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  • Lipid Management in Clinical Practice - Section 1
  • Lipid Management in Clinical Practice - Section 1

Transcript

  • 1. Nutrition and the Metabolic Syndrome Gail Underbakke, RD, MS UW Preventive Cardiology Program
  • 2.  
  • 3. Metabolic Syndrome in Children and Adolescents
    • Prevalence of metabolic syndrome is high among obese children and adolescents and it increases with worsening obesity.
    • 439 subjects, ages 4-20, BMIs > 97 th percentile
    • 38.7% of moderately obese subjects had Met Syn
    • 49.7% of severely obese subjects had Met Syn
    • New England Journal of Medicine 2004; 350:2362.
  • 4. Definition:
    • The Metabolic Syndrome consists of multiple, interrelated risk factors of metabolic origin that appear to directly promote the development of atherosclerotic cardiovascular disease (  risk 2x), and are strongly associated with type 2 diabetes mellitus (  risk 5 x).
    • Metabolic risk factors include atherogenic dyslipidemia, elevated blood pressure, elevated plasma glucose, a prothrombotic state, and a proinflammatory state.
  • 5. ATP III: The Metabolic Syndrome* *Diagnosis is established when  3 of these risk factors are present. † Abdominal obesity is more highly correlated with metabolic risk factors than is  BMI. ‡ Some men develop metabolic risk factors when circumference is only marginally increased. Waist circumference measured at iliac crest. <40 mg/dL or on meds <50 mg/dL or on meds Men Women >40 in >35 in Men Women  100 mg/dL or on meds Fasting glucose  130/  85 mm Hg or on meds Blood pressure HDL-C  150 mg/dL or on meds Triglycerides Abdominal obesity † (Waist circumference ‡ ) Defining Level Risk Factor
  • 6.  
  • 7. Country/Ethnic Values for Waist Circumference Defining Central Obesity, International Diabetes Federation
    • Male Female
    • USA  102 cm (40”)  88 cm (35”)
    • Europids  94 (37”)  80 (31.5”)
    • South Asians  90 (35.5”)  80 (31.5”)
  • 8. Atherogenic Dyslipidemia Risk of coronary heart disease Despres J-P. Dyslipidemia and obesity. Baillere’s Clin Endocrinal Metab. 1994;8-636
  • 9. Underlying Causes of Metabolic Syndrome
    • There are multiple underlying factors –
    • abdominal obesity*
    • insulin resistance*
    • physical inactivity
    • aging
    • genetic or ethnic predisposition
  • 10. Post-prandial Dysmetabolism
    • Inflammation plays a role in the development of chronic disease - heart disease, diabetes, dementia, and probably more
    • High calorie, easily digestible, quickly absorbable foods and drinks lead to exaggerated post-prandial spikes in glucose and lipids (triglycerides)
    • Exaggerated spikes in glucose and lipids generate excess free radicals and increase inflammation and endothelial dysfunction
    • Fasting glucose and triglyceride values may be normal, while post-meal values are high.
  • 11. Effects of a beverage containing 75 gm glucose with 75 gm fat as whipping cream. Nitrotyrosine indicates oxidant stress, CRP indicates inflammation, FMD = Flow-mediated dilation. Ceriello et al, Circ 2005; 111:2518 Post Prandial Stress
  • 12. Daily Activity Reduces Post-Prandial Glucose O’Keefe, et. al. JACC 2008; 51:249
  • 13. Inflammation
    • Triggers include
      • oxidized LDLs in artery intima
      • low HDL levels (HDL inhibits inflammation)
      • hypertension (via angiotensin)
      • diabetes (via advance glycation end products)
      • obesity (adipose produces cytokines)
      • infection
    • Testing? – HS (high sensitivity) C reactive protein
    • Anti-inflammatory diet?
      • More omega-3 fats, less omega-6, more antioxidants in food
    • Circulation. 2002; 105:1135-1143
  • 14. AHA Recommendations for Management of the Metabolic Syndrome
    • Lifestyle First!
    • Reduce weight by 7-10% during first year. Continue weight loss to goal of BMI < 25.
    • 30-60 minutes moderate intensity aerobic activity, preferably daily, supplemented by daily lifestyle activity. Resistance training 2x per week.
    • Saturated fat <7% of calories, dietary cholesterol <200 mg/day, total fat 25-35% of calories. Limit simple sugars.
    • Circulation 2005;112:2735-52
  • 15. Lifestyle Recommendations to:
    • Reduce Triglycerides
    • Weight loss, exercise, total carbohydrate <60% of calories, limit alcohol
    • Increase HDL
    • Exercise, weight loss, smoking cessation, total carbohydrate <60% of calories
    • Reduce blood pressure
    • Weight loss, exercise, DASH diet, limit alcohol
    • Reduce blood sugar
    • Weight loss, exercise, consistent moderate carbohydrate
  • 16. Carbohydrate and Triglycerides
    • High carb diets can overwhelm normal metabolism, increase synthesis of fatty acids
    • Sugar, especially fructose, has greatest effect, but all carbohydrates matter
    • Goal <60% of calories from carbohydrate
      • Fat intake should be 25-35% of calories. Cutting carbs may mean adding fat.
    • Higher fiber diet can help minimize effects of carbohydrate
  • 17. Effects of Lifestyle Modification to Manage Hypertension
    • Approximate Reduction in
    • Modification Systolic BP, mmHg
    • Weight reduction 5-20 w/ 10-kg wt loss
    • DASH Diet 8-14
    • 2400 mg sodium/d 2-8
    • Physical activity 4-9
    • Moderate alcohol 2-4
    • JNC 7, May 2003
  • 18. Dietary Approaches to Stop Hypertension (DASH and DASH-Sodium)
    • Moderate sodium use (2400 mg per day or less)
    • Maintain a healthy weight
    • Increase intake of fruits and vegetables to 8-10 servings per day and include 2-3 servings of low-fat dairy products per day
    • Emphasize whole grains, poultry and fish, lean red meats, vegetarian proteins and some nuts
    • SBP decreased 11 mm Hg, DBP 6 mm Hg
    • NEJM 1997;336;1117-24
  • 19. Overall Lifestyle Recommendations for Metabolic Syndrome
    • Exercise
    • Weight Loss
    • Total carbohydrate <60% of calories
    • DASH diet
    • Limit alcohol
    • Smoking cessation
  • 20. The Continuum of Diets to Reduce CVD Risk
    • Total Fat 30-40% 34% <30% <30% <10%
    • Sat Fat < 7% 11% <10% <7% --
    • Cholesterol < 200 256 <300 <200 <5 mg
    • MUF 15-20% -- 10-15% 10-15% --
    • PUF <10% -- <10% <10% --
    • CHO 45-55% 50% 55-65% 55-65% 75%
    •     
    • “ Mediterranean” Current AHA AHA Ornish,
    • Average Step TLC Pritikin
    • American One
  • 21. One Diet for All?
    • Case # 1
    • 62 y.o. male
    • CAD
    • BMI - 24
    • Waist circumference - 34”
    • Cholesterol - 285
    • Triglycerides - 78
    • HDL - 47
    • LDL - 222
    • Fasting Glucose – 87
    •  Saturated and trans fat
    •  Soluble fiber
    • Add plant sterols
    • Case #2
    • 62 y.o. male
    • CAD
    • BMI - 31
    • Waist circumference - 42”
    • Cholesterol - 217
    • Triglycerides - 283
    • HDL - 30
    • LDL - 130
    • Fasting Glucose – 122
    • Control carbohydrates and calories
    •  Saturated and trans fat
    •  Soluble fiber
  • 22. Copyright restrictions may apply. Gardner, C. D. et al. JAMA 2007;297:969-977. Which Diet Works?
  • 23. Dansinger, JAMA 2005; 293:43-53 
  • 24.  
  • 25. Change From Baseline (%) P <0.001 LDL-C TG
  • 26. Fish Sources of Omega-3 Fatty Acids
    • Salmon, Atlantic, farmed, 3 oz 1.09-1.83 gm
    • Herring, Atlantic, 3 oz 1.71
    • Sardines, canned, 3 oz 0.98-1.70
    • M ackerel, Atlantic, 3 oz 0.34-1.57
    • Salmon, Atlantic, wild, 3 oz 0.9-1.56
    • Tuna, fresh, 3 oz 0.24-1.28
    • Salmon, pink, 3 oz 1.09
    • Rainbow trout, farmed, 3 oz 0.98
    • Rainbow trout, wild, 3 oz 0.84
    • Salmon, sockeye or chum, 3 oz 0.68
    • Tuna, canned, white, 3 oz 0.73
    • Tuna, canned, light, 3 oz 0.26
    • Cod, Atlantic, 3 oz 0.24
    • Catfish, wild, 3 oz 0.2
    • Kris –Etherton. Circulation 2002; 106:2747
  • 27. Plant Sources of Omega-3 Fatty Acids, Per gram of fat
    • Flax seed oil 0.66
    • Fish body oil 0.3
    • Cod liver oil 0.19
    • Canola oil 0.12
    • Walnuts 0.11
    • Soybean oil 0.08
  • 28. Contains: 180 mg EPA 120 mg DHA Per capsule For more information: Fish Oil Supplements www.heartdecision.org
  • 29. Facts about the Glycemic Index
    • Defined as the area under the blood glucose curve for a test food, compared to the area under the curve for a carbohydrate equivalent amount of a reference food.
    • Starches higher in amylose (some varieties of barley and corn) are more resistant than those higher in amylopectin.
    • Food processing - gelatinization of starch increase GI (most breads and cereals), crystallization of starch reduces GI.
    • Organic acids (sourdough bread, fermentation of water-soluble fiber) reduce GI.
    • GI affected by fat, protein, and fiber in the current meal, content of previous meal.
  • 30. Glycemic Index of Selected Foods
    • Potatoes 80-100 Baked beans 48
    • Corn flakes 84 Orange, Grapes 43
    • Whole Wheat bread 72 Pumpernickel bread 41
    • White bread 70 Apple 36
    • Rice, brown and white 70 M & Ms, peanut 33
    • Spaghetti, 20 min. 61 Yogurt with fruit 33
    • Ice Cream 61 Spaghetti, 5 min. 34
    • Basmati rice 60 Lentils 28
    • Sweet potato 54 Peach 28
    • Sourdough bread 54 Barley 25
    • Banana 53 Soybeans 18
    • Glucose = 100, 50 gram carbohydrate dose. AJCN 2002; 76:5-56.
  • 31. Glycemic Index of Mixed Foods
    • White rice 100
    • with pickled cucumber 73
    • with yogurt 72
    • with fermented soy 68
    • with whole milk 59
    • with ice cream 57
    • Sushi (rice, vinegar, sea algae) 67
    • 50 gm carbohydrate test food, European J Clin Nutr (2003) 57, 743-752.
  • 32. Alcohol – What’s a serving? 12 oz beer 5 oz of wine 1.5 oz of 80 proof liquor Size of typical wine glass - 10-14 oz. Recommendations: No more than 2 drinks per day for men No more than 1 drink per day for women
  • 33. Benefits of Nuts
    • Low in saturated fat, good source of monounsaturated fat
    • No cholesterol
    • Convenient source of protein
    • Rich in the amino acid arginine, may improve vasodilation
    • Rich in Vitamin E, folic acid, copper, and magnesium
    • A handful, not a can full!
  • 34. Nuts - Fat Content, 1 ounce
    • Calories Total Sat. MUF PUF
    • Almonds, 24 170 14.5 1.5 10 3.0
    • Brazil, 8 190 19 5.0 7.0 7.0
    • Cashews, 18 160 13 2.5 8.0 2.5
    • Filberts, 12 180 18 1.0 15.0 2.0
    • Macadamia, 12 200 20 3.0 16.5 1.0
    • Peanuts, 35 pcs 160 13.5 2.0 7.0 4.5
    • Pecans, 15 hlvs. 190 19 2.0 12.0 5.0
    • Pistachios, 47 160 14 2.0 9.5 2.0
    • Walnuts, 14 hlvs. 180 17 2.0 4.0 11.0
    • Soy nuts, 3 Tbsp 129 6 0.9 1.4 3.5
  • 35. Oxidative Stress
    • An imbalance of pro-oxidants and antioxidants results in
      • generation of reactive oxygen species (free radicals)
      • increased inflammation
    • Pro-oxidants
      • Saturated and trans fats
      • High glycemic index carbohydrates
      • Excessive alcohol intake
  • 36. Foods / Nutrients with Antioxidant Effects
    • Omega-3 fatty acids
    • Dietary fiber
    • Moderate alcohol intake
    • Antioxidants from food
      • Vitamin C
      • Vitamin E
      • Vitamin D?
      • Carotenoids
      • Selenium
      • Polyphenols (phytochemicals)
  • 37. Phytochemicals are measured in ORAC Units
    • ORAC per 100 grams ORAC per calorie
    • Cloves, ground 125,549 389
    • Turmeric, ground 15,679 44
    • Dark Chocolate 13,120 22
    • Milk Chocolate 6740 13
    • Prunes 5770 24
    • Pomegranate 3307 40
    • Raisins 2830 9
    • Blueberries 2400 43
    • Blackberries 2036 47
    • Kale 1770 35
    • Strawberries 1540 48
    • Spinach 1260 55
    • Raspberries 1220 24
    ORAC = Oxygen Radical Absorbance Capacity, AJCN 2006;84:95.
  • 38. To Minimize Post-Prandial Dysmetabolism
    • Minimally processed, high-fiber, plant-based foods (whole grains, vegetables, fruits, nuts, legumes)
    • Lean protein, fish
    • Moderate calorie intake
    • Regular physical activity
  • 39. Sample Mediterranean Menu
    • B - Cooked cracked wheat cereal with walnuts
    • and yogurt Melon
    • Snack - Orange 2 handfuls sunflower seeds
    • L - Lentil spinach soup Tomato cucumber salad
    • Whole Wheat bread with olive oil
    • Snack - 2 oz Camembert cheese 1 mango
    • D - Spaghetti w/ tomato, peppers, Parmesan, mussels, and olive oil,
    • Lettuce salad with V and O dressing
    • Baked figs Red wine
  • 40. DASH - Sample Menu (2000 calories)
    • Breakfast Dinner
    • Orange Juice Baked cod
    • Oatmeal, 1 t. sugar Rice pilaf
    • 1 c. 1% milk 1/2 c. broccoli
    • Banana 1/2 c. stewed tomatoes
    • WW toast, soft margarine 1 c. green salad w/ dressing Dinner roll, soft margarine
    • Lunch Melon
    • Chicken salad, pita half
    • Part-skim Farmer’s cheese Snack
    • Lettuce leaves 1/4 c. dried apricots
    • Raw carrots, celery 1/3 c. mixed nuts
    • 1 c. 1% milk 3/4 c. pretzel sticks
    • Canned fruit
  • 41.  
  • 42. Resources
    • American Institute for Cancer Research - Veggies
    • http://www.aicr.org/site/PageServer?pagename=pub_new_amer_plate_veg
    • DASH diet
    • http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm
    • MyPyramid from USDA
    • http:// www.mypyramid.gov
    • National Heart Lung and Blood Institute publications
    • http:// www.nhlbi.nih.gov/health/index.htm