March 13, 2019 Diabetes and the mediterranean diet

[00:00:02] Welcome everyone to the kickoff of our Canadian Diabetes Association's Diabetes Awareness Month webinar series. Now my name is Farrah and I'm a program manager here at the CDA and I will be your host for this evening. We are delighted that you're able to join us today for the webinar to learn about the Mediterranean diet. Now to start off I would like to draw your attention to the survey at the top right hand section of your screen in order to serve your needs better we kindly ask that you provide us with your input by completing a short survey towards the end of a presentation and we do thank you in advance for all of your input. Now throughout the presentation you will have the opportunity to type in the question and answer box that's located at the bottom right hand section of your screen and we ask that you use this for any questions that you have for our presenter throughout the presentation and we will be sure to do our very best to answer it at the end. We will be displaying a few polling questions throughout the presentation and would love for your participation in the questions. Please note that your answers will be completely anonymous. Also note that you're able to customize your screens to expand and collapse any of them as you see so feel free to adjust them as needed by dragging down the bottom right hand corner of each of the webinar pods. The presentation itself will last about 40 to 45 minutes and then we'll do another 10 to 15 minutes for questions and answers. Please note that our webinars will be available on our Web site at diabetes.ca/webinars at a later date. So now I'd like to welcome our speaker Dr. Catherine Chan and thank her for joining us today. But before turning it over to Dr. Chan I'd like to give you a brief introduction. Dr. Chan Is a Professor in Human Nutrition and Physiology and is a member of the Alberta Diabetes Institute. She is also the scientific director of the diabetes obesity and nutrition strategic clinical network of Alberta Health Services. With Dr. Rhonda Bell in 2013, she authored the Pure Prairie Eating Plan which has been called by some the Mediterranean diet for the prairies. So for more information on Dr. Chan please read the speaker bio section which is on the left-hand side of your screen. So without further ado I would like to present to you Dr. Chan.

[00:02:33] Well thank you Farrah for the introduction and welcome everyone. I'm really glad to be able to join you this evening to talk about the Mediterranean diet and diabetes. I'm sitting here in Edmonton and it's pitch dark. But we had a lovely day today. Nice and sunny and around freezing so quite nice for getting outside. So in tonight's presentation about the Mediterranean diet, I'm going to go through about four different topics. The first one is just to review what the diet recommendations are for people with diabetes in Canada. The second part is to look at the Mediterranean diet pyramid and the evidence that it is a healthy diet pattern. And then I'll spend a little bit of time comparing how the pyramid might work in Canada, by looking at eating well with Canada's Food Guide and other Canadian perspectives. And some of the research that we've done out here at the Alberta Diabetes Institute to think about how the Mediterranean diet could be adapted for Canadians and a little bit about the Pure Prairie Eating Plan. Finishing off with a couple of our favorite recipes which I hope you will enjoy.

[00:04:00] So to start off I'm going to talk about the CDA Nutrition Therapy Guidelines the CDA publishes these guidelines about every five years. And the most recent ones came out in 2013. They're based on the most recent scientific evidence that's available to us and they're compiled by a team of experts. But what do the 2013 Nutrition Therapy guidelines for diabetes say. The first thing they say is that people with diabetes should follow Canada's Food Guide for general advice. And so this is really saying that people with diabetes should be eating the same healthy way that all Canadians do. And they say that the diet should be nutritionally balanced with respect to carbohydrates, protein and fat and people with diabetes should watch their intake of saturated fat and added sugar. They're also recommended to consume foods with a low glycemic index because we know that such foods with a low G.I. raise blood sugar more slowly and to a lesser extent than those with a higher Glycemic Index. And what's new and interesting this time in the 2013 guidelines is that alternative dietary patterns may be used and may be recommended by your dietitian. So one of those particular patterns that has been noted by the expert panel for Nutrition Therapy guidelines is a Mediterranean style dietary pattern. So I'm going to talk a little bit about the Mediterranean dietary pattern: what it is, how it came to be, and some of the evidence around that. But before I start we just have some audience participation for you and we'd like you to answer the statement: my knowledge about the Mediterranean diet is very strong, strong, fair for poor. So you can just click on which of those you think best describes your knowledge. I'll give you a couple more seconds to move your mouse and then we'll see how the audience responded. All right. So we've got a really great mix of people in the audience. We've got about 25 percent saying very strong or strong knowledge of the Mediterranean diet. About 40 percent saying fair and about 35 percent saying poor. So hopefully through the course of the presentation everyone in the audience will have the opportunity to learn something new.

[00:07:11] So if we think about basic dietary patterns and dietary patterns refer to kind of the overall balance of foods that we include in our diet. Really it's an evolutionary process. And until recently and by recently I mean approximately the Second World War when we started or after the Second World War. When we started having a more global economy we started importing and exporting food to different locations around the world. Until that time people really lived in a much more local environment. And so they had to rely on whatever foods were present nearby to them. So whatever they could hunt whatever they could gather whatever they could grow the livestock that they could raise that happened to live in their area was what they ate. And particularly in climates like Canada's where we have distinct seasons, people also had to learn how to preserve things that were only around in the summertime. So canning drying keeping things in cold rooms or cold cellars. Those are the things that people had to rely on for their food. And it's really quite amazing when you think about it. The differences in dietary patterns that allow people to survive all around the world. The diet of people who live in Canada's north is much different than people who live in more southern climates or in Borneo or places in Africa, totally different foods. And yet we all survive. But what's interesting is that survival and health are not necessarily the same thing. And now that we're living longer we've come to realize that what we eat over the long term can really have an important effect on the absence or presence of chronic disease and our longevity.

[00:09:22] So the Mediterranean diet pyramid looks like this. And before I get into the details of what's in the pyramid I just want to talk about a couple of basic things. The first one is if you look at the very base of the pyramid there's something that's not related to food at all. It's related more to lifestyle general lifestyle principles. And so as part of the Mediterranean diet, it's believed that physical activity is a real strong underpinning of health and really incorporating physical activity into your day. Whether it's through sport or through walking or through other activities like dancing we should all try to be as physically active as we can each day. And the other thing that the Mediterranean diet pyramid really espouses is the social aspect of food, so consuming our meals with our family and friends sitting down, taking time to enjoy the food and enjoy the company is a really important part of the Mediterranean culture and a really important part of Mediterranean diet pyramid.

[00:10:34] A second key feature of the pyramid is that the layers that are on top of the lifestyle layer, their size is in proportion to the amount of foods in each layer that are recommended to be eaten daily, weekly, and so on. So now I want to just talk about those food layers. So the first food layer I'm going to talk about is the largest food layer, which is just above the lifestyle layer at the bottom. And it is all of the plant foods grouped together so it includes things that perhaps in Canada we don't think of as being part of plant foods. So it includes olive oil because olive's a fruit, it includes all the vegetables and fruits that we would normally associate with plant foods, it includes the grains whereas in Canada we put those separately, it includes legumes such as dried peas, lentils, chickpeas and so on, which in Canada we put under meat and alternatives, it includes nuts and seeds and it also includes herbs and spices, so garlic and thyme, basil and other spices that grow abundantly as weeds really in the Mediterranean. And it's recommended that we consume some of these things in this large group of food at every meal. The Mediterranean diet really is based on eating, consuming a large amount of plant based foods. Then we have three layers above that and the next largest layer is for fish and shellfish and in the Mediterranean diet these would comprise the primary source of protein which makes a lot of sense because of course people in the Mediterranean live next to the Mediterranean Sea where there is a lot of fish. So it's recommended that these be consumed at least twice per week. And then about that is more protein including poultry, eggs, cheese and yogurt. And these are recommended in moderate portions from daily to weekly. So there's a lot of leeway left there to individuals taste. And then at the very top of the pyramid is meats and sweets. So red meats and desserts and the pyramid now says that these should be consumed less often. If you see older versions of the pyramid it actually says monthly. So once a month red meat and once a month sweets. In the more modern versions they've softened that message a little bit. Then the other thing that we see in the Mediterranean diet pyramid is a recommendation to drink water and also wine in moderation, which is a little bit different than our Eating Well with Canada's Food Guide which really doesn't speak to alcohol very much. So that's the basics of the Mediterranean diet. And I just want to go back to why the Mediterranean diet pattern emerged. It was not due to the work of nutrition researchers feeding people different things and finding out what made them healthier. It was really due to the fact that the foods that are in the Mediterranean diet are what is grown, what can be caught in the Mediterranean so it's really a cultural choice and reality more so, at least originally, than a healthy diet pattern. And just as a side note the reason that I put this particular picture on this slide is I took this picture myself when I was in Italy this summer and enjoying a restaurant meal where they brought us this beautiful cone of local fish and shellfish. It was all very delicious and it was all deep fried and it really surprised me initially how much fried food these particular Italians did eat. But then I was talking to some people and realized that of course they have lots of food and they have lots of oil. And so one of the ways that they can use their oil is to deep fry everything but it was somewhat counter to my naive impressions about what the modern Mediterranean diet actually looks like. So now I want to just address some of the research that suggests that the Mediterranean diet is a healthy diet pattern and how we came to that conclusion through a variety of different research studies. The very first one was conducted almost 60 years ago now and it was called the Seven Countries Study and it was initiated by a man named Ansel Kees.

[00:16:21] And he wanted to look at the relationship between diet and lifestyle with the amount of deaths from coronary heart disease in different parts of the world. And one of the strengths of his study was that he tried to measure dietary intake very carefully and so he had all of the participants in his study fill out food records for several days so that he could analyze what they ate. The people that were included in this study were 16 different groups of middle aged men from seven different countries. So some of the countries did have more than one group. Most of the settings were rural and most of the men had quite physically intensive jobs, which would have been fairly common back in the late fifties. This is probably the only graph of data that I'm going to show you but it portrays some of the key findings from Ansel Key's study. So he wanted to try and predict what the death rates would be in the various groups of men as it related to the amount of different types of fat that they had in their diet. So he looked at mono unsaturated fats such as olive oil versus saturated fats such as we would find in animal sources such as butter or lard. And what he found was that people who ate more monounsaturated fat had lower death rate from coronary heart disease and these people tended to live in the Mediterranean area like Crete in Italy and other parts of Greece and so on. Whereas people who were more likely to die of coronary heart disease had a higher intake of saturated fat and they lived in areas like Finland where there's a large dairy industry and people were eating a lot of butter, and the United States for example. So these were the first studies to show a strong relationship between our eating habits and some long term health implications such as dying of coronary heart disease. The differences in the death rate over 25 years were quite striking, about ten fold difference. So more than two hundred and fifty per thousand in East Finland versus twenty-five per thousand in Crete. So really showed that there could be big differences that were at least in part related to diet. And emphasized for the first time that there might be a relationship between the different types of fat that we were eating and coronary heart disease. Now these studies have been criticized for a number of different reasons. For example they only looked at middle aged men, they were relatively homogeneous in terms of their ethnicity and so on but they were the first studies and they really generated a lot of interest in this field and jump started a lot more research in the years going forward. And so now if I look in the literature there's new studies coming out every month, every week about the Mediterranean diet or other dietary patterns on various health outcomes so for example the benefits of Mediterranean diet can be summarized as having favorable effects on quite a few cardiovascular risk factors such as cholesterol levels. It can have favorable effects on the metabolic syndrome by improving the sensitivity of different tissues in the body to insulin. And it also lowered cancer incidence or the people getting cancer, particularly if people were obese or if they had had a previous heart attack. So it seemed to mitigate some of the negative effects of having a chronic disease. In terms of getting a second chronic disease such as cancer. And one author has estimated that if we could adhere to a Mediterranean diet pattern, along with taking physical activity and refraining from smoking, that we could prevent over 80 percent of coronary heart disease, 70 percent of stroke and 90 percent of Type 2 diabetes, which is really quite phenomenal when you think about it.

[00:21:18] So now we've come to our second audience participation time and this time if you could answer the question: the Mediterranean diet is beneficial for people at risk of living with diabetes, people at risk of and living with cardiovascular disease, people with high blood pressure or all of the above. I'll give you a few seconds to answer that and then we'll see how the audience has responded. All right. Well ninety eight percent said any one or all of the above. And I think that is an important message for everyone to take forward that really all of us could benefit from such a pattern.

[00:22:24] So just to finish off a discussion of the Mediterranean diet and its health benefits, I wanted to summarize what the expert panel thought about the Mediterranean diet when they decided to include it in the Clinical Practice Guidelines for Diabetes in 2013. So in their review of the literature and I've included some of these references at the end of the slide deck if you're interested they found that following a Mediterranean diet for people with diabetes could lead to reductions in hemoglobin A1C, so improved blood glucose control. It improved their cholesterol by raising good cholesterol and lowering total cholesterol and triglycerides. It was associated with weight loss, with blood pressure reduction, with reduction of chronic inflammation, which we know accompanies a lot of different chronic diseases and also reduced heart attack and other cardiovascular events over a period of five years. And that's really important too because we know that people who have diabetes are at much higher risk of having a cardiovascular event than somebody without diabetes. And the authors of the Nutrition Therapy Guidelines did not note any disadvantages of somebody with diabetes following a Mediterranean diet. Now in our research at the University of Alberta, we often think about things that aren't related strictly to nutrition and to health outcomes. One of the things that we think about is something we call the food environment, and that's how the world that we live in actually influences what we eat. So the aspects of our culture our lifestyle our agricultural practices. How is it that they might derail or facilitate us adopting a particular dietary pattern. We thought about the Mediterranean diet and how it might translate into a Canadian population. We thought about how in the Mediterranean it's still relatively common to eat a main meal at lunch vs. in the evening. Snacking may be less frequent, they typically would eat fruit for dessert instead of sweets, they cook their food differently. I had to look high and low to get a salad when I was in Italy because they typically cook most of their vegetables. Food production is much easier in a climate where it's always balmy and warm. Whereas here in Canada we might have to grow more Mediterranean style vegetables in greenhouses if we wanted to consume them more frequently. And then there's other lifestyle factors such as our eat and run mentality always on the go. Perhaps less physically active jobs than were previously associated with health benefits in the Mediterranean diet. Whether or not we have an afternoon siesta, the amount of sun exposure that we get that influences our bone health for example. So these are all things that we should take into consideration before we adopt another dietary pattern. We did think about ways that our modern society allows us to, perhaps implement the Mediterranean diet more easily than would have been possible back in 1958 for example. We have very intricate shipping systems for food that goes all around the world. We have the scientific ability to modify crops to grow differently. We have the ability to modify growing conditions through greenhouses and other practices and we also have the ability to change food preferences and cooking methods through education. But over the long term when we were thinking about it was it may not really be sustainable to implement all of these different things if they're not realistic. So for example, could we really ever grow olives in Charlottetown. These are some of the things that might prevent us from wholeheartedly adopting something like the Mediterranean diet. But still we should try to strive to achieve a pattern of eating that would be just as healthy but more Canadian in its scope. So we started to think about what that dietary pattern would look like if we translated it into a Canadian reality. And we use something called the 4A framework to do that. We said that if we were going to construct a dietary pattern, that it should be nutritionally adequate that the foods that were in the diet should be generally available in regular grocery stores, that they should be accessible to people both financially and from a food knowledge point of view and from a cultural standpoint, from a general taste standpoint they should be acceptable to us to eat. So I have a few examples about each of the four A's in the 4A framework. First of all, dietary adequacy, if we adopted a Mediterranean diet is it really meeting our dietary recommendations for things like calcium and iron? If we reduce our red meat intake for example, does it address issues of maternal health? Does it address the lack or lessening of physical activity? Is the dose of Vitamin D sufficient for Canadians because we don't have the sunny climate that the Mediterranean has? With respect to acceptability we asked questions like: Is it acceptable to promote alcohol intake? Are Mediterranean food items acceptable in different cultures? And if we choose those Mediterranean foods more often are we losing something valuable to us as Canadians in terms of our food culture? And not only that, but the Mediterranean diet really is promoting choosing locally grown and seasonal foods which you would see if you went to a grocery store in Italy. And so if we adopt the Mediterranean diet in Canada we're really going counter to that philosophy. And so we should think about what is feasible and sustainable in our own climate and geography. There are issues of accessibility as well. The costs of certain food items may be greater in Canada than they are in the Mediterranean. And we may not know how to prepare or eat different foods that are very commonly seen in that region. So I like to cook squid but perhaps not everybody in Canada is familiar with such things. And lastly availability, Canada is largely landlocked and so we have less access to fish from the ocean than people in the Mediterranean for example and because of our weather many of the products that we eat are not available fresh, all year round. And so we do tend to rely perhaps more on canned or packaged or frozen foods and to a great extent on imported produce during the winter months. Much more so than in the Mediterranean. And now just to finish off this line of thinking. Just a few specific examples. I looked up fish consumption for as one example in Italians it's about 20 kilograms per person per year, which is almost three times as much as the average Canadian. Although certainly if we looked at different regions of Canada we would see that there's great regional variation. There are issues about availability not just between Canada and Italy. If we want to compare small round blueberries with fruits that are commonly eaten in Italy, but also across Canada blueberries are more abundant in the Maritimes and British Columbia than they are in the prairies where we typically would pick Saskatoon berries. And then with respect to financial accessibility. I looked up the price of olive oil relative to canola oil and as you can see it's about a two to four times more expensive to eat olive oil than it is to eat canola oil. And while that may be acceptable to some people, for those who are watching their food budgets that might not be an option for them. And lastly just to look at how Canada's Food Guide organizes our foods and I'm sure you've seen reference to Canada's Food Guide many times, but instead of organizing our food pyramid by the frequency at which we recommend people eat these foods we organize our foods into groups based on the type of nutrients that are present in the different foods. So green products tend to all have a similar complement of vitamins and minerals as well as carbohydrates and fiber. Same for fruits and vegetables, milk an alternative, and then meat an alternative including the legumes and also including nuts because of their high protein content. So if we look at foods that are eaten in the Mediterranean and foods are eaten in Canada and thought about how we would rationalize or substitute some things or think about the frequency at which we would recommend people eat them. Based on those four A's, we see that in Canada we might substitute canola oil for example instead of olive oil because canola does have a high amount of mono unsaturated fats. And is abundant and cheap. We would see that there were different fruits and vegetables included in the diet and that we would have to rely more on imports to meet the desire for variety in our diet. The amount of protein that we got from different sources might vary. So Canadians do tend to eat poultry more frequently than fish and shellfish and red meat more frequently than in Italy. So there's a little bit of juggling that we would want to do. But it's also important to recognize that in the Mediterranean diet, fish and shellfish are recognized recommended twice per week, which is very similar to what health Canada recommends in Canada's Food Guide. And then just going through the other food groups and macro nutrient sources. So dairy, the Mediterranean relies mainly on cheese and yogurt. Whereas in Canada we also eat a lot of cheese and yogurt. But we also consume a relatively large amount of fluid milk. Carbohydrates very similar but perhaps a different order in terms of frequency of consumption. And then with respect to beverages of course, we both recommend water. The Mediterranean diet specifically recommends wine whereas we would not specifically recommend it but we do recognize and Health Canada does have guidelines on maximum amounts of alcohol that are recommended for consumption. We would try to think about some of the challenges that we would face in implementing a healthy diet pattern even within the diversity of Canada. So food availability may be less important than 40 or 50 years ago when we were still living in a relatively small circle and with locals products mainly available. But there are still challenges in Canada, particularly in rural and northern sites where fresh foods are either non-existent or more expensive or not as fresh as we would like them to be. We want to make sure that what we recommend is financially accessible to people of all incomes. And if we can't use the foods in the Mediterranean diet pyramid what would we use instead and try to keep the cooking skills that are required fairly simple, recognizing that we do have some generational changes in people's food knowledge and cooking skills. And then we also have to recognize that Canada has amazing cultural diversity that no one diet pattern is really going to fit everyone but to hopefully introduce people to many different flavors and tastes but at the same time also recognizing that we begin to become fairly set in the tastes and the foods that we like when we're fairly young and so it's not always easy to make big radical changes to our tastes. So I'm going to finish off our presentation tonight by giving you an example of what we ended up creating in the course of our research on diabetes and nutrition and how we adapted a Mediterranean style dietary pattern to a Canadian reality.

[00:37:25] So I was part of a large research project called Physical Activity and Nutrition for Diabetes in Alberta and one of the goals of our research program was to develop simple and practical nutrition programs for people with diabetes. People told us that they wanted to be able to eat what other people eat. We also wanted to take into account the 4A framework and we wanted to be consistent with Canada's Food Guide and the nutrition therapy guidelines from the Canadian Diabetes Association. So what we came up with is something that is now called the Pure Prairie Eating Plan and we've tested the Pure Prairie Eating Plan in 88 people who have type 2 diabetes and we asked them to follow the eating plan for three months. And after that time we found that there was a decrease in hemoglobin A1C, so they had better blood sugar control, they had lower blood pressure, they had higher amounts of good cholesterol, and lower amounts of bad cholesterol and we also found that their diet quality and the so-called dietary adherence, in other words were they following the guidelines of CDA, those things both improved as well.

[00:38:54] So I can tell you a little bit about what's in the Pure Prairie Eating Plan. It's a four-week menu plan and each day has three meals and three snacks. It has easy to find ingredients. So look thinking about food availability. Simple recipes, so the recipes should be accessible to people with relatively basic cooking skills. And we provide lots of nutrient breakdown for the menus and the recipes so that people with diabetes know what they're eating. So here's an example of a daily menu. There are three meals as I said breakfast, lunch and dinner and three snacks interspersed throughout the day. And this particular menu there's a breakfast parfait for breakfast and a muffin for snack with some nuts. There's a sandwich at lunchtime with milk and fruit, some hummus with Melba toast, and tomatoes for an afternoon snack. It's roasted apple pork tenderloin with potatoes and green beans for dinner, and some toasted bagel with milk for an evening snack. And as you can see it also tells you what the serving size is, it tells you how many servings from Canada's Food Guide with each meal and for the day. There's lots of nutrition facts including carbs and total calories, and some tips on how to adjust the menu to meet your caloric requirements. And the two recipes that I'm going to share with you today are from the menu plans. One is for really great tomato bean soup that I had for lunch today myself and the second recipe is for four muffins.

[00:40:54] The tomato soup recipe is super easy to make and very versatile so it's easily converted to vegetarian by leaving out the chicken that we have in it. It's gluten free already. And if you paired it with crackers for example you would have three vegetables and fruit servings, a half a grain serving, one and a half meat an alternative servings, and half a serving of milk and alternatives. The muffin, if you paired it with half a cup of blueberries and half a cup of milk it would be one vegetable and fruit serving, one serving of grains, and half a serving of milk and alternatives. And I'll just point out that we do produce a newsletter four times a year and we usually include more recipes in our newsletter. And it's been provided to you in the resources that are attached to the webinar today. You could have a look at that. So here's our soup recipe we make most of our recipes to serve four people so that that's easy to cut in half if your family's small or to make larger if your family is large. There's nutrition information about every recipe, there is tips on how to make substitutions that are still healthy. So we say if you want to make this recipe into a you can add some macaroni for example that would increase the grains and other tips like that for each recipe. And then the pecan pumpkin bran muffins. I made these just after Thanksgiving because I had some leftover frozen cranberries and I thought oh cranberries and pumpkin go well together. So I just chopped up some cranberries and added it to the recipe and I have to say my husband thought they were quite delicious that way. And again we've got the nutrition information and also some tips if you wanted to freeze them or save them for later in the week how they could be served more than once. So we're getting close to the end of a presentation this afternoon or this evening. So we have one last question for you and that is: I now understand the Mediterranean diet and some Canadian adaptations and would be comfortable incorporating it into my meal plan. And you can answer yes maybe or I would like more information. All right. Let's see. All right so about two thirds of people said that yes they would be comfortable incorporating it into their meal plan and the rest of people though 40 said maybe you or I would like more information. And I think that there is lots of information out there. I hope that I've been able to convince you a little bit that the Mediterranean diet might be right for your diabetes. There are benefits health benefits that have been established by research. It is relatively consistent with eating well with Canada Food Guide and it is included as an alternative in the CDA 2013 guidelines. So if you are interested in following more of a Mediterranean diet pattern you could certainly talk to your dietitian or another health provider about it and get their opinion as well. If you do consider adopting the Mediterranean diet to the Canadian realities think about the 4A's because when you change your diet you do want it to be sustainable and and so think about your own situation, your financial situation your culture, your life stage, your physical activity levels, and how you could make a Mediterranean diet pattern more of a reality for you. I've listed some of the resources. These are scientific papers that the expert panel consulted when they were constructing the clinical practice guidelines for nutrition therapy. And these are the papers that highlight the benefits for people with diabetes. If you're interested in reading those. And finally to finish off I'd just like to acknowledge that the research that we've done here in Alberta has been done with the help of a great many of my colleagues and students here at U of A. And also for those of you who might be interested in having a closer look at the pure prairie eating plan we do have a website listed here: www.pureprairie.ca. As well as the Facebook page and as I mentioned the newsletters are also available online. So now I think I'll turn it back over to Farrah who is going to field the questions for this afternoon.

[00:46:31] Great. Thanks so much Dr. Chan. You've definitely shared with us a lot of great learnings about the Mediterranean diet and how we can incorporate it into our lifestyle. So I know myself I've actually learned quite a bit and definitely do look forward to utilizing the recipes that you've provided with us today. So I'm really excited about that. So you have just as you said we'll get started with the questions. There's been an abundance of questions and I'm really excited to get that started. I just want to let everyone know on the line that unfortunately if we cannot answer your questions today at this time during the webinar please feel free to even email us story at webinars@diabetes.ca And we'd be happy to answer the questions through via email.

[00:47:17] We've had a few participants ask how we might be able to adapt the Mediterranean diet for those who are vegetarian and then a specific individual has also added to that: what if they have an allergy to fish? Well I think if we take Alberta as an example people in Alberta really don't eat a lot of fish to begin with. We'll maybe have a bit of salmon. But I did live in Prince Edward Island for almost 20 years and recognized that people in the Maritimes are much more comfortable eating fish and incorporate a lot more fish into their diet. So in our version that we've really developed for people in the prairies who don't eat a lot of fish we did try to include two servings a week because that's what Canada's Food Guide recommends. But if you don't eat a lot of fish. One of the nutrients that we're interested in fish comes mainly in fatty fish like salmon. And that's the omega 3 fats. And there are plant sources of omega 3 fatty acids such as flax seed for example. So one way that I get more omega 3s in my diet is by adding flax, ground flax seed to smoothies that I tend to have in the morning for breakfast. So there are ways to get around fish specifically. If you're a vegetarian then I think it would be relatively easy to adapt the Mediterranean diet because they do have quite a reliance on plant sources of protein so nuts, the legumes, with dried peas dried beans, lentils, chickpeas are much more abundantly eaten in the Mediterranean than then in Canada. I'm just going back to the Mediterranean diet pyramid so that we could have a look at that and what some of the the protein sources would be that so even the grains are a source of protein. As I said the nuts and and the legumes would all provide protein and then of course many vegetarians do eat at least some dairy or fish. So that would be another source there as well.

[00:49:57] OK great. Thanks for that response. I'll move on to the next question. One of our participants has asked would meat include wild game? Yes. In general, wild game does tend to be leaner than livestock that's been raised on farms, so the amount of calories that we would get or the amount of fat that we would get from meat would be less from game but it's really about moderation. And so I think nobody would recommend that we eat red meat every day of the week anymore and that we should try and mix things up with different sources of protein whether it's poultry or fish or legumes or nuts that variety is really important for overall health.

[00:51:06] Great. Thanks for that response. I'll move on to our next question. One of our participants asked: Did the studies looking at the Mediterranean diet affect on cardio vascular disease in people with diabetes differentiate between type 1 and Type 2? Most of the studies are looking at type 2 because diet can both prevent and be used as an important treatment for Type 2 diet. It is important for type 1 as well, but from a different perspective. So because we know that people with Type 1 are reliant on insulin primarily so the studies that I'm aware of have mainly focused on type 2.

[00:52:06] Great. Okay so we'll move on to our next question. One of our participants asked: Will deep fried seafood or fish not be the best option. Should there be a limit. And if so how often should that be OK to eat? Yeah. So deep fried would not be my first choice. Like I said I was quite astonished at how much of fried and deep fried food we did eat in Italy and it was all delicious including the zucchini. Personally I'm not a dietitian so this is really personal opinion. I think we should try and limit our fried food and deep fried food, so it's not that we should never eat it. If we want to have some fried fish once a month something like that. Personally I don't think that's a problem. But, every time we have fish we shouldn't have fried fish would be my response I guess.

[00:53:20] OK great. Thanks for that response. I'm going to ask another question which I do believe you did speak to earlier but I will ask it anyway. Can the Mediterranean diet be used for people that might have heart problems? Yes I guess you should always consult with a health professional before embarking on these things. But it has been shown to help with things like blood pressure with cholesterol and with some of the other cardiovascular risk factors that are thought to increase the risk of having a heart attack or other cardiovascular events and also stroke. So yes I would say Mediterranean diet is suitable for people with heart problems.

[00:54:13] Great. Thanks for that response Dr. Chan. A few of our participants have been asking in relation to the consumption of wine and what an acceptable amount would be according to I guess Canada's Food Guide and the Mediterranean diet. So maybe I can quickly look that up on the Internet. It seems to me that it is not more than one drink per day for women and not more than two for men. Health Canada drinking guidelines. And of course for pregnant women it's zero. OK so reduce your long term health risk by drinking no more than 10 drinks a week for women with no more than two drinks a day most days and 15 drinks a week for men with no more than three drinks a day most days. Plan on drinking days every week to avoid developing a habit. So and then they also have other recommendations on binge drinking and not drinking when you're operating motor vehicles or other dangerous tools and so on. But that's the basic recommendation.

[00:55:47] Great. Thanks for that and definitely thank you for looking that information out. That's very helpful. We have a few other participants speak to the costs of living on a particular diet and how they might be able to adapt to the Mediterranean diet on something such as a welfare budget. And if you think that might be possible if you have any tips or ideas for somebody on a small budget. Oh well it's certainly much more challenging on a small budget. I think you know there are the basic tricks, buying larger quantities of non-perishable food items that makes it less expensive in the long run. And certainly by following a menu plan like the Mediterranean diet or another menu plan where there's really a minimum of food that's sort of in the other category or a junk food category and even spending a small amount of money on food that has low nutritional value takes away from what you can buy otherwise you know other tricks buying things frozen or canned instead of fresh may help to reduce the price. And if they've been prepared properly prior to freezing for example the nutritional composition of the food can be just as good as fresh and yet cost much less. So for sure I don't want to underestimate the challenges of trying to feed your family in a healthy way on a on a very small budget because it's super challenging. But there are small things I think that can be done to maximize the healthiness of the diet. Despite the challenges.

[00:58:02] Great. Thank you for that response. Again I see that there's still quite a few questions that are coming in folks and unfortunately just have one question left that we'll take. So for the questions that we do not get answered. Please feel free to email us at webinars@diabetes.ca. The last question Dr. Chan, and you've kind of already again addressed this earlier but participants are looking to see if where the Prairie Eating Plan is possible to purchase? And perhaps if an online purchases is also available? If you could just speak to that. Right. So on the Prairie provinces there are two bookstores in the large cities that carry pure prairie eating plan and there is information about which stores those are on our website www.pureprairie.ca. And likewise on the Web site there is an online store so that if it's not available in your community you can purchase it online.

[00:59:01] Great. Thanks so much. That does conclude our webinar for today. I would really like to thank Dr. Chan for speaking on behalf of the Canadian Diabetes Association. It has been a very great learning experience for all of us here and I know everyone on the line is also grateful, based on the comments and receiving in our question and answer box. I just want to remind everyone that our webinars are available on our website. So that's diabetes.ca/webinars and then especially this one will be available in the coming weeks. I do want to spend just a moment to thank our sponsor Lilly for making this webinar possible. For the rest of our series we have four more topics left so please feel free to join us next week on learning how to get support and give support to people living with diabetes and that'll be brought to you by Certified Diabetes Educator, Gail McNeil. And visit our web site to see all the lovely topics that we will be having there after. For those of you that live in the Ontario region we will be having our Toronto expo. So that's this Thursday November the 12th. It's a free event and we do hope that you'll come out and participate. We have some really great speakers including how Johnson and Joanne McCloud that we'll be presenting and it's just a great event and a great learning experience. So registration is limited so we do hope that you register and participate in the event. We do have a virtual health coaching program here at CDA. It's an on over the phone program. And if you'd like more information on that please give us a call at 1 800 Banting. So we do hope that you've enjoyed our webinar today. I just want to thank again Dr. Chan and you all the participants for joining us. We definitely hope to see you back again next time. Have a great day. Thanks.