What should I eat? I am so confused. Jennifer Lyon DO

Conflict of Interest Disclosure I have no conflict of interest to report

Overview 2015-2020 Dietary Guidelines 5 primary guidelines Sugar intake Sodium intake Fat intake Research Review: BuGer, Dairy Fat, Coconut Oil on Diabetes, Heart disease, and overall mortality Vegetables: how important are they?

GERD and PPIs (Expert Review of Clinical Pharmacology, Jul., 2013) Links infections such as pneumonia and C.diff with PPI use (Journal of Nutrition, Health and Aging, Jan., 2016). Links to malabsorption of B12 and magnesium and zinc leading to bone density loss (JAMA Internal Medicine, Feb. 2016) Links to renal disease. (20 to 50 percent more likely to be diagnosed with chronic kidney disease) Circulation (online, July 3, 2013) May reduce the flexibility of blood vessels by slowing the production of Nitric Oxide PLoS One (June 10, 2015) Associaton between PPIs and Myocardial Infarctions JAMA Neurology (online, Feb. 15, 2016) PPIs and Dementia (Cancer Epidemiology, Biomarkers and Prevention, July, 2015) Danish epidemiological study reported that use of PPIs among patients with Barrett s esophagus did not appear to protect them from cancer

Sugar vs Fat 1950s: Increase in CAD Mortality in men which led to increase in research 1960s: 2 divergent hypothesis of CAD 1. John Yudkin: sugars primary cause 2. Ancel Keys: Total fat, Saturated fat, dietary cholesterol primary cause 1967 Review ArYcle published in New England Journal of Medicine downplaying the link between sugar and heart disease and emphasized the role of saturated fats and heart disease 1980s: 1980 dietary Guidelines for Americans focused on reducing total fat, saturated fat, and dietary cholesterol

Dietary Guidelines for Americans 2015-2020 Guideline 1: Follow A Healthy EaYng PaGern Across A Lifespan Guideline 2: Focus on Variety, Nutrient Density, & Amount Guideline 3: Limit Calories from Added Sugars, Saturated Fats, & Reduce Sodium Intake Guideline 4: Shic to healthier Food & Beverage Choices Guideline 5: Support Healthy EaYng PaGerns for All

a. Vegetables and fruit are the only characteristics of the diet that were consistently identified in every conclusion statement across the health outcomes. b. Whole grains were identified slightly less consistently compared to vegetables and fruits, but were identified in every conclusion with moderate to strong evidence. c. Low- or non-fat dairy, seafood, legumes, nuts, and alcohol were identified as beneficial characteristics of the diet for some, but not all, outcomes d. Higher intake of red and processed meats was identified as detrimental compared to lower intake. e. Higher consumption of sugar-sweetened foods and beverages as well as refined grains was identified as detrimental in almost all conclusion statements with moderate to strong evidence.

Food PaGern Modeling Healthy US -style pagerning DASH https://health.gov/dietaryguidelines/2015/guidelines/appendix-3/ Healthy Mediterranean-style pagerning https://health.gov/dietaryguidelines/2015/guidelines/appendix-4/ Healthy Vegetarian- style pagerning https://health.gov/dietaryguidelines/2015/guidelines/appendix-5/

What We Eat in America, NHANES 2007-2010 for average intakes by age-sex group.

New RecommendaYon: Keep Sugar intake to <10%

THE REPORT DID NOT FOR THE FIRST TIME PUT A LIMIT ON TOTAL FAT or LIST TOTAL FAT AS A NUTRIENT OF CONCERN 1. Saturated Fatty Acids and effects related to CVD/lipoproteins: Strong Evidence. a. Strong and consistent evidence from RCTs and prospective cohort studies shows that replacing SFA with PUFA reduces total and LDL-C and the risk of CV events and coronary mortality. b. Replacing SFA with CHO reduces total and LDL-C, but increases TG and reduces HDL-C. c. Reducing total fat with CHO does not lower CVD risk. d. Consistent evidence from prospective cohort studies shows that higher SFA intake compared to CHO is associated with similar CVD risk. e. For every 1% of energy intake from SFA replaced with PUFA, incidence of CHD is reduced by 2 to 3%

What do we replace the saturated fats with? Carbohydrates ( Refined vs Unrefined) Omega 6 Polyunsaturated fats ( Linoleic Acid in Vegetable oils) American Heart AssociaYon supports Cardiovascular Heart Study ( 4707 parycipants followed for 18 years had higher linoleic levels and had a decrease of all cause of death) Not all research supports. Linoleic acid ( omega 6 converts to AA) Omega 3 Polyunsaturated fats ( Salmon, Fish oil Supplements) Higher levels are linked to lower risk of CVD related outcomes, TG, Blood pressure, Heart rate, and endothelial funcyon Monounsaturated fats ( Olive Oil, avocados, pistachios) Those with the highest intake of olive oil have a 9% reducyon in death from CV events, 17% reducyon in stoke, 11% all cause of death. Replacing 5% of energy from saturated fats with MUFAs is associated with 13% reducyon in total mortality

What about buger?

Summary review. Nutrition Reviews Vol. 74(4):267-280, 2016 Twenty-one research papers were identified for inclusion in the review: 8 clinical trials and 13 observational studies. The majority examined the effect of coconut oil or coconut products on serum lipid profiles. Coconut oil generally raised total and low-density lipoprotein cholesterol to a greater extent than cis unsaturated plant oils, but to a lesser extent than butter. The effect of coconut consumption on the ratio of total cholesterol to high-density lipoprotein cholesterol was often not examined. Observational evidence suggests that consumption of coconut flesh or squeezed coconut in the context of traditional dietary patterns does not lead to adverse cardiovascular outcomes. However, due to large differences in dietary and lifestyle patterns, these findings cannot be applied to a typical Western diet. Overall, the weight of the evidence from intervention studies to date suggests that replacing coconut oil with cis unsaturated fats would alter blood lipid profiles in a manner consistent with a reduction in risk factors for cardiovascular disease.

References United States Department of Agriculture. Scientific Report of the 2015 Dietary Guidelines US Department of Health & Human Services. Dietary Guidelines for Americans 2015 2020: Eighth Edition. http://health.gov/dietaryguidelines/2015/guidelines/. Published January 7, 2016. Advisory Committee. http://www.health.gov/dietaryguidelines/2015-scientific-report. Published February 2015. Mozaffarian D, Ludwig DS. The 2015 US Dietary Guidelines: lifting the ban on total dietary fat. JAMA. 2015;313(24):2421-2422. Slide 15: JAMA Intern Med. 2016;176(11):1680-1685. doi:10.1001/jamainternmed.2016.5394 Slide 43: Reevaluation of the traditional diet heart hypothesis BMJ2016;353:i1246 Slide 47: Pimpin, L., Wu, J. H., Haskelberg, H., Gobbo, L. D., & Mozaffarian, D. (2016). Is Butter Back? A Systematic Review and Meta-Analysis of Butter Consumption and Risk of Cardiovascular Disease, Diabetes, and Total Mortality. Plos One,11(6). doi:10.1371/journal.pone.0158118 Slide 48:Amj Public Health 2013 September; 103(9): e31-342 Slide 50: Yakoob, M., Shi, P., Willett,W., Rexrode, K., Campos, H., Orav, J., Hu,F., & Mozaffarian, D., Circulating Biomarkers of Dairy Fat and Risk of Incident Diabetes Mellitus Among US Men and Women in Two Large Prospective Cohorts. Circulation. 2016 April 26; 133(17): 1645 1654. Slide 52: Harris M. et al JMed Food 2017 Slide 53: Vijayakumar M,et al Indian Heart J. 2016 Jul-Aug Slide 54: JLipid Res.1995 Aug;36(8):1787-95 Slide 55:Eyres, L., Eyres, M. F., Chisholm, A., & Brown, R. C. (2016). Coconut oil consumption and cardiovascular risk factors in humans. Nutrition Reviews, 74(4), 267-280. doi:10.1093/nutrit/nuw002 Slide 57: Mujcic R, Oswald A. Evolution of well-being and happiness after increases in consumption of fruit and vegetables. Am J Public Health. 2016;106(8): 1504-1510. Slide 59: Nutr Metab Cardiovasc Dis 2013 Apr; 23 (4): 292-9.doi 10.1016/j.numecd.2011.07.004.Epub2011 Oct 7