Optimizing Nutrition in Aging: A Podcast with Anna Pleet, Elizabeth Eckstrom, and Emily Johnston

Eric 00:00

This episode of the GeriPal podcast is CME eligible.

Alex 00:05

To claim credit, please go to the CME tab on GeriPal.org

Eric 00:09

Welcome to the GeriPal podcast. This is Eric Widera.

Alex 00:12

This is Alex Smith.

Eric 00:13

And Alex, today we’re going to be talking about optimizing nutrition in aging. Who do we have with us on this podcast?

Alex 00:20

We are delighted to welcome Anna Pleet, who did her medical training in Italy and is now doing internal medicine residency in the United States. And she is on YouTube at @annapleetmd. Anna, welcome to the GeriPal podcast.

Anna 00:36

Thank you so much. Great to be here.

Alex 00:38

And we’re delighted to welcome Emily Johnston, who’s a registered dietitian and research assistant professor of medicine at NYU. Emily, welcome to the GeriPal podcast.

Emily 00:47

Thanks for having me.

Alex 00:49

And we’re delighted to welcome back Elizabeth Eckstrom, who’s a geriatrician extraordinaire and professor of medicine at OHSU. That’s Oregon Health Sciences University, and whose new book is The Gift of Aging. Elizabeth, welcome back to GeriPal.

Elizabeth 01:04

Thank you, Alex. Glad to be here again.

Eric 01:06

So we’ve got a lot to cover on nutrition and aging, but before we jump into that, we always have a song request. Elizabeth, I think you have the song request.

Alex 01:13

She’s embarrassed to say it.

Elizabeth 01:15

I’m completely embarrassed. But the song I came up with was Cheeseburger in Paradise.

Eric 01:20

Why are you embarrassed? This is our second Jimmy Buffett song.

Alex 01:24

The late, great Jimmy Buffett. I think he died. In memoriam.

Elizabeth 01:27

Even I’m not even going to be able to sing along. I don’t know the words, but go for it.

Eric 01:34

In college, I worked security for Jimmy Buffett’s concert in Orange county.

Alex 01:42

With the parrot heads.

Eric 01:43

So much smoke.

Alex 01:45

I could imagine.

Eric 01:48

I would say, what’s in that smoke? But there is a lot of smoke. What other song did we do for Jimmy Buffett?

Alex 01:55

We did one recently. I don’t remember.

Eric 01:58

I remember talking about the parrot heads.

Alex 01:59

Yeah. Yeah.

Eric 02:01

All right, let’s hear it, Alex. Okay.

Alex 02:09

(singing) “Tried to emit my carnivorous habits, made it nearly 70 days losing weight without speed eating sunflower seeds, drinking lots of carrot juice, and soaking up rays. But at night, I’d have these wonderful dreams some kind of sensuous treat. Not zucchini, fettuccine, or bulgur wheat, but a big warm bun and a huge chunk of meat. Cheeseburger in paradise heaven on earth with an onion slice. Not too particular, not too precise amounts. Cheeseburger in paradise.”

Eric 02:55

It starts off very apropos to what we’re going to be.

Alex 02:59

Talking about sunflower seeds, carrot, zucchini, bulgur.

Eric 03:03

Wheat, but, uh, kind of swerves off into a particular burger. Okay, so I gotta ask. I’m gonna start off this. I love to hear all of your thoughts on this. So we’re going to be talking about optimizing nutrition and aging. How important is it? Like, I’m about to be 50 years old.

I feel like my diet is like, I’m paying attention to my diet a lot more now, eating a lot more fruits and vegetables, taking in more fiber, doing a lot of things. How important is it that we also think about that when people are in their seventies, eighties, they’ve been eating probably the same diet for 70, 80 years. Why change now?

Emily 03:47

It’s never too late. It’s ideal to have a good, healthy, balanced diet through your whole life, but it’s never too late. And you can work at different levels of prevention. So if you already have a condition, you might be able to prevent events. You could improve quality of life, have better bowel habits, less constipation. You can have short term things as well as long term things at any age. So it’s never too late. You know, based on our song choice, if people are dreaming about a big, juicy cheeseburger because they’re really depriving themselves during the day, that’s not balance either. So, you know, there’s a really, there’s an argument for having balance throughout life, and that’s important at any age.

Alex 04:29

All things in moderation, including moderation.

Eric 04:33

I love that line.

Alex 04:34

Yogi bear are one upping the Buddha.

Eric 04:39

And I’m going to turn to you. Safe question from your thoughts, because you actually have a YouTube channel that focused on public education around this. Do you know if is your audience mostly younger people, older people mix? Do you know much about your audience?

Anna 04:55

Yeah. So to answer your question, I know a lot about my audience, thanks to YouTube’s backend algorithm gives you all these analytics, and it tells you a lot more about your audience than you probably want to know. To be honest, I’m glad that you ended the question with that, because that’s really what drew me into realizing that this is a much bigger topic than I realized when I first started making YouTube videos teaching about healthy eating, the mediterranean diet specifically, and just healthy lifestyle practices.

More than 50% of my YouTube audience is age 65 plus. Like, that’s a lot of people in that cohort who are a on YouTube, which I didn’t realize. I thought, okay, this makes sense. Just as time goes on. More and more people are on YouTube in general. So, hey, people are getting their grandparents involved or their aunts and uncles saying, oh, I think I know someone who you might like to follow. They’re this influencer. And so people are getting hooked into it, but on their own. People are also using YouTube specifically, but social media as its own search engine. It’s not just Google anymore. People want to see a video. It’s somebody explaining to them this thing that they’re confused about. And one of the classic things people are confused about, I think, is how to eat healthy.

So it just made sense to kind of bring that all together. But at any age, like, as Emily said, it is so important to pay attention to nutrition and healthy eating because it’s not just about, oh, chronic disease prevention or even treatment and management. You feel better in the moment, so it doesn’t matter how old you are, feeling good helps you have a better quality of life. And I think that’s something that we can really focus on, especially with geriatric patients. They really need that.

Eric 06:41

Yeah. And I love your videos, too, because for myself, I liked watching them to see, like, oh, what actually goes into a mediterranean diet? Like, what would a breakfast look like? I just watched a video of you kind of going through a breakfast, lunch, and dinner, just seeing what a breakfast could look like in a mediterranean diet. We’ll have a link to that video and to the YouTube page, too, which I thought, again, was absolutely fabulous.

Anna 07:06

Thank you. Yeah, it’s a good question. I know Elizabeth has a lot of information about the way to structure the mediterranean diet. When I was a medical student, I actually worked with Elizabeth in her research group at OHSU. And so we did, like, a little project about it, and I think she’ll probably be able to fill in the details. But I realized there’s not just one mediterranean diet, which makes sense because there’s also not just one vegan diet. Vegan is a little bit more clear cut of, you don’t eat these things, so by default, you’re eating all the rest of the stuff.

Eric 07:40

There’s a lot of mediterranean countries.

Anna 07:42

That’s the point. Right. And I didn’t appreciate that until I lived in Italy, and that’s where I did medical school for six years. And I thought, okay, we have the Italian version, we have the spanish version, we have the north african version, we have the turkish version, we have the greek version. They don’t all agree, but the commonalities between them are the things that are healthy. So I realized, okay, it can be kind of a malleable concept. And for any, any diet, it can, we can really tweak it to an individual’s preferences, their needs, that kind of thing.

Eric 08:13

And Elizabeth, you just read a book. What was the title of the book again?

Elizabeth 08:16

It’s called the gift of aging.

Eric 08:18

The gift of aging. What do you say in your book about nutrition and aging?

Elizabeth 08:25

Well, I say it’s pretty much the key to life, certainly between nutrition and exercise. If everybody did that well, they would live much longer, be much healthier. Emily said it can start right away. It’s so true. And, Eric, you’re hitting that magic number 50. I have to say. I’m hitting the magic number 60 along with you. So we’re starting to see some of those changes of aging, and I think that getting started early is great. I’ll just throw out this kind of fun little term that a lot of people haven’t learned before. It’s called hormesis.

And hormesis is when something is a little bit acerbic or it’s a little bit poisonous to you, but if you eat it over and over again, you get used to it and your body builds up resilience. Vegetables and fruits have a little bit of hormesis to them, so they’re a little bit toxic to our systems. And as we build up resilience, it makes our immune system stronger. It just makes us stronger in general. And you want to start fairly early. And I can add on, there’s this fascinating research on the microbiome, which I’m sure you’ve all read about quite a bit, but they say that people at midlife, kind of our age, can have a gut midlife crisis, and we can start to really go down downhill with our GI system.

And as Emily mentioned, the constipation, those kinds of things. And if you eat, and this is more prebiotics than probiotics, but things like garlic and asparagus, if you eat those things, you can overcome that midlife crisis and kind of have your aging gut age well with you. And then the microbiome itself, just give me a guess. If you start eating the mediterranean diet, how long does it take to change your microbiome from an unhealthy microbiome to a healthy microbiome? Alex, you guessed, too. Eric and Alex, both of you, give me a guess.

Eric 10:30

What is a healthy microbiome versus unhealthy? I’m gonna go now.

Alex 10:34

We gotta answer the question. I’m going. Three months.

Eric 10:38

Three months? Three months for what?

Alex 10:40

To change the microbiome.

Eric 10:41

To change the microbiome, unhealthy to healthy.

Elizabeth 10:44

Yeah, the gut bacteria. From the gut bacteria, from bad bacteria to good bacteria.

Eric 10:49

I’m going to say a year, three weeks.

Elizabeth 10:53

Wow. So you asked the question, if you’re, isn’t the horse already out of the barn? Right. But really, you could be 85, you can be 95. It only takes three weeks to make your gut healthier. And when you tell your patients that, they’re like, what? You’re kidding. So it’s just a really good kind of starting place around some of this information of what you’re actually doing when you do the mediterranean diethyde.

Eric 11:16

Okay, I’m gonna play the cynic here. If it is so amazingly good, it only takes three weeks and you feel better and you maybe lose weight, your microbiome changes. Do we have a lot of randomized controlled trials that doing a diet like the mediterranean diet improves all of those outcomes?

Elizabeth 11:41

Oh, boy, that is such an easy question to answer, Eric, there’s so much evidence out there. So really there are big randomized trials, like predimed in Europe. And Anna will talk some more in a moment because she spent so much time over there. But, yeah, there’s excellent randomized trial data on the benefits of mediterranean diet for cardiovascular risk reduction for stroke, risk reduction for dementia, risk reduction for diabetes, risk reduction for depression, risk reduction for pain and osteoarthritis. Go on, Anna. What are some of the others?

Anna 12:17

Yeah, actually, I was seeing a study for PCOS. Now there’s evidence for some more specialized hormonal conditions. I think what Elizabeth’s touching on is there’s actually so much evidence, and that’s why it’s almost funny that this is not something more well understood and disseminated. I had the same kind of aha moment, and Elizabeth helped me think through this while I was in school. And we were talking about, we both obviously love food and diet, and we thought, you know, there’s like, a missing piece.

And there’s so much research. Like, I think there’s a lot of evidence. I don’t know if the world needs more bigger RCT’s just about something like the Met diet. But I started to see, like, okay, well, if this is so great, why is it not maybe more top of line for, like, treatment protocols? And why is it not more well understood? Well, part of what I said before, where there’s more than one, like, for example, mediterranean diet is actually, like, it’s not that specific. It doesn’t mean you must eat two tablespoons of olive oil on two cups of lettuce, and then here’s your chicken. Like, it doesn’t have to look like that. So the practicality of actually running a trial is tricky when is. It’s hard to fit it all into a box, obviously. And notoriously, I think this is really in Emily’s wheelhouse more.

But, like, diet research is inherently challenging for so many reasons beyond studying one thing at a time. Because you’re not studying one thing at a time, you’re not looking for just one outcome. And so all of, a lot of the research is very preventive. So it’s like we’ve all this evidence for the prevention of x, y and z chronic condition because that’s easier to kind of deal with.

Eric 14:06

But looking, or like a pill like ozempic where you can give it charge, you know, several thousand dollars a month.

Anna 14:14

Yeah. The time it takes to look at chronic disease prevention or outcomes is just, it’s in the word chronic. It takes time. So those are expensive studies to run in the first place. Emily, you probably have a lot more to say just about the research alone.

Eric 14:30

Yeah. And there’s no big pharma company that’s going to rake in all that money based on the mediterranean diethyde.

Elizabeth 14:37

Yeah.

Emily 14:38

It’s hard to get funding for big nutrition studies, but we do have a lot of great evidence. And one of the really fantastic programs and studies that we have is the diabetes prevention program. So the first diabetes prevention program was published in 2002. So diabetes prevention programs have been going on for over 20 years. And this is especially important for older adults because the program is a year long and it’s a lifestyle change program.

And something great about it is that it’s flexible. So it’s actually not based specifically on the mediterranean diet. It’s more about balance and cooking more at home and learning to read labels and being active. It’s the whole lifestyle picture. But for adults over 60 who completed the program, they reduced the risk of diabetes by 70%. So we have some really great evidence for lifestyle interventions for chronic disease prevention.

Eric 15:28

Oh, yeah. Emily, I got a question for you. So I’m hearing, and I’d love to talk about specific diets and maybe the evidence for them, but before we do that, how should we ask about this in our clinics? Not just about like we think in geriatrics training, it was about like, you had one category about, like, obesity, in one category about inadvertent weight loss. But we don’t talk a lot about, like, healthy nutrition in the middle. Do we ask about that?

Emily 15:56

I vote for yes. I think if you bring it up, the patient sees that it’s really important to their health.

Eric 16:03

How do we bring it up?

Emily 16:04

One option is using the five a’s. So is it okay if we talk about what you eat today and so you ask permission first? You can also put it into as you’re discussing other, like at an annual visit, like, oh, have you been sleeping well, you know, have you been vaccinated? Oh. And what are you eating these days? And so there are screeners, lots of validated screeners, but there’s also the option to just say, do you eat one or more servings of fruit each day? Do you eat one or more servings of vegetables each day? Do you consume sugar sweetened beverages?

Eric 16:38

I’ve always been a little bit confused, though, about the servings. Do most people know what a serving of vegetable? No, I’m seeing a shake.

Anna 16:46

Yeah. I got this question on my YouTube channel lot.

Elizabeth 16:50

Yeah.

Emily 16:52

If you look at the, if you look at the dietary guidelines, it’s actually a little bit confusing. It’s like one cup equivalent is like raw versus cooked versus juice.

Eric 17:00

Like, I just had a whole apple. Does that count as a serving?

Emily 17:04

Pretty much. So, like, a rule of thumb is you could use your fists. Like, this is the medium sized apple. So that’s one serving of fruit. So you can be, you can do the sort of shortcuts. There you go.

Alex 17:15

I was holding up an apple for our listeners.

Emily 17:18

Oh, yeah. So you can use your, your fist for serving of carbohydrates or a medium piece of fruit. You know, a handful is like a serving of almonds or other nuts. So you can use some of these shortcuts. You don’t have to have a measuring cup necessarily, but you could tell people half a cup to a cup is a serving of fruit. And same for vegetables. You want to have two or more of each of those in a day, but you don’t have to do full nutrition counseling with your patients. You’re not dieticians. We want you to refer your patients to us.

But if you just start that discussion with them and say, hey, you’re starting metformin today, for example, it will really help that to work for you in the long term if you take more steps each day. Try to drink more water and less soda, try to eat more fruits and vegetables and less snack foods. So you can just really be very, very general, but just have that discussion so they see it’s part of their plan of care.

Eric 18:14

Elizabeth, how do you bring it up in your clinic?

Elizabeth 18:17

I typically bring it up on the very first day I meet people because I. Yeah, absolutely.

Eric 18:23

Up to the front of the line.

Alex 18:25

Yep.

Elizabeth 18:26

What’s your diet like? What do you do for exercise? You know, have you, have you done your advanced care planning and a few other things, but diet is right at the top of the list. And I’ll be like, what do you usually have for breakfast? What do you usually have for lunche, what do you usually have for dinner? What do you eat in between? And we’ll kind of go through and I’ll be like, well, how’s that feeling to you? Is it feeling pretty healthy or are there things we could talk about? And, I mean, you know me, I have opinions about everything, right? So I’m like, bacon and eggs that you’re having every morning, that’s going to kill you. And you know what? It’s not going to kill you very long from now.

So we start talking about, you know, what they’re, what they’re doing. What are some things that would be a little bit better if they, if they’re eating bacon every morning? We’ll switch them to some turkey bacon and just start making gradual changes. But I try to get my patients to kind of go all the way, as Anna saw when she was working with me. I mean, we’re into the lentils and roasted vegetables and just really getting into the plant based diet. And I’m constantly working with my patients to try to get at least 70% of their protein from plant based sources so that they have really mostly plant based diet and are getting plenty of protein in their diet.

And sometimes my whole session will, we’ll spend time talking just about diet or diet and exercise, and they’ll be like, wait a minute. You didn’t talk about my diabetes or my heart failure or my COPD. And I’m like, well, if you do diet and exercise, those things are not going to matter anymore.

Eric 19:56

I guess the other question is, when we’re thinking about for older adults, being overweight is not good for your health. Being underweight is not good for your health. There’s this thought, like there’s a j shaped curve as far as mortality. And when we look at prognostic indices, too, like being very underweight and losing weight is a bad sign for older adults, how do you incorporate things like energy balance into talking with patients? Emily?

Anna 20:25

Yeah.

Emily 20:25

So just thinking about the diabetes prevention program as an example, because that is where I’m doing a lot of my research right now. We talk to patients about slow, consistent weight loss. We don’t want them losing more than really a half a pound a week at the most. And so we talk to them about maintenance and slow progress. So they do some diet tracking. Some like, they’ll have either a paper food record or they’ll use an app to keep track of their diet, just for a short time. They don’t have to do it for the whole year, but it gives them an idea of what they’re eating. And then we show them some recommendations for ket energy intake, for their I age and weight and activity level, and we do some comparisons. But you’re not recommending that these patients cut 1000 calories? You know, we’re doing very, very small changes, particularly with older adults, because we’re concerned about muscle loss and we want them to lose weight really gradually.

Eric 21:20

Yeah. And I also get this. First of all, I think all three of you would be fair to say you’re proponents of a mediterranean diethyde. Yes, we’re nodding, but it’s also hard because diet implies, for a lot of people, like something you do to lose weight. But I also get a sense watching your YouTube videos, Anna, is it’s not necessarily like a diet diet. It’s a way of life. Part of the diet is actually the socialization that comes with just sitting at the table around food that is good for you and healthy and encourages socialization, which is important for older adults. Is diet the right word I should be using?

Anna 22:04

I love this question because it touches on one of my buttons that gets pressed. It’s such a misnomer, mediterranean diet. And I’ll tell you a story that really clarifies this. So this was when I was probably my. Yeah, I was in my fourth year of medical school. Now, training outside of the US and Canada is usually a six year program. So fourth year is where you start your clinicals. So I was on rotations, and there were two things that happened simultaneously that both were like, what is going on? The first was that I was training in Italy, where is, you know, the capital of the Mediterranean, let’s say it’s food centric culture.

And Milan, where I was specifically, is also really a hub for the rest of the country. So a lot of the time specifically for medical care, because the north of Italy has some of the best technology. People are coming from the south, they’re coming from the islands for their surgeries or for their rare disease consultations or their specialty follow ups for really advanced or difficult cases. And I was shocked at the number of patients that were asking the doctor, doctor, what should I eat? And I’m thinking, wait, you guys are the mediterranean diet and lifestyle? You don’t need to ask because you’re doing it already. They don’t even realize that. So that was sort of like a wake up moment for me where I thought, okay, there’s confusion everywhere in the world in general. That’s the first point. The second thing that happened was once I started really getting into the Italian culture more, and I was able to converse with nurses and other students in Italian.

I really got to connect with the way they think a lot better, which happens whenever you speak a local language to somebody, you see a whole different side of them. And it was crazy to me how many people, Europeans, not just Italians, but general Europeans, had never heard of, for example, the mediterranean diet. And I thought, this doesn’t make any sense. You guys made it up. Like, this is your. This is the stuff. Like, all the research has come out of this region to show all of this benefit to our health, and you guys have never heard of it. So I thought, wait a second, how did this come about? And that’s when I started, like, studying more formally, like, what is the mediterranean diet? Because you don’t get that in your medical training. Like, nobody sits down and is like, these are the healthy, evidence based dietary recommendations that we should probably be focusing on when we have conversations with patients. Like, that lesson doesn’t happen.

I don’t know whose medical training has that course, and if so, please share with the rest of us. But I realize, okay, so we don’t even know what it is over here in the mediterranean region. So what are we talking about? So if you look at the literature, you’re going to see these very regimented, kind of like clear cut components of a mediterranean diet. And what are those things? It’s a mostly, or if not all whole foods, plant based diet that also includes a good amount of animal proteins, mostly coming from fish about two to three times a week, and then eggs and dairy, ideally high protein dairy, typical dairy that you would see greek ogre, ricotta cheese, mozzarella, but not necessarily a lot of butter.

That’s not really even considered dairy. If you look at it nutritionally, it’s really just an oil. And then at the less amount eaten, but still included is things like poultry, and then the least amount is red meat and sweets. So there’s a nice pyramid that people can look up. And if you want, you can put the link in the show notes because I think it’ll be useful for people. There’s a group, old ways in Boston, and they teach this really well. So they have, like, a little mediterranean diet pyramid, and it shows you all the components, and that’s sort of like a nice foundation to teach people and use it as a visual aid of, like, okay, this is what’s supposed to be inside of the mediterranean diet. But when you take a step backwards and realize, where did this all come from? This was not an approach to eating that was theorized and then deduced. It was observed in reality the way people live over hundreds of years, honestly, thousands of years in some places.

Places like Sardinia, for example. And it works. And it works because it survived for so long. But the funny thing, and this is like a classic myth of the mediterranean diet, it’s like, it’s too expensive. Well, the irony is that this diethye resurrected from the poorest communities in the mediterranean region. So it’s rice and lentils and beans and vegetables that grew seasonally, and fish, because they lived by the sea. And that was more available and affordable than getting something like red meat or having your own farm. I mean, picture a thousand years ago, people eating.

Eric 26:52

So, and I also imagine that, like, even when you think about Italy, is that there’s. There’s a big difference between what they eat, like, in Sardinia. Right, versus what they may be eating in other places, even like Milan.

Anna 27:05

Oh, yeah, for sure.

Eric 27:07

When we think of the prototypical mediterranean diet, I think about Sardinia and that area. The people really farm to table stuff. Lots of fish, lots of vegetables.

Anna 27:19

This is it. I had an amazing opportunity of being an au pair in the summer in Sardinia. So I lived with a family there. That’s where I actually really learned this stuff. I was not learning it in Milan because Milan has guys. They have Burger King. People are into that now.

Alex 27:35

Germanic influences up in, let’s call it alpine.

Anna 27:40

Yeah, I’m biased because I also used to live in Germany, so I do like Germany. But anyway, the point is there’s a lot of variance, and if you think about what the poorest people can afford, it’s likely more mediterranean. That’s honestly the easiest way for me to.

Eric 27:58

And you actually did that, right, with Elizabeth? You actually looked in grocery stores around the Portland area, looked at accessibility, cost, and how hard it was to cook. Was that what you looked at? If I remember your ags talk?

Elizabeth 28:13

Yep.

Eric 28:13

Tell us about that, Elizabeth.

Elizabeth 28:15

Anna went out to the grocery stores and with another one of our research assistants at the time, and they bought, you know, a bag of lentils for $0.89, enough to, you know, cook for, like, ten meals and bok choy and, and various things that were really inexpensive and put together a whole bunch of meals that were like $8 for four people for this delicious meal. And so it was really inexpensive. And so we overlaid, we took the map of the lowest income neighborhoods in Portland and the neighborhoods in Portland that had the highest percentage of older adults.

So we overlaid resource poor neighborhoods with the oldest neighborhoods. And we shopped at the grocery store. They shopped at the grocery stores. I didn’t go with them. Right in those. Exactly. Neighborhoods. And that’s where they found all these ingredients that were totally mediterranean diet and really inexpensive. And I mean, you know, olive oil in the US is a little bit of a misnomer because it’s hard to get super cheap olive oil. Actually, when I was preparing for this, I went out to the grocery outlet or whatever it’s called, like the cheapo place, and they actually had some pretty cheap olive oil. So it’s not like it doesn’t exist. But that’s a, it’s a little bit harder to find cheap olive oil, especially when you’re buying extra virgin, which we certainly do recommend.

But it’s, but it’s just a matter of cooking. I mean, you cook up some, you cook up some lentils, you add some garlic and onion and, you know, some red pepper and, you know, fresh spinach, or you can even use frozen spinach and your meal costs a dollar and it’s absolutely delicious and so incredibly healthy for you.

Eric 29:51

Go to your house for dinner tonight. Elizabeth.

Elizabeth 29:53

Yeah, come on over. It’s going to be farro and roasted vegetables and toasted pumpkin seeds.

Eric 29:59

All right. Emily, I got to ask you a question. We’re talking a lot about mediterranean diet. Where do the other, other diets, your dash diets, your keto diets, your give me another diet.

Alex 30:12

Alex, there are a lot of people who are doing the intermittent fasting.

Eric 30:16

Alex, intermittent fasting. Do you recommend a specific diet like Mediterranean? Do you see what they’re like tailored to the, I’m guessing you’re going to say tailored to the person, but how do you think about all these different diets?

Emily 30:29

Yeah, it’s a really good question. And just to go back to your previous question for a second, you know, I recently talked to some patients on an advisory board, and they said, don’t ask me about my diet. Ask me about the foods I eat. So just in terms of, like, terminology, you can also say plan. In research, we’re saying dietary patterns more now than diet, but patients don’t necessarily want to hear about that. So either plan or, you know, think about which foods you should have more of and which foods you should have less of.

That can be helpful in terms of the dietary patterns that I would recommend for or against. Mediterranean. Absolutely. Lots of evidence and a lot of really simple, inexpensive recipes like Elizabeth was talking about and like Anna experienced. And the mind diet is a focus of one of my research studies right now. The Mediterranean dash intervention for neurodegenerative delay. It’s quite a mouthful, but it’s a combination of the dash diet and the mind diet, and it’s really focused on neuroprotective food. So it has olive oil, it has berries, it has dark, leafy greens. It’s really focused on carotenoids, which are the bioactive pigments and fruits and vegetables that protect your heart and your brain.

And so we have the mind diet. It’s, you know, in the news a little bit more. People are talking about it for dementia prevention because we have a lot of evidence showing that it is associated with lower cognitive age. So, again, good evidence, really simple and straightforward messaging you can give patients you don’t have to.

Eric 32:03

Are there studies looking at whether or not it decreases risk for dementia?

Anna 32:07

Yeah.

Emily 32:08

So studies out of rush have been coming out about this, and Martha Claire Morris has been talking about the mind diet now for, I think, since, like, 2012. So she’s got some really great research about the mind diet and how it really does protect against cognitive decline. But as we know, it’s not just your diet, right? It’s your whole lifestyle. And, like, in the mediterranean diet, socialization and, you know, eating together and moving more, all these things contribute. But if you focus on these foods that are protective of your heart and brain, you may have a lower risk of chronic disease in the future.

Anna 32:47

There’s.

Emily 32:47

There’s very little long term evidence of the ketogenic diet or paleo diet or any of these diets that are really high in animal protein, and they’re not recommended by any of our scientific bodies except in, like, extreme cases, like in epilepsy, it’s been shown to be beneficial in certain cases, but for long term health and chronic disease prevention, there’s really no evidence for that. And I’ll just make one comment about intermittent fasting, and that is as long as you’re intermittent fasting when you’re eating, you’re eating something healthy. Some people eat on different schedules, and I don’t object to that.

But I think from personal and patient experience, I’ve found that some people intermittent do intermittent fasting and eat nothing but mashed potatoes in a day, because they can eat whatever they want as long as it’s in this four hour window. And so that’s the misconception that concerns me.

Eric 33:39

Yeah.

Alex 33:40

I have a couple questions. Our listeners may also be curious. What is farro?

Elizabeth 33:47

High protein grain. It’s an ancient grain that is absolutely delicious. It’s also called spelt. Especially in Europe, it might have that name instead of farro or farro. And you can put anything in it. I mean, I was in Italy and had this delicious salad that was a spelt salad. Cold. It was a cold salad that had arugula, fresh tomatoes, and bunch of olive oil. And just that combination was so absolutely delightful. You know, you just. You can’t kind of can’t beat using those whole grains for things. And so I’m. I mean, I already cooked some this morning.

I cook something like that practically every day just to kind of add in, to add my protein, get my whole grains into my vegetables, whatever I’m doing with the vegetables, a salad, roasted vegetables, those kinds, kinds of things. I’ll add one of those ancient grains to it.

Alex 34:38

All right.

Elizabeth 34:39

My wife, or lentils, legumes.

Alex 34:42

I’m half asian. My wife’s full asian. We have rice, like, two to three times a day, every day. How do you feel about rice?

Elizabeth 34:51

Is it whole grain?

Alex 34:54

We usually mix the white and the brown rice, though. The kids try and up the proportion of white rice, whereas my wife and I try and up the proportion of brown rice when we make it.

Elizabeth 35:04

When I met my husband, one of the first meals he cooked for me had, like, this white sushi rice, and I was like, darlin if we’re going to be together, we got to get rid of the sushi rice. But it’s a great question because, you know, we talk about Mediterranean, but really, there are a lot of places in Japan that are eating exactly the same diet now. They’re all dying of stroke because they add soy sauce, and that’s really, really gives really high salt.

So it can make a huge difference. And I have to take all my japanese patients off of their soy to get their blood pressure under control, but there’s so many fresh vegetables, and they’re just cooked quickly. And the Japanese blue zone has, eats, like, 60% of their diet is these purple yams. Emily might remember the exact name of them, but we eat garnet yams, kind of the reddish ones, and they’re delicious, too. But these purple yams have so much health benefits to them. I think they taste a little more mealy I like.

Eric 36:00

Can I ask you brought a blue zone? Are blue zones those areas where you have Sardinia, high populations of people who, who’ve lived a very long time. Is that right?

Elizabeth 36:09

Over 105 of them. The highest populations in the world of people living over 100. And guess what, here I am asking you a question again. Guess what the rate of dementia in the blue zones are. Most centenarians in the entire world, what.

Eric 36:24

Is their rate of dementia in 100 year olds? I don’t know.

Alex 36:31

20%?

Eric 36:32

35.

Elizabeth 36:34

Less than ten.

Alex 36:35

Wow, that’s amazing.

Elizabeth 36:39

So one of them is in Japan, right? And one of them is Costa Rica. So you don’t have to, it doesn’t have to just be mediterranean. I mean, the Costa rican diet is so incredibly healthy. They have so many fruits and vegetables in it. And so you can, you can eat many different styles of food as long as you kind of stick with these elements of whole grains. And Alex, I’m totally into whole grains. You are absolutely fine with your whole grain rice. Just get those kids to go down.

Alex 37:06

And I love Costa Rica, too. Pura vida. But okay, another question. How about the fake meat? We love impossible meat. Is that are we getting any health benefits by having the plant based meat? It’s plants. Right.

Elizabeth 37:23

But it’s processed. Right. And I have no idea what the answer to this question is. So, Emily and Anna, please.

Emily 37:30

Well, I’ll just give one example. And that is the, the impossible whopper is really quite similar to the regular whopper in terms of calories, sodium, and even saturated fat because it’s made with coconut oil, which is a plant oil, but it’s saturated fat. So you can use it occasionally. But I don’t recommend using processed plant based foods on a regular basis because it’s very salty and it has, has some ingredients we don’t love.

Eric 37:58

Okay, I got another question then. I want to go to the practicalities of, like, what does a breakfast lunch? Because we often do that. Like, oh, just tell me how to treat, like, neuropathic pain with what medicine? We’re going to do the same, but with food. But before we do that, I got to ask about supplements like ensure. Emily, what do you do with that? Because it’s used by so many older adults.

Alex 38:21

Yeah.

Emily 38:21

Yes.

Eric 38:22

And I don’t think it’s part of the sardinian diet. Is that right, Anna?

Emily 38:29

Yeah, there’s lots of ways to get extra protein and, and calories. And for people that have difficulty preparing their foods or, or, you know, need some kind of ready to eat food, that might be a great solution, but it’s not the number one choice. We always recommend food first. So I mean, you could have somebody drinking, somebody having like a peanut butter sandwich on whole grain bread, and that’s got, either know, a few hundred calories, it’s got healthy fat, it’s got protein. So if they’re able to prepare something, even something small, they could make themselves a shake at home. But if your patient is not able to do those things, I wouldn’t say don’t have insurer. That might be a great solution for them. But if they have family support or they’re able to make some foods from scratch at home, that would be preferable.

Eric 39:17

And when you think about nuts, because we brought up peanut butter, do you think about nuts as like a big category? Are there specific nuts? I’m kind of nuts about with nuts right now. My own diet that you look at like pistachios, walnuts, almonds.

Emily 39:31

Yeah, walnuts. There’s the most research for walnuts and almonds, but all nuts have healthy fat and plant based protein and fiber. Don’t get the honey roasted ones is my usual number one suggestion.

Alex 39:45

I love those.

Emily 39:46

And actually, like, dark chocolate covered nuts is, are a great dessert, but they’re not like a, necessarily like a healthy snack food. But having a couple of those as a dessert is a great way to have something sweet that’s not too unhealthy. But, yeah, I think, you know, especially if you’re buying natural nut butter so there’s no added sugar or palm oil or anything like that in there. Really great, even. And peanut butter is just fine, too.

Eric 40:09

Okay, I’m going to go ahead.

Elizabeth 40:11

Something that a lot of people don’t know is that when you have kidney failure, you know, you have to decrease the nuts that you eat. And that’s when peanuts are great, because peanuts are legumes and you can, you can eat those, like into stage five CKD where you have to stop some of the other nuts before that.

Eric 40:26

So is that because of potassium content?

Elizabeth 40:29

Um, I don’t think it’s terrible.

Emily 40:32

Oh, I think it’s phosphorus, but I.

Eric 40:34

Oh, phosphorus and the nuts. Okay.

Elizabeth 40:35

Yeah, yeah, but.

Eric 40:37

All right, let’s, let’s go with breast tax breakfasts. And I’m gonna start off with you give me like some, an example or what you had for breakfast today. Like, what does a mediterranean diet look like from a breakfast standpoint?

Anna 40:53

It’s a great question. And there’s not only one correct answer.

Eric 40:57

Yeah.

Anna 40:58

I will also say before I give you the, ooh, this is the healthy version. If you actually go to the mediterranean region, looking around at the bar. People are not eating this way. Often they’re eating this way in their houses, but not in the cafe. It is not the coffee with the milk and the sugar and the cream in the pastry. Croissant. Yeah, we love that. Obviously. Who doesn’t love that? But that’s not like a mediterranean diet breakfast. Mediterranean breakfast. So.

Eric 41:24

But give me your favorite something.

Anna 41:27

Whole produce form. If you like sweet, have a piece of fruit. If you need savory, go with vegetables, a source of protein. So on the sweet side, that could be like a greek yogurt is the classic. I also enjoy a lot of cottage cheese. It’s very high in protein. Or if you like the savory side of things, eggs are the easiest go to. And pretty much every variation of the mediterranean diet has an egg dish for breakfast. So it’s a safe choice. And then some kind of a whole grain or green if. If you can’t do from whole form because people aren’t usually eating rice or far for breakfast, I think having a whole grain bread or a cracker is totally fine.

Or even a rice cake. When I’m in a rush, I eat a rice cake. Like, there’s nothing wrong with a rice cake. Sometimes that’s the best you can do. So, yeah, that’d be like a good breakfast. Like a piece of produce. Focus on the protein. Something that is fibrous, ideally from a whole grain or just extra vegetables.

Alex 42:23

Cottage cheese is healthy.

Speaker 6 42:26

Wait, as long as you don’t get.

Elizabeth 42:28

The full fat version.

Anna 42:30

As long as you get the fruit on the bottom version. I have to say, I think I have a slightly different perspective than a lot of nutrition professionals on this, but I’m not that concerned about one food in someone’s diet. If someone’s like, that’s my thing, that I need that full fat flavor, I’m like, okay, let’s talk about the whole thing.

Eric 42:47

And so it’s okay for me to have that cheeseburger occasionally?

Anna 42:51

Well, we’re talking about a meal there, but, yeah, but honestly, totally. And like, that’s built into, I think, any healthy diet regimen, you want to have a good balance, otherwise you’re not going to stick with it. It becomes too diet like and not lifestyle like.

Eric 43:06

Yeah, yeah.

Alex 43:08

Emily, I think, had a comment on my idea that I’m now going to eat cottage cheese regularly.

Emily 43:15

Well, I actually also would be more concerned about the fruit on the bottom than the whole fat because that it’s just like a bunch of syrup. So if you’re eating like one serving of cottage cheese with some fresh blueberries. That’s a great breakfast, very high in protein. You get your fruit if you can. If you don’t hate reduced fat cottage cheese, that’s a better option. Sure. But like Anna said, I mean, that is the approach of nutrition professionals. Like, if you love cottage cheese. Yes. Eat it. How healthy can we make it? What’s the healthiest version of it that you can eat and still enjoy?

Eric 43:50

That’s the goal, Elizabeth, when you’re talking with patients, like, if you’re giving them, like one of your ideal, like, get them excited about a lunch, mediterranean diet lunch, what would that look like?

Elizabeth 44:02

Yeah. So again, I’ll go back to some hearty greens, you know, spinach, kale, chard, something like that. Have them put some cooked, cooked farro or cooked lentils on it. Add some, you know, red peppers, toasted pine nuts, toasted pumpkin seeds, toasted, you know, whatever, toasted walnuts, and then just a little bit of olive oil and maybe some seasoned rice vinegar and salt and pepper. And good to go. It’s a fantastic lunch. If you don’t have that much time. I mean, I’ll go back to, I eat low fat cottage cheese.

Anna 44:35

I love it.

Elizabeth 44:35

And I’ll, I’ll add some fresh tomatoes to that. I’ll add some spinach. You know, chop up a little spinach, chop up a little shallot. Just put that in and you get your plenty of protein. But really having some, some of those cooked lentils or whole grains that you can just add into anything, you’re going to get your protein source and it tastes just absolutely delicious. People love it.

Eric 44:58

All right, Emily, you talked about mind diet. Give me a good mind diet dinner.

Emily 45:02

Sure.

Eric 45:03

So convince me to do the mind diet based on the most delicious dinner you can think of on a mind diethyde.

Emily 45:09

So think about your plate. You’re going to divide it in half. Half of it’s going to be vegetables, a quarter of it’s going to be protein, and a quarter of it’s going to be a carbohydrate. So I love salmon. And any kind of fatty fish is on the Mediterranean and the main diet. So we’re going to have some salmon, we’re going to have some quinoa because it cooks really fast. And we’re going to have a nice sauteed spinach with lemon and olive oil and chickpeas.

Eric 45:37

I love that. So wait, wait, half of the plate is vegetables. Does fruit fall into that, too, like that? No vegetables.

Emily 45:45

Just vegetables.

Eric 45:47

A quarter of it is your protein.

Elizabeth 45:49

Yep.

Eric 45:50

And then a quarter of it is carbohydrate. Carbohydrates. Give me some example. Other examples of carbohydrates I can put in there.

Anna 45:57

Sure.

Emily 45:58

So Farro, like Elizabeth mentioned, Alex, rice is, is also a carbohydrate. And again, it’s a quarter of your plate. So if rice is your food, you can’t give up. You can eat it. Just put it on the quarter of the plate. Don’t make it the focus of the meal. Bread, potato, those beautiful purple yams Elizabeth mentioned, you can have fruit as the carbohydrate in your meal if you prefer not to have a starch. So that’s another option as well. Let’s see. Did I miss any? If it’s breakfast or if you love oatmeal. Oatmeal is a carbohydrate. It’s nice and high in fiber, and you can have that at any meal.

Eric 46:30

Great. All right, Anna, you’ve done a lot of videos on this, which are the meals that you get the most feedback like, or do you get feedback like, this was a great meal. I did this today. Loved it.

Anna 46:42

People really appreciate the fact that I’m talking about pasta. I can’t not.

Eric 46:48

How do you talk about mediterranean diet and not talk about pasta?

Anna 46:51

I think there’s, I actually had a lot of fun making my video about, like, the research on pasta because I learned a lot just in going to the literature and trying to figure out, like, what is the evidence for pasta? There is so much misconception about, like, what pasta does for our body or blood glucose and what it doesn’t.

Eric 47:08

It is pasta good or bad?

Anna 47:10

I’d say it’s great. And it’s, and I can tell you there are millions of people out there who’ve been eating this for a long time, and they’re doing pretty well.

Anna 47:22

I’ll say this, it is more typical in an Italian dinner to have a first and then a second course. So you have a small plate first. And I have no idea physiologically if that makes a difference. By eating orzo, you think it’s the other way around, that you’d want to put the protein and the high fiber in there first, but you have the pasta first and then you do the vegetable plus the protein second. That’s like a classic Italian dinner in any restaurant, restaurant where wherever you go. So that’s also an easy way. If people prefer doing, like, the first and second course, like, they can play around with that.

Emily 47:56

But how big is the plate of pasta. It’s not like when you go out to dinner in the US, right? You get pasta, like, tiny.

Eric 48:03

I was gonna say all you can eat bread, bread sticks.

Alex 48:07

Yeah.

Elizabeth 48:09

And I. And I do tell people, get the Italian pasta, the Durham semolina, because that flour is a lot healthier than what you get at the cheapo pasta places. And also you can get, like, chickpea pasta and all sorts of other super healthy pastas that just. They taste great.

Eric 48:25

One last question, though. It’s also hard not to think of a mediterranean diet and not think about wine. Where does that fall into it?

Emily 48:35

Moderation. One glass per day for one drink per day for women, two drinks per day for men, maximum. You can’t save them up and have them all on the weekends.

Anna 48:47

With the meal, with the meal with the meal.

Elizabeth 48:50

And some of the newer research now is saying both men and women should limit to about three drinks per week.

Anna 48:56

Week.

Elizabeth 48:56

So it’s not a super high wine.

Eric 48:59

Red, white wine, doesn’t matter. Depends on what you eat.

Anna 49:02

Perfect.

Eric 49:03

That’s smoking like an Italian food, obviously. Yeah. Alex, what goes with a cheeseburger in paradise?

Alex 49:13

Onion slice and mustard. Medium rare with mustard would be nice. Here we go.

Alex 49:27

(singing) “Try to amend my carnivorous habits. Made it nearly 70 days. Losing weight without speed. Eating sunflower seeds, drinking lots of carrot juice, and soaking up braids. But at night, I’d have these wonderful dreams. Some kind of sensuous treat. Not zucchini, fettuccine, or bulgur, but a big, warm bun and a huge chunk of meat. Cheeseburger in paradise. Heaven on earth with an onion slice. Not too particular, not too precise. I’m on cheeseburger in paradise.”

Elizabeth 50:10

And Alex, I can tell you I’ve got a zucchini fettuccine recipe that is to die for.

Anna 50:16

Love it.

Eric 50:19

Well, I want to thank all three of you for being on this podcast. That was so great. I learned a ton. Encourage everybody also to check out that YouTube site and buy Elizabeth’s book. What’s it called again?

Elizabeth 50:30

Gift of aging.

Eric 50:33

Gift of aging. And thank you to all of our listeners for your continued support.