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In the Loop 
Issue 243 - April 8, 2020

Coronavirus Disease (COVID-19) and the Eyes

The Vision UK website notes that “we still don’t have concrete information on how it’s [COVID-19] spread.” One area lacking research is the ocular implications of the virus (the impact on the eyes), as noted in a February 2020 review. The review authors conclude, “As the current epidemic continues, a better understanding of the virus will emerge, hopefully with more emphasis on research into the relationship between human CoVs and the eye.” Experts are not in complete agreement when it comes to whether you should continue to wear contact lenses and whether wearing glasses will reduce your risk of transmission of COVID-19.

Transmission of COVID-19 and the eyes
The American Association of Ophthalmology (AAO) website states that the coronavirus can spread through the eyes, therefore, limiting eye exposure can help. When a person coughs or talks, the virus particles can spray from their mouth and while you are more likely to breathe them in, they can enter through your eyes. You can also touch something with the virus and then touch your eyes. Peking University respiratory specialist Wang Guangfa believes his lack of eye protection may have been the cause of him contracting the virus. It is suspected that he may have touched his eyes or had infected droplets enter his eyes.

Wearing Eye Protection
During the COVID-19 pandemic, the University of California Berkeley Wellness Letter advocates that glasses or sunglasses should be worn by all people when going out in public. They acknowledge that eyewear will not provide complete protection, because glasses cannot seal around the eye but wearing glasses will “protect you substantially more than no glasses.” Glasses will also discourage people from touching their eyes. The Berkeley Wellness Letter cites experts recommending that even people without prescription glasses should wear glasses when they are out in public and suggest purchasing non-prescription glasses. People wearing contact lenses can benefit from wearing non-prescription glasses in addition to their contact lenses.  Dr. Thomas Steinemann, a clinical spokesperson for the American Academy of Ophthalmology (AAO) believes glasses may provide a “tiny bit more protection” from any coronavirus particles floating in the air, but admits it is still more likely that a person will be infected via their nose or mouth.

Should you wear contact lenses?
The Centre for Ocular Research and Education (CORE), an international group of experts, states that people can continue to wear contact lenses during the COVID-19 pandemic, but they need to be vigilant about proper hygiene and not touching their face. Other experts are encouraging people to wear contact lenses less often because wearing contact lenses can be irritating to the eyes and people will touch their eyes more.

Continue to wear contact lenses
CORE’s position - the group responded to what they describe as misinformation surrounding contact lens use and glasses during the COVID-19 pandemic that was put forth in the 48 hours before their press release dated March 12, 2020. The headline was “Top Contact Lens Experts Dispel Misinformation Regarding Coronavirus / COVID-19 Protections for Contact Lens Wearers.” The CORE press release states, “Despite myths and misinformation that have arisen over the past 48 hours, contact lens wear remains a safe and highly effective form of vision correction for millions of people worldwide.” CooperVision, a manufacturer of contact lenses, agrees, stating on their website, “There is currently no evidence to suggest that there is any increased risk of infection or contracting coronavirus through contact lens wear.” The CORE press release provides the following tips for people who wear contact lenses or glasses:
  • Proper handwashing is essential when inserting and removing contact lenses
  • Regularly disinfect or dispose of contacts as per the manufacturer's instructions
  • Disinfect glasses because the virus can stay on hard surfaces for hours to days, and the virus can be transferred to fingers and faces, especially by people who repeatedly put on and remove reading glasses
  • Discontinue lens wear only if sick - this is the same recommendation for other illnesses such as the flu or common cold
  • There is no scientific evidence to support wearing glasses or spectacles to protect against COVID-19 or other viral transmissions (in contrast to the UC Berkeley Wellness Letter)
  • The lowest risk of contact lens-related complications comes from clean hands and the use of daily disposable contact lenses, as opposed to reusable contact lenses
A recent literature review from Professor Emeritus Desmond Fonn and CORE indicates that proper hand hygiene is especially important for people who use contact lenses. The review was published back in April 2019 in the journal Contact Lens and Anterior Eye and discusses the negative repercussions of improper handwashing for people who wear contact lenses e.g., microbial keratitis, an infection of the cornea (the clear, dome-shaped window of the front of the eye) which can lead to blindness if not treated. Contact lenses should be handled by clean, dry hands. This includes washing your hands before not only touching your contact lenses but also when handling the contact lens case and solution bottle. You can view the images of the effects of handwashing in this CORE website link. The samples touched with unwashed hands show significantly higher numbers of visible bacteria compared to the contact lens touched by clean hands. 

Wear contact lenses less 
The AAO's position is that wearing glasses can help you to stop touching your face. They list the following points:
  • Wear your glasses more often. Dr. Sonal Tuli of the AAO states, “Consider wearing glasses more often, especially if you tend to touch your eyes a lot when your contacts are in. Substituting glasses for lenses can decrease irritation and force you to pause before touching your eye."
  • Avoid rubbing your eyes - the organization reminds us to be mindful of this natural habit. If you feel the urge to rub or itch your eyes or adjust your glasses, use a tissue and not your fingers. If your eyes are dry, you are more likely to feel the urge to rub them, so consider using moisturizing eye drops. If you must touch your eyes e.g., to put in medicine, remember to wash your hands with soap and water for at least 20 seconds and wash them again when you are finished.
  • Stock up on eye medications - when possible, ensure you have an adequate supply of critical medications so that you won't be left without them if supplies become limited.
CooperVision, a contact lens manufacturer, lists three questions you should ask yourself each time you wear your contact lenses: 
  • Do my eyes feel good with my lenses? There should be no discomfort.
  • Do my eyes look good? There should be no redness.
  • Do I see well? There should be no unusual blurring with either eye. If you have any concerns, they advise a person to remove their lenses and contact their eye care professional.
What about the transmission of COVID-19 and pink eye?
Another health condition that could arise from COVID-19 is conjunctivitis or pink eye, which is an inflammation of the thin transparent layer of tissue (conjunctiva) that covers the white part of the eye and the inside of the eyelid. Viruses like these areas of the eye because they are moist. Dr. Steinemann reports that viruses can stick on a contact lens that is placed on your conjunctiva. China reports that about 1 to 3 percent of people with COVID-19 also had pink eye.

A study by the AAO did not involve people with pink eye but also did not find that people with COVID-19 were shedding the virus from their tears, therefore, it still is not known if COVID-19 can be spread by tears. The bottom line: experts stress that having a red or pinking eye does not mean it is a sign of COVID-19.

PLEASE NOTE: COVID-19 is an emerging, rapidly evolving situation and information can change. If you have questions or concerns regarding your vision and eye protection during the COVID-19 pandemic, speak with your family doctor or eye care health professional.

Resources - CORE has resources for people who wear contact lenses
  • Good Habits, Healthy Eyes patient handout
  • Cleaning Instructions for Contact Lens Wearers patient handout for people who wear reusable contact lenses
Sources: Berkeley Wellness Letter website, American Optometric Association (AOA) website, AAO website, CNN website, CORE website, Eyewire News website, South China Morning Post website, VisionDirect.co.uk website, CooperVision website, KALB website 
 


Guidance for At-Risk Adults During the COVID-19 Pandemic

The government of Canada lists groups having an increased risk of more severe outcomes from the coronavirus disease (COVID-19): aged 65 and over; with compromised immune systems; and with underlying medication conditions. The US Centers for Disease Control explains that many conditions can cause a person to be immunocompromised, including cancer treatment, smoking, bone marrow or organ transplantation, immune deficiencies, poorly controlled HIV or AIDS, and long-term use of corticosteroids and other immune weakening medications. In Canada, a 2019 survey found that 44% of Canadian adults aged 20 and over have at least 1 of 10 common chronic conditions.

Some facts about COVID-19
  • Increased risk with increasing age - in general, an elevated risk begins at 60 years of age, says Nancy Messonnier, MD, director of the Centers for Disease Control National Center for Immunization and Respiratory Diseases. She notes that the highest risk of serious illness and death is in those over 80 years of age.
  • Increased risk from being older and having an underlying condition (diabetes, heart or lung disease) - older adults and people with underlying health conditions appear to be about twice as likely to develop serious outcomes versus otherwise younger, healthier people. 
  • Lifestyle - an individual’s risk also depends on their lifestyle e.g., a 70-year old who runs marathons will have a lower risk than someone who smokes.
What to do if you think you have coronavirus disease (COVID-19)
The HealthLink BC website answers the most common questions about COVID-19 and it lists the actions to take if you think that you may have contracted it.

What about being around children?
Children who have the virus are less likely to display symptoms, yet as a group, they are notoriously adept at spreading germs. Nick Etches, a medical officer of health with Alberta Health Services, tells the National Post that “seniors consider limiting their babysitting duties to reduce their risk of exposure.”

Have grandchildren contact grandparents or persons living with chronic conditions/compromised immune systems in other ways such as through Apple Facetime, Facebook Messenger, Skype, Zoom or a telephone call. Claire McCarthy, MD, a pediatrician at Boston Children’s Hospital and faculty editor for Harvard Health Publishing, says that to keep grandparents safe, they “really shouldn’t be doing childcare.” She adds that it is older adults who are the ones who really need to isolate themselves. It is important to stay socially connected by phoning or video chatting with friends and family members.

What about visitors?
Dr. Sean Morrison, a geriatrician with Mount Sinai Health System in New York, advises against visiting older relatives unless it’s “absolutely necessary.” This means the delivery of care packages with food and medications and not in-person visits. Older adults and persons with underlying medical conditions should stay home and avoid other people.

What about medical appointments
Currently, most doctor’s offices are preferring to use the phone or video visits in lieu of face-to-face visits. According to Neha Pathak, MD, of the Mayo Clinic, the situation is “rapidly evolving” and although people are being told to avoid congregating in groups this can be difficult to do in health care office waiting areas or hospitals. However, if you have a health emergency do not hesitate to call 911.
 
Patients should phone their doctors’ and dental offices to discuss postponing any routine, non-urgent in-person appointments. Please be sure to phone your dentist to arrange in-person appointments for emergency visits such as broken teeth, toothache pain, and infections.
 
People with health conditions including heart disease, transplants, and other chronic conditions, should speak with their doctor’s office regarding their upcoming in-person appointments and lab appointments. Regarding in-person appointments, pregnant women should continue to follow the advice of their family doctor or obstetrician. BC Cancer outlines its plans for office visits on its website.
 
What if I live with someone who is socially isolating? 
If you are over 70 and live in a household where someone is socially isolating, please take precautions. The greatest risk of infection is among those who are in close contact with people who have COVID-19. Steps to take include: having the person self-isolating wearing a mask; assigning one bathroom to the person being isolated; using separate kitchen/kitchen utensils/bedroom; and regularly cleaning and disinfecting commonly used surfaces e.g., light switches, doorknobs, faucets, countertops, and cabinet handles.
 
What resources are available for someone who is practicing social isolation? 
  • 2-1-1 phone line - call 2-1-1 or visit the website to connect with people who can support older adults with resources including meal delivery, help with cooking, delivery of groceries and medications, and wellness calls and visits. Contact 2-1-1 if you are interested in volunteering to help others. Volunteer roles include making deliveries to helping participate in virtual calls with seniors who face isolation. 
  • Share the goods - a website service that matches individuals to a volunteer. If you need a little help with food or household supplies, or you want to help someone in need, this website can help. You provide your email and answer a few quick questions. For more information, visit the FAQs page.
  • Seniors First BC has developed a list of resources for seniors (dated March 30, 2020)
What can I do if my older adult parents do not take the warnings about the virus seriously? The MSNBC website suggests a three-pronged approach:
  • Trusted sources - find out who they trust for information. The government websites listed above are trusted sources of information. Print out some information and review it together, or just leave it with your parents to read. Having this trusted source may change their perception of the situation. 
  • Ask questions - find out what they are feeling. If they underestimate the severity of the situation, you can ask them to invite you into the conversation e.g., “Do you want to know what I am worried about?” Share how you have prepared (modelling), rather than forcing them to do something. If you don’t live nearby, investigate arranging deliveries of groceries and medications, or find a non-profit that might be providing this service. In BC, older adults can call 2-1-1 if they require assistance. 
  •  Don’t pressure or badger - this pushes people further away and they tend to then stand their ground. If you have offered information and they have not changed their minds, respect their decision and keep space open for future conversations.
  • Other resources: The Canadian Frailty Network has a helpful handout entitled Help older adults in your life prepare for potential illness or quarantine in the following ways and for more tips here is a link to How to Talk With Your Older Parents about COVID-19- and have them actually listen
What can I do to maintain my health?
Follow a healthy lifestyle. This means engaging in physical activity on a regular basis, eating healthy food, paying attention to portion sizes, getting adequate sleep, quitting smoking or staying smoke-free, and following low-risk drinking guidelines. Now, more than ever, it is especially important to manage your medical conditions by being sure to take your medications as prescribed and monitoring your condition(s) frequently.
 
When it comes to physical activity, the US National Council on Aging (NCOA) encourages older adults to stay active and maintain the gains they have achieved in strength, balance, and flexibility that reduce fall risk, strengthen their immune system, and improve their quality of life.
 
An important fact shared by NCOA is that while older adults may be concerned about their safety when exercising in their home, the good news is that the risks of exercising at home are no greater than the risks of exercising in most group settings. Wear proper shoes and clothing. Ensure the space is free of obstacles that could cause a fall, including pets. Remember to warm up and cool down, and to use the talk test to make sure you are exercising at a moderate level. The talk test means that you are still able to talk and that you are not out of breath while you are exercising. Here are some videos and written information about how to exercise at home:  

 Home exercise videos
  • Active Aging Canada One Minute Exercise videos
  • National Institute on Aging - Go4Life Workout Videos
  • National Center on Health, Physical Activity and Disability (NCHPAD) - Home Workouts videos
Home exercise information
  • American College of Sports Medicine handout - Staying Active During the Coronavirus Pandemic
  • American College of Sports Medicine handoutSit Less. Move More
  • MedlinePlus handout - Indoor Fitness Routine
  • Harvard Heat Letter article - An Efficient (and thrifty) Way to Exercise at Home 
Other resources 
  • BC Centre for Disease Control March 13, 2020 handout - Novel coronavirus (COVID-19) information for patients with chronic health conditions
  • US Centers for Disease Control (CDC) video - COVID-19: What Older Adults Need to Know
Here are more of the sources we used and these links contain additional information to help us look after ourselves and others:
National Post website, Senior Planet website, CDC website, National Foundation for Infectious Diseases website, Harvard Health Blog website, Harvard Health Blog website, Windsor-Essex County Health Unit website, National Public Radio website, WebMD website, World Economic Forum website
 

 

 
Growing Vegetables at Home

The coronavirus disease (COVID-19) pandemic has put our lives on hold and made us realize our dependence on grocery stores for food. Because of this, growing your own food is becoming increasingly popular. 

Some of us are intimidated by growing plants, having had a poor track record for keeping indoor plants alive. For some, growing even drought-resistant plants can be a challenge. Don’t be dismayed, however, as there is plenty of support available online. Lisa Giroday, the co-founder of the Victory Gardens Vancouver co-operative, shares tips for would-be gardeners:  
  • Everyone can plant something - people with yards and balconies can easily grow vegetables, and even those with only windowsills can still grow herbs and microgreens. 
  • Community gardens may still be an option if social distancing is practiced. 
  • Plants that can be started now include kale, peas, radishes, mustard greens and herbs like cilantro. You can start seedlings indoors for plants that like the sun, such as tomatoes, peppers, and eggplant. 
  • Now is a good time to prepare your garden and containers e.g., weeding, adding compost to garden beds, and adding fertilizer. 
  • Good soil is the key to success. The Old Farmer’s Almanac states, “Plants depend on the soil for nutrients, stability, and drainage. To grow your best garden, start with well-drained, sandy loam [loam is soil composed mostly of sand, silt, and a smaller amount of clay] and add as much organic matter as possible.” 
  • For beginner gardeners, it is wise to try the “easy-to-grow” vegetables. The top ten vegetables that are easy to grow, according to the Old Farmer’s Almanac, are tomatoes, zucchini, peppers, cabbage, bush beans, lettuce, beets, carrots, chard, and radishes. To this list of vegetables add marigold flowers to keep pests away.
   How to plant each vegetable
  • Seeded where they grow - most garden vegetables can be directly seeded where they are to grow, such as lettuce, beans, carrots, beets, chard, spinach, peas, cucumbers, and squash. 
  • Seedlings to plant in a garden - choose seedlings for plants that take longer to produce fruit, such as tomatoes, peppers, eggplant, and melons or start your own indoors 6 to 8 weeks before planting them outside. Tony Maniezzo, formerly of the UBC Botanical Garden, adds squash to this list.
  • Size of the garden - many sources, including The Old Farmer’s Almanac, suggest that the size of the garden should be about 16 by 10 feet or smaller to feed a family of four for the summer. This includes having leftovers for canning/freezing. As the website states, "It’s better to be proud of a small garden than be frustrated by a big one!" Make 11 rows each 10 feet in length by 6 inches apart running north to south to take advantage of the sun. 
  • You can do intercropping which means planting two plants together that mature at different rates e.g., radishes and carrots. The radishes can be harvested first to make room for the carrots. 
  • If your space is limited, avoid growing sweet corn and vine crops e.g., pumpkins, winter squash, and melons. For container gardens, good choices include strawberries, tomatoes, herbs, and lettuce. Basil or other herbs can be grown on your windowsill. Some grocery stores sell the full-sized plants or you can start them from seed.
Here are a few tips from Brian Minter of Minter Gardens in Chilliwack, BC:
  • Bargain seeds are not a bargain.
  • Freeze all your vegetable seeds for 48 hours before sowing to help stratify them (stratification is a process of treating seeds to simulate natural conditions that the seeds must experience before germination can occur). He explains that this should speed up and improve germination.  
  • Be aware that most people plant their seeds too deep.
  • Raised beds are popular – he suggests making a raised bed that is 4 feet by 8 feet by 2 feet high.
For more details, read Brian Minter's article from the Chilliwack Progress website. 

When you should plant
Here are some resources providing information on when to plant your vegetables:
  • West Coast Seeds website has regional plant charts 
  • The National Gardening Association Learning Library website
  • The Old Farmer’s Almanac website  
Grow vegetables from table scraps
Here’s a project you could do with the whole family - grow healthy produce from leftover parts of your vegetables. The benefits include saving money and reducing food waste. Start your vegetables indoors. They can be kept inside or moved outside with warmer temperatures. An easy place to start is with leafy vegetables i.e., those that grow in heads such as celery, romaine, and bok choy. Check out these resources for more information. You can do a Google search on “growing vegetables from table scraps.” A sample of resources are listed below: Videos
  • Did you know you can Grow Vegetables from Scraps? video
  • How to Grow Everything video 
  • How to Grow an Organic Vegetable Garden video from Victory Gardens
Sources: Buzzfeed website, Gardentech website, The Old Farmer's Almanac website, CBC News website, The Vancouver Sun website, The Chilliwack Progress website, Vancouver Observer website   

 
 


National Advance Care Planning Day April 16th

The BC Centre for Palliative Care is promoting “National Advance Care Planning Day” April 16th when Canadians are encouraged to speak with their loved ones between 6 pm and 8 pm about their values, wishes, and what is important to them. The theme for 2020 is “A life well lived is a life well planned.”
 
Background
The Advance Care Planning website cites two studies indicating that Canadians are not prepared for the end of life. One national study of older adults who are ill and their caregivers, and a national Ipsos-Reid poll indicate that most Canadians have failed to talk with their family or their doctors about their preferences for care should they be unable to speak for themselves. In fact, the Ipsos-Reid national poll found that 86 percent of Canadians had not heard of advance care planning, with only 9 percent actually speaking with their health care provider about their health care wishes. While the majority of Canadians think advance care planning is important, less than one in five Canadians have an advance care plan.

What is Advance Care Planning?
Advance care planning involves talking with others about your wishes for your future health care and deciding who speaks on your behalf if you cannot. As the organization states, “A key part of Advance Care Planning is deciding who can make health care decisions on your behalf should you be unable to. This person is known as a “Substitute Decision Maker." The “Speak Up” initiative provides a more detailed definition - “a process of reflection and communication about personal care preferences in the event that you become incapable of consenting to or refusing treatment or other care.” Here is a video from the Speak Up initiative. 
 
What are the benefits of Advance Care Planning?
  • Helps people close to you honour your health care wishes
  • Avoids unnecessary family disputes or confusion by having a voice in your future health care
  • Allows you to plan early before health problems get in the way
Two of the important components of an advance care plan are to choose one or more “Substitute Decision Makers” – individuals who will speak on your behalf and make decisions for you when you are not able to do so yourself, and having a conversation with them about your wishes.

Resources
  • The Speak Up! Initiative - this website includes information, tools, and prompts to help with starting these difficult conversations. Each province and territory has its own resources because the process of expressing values and wishes differs across the country. Here is the link for getting started in BC. Includes a video with Walter Gretzky Speaking Up! About Advance Care Planning 
  • BC Centre for Palliative Care - works with partners in the health system and community to accelerate best practices and promising innovations in palliative care and supports. They strive to help British Columbians affected by serious illness have the best quality of life possible. The website now features advance care planning resources and has a section for “individuals and families” providing information on how to start an advance care plan, advance care planning resources, and talking with your health care team.
  • HealthLink BC website

 



Energy Density of Foods

The Mayo Clinic explains that foods that are “less calorie dense” are those foods that have fewer calories with a larger portion. Energy density is the number of calories for a specific amount of food. Energy density = number of calories divided by weight (grams). High energy density means a lot of calories in a small portion of food, while low energy density means there are few calories in a large portion of food.

Benefits of eating low-energy-dense foods
By eating low-energy-dense foods, you will feel fuller on fewer calories. Eating less calorie-dense foods can help you to feel less hungry and, therefore, eat less. The US Centers for Disease Control state, “Satiety and hunger control are important for long-term satisfaction and compliance with an eating plan.” Another benefit of eating this way is the positive messages used i.e., eat satisfying portions of low-energy-dense foods as opposed to restrictive messages about eating smaller portions. Studies show that people tend to eat about the same amount of food in terms of weight each day, but not necessarily the same amount of energy or calories. If a person follows a lower-density eating plan (same weight each day) they will get a lot more food for the same amount of calories. An example given by the Mayo Clinic is that 1 cup of grapes has 84 calories (low-energy-dense food) while 1 cup of raisins has 434 calories (high-energy-dense foods). Below is an image of two lunches with the same amount of energy, but clearly large differences in the amount of food (permission to use image granted by Barbara Rolls, PhD, Penn State University).

What determines the energy density of a food?
In a nutshell - the more water and fibre in a food, the lower its energy density. The more fat in a food, the higher its energy density. Whole fruits, vegetables, grains, and legumes are all in the lower end of energy density because they often contain high water content, lots of fibre and/or little fat.
  • Water - in general, fruits and vegetables have high water content. The water gives the food more volume and weight but fewer calories. Water lowers the energy density of foods because it has an energy density of 0 kcal/g and contributes weight but not the energy to foods. Grapefruit is about 90 percent water, with one-half of a grapefruit representing 37 calories. Watermelon is very healthy and one of the most hydrating foods you can eat, with a 1-cup (154-gram) serving containing over one-half a cup (118 ml) of water or 92 percent water content. A cucumber is only 8 calories in a half-cup (52-gram) serving or water content of 95 percent.
  • Fibre - fibre provides volume and takes time to digest so you feel full longer. Fibre can be found in fruits, vegetables, and whole grains. For example, a cup of air-popped popcorn has only 30 calories (with no toppings - try a spritz of oil and some herbs for flavour). According to the Unlockfood website, many Canadians are getting only about half the amount of fibre they need.
  • Fat - fat is high in energy density. Fat (9 kcal/g) is the most energy-dense component of food, providing more than twice as many calories per gram as carbohydrates or protein (4 kcal/g). For comparison, the Mayo Clinic indicates that a pat of butter has the same number of calories as 2 cups of raw broccoli. Other examples of higher fat foods include dairy products and meats.
What to focus on:
Vegetables - high volume or weight for low calories. Choose a variety, including dark green vegetables, red and orange vegetables, legumes, and starchy vegetables. Use vegetables and fruits as substitutes for high-energy dense foods to decrease the overall energy density of a meal.

Fruits - look for fresh, frozen and canned versions in water. Fruit juices and dried fruits are concentrated sources of natural sugar so are considered high-energy-dense foods and they don’t fill you up. Prepare without added fat.

Carbohydrates - whole grains are the best choice because they are high in fibre and other nutrients. Look for whole-wheat bread, pasta, brown rice, oatmeal, and whole-grain cereal.

Protein and dairy - choose lower-energy dense foods high in protein but low in fat and calories e.g., legumes (beans, peas, and lentils), fish, skinless white meat poultry, fat-free dairy products, and egg whites.

Fats - look for healthier monounsaturated and polyunsaturated fats e.g., nuts, seeds, and oils (olive, flaxseed, and safflower). Use low-fat cooking methods e.g., grilling chicken instead of frying chicken or choosing low-fat Greek yogurt instead of sour cream.

Sweets - these are generally high-energy-dense foods, so look for those that are low in added fat, e.g., fruits, whole grains, and low-fat dairy. Take small portions. Healthier dessert choices include low-fat plain yogurt and fresh fruit, whole-wheat flour cookies or low-fat ice cream. 

Limit or eat less often:
  • Dry snack foods such as crackers, pretzels, cookies, chips, and dried fruits
  • Higher-fat and higher-sugar foods such as croissants, margarine, shortening and butter, candy bars, cakes, and pastries
  • Fatty cuts of meat such as bacon, brisket, and regular ground beef
  • Foods with saturated and trans fat
  • Fried foods - when it comes to food preparation, fried foods such as eggs fried in butter and french-fries should be chosen less often
The British Nutrition Foundation suggests:
  • Base your diet around foods low or very low in energy density
  • Have moderate amounts of some medium energy density foods
  • Small amounts of higher energy density foods and less often

The Volumetrics Diet

Volumetrics, a dieting approach developed by Penn State nutritional sciences professor Barbara Rolls, PhD, was listed in U.S. News and World Report’s 2020 annual rankings as being one of the most effective diets to follow in a wide variety of categories. It was ranked as the fifth-best diet overall and tied for second with the Vegan Diet for best weight loss diet after WW (Weight Watchers). Dr. Rolls sums up the approach by stating, “Go for your fruits and veggies, fill half your plate with that and then take reasonable portions of your grains, your meats, and your higher-density calorie foods.” Volumetrics is a science-based strategy focused on the power of feeling full and managing hunger using high volume and low-calorie foods, such as soup and vegetables. The challenge with this way of eating is to have the discipline to manage the portion size of your higher-density foods. She warns of the dangers of drinking high-calorie beverages like soda, as they can cancel out the calories you are avoiding with high-density foods. Her research has led to a better understanding of the importance of allowing people to feel fuller both physically and psychologically by choosing foods that have high water content and low-calorie density. A study found that 30.8 percent of people stop following a diet because they do not feel full.
  • Food is divided into four categories:
    • Category one (very low-density) includes non-starchy fruits and vegetables, non-fat milk and broth-based soup.
    • Category two (low-density) includes starchy fruits and veggies, grains, breakfast cereal, low-fat meat, legumes and low-fat mixed dishes like chili and spaghetti. Choose a lot of foods from categories one and two.
    • Category three (medium-density) includes meat, cheese, pizza, french fries, salad dressing, bread, pretzels, ice cream, and cake. Watch your portion sizes (the amount of food you take).
    • Category four (high-density) includes crackers, chips, chocolate candies, cookies, nuts, butter, and oil. Keep these food choices to a minimum.
Dr. Rolls co-authored a 2018 article in the journal Medical Clinics of North America, indicating that a key strategy for weight management that can be applied across dietary patterns is to reduce energy density. The authors indicate that patterns of eating with lower-energy-dense foods include the DASH diet and the Mediterranean diet (focus on low-energy-dense fruits, vegetables, legumes, seafood, and dairy foods – however, 30 to 40 percent of total energy in the Mediterranean diet come from higher amounts of fat (healthy fat) such as olive oil. They state, “Even with this level of healthy fats, the high proportion of vegetables and fruits included in this pattern can help to keep the overall diet relatively low in energy density.” Additional tips for following this approach to eating include:
  • Decrease the energy density of the main course as the main course or entrée often represents the most calories of a meal
  • Eat a low-energy-dense first course before going to the “heavier stuff” e.g., a 100 to 150 calorie broth-based soup, leafy green salad or whole fresh fruits before a meal.
  • Manage added sugar intake and consider using non-nutritive sweeteners. Every weight loss program should reduce added sugars, the main sources being beverages, snacks, and sweets (beverages and foods that are nutrient-poor, higher-energy-dense). With regards to non-nutritive sweeteners, the authors note that observational studies have shown an association between non-nutritive sweeteners and weight gain, while randomized controlled trials have found the opposite (and randomized controlled trials are stronger evidence). Therefore, non-nutritive sweeteners can be a substitute for higher-energy-dense foods e.g., sugar-sweetened beverages. The preferred beverages are water and other low-calorie beverages versus higher-calorie beverages. 
More tips to incorporate low-energy-dense foods
  • Add extra vegetables where you can e.g., stews, soups, stir-fries, chili, pasta and salads
  • Add beans, peas, and lentils to soup, salad or chili
  • Avoid using too much oil or fat in cooking, and use only a little butter on your bread
  • When having a salad, avoid using high-fat dressings; instead, use lemon juice or vinegar-based dressing you can make yourself
  • Leftover vegetables can be used in stews and soups, and add extra pulses such as beans or lentils
  • When it comes to desserts, add extra fruit and instead of ice cream use low-fat yogurt
The University of California - Integrative Medicine website makes two important points for people following a plant-based diet who want to lose weight:
  • Keep your consumption of  high-energy dense whole-fat foods (e.g. nuts and seeds) to a minimum (1 serving per day) or eliminate them entirely, with the exception of ground flaxseed, which they suggest you consume daily to get omega-3 fatty acids
  • Be aware that eating only fruits and vegetables will never allow you to feel completely full. Therefore, to feel full, balance vegetables with slightly higher-energy-dense foods e.g. starchy vegetables, whole grains, legumes, and seeds and nuts
Resource: The Science of Feeling Full video by Dr. Barbara Rolls
 
A comparison of a high and low-energy density meal with the same kcal
(image used with permission from Dr. Barbara Rolls, Penn State University)

Sources: Onward State website, US News website, US Centers for Disease Control website, US Centers for Disease Control handout, UC Davis Integrative Medicine website, Mayo Clinic website, Healthline website, Unlockfood website, British Nutrition Foundation website, International Food Information Council Foundation website  
 


Family Caregivers of BC Caregivers Out Loud Podcast 

Now more than ever unpaid family and friend caregivers are stepping up to care for others and keep them safe during a time of increased vulnerability. Family Caregivers of British Columbia launches its podcast, “Caregivers Out Loud” on April 14th, 2020. The podcast, hosted by Jodie McDonald, explores the ways in which the role of a caregiver can be both rewarding and also emotionally, psychologically, and physically taxing. Through sharing caregiver stories, they bring you perspective and connection, ensuring that you have support and balance from inspired caregivers. Please listen and share the podcast on your favourite podcast app or at www.familycaregiversbc.ca/podcast/ 
 
 
Please send your ideas and suggestions to theloop@uvic.ca.


Self-Management BC is supported and funded through a partnership with the Patients as Partners Initiative within the BC Ministry of Health.
 
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