Food, glorious food: Cardiovascular risk and healthy eating in older people

The article in this month’s section focuses on cardiovascular risk in older people with diabetes. The article highlights to me the current and ongoing debate about healthy eating and food choices. These topics are commonly found in the general press, such as women’s magazines and daily newspapers, and not solely in medical or nursing journals. This means that much of the discussion, unlike the article here, may have no scientific basis, yet may be persuasive. Unfortunately, such articles may also be misinforming. Often, more extreme diets are discussed, instead of advocating healthy-eating choices, lifestyle change and portion control.

A recent editorial in the Independent newspaper had a picture of an oversized beef burger with this logo emblazoned on it “Overeating kills!” It certainly was a powerful image, but what if you do not eat beef burgers, as many of our older population do not; does that mean the message does not apply to you? Does it mean that if you do not eat a beef burger, you are safe? Furthermore, people may ask: “How do I know if I’m overeating anyway?”

Therein lies much of the confusion about food choices, which is hyped up by these headlines and by general confusion from food labelling. Sometimes, there is a lack of knowledge about what is a fat or a carbohydrate and what is good or bad. Our older population often have habits built around regular meals, often “meat and two veg”, but these habits can change according to circumstance and/or ability to self care. If a man is widowed, for example, and it was his wife who cooked and shopped, where does he learn what to eat and how to prepare it? 

Dementia can cause erratic eating habits, often due to confusion about night and day, and tastes can also change dramatically, which can drastically change food choices.

Even if you can cook and know enough about food to make healthy food choices, recent debates and research have challenged previous advice and caused confusion. In the past, fats, particularly saturated fats, have been identified as contributing to atheroma and cardiovascular risk. As a population, we have been advised to reduce fats in general and instead use complex carbohydrates.

Currently, there is an interesting debate in Practical Diabetes with the notion that “saturated fat does not increase coronary heart disease in people with diabetes”, with evidence both for and against presented. The argument by Trudi Deakin states that saturated fat is not implicated in coronary heart disease and suggests that likely dietary culprits are trans fats, processed foods and snacks with refined vegetable fat and carbohydrates, excessive consumption of sugars and refined carbohydrates, causing increased insulin resistance and atherogenic dyslipidaemia (Deakin and Garden, 2015).

The opposing argument from Leonie Garden suggests that saturated fat should be replaced by unsaturated fats, particularly monounsaturated fats, and not carbohydrates. The point is made that replacing saturated fats with refined carbohydrates has potentially negative side-effects, such as insulin resistance and dyslipidaemia.

So, clear as mud?! If it is confusing for us as clinicians, we can empathise with the difficulties our patients face and should try to simplify these messages when advising them. If we accept that obesity is the greatest cause of type 2 diabetes, poor glycaemic control and many other health problems, then our advice should include healthy food choices, including portion control and reduction in calorie-dense foods. If this is done in the context of their current food choices, then useful alternatives can be suggested. In this way, advice can be individualised and potentially be more useful, particularly if it includes their lifestyles, their confidence, and their time and capability in food preparation.