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Nutrition in the New Year: What is Our Role as Cardiologists?

As we embark on this new year, we are bound to field questions from our patients (and likely, family members) centered around the most popular new year’s resolution: Eating healthier. Reflecting upon my own answers to these questions in clinic over the years, I realize they have been some combination of:

“Eat smaller portions.” “Eat less meat.” “Cut out soda or juice.” “Don’t eat for 3 hours before going to bed.” “Have you heard of the Mediterranean diet?”

And the basis for my recommendations? While I’m sure my years of medical training were factored in somewhere, I feel like these suggestions were largely based on a combination of my own experiences with managing my nutrition, anecdotes from colleagues and friends, and quite possibly my favorite podcasts.

Upon further reflection, though, this is not all too surprising. For all the years that we spend in medical school, residency, and fellowship learning about pathophysiology and pharmacology, we receive much less structured education on nutrition.1 In four years of medical school, one study estimates that the average medical student receives approximately only 19 hours of didactic lectures in total on nutrition, with most of this education focusing on the manifestations of nutritional deficiencies (thiamine, vitamin C, etc.).2 If your recollection is like mine though, 19 hours seems like an overestimation, and it only declines in post-graduate medical training. In a recent study published in the American Journal of Medicine, 31% of cardiologists reported receiving no nutrition education in medical school, 59% reported none during residency, and 90% reported receiving no or minimal nutrition education during fellowship.3

Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

Figure 1: Nutrition Education from Medical School to Fellowship. (From Devries et al.3)

“But we are cardiologists, not nutritionists,” one might say. Yet in the same study, 95% of cardiologists believed that their role is to provide their patients at least basic nutrition information (68.6% believed they should personally provide detailed nutrition information to patients).3 While many of our cardiovascular care teams include dieticians specifically trained to counsel our patients on their nutrition habits, we as cardiologists often find ourselves directly answering these questions from our patients.

Indeed, some physicians have made names for themselves by proselytizing specific diets for their patients. Yet what I find a bit unsettling is the variability of the messages we deliver to our patients when it comes to nutrition. While the AHA provides dietary recommendations we can share with our patients, new diets continue to pop up and gain traction in the headlines, inevitably leading to questions from our patients about whether it is safe for them to adhere to these diets. Notably, (1) intermittent fasting, (2) plant-based or vegan, and (3) ketogenic or “keto” appear to be the diets du jour.

While I personally have experimented with intermittent fasting and a plant-based diet, I am a bit uncomfortable fully endorsing one or the other to my patients, each with his or her own metabolic profile and potential list of glucose-lowering medications. When it comes to diet, more than anything, individualization is key. More so than exercise and medications, diet has deeper roots in the cultural, financial and societal environments in which our patients live. Helping them navigate a healthy lifestyle through these obstacles requires not only more time in clinic but also a deeper, more evidence-based foundation in cardiovascular nutrition.

Fortunately, we are entering an era in which we are gathering more evidence in nutrition science. A recent study published earlier this month in Cell Metabolism studied “time-restricted eating” (AKA intermittent fasting with a 10-hour eating window) in patients with metabolic syndrome,4 finding that it had beneficial effects on weight loss and metabolic profile in its albeit small sample size. (Figure 2) Additionally, a New England Journal of Medicine review article published over the holidays highlighted the existing evidence we have, both in animals and in humans, of intermittent fasting on health, longevity, and various disease states (including cardiovascular disease and cancer).5 Importantly, these recent publications and the responses they have elicited in the news and on social media have called attention to the need for more dedicated studies to address the safety and efficacy of specific diets and dietary patterns in our patients with metabolic and/or cardiovascular diseases. Indeed, more clinical trials are underway: a quick search on ClinicalTrials.gov shows that 24 registered clinical trials with an “intermittent fasting” intervention are actively recruiting participants, including the LIFE AS IF trial from the University of Chicago.

Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

Figure 2: Graphical Abstract from Wilkinson et al study on Time-Restricted Eating in Metabolic Syndrome.4

In a prior blog post on “Wearables in Medicine,” I recommended that we consider trialing wearable devices ourselves before counseling patients based on data obtained from them. While I do think our own experiences with diets and dietary patterns may be informative, our personal experiences should not be the sole pillar upon which we base our nutritional recommendations to our patients. Again, individualization is key, and a nuanced approach, factoring in living environments, medications, and metabolic profiles, is necessary.

So what should we do as members of cardiovascular care teams? Well, to provide basic nutrition recommendations to our patients, we can use the AHA Diet & Lifestyle Recommendations. However, we must acknowledge our own limitations regarding the lack of formal training on nutrition during our medical education. As such, my resolution this year is to further my education on nutritional science and attempt to understand how these popular diets may fit within modern cardiovascular disease management. To achieve these goals, I will:

  • Read: Some books recommended by my attendings that I plan to read include The Obesity Code by Jason Fung, MD and The Plant Paradox by Steven Gundry, MD. Additionally, for those interested in learning more about the role of a “keto” diet in cardiology, the ACC.org Sports and Exercise Cardiology section recently published a series of high-yield, informative articles (Link 1 and Link 2).
  • Collaborate: We have a dietician in our cardiovascular care team with whom I regrettably had not spoken directly with until recently. I previously had just referred patients to her, but I did not necessarily know exactly what advice she was giving to our shared patients. Opening and maintaining this channel of communication is essential to delivering a consistent message from our team.
  • Ask: I am now making it a habit to include a simple question in my clinic encounters: “How’s your diet?” I have found the open-endedness of the question to be quite enlightening, often helping me to uncover a new aspect of the world my patient lives in and their own perspective on how their nutrition impacts their health.

I would love to hear your input on this topic. What do you feel our roles are in nutrition counseling for our patients? What are reliable resources to learn more about this topic? How can we be better at delivering appropriate nutrition information to our patients? Please reach out to me on Twitter (@JeffHsuMD) with your thoughts and ideas.

References:

  1. Devries S, Willett W, Bonow RO. Nutrition Education in Medical School, Residency Training, and Practice. JAMA. 2019;321:1351–1352.
  2. Adams KM, Butsch WS, Kohlmeier M. The State of Nutrition Education at US Medical Schools. Journal of Biomedical Education. 2015;2015:357627.
  3. Devries S, Agatston A, Aggarwal M, Aspry KE, Esselstyn CB, Kris-Etherton P, Miller M, O’Keefe JH, Ros E, Rzeszut AK, White BA, Williams KA, Freeman AM. A Deficiency of Nutrition Education and Practice in Cardiology. Am J Med. 2017;130:1298–1305.
  4. Wilkinson MJ, Manoogian ENC, Zadourian A, Lo H, Fakhouri S, Shoghi A, Wang X, Fleischer JG, Navlakha S, Panda S, Taub PR. Ten-Hour Time-Restricted Eating Reduces Weight, Blood Pressure, and Atherogenic Lipids in Patients with Metabolic Syndrome. Cell Metab. 2020;31:92-104.e5.
  5. de Cabo R, Mattson MP. Effects of Intermittent Fasting on Health, Aging, and Disease. N Engl J Med. 2019;381:2541–2551.

The views, opinions and positions expressed within this blog are those of the author(s) alone and do not represent those of the American Heart Association. The accuracy, completeness and validity of any statements made within this article are not guaranteed. We accept no liability for any errors, omissions or representations. The copyright of this content belongs to the author and any liability with regards to infringement of intellectual property rights remains with them. The Early Career Voice blog is not intended to provide medical advice or treatment. Only your healthcare provider can provide that. The American Heart Association recommends that you consult your healthcare provider regarding your personal health matters. If you think you are having a heart attack, stroke or another emergency, please call 911 immediately.

 

 

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A New Year, A New Story: Tips for a Healthy Lifestyle in 2019

A new year presents a new opportunity for improvement. Each year, thousands of advertisements beckon us to join or buy the most recent fitness and wellness craze – wearable technologies, personal coaching, pea protein and oat milk. However, if trends are not your thing, you may find it reassuring that “traditional” fitness and wellness strategies (e.g., training for a 5K walk/run, taking the stairs instead of the elevator, and reducing your sugar intake) can also be re-imagined and integrated into your daily routine leading to a healthier, and likely happier you.

Perhaps contrary to the many images trying to sell wellness products, adopting fitness and wellness strategies are equally if not more important for those who are living with a chronic disease. In November 2018 at the American Heart Association Scientific Sessions, the Physical Activity Guidelines were updated and, for the first time, specified that physical activity can help to manage chronic conditions including decreasing pain, reducing the rate of progression for high blood pressure and diabetes, reducing anxiety and depression, and improving cognition in those with chronic comorbidities. These critical health outcomes symptoms are particularly important for adults living with HIV, who tend to experience worse symptoms than many living with other chronic illnesses – and consequently, they may stand to benefit the most from increased and improved physical activity.

Figure 1 Photo by Christine Schmitt via flickr (http://bit.ly/2LZufoz)

However, in addition to physical activity, nutritional intake is a critical part of improving health and wellness among adults living with HIV. A recent practice paper of the Academy of Nutrition and Dietetics found that nutritional status affects the overall health and longevity of this population. They suggest that improved diet can lead to reduced blood pressure, obesity, and diabetes, which will result in improved cardiovascular health. Lead author of the report, Amanda Willig, RD, PhD, from the University of Alabama at Birmingham, suggests that when anyone (especially someone with a chronic disease such as HIV) is starting to adopt a new diet to “Remember, the enemy of good is perfect. A perfect diet is not needed to see big changes in your health.”

So what are the good diet changes needed to improve health? Regardless of one’s HIV status, Dr. Willig’s recommendations on healthier eating are the same: “Watch your portion sizes, try to eat vegetables every day / fill ½ of your plate with vegetables at meals, limit the amount of sugar in your diet, and choose water over sugar sweetened beverages like soda, sports drinks or sweet tea.”

However, for those with HIV, there are some special considerations. While the evidence is still emerging, Dr. Willig indicated that those with HIV may need more Vitamin D than they did prior to their HIV infection for their overall health.  And if one’s CD4+ T-cell count is less than 250, they may want to avoid eating raw or undercooked meat and seafood, as they be at higher risk for food poisoning. Additionally, for the growing number of people living with HIV who are over 50, they may need to increase their protein intake from 0.8 grams per kg per day to 1.2 grams per kg per day. This will help with maintaining muscle mass and preventing bone loss.

Yet whether you are decreasing your portion size or increasing your daily protein intake, changing behavior can be hard and as we age, it can seem complicated and sometimes discouraging. In addition to seeking help from registered dietitian or a Physician Nutrition Specialist who can help you decide which lifestyle nutrition plan is best suited to you, Dr. Willig also suggested several tips for adopting a healthy diet in 2019 (see insert).

 

Dr. Willig’s Tips for Adopting a Healthy Diet in 2019

  • Keep a food diary for 3-4 days to learn not just what you are eating but why.
  • Start with the small steps that can produce big changes, such as cutting out sugary drinks or not eating during the night.
  • Regardless of the nutrition plan, portion sizes still matter. One can eat too many of the “right” foods, so learn what a portion of the foods you eat actually looks like.
  • Make sure your nutrition plan fits your lifestyle. If you want to cook, you can to experiment with baking and sautéing instead of frying foods. If you travel often, learn to read nutrition labels and restaurant nutrition information to avoid eating too many calories.

 

Additional strategies can be found on the American Heart Association’s Healthy Living Website.

As you start to navigate how to start the year committed to becoming healthier you, there will undoubtedly be challenges – busy schedules, competing demands, mood, weather and so on. But you can overcome them and take small steps to become a healthier you in 2019. As you start this journey, consider the words of writer Alex Morritt, “New year — a new chapter, new verse, or just the same old story? Ultimately we write it. The choice is ours.” The new year has just begun, and regardless of your age, sex, health status, or neighborhood in 2019 you get to write your own story – one in which you relentlessly pursue a healthier you.

 

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Improving Vascular Health: Nutritional Coaching

There has been an ongoing misconception of weight being a consequence of over-nutrition. The relationship between calorie intake versus calories spent continues to overshadow the biological forces that resist the maintenance of weight. Although scientists started to recognize obesity as a chronic disease in 1985, it was about 28 years later before the American Medical Association made the acknowledgement. The recognition of obesity being classified in the cluster of metabolic syndrome (MS) was a significant milestone in weight loss and primary health care.

Metabolic syndrome (MS) is defined as a homeostatic disturbance in the metabolic system characterized by visceral obesity, atherogenic dyslipidemia, hypertension, insulin resistance, and more recently, adipose tissue dysfunction. Increasing studies are exploring adipose tissue (AT) as an endocrine organ system encompassing physiological functions that assist in the regulation of weight, insulin sensitivity, inflammation, and vascular function. Matthews et al (opens in a new window) described the role of macrophages in the inflammatory response. Additionally, Dias et al (opens in a new window) expounded on the various inflammatory cytokines in AT that can potentially be modulated suggesting an anti-inflammatory role for statins. These reports have demonstrated a reduction in stress-induced inflammatory cytokines such as IL-6 and C-reactive protein as well as the upregulation of PPARγ, inhibition in ER stress, PA1 promoter activity through MAPKKK1 and to a lesser extent NFκB with the therapeutic use of statin drugs. There are conflicting data on the utilization of statins; however, their potential to induce the expression of PPAR and SRB1 in adipocytes can directly and inadvertently lower cholesterol and SRB1 stimulation. Generally, obesity has been controlled using pharmaceutical supplements; some examples include: Topiramate, Diethylpropion, Phentermine, and Lorcaserin. Among the medicinal weight therapies, Orlistat plays a direct role in digestion by inhibiting the absorption of dietary fat and subsequently body weight reduction. Orlistat inhibits diacylglycerol lipase (DAGL), the enzyme that catalyzes the hydrolysis of diacylglycerol leading to the liberation of free fatty acids and monoacylglycerol. This information is noteworthy due to the mechanistic pathways delineated in an article by Matthews and Lee (opens in a new window) (Figure) suggesting an important connection between the endocannabinoid ligand 2-arachidonylglycerol (2-AG) and oxidized low density lipoproteins (oxLDLs). This group and others have demonstrated DAGL and PLC-β are Ca2+ dependent enzymes that are important in the biosynthesis of 2-AG. However, during my time in Dr. Matthew Ross’s lab we found oxyradical fluxes and 2-AG generation had a positive correlation that lead to an antioxidant and anti-inflammatory effect associated with the 2-AG ligand. Thus, Orlistat combined with a low-calorie diet can have a synergetic effect of inhibiting fat absorption, reducing leptin concentration in plasma, CRP, IL-6 TNFα and inducing vascular protection.

In relation to food and nutrition, there are several articles that are related to the mechanistic action of the gut in relation to blood pressure including the role of gut microflora, oxidative stress, and lipid pathways that lead to metabolic changes. Being that my knowledge of nutrition is limited. I interviewed Tina Brown, FNP (opens in a new window) from Elite Health for expert advice.

Improving Vascular Health: Nutritional Coaching

 

I met Tina one morning on my way to campus. As I started my long walk down the sidewalk, I saw a sign across from a restaurant saying, “Weight Loss”. I thought to myself, “There is always a weight program somewhere. I’m in Memphis after all.” Memphis is known for their food, such as the Green Beetle that became popular back in 1939, the flavorful Curry-N-Jerk Caribbean cuisine, BB King BBQ Joint, the Redbird Field food court, and anything down Beale Street. Memphians are foodies and have the whole month of May dedicated to Blues and Barbeque! So, it comes as no surprise to see a “Weight Loss” facility in Memphis. Shelley White-Means, PhD (opens in a new window), University of Tennessee Health Science Center presented on, “Disparities in Breast Cancer Mortality: A Perfect Storm in Memphis.” I would like to modify that to say, “Disparities in CVD mortality: A Perfect Storm in Memphis” due to the culture and prevalence of food, as well as the activities surrounded by an abundance of great barbeque.

I spoke with Tina via phone in addition to a face-to-face interview. To give some background as to why nutrition is an important second step in one’s health journey, it is important to understand that one in three Americans are diagnosed with a metabolic dysfunction consistent with cardiovascular disease, such as hypertension, diabetes, renal dysfunction, or obesity.

The interview went as follows:

Q1. What are your qualifications?

A. I attended Nursing school at University of Memphis (@UofM) as an adult learner receiving a Bachelor of Science in Nursing. After working for several years as a nurse, first doing rotations and finally settling in the medical surgical unit I returned to UofM to specialize.

Q2. Are you aware of any nutritional requirements for a patient that has cardiovascular disease namely, hypertension?

A. I was watching an infomercial about L-Arginine and how it helps with cleaning the vascular system and vasodilation. After watching for several minutes, I realized it was an infomercial, but it was good information and research. I don’t recall the author.

Note: Upon looking for the information, I was not able to find the exact infomercial that Tina was referring; however, I did find information on L-arginine’s effect on the vascular system. Arginine is the precursor for nitric oxide (NO) in endothelial nitric oxide (eNOS), since eNOS is necessary for gas exchange and the regulation of various biological functions it is reasonable that L-arginine can play a role in maintaining vascular homeostasis. Allerton et al (opens in a new window) (Figure) compared in a review the use of L-arginine with citrulline supplementation to determine whether there were any significant changes in cardiometabolic health. Patients with elevated blood pressure has been reported to display labs with reduced NO bioavailability and subsequent vasoconstriction. Incorporating L-arginine (and l-citrulline) into the diet can potentially indirectly or directly increase vasodilation by increasing eNOS expression and NO production thereby its bioavailability leading to reduced blood pressure.

Q3. What advice will you give a patient regarding these diagnoses?

A. Eating a low carbohydrate diet. Choosing the good carbs such as eliminating white bread and sugars.

Note: In a randomized clinical trial, Dr. Christopher Gardner et al (opens in a new window). evaluated the effects of low-fat (HLF) versus low-carbohydrate (HLC) healthy diets to determine whether there were any genotypic alterations in regard to weight loss that were effected by either of the dietary patterns. The HLF or HLC diets had no statistical significant in weight loss by genotype, insulin interactions. These data and others suggest that eating a low carb diet can be beneficial in weight loss, but in addition to other healthy lifestyle changes. Especially in light of statin therapy assist in reduction in fat absorption.

B. Combining the ketogenic diet (high protein, high fat) and paleo (organic) diets together can work as a sustainable diet that will allow one to get all the nutrients the body need to work properly. The keto diet done alone is not as healthy:

  • Ketogenic diet is a plan that consist of minimizing carbohydrate intake while maximizing fats to force the body to use fat as its form of energy for expenditure. Generally, this mechanism translates to calories being consumed from 60-75% fat, 15-30% protein, and 5-10% carbohydrates. On average it takes about 2-7 days for the body to go into ketosis on this meal plan.
  • Paleolithic times was a period when certain food stuffers were not available, thus the paleo diet is a nutritional approach that is focused on eating unprocessed foods based on those guidelines. The primary backbone of it is to only consume food that would have been available before the industrial agriculture, domestication of animals, and modern food processing.

Note: There is a vast amount of research indicating that branched chain amino acids (BCAA) are linked to diabetes, and this is showing an increasing trend over the past decade. In an Editorial in the Journal of Diabetes (opens in a new window), Bloomgarden described a Young Finn’s Study suggesting phenylalanine and tyrosine, aromatic amino acids are linked to insulin resistance in men and obesity my track more strongly in the presence of BCAA. In addition to BCAA leading to increased risk of MS: obesity CVD, dyslipidemia, and hypertension; medium-and long-chain acylcarnitine’s, the metabolic byproducts of mitochondrial catabolism of BCAA, plays a role in insulin resistance.

C. Know that vitamins are being taken and do not just listen to what you are hearing. If you are healthy, you will lose weight as a side effect if weight loss is necessary. Making lifestyle changes that will result in small gains will generate the momentum needed to be successful in moving forward in sustaining the lifestyle. Once a person sees results, compliance becomes easy.

Note: Dalia Gaddis, PhD and Wei Ling Lau, MD also gave some insightful information in their blogs on these topics such as: “Weight Loss and Exercise: A Remedy For A Better Functioning HDL”, “Can Increasing HDL Reduce Heart Disease? An Issue of Constant Debate!”, “Natural Supplements Can Be A Pain in The Kidneys” and “If you give a patient calcium…” respectively.

D. Increasing physical activity is important. One must get the heart rate up and maintain the increased heart rate for short intervals (Note: it is recommended to get heart rate up for ~30 minutes 3 days per week). Doing simple things make a big difference such as standing up and moving around. Incorporate things that will make the muscles work rather than just sitting or standing stationary. For example, there are now the balance boards to stand on at the standing desk, or a body ball to sit on at a sitting desk.

Note: “Therapeutic elevation of HDL-Cholesterol to prevent atherosclerosis and coronary heart disease” Pharmacology and Therapeutics 2006 (opens in a new window); 111(3):893-908. The study delineated that HDLs play a role in cholesterol transport. However, Ross et al (opens in a new window) suggested only free cholesterol is effluxed from macrophages via ABCA1 transporters. It has also been reported that macrophage cholesterol exchange can be modulated by toxins in the body by down regulation of CD36 and SR-A protein expression.

Q4. How will you advise a patient suffering with CVD symptoms on improving their vascular health from a nutrition standpoint?

A. Get weight under control. Determine the underlying reason/condition behind the weight gain/vascular injury. Determine whether there is a metabolic disorder, rule out any hormonal deficiencies such as thyroid or testosterone, vitamin levels

B. Reduce any inflammation if necessary by potentially using a low dose pharmaceutical regimen until the patient lose weight or get hypertension under control. Especially if it is acute rather than chronic.

Q5. Any overall/general nutritional guidelines you would suggest for a patient with hypertension to consider modifying?

A. Meal preparation is the best option. By planning meals, one can look ahead at the menu and make good choices about what is being prepared. Even going to the grocery store, shopping the perimeter will generally give the healthier options.

B. Avoid eating out. When meals are prepared at home everything that goes in the meal can be a healthy option without any cheats. When eating out, one never knows whether there are cheats such as saturated fats or salts

C. Limit sodium intake

D. Have healthy snacks readily available. This will help cut cravings and avoid picking up unhealthy sugary snacks due to the feeling of needing to eat quickly. If a person has the personality that they must eat all the time, it will be hard if not impossible to change, having healthy snacks on hand such as fermented snacks (pickles or sauerkraut) or dehydrated fruit and veggies is better than forcing them to change and these snacks assist in weight loss.

Q6. How important is reporting back to the physician/counselor?

A. Very important, accountability helps with compliance. It is also a trust issue; the medical professional wants them to want to come back. The patient needs to be able to ask questions and discuss any changes in treatment. If a patient starts to lose or gain weight their medicine may need to change thus making it necessary to visit the physician/counselor regularly. It is also a good idea to have a fitness buddy to hold each other accountable.

It is important to not only visit the doctor but also to ask questions about your health. Take the challenge to be the best you that you can be.

 

Upcoming posts:
• Fitness coaching
• Mental coaching

Leave a comment or tweet @AnberithaT and @AHAMeetings if you have questions or are interested in something else specifically.

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Anberitha Matthews, PhD is a Postdoctoral Fellow at the University of Tennessee Health Science Center in Memphis TN. She is living a dream by researching vascular injury as it pertains to oxidative stress, volunteers with the Mississippi State University Alumni Association, serves as Chapter President and does consulting work with regard to scientific editing.