Every day 20 Jamaicans die from heart disease WORLD HEALTH ORGANIZATION

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1 Every day 20 Jamaicans die from heart disease WORLD HEALTH ORGANIZATION

3 Food as Medicine How to Counsel Your Patient on a Heart Healthy Diet Dainia Baugh, MD

4 First: The Facts Heart Disease and Stroke (cardiovascular Disease, CVD) account for 56% of all deaths in Jamaica. CVD is the #1 cause of death and disability in Jamaica WORLD HEALTH ORGANIZATION

5 Jeans versus Genes WHAT CAUSES HEART DISEASE?

6 Risk Factors for Heart Disease High Blood Pressure Diabetes High Cholesterol Sedentary Lifestyle Overweight Smoking Family History Male age greater than 55

7 High Blood Pressure 40% of Jamaican Adults have high blood pressure Most important contributor to strokes, heart failure, kidney failure and heart attacks Easily detected and controlled Less than 30% are adequately treated

8 Prevalence (%) of diabetes among adults in the Americas Barbados Trinidad/Tobago Jamaica Belize Cuba Mexico USA Nicaragua Suriname Bolivia Guatemala Colombia Costa Rica Argentina Brazil Haiti Paraguay Urban Peru Chile Honduras Source: Pan Am J Public Health 10(5), 2001; unpublished (CAMDI), Haiti (Diabetic Medicine); USA (Cowie, Diabetes Care)

9 Regional Stats on DM prevalence 1 out of every 5 Jamaicans have Diabetes. 20% of Jamaican children are overweight and 20% of those with DM already have Type II diabetes 1 1 Tulloch-Reid, M et al.

10 Diabetes 75% of the deaths among people with diabetes are due to heart disease and stroke. The risk of having a stroke or heart attack is three times higher if you are diabetic.

11 Rate/100,000 Caribbean Trends in Diabetes Deaths Male Female

12 Prevalence (%) Trends in Adult Overweight/Obesity in the Caribbean Male Female s 1980s 1990s YEARS Journal of the American College of Cardiology

13 Do we Ignore the Facts?

14 Examining the Roots not just the Vines HOW DID WE GET HERE?

people (53,440 men and 69,776 women) with no history of disease who were

15 From Ancient to Modern Work July 22 study in the American Journal of Epidemiology, analyzed responses from questionnaires filled out by 123,216 people (53,440 men and 69,776 women) with no history of disease who were participating in the Cancer Prevention II study conducted by the American Cancer Society.

blood pressure, a 20-year study of young adults shows.

16 From Ancient to Modern Transport Low levels of physical activity and fitness significantly increase the risk of developing high blood pressure, a 20-year study of young adults shows. SOURCES: Mercedes Carnethon, Ph.D., et al. June 1, 2010, Hypertension, online

17 From Ancient to Modern Diets

18 Ancient Diets Dietary and lifestyle patterns have dramatically changed since the Agricultural Revolution approximately10,000 years ago, Prior to the revolution, for about 2 million years, people consumed an enormous variety of wild plants and animal foods commonly referred to as a Paleolithic diet or Hunter-Gatherer diet. The Paleolithic diet : protein 19% to 36%, carbohydrates : 22% to 46% cholesterol 520 mg, fiber :100 to 150 g, sodium 690 mg, calcium:1500 to 2000 mg ; vitamin C 400 mg; a potassium/sodium ratio of approximately 10:1 and a polyunsaturated-to-saturated fatty acid ratio of ,2. The Paleolithic diet, of course, was devoid of all processed foods. 2,, 1. Simopoulos AP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002;56(8): O'Keefe JH Jr, Cordain L. Cardiovascular disease resulting from a diet and lifestyle at odds with our Paleolithic genome: how to become a 21stcentury hunter-gatherer. Mayo Clin Proc. 2004;79(1): CordainL,EatonSB,SebastianA,etal. Origins and evolution of the Western diet: health implications for the 21st century. Am J Clin Nutr. 2005;81(2):

19 Modern Diets Today s Western dietary pattern: high in saturated fatty acids, trans fatty acids, and processed foods; and low mono- and polyunsaturated fatty acids, dietary fiber, and micronutrients. Commonly consumed foods: Grain-fed beef, processed meat (eg, deli meats or hotdogs), refinedgrain products, eggs, French fries, high-fat dairy products, and sweets and other desserts. 1,2 1. Schulze MB, Hoffmann K, Manson JE, et al. Dietary pattern, inflammation, and incidence of type 2 diabetes in women. Am J Clin Nutr. 2005;82(3): ; quiz KerverJM,YangEJ,BianchiL,SongWO. Dietary patterns associated with risk factors for cardiovascular disease in healthy US adults. Am J Clin Nutr. 2003;78(6):

20 Waiting on.

21 ..This

22 A Western diet in the developing world No one can withstand the effects of poor dietary choices

24 It s not just about fast food The typical Western diet has about 16 to 30 times more omega- 6 fat than omega-3 fat 1,2 and a potassium-to-sodium ratio of 1: The potassium, found primarily in plant foods, is mostly in the form of potassium bicarbonate (KHCO3), while sodium is in the form of sodium chloride (NaCl) from processed foods. There is an imbalance of potassium to sodium + high chloride consumption and lower dietary bicarbonate 2.O'Keefe JH Jr, Cordain L. Cardiovascular disease resulting from a diet and lifestyle at odds with our Paleolithic genome: how to become a 21st-century hunter-gatherer. Mayo Clin Proc. 2004;79(1): Simopoulos AP. Essential fatty acids in health and chronic disease. Am J Clin Nutr. 1999;70(3 suppl):560s-569s.

26 Today industrialized societies are characterized by Higher energy intake and lower in energy expenditure. Higher saturated fat, omega-6 fatty acids and trans fatty acids, and a decrease in omega-3 fatty acid intake Decreased complex carbohydrates and fiber; Increased cereal grains and decreased fruits and vegetables Lower protein, antioxidants, and calcium intake. 1 Simopoulos AP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002;56(8):

27 The REAL reason a healthy Diet matters. Just in case you thought it was all about looks

28 So what s the solution? If a patient is ill, treat the patient; If the community is ill, treat the community

29 So what does the Doctor order? STEP 1: PHYSICIANS HEAL THYSELVES

30 The General Guidelines A LITTLE BIT OF THIS; A LOT LESS OF THAT

31 The goals of a heart-healthy diet 1. Foods that help obtain or maintain healthy levels of cholesterol and fatty molecules called lipids. Reduce overall cholesterol levels and low-density lipoproteins (LDL), which are harmful to the heart Increase high-density lipoproteins (HDL), which are beneficial for the heart Reduce other harmful lipids (fatty molecules), such as triglycerides and lipoprotein(a) 2. Foods that help maintain ideal body weight 3. Foods that decrease inflammation

32 Portion Control

33 The Power of Brown. Eat more fiber and less sugar CHANGE

34 Get an Oil Change CHANGE

35 Go Fishing

36 Color Your World (and Your Plate)

calories.) 2 1.American Heart Association Nutrition Committee; Lichtenstein AH, et al.

37 How sweet it is (not) No more than 10% of daily calories should come from sugar. 1 (Currently, Americans eat nearly half a pound of sugar a day on average, and sugar intake constitutes 25% of a day's calories.) 2 1.American Heart Association Nutrition Committee; Lichtenstein AH, et al. Diet and lifestyle recommendations revision 2006: a scientific statement from the American Heart Association Nutrition Committee. Circulation Jul 4;114(1): USDA factbook. Chapter 2

38 I ll drink to that FLUIDS

Bottoms up? higher HDL levels, blood clot prevention, anti-inflammatory properties lower rates of heart failure and heart attack. BUT Arch Intern Med.

39 Bottoms up? higher HDL levels, blood clot prevention, anti-inflammatory properties lower rates of heart failure and heart attack. BUT Arch Intern Med Oct 23;166(19): Alcohol consumption and risk for coronary heart disease in men with healthy lifestyles. Mukamal KJ, Chiuve SE, Rimm EB.

Thy Cup Runneth Over Water for Life Whole blood viscosity, plasma viscosity, hematocrit, and fibrinogen are considered independent risk factors for coronary heart disease and

40 Thy Cup Runneth Over Water for Life Whole blood viscosity, plasma viscosity, hematocrit, and fibrinogen are considered independent risk factors for coronary heart disease and can be elevated by dehydration. Am J Epidemiol 2002 May 1;155(9): Water, Other Fluids, and Fatal Coronary Heart Disease The Adventist Health Study Jacqueline Chanet al.

41 From Atkins to Zone and in between SPECIFIC DIETARY PLANS

42 Mediterranean Diet Rich in heart-healthy fiber and nutrients, including omega-3 fatty acids and antioxidants. Consists of fruits, vegetables, and unsaturated good fats, particularly olive oil. Olive oil has been associated with lower blood pressure, a lower risk for heart disease, and possible benefits for people with type 2 diabetes. fats make up about 40% of the calories found in the traditional Mediterranean diet, they are mostly unsaturated. prevents heart disease, reduces the risk for a second heart attack and helps cholesterol-lowering statin drugs work better.

43 DASH diet (Dietary Approaches to Stop Hypertension) Helps lower blood pressure. May have additional benefits for preventing heart disease, stroke, and heart failure 1. Effects on blood pressure often seen within weeks. Rich in important nutrients and fiber. Provides far more potassium (4,700 mg/day), calcium (1,250 mg/day), and magnesium (500 mg/day) -- but much less sodium -- than the average diet. Fung TT, Chiuve SE, McCullough ML, Rexrode KM, Logroscino G, Hu FB. Adherence to a DASH-style diet and risk of coronary heart disease and stroke in women. Arch Intern Med Apr 14;168(7):

44 Low Carbohydrate Diets -Atkins, Zone, Sugar Busters 1 PROS Helps with weight loss, better than diets that allow normal amounts of carbohydrates and restrict fats. Lowers triglyceride levels and raise HDL cholesterol levels. Total cholesterol and LDL levels remains stable or possibly increases slightly. Despite this large studies have found no increased risk for heart disease. Studies indicate that these diets may help lower blood pressure and stabilize insulin levels. CONS However, overall, there is not good evidence showing longterm efficacy for these diets. restrict the amount of carbohydrates but do not restrict protein sources. Atkins can cause excessive calcium excretion in urine, which increases the risk for kidney stones and osteoporosis. Halton TL, Willett WC, Liu S, Manson JE, Albert CM, Rexrode K, et al. Lowcarbohydrate-diet score and the risk of coronary heart disease in women. N Engl J Med Nov 9;355(19):

45 Low-Fat Diets The Program The Ornish program, recommended for some heart disease patients, limits fats even more drastically. It aims to reduce saturated fats as much as possible, restricting total fat to 10%, and increasing carbohydrates to 75% of calories. It excludes all oils and most animal products. Emphasizes whole grains, legumes, and fresh fruits and vegetables. The Data Claims regarding a significant reduction in angina and even reduction in coronary artery stenosis have been made by the Ornish program directors. Actual regression in atherosclerosis or prevention of heart disease has only been shown in a small number of patients.

46 Low Fat Diets Benefits Low-fat programs may help keep weight off. Low-fat diets that are high in fiber, whole grains, legumes, and fresh produce offer health advantages in addition to their effects on cholesterol. These foods are also lower on the glycemic index which may help increase weight loss and heart benefits for high-carbohydrate diets. Concerns The Ornish program is so difficult to maintain that most people have difficulty staying with it. Very low-fat diets may reduce HDL ("good") cholesterol levels. These diets may also reduce calcium absorption, which can be harmful for women at risk for osteoporosis. Many people who reduce their fat intake do not consume enough of the basic nutrients, including vitamins A, D, E, calcium, iron, and zinc..

47 The Prudent Pattern Diet The prudent pattern diet is closer to a Paleolithic diet and contains larger amounts of vegetables, fruit, legumes, whole grains, fish, and poultry. 1 Nurses Health Study

49 Vitamins and Minerals. Yes or No? MICRONUTRIENTS

50 Let the sunshine in. Vitamin D is ESSENTIAL

51 Antioxidant Vitamins. Vitamins E and C have been studied for their health effects because they serve as antioxidants. High intake of foods rich in these vitamins have been associated with many health benefits, including prevention of heart problems. Some older research initially observed favorable effects from vitamin E in preventing blood clots and preventing build-up of plaque on blood vessel walls, many recent studies have found no heart protection from either vitamin E or C supplements. Supplements of vitamin E, vitamin C, and beta-carotene are not recommended. 1 Sesso HD, Buring JE, Christen WG, Kurth T, Belanger C, MacFadyen J, et al. Vitamins E and C in the prevention of cardiovascular disease in men: the Physicians' Health Study II randomized controlled trial. JAMA Nov 12;300(18): Epub 2008 Nov 9.

52 B Vitamins (Folic Acid). Deficiencies in the B vitamins folate (known also as folic acid), B6, and B12 have been associated with a higher risk for heart disease in some studies. Such deficiencies produce higher blood levels of homocysteine, an amino acid that has been associated with a higher risk for heart disease, stroke, and heart failure. While major studies have indicated that B vitamin supplements help lower homocysteine levels, they do not protect against heart disease, stroke, or dementia. Homocysteine may be a marker for heart disease rather than a cause of it. 1 Bazzano LA, Reynolds K, Holder KN, He J. Effect of folic acid supplementation on risk of cardiovascular diseases: a meta-analysis of randomized controlled trials. JAMA Dec 13;296(22):

53 Potassium. A potassium-rich diet can provide a small reduction in blood pressure 1. Potassium-rich foods include bananas, oranges,tomatoes, dried peas and beans, nuts, potatoes, and avocados. Potassium supplements should not be taken by patients without checking with your doctor first. For those using potassium-sparing diuretics or have chronic kidney problems, potassium supplements may be dangerous. Dickinson HO, Nicolson DJ, Campbell F, Cook JV, Beyer FR, Ford GA, et al. Magnesium supplementation for the management of essential hypertension in adults. Cochrane Database Syst Rev Jul 19;3:CD

54 Magnesium Some studies suggest that magnesium supplements may cause small but significant reductions in blood pressure. However, a clinically significant benefit on blood pressure has not yet been proven. 1 The recommended daily allowance of magnesium is 320 mg. Dickinson HO, Nicolson DJ, Campbell F, Cook JV, Beyer FR, Ford GA, et al. Magnesium supplementation for the management of essential hypertension in adults. Cochrane Database Syst Rev Jul 19;3:CD

55 Calcium Calcium regulates the tone of the smooth muscles lining blood vessels. Studies have found that people who consume enough dietary calcium on a daily basis have lower blood pressure than those who do not. The effects of extra calcium on blood pressure, however, are mixed, with some studies showing higher pressure with calcium supplementation. Studies have indicated that calcium supplements do not prevent heart disease and one controversial report suggests that they might even increase risk.

56 Add an Exercise Prescription

57 THE TAKE HOME MESSAGE

58 Summarizing the problem Inflammation contributes to the development and progression of the most prevalent chronic, degenerative diseases and diet is a major contributor to inflammation. The modern diet, is a pro-inflammatory diet, high in omega-6 fatty acids, calories, and trans fatty acids. Diet and lifestyle habits create the foundation for health. Clinicians should educate and encourage patients to improve their health by improving their diets.

59 A quote from Ann Wigmore. She is correct.

60 HEALTHY DIET & LIFESTYLE RECOMMENDATIONS

The Paleolithic Diet. A Review

The Paleolithic Diet. A Review The Paleolithic Diet A Review by: Philip Rouchotas, MSc, ND Bolton Naturopathic Clinic 64 King St. W, Bolton, Ontario L7E 1C7 info@boltonnaturopathic.ca What is the Paleolithic Diet? Today s modern diet