), thromboxane- A2, and leukotrienes have health diminishing effects – pro-inflammatory – immune suppressing – increase platelet stickiness Prostaglandins • All prostaglandins have a purpose, the important quality is their ratio • factors that increase PGE-2 and decrease PGE-1 and PGE-3 are – Increased insulin – lack of omega-3 fatty acids – hydrogenated oils/trans fats Conditions that Block PGE- 1/PGE-3 Synthesis • Trans fatty acids • Hyperinsulinemia • excess saturated fat • lack of protein • high serum cholesterol • heavy metal toxicity • alcohol • radiation • sugar and excess • oxidative stress insulin • cortisol • diabetes • yeast • impaired glucose tolerance Over-consumption of Refined Sugars • Sugar - problem is the large amounts consumed, avg. 64 -150lb./person/yr. When considering all caloric sweeteners- 158 lb.per capita. • Increase is attributed to the increased use of added sweeteners in processed foods and increased soda intake (sugar sweetened drinks are the primary source of added sugars in the diets of U.S. children) Sugar statistics, cont’d • Total energy intakes of Americans continues to rise, as do obesity rates, Type II diabetes, and insulin resistance (syndrome X) • Studies show obese children and adults have higher soft drink intake than lean counterparts. Sugar, cont’d • Dental caries rates are now at same levels prior to fluoridation of water. • Sugar provides calories but no vitamins or mineral or fiber and displaces more nutritive calories, making it hard for individuals to meet RDA’s for micronutrients. • Glucose ingestion inhibits resorption of calcium and magnesium (Lemann, AJCN 70 (1967), 236- 45) Sugar • High sugar intake increases oxidative stress in the body via glycation; oxidative stress may create some of the damage in the cells that creates insulin resistance • Lowers HDL, decreases immune cell activity, depletes minerals, increases trigs, contributes to imbalances of gut flora, raises stress hormones Sugar guidelines • USDA Dietary Guidelines say to use sweets “sparingly” • ADA recommends consuming no more than 5- 10% of kcal from sugar. (Approx. 6 tsp/d. on 1600kcal, 12tsp/d. on 1800 kcal.) Avg. daily intake in person >2y.o.= 21.tsp. • The avg. 12 oz. soda contains 9-10 tsp. sugar --2005-- MyPyramid New USDA Food Guidance System • New pyramid recommendation – eat 50% of grains as whole grains, limit solid fats/eat oils, eat more dark green and orange veggies, go easy on fruit juices, eat lean meats/eat more fish nuts beans seeds, discretionary calorie system for limiting candy, high fat cheese, alcohol, placed pyramid on base of physical activity Issues – now addressed by pyramids that weren’t before • Sugar intake of Americans is too high • Hydrogenated oils and trans fats increase heart disease risk • Increased disease risk with too much red meat consumption • Not everyone can drink milk • Caloric consumption level to prevent obesity depends on activity level Other Nutrition Issues • Macronutrients – what are the right percentages? • Toxicity of environment affects health and nutrition needs • Health effects of food chemicals • Health effects of antibiotic and hormone use in animals • Assessment of vitamin and mineral status – effects of micronutrient status on disease states • Probiotics Macronutrient Percentages • Atkins – 20% or less CHO, 30% Pro, 50% fat to induce ketosis and burn fat stores. Improves lipid profiles. Could increase cancer risk. Weight regained rapidly when diet is stopped. • The Zone and South Beach diets – 40% CHO, 30% fat, 30% pro. Reducing carbs lowers insulin production, resulting in weight loss. Low Carb diet, 2002-2004 • Do lead to weight loss and improved blood lipid profiles, though studies are short term 3-6 months in duration • Concerns over high protein leading to kidney damage and/or liver damage. • Side effects: constipation, increased colon cancer risk, kidney stones, ketones (liver damage, ketoacidosis) • Long term – when carbs are added back in weight is regained making the overall weight loss results similar to a normal low calorie diet Low Carb studies • Brehm B, J of Clin Endocrin and Metab, April 2003 • Westman EC, American Journal of Medicine, Jan. 2002 • Bravata AM, JAMA, Apr. 2003 • Foster GD, NEJM May 2003 Studies on 40 /30 /30 Plans • South Beach (SB) vs. AHA Step II in 60 vol. 12 wks. SB avg. 14 lb. AHA avg. 7lb wt. loss, SB also had signif decreased waist/hip and decrease trig. vs AHA* *Arch Intern Med 2004;164:2141-46 40/ 30/30 studies • The Zone vs. AHA Step I (60/15/25) - 29 overweight men and women in 6 wks. - The Zone lost 6.2 lb. and .5% body fat - AHA lost 2.6 lb. and no body fat. - Profile of Mood Analysis (POMS): the Zone 44% fatigue reduction and incr 15.7% vigor vs. no change in AHA group JADA 1998;98(9):s1,a43 40/ 30/ 30 studies • A 40/30/30 diet plan consisting of 3 meals and two protein bars per day with fish oil supplements led to ↓23% insulin, ↓ 7% HbA1c, ↓ 14% TG, ↓ 26% TG/HDL, and 7 lb. wt loss in 12 wks. Sears, et al. A Nutrition Intervention Program to Improve Glycemia, Lipid Profiles and Hyperinsulineamia in Patients with Type 2 Diabetes. Presented at the 58th Annual American Diabetes Association, Chicago. Study of Low Glycemic Index Foods in Teenage Boys • Subjects were given equal kcal meals with either high, med. or low GI • High GI meals led to incr kcal intake and higher serum insulin, lower plasma glucagon, and elevated serum plasma epinephrine Ludwig, et al. High Glycemic Index Foods , Overeating and Obesity. Pediatrics 103:e26 (1999) Modified Low Carb Better than High Carb in Insulin Resistance • Low Carb High Protein (HP)diets were compared to high fat (HF) and High Carb High Fiber (HC) diets in 96 overweight women. 16 weeks • Participants were given general weight loss counseling during first 8 weeks, cont’d diets on their own during second 8 weeks. Results • HC - wt. loss 5 kg., waist 7 cm., TG .32 mmol/l, insulin 4.2 mIU/l • HF - wt. loss 7 kg, waist 9cm, TG .56, Insulin 5.9, 25% showed a > 10% LDL increase. • HP - wt loss 7 kg., waist 7.7cm, TG .63, insulin 3.8, Waist circum cont’d signif Authors concl. - HP diet best overall approach for risk of CVD and Type II Diab in insulin resistant people McAuley, et al. Diabetologia (2005) 48:8-16 Higher protein intake • Exercise is much more effective when it’s combined with high protein diet – protects muscle, improves fat burning • Leucine (an amino acid) may be the key •Layman et al. Journal of Nutrition Aug. 05 Higher Fat and Protein enhanced Fat Loss Carb Restricted Diets high in MUFA or Pro are equally effective at promoting fat loss and improving blood lipids (AJCN Apr. 2005) When substituted for carb, protein enhances fat loss. This study looked to see if the effect was from HP or higher MUFA. Both higher fat and protein diets led to fat loss, lower glucose and insulin responses and NO calcium loss, bone loss or renal changes. Lower Carb DASH diet/OMNI study • DASH diet - High carb, low fat, low sodium, high magnesium diet - lowered BP, lowered HDL • OMNI - replaced some carb with fat or pro further reduced heart disease risk by 13%, (higher MUFA diet protected HDL.) Low Carb High Protein Safe and Effective • Comparison of 4 diets - lowest carb was most effective for weight loss, lowering of trigs, increasing HDL and lowering BP JAMA. 2007;297:921. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Authors’ Conclusions • Women assigned to the Atkins diet lost the most weight and experienced the most beneficial overall metabolic effects through 1 year of follow-up. High Carb Diets • Increased triglycerides, insulin resistance, higher waist to hip ratios, higher muscle loss, lower body fat loss • Need to be done fat free (vegan.) • If too many Omega 6’s, incr. fructose - great potential to shut down HDL production and increase triglycerides (trig/hdl=strong predictor of CAD) Gaziano, Circulation 96(1997):2520-25. Low Carb Diets • Type 2 Diab. Given 25% carb diet for 8 wks., then 55% carb calorie equiv diet • 25% diet - signif decreased wt., bl. glu and HbA1c, also BP decreased from 136/83 to 133/77, sulfonylureas D/C • 55% - HbA1C increased, wt incr. • Concl 1.6% reduction of low carb diet comparable to that seen with acarbose, can achieve same benefit without exposure to an additional drug Guiterrez, et al. JACN 1998;17(6) 595-600. Low Carb Diet Studies • 120 young adults - comparing 2 low vs. 2 high GL (all diets were LF reduced kcal) • All groups lost wt. and waist circum • High carb groups - one had lower GI, this group nearly doubled fat loss compared to high carb, high GI • GI and GL influenced results even within a low kcal diet. Reducing GL increased rate of fat loss esp. in women Arch Int Med, July 24, 2006 Low Carb in Type 2 Diabetes • 10 obese pts - low carb diets led to spontaneous lower kcal intake, wt. loss, much improved bl glu, HbA1C, trig and chol. • HbA1C 7.3 to 6.8 % in 2 weeks Ann Intern Med 2005 Mar 15;142(6):469-70 • Contrast with ACCORD trial - which intensive arm was D/C due to incr. risk of death. Goal of study was HbA1C under 7% Low Carb Studies • 162 subjects RDB study 1 yr. comparing high carb/ high GI, high carb/low GI, and low carb/high MUFA • In well controlled Type 2 Diabetics (bl. glu near normal) a low GI led to lower 2 hr postload glu and CRP were lowest in the low GI diet (1.95), highest in high carb/high GI (2.75) Am J Clin Nutr 2008;87;114-25 Low Carb Diets and Metabolic Syndrome • Low carb/High fat diet improved BP, increased HDL, lowered Trig, reduced bl glu and insulin, and reduced weight. • Low fat/High carb diet exacerbated Metabolic Syndrome • Authors discussed the persistance of AHA/NHBL in recommending Low fat diets as being in error for Met S Volek J, Feinman R. Nutr and Metab 2005,2:31 Low Carb and REE • 2 kcal restricted diet, either low fat or GL • Bl glu, trig, CRP and BP all improved more in low GL group • REE’s reduced less in the low GL group • Low GL group also had less hunger Pereira, MA, et al. JAMA 292:2482-2490 Low Carb and Lipids • Low carb diets lowered trig, increased HDL and lowered apoB even in absence of wt. loss or presence of higher sat fat when compared to low fat diets • Krauss, et al. AJCN 2006;83:1025-1031 Low Carb and Macular Degeneration • 4100 adults age 55-80 completed surveys of dietary habits • High intakes of high GI and GL were associated with greatest risk of developing AMD in at least one eye Chiu C, et al. AJCN July 2007;vol 86:180-188 Fructose • Lit Review - effects of fructose (doesn’t raise insulin, so GI not a factor) • Fructose increases wt and trigs • Decreases leptin, doesn’t suppress Ghrehlin • Decreased adiponectin (secreted by fat cells improves insulin sensitivity) • In children, obesity risk increased 1.6 times for every glass or can of sugar sweetened drink they consumed Obesity Research 12:124S-129S (2004) Fructose • Major dietary sources- high fructose corn syrup, fruit juices, fruit • High intakes greatly increase risk of insulin resistance and heart disease • Authors of this review urgently called for the reduction of high fructose additives in food supply • Nutrition & Metabolism 2005, 2:5 doi:10.1186/1743-7075-2-5 Nutrition and Metabolism, 2005 • The general increases in consumption of calories, and specifically of refined carbohydrates and fructose, is clear and correlates positively with an alarming increases in metabolic syndrome. (Basciano, Federico, Adeli) Insulin causes Hypertension • Obese subjects placed on low carb, high fat diet. No kcal restriction. Sodium intake went from 2 g to 20 g • Lost 5% of body wt in 6 wks, had signif reductions in fasting insulin and mean aterial pressure • Auth conclusions - we need to stop paying so much attn to sodium and start paying attn to fasting insulin Hays JH Mayo Clin Proc 2003:78;1331-1336 Diet and CVD • Paradigm Shift Needed - Multiple lines of evidence implicate high GL diets increase risk of diabetes and CVD • IT IS TIME TO SHIFT THE DIET/HEART PARADIGM AWAY FROM RESTRICTED FAT AND TOWARD REDUCED GLYCEMIC LOAD Frank Hu, MD PHD Harvard School of Public Health Editorial J A Coll Cardiol 2007;50-22-24 Diet Recommendations • J Am Coll Cardiol. 2008;51:249-255. • Carbs shoud be high fiber, low GI • 1 handful nuts daily • Avoid processed food/drink containing sugar, HFCS, white flour, trans fats • Eat leafy greens daily with olive oil/vinegar • Eat lean protein at 3 meals • Eat foods high antiox’s - berries, dk.choc, tea, red wine • Called an anti-inflammatory diet Sample Low Carb Intake • 1500 kcal, 20% carb = 75 g • Non-starchy veg’s avg. 5 g carb/svg (1/2 cup cooked, 1 cup raw) • Starches and Fruit - 15 grams per serving varies widely, 1 slice bread, 1 small to med apple, 1/2 cup potato or rice, 3/4 c unsweetend dry cereal, 1/3cup fruit juice • If consuming recommended 10 veg/day, this leaves 1-2 starches, 1-2 fruits/day High Quality Carbs • Too many refined flours in pasta, cereals, breads • Whole grains are cholesterol free, low fat, high in fiber, good source of B vitamins and trace minerals • Current recommendations 3 svg/day. Avg Am., only 13% eat 1 or more svg./day. Fiber • Significant health benefits with adequate intake- bowel health, aids blood sugar control, decreases certain cancer risks, heart health • Breast cancer and fiber - fiber inhibits Beta glucoronidase activity (associated with increased risk breast cancer) Fiber, cont’d • Recommended intake > 25 g./day • Foods - frts&veg’s - 2g/svg., whole grain breads - 2 g/svg., beans - 7 g/svg, metamucil - 15 g/svg. • Glycemic index vs. glycemic load – Glycemic Index and Load • Foods with high glycemic index – sugar, starches (foods from grains and potatoes), carrots • Foods with high glycemic load – sugar and starches, some fruits ie dates Sweeteners • Artificial sweeteners – Splenda, Nutrasweet, saccharin • Natural sweeteners – honey, stevia, brown rice syrup, unrefined cane, agave nectar • Sugar alcohols – sorbitol, maltitol, xylitol Vitamins and Minerals • Crucial coenzymes biochemical pathways- • Structural component of body tissues and cells • Other functions - antioxidants, blood clotting, hormone-like activity Vitamins and Minerals • Inadequate intakes are associated with inadequate fruit, vegetable, and whole grain consumption and intake of excessive sugar (Sugar increases excretion of minerals, incl. calcium, chromium, magnesium, zinc, and copper.) • RDA’s being updated for adequacy - still based on level needed to prevent deficiencies and maintain health in the majority of the health population, not preventive health levels. Not based on individual needs. Vitamins and Minerals • Harvard Pyramid – first acknowledgement that intake of vits /mins above RDA’s is needed to prevent chronic diseases • JAMA June 2002 Fletcher and Fairfield – recommended all adults take a multivit/min daily because SAD does not provide enough vits/mins to prevent chronic ds. Nutrients in foods Declining • From 1950’s to 1999 – protein, calcium, phos, iron, riboflavin, and vitamin c all declined in 43 garden crops • Due to – high yield crops, gradual depletion of soil micronutrients and organic matter, and changes in pest complexes and levels Mayer, Brit Food J 99(6), 1997 Davis, J Am Col Nutr 23(6), Dec. 205. Sample Studies • Vitamin C - upregulates carnitine production and therefore fat burning • This study finds that individuals with marginal vit. C status burned 25% less fat during exercise. Repletion of vit. C raised fat burning 4 fold. Nutrition & Metabolism 2006, 3:35 doi:10.1186/1743-7075- 3-35 Sample Studies • Magnesium may influence the release and activity of insulin . Low blood levels of magnesium (hypomagnesemia) are frequently seen in individuals with type 2 diabetes. Hypomagnesemia may worsen insulin resistance or may be a consequence of insulin resistance. Individuals with insulin resistance do not use insulin efficiently and require greater amounts of insulin to maintain blood sugar within normal levels. Sample Info • The kidneys possibly lose their ability to retain magnesium during periods of severe hyperglycemia (significantly elevated blood glucose). The increased loss of magnesium in urine may then result in lower blood levels of magnesium . In older adults, correcting magnesium depletion may improve insulin response and action . • http://ods.od.nih.gov/factsheets/magnesium.asp Phytochemicals • Naturally occurring substances in fruits, vegetables, legumes, and whole grains that plants naturally produce to protect themselves against viruses, bacteria, and fungi. They include carotenoids, flavonoids, indoles, isoflavones, capsaicin, and protease inhibitors. • Their role in promoting health is still being determined. Certain phytochemicals protect against some cancers, heart disease, and other chronic health diseases. Special Topics • Probiotics/Food allergies, sensitivities, intolerances • Pesticides on foods • Growth hormone in milk and beef– may increase cancer risks • Organic foods • GMO - genetically modified foods Why Organic? • Organic foods are being proven in studies to be higher in nutrients and antioxidants. • Lowers toxic burden on body (liver) which also spares nutrients • “Organic Diets Significantly Lower Children’s Dietary Exposure to Organophosphorous Pesticides.” Environmental Health Perspectives, Volume 111 (2003): pages 377-382. Organic Foods • Chensang L, et al. Environ Health Perspec 114:260-263 (2006). Study of school age children. Substitution of organic foods immediately lowered organophosphate pesticide metabolites in urine to non- detectable levels. Metabolites remained non-detectable until conventional foods were re-introduced. Organic Foods Higher in Many Nutrients • Antioxidants • Higher Lycopene • Higher Vitamin C • Higher minerals and trace minerals (Organic Center State of Science Review, 2005) Quality Proteins • Concerns regarding antibiotic residues, pesticides concentrated in animal fats, hormones, mercury levels in fish. Nitrates in hot dogs and other lunch meats • Can avoid by buying free-range poultry, beef and pork fed organically-grown foods and given no hormones, dairy should be antibiotic free. Use organically grown beans and soy to meet some of the protein need. Protein Recommendations • If can’t afford organic grass fed - don’t eat beef more than once a week. • Emphasize chicken, fish turkey - look for raised without antibiotics • Can eat fish 2 to 3 x/wk, but limit high mercury fish to no more than 1 or 2 x/month. Tilapia, orange roughy, cod/halibut OK. Watch tuna/ shark/sea bass. • Limit nitrite treated meats - hot dogs, salami, etc. Net acid Load • Modern diet lead to increased of net acid load, which affects bone density and renal health (accumulation of urid acid in kidneys causes kidney stones) • Primary difference in paleolithic diets and today’s is the addition of grains and sugars and refined oils • Researchers concluded we need to replace grains and sugars with leafy greens and other vegetables AJCN Vol 76 (6) 1308-1316. Dec. 2002 Probiotics • Probiotics – beneficial bacteria that compose the intestinal microflora that line the intestinal walls • Provide a physical barrier to translocation of pathogenic bacteria and undigested food, inhibit e- coli adherence • Help form some of the B vits, vit K, short chain fatty acids • Enhance immune system and prevent carcinogenesis • Enhance gut lining function and integrity • Gut integrity is strongly implicated in food allergies/sensitivities Probiotics • Certain strains of probiotic bacteria block intestinal absorption of aflatoxin fungus, thereby leading to reduced urinary excretion of an aflatoxin metabolite associated with liver cancer Am J Clin Nutr, 83, 5:1199- 1203, 2006. Factors influencing Intestinal Flora • Antibiotics • Pesticides in food • BCPs • Alcohol • Radiation/chemo • Heavy metals • Corticosteroids • H.pylori • Sugar in the diet • Gastrointestinal pH • Bacteriocidal • Stress chemicals in drinking • Bowel transit time water Food Intolerances • Majority of people have compromised gut integrity due to high sugar intake, NSAIDS, alcohol, and antibiotics predisposing them to food sensitivities • Ability to properly digest wheat and dairy becomes compromised • Up to 1 in 7 people have gluten intolerance • Up to 1 in 4 have lactose intolerance • If intolerant, causes inflammation which can contribute to insulin resistance and weight gain Food Allergies • 7 foods make up 90% of food allergies - Peanuts/Walnuts - Shellfish - Wheat - Cow’s milk - Eggs - Soy - Yeast Food Rotation Diets help prevent food allergies and are strongly encouraged by LMI GMO’s • Take genes from bacteria, viruses or other substances like latex add to DNA of soy, corn, cottonseed, canola, tomatoes • First occur of allerg brazil nut gene put into soy (Ordlee NEJM Mar 14, 1996) • UK study 1999 soy allergies incr. 50% from prev yr. after US import of GM soy • Instead of reducing pesticide use, GM crops need more pesticides (Benbrook C. BioTech Info Net Tech Paper No. 7, Oct. 2004) Summary • New Pyramids – decrease intake of refined carbs, increase frt/veg intake, take a vit/min, get omega 3’s, increase exercise. • Carbohydrate level – tailor to activity level and/or pre-existing disease. Average person with no significant health issues who exercises will benefit just by eliminating soft drinks, refined sugars, and changing to whole grains. • 20 to 30% carb with increased protein and healthy fat - so far showing benefits for fat loss, insulin resistance (Type 2 Diab, Metabolic Syndrome) and CAD risk reduction. Summary, cont’d • MD’s should remember to recommend and refer their patients to dietitians, who are very good at helping people implement new diets with stepped changes. (Tell them you want lower carb, limited refined sugars or 20-30% carb in insulin resistant patients, which can be liberalized after weight loss to highest tolerated level.) Summary, cont’d • Organically grown foods – reduce risks from pesticide intake and provide higher levels of nutrients. If cost is an issue, consider using just organic milk. • Remember - as availability increases costs will come down. Your patients need to know they are preferable. Simple Changes • Consider starting point - if someone lives on fast food and junk foods • Suggest not drinking soft drinks for starters, change to water, iced tea, or diluted fruit juices • Try to start eating more fruits and vegetables, try vegetables prepared different ways. Start with 2 or 3 servings, work your way up. • Ripeness and Freshness is important for taste. • Can trade fruit for candy at first, then try to reduce amount of fruit. LaValle Metabolic Institute Diet Approaches • Modified Low Carb/Higher Protein/Healthy fats – mega vegetables, limit fruit and grains/starch, eliminate refined sugars • Address food allergies/intolerances • Organic foods when possible • Multivitamin/mineral • Omega 3’s • Probiotics • Other supplementation based on individual needs - ie glucosamine/chondroitin for painful joints • Increase activity – individualize exercise. Contact Information lmihealth.com Laura LaValle is a registered and licensed dietitian who has specialized in integrative medicine. Laura currently provides individual dietary counseling at the Living Longer Institute in Cincinnati, Ohio. Her previous experience in dietetics includes working in clinical nutrition in general medical conditions , intensive care nutrition support, and cardiac rehabilitation nutrition. Laura has also worked as community outreach dietitian and for manufacturers of dietary supplements as a product information specialist. Laura has delighted audiences all over the state of Ohio with her always fresh and unique perspective on nutrition and its importance for health and wellness. – Llavalle@lmihealth.com – 1-513-924-5300 ext 113