478 - Best “Diets” 2023, Osteoporosis and Fractures, Words Create Worlds

From the US News and World Report

1)    “Best Diet” Rankings for 2023

U.S. News recently released its annual assessment of the best diets, ranking 24 based on specific criteria and providing in-depth profiles for 38 popular eating plans. The rankings were established by a reputable panel of 33 experts in nutrition, obesity, food psychology and chronic disease management, who rated each diet on multiple criteria, including healthiness, ease of use, adaptability to various preferences and restrictions, likelihood of promoting weight loss, sustainability, and safety. To ward off possible bias, each panelist provided information indicating clear or apparent conflicts of interest. In such cases, panelists did not rate the diet where a potential conflict existed.

For the 6th consecutive year, the Mediterranean Diet ranks as the No. 1 Best Diet Overall with the DASH Diet and the Flexitarian Diet (a plant-based plan with meat in moderation) tied for 2nd. The MIND diet (Mediterranean-DASH Intervention for Neurodegenerative Delay), designed to help prevent dementia, was 4th.

The Mediterranean diet was rated the best diet (or tied for best) in 5 out of the 11 categories, including best plant-based diet, best diet for healthy eating, best family- friendly (tied with Flexitarian and TLC/Therapeutic Lifestyle Changes), and best for bone and joint health (tie with DASH). The DASH diet was the top-rated diet for diabetes and heart health, with the Mediterranean rated 2nd in both categories. The Flexitarian and TLC diets were rated Easiest Diets to Follow with the DASH and Mediterranean close behind.

WW (Weight Watchers) was rated the top Weight-Loss Diet with DASH rated 2nd. The Keto diet was rated the best Fast Weight Loss diet. The top Diet Program (formerly called commercial plans) was WW, with a tie for 2nd between Jenny Craig and Noom.

It is important to note that there isn't "a" Mediterranean diet. The cultural lifestyle of people in countries bordering the Mediterranean Sea shares common principles, including an active lifestyle, weight control, and a diet high in produce, nuts and healthy oils and low in red meat, sugar, and saturated fat. A Mediterranean diet pyramid has been developed to help guide those desiring to follow this nutritional approach (see References).

The DASH Diet (Dietary Approaches to Stop Hypertension) is promoted by the NHLBI to stop or prevent HTN. It emphasizes vegetables, fruits, whole grains, lean protein and low-fat dairy. DASH also discourages foods that are high in saturated fat, such as fatty meats, full-fat dairy foods and tropical oils, as well as sugar-sweetened beverages and sweets and sodium. The NHLBI publishes free guides on the plan (See references).

Mark’s Comments (With Guest Commentary):

The word “diet” is a misnomer. The most highly rated “diets” are really about healthy, structured, intentional approaches to eating over a lifetime. And despite the present push for the increased use of medications for weight loss, particularly the incretins and “twin-cretins,” how one eats will always serve as the foundation for their overall health.

To that end, I reached out to colleague and “Lifestyle Medicine guru” Beth Polk, MD, for her insights. In addition to regularly speaking nationally on this topic, Beth served as one of 4 national faculty on an AAFP Advisory Committee for Lifestyle Medicine and is one of 3 co-chairs for the new AAFP Lifestyle Medicine conference. This past May she started a clinic focusing on Lifestyle Medicine as part of her clinical practice. Beth replied: “Despite the large body of evidence that it can prevent chronic disease, I have heard criticism of the Mediterranean diet as unaffordable and that it is not translatable to other cultures. However, if we think about the diet in terms of the general principles of increasing fruits, vegetables, beans, nuts and seeds, and eliminating processed foods and decreasing meat intake, the top 5 diets meet these criteria, and they can be easily adapted to regional and cultural differences. There are many alternative pyramids available to help promote creative thinking about using local produce, farmer’s markets and staples such as beans and rice to make this approach both more accessible and affordable. And remember, the best advice we are able to give our patients is still ‘eat

food (unprocessed), mostly plants, and not too much.’”

References:

·         U.S. News Best Diets Rankings for 2023. January 3, 2023. Link

·         Oldways Mediterranean Diet: Link and Diet Pyramid: Link

·         DASH Eating Plan:   Link

From the NCAQ, USPSTF, and the Literature

2)    Osteoporosis and Fracture Prevention

There is a relatively new osteoporosis quality measure being assessed by the payors: Osteoporosis Management in Women Who Had a Fracture: Assesses women 67–85 years of age who suffered a fracture and who had either a bone mineral density test or a prescription for a drug to treat osteoporosis in the six months after the fracture.

This is a little different from the USPSTF recommendations on osteoporosis screening: Women 65 years and older: The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. (B recommendation)

Postmenopausal women younger than 65 years at increased risk of osteoporosis:The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. (B recommendation)

The measure focuses on secondary prevention of fracture in postmenopausal women, given the known risks of morbidity and mortality in this age group. It does not consider if the fracture is “likely osteoporotic” – it could be any fracture. Exclusions for this measure would be a consistent diagnosis of frailty, residence in a skilled nursing facility, or participation in a hospice program.

The main driver of this measure is not completely clear – there is an Endocrine Society guideline on the pharmacologic management of osteoporosis that advocates assessment for osteoporosis in this age group after a fracture, but lists as examples wrist, hip, and vertebral fractures (which specifically suggest osteoporosis). This guideline emphasizes rapid assessment and treatment of osteoporosis after these fractures due to evidence of a high short-term risk of an osteoporotic second fracture. There have been numerous observational studies that have associated bisphosphonate use after fracture with improved mortality, but this association is questioned because it has not been found yet in randomized controlled trials.

John’s Comments:

On the whole, this is a reasonable guideline-based metric, since we do a poor job in the United States of accomplishing osteoporosis screening in general. In addition, we don’t do very well at screening for osteoporosis after a documented fragility fracture (research done here at Carilion Clinic, see reference 3). I think the wording of this measure was broadened to “any fracture” (except for fingers, toes, face, and skull) for simplicity’s sake, but I cannot be sure. To succeed at this measure, we must consider fractures in this age group as sentinel events and get these patients screened for osteoporosis.

Other system interventions (collaborating with orthopedic colleagues, utilizing EHR alerts, etc.) may also help.

References:

·        US Preventive Services Task Force, Curry SJ, Krist AH, et al. Screening for Osteoporosis to Prevent Fractures: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(24):2521. Link

·         Eastell R, Rosen CJ, Black DM, Cheung AM, Murad MH, Shoback D. Pharmacological Management of Osteoporosis in Postmenopausal Women: An Endocrine Society Clinical Practice Guideline. The Journal of Clinical Endocrinology & Metabolism. 2019;104(5):1595-1622. Link

·         Barton DW, Behrend CJ, Carmouche JJ. Rates of osteoporosis screening and treatment following vertebral fracture. The Spine Journal. 2019;19(3):411-417. Link

From PeerRxMed ( www.PeerRxMed.org )

3)    Let Your “Word” Help Create Your World in 2023

“Words create worlds.” – Attributed to many

I believe words matter. Apparently, so do the many others who make one of their New Year’s rituals to pick their “word for the year.” This is a word or short phrase that represents a personal and/or professional aspiration that will serve as an inspiration, motivation, guide, anchor, or “theme” for the upcoming year. Mine has traditionally been a “made-up” word, often a combination of words, that energizes me and

serves as a compass to help keep me aligned with my stated priorities … it helps me create my world for the year.

Indeed, words are symbols for thoughts and ideas, and we personalize them according to the meaning we associate with them. Consider some words that have taken on a whole new meaning (or multiple meanings) in the past 3 years, such as zoom, distancing, variant, hero, vacation, mask, quarantine, incubation, booster, transmission, and even cloth! Each of these words now have a newly acquired “emotional charge” attached to them, and depending on your perspective, symbolize different meanings, and those differences have indeed often created very different “worlds.”

In the past 4 years, my self-created words have been “zilience,” “reslove,” “cor,” and in 2022, “bemusedament.” My understanding of bemusedament helped me to tap into the creative spirit around my core values of connection, wonder, love, growth, and fun, and informed as well as inspired my writing, including the recently written poem “Epiphany” (attached). This poem served as the inspiration for this year’s word, “Rēpiphany,” which I intend will help raise my awareness to the many “Holy moments” in my life, remind me that our lives are part of something much larger, and inspire me to show up as my “better self” more often.

How about you? What might be the word or words to help you frame your year – or perhaps for you it’s a picture, quote, song, or poem (or all of the above!). Consider picking one or more and sharing their meaning with those close to you, including your PeerRx partner. I’ve found that doing so is great fun, can provide you insights into your psyche, and by inviting others into the conversation, can supercharge your intention by providing some encouragement and accountability around it.

Looking back one year from now, what kind of world do you want to have helped create in 2023? Well, it can all start with just one word. Why not give it a try ….

______________

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