The Western Diet: Are We Killing Our Patients. Holly Kramer, MD, MPH Loyola Medical Center Maywood, IL

The Western Diet: Are We Killing Our Patients Holly Kramer, MD, MPH Loyola Medical Center Maywood, IL

Let food be thy medicine Hippocrates

Westernization Clothing Diet Entertainment Language Social engagement Religion

Industrialization

Westernization Refer to western traditions of diet which have evolved over time due to the cumulative result of industrialization within the U.S.

Question: During the early part of the 20 th century, what proportion of the workforce was found in agriculture? A. 10% B. 25% C. 30% D. 40%

Question: What proportion of the U.S. workforce works in agriculture today? A. 10% B. 5% C. 15% D. <2%

USDA Economics Research Services

Industrialization of Food Synthetic man made fertilizers 1900 Highly specialized farms Consolidated farms Animal farms highly specialized Hormones and antibiotics to speed growth of food animals Economies of scale-large production to reduce cost

Percentage of family income spent on food over time D.S. Johnson et al. A century of family budgets in the U.S. Monthly Labor Review May 2001

Increased life expectancy

the single greatest threat to public health in this century

Epidemic

Classification of Overweight and Obesity by BMI Obesity Class BMI kg/m 2 Underweight <18.5 Normal 18.5 24.9 Overweight 25 29.9 Obesity I 30.0 34.9 II 35.0 39.9 Extreme Obesity III 40.0 Only 1 out of 3 U.S. adults now has an ideal BMI (18.5-24.9 kg/m2) Extreme obesity affects 1 in 20 U.S. adults and is the fastest growing group

Reasons for the obesity epidemic H. Kramer. Current Hypertension Reports. 2014

Question: Since 1983, the price of sugar has increased by 30% while the cost of fresh fruit has increased by A. 10% B. 50% C. 100% D. 200%

All these science-based tools have transformed the U.S. food system into one of the most technologically advanced and productive in the world, and our citizens have become accustomed to the safest and least expensive food supply anywhere. And all that was achieved by using fewer resources, while minimizing environmental impact. - John Floros, PhD, Professor & Head, Department of Food Science, Penn State University, University Park, Getting Real About Our Modern Food System, Food Technology eperspective (online), September 1, 2009

Once, food was all you could eat, but today there are lots of other edible foodlike substances in the supermarket. These novel products of food science often come in packages festooned with health claims, which brings me to a related rule of thumb: if you re concerned about your health, you should probably avoid food products that make health claims. Why? Because a health claim on a food product is a good indication that it s not really food, and food is what you want to eat.

Western diet Characterized by high intake of Red meat Processed foods Saturated and trans fats Salt Characterized by Low intake of Fruits and Vegetables Fiber

Animal protein

Animal Protein Intake Matters Renal blood flow and glomerular filtration rate increase by at least 30% when healthy persons transition from a low animal protein diet to a high animal protein diet These hemodynamic effects are limited to animal protein as increasing vegetable protein intake does not increase renal plasma flow

Obese State Increases Metabolic rate Glomerular diameter Glomerular filtration rate Renal Plasma flow

Amino acids trigger humoral mediators of afferent vasodilation Impair autoregulation and increase transmission of systemic pressures which may be elevated in the obese patient

Question-70 kg male eating 100 gm animal protein/day. How does this protein intake differ from the current Recommended Daily Allowance of animal protein intake? A. 79% more than RDA B. 50% more than RDA C. Consistent with RDA D. < RDA

Question A. 79% more than RDA B. 50% more than RDA C. Consistent with RDA D. < RDA 1.43 gm per kilogram of body weight, or approximately 80% more protein intake than the RDA

Fresh fruits and vegetables

Question: What percentage of U.S. adults eat 2 or more servings of fruit A. < 20% B. 25% C. 30% D. 35% per day?

Alkali from fruits and vegetables Nonvolatile acids Net endogenous acid production = endogenous acids-alkali

Vegetable and Fruit Intake Low vegetable and fruit intake accompanied by high intake of animal protein and cereal grains (AKA-Western diet)-leads to high net endogenous acid load Excessive workload on kidney Increased ammonium production Increased hydrogen ion excretion J. Scialla et al. Dietary acid load: a novel nutritional target in CKD? Adv Chronic Kidney Dis. 2013

Higher net endogenous acid load Heightens renin angiotensin system Increases endothelin-1 Activates alternate complement cascade Kidney injury

Among 26 patients with stage 1 CKD, increasing fruits and vegetables or use of sodium bicarbonate supplements reduced urine aldosterone excretion, and plasma Endothelin -1 levels. Only increased fruit and vegetable intake associated with significantly decreased systolic blood pressure (-2.4 +/- 2.3 mmhg).

Dietary Fiber Whole grains Legumes Fruits Vegetables

Low Dietary Fiber Intake Elevated levels of biomarkers of inflammation Increased cardiovascular disease risk and mortality-especially in CKD CKD progression

Fiber intake impacts gut microbiome Healthy intestinal barrier impacts systemic inflammation High fiber intake prompts growth commensal bacteria and resistance to growth of pathogenic bacteria Bifidobacterium endosymbiotic colonizer Ferment carbohydrates

Patients with CKD Urea directly disrupts gut barrier function by reducing the presence of occludin and zonula occludens proteins in the tight junctions and increases intestinal permeability

Question: the currently recommended levels of dietary fiber intake specifically for adults with CKD are: A. 14 g per 1000 kcal per day B. 30 g/day for males age 50 and older C. 21 g/day for females age 50 and older D. This is a trick question

Processed Foods and Addiction

Processed Foods High in Salt High in inorganic phosphate Addictive

Question: High salt intake is bad for the kidneys because: A. It can increase blood pressure B. It magnifies oxidative stress in the kidney C. It upregulates factors that may increase fibrosis in kidneys D. All of the above

Salt High salt intake magnifies oxidative stress Stimulates renal cortical NADH- and NADPH superoxide anion generation Induces fibrogenic pathways through upregulation of transforming growth factorβ Salt restriction mitigates glomerular hypertrophy in animal models of renal mass reduction

Processed foods are preserved with inorganic phosphate salts Preservatives can add over 1 gram of daily phosphate intake-hidden Highly absorbed Increases FGF23 levels Heightens cardiovascular risk May accelerate CKD progression

Differences in urinary phosphate excretion in young adults with African ancestry Eckberg et al. NDT 2014

Scatterplot of FGF23 levels by average urine phoshate excretion based on three 24-hour urine collections Eckberg et al. Nephrology, Dialysis and Transplantation, 2014

Dietary differences among young healthy adults with African ancestry Yuen et al. J Endocrinology and Clinical Metabolism. In press

Functional MRI images of obese and non-obese adults shown images of food A. Gearhardt. 2011

Summary Western diet is high in animal protein, low in vegetable, fruit and fiber intake and high in salt For patients with CKD, can accelerate CKD progression Impair autoregulation Heighten inflammation Increase workload of kidney Increase oxidative stress Higher FGF23 levels

Question-Does Medicare cover medical nutrition therapy for patients with chronic kidney disease not on dialysis? A. Yes but only once B. Yes but co-pay is high C. Yes but only if they have diabetes or a kidney transplant D. Yes and covers for more than one visit and there is no co-pay

Question-Does Medicare cover medical nutrition therapy for patients with chronic kidney disease not on dialysis? A. Yes but only once B. Never C. Yes but only if they have diabetes or a kidney transplant D. Yes and covers for more than one visit

Dietetic Counseling Affordable Care Act expanded medical nutrition therapy for patients with CKD Medicare will now pay for 3 visits per year for medical nutritional counseling services with a registered dietician or nutritionist for Medicare Part B enrollees diagnosed with diabetes, CKD or who received a kidney transplant within three years of the clinic visit

Communicate with your patients Harms of excessive animal protein intake Harms of excessive salt intake and its sources Addictive properties of fast food and highly processed foods Addiction programs e.g. overeaters anonymous, weight watchers

Eat food, not too much. Mostly plants Michael Pollan Unhappy Meals-The New York Times Magazine Jan 28 2007

Thank you