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.

Getting to the Heart of Healthy Fats

 

saladAccording to the Centers for Disease Control and Prevention, cardiovascular disease is the leading cause of death for both men and women in the United States, with one out of every three deaths resulting from heart disease or stroke (1). As American Heart Health Month kicks off this week, now is the perfect time to speak with your clients about the ways they can make heart-healthy choices every day, particularly with regard to dietary fat.

The American Heart Association recommends that 25-35%of a person’s daily calories come from fats, with less than 7%of calories coming from saturated fat and less than 1%from trans-fat (2). Most dietary fat consumed should be monounsaturated and/or polyunsaturated fats, as they help maintain healthy blood lipid levels. Monounsaturated fats are found in foods such as avocados, olive oil and peanut butter and have been shown to provide additional benefits, such as improving insulin levels and blood sugar control (3).

Eggs can also be a great source of these healthier fats, with 1.8g of monounsaturated fat and 1.0g of polyunsaturated fat in each large egg. It’s also important to pair eggs with other good-for-you foods, such as fruits and vegetables, whole grains and low-fat dairy. To build a nutritious plate, vegetables can be added to easy egg dishes, like casseroles, quiche, or on salads.

For more information to help your clients build simple, nutritious meals –check out the education resources and recipes based on MyPlate, which are available for download on the ENC website.   In addition, our friends at the Mediterranean Foods Alliance recently released Fresh Fridays Begin with Breakfast in their Fresh Fridays e-newsletter and featured the Italian Vegetable Custard.

Here is an easy recipe combining avocados and eggs, along with veggies to deliver a tasty meal that’s rich in heart-healthy polyunsaturated and monounsaturated fats.

Tomato & Avocado Egg Salad (pictured above)

Makes 6 Servings

Ingredients:

  • 6 hard-boiled eggs, sliced
  • 2 avocadoes, chopped
  • 1 cup chopped tomato
  • ½ cup chopped red onion
  • ¼ cup chopped fresh parsley OR cilantro
  • Spinach OR lettuce leaves
  • Dressing:
    • 2 Tbsp. mayonnaise
    • 2 Tbsp.  sour cream
    • 1 Tbsp. fresh lemon juice
    • ½ tsp. salt
    • ¼ tsp. hot pepper sauce

Directions:

  • Mix dressing ingredients in a small bowl.
  • Reserve and refrigerate 6 center slices from eggs for garnish. Chop remaining eggs.
  • Combine chopped eggs, avocados, tomato, onion and parsley in a large bowl; toss gently to mix. Add dressing; stir gently until ingredients are evenly coated with dressing.
  • Refrigerate at least 1 hour to blend flavors. Serve on spinach leaves, garnished with egg slices.

Nutrition Information

Calories: 218, Total Fat: 17g, Saturated fat: 4g, Polyunsaturated fat: 3g, Monounsaturated fat: 9g, Cholesterol: 189mg, Sodium: 316mg, Carbohydrates: 10g, Dietary Fiber: 5g, Protein: 8g, Vitamin A: 867.9IU, Vitamin D: 41.8IU, Folate: 89.6mcg, Calcium: 51mg, Iron: 1.5mg, Choline: 139.8mg, Vitamin C: 16.2mg.

References:

  1. Heart Disease Facts In Centers for Disease Control and Prevention. Retrieved from http://www.cdc.gov/heartdisease/facts.htm
  2. Fats and Oils: AHA Recommendation. In American Heart Association. Retrieved from http://www.heart.org/HEARTORG/GettingHealthy/FatsAndOils/Fats101/Fats-and-Oils-AHA-Recommendation_UCM_316375_Article.jsp
  3. Mayo Clinic. Dietary fats: Know which types to choose. Retrieved from http://www.mayoclinic.com/health/fat/NU00262

 

 

Eggs and Diabetes: Increased Risk or Guilt by Association?

guy

The Background

The 2010 Dietary Guidelines for Americans (1) recommended limiting dietary cholesterol and specifically egg consumption for individuals with type 2 diabetes (T2D). The recommendation was based on epidemiology studies reporting positive statistical association of increased cardiovascular disease (CVD) risk for individuals with T2D who consumed 7 or more eggs each week. While the Dietary Guideline Committee cited the concern about egg consumption for T2D, they acknowledged that the relationship was a statistical association with no proof of cause or mechanism and emphasized the need for more research.

Shortly after the Dietary Guidelines were presented, Drs. Mozaffarian and Ludwig at Harvard wrote a commentary arguing that the focus of the Dietary Guidelines on single nutrients or single foods was inadequate and misleading for evaluation of modern diverse diets. They argued Dietary Guidelines must consider the context of foods within food patterns and lifestyles to define health risks (2).

Recent Published Studies

A recent paper from Spain evaluating the Mediterranean diet emphasizes this point (3). These investigators specifically evaluated the relationship of egg consumption to diabetes risk in a cohort of adults following a Mediterranean diet pattern. They found no relationship of egg consumption (or cholesterol intake) with T2D risk suggesting that eggs were not a risk factor when consumed within a healthy dietary lifestyle.

Still, contrary to this report, a meta-analysis published in the British Medical Journal (4) evaluated 16 prospective cohort studies that specifically examined relationships of egg consumption with incidence of T2D and CVD and found a positive Risk Ratio (RR) of 1.54 for egg consumption with CVD within the population of T2D.

If you’re not used to thinking about RR, a RR of 1.0 means there is no association, and for comparison, a 50-year old smoking a pack per day has a RR of over 20 for lung cancer. So the true risk of heart disease in a 50-year old male with normal blood lipids and normal blood pressure is about 2% and a RR of 1.54 would increase the risk to 3%.

Perhaps more important than the potential small risk in T2D, these investigators found no association of egg intake with risk of CVD or stroke in non-diabetic adults with the RR less than 1.0 suggesting that greater egg intake reduced risk of both CVD and stroke. Further, they found a RR of 0.75 for egg consumption and stroke in adults with T2D.

Concerns about egg consumption by individuals with T2D remains a question that requires better research to determine if the risk is a true relationship to eggs or if it is a guilt by association with other aspects of overall diet quality. This would include dietary intakes such as total fat, types of fat, dietary fiber, green vegetables or fruit.

Bottom Line

What should not be lost within the debate about diabetes is that study after study shows there is no association
of egg consumption with CVD risk in non-diabetic adults and that egg consumption reduces risk for stroke in both diabetic and non-diabetic adults.

References

1. U.S. Department of Health and Human Services. Dietary Guidelines for Americans. http:/www.health.gov/dietaryguidelines/  Part D, Section 3.

2. Mozaffarian D, Ludwig DS. Dietary Guidelines in the 21st Century a Time for Food. JAMA 304:681, 2010.

3. Zazpe I, Beunza JJ, et al. Egg consumption and risk of type 2 diabetes in a Mediterranean cohort: the SUN project. Nutr Hosp 28:105, 2013.

4. Rong Y, Chen L, et al. Egg consumption and risk of coronary heart disease and stroke: dose-response meta-analysis of prospective cohort studies. BMJ 2013 (doi: 10.1136/bmj.e8539).

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.