Evidence based nutrition and healthy ageing- time for a paradigm shift

Meanwhile, modern healthcare continues to focus on pharmaceutics and procedures despite their obvious limitations and incapacity to reverse chronic diseases. Complex, non-communicable diseases with multifaceted pathology warrant a different approach in which lifestyle changes are a crucial foundation of the treatment, not an optional bonus.

In our practice, we feel comfortable in the context of malnutrition and gladly recommend supplements, meat or eggs for protein and iron, milk and cheese for calcium or added butter/oil and cake to increase caloric intake in the hope of halting the progressive weight loss and ensuing frailty. But do we ever take the time to explore the bigger picture of nutrition science and how it relates to multimorbidity and frailty?

Looking closer at the concept of frailty, I cannot help pondering on the associations with poor dietary choices. Recent cohort studies show correlations of unhealthy dietary patterns with increased risk of frailty and dementia^2,3. The list of deficits from which the frailty index is derived contains diet related conditions: cerebrovascular disease, stroke, cognitive impairment, myocardial infarction, diabetes, hypertension, peptic ulcer, osteoporosis, chronic kidney disease. The suggested pathophysiological processes underlying frailty include cellular and molecular damage from chronic inflammation, oxidative stress, hormonal changes, dyslipidaemia, insulin resistance, gut dysbiosis- all of which are powerfully influenced by diet. Epidemiological studies clearly demonstrate that populations which traditionally follow plant-based diets have very low or non-existent rates of chronic diseases which in contrast are rampant in Western countries ⁴. You may have heard about Blue Zones⁵ – five places on Earth where people live very long and healthy lives with a high number of centenarians (Okinawa in Japan, Loma Linda in California, Nicoya in Costa Rica, Ikaria in Greece, Ogliastra in Sardinia).  These groups of people share a similar lifestyle with a diet based around fruits, vegetables, wholegrains and legumes (which resembles the traditional famous Mediterranean diet).

Plant-based whole food diet has been used successfully to reverse chronic diseases such as hypertension, coronary artery disease^6,7, type 2 diabetes⁸ and surprisingly, mild cognitive impairment and early Alzheimer’s, too⁹. This wealth of evidence favouring plant-based diet is supported by heart-warming stories of patients whose lives have been completely transformed by the power of their plate.

A healthy balanced diet has been promoted by the government and various organisations for years.  (if you ask a patient ‘How is your diet?’, you are most likely to hear the learned response: ‘healthy and balanced’ with little objective evidence that it truly is- source: own experience). Despite these efforts, our eating habits are nowhere near healthy with ever younger children being raised on high fat, high salt and high sugar, ultra-processed foods. Unfortunately, as doctors we do not tend to be great role models to either our colleagues or patients- we indulge in highly processed junk food the same way as everybody else- chocolates, cakes and crisps being ubiquitous on the wards. But geriatricians should know better- high sugar diets have been linked with dementia^10,11; Alzheimer’s disease has long been named type 3 diabetes for the highly damaging effects of insulin resistance and hyperglycaemia on brain neurons⁹.

We do not notice overweight and do not deal with obesity as much as other medical specialties (yet!). Nonetheless, it is not hard to imagine what medicine will look like when the current generation of young people raised on junk food will enter a phase of accelerated ageing.

So, at what point is it appropriate to educate patients about their diet? Hospital doctors mostly omit this issue and prefer to focus on the acute problem, assuming that the GP will be better placed to handle this ever present ‘elephant in the room’. Mentioning diet has become almost politically incorrect, an area that few hospital doctors venture to explore with patients in fear of stepping on the holy ground of personal choice and opinion, offending the patient, or not being able to offer any meaningful advice due to lack of sound, practical nutritional knowledge or motivational skills.

This is the time for a major change in how we think, talk and advise about food as well as in what we put on our own table- the revolution has already started and all healthcare professionals need to join in. Although due to limited resources geriatricians mainly focus on the frailest patients, who else will drive the change by promoting healthy ageing and warning about the catastrophic effects of unhealthy diet¹²? It is evident that many of the patients we look after will not be able to make major dietary changes on their own, however, we should not make assumptions based on our own preconceptions rather than using best available evidence (as we do in other areas of patient care). As doctors, nurses, allied professionals we constantly encounter patients and their relatives, colleagues and friends -there are many ways in which we can and should endorse healthy food choices in our hospitals and communities.

A similar profound paradigm shift was required 70 years ago with regards to smoking; worldwide, the healthcare community took on the challenge of educating patients while the governmental policy evolved accordingly over the years. Thus, even in an acute environment we never forget to tell patients off for smoking- dietary advice should equally become our top priority in the 21^st century. Hospital staff will play a key role in taking this task on beside primary healthcare staff, influencing our ward environments, hospital menus as well as local and national policies towards a generally more plant-based diet. By making conscious, deliberate choices each day about what we put on our plates and by empowering patients, their relatives as well as colleagues and loved ones to do the same we will contribute immensely towards the much needed and long overdue cultural change.

Why not start your journey with trying and recommending this delicious plant based, high energy, high protein smoothie which can be easily prepared using a high-speed blender. It contains beneficial plant protein, fibre, multitude of vitamins and minerals, various phytonutrients with anti-inflammatory, antioxidant and anti-cancer properties and is of course super tasty. Substituting kale and mango for half an avocado and a handful of berries will give you a great brain-healthy option, too.

1 cup (250 ml) fortified soya milk
1 ripe banana
A handful of frozen mango
2 large handfuls of spinach or kale
30 g pumpkin seeds
30 g flaxseeds

Plant protein powder – optionally for malnourished patients (will add about 20 g protein per 30 g serving)

Makes one large smoothie (500 mls= 580 kcal). Protein content is about 24 g (without supplemented protein)

PS. If you are interested in this topic but do not have time to read through all these references, I highly recommend the open access special plant-based issue of the Journal of Geriatric Cardiology (2017) 14:315 with several articles summarising current knowledge and recommendations, specifically directed at the geriatric population.

References:

1. How not to die? Michael Greger, Panmacmillan 2016
2. Gotaro K et al, Adherence to Mediterranean Diet Reduces Incident Frailty Risk: Systematic Review and Meta‐Analysis, JAGS January 2018
3. Ntanasi E et al, Adherence to Mediterranean Diet and Frailty, J Am Med Dir Assoc. 2018 Apr;19(4):315-322.e2.
4. The China Study: The Most Comprehensive Study of Nutrition Ever Conducted and the Startling Implications for Diet, Weight Loss and Long-term Health, T. Colin Campbell, BenBella Books 2004
5. www.bluezones.com
6. www.drornish.com
7. www.dresselstyn.com
8. McMaken M, Shah S A plant-based diet for the prevention and treatment of type 2 diabetes, Journal of Geriatric Cardiology 2017; 14:342-354
9. The Alzheimer’s solution, Dean and Ayesha Sherzai, Simon and Shuster 2017
10. Crane et al. Glucose levels and risk of dementia, N Engl J Med 2013;369:540-548
11. Cassar et al. Macrophage Migration Inhibitory Factor is subjected to glucose modification and oxidation in Alzheimer’s Disease, Scientific Reports 7, Article number: 42874 (2017)
12. Friedman M et al. Failing to focus on healthy ageing: a frailty of our discipline? JAGS 63:1459-1462, 2015