Cardiometabolic Health

Cardiometabolic health is a relatively new term that encompasses cardiovascular and metabolic diseases, including type 2 diabetes and metabolic syndrome. Collectively, such conditions are the leading cause of preventable death worldwide. They all share similar risk factors (e.g., overweight/obesity, elevated blood pressure) which can be modified by diet and lifestyle choices. The available evidence indicates that eggs, when consumed as part of an overall healthy diet pattern, do not affect risk factors for cardiometabolic disease. Recent recommendations from the American Heart Association, American College of Cardiology and American Diabetes Association do not limit egg or cholesterol intake, a change from earlier guidance from these organizations. In fact, several global health organizations, including Health Canada, the Canadian Heart and Stroke Foundation, the Australian Heart Foundation and the Irish Heart Foundation, promote eggs as part of a heart-healthy diet.

Given the public health significance of understanding cardiometabolic diseases, research on risk reduction remains an active area of pursuit. For example:

  • A randomized controlled study in people with metabolic syndrome showed that those consuming three whole eggs per day as part of a reduced carbohydrate diet experienced favorable changes in HDL-cholesterol, insulin sensitivity, and other aspects of the lipoprotein lipid profile
  • A randomized controlled weight loss trial in people with diagnosed type 2 diabetes showed improved lipid and glucose markers following consumption of 2 eggs per day for 12 weeks.
  • An egg-based breakfast, rich in protein (35% energy; 26.1 g egg protein), promoted glycemic control in people with type 2 diabetes and pre-diabetes relative to a high-carbohydrate breakfast.

Nutrition in the Spotlight for Health Professionals: Lessons from the AANP Conference and NNPS


Dixie-Harms-2Today’s post comes from Dixie Harms, DNP, ARNP, FNP-C, BC-ADM, FAANP. Dr. Harms is a board-certified family nurse practitioner, employed full-time at Mercy Family Medicine of Urbandale, practicing in family practice and internal medicine. In addition to family practice, her specialties include diabetes care and bio-identical hormone replacement therapy. She is also board certified in Advanced Diabetes Management. Dixie obtained her diploma in nursing from Iowa Methodist School of Nursing, Bachelor’s and Master’s of Science of Nursing from Drake University, Post-Master’s FNP Certificate from Clarkson College and her Doctorate of Nursing Practice from the University of Iowa. She is also adjunct clinical faculty at the University of Iowa College of Nursing. Dr. Harms has been involved in numerous activities with the American Association of Nurse Practitioners and the American Academy of Nurse Practitioners Certification Program.  She was inducted into the Fellows of the American Association of Nurse Practitioners in 2005 and received the State Award for Excellence in 2005. She is also on the Board of Directors of the American Nurse Practitioner Foundation and is a Health Professional Advisor with the Egg Nutrition Center.  In her spare time, Dr. Harms teaches taekwondo two nights a week and is a 6th degree black belt.

In order for health care professionals to maintain their licenses/certifications, we must maintain our level of education to stay current on the most up-to-date information. Recently I attended the American Association of Nurse Practitioners (AANP) National Conference in Nashville, Tennessee, an event that was attended by over 6,000 nurse practitioners from across the United States and many countries overseas. I was fortunate enough to earn over 30 hours of continuing education in five days. While attending lectures, I found that there seemed to be a common theme amongst many of the presenters: they included information about how nutrition can have an impact on chronic illness.  Key nutrition information presented at the conference that I thought to be most useful for health professionals is outlined below.

Benefits of Consuming Omega 3 Fatty Acids:

Helps reduce pro-inflammatory effects
Reduces risk of heart arrhythmias
Helps prevent blood clots
Slightly lowers blood pressure

American Heart Association recommendations for Omega 3 Fatty Acid Intake:

Eat a variety of fish at least twice weekly
Include oils such as flaxseed, canola and soybean
Patients with heart disease should consume about 1 gram of EPA & DHA daily
Patients with high triglycerides should consume 2-4 grams EPA & DHA daily

American Heart Association recommendations for Patients with Heart Disease:

Overweight or obese patients can reduce cardiovascular risk factors with 3-5% weight loss or more
Calorie reduction diets should range from 1200-1500 kcal/day for women and 1500-1800 kcal/d for men
500-700 kcal/day calorie intake deficit along with increased physical activity can lead to weight loss

Obesity

Obesity is a multifactorial problem caused by:

Genetics
Increased quantity of food
Gastrointestinal responses to various nutrients
Neuropeptides–hunger/satiety/mood
Brain responses to nutrients
Sedentary lifestyles

Hormones (peptides) that affect appetite regulation:

Ghrelin (stomach)
Cholecystokinin & GIP (small intestine)
GLP-1, Oxyntomodulin, PTT (large intestine)
Insulin/Amylin (Pancrease)
Leptin (fat)

Suggested interventions for obesity treatment:

Food/dietary intervention
Exercise/activity
Life coaching
Pharmacologic interventions
Surgery/bariatric interventions

Following the AANP conference, I had the opportunity to go to the National Nurse Practitioner Symposium (NNPS) in Keystone, Colorado, another very well-attended conference.  At NNPS, I presented with Dr. Mitch Kanter on the topic, Changing Paradigms Regarding Macronutrient Intake and Health: Translating Science into Meaningful PatientCommunication.  Even after three full days of continuing education, over 200 nurse practitioners attended our nutrition-focused evening session, making it quite obvious that nutrition is very important to health care providers in any setting.  Dr. Kanter shared with the audience several important points on the topic, including:

High carbohydrate diets and insulin promote inflammation, obesity and CVD
Replacing carbs with higher protein foods may create a more healthfully balanced diet that:
Promotes satiety
Suppresses food intake at subsequent meals
Stimulates the intestinal “satiety hormone” cholecystokinin (CCK)
Inhibits the “Hungry Hormone” ghrelin

Though nutrition science is ever-evolving, information presented at the latest health professional conferences continues to point to similar conclusions. While there may not be anything fancy about good health or weight loss, research consistently shows that eating a healthy, protein-rich, low carbohydrate diet along with physical activity may help people avoid many chronic illness like heart disease, diabetes and obesity.

 

Sources:

  1. Fitzgerald, M. (2014).  The Role of Inflammation in Chronic Conditions:  Prevention, Assessment & Treatment.  Presented at AANP National Conference, Nashville, TN.
  2. Kessler, C. (2014).  Fat Chance:  A realistic “Mosaic” Approach to Weight Management.  Presented at AANP National Conference, Nashville, TN.
  3. Roberts, M.E. (2014, June 20).  An Update on the 2013 Cardiovascular Guidelines.  Presented at AANP National Conference, Nashville, TN.

Low-Carb Diets: Compelling Evidence for Better Diabetes Management

Over the last 15 years, there have been numerous clinical trials evaluating the effects of low-carb diets on weight loss.  Because of this research, there seems to be a growing level of acceptance that low-carb diets produce at least equal, but more often greater, weight loss than higher-carb control diets, at least in the short term.  But recently, there seems to be increased interest in whether low-carb diets offer advantages beyond weight management. For example, the utility of low-carb diets for boosting performance of endurance athletes has recently been explored in a number of recent publications (see review article by Dave Ellis, RD, CSCS), as have the benefits of low-carb diets for type 2 diabetes (T2D) management.

Last month, Tay et al.1 compared the effects of a low-carb (<50 g/day), low saturated fat (<10% of total calories), reduced calorie diet to a low saturated fat, high-carb diet (53% of total calories; based on low-glycemic index foods) on glycemic control and cardiovascular disease (CVD) risk factors in 115 obese adults with T2D. Following the 24-week intervention, both groups achieved similar levels of weight loss; however, the low-carb diet group saw greater reductions in plasma triglycerides, glycosylated hemoglobin and antiglycemic medication use. The results were most prominent in those with greater metabolic dysfunction. There were no changes in other cardiovascular risk markers, except for a small increase in high-density cholesterol (HDL-C) concentrations in a subset of subjects with low HDL-C levels at baseline.

This is not the first study of its kind to report superiority of a low-carb diet in those with T2D. In fact, the science was recently reviewed in a paper published last month in the journal Nutrition2.  The authors, a group of 26 highly respected research scientists, critically evaluated the totality of the evidence and concluded that carbohydrate restriction is safe and more effective than other dietary approaches for the management of T2D and should be employed first as part of a diabetes lifestyle management plan.

While evidence seems to suggest that such diets may elicit a range of health benefits, whether they are practical in our carbohydrate-laden food environment is up for discussion.

 

References:

1Tay J, Luscombe-Marsh ND, Thompson CH, et al. A very low carbohydrate, low saturated fat diet for type 2 diabetes management: A randomized trial. Diabetes Care. 2014 (Epub ahead of print).

2Feinman RD, Pogozelski WK, Astrup A, et al. Dietary carbohydrate restriction as the first approach in diabetes management. Critical review and evidence base. Nutrition. 2014 (Epub ahead of print).

Leucine: Promoting Muscle Anabolism at Breakfast

Muscle Illustration

Protein is a critically important fuel source for muscles, and branched chain amino acids (BCAAs) are particularly so. Leucine is the most abundant BCAA found in muscles, and as the body of leucine research continues to grow, so does the evidence pointing to several benefits that leucine imparts, including the regulation of skeletal muscle protein synthesis. This was demonstrated in a study where leucine supplementation in a low dose of whey protein stimulated postprandial human myofibrillar protein synthesis as effectively as a much greater dose of whey protein (1). Similarly, a low-protein mixed macronutrient beverage supplemented with a high amount of leucine was found to be as effective as a high-protein beverage at stimulating muscle anabolism (2). Furthermore, results of another study on muscle recovery suggest that increasing the concentration of leucine in an essential amino acid supplement during moderate intensity exercise may increase post-exercise skeletal muscle metabolism (3). In addition to tissue protein synthesis, leucine in combination with vitamin B6 also increased fat oxidation and insulin sensitivity and reduced oxidative and inflammatory stress, thus suggesting a potential approach in the management of obesity (4).

Leucine-3D

Leucine is an essential amino acid, and as such, it must be obtained from dietary sources, since our bodies cannot produce it. Animal proteins in general are among the best sources of dietary leucine. Eggs contain 1.086g of leucine per 100g weight, which translates to approximately 9% of its total protein content (5). When compared to other foods commonly consumed for breakfast, eggs are not as high on a gram for gram basis as oats or cheese (see figure below). However, when a comparison of leucine content is made on a per calorie basis, eggs come out looking better than most other common food sources. At only 72 calories, with 6.3 grams of protein and a high leucine content, eggs are a nutritionally- and protein-dense food source, perfect for those trying to get a little more protein, leucine and other essential micronutrients in their diets.

Charts_Leucine-in-Breakfast-Protein

As noted in the dialogue from the recent fourth meeting of the Dietary Guidelines Advisory Committee, protein is notoriously under-consumed at breakfast. Given their robust nutrient profile and leucine content, eggs can be an easy fix to this nutritional shortcoming and an important protein source to consider when helping patients and clients build healthful diets.

References:

  1. Churchward-Venne TA, Burd NA, Mitchell CJ, West DW, Philp A, Marcotte GR, Baker SK, Baar K, Phillips SM. Supplementation of a suboptimal protein dose with leucine or essential amino acids: effects on myofibrillar protein synthesis at rest and following resistance exercise in men. J Physiol. 20012; 590(Pt 11):2751-65.
  2. Churchward TA, Breen L, Di Donato DM, Hector AJ, Mitchell CJ, Moore DR, Stellingwerff T, Breuille D, Offord EA, Baker SK, Phillips SM. Leucine supplementation of a low-protein mixed macronutrient beverage enhances myofibrillar protein synthesis in young men: a double-blind, randomized trial.Am J Clin Nutr. 2014; 99(2):276-86.
  3. Pasiakos SM, MClung HL, McClung JP, Margolis LM, Andersen NE, Cloutier GJ, Pikosky MA, Rood JC, Fielding RA, Young AJ. Leucine-enriched essential amino acid supplementation during moderate steady state exercise enhances postexercise muscle protein synthesis. Am J Clin Nutr. 2011; 94(3):809-18.
  4. Zemel MB, Bruckbauer A. Effects of a leucine and pyridoxine-containing nutraceutical on fat oxidation, and oxidative and inflammatory stress in overweight and obese subjects. Nutrients. 2012; 4(6):529-41.
  5. USDA National Nutrient Database for Standard Reference. U.S. Department of Agriculture, Agricultural Research Service, USDA Nutrient Data Laboratory Website. Updated Dec 7, 2011.http://ndb.nal.usda.gov/. Accessed July 28, 2014.

Re-evaluating What Constitutes a Healthy Diet

The-Big-Fat-Surprise-209x300The ongoing, seemingly endless nutrition debate about what constitutes a healthy diet just got a little hotter. In recent weeks a new book entitled The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet [1] hit bookstore shelves, and was followed by an article in the current issue ofTime magazine called “Ending the War on Fat.” The primary message of both the book and the article is that the past fifty years or so of diet advice dispensed by various health agencies, and countless research studies performed on the diet/heart disease relationship, have been mostly flawed.  And before you discount these two recent sources as the work of lay authors, it should be pointed out that a couple of well-done, albeit controversial, meta analyses out of UC-Berkeley [2] andCambridge University [3] in England largely support the principal conclusions of the book and the Time article -that current evidence does not support low consumption of saturated fats or cholesterol as antidotes to cardiovascular disease (CVD).

How did this change in thinking come about, and where might it lead us in the future? Regarding the former, the realization that fifty years of dietary advice (that was mostly adhered to by a large segment of the population) suggesting we eat less red meat, fewer eggs and less dairy products has done little to limit the rate of CVD in the U.S. and that at the same time we were becoming more and more overweight and obese as a nation, has caused many health experts to re-evaluate the data on which these recommendations were based. And what this re-analysis indicates, among other things, is that the majority of the studies on which macronutrient intake recommendations are based were epidemiological studies, which are great for hypothesis generation but marginal for establishing cause-and-effect. Worse yet, information gleaned from some of these studies have been extrapolated or inferred to help create a story that may not exist. Both the aforementioned book and Time article tell the story of how some of the data from Ancel Keys’ well-known Seven Countries Study was apparently cherry-picked so that only data from countries that supported a saturated fat/CVD relationship were included in Keys’ analysis, and countries that did not fit this paradigm were excluded.

Another point worth noting is the possible unintended consequence of food substitution: if a person adheres to dietary advice suggesting less saturated fat and cholesterol consumption, what would he/she likely add into the diet to make up for the nutritional and caloric shortfall created by removing fats? The answer is, of course, carbohydrates. Primarily refined carbs and sugars. And newer research indicates that many of the consequences of a low fat/high refined carb diet – elevated triglycerides, decreased insulin sensitivity, more small, dense LDL particles, greater vascular inflammation, increased body weight, etc. may be the real culprits in elevated CVD risk. Ironic, isn’t it, that the foods once promoted as a healthier alternative to higher fat fare may turn out to be “the bad guys” after all?

Where will this new information lead? Still too early to tell. As any nutrition professional can tell you, diet research is fickle, and alternative hypotheses on what constitutes the healthiest diet will undoubtedly change many times in the future as new data become available. One thing that seems obvious is our need for more diet-based studies, and less single-nutrient research. When single nutrients are studied outside the context of the entire diet, misinterpretations are bound to occur. For example, dietary cholesterol as a part of a diet loaded with fruits and vegetables, whole grains, and various healthy fats and proteins may be largely innocuous; the same amount of cholesterol in a high calorie, high sugar and refined carb diet may be disease-promoting.

A healthy re-evaluation of the data on which we’ve based many of our dietary beliefs is certainly in order if we’re ever to move closer to understanding what constitutes a truly healthy diet.

 

References:

1.            Teicholz N: The Big Fat Surprise: Why Butter, Meat and Cheese Belong in a Healthy Diet.Simon & Schuster; 2014.

2.            Siri-Tarino PW, Sun Q, Hu FB, Krauss RM: Saturated fat, carbohydrate, and cardiovascular disease. The American Journal of Clinical Nutrition 2010, 91:502-509.

3.            Chowdhury R, Warnakula S, Kunutsor S, Crowe F, Ward HA, Johnson L, Franco OH, Butterworth AS, Forouhi NG, Thompson SG, et al: Association of dietary, circulating, and supplement fatty acids with coronary risk: a systematic review and meta-analysis. Annals of Internal Medicine2014, 160:398-406.