Disclosure in Offic e Pra c tic e No re le va nt fina nc ia l - PDF document

Nutrition a nd We ig ht Ma na g e me nt Disclosure in Offic e Pra c tic e No re le va nt fina nc ia l Robe rt Ba ron, MD MS re la tionships Profe ssor of Me dic ine Assoc iate De an for Gr aduate and Continuing Me dic al E duc a tion F ounding Dire c tor, UCSF Adult We ight Manage me nt Pr ogr am Why Do We Ca r e About Wha t We E a t? Why Do We Ca r e About Wha t We E a t? US L e a ding Ca use s of De a th, CDC US L e a ding Ca use s of De a th, CDC 1. He a rt Dise a se 32.6% 1. He a r t Dise a se 32.6% 2. Ca nc e r 30.9% 2. Ca nc e r 30.9% 3. Chr onic lowe r r e spir a tor y dise a se 7.5% 3. Chr onic lowe r r e spir a tor y dise a se 7.5% 4. Stroke 7.0% 4. Stroke 7.0% 5. Ac c ide nts 6.4% 5. Ac c ide nts 6.4% 6. Alzhe ime r ’ s dise a se 6. Alzhe ime r ’ s dise a se 4.3% 4.3% 7. Dia be te s 3.7% 7. Dia be te s 3.7% 8. Influe nza a nd pne umonia 2.9% 8. Influe nza a nd pne umonia 2.9% 9. Ne phr itis, ne phr otic syndr ome & ne phr osis 2.7% 9. Ne phr itis, ne phr otic syndr ome & ne phr osis 2.7% 10. Inte ntiona l se lf-ha r m (suic ide ) 2.0% 10. Inte ntiona l se lf-ha r m (suic ide ) 2.0%

Lifestyle and Disease Question for Discussion  1/ 3 of pre ma ture de a ths in the U.S. a re a ttributa ble to poor nutrition a nd physic a l ina c tivity.  How would you de sc ribe your own  We ll ove r 50% of Ame ric a n a dults do not g e t die t? the re c omme nde d a mount of physic a l a c tivity.  Only 10% of Ame ric a ns e a t a die t c onsiste nt with c urre nt nutrition re c omme nda tions . Topics Question for Discussion  T  Ve g e ta ria n Die ts ota l c a lorie s a nd ma c ronutrie nt  Me dite rra ne a n Die ts ba la nc e  How do you a sk pa tie nts a bout the ir  Othe r Mic ronutrie nts  We ig ht L oss Die ts die ts?  F ina l  Die ta ry F ibe r Re c omme nda tions  Die ta ry Guide line s  Sodium

Top calorie sources in U.S. U.S. Calorie Intake 1. Gr a in- ba se d de sse r ts  Ca lorie c onsumption in the U.S. ha s 2. Ye a st br e a ds inc re a se d 30% ove r the pa st 4 de c a de s. 3. Chic ke n a nd c hic ke n- mixe d dishe s 4. Soda , e ne r g y dr inks, a nd spor ts dr inks Year Average 5. Pizza calories 6. Alc oholic be ve ra ge s consum ed 7. Pa sta a nd pa sta dishe s 1970 2,057 8. Me xic a n mixe d dishe s 2008 2,674 9. Be e f a nd be e f dishe s 10. Da ir y de sse r ts Macronutrient Composition E xtra Ca lorie s F rom E a ting Awa y F rom Home  Ma c ronutrie nt c omposition: the re la tive proportions of fa t, c a rbohydra te , a nd prote in in the die t Calories/ m eal Calories/ m eal at hom e at a restaurant  Bottom line : Normal Weight 550 825  A wide ra ng e of ma c ronutrie nt c omposition Overweight/ Obese 625 900 is c onsiste nt with a he a lthy die t  In most c linic a l c irc umsta nc e s, tota l c a lorie s “trump” ma c ronutrie nt c omposition  Ac hie ving de sire d c a lorie inta ke will a c hie ve most c linic a l g oa ls Public Health Nutrition, 2013

COMPARISON OF WEIGHT LOSS DIETS WITH Princ iple s of We ig ht Ma na g e me nt DIFFERENT MACRONUTRIENTS < RCT of 811 patients, 4 diets: fat/protein/carbs 20/15/65; 20/25/55; 40/15/45; 40/25/35  Be a s fit a s you c a n be a t your < 6 months: 6 kg, 7% weight; c urre nt we ig ht < 2 years: completers lost 4 kg. 15% lost 10% of  Don’t g a in a ny mor weight e we ig ht < Results similar for:  If hig hly motiva te d, a tte mpt < 15% pro v. 25% pro < 20% fat v. 40% fat we ig ht loss < 35% carbs v. 65% carbs < Weight loss highly correlated with adherence; satiety, hunger, lipids, insulin all equal Die ta ry F ibe r: Die ta ry F ibe r T he Most Importa nt Nutrie nt?  Pla nt ma tte r  He a rt: L owe rs L DL , lowe rs trig lyc e ride s  Not dig e ste d by huma n dig e stive e nzyme s  Some c a n be dig e ste d by g ut ba c te ria  Dia be te s: Re duc e s blood sug a r  Gut: Pre ve nts c onstipa tion, he morrhoids,  Inc lude s  Ce llulose , he mic e llulose , pe c tins, g ums, a nd dive rtic ula r dise a se muc ila g e s, lig nins  We ig ht: Promote s sa tie ty  Cla ssifie d a s soluble or insoluble  IOM: Me n 30- 38 g / da y. Wome n 21- 25 g / da y. Baron RB, BMJ 2013

Die ta ry F ibe r: Quantifying Dietary Fiber (per serving) T he Most Importa nt Nutrie nt? Apple : 4.4 Oatme al 4.8 Blue be rrie s: 3.6 Shre dde d whe at 6.1  Me ta - a na lysis of 22 c ohort studie s: Cornflake s 0.9 Orange : 3.0 Grape s 0.8  E ve ry 7 g ra ms of fibe r a ssoc ia te d with a Pe anuts 9.1 Pe ar: 5.5 9% de c re a se in CV e ve nts Kidne y be ans 6.8 R aspbe rrie s 8.0  One portion of whole g ra ins a nd one Aspara g us 1.4 White bre ad 0.7 portion of le g ume s, or from two to four Broc c oli 1.1 Whe at bre ad 1.9 se rving s of fruits a nd ve g e ta ble s. Carrot 1.7 Brown ric e 1.5 Spinac h 3.5 White ric e 0.3 Threapleton DE, BMJ, 2013 Powde re d psyllium 3.0 Whe at- bran c e re al 7.4 Die ta ry Guide line s 2015 Princ iple s of a He a lthy Die t  L imita tions on die ta ry c hole ste rol ha ve  Wide va rie ty of foods be e n re move d  Hig h food qua lity  Consume a die t ric h in fruits a nd ve g e ta ble s, whole g ra ins, low- fa t da iry,  Mode ra tion (rig ht qua ntity) se a food, le g ume s, a nd nuts  Consume a die t low in re d or proc e sse d me a ts, sug a r swe e te ne d foods a nd be ve ra g e s, a nd re fine d g ra ins

Die ta ry Guide line s 2015 MyPla te  L imit da ily c onsumption of a dde d sug a rs (<10% of c a lorie s), sa tura te d fa t (<10% of c a lorie s), a nd die ta ry sodium (2300 mg )  Ha lf of a ll g ra in inta ke should c ome from whole g ra ins  Mode ra te a lc ohol is fine in most (non- pre g na nt) a dults  Up to five c ups of c offe e pe r da y is not a ssoc ia te d with a dve rse e ffe c ts in most a dults MyPla te T oo Ma ny Re fine d Gra ins  Guide line s re c omme nd six, 1- ounc e se rving s pe r da y for a 2000 c a lorie die t, a nd ha lf should be whole g ra in.  T he a ve ra g e pe rson e a ts 8 se rving s of g ra ins pe r da y, a nd 7 of the 8 a re re fine d.

Select whole grains What is a serving of grain?  1/ 2 c up c ooke d ric e or othe r c ooke d g ra in  L ook for “ whole ” in the first ing re die nt  1/ 2 c up c ooke d pa sta on the la be l.  1/ 2 c up c ooke d hot c e re a l, suc h a s oa tme a l  Aim for tota l c a rbs/ fibe r = <10 for  1 six inc h tor tilla bre a d a nd <5 for c e re a ls.  1 slic e of bre a d (1 oz.); ½ bun  Whole g ra ins: whe a t (spe lt, fa rro,  1 ve r y small (1 oz.) muffin durum, bulg ur, othe rs), ba rle y,  ½- 1 c up r e a dy- to- e a t c e r e a l buc kwhe a t, c orn, mille t, oa ts, quinoa , (½ c up = ½ a ba se ba ll) ric e , rye ) Wa y T oo Muc h Adde d Sug a r Salt and Public Policy  Coronary Heart Disease Policy Model to quantify T he a ve r a g e pe r son in US c onsume s 30 te a spoons of sugar and swe e te ne r s pe r day (up to 600 benefits of modest salt reduction in U.S. c a lorie s)  Benefit through a reduction in systolic blood (Inc lude s c ane and be e t sugar , high fruc tose c or n pressure from 1-9 mm Hg in selected populations syr up, c or n syr up, de xtr ose , hone y)  New cases of CHD decrease by 4.7 - 8.3 and  T he Die ta ry Guide line s re c omme nd <10 te a spoons stroke by 2.4 to 3.9 /10,000 (200 c alor ie s) of adde d sugar pe r day for wome n. Am. He art Asso c iatio n says <6 te aspo o ns (120  Regulatory change leads to wide benefit and is c alo rie s) cost-effective  A 20 oz. soda has 240 c alor ie s Bibbins-Domingo K, et al. NEJM 2010 from sugar

Sodium Salt in the US Diet  Ave r a g e c ur r e nt inta ke 3,400 mg pe r da y (1.5 te a spoon sa lt)  Institute of Me dic ine , 2013  L 80% in processed or pre ‐ imit e ve ryo ne to 2,300 mg pe r da y (1 te a spo o n) prepared foods  E vide nc e do e sn’ t suppo rt lo we r re c o mme nda tio ns  Die ta r y Guide line s, 2015  L imit e ve ryo ne to 2,300 mg pe r da y Sources: Mattes et al. Top sodium sources in U.S. Cla ssific a tion of Die ta ry F a t 1. Ye a st br e a ds 2. Chic ke n a nd c hic ke n- mixe d dishe s 3. Pizza 4. Soda , e ne r g y dr inks, a nd spor ts dr inks 5. Cold c uts 6. Condime nts 7. Me xic a n mixe d dishe s 8. Sa usa g e , fr a nks, ba c on a nd r ibs 9. Re g ula r c he e s 10. Gr a in- ba se d de sse r ts

Sa tura te d F a t a nd Ca rdiova sc ula r Sa tura te d F a t a nd Ca rdiova sc ula r Dise a se (CVD) Dise a se (CVD) • T wo re c e nt me ta - a na lyse s of • Cur obse rva tiona l studie s: no a sso c ia tio n r e nt r e c s: L imit sa tur a te d fa t, but be twe e n hig he r sa tura te d fa t a nd CVD be c a re ful wha t re pla c e s it • But strong e vide nc e from ra ndomize d tria ls: re plac ing saturate d fat with unsa tura te d fa t re duc e s to ta l a nd L DL • Use oils (soy, c orn, olive , c a nola ) to c ho le ste ro l. re pla c e a nima l fa ts (butte r, c re a m, la rd) or tropic a l oils (pa lm, c oc onut) • Re pla c ing sa t fa t with c a rbohydra te s: re duc e s to tal a nd L DL c ho le ste ro l but inc re a se trig lyc e ride s and lo we rs HDL Mediterranean Diet: Healthy fats and good carbs with a big side of fruits and vegetables