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Plant based nutrition 2019
- 1. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Plant-Based Nutrition Alap Shah, MD Associate Program Director La Grange Family Medicine Residency
- 2. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Disclosures ● No financial disclosures to report ● No commercial products will be promoted ● My views are my own, and do not necessarily represent those of AMITA Health, La Grange FMR, or the IAFP, or anyone else who eats a plant-based diet
- 3. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Background / Credentials • Vegan (no meat, fish, eggs, dairy) since 2003
- 4. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Objectives ● Individual and societal benefits of a plant- based foods ● Indications for increasing plant-based foods ● Incorporating plant-based nutrition through the life cycle ● Dispel common misconceptions ● Billing codes for plant-based nutrition counseling
- 5. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Keep In Mind… • Complexities: – Human biology, metabolism, microbiome – Dietary components and lifestyles – Environments we live and work – Life stressors
- 6. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Continuum of Plant-Based Nutrition ● Vegan ○ No animal products (often includes clothing) ● Vegetarian ○ “Lacto” - dairy products ○ “Ovo” - egg products ● Pescatarian ○ Fish ● Flexitarian / “Plant-Forward” ○ “Eat Food, Not Too Much, Mostly Plants” - Michael Pollan (NYT)
- 7. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Why Might Patients Choose Plant- Based? ● Health (often cardiovascular) ● Religious (Hindu, Jain, Buddhism, Adventist, Lenten observations, etc.) ● Ethical (opposed to the use of animals as commodities in the developed world) ● Environmental / Climate Change
- 8. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Leading Causes of Death - US
- 9. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Cholesterol and CV Death
- 10. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 What Increases Cholesterol? • 1% in saturated fat intake • 2% in serum LDL • Linear relationship between dietary and blood cholesterol
- 11. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Sources of Dietary Cholesterol • Animal-Based – 2% Milk: 20mg – Cheese slice: 30mg – Lean beef: 90mg – Salmon: 52mg – Chicken: 123mg – Fried egg: 184mg – Butter: 31mg – Shrimp: 189mg • Plant-Based – Broccoli: 0mg – Corn: 0mg – Olive oil: 0mg – Carrots: 0mg – Flax seeds: 0mg – Black beans: 0mg
- 12. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Sources of Saturated Fat • Animal-based – Lean beef: 5g – Chicken breast: 1.4g – Turkey slices: 2.2g – Salmon: 6g – Butter: 7g – 2% milk: 1.5g • Plant-based – Apple: 0.1g – Black beans: 0.24g – Wheat bread: 0.2g – Peanut butter: 3.3g – Olive oil: 1.9g – Soymilk: 0.5g – Coconut oil: 12g
- 13. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Cornell China Study (JACC 1998) • Analysis of diets and disease correlation in rural China vs US in 1983-1984 • Data for >50 diseases from 65 counties, ~6500 people sampled • Takeaways: ● Breast CA mortality with higher dietary fat, blood cholesterol ● Higher blood Vit C and B-carotene assoc. with CA risk ● CAD (ages 0-64): 17x higher in US men, 6x for women
- 14. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 ARIC Study • Cohort study of ~12K adults (45-64y) in 4 states over 30y, assessed 6x starting in 1987 • Takeaways: – Higher whole-grain intake assoc with lower all cause mortality and CAD (26% lower) – Incr fruit/veg intake assoc w lower all cause mortality (22% decr) – CAD risk in AA pts with 5 servings refined grain/d was 2x higher than 0.5 servings/d
- 15. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Cornell China Study (JACC 1998) • Average office worker • Diet vs Blood cholesterol
- 16. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 A Way To Reverse CAD? (JFP 2014) • 198 patients (mostly men) with HL, DM, and/or HTN and CAD sought out a plant-based diet – Diet: vegan, based on whole grains, lentils/beans, fruit, veg, with B12 + flax supplement – Pts continued other usual care (meds, exercise) – Followed for 3.7yrs – All had confirmed CAD or PVD • Most had angina
- 17. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 A Way To Reverse CAD? (JFP 2014) • 11% nonadherent (of which 62% had MACE) • 89% adherent to diet – Average wt loss: 18.7 lbs – MACE rate 10% or lower – 27 pts avoided PCI/CABG – 93% had improvement in angina – 22% had documented reversal of CAD on angio or stress test
- 18. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 A Way To Reverse CAD? (JFP 2014)
- 19. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Cornell China Study (JACC 1998)
- 20. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 The Mediterranean Diet?
- 21. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 The Mediterranean Diet • Dr. Ancel Keys (1904-2004) – “The Seven Countries Study” • Mediterrean diet: – Bread, pasta, tomato sauce – Fresh vegetables, beans – Fruit for dessert – Occasional meat or fish – 23% fat
- 22. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 PREDIMED Trial (NEJM 2013) • Multi-arm RCT in Spain, ~7500 people for 5 yrs • Age 55-80, no heart dz, but with RFs – Mediterranean Diet + EVOO – Mediterranean Diet + nuts – Usual diet + advise to eat less fat
- 23. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 PREDIMED Trial (NEJM 2013)
- 24. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 PREDIMED Trial (NEJM 2013)
- 25. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 PREDIMED – Provegetarian (Am J Clin Nutr 2014)
- 26. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Other Studies • REGARDS (JACC 2019) – 41% decr new HF risk • (JAMA IM 2016) – plant protein intake assoc with lower all cause and CV mortality
- 27. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Real World Examples - “Blue Zones” • “Stop eating when your stomach is 80 percent full to avoid weight gain. • Eat the smallest meal of the day in the late afternoon or evening. • Eat mostly plants, especially beans. And eat meat rarely, in small portions of 3 to 4 ounces. Blue Zoners eat portions this size just five times a month, on average. • Drink alcohol moderately and regularly, i.e. 1-2 glasses a day.”
- 28. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 4-Leaf Survey • https://4leafsurvey.com/
- 29. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Diet Comparison • EAT-Lancet
- 30. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Macronutrients • Carbohydrates –found in abundance in plant foods • Fat – usually not a problem – Nuts, Seeds, Oils, Avocado – Omega-3 (ALA) found in flax, walnut, edamame, canola oil, chia seeds, seaweed
- 31. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Macronutrients • Protein – Adventist Health Study – 61% higher mortality than avg for highest animal protein intake group – WHO Protein Requirements: • Adults: 0.83g/kg/day (~58g for 70kg) • Infant: 1.3g/kg/day -> Teen: 0.86g/kg/day • Athletes: more protein not necessarily better • Protein quality scores
- 32. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Micronutrients • Iron – deficiency rare among vegetarians in the developed world • Zinc – less bioavailable in plant-based foods, deficiency rare in developed world • Calcium – 500-700mg/day, easily obtainable • B12 – need to supplement
- 33. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Plant-Based Through Life Cycle • ADA Position Statement: – “Well-planned vegetarian [including vegan] diets are appropriate for individuals during all stages of the lifecycle, including pregnancy, lactation, infancy, childhood, and adolescence, and for athletes.” • Pregnancy / Lactation • Infancy / Childhood • Adolescence • Adulthood / Elderly
- 34. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Obligatory Photos
- 35. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Athletics • Kenyan Marathoner’s Diet – mostly carbs, rare meat • Tom Brady’s ‘TB12’ diet - mostly plants, some meat • Arian Foster (NFL RB) • Nate Diaz (MMA)
- 36. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 What about Keto? • Keto – High fat, moderate protein, low carb – Carb intake <50g day – Similar to Atkins • NEJM 2003 RCT – 63 obese adults – No difference in weight loss at 12 months between Atkins and traditional low fat (both about 5% BW) • Ann Int Med 2004 RCT – 132 obese adults – No difference in weight loss at 12 months between the two
- 37. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 EAT-Lancet Commission 2019
- 38. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 EAT-Lancet Commission 2019 ○ “820 million people have insufficient food… many more consume unhealthy diets” ○ “Global food production is the largest pressure caused by humans on Earth.“ ○ “Food is the single strongest lever to optimize human health and environmental sustainability on Earth.”
- 39. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 EAT-Lancet Commission 2019 ○ “Transformation to healthy diets by 2050 will require… doubling in the consumption of healthy foods such as fruits, vegetables, legumes and nuts, and a greater than 50% reduction in global consumption of less healthy foods such as added sugars and red meat” ○ “...Achieving these targets will depend on providing high- quality primary health care that integrates family planning and education on healthy diets.”
- 40. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Livestock and Climate Change • “Livestock and their byproducts account for at least 32,000 million tons of carbon dioxide (CO2) per year, or 51% of all worldwide greenhouse gas emissions.” • “US Methane emissions from livestock and natural gas are nearly equal.” • “Emissions for agriculture projected to increase 80% by 2050.”
- 41. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Livestock and Climate Change • “Growing feed crops for livestock consumes 56% of water in the US.” • “Livestock or livestock feed occupies 1/3 of the earth’s ice-free land.”
- 42. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Is Plant-Based Ever Contraindicated? • Low Residue diet – no problem • Gluten intolerance, allergies – no problem • “Universal Meal” – Vegetables, non-gluten grains, beans/legumes, fruit
- 43. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Plant-Based Meal Ideas • Breakfast – Oatmeal, Cereal, Toast, Smoothie • Lunch – Sandwich/Wrap, Salad • Dinner – Pasta, Soup/Stew, Casseroles, Fajitas, Noodles, Curries • Snacks
- 44. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Billing and Coding • Bill for time – 99213: 15 min – 99214: 25 min • Bill for preventive counseling, add-on to another visit – 99401: 15 min - $39.64 – 99402: 30 min - $65.23
- 45. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Memes
- 46. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Memes
- 47. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Citations • “What's at stake in nutrition education during med school.” Accelerating Change in Medical Education. AMA website, Jul 2015. • Am J Clin Nutr 2003;78:383–90 • Patterns of plant and animal protein intake are strongly associated with cardiovascular mortality: the Adventist Health Study-2 cohort. Int J Epidemiol. 2018 Oct; 47(5): 1603–1612. • Joint WHO/FAO/UNU Expert Consultation on Protein and Amino Acid Requirements in Human Nutrition Geneva. Apr, 2002 • “On The Road To Olympic Gold, Kenyan Marathoners Fuel Up On Carbs.” NPR, Food for Thought. Aug 2012.
- 48. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Citations • Updated Cost-effectiveness Analysis of PCSK9 Inhibitors Based on the Results of the FOURIER Trial. JAMA 2017; 318(8). • “How The DASH Diet Can Lower Your Blood Pressure.” OhioHealth blog, accessed Nov 2019. • A plant-based diet and coronary artery disease: a mandate for effective therapy. J Geriatr Cardiol 2017; 14: 317-320. • Association of Animal and Plant Protein Intake With All-Cause and Cause-Specific Mortality. JAMA Intern Med. 2016;176(10):1453-1463. • A Review of Plant-based Diets to Prevent and Treat Heart Failure. Card Fail Rev. 2018 May; 4(1): 54–61.
- 49. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Citations • “Deaths: Leading Causes for 2017.” National Vital Statistics Reports, Jun 2019; 68(6). • “Position of the American Dietetic Association: vegetarian diets.” Journal of the American Dietetic Association, 2009;109(7). • A Randomized Trial of a Low-Carbohydrate Diet for Obesity. NEJM 2003; 348:2082-90. • Dietary Patterns and Incident Heart Failure in U.S. Adults Without Known Coronary Disease. JACC 2019 Apr; 73(16).
- 50. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Citations • The effects of low-carbohydrate versus conventional weight loss diets in severely obese adults: one-year follow-up of a randomized trial. Ann Intern Med 2004;140(10). • A provegetarian food pattern and reduction in total mortality in the Prevención con Dieta Mediterránea (PREDIMED) study . Am J Clin Nutr 2014; 100(320S–328S). • “Eating To Break 100: Longevity Diet Tips From The Blue Zones.” NPR Apr 2015. Accessed Nov 2019.
- 51. Empowering Patients & Communities: Celebrating Diversity & InnovationJoin the conversation: #FMMidwest19 Questions?
Editor's Notes
- Vegan and plant-based are often used interchangeably. They often can be the same, but the important distinction is that plant-based implies that most of the food is as closely sourced from plants as possible. Coke, French fries, and oreos are vegan, but they wouldn’t really be considered plant based.
- Next, we will get into some of the evidence and literature…
- Let’s start by giving some background on the problem. This is to highlight the scope of the problem in terms of mortality. Data is from the CDC, leading causes of death.
- So let’s start with cardiovascular health. The basis for much of preventive medicine is that that the higher the cholesterol, the higher the CV mortality. This is from the MRFIT trial from 1982 showing as much. Pretty easy curve to follow. The higher the cholesterol, the higher the 6 year mortality per 1000 men.
- Much of cholesterol is genetic. Not much can be done about that. One affect is from saturated fat. The NCEP panel reported this: For ever 1% increase in dietary saturated fat intake, there is a 2% increase in serum LDL. In addition, dietary cholesterol plays a large part in serum levels. Approximately 50% of cholesterol that is eaten is absorbed. This is hard to read but on the vertical axis is the change in serum total cholesterol (TC). On the horizontal is the in dietary cholesterol, increasing from 0 to over 1000. At the levels that most people eat, which is from 200-500mg daily, there is a linear increase in serum levels. When you get to approximately 1000mg and higher, which is a LOT, there is a bit of a leveling off.
- On the left is a list of all the sources of dietary cholesterol. We physicians are very highly trained to notice trends, and we can analyze data closely…
- Here are some sources of saturated fats. Animal based have quite a bit more than plant based, even the leanest type of meat. The primary source of saturated fats in plant foods is coconut and palm oils. Coconut is a little different – it is a shorter chain than stearic acid, which is the primary saturated fat in meat, and palmitic acid, which is in butter and milk. Shorter chain isn’t quite good for you but it’s at least considered not as harmful. Some of the longest lived people in the world do have coconut in their diets – for example in certain Pacific island populations. But those people have historically had excellent diets and lifestyles in all other aspects. And who wouldn’t want to live 100 years near a beach on the Pacific?
- Remember – as of now, you can’t extract the B-carotene from the vegetable and get the benefit – in fact, it increased lung cancer risk, along with vitamin E. The same is possibly true of the other antioxidants in fruits and vegetables. They also found less green vegetables, higher Apo B levels, more salt assoc with more CAD In terms of Apo B, higher animal protein and fat intake assoc with higher Apo B, and higher plant protein intake assoc with lower Apo B. Also keep in mind that higher wheat flour assoc with higher CAD.
- The ARIC (Atherosclerotic Risk in Comunities) cohort is a multicenter, population-based prospective investigation of the etiology and natural history of atherosclerotic disease in middle-aged adults. Similar to the Nurses Health Study, they follow a large cohort and track all kinds of things. For whole grains, the highest quintile (3 servings/d) vs the lowest (0.1 servings/d) For fruit/veg, The highest quintile (7.5 servings/d) vs the lowest quintile (1.5 servings/d)
- The graph on the left shows the average dietary pattern of the average Chinese office worker vs American. Interestingly the average Chinese worker bikes to work, and needs a bit more calories. Their protein intake was approx. 10%, or approx. 65g a day, most of it non-animal sourced. On the right, the plot shows the increased correlation with higher plasma cholesterol with fat, animal protein, and meat. We are using cholesterol measurement as a surrogate measure for cardiovascular health, but so do most of the trials and recommendations surrounding statins.
- This is from a small prospective cohort study. The aim wasn’t to compare – it was to see if CAD or PAD was reversible.
- This is an interesting study with several limitations. But, mostly it shows that motivated people CAN adopt this diet, if they are motivated. It also shows that reversal CAD is possible and CAD progression is not set in stone! If there were a medication that could do this, can you imagine the marketing?
- Figure 1 is an example of a patient who, after 3 weeks, had improved perfusion on their nuc med scan. Figure 2 Is after 2.5 years of a plant based low fat diet. These are just 2 people but the trend was definitely significant. Of course it’s a small sample size of motivated patients – but I like to think of this study as what is possible, not what will necessarily happen with everyone.
- Now, in full disclosure, Dr Campbell in the last few years has made a name for himself in the plant based world. I’m not sure how much money he makes from these things though.
- Next we’ll talk about the Mediterranean diet. A lot of people think the Mediterreanean diet is olive oil and wine and fish. In fact, that is hardly the case.
- Dr Ancel Keys was a famous researcher in diet and health. He developed the K ration during WW 2, actually, named for him. He lived a long time himself, discovered that the poor people in rural Italy lived longer than wealthy Americans. He studied the dietary habits of 7 countries around the world. They ate copious amounts of bread (nothing spread on it), pasta, tomato sauce, vegetables sprinkled with olive oil, beans. They would have occasional meat and fish, and a sprinkling of Parmesan at most. It actually didn’t have that many calories from fat – only 23%, which comes out to about 460 calories a day, or 50g a day – which is a little more than 3 tablespoons of olive oil for the whole day. So unfortunately you can’t just pick and choose your favorite parts of the diet – for most this is the olive oil and wine – the rest is also important, and what’s not in it is just as important.
- All patients had a RF for CV disease: DM, or 3 of the following: smoking, bad lipid profile, obesity, strong FHx.
- Here is the result. There was a relative risk reduction of approximately 30% from the control group for the CV endpoint, which is pretty good. Statistically significant. But…
- But on total mortality, things didn’t really change that much. The benefit was about 4%, and it wasn’t even statistically significant. It’s a trend in the right direction. However, the same group of researchers dove deeper and looked at a subgroups of those who ate the closest to a vegetarian diet. They called this the provegetarian analysis. ..
- This is what they found. They divided the participants into quintiles, based on how vegetarian a diet the participants had, taking into account food quality. They found the quintile that followed a vegetarian diet the closest had the lowest mortality – by a pretty good margin – the hazard ratio was close to 0.6. Imagine a medication that decreased mortality by 40% over 6 years for primary prevention in a higher risk age group – that would be pretty powerful. If this were a medication – it would decrease total mortality from 10% to 6%, that is a NNT of 25. To put it in perspective, the NNT for PCSK9 inhibitor, also used for primary prevention in higher risk groups, is about 167. The number needed to screen for colon cancer to reduce mortality is about 240.
- The REGARDS group followed people who adhered to 5 different dietary patterns – plant based, southern, fast food, sweets, and alcohol+salads, in 16K people with no existing heart disease. The plant-based diet had a 41% lower chance of heart failure over 9 years. And, probably to no one’s surprise, the southern diet had a 72% higher chance. There is a JAMA IM article from 2016 that looks at the Nurses Health Study cohort and the Health Professionals Study Followup, total of 131K people. They looked at animal and plant protein intake and looked at all cause mortality. Higher plant protein intake was assoc with lower all cause and CV mortality, and higher animal protein intake was assoc with higher CV mortality, and there was a nonsignificant trend towards higher all cause mortality. Most of this seemed to come from processed red meat, moreso than white meat or fish. Again we can think of it in terms of a medication – that would lower their risk of developing heart failure by 41% - with no side effects! There are quite a few other large cohort studies, which I did not include here, which show a modest trend favoring plant protein intake over processed meat, particularly red meat intake, in regards to all cause and CV mortality, sometimes cancer as well.
- Dan Buettner, a Nat Geo explorer and author, wrote a book about the ‘Blue Zones’ – 5 places in the world where people live the longest, places with a lot of centegenarians. He found 5: Ikaria, Greece. Okinawa, Japan. Sardinia. Loma Linda CA. Nicoya Peninsula, Costa Rica. He distilled down the diet to a few rules that they all had in common. So this leads us into – what constitutes an ideal plant based diet? And more importantly, how do we counsel patients on how to increase the amount of plant food they’re eating?
- If you have a phone handy, point it to the 4leaf survey. It’s a quick 12 question survey about how plant-based your diet is.
- This is the idealized plate / food radio, based on calories. These two come from completely different origins, but in fact are fairly similar! On the left is the EAT Lancet plate, which is the ideal diet for individual, community, population, and environmental health. On the right is the DASH diet, the dietary approach to stop hypertension. Except, there are more veggies and less grains in the EAT-Lancet plate. Still they’re both very plant-based. Now, let’s talk about planning a diet. The important thing is that it’s a shift away from the way many diets are portrayed. Like the 30/30/40 diet, I often see that foods are categorized primarily by how many macronutrients they have. I can’t tell you the number of times that patients have told me, ‘I eat too many carbs’. Carbs can be refined sugar, they can be potato chips, but they can also be from an apple, a sweet potato, or whole grain toast. It’s more productive to think of a plant-based diet in terms of the actual foods eaten. This also alleviates patients from having to calorie count – a pretty hard thing to do.
- Carbs – naturally not really an issue on vegetarian diets. The exact need for Omega-3 hasn’t been established, but it is essential as the body can’t make ALA from other fatty acids. However, once you have ALA, it can make its own EPA and DHA. It’s rare for this to be an issue on an individual level, but it’s not a bad idea to counsel on ensuring adequate omega 3 intake by adding some walnuts, maybe ground flax seeds (whole flax seeds tend to pass through your system fairly intact, you can try it yourself if you are curious). Flax is pretty cheap as a ground meal. Also, flax with water makes an excellent egg substitute in baking!
- The Adventist Health Study is another huge cohort – 82K people. This particular study found that, even adjusting for fruit and veg intake, BMI, smoking, and all sorts of other factors, those who ate the highest amount of proteins from meat had a 61% higher rate of CV mortality than average, and those who ate the most protein from nuts and seeds had a 40% LOWER CV mortality than average. The WHO provides a table of protein quality scores, scored 0-100. Most animal sourced proteins, such as meat and eggs, are 95-96. Interestingly, plant sources range from 78 (beans) to 94 (peanuts), and most wheat is in the upper 80s-90s. Technically, the 0.83g/kg/day refers to a perfect protein source, so if you are at an average of a score of 80-90, you might need to up your intake by 10-15% or so. For a 2000 calorie diet, it ends up being about 50-60g a day on the lower end to 90-100g a day on the higher end. As an aside, excluding severe eating disorders, I have yet to see a protein calorie malnutrition from someone who is vegan or vegetarian.
- Regarding Iron – it’s actually far more rare than board questions would suggest to have an iron deficiency from being vegan or vegetarian. Plant foods have non heme iron, which can be less bioavailable than in animal foods, so the recommendations for vegetarians are a bit higher. The daily need varies, but most people can upregulate their absorption based on their intake. It doesn’t generally hurt to check serum levels and evaluate based on that. Vegetarians have on average normal iron stores, though a bit lower, than non veg. And in the general population, iron deficiency has a similar incidence among veg and non veg. I do see some patients who are vegetarian or vegan. In my experience, I have seen iron deficiency far more commonly in the situation of excess dairy milk intake, particularly in children, and in young women who are not vegetarian, who eat a diet high in fast foods and fried foods, even with normal menses. I don’t have an explanation for that. Zinc – you can get about 10% of your RDA from most servings of beans, nuts, oatmeal. Zinc deficiency is rare in the modern world. If you want, you can take a multivitamin with 50-100% daily zinc and you will be covered. A WHO review found that regions with lower intake of dairy foods and calcium actually have LOWER fx rates than regions with higher intakes. WHO recommends 500mg/day, UK 700mg/day (US is 1200 mg/day). The 1200mg/day comes from a few 3 week studies in the 1970s that showed a higher intake of calcium could help postmenopausal women with calcium balance…. In fact, Ca and Vitamin D are actually no longer recommended to prevent hip fractures, and there was a slight increase in heart attacks and kidney stones in women who took calcium supplements. However, the recommendation never changed. A glass of dairy milk, a serving of cheese has about 200-300mg calcium. And most fortified plant milks have about the same. Basically a well balanced plant based diet takes care of all calcium needs. B12 – found only in microorganisms, which are much higher in number in animal based foods. Vegetarians may need to supplement, vegans definitely do. Again, in my own practice, the vast majority of patients with B12 deficiency are taking a PPI, metformin, are elderly, or have had gastric bypass or some other major surgery. But take the supplement – it’s cheap.
- The ADA’s position is that a well planned vegetarian diet, including vegan diet is appropriate through the life cycle. There are always people who say that they tried it and it made them fatigued, no energy, craved meat, etc. I don’t ever discount someone’s own experience with it. My personal feeling, somewhat well-informed but not backed on any research, is that it might have something to do with the microbiome and how they process foods. In some studies, it can take 4-6 weeks, maybe longer, for gut microbiomes to start changing based on dietary input. So, it might be something someone has to stick with for a while. Pregnancy – can be safe, of course caloric needs increase, but make sure some of the increased caloric needs are met with more protein rich foods such as beans and whole grains and such. Prenatal vitamin takes care of micronutrients. Lactation is similar. Gestational diabetes can make things a bit harder to plan, but it’s still very possible – my wife did it twice. Lots of tofu lettuce wraps which I grew to like quite a bit actually. Infancy – breastmilk or formula. Soy formulas are equally acceptable as dairy formulas for nutrition purposes. Childhood –of course, we counsel parents to offer plenty of fruits and vegetables to kids. Whole grains, including oatmeal, brown rice, whole grain bread, tortillas, pastas, and such can be a healthy base for their diet. Add in different beans, legumes, or tofu. 2 glasses of fortified non dairy milk – soy, oat, flax, almond, rice, coconut – can be substituted for dairy. Almondilk and rice milk tend to be pretty high in added sugar so I generally don’t recommend it. Soy, flax, and sometimes oat milks have higher amounts of protein than the others. For those who have concerns about soy beans – there was a study called the Shanghai Women’s Health Study. Consumption of soy foods during childhood and early adult life was associated with a LOWER risk of premenopausal breast cancer. This includes about 25g soybeans a day. No added risk of cancer, menopause, estrogen toxicity, or whatever the internet spews out at you. You might have heard of ‘bro science’ – this is an example of that.
- Speaking of life cycle, since we’re talking about family, I am obliged to show photos of my children. They are in fact wearing ‘Vegan walt Disney world’ shirts.
- You might have heard about some athletes dabbling in plant-based diets. Here are a few examples. An NPR reporter stayed with some of the Kenyan athletes training for the marathon in Kenya (the best marathoners in the world). They ate ugali, a cornmeal paste, flatbread similar to Indian flatbread, kale and cabbage, beans, corn on the cob, fruit, some eggs. Meat occasionally – once a week, more or less. So, similar to Mediterranean actually. On our side of the ocean, Tom Brady has an entire side hustle selling his lifestyle brand in the form of shakes, electrolyte mixes, magnetic recovery pajamas, etc. But his website details his diet – a lot of fruits and vegetables, nut butters and plant protein, and some meat twice a day (no more than 20% of his meal). It’s actually pretty easy to follow for free. Similar to Mediterranean, with a bit more meat. Arian Foster was a prominent NFL RB a few years ago. He was vegan, now has some occasional white meat, similar to Tom Brady’s TB12 routine. Athletes who follow the diet tout some additional anti inflammatory benefits, none of which I can verify. But Tom Brady does seem to defy a lot of the age-related problems that plague his fellow football players. Some other athletes who compete in high impact high injury risk eat a mostly plant based diet as well as they feel it gives them a competitive edge such as Nate Diaz.
- Keto is all the rage. It’s basically the atkins diet, or maybe south beach, just repackaged a bit. It’s newer, so there are no long term studies on it for the general population. However, there are plenty of studies on its predecessor, the Atkins diet. There was a 2003 NEJM RCT that compared 63 obese men and women, half on Atkins, half on conventional low fat. At 3 and 6 months, Atkins lost more weight… but at 12 months, as with many fad weight loss studies, they gained it back and there was no difference. Similar study was in Ann of Internal Medicine, were weight loss was about 5-8kg. There was a high dropout rate in both, about 30-50%. The more important aspect, to me, is that it is a band-aid solution, not a long term one. It is EXTREMELY hard to do long term keto. If a patient can follow this diet, and lose weight for a while, great – but the lack of sustainability is the biggest downside, not to mention the potential issues with the massive intake of cholesterol, saturated fat, and animal proteins. The longest-lived people in the world eat a large amount of fruit every day. Excluding those with type 1 diabetes, I do not trust any diet that tells someone that you can’t eat more than 1 apple a day. Now there are people who do just fine on these high fat low carb diets. It is, without a doubt, the traditional diet of many people in cold and mountainous regions. However, they also live in … cold and mountainous regions, which entails a hard life, requiring much manual labor and physical activity. They’re not GrubHubbing keto pizza with a cauliflower crust and calling it a day. There may also be genetic and microbiome related factors involved that may not apply to other populations. Also, they’re not living as long as the other populations. In terms of weight loss, I won’t go into great detail but usually the first target is sodas and juices, everyone agrees on that. I next target snacks and dessert. I don’t ever have patients limit fruit and non-starchy vegetables – in fact Weight Watchers calls them zero point foods meaning they don’t count against your daily food total. Patients are often worried about the sugar in fruit, but I challenge them to look at it differently – to try to get full on fruit for snacks and dessert. Does anyone think it’s possible to gain weight eating too much fruit? A medium apple plus a banana is about 200-250 calories, but will keep you pretty full for a while and should make for a very nice snack. Even a large apple and banana might add up to 300 calories – that is large bag of chips, or 6 oreos.
- We’ll now shift gears to the EAT-Lancet commission. EAT-Lancet – is a huge commission made of a bunch of international experts in food, nutrition, environmental policy, and the like. Lancet dedicated 2019 as the year of nutrition, so it was prominently featured in the Lancet this year. Here are some of the many findings.
- I’ll summarize it by first outlining the scope of the problem as they see it. Food production and consumption is the congruence of a lot of factors affecting the health of the world. 820 million people… so changing the world’s diets can be a very influential thing.
- I’m not going to go a great deal into the hazards of climate change on human health. Suffice it to say, it is already affecting nearly every facet of the world economy and subsequently health status of all people, and the effect will only get larger and worse and more deadly in the forms of disease, starvation, and war. This slide is specific to air pollution, a surprising amount (to most people) from livestock. This is from the notoriously liberally biased organization the United Nations. They had a report in 2006 called Livestock’s long Shadow. Here are some of their findings.
- This slide pertains to water and land. I won’t get into Amazon deforestation because it is extensive and basically entirely driven by the need for land to graze livestock.
- The low residue diet recommendation is sometimes encountered when treating complicated GI disorders, including IBD and colon cancer. All it means is low fiber. Many plant based foods actually are low in fiber – not that they’re healthy in particular, but you can still do it with baked goods, starchy vegetables (like potatoes without skin), tofu, other mock meats. So those with celiac disease can follow plant-based, just with some planning. The universal meal is another way to think about what you can eat as opposed to what you can’t, when dealing with food allergies or intolerances. It starts with vegetables and non gluten grains, and builds on that.
- Breakfast is pretty easy – oatmeal, whole grain toast or cereal, a smoothie and you are good. Lunch can be sandwiches or wraps, of course salads, just don’t drown it in dressing. Dinner can be any kind of pasta with vegetables and beans, any kind of soup or stew, including chili, a casserole whether it’s savory, Italian, Mexican, fajitas, any kind of noodle bowl, and of course any kind of curry over rice or flatbread. Snacks – fruit, raw veggies, and nuts, with some dried fruit is great. You can google and find probably millions of recipes, and of course what you make will never look like the picture but that’s OK. If you want to know specific cookbook recommendations talk to me afterwards – I don’t want to promote anything in particular here.
- Codes 99401-2 are an add-on for a problem visit, not a physical and insurance coverage varies. This is only for private insurance and not for medicare/Medicaid. You have to use a Z code to bill properly such as Z71.3. You can add this to someone who is obese, or has CAD, or diabetes, and counsel them to eat more plant-based foods. It’s a win-win for everyone. Medicare code is G0447 (face to face counseling for obesity, 15 minutes) for those with BMI > 30 can be done every week for 1 month, and every other week for the next 5 months. That’s 14x they will cover it in 6 months. Then they will cover monthly for months 7-12 if beneficiary meets requirement of 6.6 lb. Not bad for an add on service.