424 - Diet and CV Health, Low FODMAP Diet and IBS, Getting (a) Physical

From the American Heart Association (AHA)

1) Evidence-Based Dietary Guidance to Improve CV Health

Suboptimal diet quality is the leading risk factor for death from major noncommunicable diseases in the US. A recent comprehensive systematic review (2^nd reference) concluded that the highest-quality diet scores were associated with lower risk of all-cause mortality, CVD and cancer incidence and mortality, T2D, and neurogenerative diseases. Indeed, it is well-established that poor diet quality is strongly associated with elevated risk of CVD morbidity and mortality, the leading cause of mortality in the US.

At the same time, there continues to be great confusion in the public as to what dietary patterns are the most effective for CVD risk prevention. To address this gap, the AHA recently updated their 2006 scientific statement regarding aspects of diet that improve CV health and reduce CV risk. The updated statement emphasizes the importance of dietary patterns beyond individual foods or nutrients, underscores the critical role of nutrition early in life, presents elements of heart-healthy dietary patterns, and highlights structural challenges that impede adherence to heart-healthy dietary patterns. It notes that there is insufficient evidence to support any existing popular or fad diets such as the ketogenic diet and intermittent fasting to promote heart health. It also emphasizes that at present, there is limited evidence on the short- and long-term health effects of manufactured plant-based meat alternatives so caution should be used if recommending them.

The statement summarized 10 evidence-based dietary patterns that have been shown to promote cardiometabolic health. They include:

• adjusting energy intake and expenditure to achieve/maintain a healthy weight;
• eating plenty and a variety of fruits and vegetables;
• choosing whole grain foods and products;
• choosing healthy sources of protein (mostly plants; regular intake of fish and seafood; low-fat or fat-free dairy products; and if meat or poultry is desired, choose lean cuts and unprocessed forms);
• using liquid plant oils rather than tropical oils and partially hydrogenated fats;
• choosing minimally processed foods instead of ultra-processed foods;
• minimizing the intake of beverages and foods with added sugars;
• choosing and preparing foods with little or no salt;
• avoiding alcohol and if choosing to drink, limiting intake;
• adhering to this guidance regardless of where food is prepared or consumed.

The guidance notes that challenges that impede adherence to heart-healthy dietary patterns include food and nutrition insecurity, targeted marketing of unhealthy foods, and cultural, socioeconomic, and racial inequalities.

Mark’s Comments:

I reached out to FM colleague and Lifestyle Medicine expert Beth Polk for her reflections on the AHA Guidance. By coincidence, she was attending the annual American College of Lifestyle Medicine (ACLM) conference. Here’s her response: "It is exciting to see the AHA update their guideline. It is in alignment with what I have found to be clear in the literature; that a predominantly whole-food, plant-based diet across the lifespan is what we should be practicing for ourselves and our families, and the message we should be sharing with all of our patients. We owe it to them to help them understand that it is within their power to prevent the development of heart disease and other chronic diseases in themselves and their children with the choices they make every day. At the same time we (and they) must understand that it may take time to understand how to apply these principles, especially when trying to change habits that are engrained in our culture. What would be helpful for the busy clinician is to have easy resources to share with their patients so they could better understand, for example, what are the plant-based sources of protein. To that end, the ACLM has several free downloads available that you can use for patient education as a place to start." (see References)

References:

• Lichtenstein A et al. 2021 Dietary Guidance to Improve Cardiovascular Health: A Scientific Statement From the American Heart Association. Circulation. Published online 2 November 2021. LInk
• Morze J et al. Diet quality as assessed by the Healthy Eating Index, Alternate Healthy Eating Index, Dietary Approaches to Stop Hypertension score, and health outcomes: a second update of a systematic review and meta-analysis of cohort studies. J Acad Nutr Diet. 2020;120:1998–2031. Link
• ACLM Patient Education Material: Resource Link

From the Literature

2) Low FODMAP Diet for Irritable Bowel Syndrome

Fermentable oligo-, di-, & monosaccharides, and polyols (FODMAPs) are implicated in the pathophysiology of irritable bowel syndrome (IBS). These sugars and alcohols are thought to pull water into the gut and then ferment to cause the gas and cramping that accompanies IBS – especially the diarrheal sub-type. A low FODMAP diet is very difficult to follow as it includes many foods that are thought to be part of a healthy diet to reduce cardiovascular risk and lose weight (see the link in the comments below). It is important, therefore, to ensure that this diet works to reduce IBS symptoms.

A network meta-analysis was performed to compare the low FODMAP diet with a “usual” diet and with other recommended diets for IBS. An exhaustive search of databases and journals was performed. After applying the inclusion and exclusion criteria, 13 trials involving 944 patients were found. These trials were all of reasonably good quality with the exception of blinding, which is understandably difficult in dietary trials. The included patients all met Rome criteria for IBS but included some patients with the constipation subtype in addition to (mostly) the diarrheal subtype.

The low FODMAP diet was better than all the others (each compared to usual diet) at reducing the global impression of IBS symptoms. However, none of the diets reduced abdominal pain severity, abdominal bloating, distention severity. None of the diets improved bowel habits. Adverse events were not reported by the trials well, so could not be compared.

The authors caution that the low FODMAP diet is not intended for long-term use, but instead as a type of elimination diet – where after starting the diet, patients would add individual foods back one at a time to understand which foods result in the worst symptoms and therefore must be avoided.

John’s Comments:

This site at Monash University in Australia makes some good points about how to work with the low FODMAP diet and what sorts of things to eat and not eat on this diet. It’s complicated. While global symptoms were reduced with this diet, none of the more specific symptoms were affected, and we don’t know about adverse effects, so it’s hard to recommend it for all IBS patients. This diet can be considered for patients with primarily IBS-D who are interested in an intense dietary approach and who are game for a serious project involving their eating habits, but not as a long-standing dietary change.

References:

• Black CJ, Staudacher HM, Ford AC. Efficacy of a low FODMAP diet in irritable bowel syndrome: systematic review and network meta-analysis. Gut. Published online August 10, 2021:gutjnl-2021-325214. Link

From PeerRxMed ( www.PeerRxMed.org )

3) Taking Care of Ourselves: Let’s Get (a) Physical!

“Take care of your body. It’s the only place you have to live.”

Jim Rohn, author and motivational speaker

In the midst of spending so much time caring for others, how well are you doing with attending to your own health? Physicians and other healthcare professionals are notoriously “bad patients,” and though there is a paucity of data, that which is published indicates we’ve earned that reputation as too many of us do not have a personal physician or other primary healthcare provider, and if we do, we’re often more likely to “curbside” them about a health concern than make an appointment to see them.

Indeed, the dominant idea in the medical profession seems to be that physicians are somehow perpetually well, and if they do become ill, they should be able to function better than others and well enough to put patient care above all else. That was certainly the “hidden curriculum” that was instilled into me. And for those of us who fall into that category, the pandemic certainly has provided a convenient excuse. If this reputation doesn’t pertain to you, that’s fantastic! But please read on anyhow – you could be just the encouragement a colleague needs.

For the past few years, I’ve had the privilege of giving a talk at the American Academy of Family Physicians annual conference that focuses on our personal well-being. As part of the talk, I lead the attendees through an “Annual Wellness Exam” with the disclaimer that in that setting I am not engaged in the practice of medicine.  Four of the questions I ask pertaining to our physical health are listed below. See how you do:

1. I regularly get at least 7-8 hours of sleep and/or wake up feeling refreshed without an alarm.
2.  I maintain a healthy body weight based on accepted guidelines.
3.  I exercise regularly following the physical activity guidelines, including both cardiovascular and strength training.
4.  I have a personal physician/healthcare provider whom I have seen within the past 18 months and have had appropriate screenings for my age/health status.

How did you do? For me, “3.5” out of 4 is not bad, but since I spend my professional days encouraging patients that the target is all 4, settling for less than all 4 is not okay. In other words, it’s time for me to set up an appointment with my physician in order to check off that 4^th box. This is even more important as this year I celebrated one of those “milestone” birthdays.

If you haven’t seen your personal physician or other primary healthcare provider for a “check-up” since the pandemic started, you are officially overdue. As we begin to slowly climb our way out of the present COVID surge, now is a good to time to make that appointment. And be sure to check in on your colleagues and encourage them to do the same. Let’s make caring about ourselves and each other one of our Superpowers … and not be afraid to use it.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org