Nutrition and Health State of the Science and Practical Application June 2007

1. Nutrition and HealthState of the Science and Practical ApplicationJune 2007 Carole Bartolotto MA,RD Regional Health Education

2. Question? What is a healthy diet?

3. Healthy Diet Macronutrients: Carbohydrates Fat Protein Whole diet approach

4. Carbohydrates and Glycemic Load The glycemic index (GI) is a rating system that tells how quickly a particular food affects blood sugar. Carbohydrate foods that break down quickly during digestion have the highest GI. Glycemic load (GL) is the product of GI and grams of carbohydrate: GI X grams of carbohydrate /100 = GL. High glycemic load foods (refined foods) include sodas, mashed potatoes, white flour, white rice and other processed grains

5. Carbohydrates and Glycemic Load A diet high in glycemic load foods was associated with: Higher fasting triglycerides and lower high density lipoprotein (aka good cholesterol) Increased risk of heart disease, especially among overweight and obese women (insulin resistance) and diabetes* 2 � times the risk of type 2 diabetes with ? glycemic load foods* Breast cancer** *Nurses Health Study II ** Carbohydrates and the Risk of Breast Cancer among Mexican Women, 8/04

6. Relative Risk of Diabetes by Different Levels of Cereal Fiber and Glycemic Load

7. Carbohydrates and Glycemic Load Short term studies show ? hunger and ? food intake following consumption of high GI meals* Medium term studies suggest beneficial effects of low GI diets on body weight or central body fat* Animal studies show improvements in adiposity (fat stores) and related metabolic variables on a diet of low vs. high GI starch* *Dr David Ludwig

8. Carbohydrates Choose low glycemic load, unrefined, high fiber foods vegetables fruit whole grains such as brown rice, quinoa, bulger nuts/seeds beans/lentils Limit high GI/GL foods, processed carbohydrates Sodas, mashed potatoes, white flour, white rice, potatoes and other processed grains Most of the micronutrients as well as fiber are lost when you process grain

9. Saturated Fat  Saturated fat is found in: Red meat (beef, pork, lamb) Whole milk Butter Cheese Lard Palm and palm kernel oil

10. Problems with Saturated Fat  ? cholesterol and low density lipoprotein (bad cholesterol) ? risk of heart disease

11. Healthy Fat Omega-3 fatty acids (n-3 fats) found in fish, canola oil, walnuts and flaxseeds and oil may reduce risk of CAD by: Preventing cardiac arrhythmias Lowering triglycerides Decreasing clot formation Makes plaque in arteries more stable (endothelial function) Decreasing inflammation

12. Omega-6 Fats and Optimal Ratio Omega-6 fatty acids are found in vegetable oils such as: Corn oil Sunflower oil Safflower oil Soybean oil

13. Omega-6 Fats and Optimal Ratio Optimal ratio of Omega-3/N-3 to N-6 fats is unknown Current ration of n-6 to n-3 fats ~10:1 to 15:1 Since N-3 levels are clearly suboptimal, choose fish and plant sources of n-3 fats such as canola oil, walnuts and flax. Olive oil improves ratio ? olive oil ? risk of breast cancer (by 35%)

14. Fats and Oils

15. What is Trans Fat? Trans fat is found naturally found in small amounts in meat and dairy foods Trans fat is created when hydrogen is added to unsaturated fat to make it more saturated (and thus stable) Partially hydrogenated vegetable oil Food manufacturers use trans fat because they increase shelf life and effect taste and texture

16. What is Trans Fat? Cis Configuration: Trans Configuration:

17. Trans Fat

18. Major Sources of Trans Fat 

19. Where is Trans Fat Found Grams of trans fat per serving: 1 tbsp stick margarine: 2 to 3 grams 1 Dunkin� glazed donut: 4 grams 1/8 Mrs. Smith�s apple pie: 4 grams 3 Chips Ahoy! Cookies: 1.5 grams French fries: 4.7 to 6.1 grams Danish or sweet roll: 3.3 grams

20. Problems with Trans Fat ? total cholesterol, LDL, and LDL/HDL ratio ? HDL This effect has been reproduced many times ? small dense LDL (the worst kind of LDL) ? inflammation ? TG May reduce endothelial function by impairing flow-mediated dilation High intakes may promote insulin resistance and increase risk of type 2 diabetes

21. Trans Fat and Heart Disease In the Nurses� Health Study, women who ate the most trans fatty acids had a 53 percent increased risk of coronary heart disease compared to those who ate the least A recent 10-year study showed similar results with men eating the most trans fats having twice the risk of heart attack According to the NEJM, eating as little as two to six grams of trans fatty acids daily can significantly increase your risk of heart disease.

22. What Experts say about Trans Fat New 2005 Dietary Guidelines say ��keep trans fat as low as possible�. NCEP Guidelines say �avoid trans fat whenever possible�. Dr Walter Willett says we should have �zero [grams] from partially hydrogenated oils�.

23. Trans Fat Lableing Effective January 1, 2006 the FDA required food companies to list trans fat on the Nutrition Facts label �0� trans fat means less than � gram of trans fat per serving so you still could be getting trans fat!

24. Trans Fat Labeling

25. Fat Goals  Avoid trans and limit saturated fats Read ingredient list for partially hydrogenated oils Choose more n-3 fats by choosing canola oil, walnuts, freshly ground flax seeds or oil, salmon, tuna, trout and sardines Choose less n-6 fats (corn, sunflower, safflower, soy oils) Use monounsaturated fats (extra virgin olive oil)

26. Protein Consumption of red meat (beef, pork, lamb) is associated with an increase risk of: heart disease colon cancer type II diabetes ? animal protein Beef is the worst ? fish (high in n-3 fats), chicken and vegetable protein Vegetable protein is lower in the food chain so ? toxins Less saturated fat

27. Mediterranean Diet  (a whole diet approach)

28. Basic Principles of the Mediterranean Diet Eat a variety of unprocessed, home-cooked foods. Eat plant-based foods every day, such as fruits, vegetables, whole grains, beans, peas, lentils, tofu, nuts, and seeds. Olive and canola oils are the recommended fats, replacing saturated, trans, and other fats and oils (including butter and margarine). Canola oil margarine without trans fats is fine. Limit or avoid foods high in trans fats (these foods will have the words �partially hydrogenated oils� on the ingredients list), such as store-bought crackers, cookies, cakes, pies, pastries, and margarine. Read the label for other foods high in trans fats.

29. Basic Principles of the Mediterranean Diet Eat at least two fish meals per week, such as (wild) salmon, trout, tuna, or halibut. Replace red meat with fish or poultry. Red meat, if eaten at all, should be limited to one or two times per month. Eat low to moderate amounts of fat-free and low-fat dairy products daily. Limit egg yolks to four per week (including those used in cooking and baking). Eat fresh fruit daily. Try it for dessert.

30. Lyon Diet Heart Study �Mediterranean alpha-linolenic acid-rich diet in secondary prevention of coronary heart disease�-de Lorgeril, Rendaud, Mamelle, Salen, et al. The Lancet, Vol 34, June 11, 1994, pp 1454-1459. �Mediterranean Diet, Traditional Risk Factors, and the Rate of Cardiovascular Complications after Myocardial Infarction: Final Report of the Lyon Diet Heart Study� - de Lorgeril, Salen, Martin, Monjaud, Delaye, Marmelle. Circulation, Vol 99 (6) Feb 16, 1999, pp 779-785.

31. Lyon Diet Heart Study 5-year prospective, randomized, secondary prevention trial aimed at reducing the risk of cardiovascular disease/death in male and female patients < 70 y/o. N=~600. The control group followed a Step One diet (a typical Western reduced cholesterol diet).

32. Lyon Diet Heart Study The intervention group followed a Mediterranean diet: More plant foods, vegetables, fruit, fish, and less meat Butter and cream replaced with canola oil margarine Canola or olive oil were the only fats recommended

33. Lyon Diet Heart Study Results The intervention group (at 27 months) experienced a 73% decrease in coronary events and a 70% decrease in all cause mortality The survival curve was so marked that the ethics committee terminated the study at 27 months so that the control group could be warned. Although this was a secondary prevention trial, they also found a 61% decrease risk of cancer

34. Lyon Diet Heart Study Amazing continued high adherence of the experimental group for the 46 months, despite the fact that it was terminated at 27 months. The continued adherence to the diet indicates it was readily tolerated. The magnitude of the benefits achieved was notable because the study was undertaken in a very-low-risk population. France is second to lowest in cardiovascular mortality in men. Only Japan is lower.

35. Indo-Mediterranean Diet Heart Study �Effect of an Indo-Mediterranean Diet on Progression of Coronary Artery Disease in High Risk Patients� -Singh, Dobnov, Niaz, Ghosh, Singh, Rastoli, Manor, Pella. The Lancet, Vol 360, November 9, 2002, pp 1455-1461.

36. Indo-Mediterranean Diet Heart Study Randomized, single blind trial in 1,000 high-risk patients with angina, MI, high cholesterol, hypertension or diabetes. The control group consumed a NCEP Step One prudent diet (less than 30% of calories from fat, less than 10% of calories from saturated fat, less than 300 mg cholesterol per day). Intervention group consumed a prudent diet plus increased amounts of fruits, vegetables, legumes, walnuts, almonds, whole grains, soy or mustard seed oil. The goal was to provide plenty of phytochemicals, antioxidants, and alpha linoleneic acid (n-3 fats).

37. Indo-Mediterranean Diet Heart Study As compared to the control diet, the intervention diet resulted in a: 52% decrease in total cardiac endpoints (MI and sudden death) 67% decrease in the rate of sudden cardiac death 53% decrease in the rate of nonfatal MI

38. Greek Mediterranean Diet Study �Adherence to a Mediterranean Diet and Survival in a Greek Population� - Trichopoulou, Costacou, Bamia, Tricholpoulos. The New England Journal of Medicine, Vol 34, June 26, 2003, pp 2599-2608.

39. Greek Mediterranean Diet Study Increased adherence to the diet was associated with significantly lower: Overall mortality Mortality from coronary heart disease Mortality from cancer

40. Mediterranean Diet, Lifestyle Factors, and Mortality Mediterranean Diet, Lifestyle Factors, and 10-Year Mortality in Elderly European Men and Women*: Study followed healthy men (n=1507) and women (n=832) ages 70 to 90 for 10 years and scored based on lifestyle factors Participants who adhered to a Mediterranean diet, were non-smokers or had stopped smoking more that 15 years ago, were physically active and used alcohol moderately had >50% lower mortality rate from all causes, CHD, CVD, and cancer. *JAMA, September 22/29, 2004, Vol. 12, pp 1433-1439

41. Mediterranean Diet and Metabolic Syndrome �Effect of a Mediterranean-Style Diet on Endothelial Dysfunction and Markers of Vascular Inflammation in the Metabolic Syndrome�*: Randomized single blind trial in patients with metabolic syndrome who were followed for two years: Intervention group (n=90) followed a Mediterranean-Style diet with increased whole grains, fruits, vegetables, nuts and olive oil Control group (n=90) followed a prudent diet: carbohydrates: 50-60%, protein: 15-20%, total fat: <30% *JAMA, September22/29, 2004, Vol. 12, pp 1440-1446

42. Mediterranean Diet and Metabolic Syndrome Results controlled for physical activity and weight loss: Intervention group had: i in markers for inflammation such as CRP, interleukin 6, 7, and 18 i insulin resistance Improved endothelial function score ~ 1/2 of the patients in the intervention group no longer had metabolic syndrome (P<.001) *JAMA, September22/29, 2004, Vol. 12, pp 1440-1446

43. Mediterranean Diet Studies Several interesting studies all heading in the same direction: ? heart disease ? sudden death ? cancer ? all cause mortality Diet principles can be applied to all populations Whole diet is more important than the sum of its parts

44. Basic Principles of the Mediterranean Diet Eat a variety of unprocessed, home-cooked foods. Eat plant-based foods every day, such as fruits, vegetables, whole grains, beans, peas, lentils, tofu, nuts, and seeds. Olive and canola oils are the recommended fats, replacing saturated, trans, and other fats and oils (including butter and margarine). Canola oil margarine without trans fats is fine. Limit or avoid foods high in trans fats (these foods will have the words �partially hydrogenated oils� on the ingredients list), such as store-bought crackers, cookies, cakes, pies, pastries, and margarine. Read the label for other foods high in trans fats.

45. Basic Principles of the Mediterranean Diet Eat at least two fish meals per week, such as (wild) salmon, trout, tuna, or halibut. Replace red meat with fish or poultry. Red meat, if eaten at all, should be limited to one or two times per month. Eat low to moderate amounts of fat-free and low-fat dairy products daily. Limit egg yolks to four per week (including those used in cooking and baking). Eat fresh fruit daily. Try it for dessert.

46. Mediterranean Diet Sample Menu Breakfast: Oatmeal with ground flax seeds Fat-free milk or soy milk Red apple with �old fashioned� peanut butter Lunch: Lentil soup Whole grain bread with trans fat free margarine Salad with fresh carrots, tomato, walnuts, and olive oil and vinegar Cubed watermelon Dinner: Grilled salmon Steamed broccoli Brown rice Salad with fresh vegetables, walnuts, olive oil and vinegar Strawberries

47. How can this information be applied to the Community  Avoid trans fat Use trans fat free foods (read the Ingredient List to be sure it does not have partially hydrogenated oil) Margarine (use Spectrum Spread or Smart Balance) Peanut butter (use old fashioned type) Baked goods and crackers Cooking oil for frying Change oil if heated beyond the smoke point Packaged foods Potato chips (Kettle over Frito Lay)

48. How can this information be applied to the Community  Cook and use the healthier fats: canola or olive oil. Smoke point Offer a whole grain side dish such as short grain brown rice; quinoa, bulger, whole grain bread, rolls and buns. Water test Offer a healthy protein option each day such as fish, beans, chicken, or turkey. Have vegetables with meals or as snacks Have fruit for dessert

49. How can this information be applied to the Community  Add ground flax seed to peanut butter sandwiches Add flax seeds and walnuts to cereal or salads Decrease the amount of candy and other unhealthy snack food for sale and instead offer healthier options such as trail mix, nuts, dried fruit, and more interesting fruit selections such as mangos or papayas.

50. How can this information be applied to the Community  Offer healthier snacks in the vending machines such as L�rabars�, trail mix, nuts, dried fruit, whole wheat pretzels, fruit, popcorn (without trans fat) etc. KP Publications

51. Barriers to Implementation? Money $$$ Change is difficult (but possible!) Other barriers?

52. Stages of Change?