presented by preventive cardiovascular nurses association in collaboration with the beverage...

Presented by Preventive Cardiovascular Nurses Association in collaboration with

The Beverage Institute For Health & Wellness of The Coca-Cola Company .

A Continuing Education Program for Nursing and Nutrition Professionals The Synergy of Diet and Exercise

Cardiometabolic Syndrome

Roberta Anding, MS, RD/LD,CSSD, CDE Baylor College of Medicine ADA Media Spokesperson Sports Dietitian for the Houston Texans Director of Sports Nutrition, Texas Children’s Hospital



Principles of MNT/Management for MetS

Assessment of risk factorsAssessment of risk factors Diet and exercise patternsDiet and exercise patterns Weight management/calorie restrictionWeight management/calorie restriction

• Assessment of visceral fatAssessment of visceral fat Whole grainsWhole grains

• MagnesiumMagnesium

Omega 3 fatty acidsOmega 3 fatty acids

Calcium and vitamin DCalcium and vitamin D

Plant sterols/stanolsPlant sterols/stanols



Nutrition Assessment

Lab valuesLab values• Vitamin DVitamin D• MagnesiumMagnesium• Lipid profileLipid profile• Liver enzymesLiver enzymes

Physical assessment & nutrition Physical assessment & nutrition analysisanalysis• Acanthosis nigricansAcanthosis nigricans• BMI/ Waist circumferenceBMI/ Waist circumference

• EAL: fair/imperativeEAL: fair/imperative

• Dietary patternsDietary patterns• Whole grainsWhole grains• Low glycemic foodsLow glycemic foods• Omega 3Omega 3• DairyDairy• Consumption of plant sterolsConsumption of plant sterols



Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin

NEJM 346:393, 2002 Standard lifestyle recommendations:

• Written information regarding food pyramid, NCEP step 1 diet and annual 30 min individual session

Intensive lifestyle intervention• 16 lesson individualized curriculum 1:1 during the first

24 wks, flexible, culturally sensitive + group sessions



Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin

NEJM 346:393, 2002

Average f/u 2.8 yrs

Incidence of diabetes 11/100 p-yrs with placebo, 7.8 with metformin (31% reduction) , 4.8 with lifestyle intervention (58% reduction)

To prevent 1 case of diabetes, 6.9 persons would have to be treated with lifestyle modification, 13.9 with metformin



Prevalence of Metabolic Syndrome at 3 yrs in The Diabetes Prevention ProgramOrchard et al, Ann Intern Med 142:611, 2005

0

10

20

30

40

50

60

70

Placebo Metformin Lifestyle

Pre

Post



Changes in Body Fat Predict Diabetes Diabetes Prevention Program (n=758)

1 year from baseline: Lifestyle InterventionFujimoto et al, Diabetes 56:1680, 2007

-25

-20

-15

-10

-5

0

%

Visc Fat SQ Fat WaistCirc

BMI

Men

Women



Physical Assessment

BMI BMI Waist circumferenceWaist circumference

• > 40 inches in men> 40 inches in men

• > 35 inches in women> 35 inches in women

Normal weight/metabolically Normal weight/metabolically obeseobese

• Waist to hip ratioWaist to hip ratio



Physical Assessment

Acanthosis nigricansAcanthosis nigricans

• Caused by the Caused by the influence of insulin on influence of insulin on the melanocytesthe melanocytes

• Not a hygiene issueNot a hygiene issue



Waist circumference and 8 year incidence of metabolic syndrome

0

10

20

30

40

50

BMI <30 BMI >30

8 year incidence of MetS



Visceral fat: the fat you can’t see, or can you?

Visceral fat is white



Calorie restriction Central to the treatment of metabolic syndromeCentral to the treatment of metabolic syndrome

Reduces hyperinsulinemic responseReduces hyperinsulinemic response

Weight loss of 5-10% of initial weight can yield significant Weight loss of 5-10% of initial weight can yield significant improvement of metabolic parametersimprovement of metabolic parameters

Questions remainQuestions remain• Should pathophysiology direct MNTShould pathophysiology direct MNT• Optimal macronutrient distributionOptimal macronutrient distribution• Dietary patterns vs individual componentsDietary patterns vs individual components

• Glycemic loadGlycemic load

• Fortified foods with plant stanolsFortified foods with plant stanols• 2 grams per day can lower LDL by 10%2 grams per day can lower LDL by 10%



How much weight loss will have an impact ?

Triglycerides

HDL Cholesterol

Total Cholesterol

Blood Pressure

HbA1c

5%-10%Weight Loss

~5%Weight Loss

1

2

3

3

1

2

3

3

4



Does insulin status predict diabetes?

Insulin resistant good secretion ~ 28%

Neither 1.5%

Low Insulin secretion, 15.9%

Poor secretion and insulin resistance 54%



Caloric Restriction Acutely Lowers HDL-C Level

Trials of very-low-calorie diets show that HDL-C Trials of very-low-calorie diets show that HDL-C levels decrease by 2–12 mg/dL during acute caloric levels decrease by 2–12 mg/dL during acute caloric restriction.restriction.

After 12 wks, HDL-C returned to pretreatment After 12 wks, HDL-C returned to pretreatment range, and this trend was still apparent after 1 year.range, and this trend was still apparent after 1 year.

Therefore, benefits of weight-loss programs should Therefore, benefits of weight-loss programs should not be assessed during acute caloric restriction.not be assessed during acute caloric restriction.

Rössner S, et al. Atherosclerosis. 1987;64:125–130.



Weight and HDL-C

Inverse correlation between body weight and HDL-Inverse correlation between body weight and HDL-C is consistently observed in both men and C is consistently observed in both men and women.women.

For every 3 kg (7 lb) of weight loss, HDL-C levels For every 3 kg (7 lb) of weight loss, HDL-C levels increase 1 mg/dLincrease 1 mg/dL.

Dattilo AM, Kris-Etherton PM. Am J Clin Nutr. 1992; 56:320–328



Macronutrient Distribution

Low carbohydrate diets(<20% CHO)Low carbohydrate diets(<20% CHO)• Some evidence of short term benefit(6 weeks)Some evidence of short term benefit(6 weeks)

• Ketogenic diets have no distinct advantages over Ketogenic diets have no distinct advantages over lowering restriction of total carbohydratelowering restriction of total carbohydrate

• Ketogenic diets may increase inflammatory risk and Ketogenic diets may increase inflammatory risk and reduce exercise capacityreduce exercise capacity

• 40% carbohydrate equally effective as traditional low 40% carbohydrate equally effective as traditional low carbohydrate diets in reducing body weight and insulin carbohydrate diets in reducing body weight and insulin resistanceresistance

Am J Clin Nutr 2006 85:238-9



Definition: GI-Quality of CHO

“ “ the incremental area under the blood the incremental area under the blood glucose response curve of 50 grams of glucose response curve of 50 grams of available CHO from a test food, expressed available CHO from a test food, expressed as a percentage of the response to the same as a percentage of the response to the same amount of CHO from a standard food (bread amount of CHO from a standard food (bread or glucose), taken by the SAME person”or glucose), taken by the SAME person”

Thomas M.S. Wolevar, DJA JenkinsThomas M.S. Wolevar, DJA Jenkins



Concept of Glycemic Load (GL)-Quantity of CHO

GI refers to single CHO GI refers to single CHO sourcesource

Captures the quality of Captures the quality of the CHOthe CHO

Glycemic Load = Glycemic Load = • GI % x Amt of CHO in GI % x Amt of CHO in

a servinga serving• GL captures the GL captures the

quantity of CHOquantity of CHO

Brown rice: contains Brown rice: contains 18 gms CHO, GI =73%18 gms CHO, GI =73%

GL for brown rice = 18 GL for brown rice = 18 x 73% or a glycemic x 73% or a glycemic load of 13load of 13

Each GL = 1 gram of Each GL = 1 gram of glucoseglucose



Not as simplistic as “less processed” foods are low GINot as simplistic as “less processed” foods are low GI



Glycemic load: Weight loss or something else?

Insufficient data in the Evidence Analysis Insufficient data in the Evidence Analysis Library to implement as a weight loss Library to implement as a weight loss strategy.strategy.

Are there benefits beyond weight control?Are there benefits beyond weight control?• Lowering the GI of a high carbohydrate diet Lowering the GI of a high carbohydrate diet

improves beta cell function in those with IGTimproves beta cell function in those with IGT

Am J Clin Nutr 85:1169-1170



Metabolic effects due to intake of high GI Metabolic effects due to intake of high GI foodfood

blood glucose β-cell

Rapid uptake of nutrients by insulin–responsive tissues

insulin response

- glucagon

Glucose uptake

Glycogen synthesisLipogenesisGlucose uptake

Glycogen synthesis

Glucose output

Gluconeogenesis

Lipolysis

NEFA release



DecreasedHDL:

IncreasedTG:

IncreasedC-reactive

protein

Increased Risk of diabetes

IncreasedRisk of CVD:

Wolevar, 1992Luscombe, 1999Buyken, 2001Liu, 2001Ford, 2001Frost, 1999

Liu, 2001 Liu, 2002 Hu, 2001Salmeron, 1997Salmeron, 1997Schulze, 2004

Liu, 2000

Epidemiologic studies reported on GI & disease:Epidemiologic studies reported on GI & disease:

Increasing GL associated with:Increasing GL associated with:



Glycemic load and liver steatosis

Links between insulin Links between insulin resistance and liver resistance and liver steatosissteatosis

High GI diets are High GI diets are associated with associated with increasing prevalence increasing prevalence of liver steatosisof liver steatosis

Am J Clin Nutr 84:136-42



Framingham Offspring Cohort Study

2834 subjects assessed for carbohydrate related 2834 subjects assessed for carbohydrate related factors and the prevalence of metabolic syndrome.factors and the prevalence of metabolic syndrome.

Total fiber, cereal fiber, fruit fiber and whole grains Total fiber, cereal fiber, fruit fiber and whole grains were were inversely associated with insulin were were inversely associated with insulin resistance.resistance.

Elevated glycemic index/glycemic load diets Elevated glycemic index/glycemic load diets positively associated with IRpositively associated with IR

Whole grains may reduce the risk of MetSWhole grains may reduce the risk of MetS



Whole Grains, Fiber & Magnesium

Dietary patterns rich in whole grains provide 3 Dietary patterns rich in whole grains provide 3 nutrients linked with a decreased incidence of nutrients linked with a decreased incidence of metabolic syndrome and improved biochemical metabolic syndrome and improved biochemical parametersparameters

In a study of adults in Tehran, the higher the intake In a study of adults in Tehran, the higher the intake of whole grains the lower the prevalence of of whole grains the lower the prevalence of metabolic markers.metabolic markers.

Cereal fiber has been linked with a decrease in Cereal fiber has been linked with a decrease in MetSMetS



Magnesium

Recent studies have demonstrated the role of Recent studies have demonstrated the role of magnesium as a risk factor for MetSmagnesium as a risk factor for MetS

NHANES III and and the CARDIA study both NHANES III and and the CARDIA study both demonstrated an inverse relationship between demonstrated an inverse relationship between magnesium intake and MetS. Highest quartile of magnesium intake and MetS. Highest quartile of Mg intake reduced prevalence by 31%Mg intake reduced prevalence by 31%

No toxicity from whole foodNo toxicity from whole food

UL 350 mgUL 350 mg



Vitamin D

Vitamin D receptor are found on the nucleus of the Vitamin D receptor are found on the nucleus of the cell and the cell membranecell and the cell membrane

Essential in the function of the beta cellEssential in the function of the beta cell

Adequate blood levels, not dietary intake can Adequate blood levels, not dietary intake can improve insulin sensitivity by 60%improve insulin sensitivity by 60%

A 30 year prevention program of Type 1 diabetes A 30 year prevention program of Type 1 diabetes indicates an 80% reduction in disease with 2000 IU indicates an 80% reduction in disease with 2000 IU of vitamin Dof vitamin D

Obesity is a risk factor for deficiency as it is Obesity is a risk factor for deficiency as it is sequestered in adipose tissuesequestered in adipose tissue

Harris, SS J Nutrition 2005; 135 (2):323-5



Vitamin D

Adequate blood levels are more effective than the Adequate blood levels are more effective than the diabetes medications metformin or TZD’sdiabetes medications metformin or TZD’s

A study of postmenopausal women taking A study of postmenopausal women taking bisphosphonates for osteoporosis and 400 IU of bisphosphonates for osteoporosis and 400 IU of vitamin D:vitamin D:

• 18% had levels less than 50 nmol/L and 52% had 18% had levels less than 50 nmol/L and 52% had values < 75nmol/Lvalues < 75nmol/L

• Serum 25(OH) levels above 80nmol/L considered Serum 25(OH) levels above 80nmol/L considered optimaloptimal



Cost of the Metabolic SyndromeResearch Options

The Cardiovascular Health StudyThe Cardiovascular Health Study• 10 year medical costs of individuals 65 and older10 year medical costs of individuals 65 and older• NCEP definitionNCEP definition• Metabolic syndrome present in 47% of the sampleMetabolic syndrome present in 47% of the sample• Costs to Medicare 20% higher with metabolic Costs to Medicare 20% higher with metabolic

syndromesyndrome• Represents an “outcome based” intervention for RD’s, Represents an “outcome based” intervention for RD’s,

nurses and other health care providersnurses and other health care providersAdherence to 2005 Dietary Guidelines are effective for Adherence to 2005 Dietary Guidelines are effective for

reducing MetS risk in womenreducing MetS risk in women



Summary

Assessment patterns for RD/RN should include the following:• Visceral fat via waist circumference• Dietary patterns

• Whole grains• Magnesium, fiber

• Dairy products• Calcium and vitamin D

• Glycemic load• Plant stanols



A Continuing Education Program for Nursing and Nutrition Professionals Question & Answer Session

Women &Cardiometabolic

Syndrome

John D. Bisognano, MD, PhD Roberta Anding, MS, RD/LD, CDE, CSSD Lynne T. Braun, ANP, PHD, CNP, CLS

SPEAKERS



To Access to the Course Evaluation and Obtain a CPE Certificate*

1. Click on LINK #5 in the LINKS BOX on the left of your screen before exiting this program today.

2. Or visit www.thebeverageinstitute.org/CPE between today and March 26.

*This program is pre-approved for nursing and dietetic professional CPE.

Other professionals may obtain a Certificate of Attendanceby emailing [email protected] or calling 1-800-274-9390

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Documents

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metformin slide

yrs incidence of diabetes

case of diabetes

lifestyle modification

metformin nejm