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Eating Patterns to Lower Cancer Risk:
More than One Route to a Plant-Based Diet
Karen Collins, MS, RDN, CDN Sharon Palmer, RDN
October 29, 2013
Learning Objectives
At the conclusion of this presentation, the participant will be able to: • Identify, compare and contrast several different
predominantly plant-based eating patterns. • Explain current research findings regarding each of
these patterns and the potential to reduce cancer risk.
• Describe practical steps for making various cancer-protective eating patterns practical and enjoyable.
• Translate lessons learned from different eating patterns to steps that can be applied to any eating pattern to enhance its healthfulness and flavor.
How to Receive CPE Credit
1. Participate in the full webinar.
2. Complete the post-webinar evaluation.
3. Receive your certificate.
Disclosures
Karen Collins, MS, RDN, CDN: Honorarium, National Berry Crops Initiative
Sharon Palmer, RDN: Consultant, Tomato Products Wellness Council, Oldways Vegetarian Network, Daisy Brand Low-Fat Cottage Cheese, Silk
Eating Patterns to Lower Cancer Risk:
More than One Route to a Plant-Based Diet
Karen Collins, MS, RDN, CDN Nutrition Advisor, AICR
KarenCollinsNutrition.com
Why eating patterns?
Carbohydrate
Fat
Protein
Vitamins
Minerals
Electrolytes
Fiber
Phytochemicals
Foods
“Good food”
“Bad food”
“Super foods” _____
Calorie Balance
Health
Important Questions
• Healthy compared to what?
• Who is in the study?
• How is the eating pattern defined?
♦ Percentiles within a specific group?
♦ Based on what standards?
Combining Strategies into
Healthy Eating Patterns
The whole can be greater than the sum of its parts
Vegetarian Diets & Health
Adventist Health Study-2 (AHS-2):
(HR compared to meat-eaters)
All-Cause Mortality Cancer Incidence
Vegetarian .88* .92**
Vegan .85 .84**
Lacto-ovo .91 .93
Pesco- .81* .88
Semi- .92 .98
*p<.05 only in total group & men; not women
**p<.05 only in men & women combined, not separately
Orlich, JAMA Int Med 2013 Tantamango-Bartley, Cancer Epid Biom Prev 2013
Vegetarian Diets & Health
Huang, Ann Nutr Metab 2012
Meta-analysis of 7 studies – 10-23 yr follow-up
Vegetarian: Vegan + L-O + Meat/fish <1/wk
Vegetarians: 18% lower Cancer Incidence
Vegetarian Diets & Specific Cancers
Adventist Health Study-2 (AHS-2):
(Vegetarian vs Non-vegetarian after BMI adjustment)
HR Cancer Diet Types
Incidence Significant
GI Tract .77* Lacto-ovo (.76*)
Respiratory tract .75 --
Urinary tract 1.21 --
Male cancer .94 --
Female cancer .97 Vegan (.71*) (breast, endometrial, ovarian, cervical, other)
*p<.05 Tantamango-Bartley, Cancer Epid Biom Prev 2013
Vegetarian Diets: Cancer-Protective Elements
• Lower average BMI • Higher dietary fiber • Higher plant foods’ phytochemicals,
vitamins, minerals • Less red and processed meat • Observational studies: Less alcohol Lacto-ovo vegetarians • Higher dairy
Very Low-Fat Vegan Diet & Prostate Cancer
*as part of multi-factor lifestyle*
After dx with early stage, non-aggressive prostate cancer
At 1 year:
• Serum PSA 4% decrease
(control group increase 6%)
• Serum on LNCaP cells ~70% decrease growth
(control group ~9% decrease)
• Change PSA & LNCaP Growth significant link
to change in lifestyle index
Ornish, J Urol 2005
Very Low-Fat Vegan Diet & Prostate Cancer
*as part of multi-factor lifestyle*
3-month study: (Ornish, PNAS 2008)
• Change Gene Expression in healthy prostate cells
♦ 48 up-regulated, 453 down-regulated
5-year study: (Ornish, Lancet Oncol 2013)
• Telomere length increase vs decrease in control group
• Telomere lengthening linked to lifestyle adherence
• Increased telomerase activity not the whole answer
Program: Diet
+ Exercise (3 hr/wk)
+ Stress Management (1 hr/day)
+ Group Support
Very Low-Fat Vegan Diet & Prostate Cancer
*as part of multi-factor lifestyle*
Ornish, J Urol 2005; Dewell, J Am Diet Assoc 2008
Very Low-Fat Vegan Diet
(Preventive Medicine Research Institute)
• Very Low Fat (11%)
• High Carbohydrate* (75%)
*avoid simple sugars; high complex CHO
• High Fiber - average 59 g/day
• Moderate Protein (20%*)
*with daily soy protein isolate drink
• Additional Supplements: vit E, Selenium, vit C,
3 gm Fish oil (900 mg n-3)
Dewell, J Am Diet Assoc 2008
Implementing Vegetarian Diets
• AHS-2 vs EPIC-Oxford:
What to eat as well as what to avoid
Vegetables, Fruits, Whole Grains
Beans (and Nuts, Seeds)
• Learning to use new protein sources
• Questions: Iron, B-12, omega-3, Vit D
• Calories matter
• Multi-behaviors & Adherence tied to benefits:
More intervention, longer follow-up
DASH Diet: Origins
Change in BP vs Control Diet (mm Hg)
Fruit & Veg DASH
Hypertensive -7.2*/-2.8* -11.4*/-5.5*
Non-Hypertensive -0.8 /-0.3 -3.5*/-2.1*
*p<.001 or .003 Appel, N Engl J Med 1997; 336:1117-1124
DASH and Colorectal Cancer Risk
High vs Low Category/Quintile DASH Diet Index
HR Colorectal Cancer Men: all 4 index scores 0.75 – 0.81* Women: 3 index scores 0.79 – 0.84* Dixon index score 1.01 *p<.05
NIH-AARP Diet and Health Study
Cross, Am J Clin Nut 2013;98(3):794
The DASH Diet • Low Fat (27%) • Low Saturated Fat (6%) • High Carbohydrate (55%) • Moderate Protein (18%) •Sodium: 2300 mg unless otherwise specified At 2000 Kcal level: • High Fiber 30 gm • High Potassium 4700 mg • High Calcium 1250 mg • High Magnesium 500 mg
At 1600-2600 Calories Daily High Vegetables & Fruit 7-12 svgs
High Grains* 6-11 svgs
Recent versions:
Whole Grains: >1/2 grains or >4-5 svgs/day
Dairy (low-fat or fat-free) 2-3 svgs
Fish, Poultry, Lean Meat up to 3-6 oz
Nuts, Seeds, Legumes 4-7 svgs/week
Low added fat 2-3 tsp oil
Limited Sweets (< 5 small/wk except at high kcal)
The DASH Diet
DASH and Colorectal Cancer Risk: A Closer Look
Significant Components of DASH Diet Index Score Multivariate HR Whole grains/High-fiber grains1 .79-.82* Low-fat Dairy (Calcium) .64-.76*(.80-88)* Red & processed meat (limiting) .82* Alcohol2 (limiting, Dixon index) .81* 1Except in women per all-or-nothing Dixon std 2Men only
Cross, Am J Clin Nut 2013;98(3):794
DASH & Cancer Risk
• Weight management: low calorie density
• May decrease oxidative stress? Variable results
• May decrease inflammation? 8-wk crossover trial in T2Diabetes: Decrease CRP: DASH diet 26.9% vs Control diet 5.1%
• May increase insulin sensitivity?? *Even after adjust for BMI, Wt loss, Kcal intake,
Activity
Azadbakht, J Nutrition 2011; Shirani, Nutrition 2013
DASH & Insulin?
ENCORE trial: DASH + Decreased Calories + Exercise vs. DASH alone
• Weight loss 19 lbs vs < 1 lb
• Decrease in Fasting Insulin
• Increase Insulin Sensitivity
Blumenthal, Hypertension 2010
DASH & OmniHeart Optimal Macronutrient Intake Trial
to Prevent Heart Disease
• DASH High-CHO
58% CHO, 15% Protein, 27% Fat
• DASH + Plant Protein
48% CHO, 25% protein:
3 svg legumes & nuts/day, 2.5 Dairy
• DASH + Unsaturated Fat
48% CHO, 37% fat, 21% MUFA, 10% PUFA
Appel, JAMA 2005
Swain, J Am Diet Assoc 2008
DASH & OmniHeart Optimal Macronutrient Intake Trial
to Prevent Heart Disease
Protein & Unsat Fat vs. CHO-DASH: • Systolic BP - greater decrease • TG – greater decrease • 10-yr CHD Risk – greater decrease
• Fasting Insulin - no significant effect • Insulin Sensitivity – increase with
Unsat Fat
Appel, JAMA 2005 Gadgil, Diabetes Care 2013
Implementing DASH
• T2 Diabetes, Metabolic Syndrome, Obese
- need calorie adjustment;
- consider CHO, protein, fat choices
• Ethnic Cultural Adaptations
local stores, cooking classes (Whitt-Glover, Prev Chronic Dis Jan 2013; DASH of Soul: Rankins, Ethn Dis. 2007)
• DASH Tracker – apps or NHLBI website form
http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/dash_brief.pdf
©2010 by American Society for Nutrition
Mediterranean Diet & Health All-Cause Mortality
Each 2-point incr. Med Diet score: 8% all-cause mortality
Sofi, Am J Clin Nutr 2010
©2010 by American Society for Nutrition
Mediterranean Diet & Health Cancer Incidence or Mortality
Sofi, Am J Clin Nutr 2010
Each 2-point incr. Med Diet score: 6% Cancer Incid / Mortality
Mediterranean Diet & Biomarkers
Consistent*
Inflammation (esp. CRP) decreased
Moderately Consistent **
Insulin & Insulin Resistance decreased
Emerging Question***
Effect on Telomere Length
* **Nordmann, Am J Med 2011; *Panagiotakos, Int J Epid 2009; **Esposito, Diab Resrch & Clin Pract 2010
*** Boccardi, Plos One 2013; García-Calzón, Int J Obesity 2013
Mediterranean Eating Pattern
• Not Low Fat (30-38%)
• Low Saturated Fat (<10%)
• Moderate Carbohydrate (39-47%)
• Moderate Protein (15-18%)
At 2000 Kcal level:
• Fiber varies 20-30 gm
• Sodium varies; may not be <2500 mg
• High Potassium 4600 mg
• Variable Calcium 1000 mg or less
• High Magnesium 500 mg
Mediterranean “Scores”
Considerations:
Compared to what other eating?
Who and where?
U.S. studies often use aMed score*:
• 1 pt each above average vegetables (not potatoes), legumes, fruits, nuts, whole grains
• 1 pt above average fish
• 1 pt below average red & processed meat
• 1 pt moderate alcohol
• 1 pt above-average ratio MUFA : Sat Fat
Range of scores: 0-9
*Fung, Amer J Clin Nutr 2005
Going Mediterranean: Olive Oil
Extra Virgin Olive Oil
♦ MUFA ♦ Polyphenols ♦ Tocopherols ♦ Squalene
• Animal studies –
Decrease mammary tumor growth
Change cell signaling pathways, gene expression
• Limited Short human interventions –
Decrease plasma oxidative stress & DNA oxidation
Change signaling pathways & gene expression
• Observational - Southern Europe, high vs lower use
? lower risk esophageal, colon, breast cancers
Machowetz, FASEB J 2007; Escrich, Pub Hlth Nutr 2011; Pelucchi, Curr Pharm Des. 2011
Going Mediterranean: Nuts
♦ MUFA, ALA (walnuts) ♦ Ellagitannins
♦ Flavonoids ♦ Gamma-Tocopherol
• Limited animal studies – Walnuts decrease growth of prostate, colon, breast tumors
• Observational (PREDIMED)-
Total nuts >3 oz/wk 40% lower cancer mortality
Walnuts >3 oz/wk 54% lower cancer mortality
Guasch-Ferré, BMC Med 2013
Mediterranean Diet & Weight
• Mediterranean vs Low-fat Diets among Overweight
♦ Not linked with wt gain; Allows wt loss ♦ May decrease waist
• % calories from fat does not produce weight loss
• Reducing calorie density for weight management:
♦ Calorie density of overall diets
♦ High vegetables makes low calorie density,
even if >35% calories from fat
Romaguera, Am J Clin Nutr 2010; Beunza, Amer J Clin Nutr 2010;
Esposito, Met Syn Rel Dis 2011; Nordmann, Am J Med 2011
Japanese Diet & Cancer
• Age-standardized international data:
♦ Stomach cancer high
♦ Breast & Prostate cancers low
♦ Low BMI & Adult weight gain minimal
• Observational studies in present-day Japan
♦ Prudent pattern: Veg, Fruit, Seafood, Soy
High vs low: 21% less colorectal cancer
♦ Healthy pattern: Veg, Fruit, Fish, Soy, Yogurt
High vs low: 13-17% lower CRP (p<.001)
GLOBOCAN 2008, IARC; Kurotani, Br J Nutr 2010; Nanri, Amer J Clin Nutr 2008
Japanese Eating Pattern • Very Low Fat (6-8%)
• Very Low Saturated fat (2%)
• High Carbohydrate (80-85%)
• Moderately Low Protein (9-15%)
At 2000 Kcal level:
• Moderate Fiber varies 20-36 gm
• Sodium may be high (esp. outside Okinawa)
Soy sauce, Pickled vegetables, Salted fish
• Potassium can be high 2600-5800 mg
• Low Calcium 300-600 mg
Eating Asian Style
• Fish and soy – re-thinking uses, learning how to prepare
• Reducing calorie density with broth soups and abundant vegetables
• Hara hachi bu
What Makes a Healthy Eating Pattern?
• Predominantly Plant-focused vs Western Diet ♦ Vegetables, Fruits, Whole Grains, Beans, Nuts, Seeds ♦ Type of Carbohydrate ♦ Limiting Red & Processed Meat ♦ Fat: Type (Amount??) • Calorie Balance for a Healthy Weight • Alcohol only in limited amounts • Long-term habit • Part of a Lifestyle: Exercise, Stress mgmt
Individual Differences Is there a BEST eating pattern?
• Genetics
♦ Insulin sensitivity
♦ Enzymes that metabolize phytochemicals
• Microbiota
• Body composition
• Physical activity
• Medical conditions & medications
• “Doability” - fit with lifestyle, preferences
Resources
• Smart Bytes® blog & website
by Karen Collins, MS, RDN, CDN
www.karencollinsnutrition.com/SmartBytes
• Vegetarian & Vegan Diet Pyramid (& materials) by Oldways
http://oldwayspt.org/resources/heritage-pyramids/vegetarian-diet-pyramid/overview
• PMRI (Dean Ornish & colleagues) research
http://www.pmri.org/about.html#research-highlights
• Dietary Approach to Stop Hypertension (DASH) http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm
More Resources
• Mediterranean Diet Pyramid (& materials) by Oldways
http://oldwayspt.org/resources/heritage-pyramids/mediterranean-pyramid/overview
• Mediterranean Diet Recipes & Shopping List from California Walnuts
http://www.walnuts.org/recipes/mediterranean-diet/
http://www.walnuts.org/walnuts/assets/File/Recipe%20Shopping%20List%20-%20CA%20Walnuts%20Mediterranean%20Diet%281%29.pdf
• Asian Diet Pyramid (& materials) by Oldways
http://oldwayspt.org/resources/heritage-pyramids/asian-diet-pyramid
More Resources From the American Institute for Cancer Research (AICR) http://aicr.org
• Recommendations for Cancer Prevention
http://www.aicr.org/reduce-your-cancer-risk/recommendations-for-cancer-prevention/index.html
• New American Plate http://www.aicr.org/new-american-plate/
• AICR’s Foods that Fight Cancer http://www.aicr.org/foods-that-fight-cancer/
• From the AICR Test Kitchen http://www.aicr.org/reduce-your-cancer-risk/diet/reduce_diet_recipes_test_kitchen.html
• Health-e-Recipes http://preventcancer.aicr.org/site/PageServer?pagename=her_current_issue
Indigenous, Traditional Diets
Common Features:
• Local whole grain
• Local legumes
• Seasonal cultivated and foraged fruits and vegetables
• Seeds and nuts
• Minimally processed
• Low use of animal foods
Image: Sharon Palmer
Plant-Based Eating Around the Globe: Peru
Image: Wikicommons, McKay Savage
• Potatoes • Quinoa • Peppers • Butter
Beans • Maize • Potato-like
tubers (oca, mashua, ulluco)
• Tomatoes • Tawri
(legume) • Fruits
Plant-Based Eating Around the Globe: Central America
• Maize • Tomatoes • Spices • Beans • Rice • Plantains • Avocados • Coconut • Squashes • Pumpkins • Mango • Bananas • Cocoa • Coffee
Image: Sharon Palmer
Plant-Based Eating Around the Globe:
India
• Millet • Lentils • Pigeon peas • Mung bean • Chickpeas • Spices • Rice • Green leafy
vegetables • Pickles • Gourds • Cucumbers • Potato • Cauliflower • Eggplant • Pepper • Mango
Image: Wikicommons, Ananth BS
Plant-Based Eating Around the Globe:
West Africa
Image: Wikicommons, Marco_Schmidt
• Chili peppers • Tomatoes • Peanuts • Corn • Cassava • Plantains • Black-eyed
Peas • Okra • Onions • Spices • Baobob fruit • Millet • Sorghum • Sesame • Eggplant • Pumpkin • Green leafy
vegetables
Mediterranean Plant-Based Patterns
• Abundance of fruits, vegetables
• Whole grains • Legumes • Nuts, seeds • Lower in
meat • Seafood • Moderate
dairy • Moderate
wine
Images: Sharon Palmer
The Flavors of the Mediterranean: Italy
Images: Sharon Palmer
• Pasta Dishes • Pesto • Risotto • Salads • Caprese • Ciaki Ciuka • Soups • Pizzas • Antipasti • Couscous • Bean dishes
The Flavors of the Mediterranean: Italy
Ingredients: • Capers • Olives • Olive oil • Citrus • Almonds • Herbs • Potatoes • Tomatoes • Pasta • Rice • Beans • Lentils • Eggplant • Greens • Grapes
Images: Sharon Palmer
The Flavors of the Mediterranean: Spain
Dishes: • Bean stew • Gazpacho • Olives,
nuts snacks
• Samfaina • Wrinkled
potatoes • Vegetable
soups • Paella • Tapas
Image: Wikicommons, Tamorian
Images: Wikicommons, Centerbuilder
Image: Sharon Palmer
The Flavors of the Mediterranean: Spain
Ingredients: • Olives • Olive oil • Fruits
(peaches, citrus, grapes)
• Beans • Potatoes • Rice • Vegetables
(eggplant, peppers, onions, garlic, tomatoes)
• Spices • Herbs
Image: Wikicommons
Image:Wikicommons, Luis Miguel Bugallo Sánchez
Image: Wikicommons, Oyvind Holmstad
Image: Wikicommons, Adam Jones, PhD
The Flavors of the Mediterranean: France
Dishes: • Salads • Socca • Ratatouille • Soupe au
pistou • Tarte aux
blettes • Vegetable
soup • Gnocchi
with chard • Pissaldiere • Fried
zucchini flowers
• Pasta dishes
Image: Sharon Palmer
Image: Wikicommons, Ian L
Image: Wikicommons, Patrice Semeria
Image: Wikicommons
The Flavors of the Mediterranean: France
Ingredients: • Vegetables
(onions, zucchini, eggplant, tomatoes, green leafy vegetables)
• Fruits (grapes, citrus, stone fruit)
• Olive oil • Herbs
(lavender, basil, rosemary)
• Chickpeas
Image: Wikicommons, Marek Gehrmann
Image: Wikicommons, fretless88
Image: Wikicommons, David Monniaux
Image: Wikicomons, Agne27
The Flavors of the Mediterranean: Greece
Dishes: • Chaniotiko
Boureki • Tiganita • Dakos • Stuffed grape
leaves • Fava • Greek Salad • Horta • Stuffed
Zucchini Flowers
• Spanakopita • Artichokes in
olive oil
Image: Wikicommons, Lemur12
Image: Wikicommons, Stu-spivack
Image: Wikicommons, Tanya Bakogiannis Image: Wikicommons, John Sullivan
The Flavors of the Mediterranean: Greece
Ingredients: • Vegetables
(artichokes, greens, peppers, eggplants, zucchini)
• Legumes (beans, peas, lentils)
• Olive oil • Herbs • Fruits
(grapes, figs, citrus)
• Wheat
Image: Wikicommons, Badseed
Image: Wikicommons, H Zell
Image: Wikicommons, Evelyn Simak
Image: Wikicommons, Lina Waters
The Flavors of the Mediterranean: Lebanon
Dishes: • Mezze • Tabbouleh • Fattoush • Hummus • Baba
Ghanoush • Stuffed
Grape Leaves
• Flat bread • Falafel • Mujaddara • Tahini
Image: Sharon Palmer
Image: Wikicommons
Image: Sharon Palmer
Image: Wikicommons, Jerem
The Flavors of the Mediterranean: Lebanon
Ingredients: • Vegetables
(tomatoes, onions, greens, cucumbers, olives)
• Spices/Herbs • Sesame seeds • Olive oil • Rice • Buckwheat • Legumes (beans,
chickpeas) • Fruits (figs,
melons, cherries)
Image: Wikicommons, Russavia
Image: Wikicommons
Image: Wikicommons, Elgarrd
The Flavors of the Mediterranean ….More: • Turkey • Morocco • Syria • Tunisia • Israel • Egypt • Croatia
Images: Sharon Palmer
The Flavors of Japan and Okinawa Dishes:
• Goya champuru
• Umi budo • Tofu • Tempura • Miso
soup • Green
leaf salads
• Rice • Noodles • Shabu
shabu • Green tea • Pickles
Images: Sharon Palmer
The Flavors of Japan and Okinawa
Ingredients: • Vegetables (cabbage, greens,
radish) • Sea Vegetables • Mushrooms • Tofu • Rice • Buckwheat • Seasonings • Fermented Foods • Seeds • Fruits (citrus, pear)
Images: Sharon Palmer
Traditional Nordic Diet Dishes: • Pea Soup • Rye breads • Jansson’s
Temptation • Open-face
Sandwich • Pancakes • Boiled
Potatoes • Beet Salad • Strawberry
Cake • Apple Cake • Whole grain
breads and crisp breads
Image: Sharon Palmer
Image: Wikicommons, Pieter Kuiper
Image: Wikicommons, Leo Johannes
Image: Wikicommons, Roger Wollstadt
Traditional Nordic Diet Ingredients: • Root
vegetables, cabbage, kale, mushrooms
• Grains (rye, wheat, oats)
• Legumes (peas, beans)
• Fruits (berries, apples, pears)
Image: Wikicommons, Sharon Palmer
Image: Wikicommons
Image: Wikicommons, David Baird
Image: Wikicommons, Anne-Sophie Ofrim
Plant-based Traditions in US
Dishes: • Black-eyed
Peas and Greens
• Beans and Rice
• Porridge • Waffles,
pancakes • Chili and
Cornbread • Stews • Lasagna • Slaws,
Salads
Images: Sharon Palmer
Tips for a Healthy Plant-Based Eating Style
Start the day right. Go veggie at breakfast.
Join the Meatless Monday bandwagon.
Shop for plants first. Instead of planning your menu around meat, plan it around plants.
Tips for a Healthy Plant-Based Eating Style
If you eat meat, use it as a seasoning. Cut down on animal food intake while pushing plants by using meat as a flavoring in dishes instead of the main event.
Create a plant-based pantry list. Many plant-based foods like beans and whole grains are shelf-stable, convenient, and economical.
Get cooking! Plan at least one night a week to try a new vegetarian recipe.
Tips for a Healthy Plant-Based Eating Style
Keep it simple. Not every meal has to involve cookbooks and cutting boards; it can be as easy as black bean burritos, vegetarian chili, or hummus pita sandwich.
Try ethnic flair. Some cultures know how to do vegetarian meals right!
Convert your favorite dishes. Turn your favorite meat-based recipes veggie for an easy dinner solution.
Tips for a Healthy Plant-Based Eating Style
Dust off your slow-cooker. Just throw in veggies, herbs, vegetable broth, canned tomatoes, whole grains, and dried beans; then turn the dial on.
Try plant-based dairy products. Try more plant-based alternatives for milk, yogurt, and cheese.
Think “yes”. Don’t dwell on what you can’t have, think about what you can have!