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DIETARY MYTHS AND HEALTHY DIETARY ADVICE LENNY LESSER, MD MSHS FAMILY DOC, RESEARCHER, QUALITY TEAM, ONE MEDICAL, SAN FRANCISCO CLINICAL INSTRUCTOR, UCSF
CASE 1: WEIGHT WOES A 45 year old male comes to see you about his weight. He is 198 pounds and 68 inches tall with a BMI of 30.1. He is a computer programmer and works for MyFitnessPal. He has been tracking his eating in the app for a few weeks, and eats about 2640 kcal a day. He wants to know what to do to lose weight. He sits all day at work, but does some walking on the weekend.
Based on the DPP data, you know that his health would improve if he lost 7% of his bodyweight. This is about 14 pounds, with a goal weight of 184. Since 3500 calories are in a pound, he sets up his My Fitness Pal for 2506/day, so that over the next year he will be an average of deficit of 134 calories per day (3500 Cals/Lbs * 14 Lbs / 365 days). You ask him to follow up in 1 year to see how he is doing.
He returns 1 year later, and his weight is 190. He has been tracking meticulously and thought he would be down to 184 by now. He shows you his iPhone and he looks like he has been consistently around his goal calories/day.
WHAT’S GOING ON?
a. He’s not logging everything
b. He changed his physical activity
c. He’s logging the wrong portion sizes
d. The data in My Fitness Pal is incorrect
e. You calculated something wrong
NIH Body Weight planner https://www.supertracker.usda.gov/bwp/index.html
The Lancet 2011 378, 826-837DOI: (10.1016/S0140-6736(11)60812-X) Copyright © 2011 Elsevier Ltd Terms and Conditions
The Lancet 2011 378, 826-837DOI: (10.1016/S0140-6736(11)60812-X) Copyright © 2011 Elsevier Ltd Terms and Conditions
A BETTER RULE Maintaining a deficit in energy intake of about 100 Calories per day will lead to an eventual weight change of approximately 10 pounds (with half of the change achieved by one year and about 95% of the change achieved by 3 years).
Reasons not to focus on weight Leads to disappointment
Difficult to change in long term
Feeds into weight bias
Other factors have bigger effect on health
CASE #2: NO BONES ABOUT IT A 72 year old female comes to you for an Annual Wellness Visit. She confesses that she hasn’t been taking the calcium pills you told her to take last year. She tells you she doesn’t like paying for them, she forgets to take them, they are hard to swallow, and they give her a stomach ache. She does consume milk products 1-2 times per day. She lives at home with her husband and walks with her neighborhood group every morning at 7am. She had a DEXA last year, which showed that her T-score was -1.2. Her ten-year risk of a major fracture, based on last year’s DEXA, is 9.5/100.
WHAT DO YOU TELL HER? a. Switch to chewable calcium
b. Drink 3 servings of milk a day
c. Stop taking the supplements
d. Screen her with another DEXA
e. Initiate a bisphosphanate
J. Nutr. November 1986 116: 2316-2319
Calcium supplementation and BMD in kids
No effect in femoral neck. Small effect in the upper limb.
The results do not support the use of calcium supplementation in healthy children as a public health intervention.
Winzenberg TM, Shaw KA, Fryer J, Jones G. Calcium supplementation for improving bone mineral density in children. Cochrane Database of Systematic Reviews 2006, Issue
2.
There is high quality evidence that vitamin D plus calcium results in a small reduction in hip fracture risk
(nine trials, 49,853 participants; RR 0.84, 95% confidence interval (CI) 0.74 to 0.96; P value 0.01).
Cochrane Database of Systematic Reviews 14 APR 2014 DOI: 10.1002/14651858.CD000227.pub4
Vitamin D and vitamin D analogues for preventing fractures in post‐menopausal women and older men
Cochrane Database of Systematic Reviews 14 APR 2014 DOI: 10.1002/14651858.CD000227.pub4 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000227.pub4/full#CD000227-fig-00402
In low-risk populations (residents in the community): NNT=1000 In high risk populations (residents in institutions): NNT=111
Cochrane Database of Systematic Reviews 14 APR 2014 DOI: 10.1002/14651858.CD000227.pub4
SIDE EFFECTS?
Gastrointestinal: likely small increased risk
Kidney Stones: likely small increased risk
Cardiovascular disease: research is mixed, but possible increased risk
Mortality: no effect
Calcium in food is not associated with these risks
Am Fam Physician. 2015 May 1;91(9):634-638.
CASE #3: OVER SATURATED A 53 year old male comes to you to follow up on his cholesterol. Last year his cholesterol was 220, with an HDL of 38. Since then, he and his wife have been eliminating saturated fat from everything he eats. They read labels on everything and have been avoiding foods with saturated fat. He just got his cholesterol test again, and his TC is 225, with an HDL of 35. He wants to know why his cholesterol hasn’t gone down.
HOW DO YOU ANSWER? a. You don’t know
b. He should stop focusing on saturated fat
c. The test is probably wrong, and you should retest him in another month or two
d. He should stop reading labels
e. He should try the Atkins Diet
Hooper L, Martin N, Abdelhamid A, Davey Smith G. Reduction in saturated fat intake for cardiovascular disease. Cochrane Database of Systematic Reviews
2015, Issue 6.
The review found no clear health benefits of replacing saturated fats with starchy foods or protein. Changing the type of fat we eat, replacing saturated fats with polyunsaturated fats, seems to protect us better, reducing our risk of heart and vascular problems.
Date of download: 12/3/2016
From: Monitoring Cholesterol Levels: Measurement Error or True Change?
Ann Intern Med. 2008;148(9):656-661. doi:10.7326/0003-4819-148-9-200805060-00005
Estimated Percentages of True-Positive and False-Positive Total Cholesterol Measurements
Table Title:
Copyright © American College of Physicians. All rights reserved.
CASE #4: FOOLING FIBER A 63 year old female comes to you because of constipation. She often has to strain while making a bowel movement, and has had blood when she wipes a few times. She had colon cancer screening with a colonoscopy 2 years ago, and everything was clear. She also is overweight and has a cholesterol of 205, with an HDL of 32. Her A1C is 6.2. Because of the above issues, she was told to increase her fiber intake. So, for the last 6 months, she has been buying products that say “high in fiber”. She says she is still constipated and now sometimes is getting stomach aches.
WHAT WOULD YOU TELL HER? a. Tell her to keep focusing on foods labeled “high in fiber” and prescribe docusate
b. Tell her to add psyllium to her diet
c. Advise her to stop buying foods that say “high in fiber"
d. Ask her about her fruit and vegetable intake
Types of Fiber Dietary Fiber
• Found naturally in foods
• Starchy: cellulose, pectin, oat/wheat bran
• Non-starchy: inulin, lignin, fructans, oligosacs
Functional Fiber
• Processed
• Isolated, non-digestible plant: pectin, gums
• Animal: Chitin
• Commercially made: polydextrose, inulin, dextrins
Types of Fiber Dietary Fiber
• may help prevent cardiovascular disease, diabetes, constipation, and gastrointestinal and breast cancers
• few adverse effects
Functional Fiber
• not show to prevent disease
• may help with constipation
• may cause gastrointestinal distress
Theme for healthy eating: Focus on foods, not food constituents. Limit processed foods and eat whole foods (or minimally-processed foods), generally in a form that is as close to what occurs in nature as possible).
Pollan, M. Food Rules. 2009.
DON’T EAT ANYTHING YOUR GREAT-GRANDMOTHER WOULDN’T RECOGNIZE AS FOOD.
IF IT CAME FROM A PLANT, EAT IT; IF IT WAS MADE IN A PLANT, DON’T.
Ultra-processed foods Select possible reductionist concerns
Whole Food Alternatives
White breads and refined bakery products (with or without added fiber, calcium, or other supplemental constituents)
+ refined carbohydrates
- Vitamins, minerals, antioxidants, phytochemicals, protein, healthy fats
Whole-grain or sprouted/flourless breads and baked products
Chips and various salty snacks, even if prepared without frying in saturated oils
+ Sodium; artificial colors, flavors, and preservatives
- Vitamins, minerals, antioxidants, phytochemicals, protein
Nuts
Candies, cookies, and various confections even if “low-calorie”
+ Refined sugars; artificial colors, flavors, and preservatives; unhealthy fats
- Vitamins, minerals, antioxidants, phytochemicals
Fresh or dried whole fruits
White rice + refined carbohydrates
- Vitamins, minerals, antioxidants, phytochemicals, protein
Brown rice
Cold cuts, hotdogs, various other preserved meats
+ sodium, preservatives
- healthy fats
grass-fed meats or wild game; whole soy; lentils, beans, nuts
SUMMARY Supplemental calcium hass limited efficacy in the prevention of bone fracture.(NNT = 1000 in community dwelling women, NNT = 111 in nursing-home residents)
A
Supplemental calcium increases the risk of kidney stones and possibly cardiovascular events B
Higher-fat diets produce and sustain as much or more weight loss than lower-fat diets A
Food sources of saturated fat like preserved meats (highly processed food) are not recommended as they are associated with increased risk of mortality, whereas food sources of saturated fat like dairy products (whole foods) are inversely associated with cardiovascular disease, type 2 diabetes and obesity.
B
SUMMARY Consuming a higher amount of dietary fiber in the form of whole foods may help prevent cardiovascular disease,diabetes, constipation, and gastrointestinal and breast cancers. Functional fibers have not been shown to have this benefit.
B
Maintaining a 3500 Calorie energy deficit per week will not result in a pound of weight loss per week. C
Maintaining a deficit in energy intake of about 100 Calorie per day will lead to an eventual weight change of approximately 10 pounds (with half of the change achieved by one year and about 95% of the change achieved by 3 years).
C
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