Nutrition Workshop James Deckert MD Kimberly Zoberi MD

Nutrition Workshop James Deckert, MD Kimberly Zoberi, MD

Station #1 § 70 yo with CAD, CHF, elevated cholesterol, and hypertension. Drinks a glass of juice with breakfast. Any potential risks for this patient with the juices displayed?

Fruit Juices § Positives: Provide a wide variety of vitamins, minerals, and other nutrients § Negatives: Lot of concentrated calories, minimal fiber Overall, eating fruit a better choice than fruit juices

Tomato Juice High level of sodium in most commercially available products Avoid in patients with hypertension

Grapefruit Juice § Metabolized by cytochrome p 450 system § Intereferes with metabolism of multiple drugs including statins, beta blockers, and calcium blockers § Avoid or minimize in patients taking any of these medications

Station #2 § Which of these products has the highest potential for mercury toxicity? Which patients are at increased risk from mercury exposure?

Mercury in Fish § § § § Clams, oysters, shrimp Salmon Tilapia Sardines Flounder Whitefish Light Tuna Albacore Tuna undetectable 0. 01 0. 02 0. 05 0. 07 0. 12 0. 35 § Shark, swordfish, tilefish, king mackeral HIGH

Mercury in Fish § EPA recommendations for pregnant women and small children: § § Avoid high mercury fish Limit fish intake to 12 ounces total per week Limit albacore tuna to 6 ounces total per week Limit intake of locally caught fish to 6 ounces per week unless known to be low in mercury § Consider smaller portions for young children

Station #3 § 50 yo male has read that alcohol is “heart healthy”. What would you tell him? Do any of the alcoholic beverages shown provide particular benefit?

Is alcohol a health food? The answer is a qualified yes.

Alcohol Effects on Lipids

Cardiovascular benefits of alcohol § 1 -2 drinks per day result in decreased risk of cardiovascular disease. § Possible mechanisms: Increased HDL, decreased platelet aggregation § Red Wine alcohol of choice

“French Paradox”

Red Wine § Appears to offer additional protection from cardiovascular disease beyond generic alcohol effect § Flavonoid content provides antithrombotic, antioxidant effects § Flavonoids are derived from red grape skin not present in other alcoholic beverages

Alcohol, the dark side § 18 + (2 -3/day) drinks per week result in increased risk of cardiovascular disease: associated with hypertension, CHF § Additional risk of inducing or sanctioning alcohol addiction

Is Alcohol a health food? § Alcohol has a narrow therapeutic window: a J-curve response § Both risks/benefits need to be discussed with the patient and § Patients chosen who are most likely to benefit and are unlikely to escalate dose

Station #4 A 30 y. o. working woman is 35 weeks pregnant. You haven’t been able to convince her to stop smoking. She wants to discuss what is the best option for feeding her baby when she goes back to work after maternity leave.

Rank the choices from best to worst

Infant feeding § Breast is best – even if she smokes. § “Regular” formula with lipids. § Soy formula – for milk allergies or lactose § § intolerance Elemental formula – only for milk allergies Low iron – do not use! Formula without lipids – do not use! Cow’s milk – do not use until one year!

Station #5 Your patient asks for advice regarding which oil is best for cooking. She wants to choose a “heart healthy” option for frying, baking or adding to sauces.

Cooking oils § Smoke point: the temperature at which an oil begins to denature, producing unpleasant and toxic compounds. § Chinese studies regarding lung cancer implicate fumes from cooking oils.

Cooking oils § Unrefined oils have a much lower smoke point than refined oils.

Smoke points § Unrefined olive oil § Butter § Canola § Corn oil § Peanut oil § Sesame oil § Refined “light” olive 320 350 400 450 450 460

Cooking methods § Boil, simmer, stew § Low heat frying § Sauté § Deep fry § Wok cooking § Sear, brown § Baking <212 320 375 450 -500 350 -450

Station # 6 Judging by the fat content, which of these snacks are: § to be eaten in moderation? § heart healthy? § a nutritional disaster?

Trans fatty acids § Raises LDL and lowers HDL (nice combination!) § Has about twice the impact on LDL: HDL ratio as saturated fats § Have been linked with plasma biomarkers of inflammation and endothelial dysfunction

Trans fatty acids § Have been linked to a higher incidence of Type II DM § Have been linked to a higher incidence of heart attacks § Harvard School of Public Health estimates that hydrogenated fat accounts for at least 30, 000 premature CAD deaths/year

Saturated fats § Raises LDL § +/- HDL § Stearic acid (cocoa butter) – not so bad

Monounsaturated fats § Decrease LDL, neutral to HDL § May be anti-thrombotic § May reduce insulin resistance

Polyunsaturated fats § Omega 6 family lowers LDL and HDL § Possible pro-inflammatory effects § Omega 3 family lowers chol and triglycerides § Strong anti-arrythmic effects § Likely anti-inflammatory effects

Station #7 Estimate the calorie content of the following items: § Starbucks Cinnamon scone § Einstein’s Plain Bagel § § ( no cream cheese) English muffin Starbucks Low fat muffin Starbucks soy latte (without whip cream) Starbucks hot chocolate (without whip cream)

Station #7 Estimate the calorie content of the following items: § Starbucks Cinnamon scone § Einstein’s Plain Bagel § § ( no cream cheese) English muffin Starbucks Low fat muffin Starbucks soy latte (without whip cream) Starbucks hot chocolate (without whip cream) 510 350 100 380 270 450

Doing the math Breakfast on the way to school/work consisting of cinnamon scone washed down with a starbucks soy latte totals: 270 + 510 = 790 calories Moderately active 50 y/o female: height 5’ 5’’ weight 130# approximate daily calorie requirement: 1650 calories Calories remaining for the day: 1650 – 790 = 860 calories

Choice of low fat, high fiber foods can substantially reduce calorie content

Size also matters: Portion Distortion § Increasing portion sizes have contributed substantially to obesity in the U. S. § Prepared foods, fast foods, restaurant portions all have dramatically increased in in size in past 20 years

BAGEL 20 Years Ago 140 calories 3 -inch diameter Today 350 calories 6 -inch diameter Calorie Difference: 210 calories

MUFFIN 20 Years Ago 210 calories 1. 5 ounces Today 500 calories 4 ounces Calorie Difference: 290 calories

SPAGHETTI AND MEATBALLS 500 calories 1 cup spaghetti with sauce and 3 small meatballs 1, 025 calories 2 cups of pasta with sauce and 3 large meatballs Calorie Difference: 525 calories

FRENCH FRIES 210 Calories 2. 4 ounces Calorie Difference: 400 Calories 610 Calories 6. 9 ounces

COFFEE 20 Years Ago Today Coffee (with whole milk and sugar) Mocha Coffee (with steamed whole milk and mocha syrup) 45 calories 8 ounces 350 calories 16 ounces Calorie Difference: 305 calories

Calories In = Calories Out If you walk 1 hour and 20 minutes, you will burn approximately 305 calories. * *Based on 130 -pound person

Station #8 What are the cardioprotective effects of chocolate? Which of the displayed bars provides most benefit? Why? What is the primary saturated fat contained in cocoa beans? Is it harmful?

Cardioprotective effects of chocolate Flavonoids present in cocoa beans are varied, well absorbed Chocolate flavonoids provide antioxidant, antiinflamatory, antithrombotic effects Also, shown in some studies to increase insulin sensitivity, lower blood pressure, and improve endothelial function

Antioxidant effect of chocolate (Oxygen radical absorption capacity)

Chocolate Details § Dark chocolate provides highest level of § § § flavonoids due to higher concentration of cocoa Minimum 70% cocoa solids used in most studies Milk chocolate, with added milk fat and sugar, probably negates most of the beneficial effects All types of chocolate are high in calories Daily intake of 1 -2 ounces used in most studies Saturated fat in cocoa is stearic acid – neutral cardiovascular effect