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The NEW Canada’s Food Guide: Is it Relevant to the way we Eat Today? Christina Seely RD CDE Clinical dietitian at Parkwood Mental Health Care Contributing authors: Christine Kijak, RD, CDE Jamie Yermus, RD, MPH Faculty/Presenter Disclosure • Presenter: Christina Seely • Relationships with commercial interests: – • Previous speaker honoraria received from Novo Nordisk No other conflict of interest for today’s presentation Learning Objectives ⚫ ⚫ ⚫ To review the evolution of and evidence behind Canada’s Food Guide To review how the guide and Canada’s Healthy Eating Strategy compare to current eating habits and hot nutrition topics To provide practical ideas and resources based on the nutrition recommendations for the general population Knowledge is Only One Part of the Picture Wealth is a Strong Determinant of Health Canadian Health – the Good News ⚫ ⚫ ⚫ Life expectancy has steadily increased in past decade, and gap between

men and women has been narrowing Overall mortality and premature mortality rates, particularly for CVDs, continues to decrease Declining rates for CVDs and COPD are linked to the major decrease in smoking across all ages Health Canada report - Health Status of Canadians 2016 Canadian Health – Areas of Concern ⚫ ⚫ 11 million live with diabetes or prediabetes in 2019, costs of care have increased from $14 billion (2008) to $30 billion (2018) -Diabetes Canada Approximately 4 in 5 adults have at least 1 modifiable risk factor for chronic disease – ⚫ self-reported tobacco smoking, physical inactivity, unhealthy diet or harmful use of alcohol Inequalities in chronic disease prevalence across subgroups of Canadians exist Canadian Eating Habits Health Canada Infographic Canadian Food Environment ⚫ ⚫ “In recent decades, highly processed products are now readily available, competitively priced, offered in large portion sizes, and heavily marketed” –

Health Canada Buying in bulk - Costco is increasing market share from traditional grocery stores Canadian Food Environment ⚫ ⚫ Bombarded with marketing - Kellogg’s spent $32 million in 2018 advertising Pop Tarts alone. CocaCola spent $269 million advertising coca-cola Exploding options - Between 1975 and 2008, the number of products in the average supermarket swelled from an average of 8,948 to almost 47,000 – There are ~ 300 options for yogurt alone How Canadians Eat ⚫ ⚫ ⚫ ⚫ Trends include foodie culture vs convenience Single-person households have more than doubled and are now most common type at 28% Time cited as biggest barrier to food preparation avg < 30 mins / day for food preparation Younger generations use more convenience items related to schedules and lower food and nutrition skills learned at home / school Journal of Nutrition and Education Behaviour, 2017 How Canadians Eat ⚫ ⚫ Mobile food delivery apps are estimated at 11 percent of

all quick-service restaurant sales Apps are reshaping how food is purchased and consumed, especially amongst millennials – ⚫ Millennials >44% of food budget on restaurant food UberEats, Just-Eat, Skip the Dishes, and Foodora, are growing 10-15% a year and have a $97 billion market globally Health Canada Infographic General Social Survey (Canadians at Work and Home), 2016. Book about the Food Revolution ⚫ “Food has never been so angrily polarized into virtues and vices, elixirs and poisons. I worry that in many cases, our pursuit of the perfect meal has become the enemy of the good-enough meal. While we fixate on this or that wonder ingredient, the thing that seems to be in short supply is the unglamorous home cooked dinner” Canadians Have a Relatively Affordable Food Supply Compared to countries like Nigeria where 56.4% of consumer expenditure spent on food Food Insecurity Still Prevalent Challenge of Eating Well in Today’s Food Environment ⚫

Healthy behaviour is abnormal behaviour – – – – ⚫ Pleasure principle Path of least resistance Preference for short term gain Environment pulls for unhealthy behaviours “If you are pressed for time doesn’t picking up food through a drive-through make perfect sense?” - Dr. Michael Vallis, leader of the behaviour change institute Feeding Families ⚫ ⚫ The vast array of conflicting information can create fear and anxiety around feeding children “Most parents understand that they should provide healthy food for their children, but the reality of work schedules, children’s activities and different food preferences can make meal preparation a hectic and frustrating experience” – From a 2017 poll of 1,767 parents who had at least one child age 4-18 years Canada’s Healthy Eating Strategy Changes to labels (must be completed by 2022) Front of the Package Symbols (roll out pending) Canada’s NEW Food Guide – released Jan 2019

Canada’s Dietary Guidelines ⚫ ⚫ 55pg document expanding on the information on the guide Another health professionals document pending later in 2019 with information about portions, nutrients etc Does the Food Guide Matter to Canadians? ⚫ ⚫ ⚫ ⚫ Integrated widely by governments and stakeholders into nutrition policies, programs and resources Taught in schools and promoted by health professionals Influences foods served in Canada’s public institutions – day cares, schools, LTC, hospitals Second most downloaded document from HC after income tax form Food Guides THEN and NOW ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ 1942- Canada’s Official Food Rules 1944- Canada’s Food Rules 1949- Canada’s Food Rules 1961- Canada’s Food Guide 1977- Canada’s Food Guide 1982- Canada’s Food Guide 1992- Canada’s Food Guide to Healthy Eating 2007- Eating Well with Canada’s Food Guide 2019- Canada’s Food Guide (9th edition) 1942- Canada’s Official Food Rules

⚫ ⚫ ⚫ 2nd World War origins- address crisis of malnutrition, focused on rations and fueling solders Met 70% of the dietary standard due to limited supplies 6 Food Groups – – – – – – Milk Fruit Vegetables Cereals and Breads Meat and Fish Eggs 1942- Canada’s Official Food Rules 1961- Canada’s Food Guide 1992- Canada’s Food Guide to Healthy Eating 2007- Eating Well with Canada’s Food Guide 2007- Eating Well with Canada’s Food Guide Criticisms of the 2007-2018 Version ⚫ ⚫ ⚫ ⚫ Serving sizes difficult to follow Too much information on the guide, had all ages and genders listed Protein food group was called “meat and alternatives” put focus on meat Criticism about juice as a fruit serving, and that having a dairy food group was influenced by industry 2019 - Canada’s New Food Guide Rainbow Healthy Plate A healthy meal is comprised of a variety of foods from these three food groups: ½ plate vegetables choose water ¼

plate protein foods ¼ plate whole grains 2019- Canada’s Food Guide Milk and Alternatives and Meat and Alternatives now in Protein Foods Basic Principles and Concepts Behind The New Food Guide ✓ Focus on HOW to eat, promotes cooking ✓ Promotes plant based foods, whole foods ✓ Can be individualized to taste, culture, budget and lifestyle ✓ Limiting the 3 S’s (sugar, saturated fat, sodium) ✓ Emphasis on health risks of alcohol Resembles Other Countries’ Guides USA since 2011 Korea Translations Released June 24, 2019 Feedback from Public and Professionals ⚫ ⚫ More positive reactions than negative, seen as an improvement, move to digital resources Mixed views from public on social media: – – – “Makes a healthy diet look like punishment. Is this really all we get to eat in a day?” “I love it. The photo of the plate is easy to follow” “This new guide looks realistic and healthy. I sincerely hope it will make a

positive impact for people” Solid Evidence ⚫ ⚫ ⚫ Only high-quality scientific reports on food and health were used including systematic reviews on over 100 food-related topics Over 400 convincing conclusions summarized in the Evidence Review for Dietary Guidance 2015 and the Food, Nutrients and Health: Interim Evidence Update 2018 Industry-commissioned reports were excluded to reduce potential conflict of interest Is the new CFG appropriate for People living with Diabetes? ⚫ “Starting point of nutrition therapy is to follow the healthy diet based on Eating Well With Canadas Food Guide. Choose the dietary pattern that best aligns with values, preferences and treatment goals for long-term adherence” – Diabetes Canada 2018 Guidelines ⚫ Plate model can provide as low as 25% carb Starchy veg can be considered for the 25% starch/grain portion instead of the veg portion Further adaptation needed for medical dx such as renal impairment, IBS, wounds ⚫ ⚫

Plant-Based Diet Movement ⚫ ⚫ ⚫ Does not apply only to vegetarians Refers to eating plant based foods more often “Flexitarian” has become more popular – meat or fish ~3X / week Plant Based Foods ✓Plant based proteins: Beans, nuts, lentils, peas, nut butters, soy beans, soy nuts, tofu, chickpeas, etc. ✓Plant based beverages: soy milk, almond milk, etc. ✓Fruits and vegetables: apple, broccoli, carrots, spinach, tomatoes, berries, etc. ✓Whole grains: Quinoa, barley, oats, wild/brown rice, whole grain pasta, whole grain bread, buckwheat, farro, amaranth, etc. Q: Is Soy Safe to Eat? ⚫ “Results of recent population studies suggest that soy has either a beneficial or neutral effect on various health conditions. Soy is a nutrientdense source of protein that can safely be consumed several times a week, and is likely to provide health benefitsespecially when eaten as an alternative to red and processed meat” Harvard School of Public Health Lentils

⚫ ⚫ ⚫ ⚫ ⚫ High in fibre and protein. They are a good source of folate, potassium and iron Delicious, low-cost substitute for meat Cook quickly, versatile in different dishes French/Indian/Lebanon cuisine includes lentil dishes Can be mixed in ground meat dishes Beans ⚫ ⚫ Beans are good sources of protein, potassium, excellent sources of fiber, and naturally fatfree, sodium-free, and cholesterol-free Can add chickpeas, navy/black/kidney beans in any salad, pasta, or rice dish Not Just Plants ⚫ ✓ ✓ ✓ ✓ ✓ Although the Food Guide emphasizes plant-based foods, it still includes nutritious foods such as: fish eggs poultry lean red meat lower-fat milk, lower-fat yogurts, and cheeses lower in fat and sodium Limiting the 3 S’s Limiting highly processed foods: ✓ Sodium • i.e processed foods and beverages (deli meat, canned foods, chips, cereals) ✓ Sugar • i.e sugar sweetened foods and beverages, confectionaries, sugars, syrups, preserves,

desserts, bakery products ✓ Saturated fat • i.e red and processed meats, high fat dairy products, pastries Limiting the 3 S’s Some processed foods do not have added salt, sugar and saturated fat and can be part of a healthy dietary lifestyle: ✓ Canned Foods ✓ Dried Foods ✓ Frozen Foods Study of Dietary Risks in 195 Countries from 1990-2017 ⚫ ⚫ “Suboptimal diet is an important preventable risk factor for non-communicable disease. Improvement of diet could potentially prevent 1 in every 5 deaths globally” “High intake of sodium, low intake of whole grains, and low intake of fruits were the leading dietary risk factors for deaths and disability-adjusted life years” The Lancet Health effects of dietary risks in 195 countries. Pub April 3, 2019 Whole Grains / Fibre ⚫ ⚫ ⚫ Avg fibre intake is 14 g per day intake (25g women, 38g men recommended) 30-50g per day for DM Comprehensive review suggested high-fibre eaters have a 15- to 30-per-cent lower

risk of heart attack, stroke, type 2 diabetes, colorectal cancer and cardiovascular-related death compared to low fibre Consuming 25 - 29 grams of fibre a day was protective The Lancet Carbohydrate quality and human health 2019 Study on Recommended Carbohydrate Intake ⚫ ⚫ ⚫ A large population study reported 50–55% of diet from carbohydrate associated with the lowest risk of mortality Both lower carb consumption (<40%) and higher carb consumption (>70%) conferred greater mortality risk Mortality increased when carbohydrates were exchanged for animal fats or protein, and mortality decreased when the substitutions were plant-based (vegetables, nuts, and whole-grains) Dietary carbohydrate intake and mortality: a prospective cohort study and meta-analysis 2018 The Lancet Fruit vs Vegetables? ⚫ ⚫ Higher fruit and veg intake associated with slower cognitive decline, healthy bp, lower risk of heart disease, stroke and certain types of cancer Some vegetables are

the best sources of nutrients – – leafy green veg for certain carotenoids associated with healthy brain aging and immune function cruciferous veg (broccoli/cauliflower) only source of glucosinolates (anti-cancer phytochemicals) https://www.theglobeandmailcom/life/health-and-fitness/article-isfruit-just-as-healthy-as-vegetables-on-your-plate/#comments Recommendations Around Sugar ⚫ ⚫ “Limit free sugar to <10% of total energy intake” Free sugars are any sugars added to food – ⚫ ⚫ Includes honey, syrups, fruit juice concentrates For 2000 kcal this is 200kcal / 50 g sugar (12.5 tsp) Examples of sugar content: – – – – Can of pop 39g Greek yogurt 10g Kashi granola bar 8g Package of maple instant oatmeal 13g Make Water your Drink of Choice ⚫ ⚫ ⚫ In 2015, sugary drinks were the main sources of total sugars in the diets of Canadians, with children and adolescents (9 to 18 years of age) having the highest average daily intake Water,

unsweetened milk or fortified soy beverage, and fruit are recommended Average total fluid requirement is 2.2L / day for women and 3L/ day for men Canadian Beverage Intake Q: How to get enough calcium without a dairy food group? Age in Years Aim for Intake of (mg/day) Men and women 19-50 1000 Women 51-70 1200 Men 51-70 1000 Men and Women 71 and older 1200 Food Item Mg calcium 3.3% homo, 2%, 1%, skim milk 250ml (1 C) 291-322 Cheese 50g (1.5 oz) 252-386 Yogurt, fruit bottom 175g (¾ C) 221-291 Other Calcium Sources Food Item Mg Calcium Spinach, cooked 125 mL (½ C) 129 Salmon canned, with bones 75 g (2 ½ oz) 179-208 Tofu, set with calcium 150 g (¾ C) 234-347 Soy beverage 250ml (1 C) 321-324 Almonds, dry roasted 60 mL (¼ C) 93 Beans (white, navy), canned or cooked 175 mL (¾ C) 93-141 Broccoli 125ml (½ C) 35 Calcium bioavailability from dairy - 30% absorbed. Bioavailability from plant foods varies considerably. Oxalates and phytates in

vegetables reduce calcium absorption https://www.dairynutritionca/nutrients-in-milk-products/calcium/calcium-and-bioavailability Sample Day Menu Based on Guide ⚫ ⚫ ⚫ Vegetable stuffed omelet with slice whole grain toast or fruit Whole grain tuna wrap with raw veggies or vegetable soup, and a fruit or yogurt Bean burger with salad “Healthy Eating is More than the Foods you Eat” Additional messages from health professionals resource Shift from what to eat how to eat ✓ Mindful eating - Be present in the eating experience without judgement - Take time to eat - Listen to hunger and fullness cues - Enjoy your food and being mindful of the eating experience - Avoid distractions while eating Mindful Eating can be Incorporated into Diabetes Care ⚫ ⚫ Not currently in CDA guidelines but promising research is ongoing “Mindful Eating for Diabetes is a practical mind-body approach that shifts focus from strict nutrition rules and exercise regimens to learning

to listen to and understand your “inner expert”, putting you in charge of your eating and health decisions.” – Eat What You Love, Love What You Eat with Diabetes by Michelle May, MD and Megrette Fletcher, MEd, RD, CDE Enjoy your Food ⚫ The benefits of enjoying your food include: – – – ⚫ tasting the flavours being open to trying new foods developing a healthy attitude about food A healthy diet should allow for personal food preferences, which can reinforce the enjoyment of healthy eating Cook More Often ⚫ Compared to those with “basic or limited” mechanical food preparations skills, those who reported having “very good skills” were more likely to also report: – – – Higher frequency of vegetables and fruit consumption Better self-perceived eating habits Higher levels of perceived health. Dietitians of Canada +

Health Canada Study Is the New Guide More Expensive? ⚫ If a family of 4 decided to change the type and proportions of food they ate from recommendations in the 2007 Food Guide to those of the 2019 Food Guide, it would cost on average, 6.8% less Eat Meals with Others ⚫ ⚫ ⚫ Meals may be the only time of day for families to reconnect, relax, recharge, laugh, tell stories and catch up on the day’s ups and downs Benefits start at two family meals together a week with five or more recommended All meal times count including breakfasts or weekend lunches Benefits of Family Meals ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ Better academic performance Higher self-esteem Greater sense of resilience Lower risk of substance abuse Lower risk of teen pregnancy Lower risk of depression Lower rates of eating disorders Some Fad Diets can be Restrictive and Pose Nutritional Risks ⚫ ⚫ ⚫ “Canadians are

exposed to the promotion of diets that are often commercially driven and promise a quick fix for weight loss or the management of a chronic disease” “Fad diets can be restrictive and pose nutritional risks, particularly without appropriate planning for nutritional balance” – Health Canada 1-5% will stay on a diet long-term Popular Diets Searched on Google Why Diets Remain Popular ⚫ ⚫ ⚫ ⚫ Whole 30, ketogenic diet etc promote eliminating foods and following (often strict) guidelines Reduces decision fatigue, clear rules, removes craved foods Provide on-line community of support and many examples of weight loss stories (few at 5yr+ mark) Appeal lies in providing new and straightforward solutions (ie. change macronutrient content of diet) to a complex area influenced by many factors Dieting is a Risk Factor for Weight Gain ⚫ ⚫ “.obesity prevalence keeps increasing, in a similar speed as diet attempts. As many as 45 million Americans are always in the

on-and-off process of diets. This apparent paradoxical correlation is based on the deluding assumption that dieting automatically means weight loss. For most, diets will bring further over-compensatory weight gain”* Possible resource: Weight Neutral 4 Diabetes Care – *http://www.digitaljournalcom/pr/4335262 Popular Diet – Ketogenic Diet ⚫ ⚫ ⚫ ⚫ Avg Western diet 55% carb, 15% pro, 30% fat Keto diet 5-10% carb, 20% pro, 70% fat Keto diet associated with significant improvements in blood sugar control, similar weight loss to other diets at 12-24 mos. Longterm data lacking in adult population Demonstrates improved HDL and triglycerides, but also increases LDL Keto Diet Risks ⚫ ‘Keto flu’ – Nausea, vomiting, headaches, fatigue, dizziness, insomnia, constipation, exercise intolerance – Resolves in a few days to a few weeks ⚫ Constipation ⚫ ⚫ ⚫ ⚫ ⚫ Heartburn Hypoglycemia – need to adjust diabetes medications Vitamin and

mineral deficiencies (B vitamins, folate, K, Mg) Potentially negative impact on gut microbiome May not be efficacious for everyone – mixed results Caution for use of Keto Diet in. ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ People with type 1 diabetes or type 2 diabetes on insulin, sulfonylurea or SGLT2 inhibitor History of eating disorder or disordered eating Mood disorders GI disturbances Alcohol abuse High cholesterol >10mmol/L or LDL >6.5mmol/L Risk of or current malnutrition Children, teens, breastfeeding Source Andrea Langley, RD, MSc, CDE Sample Day Keto Diet ⚫ ⚫ ⚫ ⚫ BREAKFAST: 2 eggs in butter + spinach, onions + ½ avocado + “Bulletproof coffee” LUNCH: 3.5 oz salmon on mixed greens salad with mixed veggies + walnuts, olive oil + balsamic vinaigrette ¼ cup blueberries DINNER: 3.5 oz roast chicken w/ skin on Pancettawrapped asparagus, cooked in olive oil + creamed cauliflower SNACKS: Cheese, celery & cucumber, olives, cashews Menu from Jen Sygo RD

Canada’s Food Guide 2019 Areas for improvement Areas for Improvement • Cultural sensitivity – Few cultural foods appear on guide – no roti, dumplings, dragon fruit etc. Translated versions do not include different food examples. Areas for Improvement • Indigenous population – previous guide is still on website but is being revised Idealism vs Realism ⚫ ⚫ ⚫ Does not include the concept of moderation Can promote black and white thinking about good or bad foods Does not review how convenience foods can fit other than canned/frozen produce Areas for Improvement ⚫ ⚫ ⚫ ⚫ Higher percentage of protein are typically recommended for older adults Website does not yet contain in-depth content to be more helpful to a well-educated populace Recipe section could be greatly expanded, currently about 75 recipes Pending document for release in 2019 should provide more comprehensive guidance Resources ⚫ ⚫ Employers may have dietitian services

available through employee assistance programs Telehealth Ontario now has dietitians available for free information over the phone Resources ⚫ Unlock Food – Resources and Recipes by RDs – ⚫ Family Dinner Project – recipes and strategies – ⚫ My Plate Resources – recipes, handouts, ideas – ⚫ http://www.unlockfoodca/en/defaultaspx https://www.choosemyplategov/ www.halfyourplateca/ Plant-Based Protein / Mindful Eating Resources ⚫ ⚫ ⚫ ⚫ ⚫ ⚫ http://ontariobeans.onca/consumerresources/download/ http://www.pulsecanadacom/resources/ https://www.lentilsorg/recipes-cooking/ https://www.meatlessmondaycom/ https://www.thecenterformindfuleatingorg/ Dr. Michelle May - Eat Mindfully Live Vibrantly – Other Recipes ⚫ Leslie Beck RD recipes – ⚫ Guelph Family Health Study – 4 e-cookbooks – ⚫ Real Mom Nutrition Recipes – ⚫ https://www.realmomnutritioncom/recipes/ Heart and Stroke Recipes – https://www.heartandstrokeca/get-healthy/recipes Subscribe for Food Guide Updates ⚫ https://www.canadaca/en/healthcanada/services/canada-foodguide/subscribehtml?hq e=el&hq m=1782962 &hq l=4&hq v=74fb0c9e7b Conclusion ⚫ ⚫ ⚫ ⚫ Canada’s new Food Guide is a source of credible general information about nutrition. Customization at an individual level is most relevant. Canadians have access to a huge array of food choices and nutrition information. Access to professional guidance remains important. Much more is needed to help address equal food access, food security, and the challenges of eating well in today’s food environment/busy lifestyles. Development of food skills and promoting enjoyment as well as health in eating habits can be common goals. Thank you! Questions? E-mail anytime Christina.Seely@sjhclondononca