calming cardioovascular inflammatiioonn with diet · inflammation is very related to visceral...

Calming Cardiovascular Calming Cardiovascular I nflammation I nflammation

with with D I E TD I E T

Cindy Brinn MPH, RD, CDE, BC-ADM PeaceHealth St. Joseph Medical Center

Nutrition & Diabetes Clinic [email protected]

Natarajan P. Arterioscler Thromb Vasc Biol 2010;30:2081-83

Devaraj S. Expert Rev Endocrinol Metab 2010:5(1):19-28

CC--reactive protein (a marker of inflammation) reactive protein (a marker of inflammation) predicts diabetespredicts diabetes

27,000 women in 27,000 women in WomenWomen’’s Health s Health Study followed 4 yrsStudy followed 4 yrsCRP powerful CRP powerful predictor of diabetespredictor of diabetes

0

1

2

3

4

5

6

Rel Risk

Low Mid High

CRP TertilesBMI<29BMI>29

Pradhan A. JAMA 2001;286(3):327-334

Women with the highest CRP had 4-5X risk of developing diabetes

Ta ke Home MessageTa ke Home MessageInflammationInflammation is present in diabetes, cardiovascular is present in diabetes, cardiovascular disease, obesity & disease, obesity & mostmost other chronic diseasesother chronic diseasesInflammationInflammation increases insulin resistanceincreases insulin resistanceInflammationInflammation is very related to Visceral (belly) fatis very related to Visceral (belly) fatInflammationInflammation is related to Gut bacteria is related to Gut bacteria The diet recommendations for cardiovascular disease & The diet recommendations for cardiovascular disease & diabetes are moving well beyond the diabetes are moving well beyond the ““low fat low low fat low cholesterol, carbohydrate controlledcholesterol, carbohydrate controlled”” dietdietFood Food has both has both pro & anti pro & anti inflammatory effectsinflammatory effectsThe phytonutrients and synergy in whole foods are The phytonutrients and synergy in whole foods are magic.magic.Food talks to our genes (including gut bacteria genes!)Food talks to our genes (including gut bacteria genes!)How to limit proHow to limit pro--inflammatory foods and maximize inflammatory foods and maximize antianti--inflammatory foodsinflammatory foods

NormNorm’’s Stats at MD Offices Stats at MD OfficeNew Type 2 DMNew Type 2 DM

10/19/10/19/

A 1C = 1 0 .0%A 1C = 1 0 .0%

FBG = 25 5 mg/dlFBG = 25 5 mg/dlLFTLFT ’’ss

BP 1 77 / 9 2BP 1 77 / 9 2

Weight = 35 2#Weight = 35 2#

LDL LDL CholChol 16 516 5

N o rm Re f use d a l l m e d ica t i o ns! . . Se n t t o t h e D i a b e t es Cl i n ic

CVD & DiabetesCVD & DiabetesAn Inflammatory DiseasesAn Inflammatory Diseases

inflammation in endothelial wallinflammation in endothelial wallinflammation markersinflammation markers——CRP, adhesion CRP, adhesion

molecules, cytokines, WBCmolecules, cytokines, WBC——interleukininterleukin--6, 6, tumor necrosis factor, interferon gamma, tumor necrosis factor, interferon gamma, monocytemonocytechemoattractantchemoattractant protein, nuclear factor kappa B, protein, nuclear factor kappa B, CdCd 40, 40, lipoproteinlipoprotein--associated associated phospholipasephospholipase A2, A2, myeloperoxidasemyeloperoxidase, , introtyrosineintrotyrosine, matrix , matrix metalloproteinasemetalloproteinase--9 . .the list grows longer weekly . . .9 . .the list grows longer weekly . . .

NormNorm’’s Statss Stats——33 weeks laterweeks later

10 / 1 9 /10 / 1 9 / ——at at DxDx

A 1C = 1 0 .0A 1C = 1 0 .0FBG = 25FBG = 25 55

LFTLFT ’’ssBP 1 77 / 9 2BP 1 77 / 9 2


LDL LDL CholChol 16 516 5

11 / 8 /11 / 8 / ——arrival at D M C linicarrival at D M C linic

FBG = 12 0FBG = 12 0

BP 1 40 / 8 0BP 1 40 / 8 0


NormNorm’’s Diet: s Diet: ““Cut out Processed Foods, reduced CHO . . .ate Cut out Processed Foods, reduced CHO . . .ate

Real Foods!Real Foods!””Breakfast

Chopped

Fruit / Nuts

O atmeal 1 / 4c. Ground flax

seeds

Whole wheat toast

¼ grapefruit 1 date

6 oz. v-8 juice

Lunch

Salad or soup

with veges, dry

beans, barley, salmon

occasionally

olive oil &

vinegar on salad

Dinner

V eges, beans

PB & WW

crackers salmon

Snacks: Snap peas, few nuts, veges

N orm choose to eliminate: Meats, poultry, bread, cold cereal, rice, pasta, potatoes, sweets, juices, fried foods, white flour foods

Inflammation??

NormNorm’’s Statss Stats——33 months latermonths later

10 / 19 /10 / 19 /

A 1C = 10 . 0A 1C = 10 . 0FBG = 255FBG = 255

LFTLFT ’’ssBP 177 / 92BP 177 / 92

Weight = 352#Weight = 352#

LDL LDL CholChol 165165

1 / 16 /1 / 16 /

A 1C = 6 . 5A 1C = 6 . 5FBG = 115FBG = 115

N ormal N ormal LFTLFT ’’ssBP 140 / 80BP 140 / 80

Weight = 314# Weight = 314#

(38# loss / 12 (38# loss / 12

weeks)weeks)

LDL LDL CholChol 135135

11 / 8 /11 / 8 /

FBG = 120FBG = 120

BP 140 / 80BP 140 / 80

Weight = 340#Weight = 340#

On no medications . . . .Inflammation??

3 Weeks to Metabolic Improvement3 Weeks to Metabolic Improvement

Medications (BP, BG, Cholesterol MedsMedications (BP, BG, Cholesterol Meds))Gastric Bypass SurgeryGastric Bypass Surgery


Medications (BP, BG, Cholesterol Meds)Medications (BP, BG, Cholesterol Meds)Gastric Bypass SurgeryGastric Bypass Surgery (nearly immediate (nearly immediate reduction in BG, insulin needsreduction in BG, insulin needs——unrelated unrelated to weight loss)to weight loss)

G Mingrone. Diab & Metab 2009;35:518-523


Medications (BP, BG, Cholesterol Meds)Medications (BP, BG, Cholesterol Meds)

Gastric Bypass SurgeryGastric Bypass Surgery (often immediate reduction (often immediate reduction in BG, reduced insulin resistance)in BG, reduced insulin resistance)

Hindgut theoryHindgut theory: Increased GLP: Increased GLP--1 produced by 1 produced by ““fedfed””gut bacteria (GLPgut bacteria (GLP--1 stimulates insulin secretion, 1 stimulates insulin secretion, suppresses glucagon, reduces inflammation)suppresses glucagon, reduces inflammation)

Foregut theoryForegut theory: Reduced secretion of anti: Reduced secretion of anti--incretinincretinhormoneshormones


Medications (BP, BG, Cholesterol Meds)Medications (BP, BG, Cholesterol Meds)Gastric Bypass SurgeryGastric Bypass Surgery (often immediate reduction (often immediate reduction in BG, reduced insulin resistance)in BG, reduced insulin resistance)

Hindgut theoryHindgut theory: Increased GLP: Increased GLP--1 produced by 1 produced by ““fedfed””gut bacteria (GLPgut bacteria (GLP--1 stimulates insulin secretion, 1 stimulates insulin secretion, suppresses glucagon, reduces inflammation)suppresses glucagon, reduces inflammation)Foregut theoryForegut theory: Reduced secretion of anti: Reduced secretion of anti--incretinincretinhormoneshormonesAltered Gut Bacteria?Altered Gut Bacteria?

G. Musso Diabetes Care 2010;33(10):2277-84

Altered Altered ““MicrobiotaMicrobiota”” in Animalsin Animals

Obesity, insulin resistance, diabetes & inflammationObesity, insulin resistance, diabetes & inflammation

Increased energy harvest from dietIncreased energy harvest from diet

Altered fatty acid metabolism & adipose/liver Altered fatty acid metabolism & adipose/liver compositioncomposition

Altered gut peptidesAltered gut peptides--YY and GLPYY and GLP--1 secretion1 secretion

Activation of Activation of lipopolysaccharidelipopolysaccharide (LPS)(LPS)

Changes in intestinal barrier integrity by GLPChanges in intestinal barrier integrity by GLP--22

G. Musso Diabetes Care 2010;33(10):2277-84

Actions related to Inflammation


MedicationsMedications (BP, BG, Cholesterol Meds)(BP, BG, Cholesterol Meds)Gastric Bypass Gastric Bypass SurgerySurgery (nearly immediate reduction in BG, (nearly immediate reduction in BG, insulin needs & BP)insulin needs & BP)

FoodFood: Norm: Norm’’s Antis Anti--Inflammatory DietInflammatory DietLow total CHOLow total CHONo refined CHONo refined CHONo sugarNo sugarHigh in vegetables, whole foodsHigh in vegetables, whole foodsHigh in healthy fatsHigh in healthy fatsLow in unhealthy fatsLow in unhealthy fatsHigher lean protein Higher lean protein

Inflammation on the RiseInflammation on the Rise

33% adults with arthritis33% adults with arthritis—— # doubled the past 20 yrs # doubled the past 20 yrs

Asthma on the riseAsthma on the rise——66thth most common chronic diseasemost common chronic disease

Allergies on the riseAllergies on the rise—— # doubled the past 20 years# doubled the past 20 years

IBD on the riseIBD on the rise

Eczema most common skin condition in childrenEczema most common skin condition in children

•Why the low grade inflammation?

•What does abdominal obesity have to do inflammation?

•How does inflammation promote disease?

•Can diet promote or prevent this inflammation?

Low-Grade Systemic Inflammation

Immun e Re spons e : In f l a mm a t Ion t e a m

O’Keefe J. JACC 2008;51(3):249-55Giugliano D. JACC 2006;48(4):677-685 Mathieu P. Hypertension2009;53:577-84

Who is c a l l in g f o r t h e in f l a mm a t ion t e a m?Ch r oniC S t r eSS (Cu r r e n t l i f eS t y l e )In j u r e d t Issu e s A bdomin A l A dipo c y t e s (h y p e r t r oph y )Pos t p r a ndi a l Food / di e t Ch a os /D y sme t a b o l ismA l t e r e d Gu t B A c t e r i A

•Abdominal Adipocyte

Not just about fat storage . . . an endocrine organ.

•Abdominal Adipocyte

Close ties between metabolic & immune

systems

Wellen KD. JClinInvest 2005;115:111-1119

A bd omin A l A dipo c y t e s (h y p e r t r oph y )

Optimal Nutrition

Malnutrition / Energy Deficit

Over nutrition / Long term Energy Surplus

Immuno-suppression, Susceptibility to infection

Immuno-activation, Susceptibility to

inflammatory disease

Normal immune function

Wellen KD. JClinInvest2005;115:111-1119

Starvation

Obesity

FFA’s

InsulinResistance

Type 2 Diabetes

EndothelialDysfunction

BP

Visceral Fat

CVD

Pro-Inflammatory Cytokines

CRP

Lipids

Consequences of elevated pro-inflammatory cytokines

Bruce K. PostgradMedJ2009;85:614-21

NAFLD

High Fat High CHO Meal Inflammation IL-6, TNF, CRP

Interference w/insulin & leptin signaling

Ghanim H. Diabetes 2009;32:2281-2287

Diet & InflammationDiet & Inflammation

ProPro--inflammatory Foodsinflammatory FoodsInflammatory triggersInflammatory triggers——TNF, ILTNF, IL--66Free Radicals/Oxidative stressFree Radicals/Oxidative stressLipidemia (TG, VLDL)Lipidemia (TG, VLDL)Free fatty acidsFree fatty acidsGlucoseGlucose

AntiAnti--inflammatory Foodsinflammatory FoodsInflammatory triggersInflammatory triggers——TNF, ILTNF, IL--66Free Radicals/Oxidative stressFree Radicals/Oxidative stressLipidemia (TG, VLDL)Lipidemia (TG, VLDL)Free fatty acidsFree fatty acidsGlucoseGlucose

Giugliano D. JACC2006;48:677-85

Diet


ProPro--inflammatory Foodsinflammatory FoodsInflammatory triggersInflammatory triggers——TNFTNF,, ILIL--66

Free Radicals/Oxidative stressFree Radicals/Oxidative stress

Lipidemia (TG, VLDL)Lipidemia (TG, VLDL)

Free fatty acidsFree fatty acids

GlucoseGlucose

1.1. ““Damaged fatsDamaged fats””2.2. Fructose Fructose

(sucrose/HFCS)(sucrose/HFCS)3.3. Glycemic index Glycemic index

CHOCHO4.4. ““ExcessExcess”” CHO that CHO that

causes BG elevationcauses BG elevation

Giugliano D. JACC2006;48:677-85 Ceriello A. Circulation 2002;106:1211-1215

Post-prandial Dysmetabolism

postprandial glucose & TGpostprandial glucose & TGCeriello A. Circulation 2002;106:1211-1215

Glucose Excursion & Oxidative StressGlucose Excursion & Oxidative Stress

Monnier L. JAMA 2006;295:1681-7

Postprandial Endothelial DysfunctionPostprandial Endothelial DysfunctionCeriello A. Circulation 2002;106:1211-1215






GlucoseGlucose







Reactive oxygen speciesReactive oxygen speciesFree RadicalsFree Radicals

OxidationOxidationOxidative StressOxidative Stress

AntiAnti--oxidantsoxidantsOxidized CholesterolOxidized CholesterolOxidized Fatty AcidsOxidized Fatty Acids

Lipid PeroxidesLipid Peroxides


Free Radical ActionsFree Radical Actions

Damage or destroy cellsDamage or destroy cells

Damaged cells are more Damaged cells are more vulnerable to diseasevulnerable to disease

Damaged cells cause Damaged cells cause inflammationinflammation

Associated with Associated with premature agingpremature aging

What causes free radicals?What causes free radicals?

Normal respiration & metabolismNormal respiration & metabolismExerciseExerciseAir pollutantsAir pollutantsViruses, etc.Viruses, etc.StressStressInjuryInjuryAbsence of antioxidantsAbsence of antioxidantsAdvanced Advanced GlycationGlycation end productsend productsGlucose/Fructose Glucose/Fructose Dietary FatsDietary Fats——esp. oxidized or trans fatsesp. oxidized or trans fats






GlucoseGlucose







““Damaged FatsDamaged Fats”” & Inflammation& Inflammation

High heat cooking

Grilling/Broiling“Advanced

Glycation End Products”

& Free Radicals

Frying

Trans Fats Free Radicals Oxidized Fats

Refining Trans Fats

Free Radicals

HydrogenationTrans fats

Advanced Glycation End ProductsAdvanced Glycation End Products(AGE(AGE’’s)s)

Compounds formed in foods (especially meats & fats)

during heat processingCompounds formed endogenously—elevated blood glucose & proteins

Peppa M. Clinical Diabetes 2003;21(4):186-87

Serum AGE Associations Serum AGE Associations (animal & human studies)(animal & human studies)

Pro-inflammatory compounds (AGE’s)C-Reactive ProteinVascular dysfunctionPancreatic islet cell dysfunction

Linked to insulin resistance, diabetes, renal complications & Alzheimer's Disease

AGE TheoriesAGE TheoriesHow they do damageHow they do damage

Oxidized LDL cholesterolPromote inflammatory mediators (CRP, etc) leading to tissue injuryModify molecules promoting cellular oxidative stress

Cai, W. Circulation 2004;110:285-291Imani F. J Exp Med 1993;178:2165-72

AGE Content of Chicken AGE Content of Chicken (kU/90 gm serving)(kU/90 gm serving)

Raw 692Stewed 1 hr 1011Microwave 5 min 1372Roasted 4291Broiled 15 min 5245Fried 8 min 6651Nuggets 7764Breaded, fried w/skin 8965

Goldberg T JADA 2004;104(8):1287-91

AGEAGE’’s & Temperatures & Temperature

Related to cooking temp, length of time cooked & presence of moisture—(esp.meats)Broiling (425°C)—high AGE’sFrying (350°C)—high AGE’sRoasting (350°C)—high AGE’sBoiling (212°C)—low AGE’s

AGE RecommendationsAGE Recommendations

Boil, poach, simmer or stew meatsLimit roasting, broiling, grilling & fryingLimit roasted nuts—have raw instead

Traditional Cooking TechniquesTraditional Cooking Techniques

Mediterranean: Mediterranean: ““simmersimmer””, slowly roast meats, slowly roast meatsAsian: Stir fry (water in Asian: Stir fry (water in vegesveges lowers temp)lowers temp)Oils often added as a Oils often added as a ““dressingdressing”” . . .not heated. . . .not heated. ExEx——sesame oil, olive oil w/breadsesame oil, olive oil w/bread

““In summary, dietary In summary, dietary AGEAGE’’ss are significant contributors to are significant contributors to sAGEsAGE’’s in humans. Sustained reduction in s in humans. Sustained reduction in AGEsAGEs intake intake

may result in effective suppression of inflammatory may result in effective suppression of inflammatory molecules in diabetes, implying eventual prevention or molecules in diabetes, implying eventual prevention or

delay of atherosclerosis. delay of atherosclerosis. Further clinical studies are needed to establish this Further clinical studies are needed to establish this modality as a nonmodality as a non--pharmacological intervention for pharmacological intervention for

diabetic macrodiabetic macro--vascular disease.vascular disease.””

Vlassara H PNAS 2002;99(24):15596-601

“Influence on human health of fats altered by high heat cooking is just emerging.”

“ . . . .strong relationship between fat and heart disease may be due to the presence of oxidized fats and oils in Western diets.”

Chon, J. CurrOpinLipido2000;13:19-24Cai W. AmJPath2008;173(2):327-336Birlouez-Aragon I. AmJClinNutr2010;91;1220-6






GlucoseGlucose







Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association

Circulation 2009;120;1011-1020; originally published online Aug 24, 2009;

Dietary Sugars Intake and Cardiovascular Health: A Scientific Statement from the American Heart Association

Women: 100 calories a day of added sugar = 6tsp/day Men: 150 calories a day of added sugar = 9tsp/day



Sugar associated with:Sugar associated with:HypertensionHypertension

Altered lipidsAltered lipids

InflammationInflammation

ObesityObesity

Added SugarsAdded Sugars

12 oz. 12 oz. pepsipepsi 10 tsp 40g CHO10 tsp 40g CHO!! c. pancake syrupc. pancake syrup 10 tsp 40g CHO10 tsp 40g CHO2 oz. snicker bar2 oz. snicker bar 6 tsp6 tsp 24g CHO24g CHO22”” square cakesquare cake 10 tsp 40g CHO10 tsp 40g CHO"" c. frosted cheeriosc. frosted cheerios 3 tsp 12g CHO3 tsp 12g CHO9 wheat thins9 wheat thins 1 tsp 4g CHO1 tsp 4g CHOLow fat yogurtLow fat yogurt 8 tsp8 tsp 32g CHO32g CHO1 c. tomato soup1 c. tomato soup 4 tsp 16g CHO4 tsp 16g CHO1 Tbsp jam1 Tbsp jam 2 tsp 8g CHO2 tsp 8g CHO

50%50-53%Glucose

50%42-50%Fructose

Sucrose(sugar)

High Fructose Corn Syrup

High Fructose Corn Syrup = SucroseHigh Fructose Corn Syrup = Sucrose

Fructose & InflammationFructose & Inflammation

Cells use glucose Cells use glucose (not fructose)(not fructose) as an energy sourceas an energy sourceFructose is immediately metabolized in liver to Fructose is immediately metabolized in liver to Free Fatty AcidsFree Fatty AcidsIncreased abdominal adiposityIncreased abdominal adiposityInduce metabolic syndrome in animal studies Induce metabolic syndrome in animal studies w/fructosew/fructose

Liu H. CancerRes2010;70(15):6368-76 Basciano H.NutrMetab2005;doi:10.1186/1743-7075-2-5 Stanhope K. JNutri2009;139:1236S-1241S & JClinInvest2009;119:1322-1344

Experimental Animal Studies Experimental Animal Studies w/Fructosew/Fructose

Sanchez-Lozada L. AmJClinNutr 2008;88:1189-90

Fructose induces Metabolic SyndromeFructose induces Metabolic SyndromeInsulin ResistanceInsulin ResistanceElevated TGElevated TG’’ssAbdominal obesityAbdominal obesityElevated BPElevated BPInflammationInflammationOxidative stressOxidative stressEndothelial dysfunctionEndothelial dysfunctionMicrovascularMicrovascular diseasediseaseHyperuricemiaHyperuricemia (Gout)(Gout)GlomerularGlomerular hypertension (Renal disease)hypertension (Renal disease)Fatty liverFatty liver

Metabolic Changes NOT SEEN WITH GLUCOSE

Fructose & Insulin SensitivityFructose & Insulin Sensitivity

Impairs suppression of free fatty acid Impairs suppression of free fatty acid productionproductionActivates proActivates pro--inflammatory cytokinesinflammatory cytokinesCirculating free fatty acids & fatty acids from Circulating free fatty acids & fatty acids from TG can lead to fat deposition in liver & skeletal TG can lead to fat deposition in liver & skeletal muscle (this is a longmuscle (this is a long--term effect)term effect)

Itani SI. Diabetes 2002; 51:2005-2011

RECENT RESEARCHRECENT RESEARCH

““Consuming fructoseConsuming fructose--sweetened, not glucosesweetened, not glucose--sweetened, beverages increases visceral adiposity sweetened, beverages increases visceral adiposity and lipids and decreases insulin sensitivity in and lipids and decreases insulin sensitivity in overweight/obese humans.overweight/obese humans.””

Stanhope KL. Stanhope KL. EtalEtal. April 20, 2009. J. . April 20, 2009. J. ClinClin. . Invest. doi:10:1172JCI37385Invest. doi:10:1172JCI37385

Basciano H. Nutrition & Metabolism 2005; 2(5):1-14 Le KA. CurrOpinClinNutrMetabCare 2006 9:469-75

“ . . . urgent need for public awareness of the risks associated with high fructose consumption and greater efforts should be made to curb the supplementation of packaged foods with high fructose additives (including sucrose!).”

“ . . recent findings raise serious concern regarding the deleterious effects of fructose and its potential role in metabolic disorders .”

More Fructose ThoughtsMore Fructose Thoughts

Experimental Animal Studies Experimental Animal Studies w/Fructosew/Fructose

Sanchez-Lozada L. AmJClinNutr 2008;88:1189-90

Fructose induces Metabolic SyndromeFructose induces Metabolic SyndromeInsulin ResistanceInsulin ResistanceElevated TGElevated TG’’ssAbdominal obesityAbdominal obesityElevated BPElevated BPInflammationInflammationOxidative stressOxidative stressEndothelial dysfunctionEndothelial dysfunctionMicrovascularMicrovascular diseasediseaseHyperuricemiaHyperuricemia (Gout)(Gout)GlomerularGlomerular hypertension (Renal disease)hypertension (Renal disease)Fatty liverFatty liver

Metabolic Changes NOT SEEN WITH GLUCOSE






GlucoseGlucose







High Glycemic CHO & InflammationHigh Glycemic CHO & Inflammation

Rapid rise in postprandial blood glucose increase Rapid rise in postprandial blood glucose increase inflammatory mediatorsinflammatory mediatorsHigh glycemic CHO:High glycemic CHO:

Foods made from flourFoods made from flour, rice, potatoes, rice, potatoes

Buyken A. AmJClinNutr2010; doi: 10.3945/ajcn.2010.29390

Esfahani A. JAmColNutr2009;28(4):439S-445S

Postprandial hyperglycemia & CVDPostprandial hyperglycemia & CVDEpidemiologic data show 2Epidemiologic data show 2 --h glucose is an independent h glucose is an independent

C V D risk factor, while FBG is not.C V D risk factor, while FBG is not.

ST O PST O P-- N IDDM trialN IDDM trialTxTx w/ w/ acarboseacarbose (reduces postprandial (reduces postprandial BG)BG)

36% progression to diabetes36% progression to diabetes34% dev. of hypertension34% dev. of hypertension

49% C V D events49% C V D events

De Vegt F. Diabetologia 1999;42:926-31 DECODE study group. Lancet 1999;354:617-21 Chiasson J. Lancet 2002;359:2072-7 Cavalot F. JClinEndocrinolMetab 2006;91:813-819

Effect of a lowEffect of a low--glycemic index or a highglycemic index or a high--cereal cereal fiber diet on type 2 diabetesfiber diet on type 2 diabetes

Randomized parallel study, n=210Randomized parallel study, n=210Low glycemic diet saw more significant changes:Low glycemic diet saw more significant changes:

A1c .5%A1c .5%HDL 4.7%HDL 4.7%CRPCRP & weight& weight

Jenkins D. JAMA 2008; 300(23):27422753

Postprandial State

High Plasma glucose

Elevated High plasma Endothelial Oxidative Glycated TG insulin dysfunction stress Proteins

Increased cardiovascular disease risk

Riccardi G. AmJClinNutr 2008;87:2;69S-74S

Inflammation

Wannamethee SG Diabetes Care 2009;32:1823-25






GlucoseGlucose







Postprandial chaosPostprandial chaos

ADA GoalsADA Goals

2hr postprandial BG 2hr postprandial BG << 180mg/dl180mg/dl

2hr postprandial BG 2hr postprandial BG >> 180mg/dl 180mg/dl

AGE’s & Inflammation

ADA CHO RecommendationsADA CHO Recommendations

Minimum 130g CHO/dayMinimum 130g CHO/day4545--65% calories from CHO65% calories from CHOSource of water soluble vitamins, minerals, Source of water soluble vitamins, minerals, dietary fiberdietary fiberLong term safety of lower CHO diet is Long term safety of lower CHO diet is unknownunknown

5 weeks on a Low CHO Diet5 weeks on a Low CHO Diet

Gannon MC Diabetes 2004;53:2375-82

55% CHO diet BG=165-270mg/dl

o 20% CHO diet BG 140-160mg/dl

A1C: 9.6 7.6 . . In 5 weeks

Kirk JK. JADA 2008;108(1):91-100

Low CHO Diets: MetaLow CHO Diets: Meta--AnalysisAnalysis

Improved BG, TG, A1C & HDL Improved BG, TG, A1C & HDL CholChol

Kirk JK. JADA 2008;108(1):91-100

Inflammation: Inflammation: 13% CHO13% CHO vs. vs. 56%CHO56%CHO

Forsythe C. Lipids2008;43:65-77

Low CHO diets reduce need for DM Meds.Low CHO diets reduce need for DM Meds.

Effect of low CHO diet on appetite, BG levels & Insulin Effect of low CHO diet on appetite, BG levels & Insulin resistance in obese patients with type 2 DMresistance in obese patients with type 2 DM

BodenBoden G. Ann Intern Med 2005;142:403G. Ann Intern Med 2005;142:403--1111

Low CHO diet in type 2DM. Stable improvements of Low CHO diet in type 2DM. Stable improvements of bodyweight & glycemic control during 22 bodyweight & glycemic control during 22 mthsmths f/uf/u

Nielsen JV Nielsen JV NutrNutr MetabMetab 2006;3:222006;3:22

A lowA low--CHO, CHO, ketogenicketogenic diet to treat type 2 DMdiet to treat type 2 DM

YancyYancy WS WS NutrNutr MetabMetab 2005:2:342005:2:34

Foster GD Ann Intern Med 2010;153(3):147-157

calming cardioovascular inflammatiioonn with diet · inflammation is very related to visceral...

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