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.

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Meta-Analysis Suggests No Relationship Between Eggs & Elevated CHD Risk

A new study titled “egg consumption and risk of coronary heart disease and stroke: dose-response meta-analysis of prospective cohort studies” appeared in the January issue of the British Medical Journal (BMJ). The study was co-authored by researchers from various Chinese universities and researchers from the Harvard School of Public Health. The authors scoured the literature from 1966 to 2012 for appropriate studies that examined the association between egg consumption and risk of coronary heart disease (CHD). Their primary conclusion: the analysis did not support a relationship between higher egg consumption and elevated risk of CHD and stroke.

When considering potential reasons for their results the researchers pointed out, among other things, that the effects of dietary cholesterol on serum cholesterol levels are relatively small. They also pointed out that overall dietary patterns and saturated fat intake likely have much greater influence on serum cholesterol levels than does dietary cholesterol.

From my perspective, these data uncover an issue with much of the traditional dietary cholesterol advice offered by some public health organizations. When recommendations are made that we eat cholesterol-containing foods judiciously, I believe that this guidance is based on either A) erroneous conclusions that dietary cholesterol itself greatly impacts serum cholesterol levels, or B) conclusions that because most foods high in cholesterol also tend to be high in saturated fat, it is prudent to limit cholesterol intake as a means of keeping overall fat intake low, or C) neglect of the impact that overall diet has on CHD risk.

Regarding point B above, how should one view foods that tend to be relatively high in cholesterol and relatively low in saturated fat- -foods like eggs or shellfish? Based on the BMJ study it appears that these foods tend to get a bit of a “bum rap.” For most folks, dietary cholesterol does not greatly impact serum cholesterol or disease risk, so it seems logical that eating foods of this nature should be perfectly fine, and certainly preferable to high cholesterol/high saturated fat alternatives. Further, regarding point C above, it is important to think about “the company that foods keep” when deciding the place of any individual food in the diet. So thinking about eggs in the context of a meal consisting of yogurt, low fat milk and a fruit cup is far different from a CHD risk perspective than eggs on a plate with high-fat meats and fried or heavily-buttered carbohydrates.

Bottom line- -studies like the recent BMJ study and others like it strongly suggest that dietary cholesterol is not the nutritional “boogeyman” we once thought it was, and that a highly nutritious food like the egg, despite its cholesterol content, can be a great staple in the diet.

Cholesterol & Heart Disease Guidance Worldwide

image-150x150Today’s blog post is written by Emmaline Rasmussen, previous Dietetic Intern at ENC. Emmaline studied Dietetics and Kinesiology at the University of Illinois at Chicago. She is an avid food and nutrition enthusiast as well as a certified yoga teacher.

What do adults in Canada, The United States, Australia and Ireland have in common? Other than living in a country where English is one of the primary languages, they all live in a country where the leading cause of death is Cardiovascular Disease (CVD). Each of these countries also has a national foundation or association dedicated to increasing CVD awareness. However each organization provides slightly different recommendations for how to decrease one’s risk for developing cardiovascular disease, but one common theme is the importance of lowering LDL, or “bad” cholesterol levels in the blood. In addition to lifestyle modifications that the organizations promote as strategies to lower LDL cholesterol levels (such as abstaining from smoking cigarettes and engaging in regular physical activity), they also all list several nutrition recommendations for promoting heart health.

As one might expect, all of the organizations encourage consuming a plentiful variety of fruits and vegetables and whole grains. Additionally, they all recommend decreasing overall dietary fat intake, with specific attention to limiting less healthy saturated and trans fats and instead focusing on healthy unsaturated fat sources. While some authorities provide recommended daily limits, dietary cholesterol does not appear to be as much of a focus in some cases.

The Irish Heart Foundation lists several nutrition recommendations in their tips “for healthy cholesterol and a happy heart,” but dietary cholesterol intake isn’t mentioned in these guidelines. The organization even goes as far to explain that “the level of cholesterol in your blood is affected by the amount of saturated fats you eat every day,” and specify that food containing dietary cholesterol “does not greatly affect the amount of cholesterol in your blood.”

The Australian Heart Foundation states that dietary cholesterol “has only a small effect on your LDL cholesterol,” highlighting saturated and trans fats as major culprits for increasing LDL cholesterol and subsequent plaque formation. Their guidelines recommend limiting “cholesterol-rich” food items “if advised to do so,” while across-the-board recommendations are made for lowering saturated fat intake.

The Canadian Heart & Stroke Foundation’s list of strategies for lowering LDL cholesterol levels does not include limiting dietary cholesterol intake, though RDI (Recommended Daily Intake) levels for cholesterol are in place in Canada, for those with and without heart disease. The Foundation does note that “dietary cholesterol only has an effect in some people” in terms of impact on blood cholesterol levels. The Foundation specifically states that “from a nutrition perspective, the best way to control blood cholesterol is to eat a healthy diet that is lower in fat, especially saturated and trans fat.”

The Bottom Line:
Familiarize yourself with the guidelines of several authorities on heart health to learn more about recommendations and information surrounding dietary cholesterol intake. As a health professional, be sure to focus on all of the strategies for promoting heart health, including:

  • Maintaining a healthy body weight/BMI (Body Mass Index)
  • Engaging in regular physical activity
  • Abstaining from smoking cigarettes
  • Following other dietary recommendations or heart health (including a lot of fruits, vegetables, and whole grains in the diet while limiting fat, particularly saturated and trans fat, and sodium in the diet)
  • Having regular blood pressure, blood cholesterol, and blood sugar (if you’re at risk for diabetes) checks
  • Engaging in strategies to reduce stress

Lastly, it’s important to encourage patients to speak with their doctor to clarify any questions relating to heart health and cholesterol levels in addition to working with a registered dietitian to help plan a heart healthy diet.

Paradigm Shift in Management of Type 2 Diabetes

Layman-2010-221x300Today’s post comes from Dr. Donald Layman. Dr. Layman is the Director of Research at the Egg Nutrition Center and Professor Emeritus at the University of Illinois and a leading researcher studying dietary needs for protein and amino acids.

A recent review by Dr. Acheson in the European Journal of Clinical Nutritionhighlights a paradigm shift in medical practice for management of type 2 diabetes (T2D).The shift is from recommending high carbohydrate diets combined with drugs therapies to regulate blood glucose to a new philosophy for use of low carbohydrate diets to reduce glucose exposure and minimize drug needs.The principles underpinning this shift reflect new understanding about how the body regulates blood glucose. The fundamental problem in diabetes is elevated blood glucose causing vascular damage throughout the body including the eyes, heart, and kidneys.

For most of the past century, diet and drug therapies have been aimed at increasing disposal of blood glucose in muscle and adipose. Standard treatments included high carbohydrate, low fat diets, insulin, and oral hypoglycemic drugs (ie. sulfonylurea [SU] and thiazolidinedione [TZD]). These approaches largely controlled blood glucose by accelerating glucose uptake into adipose tissue but the obvious side effect was increasing body fat and obesity.

The new philosophy emphasizes use of reduced carbohydrate, higher protein diets with limited drug therapy and is being used at leading medical centers including the “Why WAIT” program at Joslin Diabetes Center (Curr Diab Rep 8:413,2008). This philosophy shifts the focus of glycemic regulation to dietary control of glucose exposure.  By limiting glucose intake, the liver regulates the entry of glucose into the blood, minimizes the need for insulin, and reduces side effects of obesity. Metformin becomes the primary drug because it helps regulate glucose release by the liver. These programs have been shown to be highly effective for treatment of T2D and for weight loss.

In the late 1920’s, research showed that in normal subjects consumption of high carbohydrate diets increased glucose use. In other words, the more carbohydrates you eat, the more efficient you would become at regulating blood glucose. This philosophy was further supported in the 1950’s with the availability of insulin and the potential to assist the pancreas with more insulin to regulate blood glucose. Many of the current approaches to diabetes management try to control blood glucose by stimulating disposal into peripheral tissues – namely muscle and adipose.

The debate about the ideal diet for weight management often concludes that calories are the critical factor and specific macronutrient content is not important. Then, a logical assumption that controlling fat intake is important because of the higher energy density and potential negative effects on cardiovascular health. While there is intuitive logic for controlling total calories and dietary fat, evidence is accumulating that weight management is best achieved with a focus on reducing excess carbohydrate intake and maintaining dietary protein.

While Americans consume a higher percentage of dietary fat than current recommendations, the RDA for carbohydrates is 130 g/day and the average intake is about 300 g/day. So if all calories are equally important, then consumption of nearly three times more carbohydrates than the RDA is a major contribution to energy excess.

Emerging evidence suggests moving from high carbohydrate, low fat diets combined with drug therapy to diets with reduced carbohydrates and higher protein. Since insulin became available in the 1950’s, the treatment philosophy has been that use of supplemental insulin and/or hypoglycemic drugs combined with a high carbohydrate low fat diet was the best combination to control blood glucose and reduce the risk of heart disease. This treatment approach has not proven to enhance long-term outcomes, and the incidence of type 2 diabetes is increasing rapidly. Researchers and physicians are now looking at virtually the opposite approach, to reduce dietary carbohydrate intake and reduce the reliance on drug therapy.

Kidney Disease: The Protein Factor

Araceli-VazquezToday’s post comes from Araceli Vázquez, MS, RD, LD. Vázquez is one of the few bilingual/bicultural dietitians in North Texas. She began her career in nutrition in 1996 after a successful career as a microbiologist and now offers nutrition counseling as part of her private practice, DietGenics. Vázquez is also a member of ENC’s Health Professional Advisor panel.

Chronic Kidney Disease and Diabetes

Chronic kidney disease (CKD) is a global public health problem with increased rates as a consequence of the epidemic of type 2 diabetes and obesity. The prevalence of diabetes is growing rapidly and is one of the major leading causes of CKD. People with diabetes and CKD are at greater risk of experiencing major cardiovascular procedures.

Protein intake

Most people in USA consume 1.04 g/kg body weight per day as protein, which is more than the 0.8 g/kg body weight per day RDA. For people with diabetes, carbohydrate intake and glycemic control are typically the target of nutritional management, and protein usually comprises 15% to 20% of total daily calories. However, all three macronutrients – protein, carbohydrates and fats – as well as micronutrients, including sodium, potassium and phosphate must be well balanced to maintain an adequate nutritional status.

Nutritional intervention should be individualized with achievable goals that emphasize the importance of lifestyle behaviors conducive to positive outcomes. Meal plans for diabetes and CKD should consider the quality and quantity of proteins, carbohydrates and fats. Protein intake meeting the RDA, or 0.8 g/kg of body weight per day, has shown a reduction in albuminuria and stabilization of kidney function in studies of diabetes and CKD, while allowing patients to remain well nourished. Low protein menu plans are at risk of causing malnutrition.

Conversely, high-protein diets can be a concern because they increase albuminuria and may accelerate loss of kidney function in patients with diabetes. Consequently, people with diabetes and CKD should avoid high-protein diets (≥20% of total daily calories), such as many of the fad diets, shakes and protein powders.  Regardless of the level of protein intake, at least 50% to 75% of the protein should be of high biological value (HBV) and mainly from lean poultry, eggs, fish, bean, peas and soy- based proteins. For instance, the DASH diet emphasizes vegetables, low-fat or nonfat dairy products, whole grains, nuts, legumes, fish, eggs and poultry with red meats consumed in only small amounts.

End of Stage Renal Disease (ESRD) and Hemodialysis

The number of people with ESRD receiving hemodialysis is increasing dramatically. Patients with ESRD on dialysis maintenance have high incidence of Protein Energy Malnutrition (PEM). PEM can have various causes, but one of the most important is decreased nutrient intake. In order to maintain a safe dietary protein intake, patients undergoing hemodialysis need 1.2 g/kg body weight/d with at least 50% being HBV such as animal protein meats, fish, salmon, tuna, poultry and eggs.  However, such protein choices are also sources of phosphorous and potassium. Egg whites are low in phosphorus and therefore are a good source of HBV protein when phosphorous and potassium are a concern.

Dietary intervention for CKD must be individualized, since CKD changes as it progresses. The role of a Registered Dietitian is very important in the prevention and treatment of CKD, especially since addressing the diabetes epidemic and its complications requires an indispensable shift in lifestyle.

Managing Blood Glucose During the Holidays

Today’s post comes from Amy Campbell, MS, RD, LDN, CDE. Campbell is a registered dietitian and certified diabetes educator at Joslin Diabetes Center. She is actively involved in education initiatives, both at Joslin and with the American Association of Diabetes Educators, the American Diabetes Association and the Academy of Nutrition and Dietetics. She has authored several books published by the American Diabetes Association and recently received the 2012 Will Solimene Award for Excellence in Medical Communication. Campbell is also a member of the Egg Nutrition Center’s Health Professional Advisor panel.

The holiday season is upon us!  Now starts the whirlwind of shopping, cleaning, cooking and, of course, eating.  While all of us probably need to be mindful of eating healthfully, fitting in physical activity and preventing weight gain, people with diabetes have an extra challenge of trying to keep their blood glucose under control as best they can.  Here are a few tips that may be helpful for enjoying the holiday season without wreaking havoc with diabetes management:

Eat well, but eat right. There’s no reason why a person with diabetes can’t partake in a favorite holiday treat, whether it’s a slice of pie at Thanksgiving or a few home baked cookies at a holiday party.

  • Budget those carbs.  Because many holiday delicacies are laden with carbohydrate, it’s wise to help patients to budget their carbs accordingly.  Remember that one carb choice contains 15 grams of carbohydrate, the amount that’s in one slice or one ounce of bread.  As an example, a slice of pumpkin pie may contain about 45 grams of carbohydrate, or the amount found in three slices of bread.  Can one eat their pie and have it too?  Sure – it’s just a matter of perhaps cutting back on carbs elsewhere in the meal (e.g., forgoing some stuffing and potato) and having a smaller slice of pie or cake for dessert.
  • Bake and cook more healthfully.   Traditional holiday recipes tend to be laden with sugar and fat.  Help patients shave calories, carbs and fat by cutting back on sugar and fat, such as butter or oil by 1/3 to ½.  In most instances, the product will come out tasting and looking like the regular version and no one will be to tell the difference.
  • Stick with the plate method.  Aiming for a plate in which half is filled with low-calorie vegetables, one quarter with a whole grain carb (brown rice, quinoa, whole wheat pasta) and one quarter with protein (lean beef, poultry, fish , eggs) can help patients balance their portions and carbs, and aim for a variety of healthy foods throughout the holidays.

Move more.  Usual physical activity plans often fall by the wayside over the holidays, thanks to changes in eating schedules, shopping and festivities.  Patients may feel that they just don’t have time to go for a walk or get to the gym.  Remind them that physical activity is more beneficial than ever at this time of the year, helping to alleviate stress, burn calories and keep blood glucose levels in check.

  • Do shorter amounts of activity.  Doing 10 minutes of activity at a time is certainly better than doing nothing.  And doing 10 minutes of activity several times a day is often more manageable than finding a block of 30 minutes.
  • Take the stairs.  Cold, snowy, icy weather is a deterrent for many people to go for their usual walk.  Climbing stairs will give just as much of a benefit, and 10 minutes of stair climbing burns 100 to 150 calories.
  • Put up resistance.  Using a resistance band, kettle bells or hand weights while watching television or during a break from cooking is a great way for patients to tone up, burn calories and lower blood glucose, even in as little as 10 to 20 minutes.
  • Enjoy the great outdoors.  Ice skating, sledding, snowshoeing and cross country skiing are fun ways to play in the snow and get more fit, too.  Remind patients that they don’t have to be stuck inside to get a good workout.
  • Give a gift.  The gift of health is the best gift to receive.  Suggest that patients either request or give themselves sessions with a personal trainer, a new pedometer or heart rate monitor, or a gym membership this year.

Keep on Checking

The best way for a person with diabetes to know how their doing on a daily basis is to check their blood glucose with their meter.

  • Change the focus.  Blood glucose numbers are neither good nor bad; they’re just information.  Results that are below or above a patient’s target mean that a little tweaking is likely needed to the treatment plan.
  • Check after meals on occasion.  Suggest that the patient periodically check their blood glucose 2-3 hours after meal (reminding them that the goal for most people at that time is less than 180 mg/dl).  If they’re above or below their goal, brainstorm some ideas for what can be done differently the next time, such as eating less carbohydrate and more protein, or going for a walk after dinner.

Finally, remind patients to make time for themselves over the holidays.  Getting plenty of rest, saying “no” on occasion, and de-stressing with a good book, massage or just some quiet time can help make the holiday season enjoyable for everyone.  For more information on diabetes, visit Joslin Diabetes Center’s website at