Choosing a Heart Healthy Diet

Podcast Transcript

Announcer:

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Julia Zumpano, RD:

Hello, my name is Julia Zumpano. I'm a registered dietitian with Preventive Cardiology and Rehabilitation at the Cleveland Clinic. Today I am going to discuss dietary controversies, including the ketogenic diet, the low-carb diet, plant-based diet, and intermittent fasting, and what is the evidence on the best diet for clinical practice and how to apply it. I will review the clinical implications of each plan, the pros and cons of each plan, and how to choose the best plan.

What is ketosis? Ketosis is a change in your metabolism from burning carbohydrates or glucose to burning fat for energy. Fat breakdown produces ketones which can come from your diet in the form of dietary fat or your fat stores in your body. Ketones become your body and brain's main source of energy. Glucose levels decrease, insulin decreases, and your liver produces more ketones for energy for your brain. The traditional ketogenic diet, or keto, is a high-fat diet which is very low in carbohydrate and provides moderate protein. Fats are your primary source of nutritional calories or energy.

Another form of the ketogenic diet is called the protein-sparing modified fast. This diet is low in fat, it's still very low in carbohydrate, but high in protein. Fat and ketones are the primary source of energy, although protein is the primary source of calories. So the benefits and disadvantages. The traditional keto produces rapid weight loss, it also has been shown to help lower blood pressure, blood sugars, your waist circumference, triglycerides, and inflammation, although it may increase LDL and it does not spare your muscle. So it can break down muscle in the rapid weight loss. The protein-sparing modified fast also produces rapid weight loss, about three to five pounds per week, and there is potential for weight regain because of the strictness of the diet. Just like keto, it does also lower blood pressure, blood sugar, waist circumference, triglycerides, and inflammation. In addition though, it can also lower total and LDL cholesterol.

How to get started. So at Cleveland Clinic, we offer the protein sparing, modified fasts as a ketogenic plan. It is a medically supervised program, which means that a physician or a nurse practitioner must supervise the patient on the program. They meet with the patient initially and generally every three months. The dietician's role is she provides the education of the diet, the diet supervision, and routine follow-up. The patient would meet with the dietician every four to six weeks. As a part of the diet, there are labs that are required, which is a basic metabolic panel and a uric acid level. Because gout is quite common on this plan, we check uric acid every month. Daily supplements are also required in the form of potassium, which is prescribed by the provider that is supervising the plan. Then over the counter supplements include magnesium, calcium, a multivitamin, additional sodium to your diet and supplemental fiber as needed.

There are contraindications to the ketogenic diet. We do not recommend keto if you're in end-stage renal disease, if you have diabetes type one, if you're in liver failure, if you're currently undergoing cancer treatment, if you've had a recent stroke or heart attack, if you suffer from cardiac arrhythmias, if you're pregnant or breastfeeding, if you have current gout or gallstones, and we do not recommend it for children or those who are normal or underweight.

Next plan that I will be discussing is the low carbohydrate diet. So a low carbohydrate diet is classified as less than 26% of your total calories coming from carbohydrate, or less than 130 grams of carbs per day. Moderate carb is anywhere from 26 to 44% of total calories from carbohydrates, and high carbohydrate would be 45% or greater.

What is a carb? So carbs are considered not only what we think of as grains and bread, but fruit are carbohydrates and so is milk and yogurt are also considered carbohydrates. So we have some items, grains such as oats, quinoa and barley, bread products, noodles, fruit, as I mentioned, starchy vegetables like potatoes, peas and corn, beans and lentils, of course, all those snacky foods like crackers and chips and popcorn, sweets and desserts and sweetened beverages, and of course milk and yogurt as well.

So the good and the bad. So the benefits to a low carb diet is it can reduce insulin, blood triglycerides, blood pressure, glucose and your body weight. The disadvantages though is that a low carb diet can be hard to follow because in order to stay within your specific grams or percentage of calories, you do need to monitor your carb intake, whether you use a food diary or an app, you need to measure your foods, you need to read labels, and in some cases you might actually need to carb count and calculate the amount of carbohydrates you're consuming for the day.

Next plan I'm going to discuss is the plant-based diet. So at the Cleveland Clinic, we also encourage a whole foods plant-based diet, which is slightly different from just a plant-based diet. The whole foods plant-based diet really does focus on whole foods and very minimally processed foods. But a plant-based diet includes all foods that grow from the ground and excludes all foods that come from or that walk on the ground. There are several clinical benefits of the plant-based diet. It can reduce your risk of developing type two diabetes, obesity, heart disease, high cholesterol and cancer. And the mechanisms that the plant-based diet does this is that the diet is very high in fiber, which regulates blood sugars and cholesterol. Fiber binds around something called bile in our guts, and that bile is composed of cholesterol and it can eliminate that bile with the body's waste. A plant-based diet is naturally low in saturated fat because it eliminates animal products, which are our primary source of saturated fat, which therefore can improve insulin sensitivity to the cells and reduce LDL. It promotes weight loss due to providing lower calorie foods, and it avoids group one and group two A carcinogens, red meat and processed meats. The disadvantages of a plant-based diet is that it can be very restrictive and strict. So we're eliminating a good part of a standard diet, American diet. It can be difficult to follow specifically in social settings, at family meals, eating out or traveling. There's a potential to include too many carbohydrates, specifically because we're not eating meats and consuming only carbohydrate-based sources of protein that you can very easily get into too many carbs, and if you're not consuming enough protein on this plan, you could get into a trap of large portions of carbohydrate-based foods such as pasta or rice or potatoes to provide that fullness factor you could be searching for with the inactive amount of protein or even fat.

There is potential for nutritional deficiencies. So as I mentioned, you could be deficient in protein, calcium, B-12, iron, zinc, omega-3 fatty acid and vitamin D. But to note, these potential nutrition deficiencies are also present in a standard American diet, which is very heavily processed food-based.

So next we'll talk about intermittent fasting. Intermittent fasting is defined as when you alternate between periods of eating and fasting. This type of eating is also described as patterns or cycles of fasting. There are several different forms of intermittent fasting. The five main ones include time-restricted eating, twice a week method, which is also called the five and two method, which is where you eat normally and healthy for five days, and you're eating a very low calorie diet for two days out of the week, which consists of about 500 calories. Alternate day fasting where you're fasting every other day. And that's, again, a very low calorie diet on every other day. And then the 24 hour fast is where you eat, stop, eat. So you take a full 24 hour. And then the one meal a day, very similar to the 24 hour method, is where you're just consuming maybe just dinner, and then the next day you just consume dinner.

So I would like to focus on the time-restricted eating because it is the most commonly used in a clinical setting. And the reason is because it's the easiest to follow, it's the least invasive, it's flexible, there's the least amount of negative side effects, and it can still provide all the same benefits, including decreasing your appetite, it can support weight loss, it can help boost brain function, it's been shown to improve concentration and alertness, and it can decrease inflammation. So we know clinically that time-restricted eating can improve your heart health by decreasing blood pressure, blood triglycerides, LDL, blood sugars and insulin. It may also even brain function, which can improve nerve cell synthesis and protect against some neurodegenerative diseases.

The disadvantage. Weight loss can occur initially, although can taper off. And some people may develop symptoms when fasting for long periods of time, including dizziness or headache, irritability, weakness, fatigue, nausea and hypoglycemia. These symptoms can be counteracted with adjustment of daily practices such as drinking enough water or adjusting the fasting times, adjusting the fasting windows, and even supplementing with electrolytes.

So the contraindications. We don't advise fasting if you're underweight or malnourished, if you are currently being treated for an eating disorder or have a history of an eating disorder, if you're pregnant or nursing. And we do caution with menstruating women due to the potential to influence hormone fluctuations. The benefits of the intermittent fasting next to the benefits of a calorically restricted diet. So the difference is there and in the middle, they both share the benefit of improving stress response, lowering blood pressure, improving insulin sensitivity and lowering cholesterol. But the intermittent fasting does promote ketogenesis. It's linked with your circadian biology. The circadian rhythm is the natural cycle of your sleep and wake cycles. So we do encourage the time restricted eating to be specific towards eating during the daylight hours and fasting during the nighttime hours. And weight loss is pronounced with those with elevated BMIs in intermittent fasting, and then there's promising long-term adherence, so it's pretty easy to stick to from a long-term perspective. On the other hand, caloric restriction obviously centers on the reduction of calories, does not include the ketogenesis or the circadian rhythm, but we do see weight loss amongst all BMIs.

So how do you find the right match? So ask yourself these questions. What is a realistic weight for you? How motivated are you to change? Do you have family support or social support? What is your financial situation like? And do you do the grocery shopping? Do you prepare the meals? What are your dietary preferences? All of these questions will help you find the right match. So answering them honestly and then trying to match the right diet with what you think is a realistic feasible plan for you to follow.

So really, the best diet is the one that you will follow. There are several influencing factors on what may be the best plan. So meeting with a registered dietitian can really help you pinpoint what is the best plan, but the dietitian can look through your diet history, your current eating habits. She or he will ask you about any previous successful plans that you've been on, and she or he may try to mirror that plan. You'll discuss your lowest adult weight or where your goal weight may be. Your past medical history will be reviewed and your current health status will be taken into consideration, and, of course, your preference, so really speak up and indicate which plan you think is best for you.

So please feel free to reach out to the Cleveland Clinic, Department of Nutrition Therapy, or the Center for Human Nutrition. Also, the Heart Vascular and Thoracic Institute can connect you with a proper dietician and help you find the best plan.

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