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Food as Medicine. Integrative Medicine Curriculum 2014 Marc Engfield MD FRCP Internal Medicine & Acupuncture. Music: Mark Knopfler , “Classical Gas”. Objectives. Describe the main features and benefits of the mediterranean diet

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Food as medicine

Food as Medicine

Integrative Medicine Curriculum 2014

Marc Engfield MD FRCP

Internal Medicine & Acupuncture

Music mark knopfler classical gas


Mark Knopfler, “Classical Gas”


  • Describe the main features and benefits of the mediterranean diet

  • Explain glycemic index and load and understand the benefits of a low-GL diet

  • Name five specific food choices associated with increased risk of chronic disease

  • Describe the main differences between organic and conventionally-grown foods

  • Reflect on your own diet and the changes you could make to improve your health

Problems with canada s food guide
Problems with Canada’s Food Guide

  • Too many grains

  • Too much dairy

  • Nuts are considered a ‘protein’ rather than a food

    in themselves

  • How about water?

  • …and healthy oils?

Nutrition for dummies
Nutrition for Dummies

  • Eat less

  • Eat more plants

Key features
Key Features

  • Raw and cooked vegetables at every meal

  • More fish and seafood

  • Nuts, seeds and legumes

  • Fruit for dessert

  • Spices and herbs

  • Olive oil

  • Wine with meals

  • Less red or processed meat

  • Fresh, seasonal, varied diet

  • Relaxed, social meals

Mediterranean ebm
Mediterranean EBM

  • First recognized in Seven Countries Study in 1950s

  • Total mortality 0.90

  • CVD incidence/mort 0.92

  • Caincidence/mort 0.94

  • Neurodegenerative incidence/mort 0.87

    PMID: 20810976

Caloric restriction1
Caloric Restriction

  • Increased lifespan up to 40% in animals

    Mice, dogs and fish

    Primate studies ongoing

  • Human CALERIE study

    Comprehensive Assessment of Long-term Effects of Reducing Intake of Energy

    HDL  LDL, TG 

    Fasting insulin and glucose

    BP, CRP, carotid IMT

    Memory in the elderly

    PMID: 16595757

  • Phase II CALERIE study ongoing

Caloric restriction2
Caloric Restriction

  • Mechanisms

    stress-induced conservation

    Less insulin, less glycation

    Sir2 longevity genes

  •  calories - NOT nutrients

  • Nutrient density of Food

    Nutrients = Nutrient Density


    Vegetables are the primary food

    CHO 4 kcal/g

    protein 4 kcal/g

    fat 9 kcal/g

Different than mediterranean diet
Different than Mediterranean Diet!

Nutrient Density

Of Different


Why vegetables
Why Vegetables

  • Old - Vitamins and minerals

    Ca, Mg, K instead of Na

  • New - Phytochemicals

    Too many to mention

    Science is just beginning

    Raw vs cooked – it depends


  • Leafy greens

    Bok choy, Broccoli, Cabbage, Chard, Collard greens, Endive, Kale, Lettuce, Mustard green, Radicchio, Spinach, Turnip

  • Fruits and flowers

    Artichoke, Avocado, Broccoli, Cauliflower, Cucumber, Eggplant, Peppers, Pumpkin, Squash, Tomato, Zucchini

  • Bulbs and Stems

    Asparagus, Celery, Garlic, Leek, Onion, Shallot

  • Roots and tubers

    Beet, Carrot, Cassava, Ginger, Parsnip, Potato, Radish, Sweet potato, Turnip, Yam

Fruits how to
Fruits How-to

  • Eat berries

    raspberries – Ellagic acid and CAD

    blueberries – anthocyanins and dementia

    cranberries – acidity, quercetin and UTI

    Indian gooseberry – many diseases

  • Mix colors

  • The peel is most nutrient-dense

  • Eat them instead of dessert

Why eat organic
Why eat organic?

  • More phytochemicals

    Nature’s medicines

    Developed as defense system

    Drought, lack of nutrients

    Oxidative stress

    Fungal infection

    Herbivores and insects

  • Less harmful chemicals

    Pesticides and fertilizer

    No stress – no response

    Fewer phytochemicals

    Lower vitamin and mineral content

Organic evidence
Organic evidence?

  • More polyphenols and fewer pesticides


  • More Campylobacter in organic chicken 16863067

  • Reduced risk of cancer?

    Only non-Hodgkins lymphoma 24675385

Glycemic index
Glycemic Index

Reduce glycemic index
Reduce Glycemic index

  • Simple vs complex CHO

    Based on CHO structure


  • Glycemic index

    Based on blood glucose response

    Reflects metabolic burden of food

Impact of glycemic index
Impact of glycemic index

  • Increased risk of Diabetes

    More insulin required

    Shanghai Women’s Health Study

    Black Women’s Health Study

  • New era of research

    Prevents heart disease 23804161

    May reduce inflammation 24552752

    No apparent DM2 risk 24265366

    Lowers LDL cholesterol 23804161

Glycemic load
Glycemic load

  • GI x CHO (grams) = GL

    Incorporates serving size

    CHO burden of an amount of food

  • Better measure of a food’s impact on the body

Reduce carbohydrates
Reduce carbohydrates

  • CHO restriction

    Initial <20g/d run-in phase

    Prolonged <60g/d

  • Benefits in short-term studies

    Weight loss

    Decreased fasting insulin and glucose

    TG reduction

    BP decreased

    Long-term studies needed

    PMID: 23035144

Limit fruit juice
Limit Fruit Juice

  • The body cannot use fructose

    Liver metabolism like EtOH

    High intake raised uric acid


  • Preliminary link to obesity

    PMID: 20524996

  • May promote diabetes

    Inflammationand lipogenesis

    insulin resistance and satiety

    No long-term studies yet

Avoid high fructose corn syrup
Avoid High-fructose corn syrup

  • Has replaced glucose to save $

    Isomil 43% HFCS

    gatorade, chocolate milk

  • YouTube “Sugar:The Bitter Truth”

    Robert Lustig, Pediatrician, UCSF

  • Conflicting meta-analyses

  • 23630060

Diet soda is not ok
Diet soda is not OK

  • Artificial sweeteners





  • Chemical toxicity

    Leukemia PMID: 23097267

    Preterm PMID: 22854404

  • Triggers CNS insulin mechanisms

Avoid sweetened beverages
Avoid Sweetened Beverages

  • Ischemic Stroke OR 1.83

    39,786 Japanese for 18y

    Higher risk in women

    PMID: 23076619

  • DM2, metabolic syndrome

    20% increased risk of each

    Meta-analysis of 11 studies

    PMID: 20693348

Gluten allergy
Gluten allergy

  • Wheat, rye, barley, spelt

  • Celiac disease affects 1%

  • Biopsy-negative allergy 30%?

    Anxiety, insomnia

    IBS, Crohn’s, abdo pain


    Anemia NYD

  • Try it yourself for 1 month

  • The next tobacco?

Avoid processed meat
Avoid Processed Meat

  • Ham, Salami, Bacon, Sausage

  • All-cause mortality

    OR 1.18 per 50g/d in EPIC

    PMID: 23497300

  • Several cancers OR 1.38

    nitrosamines in the GI tract

    11 studies in >4700 pts

    J NCI 2006;98:1078

  • CVD risk

Grass fed beef
Grass-fed beef

  • Cows are made to eat grass

  • Agribusiness uses grain (corn)

    Changes stomach pH

    Changes bacterial flora

    Liver abscesses ABx

  • Omega-3 fats

    Omega 6:3 ratio 20 vs 0.16

  • Conjugated Linoleic Acid

  • Avoids E coli

Avoid all meat
Avoid ALL meat?

  • Vegetarians are healthier

    All-cause mortality 0.91

    Ischemic heart disease 0.71

    CVD mortality 0.84

    Cancer incidence 0.82

    PMID: 22677895

Meat and global hunger
Meat and Global Hunger

  • Every kg of beef

    4.8 kg of grain

    2200 L of water

    2.2 L of gasoline

  • We eat more meat

    50% more than in 1960

    China and India 2.2bn

  • Global food shortages

    Rising food prices

    33 countries at risk

    Many ban exports

  • Be green … go Vegan

Choose your fish
Choose your Fish

  • Wild vs Farmed Salmon

    More omega-3

    More astaxanthin

  • Sardines

    80% cheaper than salmon

    The benefits of bones

    Lower on the food chain

  • Choose low-mercury fish

    Do not eat tuna

    Eat wild, small fish

    Add garlic and onions for -SH

Plant protein
Plant protein

  • Beans, lentils, flax, soy

  • Very nutrient-dense

    K, Ca, Mg, B vitamins


    Many antioxidants

  • Alkaline

    Less renal acid load

    ?prevent end-stage renal failure

    PMID: 20872351

  • More sustainable than meat


  • Improves LDL and lipid profile

    25 trials in 483 pts

    With or without lipid disorders

    About 10% improvement

    PMID: 20458092

  • Cardiovascular risk

    5 epidemiologic studies

    45% reduction vs saturated fat

    PMID: 19321572

Eat chocolate
Eat chocolate

  • Flavan-3-ols considered the key phytomedicine

  • Improve insulin sensitivity

  • Lower BP

  • Reduce LDL improve lipids

  • Reduce CV risk

  • PMID: 22301923

Good fats
Good fats

  • Omega-3 fats


    Flax, nuts, grass-fed beef

    EPA and DHA better than ALA

  • Monounsaturates

    From olives or nuts

    Vs PUFAs in vegetable or seeds

  • Medium-chain saturated fats

    Coconut and palm oil

    Digested without bile, not stored

    Appear anti-inflammatory

Bad fats
Bad Fats

  • Trans fats

    Hydrogenated industrially

    Prevents rancidity for shelf life

    Grain-fed beef and dairy

  • Pro-inflammatory

    CAD 2x risk per 2% caloric intake

    Ca, DM2, obesity, Alzheimer’s

  • Legislation

    Banned in Denmark, Switzerland

    Banned in NYC restaurants

    No legislation in Canada

Avoid heated oils
Avoid Heated oils

  • Time-dependent damage

  • Creates trans fats, AGEs and other toxins

  • One serving equivalent to a pack of cigarettes

  • Higher smoke point

    Coconut oil or butter/ghee

    PMID: 20886885