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Matching the Right Diet to the Right Patient

Anya Romanowski, MS, RD | January 27, 2017

Matching the Right Diet to the Right Patient

Nutrition dominates news headlines. It seems that every week, a diet or a nutritional
supplement is being recommended for treating one health condition or another. Entering
"diet" as a search word on Google returns about 549 million results. As one nutrition study
is released promoting the consumption of certain foods, it often seems that another study
appears disputing the previous recommendations.

Surprisingly, adequate nutrition education is lacking at medical schools. According to a


2015 study, over 71% of medical schools failed to meet the recommended National
Research Council goal of providing at least 25 hours of nutrition education to medical
students, and 14% of physicians surveyed felt they were not sufficiently trained in
counseling patients about nutrition.

This diet guide was created to fill that knowledge void and lists the most optimal therapeutic
diets to recommend to patients on the basis of their chronic condition or disease. Links to
reputable sources of diet and patient information are included.
Hypertension and Best Overall Diet

The Dietary Approaches to Stop Hypertension (DASH) diet continues to outrank all others
as the best overall diet in the U.S. News & World Report annual ranking. It is a high-protein
and high-fiber diet that comprises primarily whole grains, vegetables, fruits, low-fat dairy
foods, and lean sources of protein (poultry, red meat, fish, nuts, and beans). The diet is
[1]
effective in lowering blood pressure and in lowering serum uric acid levels by reducing
foods high in sodium and increasing magnesium, calcium, and potassium intake. The diet
is low in saturated fat, total fat, and cholesterol. It encourages reducing sugar intake and
[2]
is also an appropriate diet for patients with diabetes.
DASH Diet

A patient guide to the DASH diet can be downloaded from the National Heart, Lung, and
Blood Institute of the National Institutes of Health.

Meal planner handouts can be downloaded from Nutrition Education Services, Oregon
Dairy Council.
Diets for Diabetes

In 2013, the American Diabetes Association (ADA) released new dietary guidelines for
[2]
patients with diabetes. These new guidelines include a section on eating patterns, which
takes into account an individual's religious and cultural beliefs and metabolic variables (ie,
glucose value, lipid levels, blood pressure, body weight, and renal function). In the ADA
press release, Jackie Boucher, MS, RD, LD, CDE, vice president for education at the
Minneapolis Heart Institute Foundation, indicated that evidence is lacking to support one
eating plan over another. "Whether you prefer a Mediterranean, vegetarian or lower-
carbohydrate eating plan is less important than finding an eating pattern that fits your food
preferences and lifestyle, can be consistently followed and that provides you with the
nutrition you need for good health," she stated.
Recommendations for Diabetes

The 2013 ADA guidelines include the following recommendations for people with
[2,3]
diabetes :

Limit or avoid beverages containing sugar or any caloric sweetener (including high-fructose
corn syrup and sucrose): energy drinks and vitamin waters, fruit drinks, soft drinks, iced tea,
and lemonade.
Choose high-fiber, nutrient-dense sources of carbohydrates instead of processed foods with
added fat, sodium and sugar. If using fixed insulin doses, keep carbohydrate intake
consistent with respect to time of day and amounts.
Reduce sodium intake to < 2300 mg/day (further reductions may be needed for persons with
high blood pressure).
Eat two servings of fatty fish at least twice per week.
Choose liquid fats instead of saturated or trans-fat varieties, and consume leaner sources of
protein (poultry, nuts, beans, and fish).
Evidence is lacking to support the consumption of vitamin or mineral supplements in
individuals who do not have a vitamin or mineral deficiency. There is also a lack of evidence
to support the use of cinnamon or other herbs or supplements.
If a carb-counting diet is preferred over the DASH or Mediterranean diet, the National
Institute of Diabetes and Digestive and Kidney Diseases recommends between 45% and
65% of total calories from carbohydrates depending on activity level (45% if inactive).
Diets for Cardiovascular Disease

Honorable mentions: Ornish, Therapeutic Lifestyle Changes

Adherence to the Mediterranean diet has been shown to reduce cardiovascular disease
[4]
incidence and mortality. However, in his documentary, The Big Fat Fix, cardiologist
Aseem Malhotra, MBChB, MRCP, challenges the emphasis on saturated fat in dietary
recommendations and feels that attention should be focused on reducing the consumption
of refined and starchy carbohydrates (eg, sugar, pasta, potatoes).

This primarily plant-based diet emphasizes the consumption of fruits; vegetables; whole-
grain breads; and cereals, beans, nuts, and seeds. The principal source of dietary fat is
olive oil, a monounsaturated fat that is rich in polyphenols (which may reverse inflammation
and potentially atherosclerosis). Consuming foods rich in omega-3 alpha linoleic acid
(ALA) is encouraged (walnuts, flaxseeds, and flaxseed oil), as is regular consumption of
fish, a rich source of omega-3 eicosapentaenoic acid (EPA) and docosahexaenoic acid
(DHA) fats. Controversy remains as to whether fish oil supplements offer the same heart-
healthy benefits as eating fatty fish does. The recent study that examined whether
EPA/DHA from both food and supplements lowered the risk for coronary heart disease
was supported by a grant from a manufacturer of fish oil products, the Global Organization
for EPA and DHA Omega-3 in Salt Lake City, Utah.
Mediterranean Diet

Information on the Mediterranean diet can be downloaded from the American Diabetes
Association website.

A guide that emphasizes nonrefined carbohydrates can be downloaded from the Egton
Medical Information Systems Patient website (registered in England).

A patient guide to the Mediterranean diet can be downloaded from the Mayo Clinic website.
Diets for Kidney Disease

The purpose of a renal diet for patients with kidney disease is to reduce the amount of
waste in their blood, which negatively affects electrolyte balance and increases disease
progression. Restriction of protein intake is recommended in the early stages of disease
to avoid the onset of uremia (high levels of urea, protein products, and amino acids in the
blood), and patients should select high-quality protein foods (poultry, eggs, fish or shellfish,
beans and legumes, dairy) and limit their red meat consumption.

In a previous Medscape article, Donald Wesson, MD, chief academic officer at Baylor Scott
& White Health in Dallas, who has been studying how the kidney adjusts to either a high-
or a low-acid challenge for the past 30 years, said, "When the kidney is challenged with
acidsuch as by eating an animal-source protein dietthe kidney increases levels of
hormones that help it excrete the acid in the short term." He further added that "[i]f you add
fruit and vegetables to the diet, we found that they are protective of kidney function."

More recent studies are focusing on the gut/kidney interaction in chronic renal failure and
how the disease alters the microbial balance of the gut flora (termed "dysbiosis").
Microbiome products (phenols, indoles, and advanced glycation end products) that are
cleared by fully functioning kidneys can become toxic and exacerbate uremia in patients
with chronic kidney disease.
Renal Diet

Consulting a renal dietitian is strongly encouraged to create a tailored diet for patients.
Depending on the stage of disease, fluids may need to be restricted to avoid edema and
increased blood pressure. A renal dietitian may also recommend reducing sodium and
potassium (to avoid hyperkalemia), and balancing phosphorus and calcium intake. The
calcium/phosphorus balance is critical in preventing the parathyroid glands from pulling
calcium out of the bones and causing vascular calcification.

Nutrition guidelines for stage 1-4 kidney disease and downloadable patient brochures are
available on the National Kidney Foundation (NKF) website. The NKF also
provides guidelines for patients on dialysis.

The US National Kidney Disease Education Program offers a downloadable patient


brochure on chronic kidney disease in English and Spanish.
Diet for Inflammatory Bowel Disease

The low-FODMAP (fermentable oligosaccharides, disaccharides, monosaccharides and


polyols) diet, termed by a group of Australian researchers, is an elimination diet that has
been promoted for patients with inflammatory bowel disease (IBD) and irritable bowel
syndrome (IBS), but not without controversy. Studies suggest that foods composed of
certain forms of short-chain carbohydrates are poorly absorbed and rapidly fermented by
bacteria in the intestine, which exacerbates symptoms in patients with IBD and IBS (eg,
cramping, bloating, diarrhea).

This diet requires restriction of certain carbohydrates, fruits that are a rich source of
fructose, dairy products in some patients, and several artificial sweeteners. It is a difficult
diet to observe owing to the exclusion of so many foods, and not all patients with IBS
respond to it.

Paul Moayyedi, MD, director of the division of gastroenterology at McMaster University in


Hamilton, Ontario, Canada, previously stated to Medscape, "We really need to know
whether this works or not. We find something new and think it's wonderful, then someone
else does a study and we realize it's all poison and awful. Eventually we come to some
sort of evidence on whether this is worthwhile or not."
FODMAP Diet

Foods to Eliminate, According to the Academy of Nutrition and Dietetics:

Oligosaccharides

Apples, artichokes, asparagus, barley, beets, Brussels sprouts, broccoli, cabbage,


chickpeas, fennel, garlic, leeks, legumes, lentils, okra, onions, peaches, peas, persimmon,
pistachios, rye, shallots, wheat, and watermelon

Polyols

Apples, apricots, avocado, cauliflower, cherries, mushrooms, nectarines, pears, peaches,


plums, prunes, snow peas, watermelon, and artificial sweeteners (sorbitol, mannitol,
maltitol, xylitol)

Free fructose

Apples, artichokes, asparagus, cherries, mangoes, pears, sugar snap peas, watermelon,
honey, and high-fructose corn syrup

Lactose (only if a patient has an insufficient level of lactase):

Milk, soft cheeses, custard, ice cream, and yogurt

The Academy of Nutrition and Dietetics provides patient information on the FODMAP diet.
Diet for Celiac Disease

According to the Celiac Disease Foundation, celiac disease is a genetic autoimmune


disorder that affects approximately 1 in 100 individuals worldwide. Although a reported 3
million Americans have been diagnosed with the disease, approximately 97% (over 2
million) are undiagnosed and at risk for health complications. Patients with celiac disease
are instructed to avoid ingesting foods with gluten, a protein found in such grains as wheat,
barley and rye, which elicits the immune system to attack and damage the small intestine.

In a Medscape video commentary, Dr Bill Balistreri, professor of pediatric medicine at the


University of Cincinnati and Cincinnati Children's Hospital, stated, "Recent consumer
surveys indicate that approximately 1 in 5 Americans have eliminated or reduced the
amount of gluten ingested in their daily diet. This estimate greatly exceeds the small
subgroup who have been diagnosed to truly have celiac disease."

Could nonceliac wheat sensitivity be the cause for many individuals to observe a gluten-
free diet? In another Medscape article, Joseph Murray, MD, a professor of medicine and
gastroenterology at Mayo Clinic, Rochester, Minnesota, stated, "I think there is now
enough data to say that there are people out there who do have symptoms that are related
to either wheat or gluten who are not [diagnosed with] celiac and not classic wheat allergy."
Gluten-Free Diet

More information on celiac disease and gluten-free diet information is available on


the Celiac Disease Foundation website.

The Academy of Nutrition and Dietetics also provides information for patients on celiac
disease and gluten-free diets.
Diets for Cancer

Potential diet under investigation: Modified ketogenic diet

Many authors have claimed to have found the cure for cancer and are touting their books
and websites without evidence supporting their claims. In examining what the guidelines
commend, the American Cancer Society, World Cancer Research Fund, and American
Institute for Cancer Research recommend eating a mostly plant-based diet, limiting red
meats and avoiding processed meats, limiting alcoholic drinks, and avoiding taking vitamin
supplements. However, recent studies dispute some of the recommendations on reducing
all red meat consumption and suggest avoiding solely processed and grilled/barbecued
and smoked meat, which may contain polycyclic aromatic hydrocarbon carcinogens.

At the 2015 annual meeting of the American Society of Clinical Oncology, Michelle Harvie,
SRD, PhD, was interviewed by Medscape and said, "Processed meat seems to be the
problem, rather than red meat. The state of the epidemiologic science on red meat
consumption and colorectal cancer is best described in terms of weak associations,
heterogeneity, and inability to disentangle effects from other dietary and lifestyle factors,
lack of a clear dose/response effect, and weakening evidence over time."

Studies also support light to moderate drinking for some types of cancer. "Light drinking,
one drink a day, can increase risk for the head and neck cancers, esophageal cancer, and
breast cancerbut what we shouldn't forget before we go around advocating no alcohol
at all is that no alcohol at all is linked to overall mortality, probably because of increased
cardiovascular events," said Dr Harvie in the Medscape interview.

Modified ketogenic diets (substituting all but nonstarchy vegetable carbohydrates with low
to moderate amounts of protein and high amounts of monounsaturated and
polyunsaturated fats) are used most commonly to treat children with refractory epilepsy;
however, they are also being investigated as a novel approach for treating cancer patients.
Because carbohydrate consumption is severely restricted, the body converts fat to energy
(a process called "ketosis"). The intent of using a ketogenic diet in patients with cancer is
to deprive cancer cells of glucose, which they convert to lactate and use for fermentation,
and to increase the level of ketone bodies for energy production in normal healthy cells.
Several studies show a direct relationship between the ketogenic diet and slowed brain
tumor growth. Other metabolic substrates, such as glutamine, may also play a role in
cancer metabolism. Unfortunately, this diet may be difficult to observe because so many
foods are restricted.

Plant-Based Diet
Resources on plant-based diets for patients and health professionals can be obtained from
the American Institute for Cancer Research.

The American Cancer Society website provides guidelines and diet recommendations for
many types of cancer.
Diets for Dementia and Alzheimer Disease

More research indicates that the Mediterranean diet (MeDi) is linked to higher total brain
volume. In a 2015 study published in Neurology, Yian Gu, PhD, and colleagues noted that
"[t]he absolute effect of MeDi on brain measures were relatively small." They went on to
say, "However, the magnitude of the effect of consuming at least 5 recommended MeDi
food components on TBV [total brain volume] is comparable to that of 5 years of increasing
age. Similarly, having fish intake of 3-5 oz at least weekly, or keeping meat intake 100 g
daily or less, may also provide a considerable protection against brain atrophy that is
equivalent to about 3-4 years of aging."

As previously reported by Medscape Medical News, the Mediterranean diet offers many
benefits, including better cognitive function and reduction in the risk for dementia. The diet
has also been associated with increased cortical thickness.

The MIND (Mediterranean-DASH Intervention for Neurodegenerative Delay) diet, created


by researchers at Rush University Medical Center, is a hybrid of the Mediterranean and
DASH diets. It was found to reduce the risk for Alzheimer disease by 35%-53% and to
slow cognitive decline among aging adults, on the basis of patient adherence. According
to Alan Jacobs, MD, "To adhere to and benefit from the MIND diet, one would need to eat
at least 3 daily servings of whole grains, a green leafy vegetable and one other vegetable
every day, drink a glass of wine daily, snack mostly on nuts, have beans every other day
or so, eat poultry and berries at least twice per week, and eat fish at least once per week.
Limiting intake of the unhealthy foods is imperative to realizing the full benefits of the diet."
Green leafy vegetables are a good source of lutein, which a recent study has found to
preserve intelligence in older adults.
MIND Diet

Information on the MIND diet can be found on the Rush University Medical center website.

A useful PowerPoint presentation on the MIND diet, which reviews the research on it and
lists specific diet recommendations, is available on the South Denver Cardiology
Associates website.
We would love to hear what you think! What diets do you recommend to your patients, and
for treating what disease? In your experience, do the diets you prescribe achieve the
desired health outcomes in your patients? What challenges, if any, have you had in
counseling your patients about diets?

Please add your comments at Voice Your Opinion: Matching the Right Diet to the Right
Patient.