Plant Based Diets What’s New in 2015?

Andrew M. Freeman, MD, FACC National Jewish Health Denver, CO freemana@njhealth.org

Disclosures

No relevant disclosures to this presentation. Other disclosures: Consulting Fees – Gilead Honoraria - Medtronic

What is Plant Based

l Not potato chips and soda l Whole foods, low fat, whole grain,

plant based diet l  Limited high fat plant foods and oils

Most Vegans

l The most vegans per capita in any country is 5%

l No more milk or honey? l And 8% are vegetarian l Compared to the US vegans

of 0.5%-2% depending on the poll. 2014 Gallup http://www.gallup.com/poll/156215/consider-themselves-vegetarians.aspx

Not Really!

Getting Enough Protein?

l Yes, yes, yes. Only 30 grams per day needed (and maybe even less).

Notice

l  It is impossible to do a nutrition study purely without imprisoning people and ensuring nutritional intake.

l Many studies are observational, and do not show cause, but show significant relationships.

The Tomato Effect

TMAO: trimethylamine-n-oxide

W.H. Wilson Tang, et al. Intestinal Microbial Metabolism of Phosphatidylcholine and Cardiovascular Risk. New England Journal of Medicine. April 2013: 368:1575-1584.

•  Choline ingested through animal products

•  Gets converted by gut flora to TMAO

•  Linked to atherosclerosis, heart attack and stroke

•  Study fed just 2 hardboiled eggs to show TMAO production

•  Study then followed outcomes of 4000 patients undergoing angiograms and measured TMAO levels

High TMAO Levels = Death

W.H. Wilson Tang, et al. Intestinal Microbial Metabolism of Phosphatidylcholine and Cardiovascular Risk. New England Journal of Medicine. April 2013: 368:1575-1584.

TMAO

“We also established a correlation between high plasma levels of TMAO and an increased risk of incident major adverse cardiovascular events that is independent of traditional risk factors, even in low-risk cohorts.”

W.H. Wilson Tang, et al. Intestinal Microbial Metabolism of Phosphatidylcholine and Cardiovascular Risk. New England Journal of Medicine. April 2013: 368:1575-1584.

Another Look at TMAO

Koeth RA, et al. Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med. 2013 Apr 7.

Feed a Vegan a Steak?!

Koeth RA, et al. Intestinal microbiota metabolism of l-carnitine, a nutrient in red meat, promotes atherosclerosis. Nat Med. 2013 Apr 7.

The formation of TMAO from ingested L-carnitine is negligible in vegans

Choline Content

Average Choline Content per 100g

Eggs 251 mg Bacon 125 mg Ground Beef 82 mg Chicken 66 mg Legumes 57 mg Vegetables 15 mg Grains 13 mg Fruit 7 mg

Zeisel SH, Mar MH, Howe JC, Holden JM. Concentrations of choline-containing compounds and betaine in common foods. J Nutr. 2003 May;133(5):1302-7.

It's not just red meat…

Choline and Cancer

l  A prospective study in 1294 men with prostate cancer l  Greater consumption of eggs and poultry with skin was associated

with 2-fold increases in risk: eggs [hazard ratio (HR): 2.02; 95% CI: 1.10, 3.72; P for trend = 0.05] and poultry with skin (HR: 2.26; 95% CI: 1.36, 3.76; P for trend = 0.003).

E. L. Richman et al. Intakes of meat, fish, poultry, and eggs and risk of prostate cancer progression. Am. J. Clin. Nutr. 2010 91(3):712 - 721

l  47,896 Men in the Health Professionals Follow-Up Study. l  Diet was assessed with a validated questionnaire 6 times during 22

years of follow-up. l  Men in the highest quintile of choline intake had a 70% increased

risk of lethal prostate cancer (HR: 1.70; 95% CI: 1.18, 2.45; P-trend = 0.005).

E. L. Richman et al. Choline intake and risk of lethal prostate cancer: Incidence and survival. Am. J. Clin. Nutr. 2012 96(4):855 - 863

Perhaps Due to Choline?

JAMA Surg. Published online November 05, 2014. doi:10.1001/jamasurg.2014.1756

TMAO and CHF

l  Fasting plasma trimethylamine-N-oxide (TMAO) and all-cause mortality over a 5-year follow-up in 720 patients with stable HF

l  Higher plasma TMAO levels were associated with a 3.4-fold increased mortality risk.

l  Elevated TMAO levels remained predictive of 5-year mortality risk

Tang WHW, Wang Z, Fan Y, et al. Prognostic value of elevated levels of intestinal microbe-generated metabolite trimethylamine-N-oxide in patients with heart failure: refining the gut hypothesis. J Am Coll Cardiol 2014; 64:1908–1914.

Milk: Get it Direct!

Newer Dangers With Milk l  61,433 women and 45,339 men followed for more than 20 years and 11 years,

respectively.

l  Women with 3 or more glasses of milk per day had a 60% increased risk for developing a hip fracture and a 16% increased risk for developing any bone fracture.

l  Additionally among women, for each glass of milk consumed: l  risk of dying from all causes increased by 15% l  from heart disease by 15% l  cancer by 7%

l  For the women who consumed 3+ glasses of milk per day, compared with less than 1, risk of dying increased by 93%.

l  Men had a 10% increased risk of dying when consuming three or more glasses of milk per day, compared with less than one glass.

Michaëlsson K, Wolk A, Langenskiöld S, et al. Milk intake and risk of mortality and fractures in women and men: cohort studies. BMJ. 2014;349:g6015.

Newer Dangers With Milk l  22,788 Swedish individuals, self-described as lactose intolerant l  Followed, and standardized incidence ratios for cancer were calculated

l  3 Types of Cancer Stood Out (SIR < 1 means lower risk) l  Lung cancer (SIR=0.55) l  Breast cancer (SIR=0.79) l  Ovarian cancer (SIR=0.61)

l  Cancer incidences in the siblings and parents of individuals with lactose intolerance were similar to those in the general population.

l  Authors concluded that “decreased risks were not found in their family members, suggesting that the protective effects against these cancers may be related to their specific dietary pattern.”

Ji J. Br J Cancer. 2015 Jan 6;112(1):149-52.

Animal Protein Exposures l  Children whose mothers ate the most

animal protein during pregnancy were more likely to become overweight in adulthood, compared with children whose mothers ate the least

l  Researchers followed the offspring of 684 pregnant participants for an average of 20 years

l  Females were more than 3 times as likely to be overweight and the males more than twice as likely to be overweight when the mothers ate the most animal protein during pregnancy.

Maslova E, Rytter D, Bech BH, et al. Maternal protein intake during pregnancy and offspring overweight 20 y later. Am J Clin Nutr. 2014;100:1139-1148.

Not Quite Vegan l  PREDIMED Analysis l  Randomized trial 2003-2010 that involved men and women

(age 55–80 yr) at high risk for cardiovascular disease. l  Participants were randomly assigned to Mediterranean diet

supplemented with extra-virgin olive oil, a Mediterranean diet supplemented with nuts or advice on following a low-fat diet (the control group).

l  5801 patients analyzed l  Compared with the control group, participants on either

Mediterranean diet were more likely to revert from Met Syndrome l  control v. olive oil HR 1.35, 95% CI 1.15–1.58, p < 0.001 l  control v. nuts HR 1.28, 95% CI 1.08–1.51, p < 0.001).

l  Participants in the group receiving olive oil supplementation showed significant decreases in both central obesity and high fasting glucose (p = 0.02)

l  Participants in the group supplemented with nuts showed a significant decrease in central obesity.

è Abandonment of the beefy cheesy American Diet does wonders – now imagine if a lower fat all-plant based diet was tested!

Babio, N. et al. CMAJ (Canada) November 18, 2014 vol. 186 no. 17

5 Factors – Act Now l  20,721 men followed for 11 years. l  No smoking l  Moderate alcohol intake l  Exercised l  Low belly fat l  Consumed the most fruits, vegetables, whole grains, and legumes = 86% lower risk for a heart attack, compared with those who did not meet these criteria.

l  Not smoking = 36% reduction l  Eating healthfully = 18% reduction l  ~2% of Americans follow the American Heart Association’s recommendations for ideal heart health.

l  Authors conclude: Change in lifestyle could reduce the burden of heart disease by as much as 79%

Akesson A, Larsson SC, Discacciati A, Wolk A. Low-risk diet and lifestyle habits in the primary prevention of myocardial infarction in men: a population-based prospective cohort study. J Am Coll Cardiol. 2014;64:1299-1306.

Fiber = Life

l  A meta-analysis published in the American Journal of Epidemiology

l  Those who consumed the most fiber: 19% less likely to die l  Researchers analyzed 17 studies comprised of more than

980,000 participants and found that every 10 grams of fiber consumed cuts mortality risk by 10 percent.

l  Fiber helps regulate cholesterol levels, lower blood pressure, and control weight.

Yang Y, Zhao LG, Wu QJ, Ma X, Xiang YB. Association between dietary fiber and lower risk of all-cause mortality: A Meta-Analysis of Cohort Studies. Am J Epidemiol. 2015;181:83-91.

Low Carb No More l  Diets and mortality of more than 118,000 men and women

from both the Nurses’ Health Study and the Health Professionals Follow-Up Study

l  After an average of 25 years follow-up, more whole-grain intake was associated with lower death

l  Every whole-grain serving was associated with a 5% lower death

l  AND 9% lower death from heart disease. l  The benefits were independent of other lifestyle factors,

including exercise and other dietary choices. Wu H, Flint AJ, Qi Q, et al. Association between dietary whole grain intake and risk of mortality: two large prospective studies in us men and women. JAMA Intern Med. Published online January 5, 2015.

You Choose

Get Your 7 (Servings) l  65,226 participants aged 35+ years in the 2001–2008 Health Surveys for

England with median follow-up: of 7.7 years

l  Fruit and vegetable consumption was associated with: l  Decreased all-cause mortality (adjusted HR for 7+ portions 0.67 (95% CI 0.58 to 0.78),

reference category <1 portion). l  Reduced cancer (0.75 (0.59–0.96)) l  Reduced cardiovascular mortality (0.69 (0.53 to 0.88)).

l  Vegetables may have a stronger association with mortality than fruit.

l  Consumption of vegetables or salad were most protective.

l  Frozen/canned fruit consumption was apparently associated with increased mortality (1.17 (1.07 to 1.28) per portion).

l  Oyebode O, Gordon-Dseagu V, Walker A, Mindell JS. Fruit and vegetable consumption and all-cause, cancer and CVD mortality: analysis of health survey for England data. J Epidemiol Community Health. 2014;68(9):856-862.

Significant Reductions l  16 studies analyzed l  Followed from 4.6 to 26 years l  833 234 participants l  Higher consumption of fruit and vegetables was significantly associated with

a lower risk of all cause mortality. l  Pooled hazard ratios of all cause mortality were 0.95 (95% confidence

interval 0.92 to 0.98) for an increment of one serving a day of fruit and vegetables (P=0.001), 0.94 (0.90 to 0.98) for fruit (P=0.002), and 0.95 (0.92 to 0.99) for vegetables (P=0.006).

l  A threshold around five servings of fruit and vegetables a day, after which the risk of all cause mortality did not reduce further.

l  A significant inverse association was observed for cardiovascular mortality (hazard ratio for each additional serving a day of fruit and vegetables 0.96, 95% confidence interval 0.92 to 0.99)

Wang X et al. BMJ 2014;349:g4490

High Blood Pressure? Go Veg l  A meta-analysis of 32 observational studies (N=21,604) + 7 trials (N=311). l  The mean age of participants was approximately 47 years. l  A vegetarian diet was associated with an approximate 5 to 7 mm Hg

reduction in mean systolic BP and an approximate 2 to 5 mm Hg reduction in mean diastolic BP compared with a normal diet.

Yokoyama Y, Nishimura K, Barnard ND, et al. Vegetarian diets and blood pressure: a meta-analysis. JAMA Intern Med. 2014;174(4):577-587.

l  A 2013 cross-sectional analysis of Seventh-day Adventists compared cardiovascular risk factors between vegetarian and nonvegetarian blacks living in the United States.

l  Vegetarian group had a 44% lower risk of hypertension compared with nonvegetarians.

l  Important finding due to prevalence of hypertension in the black population.

Fraser G, Katuli S, Anousheh R, et al. Vegetarian diets and cardiovascular risk factors in black members of the Adventist health study-2. Pub HealthNutr. 2014:1-9.

Flax Seeds

l  Potent anti hypertensive effect l  Prospective, double-blinded, placebo-controlled, randomized

trial of 110 participants l  30 g of milled flaxseed or placebo each day over 6 months l  SBP was ~ 10 mm Hg lower, and DBP was ~ 7 mm Hg lower

in the flaxseed group l  Patients who entered the trial with a SBP ≥ 140 mm Hg at

baseline obtained a larger 15 mm / 7 mm drop

l This is an effect that is more powerful than most BP medicine trials and can markedly cut stroke and heart attack!

D Rodriguez-Leyva, W Weighell, A L Edel, R Lavallee, E Dibroy, R Pinneker, T G Maddaford, B Ramjiawan, M Aliani, R Guzman, G N Pierce. Potent Antihypertensive Action of Dietary Flaxseed in Hypertensive Patients. Hypertension. 2013 Dec;62(6):1081-9.

What About Eggs? l  Analysis of 14 studies found that those who consumed the most eggs: l  19% and 68% percent increased risk for developing cardiovascular disease

and diabetes, respectively, compared with those who ate the fewest eggs. l  For those who already had diabetes, the risk for developing heart disease

from eating the most eggs jumped to 83%. l  Author conclusion: “Our study suggests that there is a dose-response

positive association between egg consumption and the risk of CVD and diabetes.”

Li Y, Zhou C, Zhou X, Li L. Egg consumption and risk of cardiovascular diseases and diabetes: A meta-analysis. Atherosclerosis. Published ahead of print April 17, 2013.

1 Egg

l 187mg cholesterol

More On Eggs…

More On Eggs…

http://www.ftc.gov/enforcement/cases-proceedings/commission-decision-volumes/volume-88

3 Eggs a Week

l  1262 patients mean age of 61.5, 47% women l  Plaque area in patients consuming <2 eggs per week

(n = 388) was 125 ± 129 mm2, versus 132 ± 142 mm2 in those consuming 3 or more eggs per week (n = 603); (p < 0.0001 after adjustment for age).

l  In multiple regression, egg-yolk years remained significant after adjusting for coronary risk factors.

J. D. Spence, D. J. A. Jenkins, J. Davignon. Egg yolk consumption and carotid plaque. Atherosclerosis 2012 224(2):469 - 473

Other Known Egg-y Issues

l  14 Study Review – High Egg Consumption increases risk for DM2 by 68%

Li Y, Zhou C, Zhou X, Li L. Egg consumption and risk of cardiovascular diseases and diabetes: a meta-analysis. Atherosclerosis. 2013;229:524-530.

l  Physician’s Health Study I (21,000 participants) 7 eggs week = 25% higher death rate

Djousse L, Gaziano JM. Egg consumption in relation to cardiovascular disease and mortality: the Physicians’ Health Study. Am J Clin Nutr. 2008;87:964-969. l  Consumption of only 1.5 eggs/week

increases colon cancer risk by nearly 5x Iscovich JM, L’Abbe KA, Castelleto R, et al. Colon cancer in Argentina. I: risk from intake of dietary items. Int J Cancer. 1992;51:851-857.

Now on to Reversing Coronary Disease

Esselstyn CB Jr. Resolving the coronary artery disease epidemic through plant-based nutrition. Prev Cardiol. 2001;4:171-177.

Now on to Reversing Coronary Disease

New work in 2014: •  198 patients followed for nearly 4 years– counseled on

going vegan; 98% with pre-existing CAD •  177 complied •  112/177 reported angina before starting; 93% - 104/112

had resolution of angina •  Of the compliant, new CV event rate of 0.6%, 10% with

any event •  Of the noncompliant, 62% event rate (13/21)

Esselstyn CB, et al. J Fam Pract. 2014 Jul;63(7):356-364b.

Nitro No More

l Plant-based, whole food diets, conquer angina

l New case series demonstrates efficacy on well known improvements in angina with this type of diet.

Massera et al. A whole-food plant-based diet reversed angina without medications or procedures. Case Rep Cardiol. February 12 2015.

Pulse (Legume) Intake and Lipids

l  26 randomized clinical trials that compared diets emphasizing pulses with similar diets without pulses to determine the effect of LDL, apolipoprotein B and non-HDL cholesterol levels in 1,037 participants

l  The mean age of the participants was 51.1 years, with a median LDL cholesterol level of 3.5 mmol/L (135 mg/dL)

l  Diets incorporating a median pulse quantity of 130 g/day significantly lowered LDL cholesterol levels (mean difference, –17 mmol/L = 7 points on US mg/dL) across 25 trials

Ha V. CMAJ. 2014;doi:10.1503/cmaj.131727.

Chicken Before the Egg

l Phosphate: The new issue

Phosphate 101

Dtsch Arztebl Int. Jan 2012; 109(4): 49–55.

Phosphate 101

Dtsch Arztebl Int. Jan 2012; 109(4): 49–55.

l Normally tightly regulated l A big issue for those with renal

dysfunction, but, now also those with normal kidneys

l May increase osteoporosis l May increase vascular aging

Phosphorus in Foods

Karp et al. J Ren Nutr. 2012 Jul;22(4):416-22.

Phosphates

l Plants contain phosphorus in phytic acid which cannot be absorbed owing to human lack of phytase

l Phosphate used in colas, meats as preservatives for color and to make meat more “appetizing.”

Purge and Color

l Purge: Released from meat while it ages

l  Injection of chicken with salt, water, and phosphate reduces purge and increases yield (i.e. more lbs = $$$)

l Can boost phosphate by up to 70% - a danger to those with kidney disease

L. Murphy-Gutekunst, J. Uribarri. Hidden Phosphorus-Enhanced Meats: Part 3. J Ren Nutr. 2005 15(4):E1-E4. B. G. Lyon, D. P. Smith, E. M. Savage. Descriptive sensory analysis of broiler breast fillets marinated in phosphate, salt, and acid solutions. Poult. Sci. 2005 84(2):345 - 349. O. Benini, C. D'Alessandro, D. Gianfaldoni, A. Cupisti. Extra-phosphate load from food additives in commonly eaten foods: A real and insidious danger for renal patients. J Ren Nutr. 2011 21(4):303 - 308.

Let’s Not Forget the Mind

l Stress takes a physical toll l Ornish work has demonstrated that telomere length is shortened with chronic stress.

D Ornish, J Lin, J Daubenmier, G Weidner, E Epel, C Kemp, M J M Magbanua, R Marlin, L Yglecias, P R Carroll, E H Blackburn. Increased telomerase activity and comprehensive lifestyle changes: a pilot study. Lancet Oncol. 2008 Nov;9(11):1048-57.

Just 12 Minutes

l  Small study of 39 caregivers to those with significant dementia

l  Randomized to 12 minutes of relaxation music or meditation.

l  The meditation group showed significantly lower levels of depressive symptoms and greater improvement in mental health and cognitive functioning compared with the relaxation group.

l  The meditation group showed 43% improvement in telomerase activity compared with 3.7% in the relaxation group (p = 0.05).

H Lavretsky, E S Epel, P Siddarth, N Nazarian, N S Cyr, D S Khalsa, J Lin, E Blackburn, M R Irwin. A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition and telomerase activity. Int J Geriatr Psychiatry. 2013 Jan;28(1):57-65.

Breast Cancer

l  World Cancer Research Fund International's Continuous Update Project.

l  A review of 85 studies with 164,416 participants diagnosed with breast cancer.

l  Eating more high-fiber plant foods before and after diagnosis may reduce the risk of dying from breast cancer.

l  Women who consume more soy after diagnosis have a lower risk of dying, while women who consumed more fat, especially saturated fat, before diagnosis had a higher risk of dying.

World Cancer Research Fund International. Continuous Update Project Report: Diet, Nutrition, Physical Activity, and Breast Cancer Survivors. 2014. vailable at: www.wcrf.org/sites/default/files/Breast-Cancer-Survivors-2014-Report.pdf. Accessed October 16, 2014

Breast Cancer

l  A retrospective analysis of a large clinical database of patient records from 2000 to 2013 in the United Kingdom.

l  Of the 664,159 women identified, 22,938 (3.5%) had high cholesterol and 9312 had breast cancer.

l  More women with high cholesterol than with normal cholesterol developed breast cancer (2.3% vs 1.4%)

l  Having hyperlipidemia increased the risk for breast cancer by 1.64 times (95% confidence interval, 1.50 - 1.79).

Potluri R, Lavu D, Uppal H, Chandran S. Hyperlipidaemia as a risk factor for breast cancer? Report presented at: European Society of Cardiology 2014 Frontiers in Cardiovascular Biology Meeting; July 4, 2014: Barcelona, Spain.

Animal Energy and Cancer

l  21 different cancers in 157 countries l  The association between animal product

consumption and cancer was as strong as that linking tobacco and cancer (in 12 different types of cancer).

l  Consumption of animal products correlated with cancer incidence with a lag time of 15–25 years.

Grant, William. Nutrients 2014, 6(1), 163-189; doi:10.3390/nu6010163 http://www.mdpi.com/2072-6643/6/1/163/htm

Don’t Forget the Exercise

l  305 trials with 339,274 participants, compared drug and exercise interventions

l  Exercise proved similar to medications for heart disease prevention, heart failure treatment, and diabetes prevention.

l  For strokes, exercise was more effective than drug treatments

l  Are You Walking With a Doc? (WalkWithaDoc.org)?

Naci H, Ioannidis JPA. Comparative effectiveness of exercise and drug interventions on mortality outcomes: metaepidemiological study. BMJ. Published online October 1, 2013.

Exercise

Diabetic Neuropathy l  Observational study of 21 type 2 diabetics with nerve pain showed that being on a low-

fat, high-fiber vegan diet for a month brought complete pain relief to 81% of participants, who lost about 11 pounds on average.

Crane and Sample (J Nutr Med 1994; 4: 431-439)

l  Dietary Intervention for chronic diabetic NEuropathy pain) in 15 patients with type 2 diabetes and neuropathy, who had a mean age of 57.

l  Patients were randomized to either a low-fat, high-fiber, plant-based diet with B12 supplementation or to B12 supplementation alone.

l  Those on the diet could only eat plant-based foods, and they had to limit fatty foods such as oils and nuts to 20 to 30 grams per day.

l  No portion limits. l  With good adherence (five of seven diet patients were fully

adherent), those on the diet had significantly greater improvements in McGill Pain Questionnaire scores than those on B12 alone (P=0.04).

l  They also had significantly greater reductions in body mass index (BMI) compared with controls (P=0.01).

DINE Study http://www.medpagetoday.com/MeetingCoverage/AADE/47120

Environmental Impact

l 1 kg of Beef = 27 kg of greenhouse gases

l Going vegan is the equivalent of not driving 1160 miles

l  For each acre of forest cleared for urbanization, SEVEN are cleared to raise meat livestock.

Hur, R. Are High Fat Diets Killing Our Forests. Vegetarian Times Feb 1984.

Water Footprints

Economics

l 75% of the $2.8 trillion in annual health care costs in the United States is from chronic diseases that can often be reversed or prevented altogether by a healthy lifestyle.

Ornish. NY Times Editorial http://www.nytimes.com/2012/09/23/opinion/sunday/the-optimal-diet.html?_r=0

Success

l  Low fat, 100% whole grain, minimally processed, whole food, plant-based diet

Geniuses Agree…

“Nothing will benefit human health and increase our chances of survival for life on Earth as much as the evolution to a vegetarian diet.” – Albert Einstein

Convinced?

l  Forks Over Knives l The China Study l The Starch Solution l Diet for a New America l Planeat

Vegan Humor

Not Sure of the Stats, But…