Obesity, Diabetes & Obesity, Diabetes & Complications Complications COPE #7999 COPE #7999 - - GO GO Stuart Richer, OD, PhD, FAAO Stuart Richer, OD, PhD, FAAO DVA Medical Center DVA Medical Center Chief, Optometry Section Chief, Optometry Section Associate Professor, Associate Professor, Family & Preventive Medicine, Family & Preventive Medicine, RFUMS, North Chicago, IL RFUMS, North Chicago, IL 9 November 2008 Jackson , MI PDF Created with deskPDF PDF Writer - Trial :: http://www.docudesk.com
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……. a balanced, healthy diet . a balanced, healthy diet and moderate exercise taken and moderate exercise taken on a regular basis can cut a on a regular basis can cut a person's risk of developing person's risk of developing
diabetes by 58 percent. diabetes by 58 percent.
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•• If current trends continue, 86% of If current trends continue, 86% of
the US adult population will bethe US adult population will be
overweight or obese by 2030overweight or obese by 2030
•• At this rate, 100% of the population At this rate, 100% of the population
will be affected by 2048will be affected by 2048
Will All Americans Become Overweightor Obese? Estimating the Progressionand Cost of the US Obesity Epidemic
July 24, 2008
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�� ““What overweight and obese What overweight and obese patients most want from their patients most want from their primary care providers is primary care providers is dietary advice, help setting dietary advice, help setting weight loss goals, and weight loss goals, and exercise recommendationsexercise recommendations””
�� ““A mere 1 in 5 are having A mere 1 in 5 are having this need metthis need met……....””
J Fam Pract. 2001 Jun;50(6): 513-18
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Course ConsiderationsCourse Considerations
�� Why is obesity associated with Why is obesity associated with
�� Visceral fat (VAT) secretes hormones Visceral fat (VAT) secretes hormones causing insulin resistance (IR) & increased causing insulin resistance (IR) & increased mitochondrial production of reactive oxygen mitochondrial production of reactive oxygen species (ROS) in insulin independent tissues species (ROS) in insulin independent tissues (liver, kidney, aorta, retina)(liver, kidney, aorta, retina)
�� VAT mobilizes free fatty acids which are VAT mobilizes free fatty acids which are oxidized by vascular endothelium to oxidized by vascular endothelium to generate ROSgenerate ROS
•• OSAS is the most frequent disorder in OSAS is the most frequent disorder in patients with NAION patients with NAION ((BJO. 2006;90(7):879BJO. 2006;90(7):879--82)82)
�� Higher IOP also associated with obesityHigher IOP also associated with obesity((DiabDiab MetabMetab Res Rev. 2005;21(5): 434Res Rev. 2005;21(5): 434--40)40)
�� 5% increased risk of advanced AMD 5% increased risk of advanced AMD with every 1 kg/mwith every 1 kg/m22 increase in BMIincrease in BMI(Am J (Am J OphthalmolOphthalmol. 2007;143(3): 473. 2007;143(3): 473--83)83)
�� In AREDS, BMI > 30 doubled the risk In AREDS, BMI > 30 doubled the risk of SRNVof SRNV (Ophthalmology. 2005;112(4):533(Ophthalmology. 2005;112(4):533--9)9)
�� Greater waist circumference and DM Greater waist circumference and DM related to lower MPOD in the related to lower MPOD in the WomenWomen’’s Health Initiative (n=1698)s Health Initiative (n=1698)(Am J (Am J ClinClin NutrNutr. 2006;84(5): 1107. 2006;84(5): 1107--22)22)
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Diabetic RetinopathyDiabetic Retinopathy�� Obesity & weight gain are the Obesity & weight gain are the
primary risk factors for T2DMprimary risk factors for T2DM (Ann (Ann
�� High levels of MUFA in High levels of MUFA in macadamia & olive oil, nuts and macadamia & olive oil, nuts and avocadoesavocadoes
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Polyunsaturated Fats Polyunsaturated Fats -- PUFAPUFA�� nn--3 and n3 and n--6 subtypes6 subtypes
�� nn--3 PUFA (e.g. 3 PUFA (e.g. αααααααα--linoleniclinolenic acid) tend to acid) tend to decrease inflammationdecrease inflammation
•• The high The high argininearginine content of tree nuts content of tree nuts (esp. walnuts) also decreases CRP(esp. walnuts) also decreases CRP (Nutrition. (Nutrition. 2005;21:1252005;21:125--130)130)
�� nn--6 PUFA (6 PUFA (linoleiclinoleic acid) tend to increase acid) tend to increase inflammationinflammation
�� Debate: does the ratio of nDebate: does the ratio of n--6:n6:n--3 PUFA 3 PUFA determine the inflammatory effect?determine the inflammatory effect?
�� A 2:1 to 6:1 ratio is recommended to A 2:1 to 6:1 ratio is recommended to maximize CV benefitmaximize CV benefit
Typical US Diet has an inflammatory 20:1 ratio
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Benefits of PUFABenefits of PUFA�� Rates of heart disease decline when Rates of heart disease decline when PUFA are substituted for saturated fatPUFA are substituted for saturated fat(Arch Intern Med. 2005;165: 193(Arch Intern Med. 2005;165: 193--7)7)
�� The nThe n--3 PUFA, 3 PUFA, αααααααα--linoleniclinolenic acid (flax, acid (flax, canola, walnut, linseed oils) is a canola, walnut, linseed oils) is a precursor to the long chain, omegaprecursor to the long chain, omega--3 3 fatty acids DHA & EPAfatty acids DHA & EPA
�� TGsTGs, , FFAsFFAs, blood glucose & insulin , blood glucose & insulin levels, visceral fat mass and many levels, visceral fat mass and many inflammatory markers decrease with inflammatory markers decrease with ��������intakeintake of DHA/EPAof DHA/EPA (J (J NutrNutr BiochemBiochem. . 2006;17: 12006;17: 1--13)13)
•• High DHA and EPA in cold water, oily fish High DHA and EPA in cold water, oily fish (salmon, sardines, herring)(salmon, sardines, herring)
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Take Home on FatsTake Home on Fats�� Keep SFA between 7% and 9% Keep SFA between 7% and 9%
of caloriesof calories
�� Eliminate all trans fats Eliminate all trans fats
�� Increase consumption of MUFAIncrease consumption of MUFA
�� Substitute PUFA for SFASubstitute PUFA for SFA
�� Increase consumption of nIncrease consumption of n--3 3
PUFA as well as DHA & EPAPUFA as well as DHA & EPA
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The Dangers of Refined The Dangers of Refined CarbsCarbs& Low Fiber& Low Fiber
�� High intake of simple sugars (glucose, High intake of simple sugars (glucose, fructose & sucrose) increases serum fructose & sucrose) increases serum FFAsFFAs and oxidative stressand oxidative stress (Am J (Am J ClinClin NutrNutr. . 2001;74: 7372001;74: 737--46)46)
�� Refined Refined carbscarbs elevate blood glucose & elevate blood glucose & insulin, reduce NO and impair insulin, reduce NO and impair vasodilatationvasodilatation
�� By a mass effect, postBy a mass effect, post--prandialprandialhyperglycemia increases cellular hyperglycemia increases cellular glucose uptake, production of ROS glucose uptake, production of ROS and proand pro--inflammatory cytokinesinflammatory cytokines (Nature. (Nature.
The Case for Fruits & VegetablesThe Case for Fruits & Vegetables�� Diets with high intake of fruits & Diets with high intake of fruits & vegetables are consistently vegetables are consistently associated with lower CV riskassociated with lower CV risk (JAMA (JAMA 2002;288: 25692002;288: 2569--78)78)
Carotid IMT before and after 1 year ofdaily PJ consumption (50 ml) in
a patient with carotid artery stenosis (CAS)
Control subjects on 80 mg simvistatinhad a mean carotid IMT increase of 9%
30% mean decrease at 12 months
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Fermentable Fermentable CarbsCarbs: The Case for : The Case for AlcoholAlcohol
�� Moderate intake of all alcoholic beverages Moderate intake of all alcoholic beverages lowers CRP and is associated with lower lowers CRP and is associated with lower rates of fatal & nonrates of fatal & non--fatal CV diseasefatal CV disease (Am J (Am J CardiolCardiol. 2005;96(1): 83. 2005;96(1): 83--88)88)
�� ½½ drink per day confers protection by drink per day confers protection by increasing insulin sensitivity and HDLincreasing insulin sensitivity and HDL--CC (J (J Am Am CollColl CardiolCardiol. 2007;50(11): 1009. 2007;50(11): 1009--14)14)
�� ResveratrolResveratrol,, a a polyphenolicpolyphenolic component component of red wine, enhances insulin sensitivity by of red wine, enhances insulin sensitivity by activating the enzyme SIRTactivating the enzyme SIRT--11•• SIRT1 extends lifespan in mammalsSIRT1 extends lifespan in mammals (Nature. (Nature.
2006;444(71): 3372006;444(71): 337--42)42)
•• SIRT activators prevent SIRT activators prevent neurodegenerationneurodegeneration in in animal models of MS & optic neuritisanimal models of MS & optic neuritis (Invest (Invest OpthalmolOpthalmol Vis Sci. 2007;48(8): 3602Vis Sci. 2007;48(8): 3602--9)9)
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David Sinclair, PhD Harvard Medical
School
CAN WE TRICK OUR GENES ?Mass. Institute of TechnologyP
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The Case For Dark ChocolateThe Case For Dark Chocolate�� 6.5 grams of dark chocolate 3x/wk 6.5 grams of dark chocolate 3x/wk reduced Creduced C--reactive protein by 17% reactive protein by 17%
in a prospective study of 11,000 in a prospective study of 11,000 healthy Italianshealthy Italians
�� Equivalent to a 25% CV risk Equivalent to a 25% CV risk reduction in men and 33% in womenreduction in men and 33% in women
�� A square Q2A square Q2--3 days3 days
J Nutr. 2008 Oct;138(10):1939-45
Polyphenols
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Do particular dietary sourcesof carbohydrate influence glucosehomeostasis and inflammation?
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GlycemicGlycemic Index (GI) Index (GI) & & GlycemicGlycemic Load (GL)Load (GL)
�� GI is the incremental area under the blood GI is the incremental area under the blood
glucose response curve of a 50g portion of glucose response curve of a 50g portion of
test food compared to a standard (white test food compared to a standard (white
bread or glucose)bread or glucose)
GL = GI x portion size (gms)100
Criticisms: Many
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GI and GL are UsefulGI and GL are Useful
�� Low GI food delay hunger, reduce Low GI food delay hunger, reduce
�� High dietary High dietary glycemicglycemic load (load (dGLdGL) ) ��
triglycerides and CRP and triglycerides and CRP and ��HDLHDL--CC(Arch Intern Med. 2001;161(4): 572(Arch Intern Med. 2001;161(4): 572--6)6)
�� low low dGLdGL diets result in much more diets result in much more
weight loss than high weight loss than high dGLdGL diets in diets in
the short termthe short term (Am J (Am J ClinClin NutrNutr 1994;60(1): 481994;60(1): 48--53)53)
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Are GI & GL useful?Are GI & GL useful?�� Low Low dGI/dGLdGI/dGL diets reduce fasting blood diets reduce fasting blood glucose, glucose, glycatedglycated protein and insulin protein and insulin resistance resistance ((Am J Am J ClinClin NutrNutr.. 2008 Jan;87(1):258S2008 Jan;87(1):258S--268S)268S)
�� High High dGIdGI increases the risk of increases the risk of developing T2DMdeveloping T2DM ((DiabDiab TechnolTechnol TherTher 2006;8(1): 452006;8(1): 45--54)54)
�� GL x Carbohydrate Content more useful GL x Carbohydrate Content more useful according to Loren according to Loren CordaineCordaine, PhD, PhD
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48 % of US Food 48 % of US Food can cause insulin can cause insulin resistance and an resistance and an
increased increased glycemicglycemicloadload
Loren Cordaine, PhD “The Paleo Diet”
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Association between dietary Association between dietary glycemicglycemic index and index and ageage--related macular degeneration in related macular degeneration in nondiabeticnondiabetic
participants in AREDSparticipants in AREDS
�� 4099 patients4099 patients
�� 5555--80 80 yoyo
�� 49% increased risk of advanced AMD (GA + 49% increased risk of advanced AMD (GA +
SRNV) if SRNV) if dGIdGI is above the sex medianis above the sex median
�� 20% of prevalent AMD cases would have 20% of prevalent AMD cases would have
been eliminated if been eliminated if dGIdGI was < sex medianwas < sex median
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100,000 cases of AMD would have beenprevented if dGI had been < sex median
Slide courtesy of Jeffrey Anshel, O.D.Slide courtesy of Jeffrey Anshel, O.D.
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Take Home on Take Home on CarbsCarbs & Fiber& Fiber�� Decrease or eliminate intake of Decrease or eliminate intake of refined refined carbscarbs (avoid white food)(avoid white food)
�� Reduce & diffuse the Reduce & diffuse the glycemicglycemic load load (smaller, more frequent meals)(smaller, more frequent meals)
�� Eat a variety of lower GI/GL fruits & Eat a variety of lower GI/GL fruits & vegetables; increase intake of dietary vegetables; increase intake of dietary fiber to > 25g/dayfiber to > 25g/day
�� Consider moderate alcohol Consider moderate alcohol consumption (1 drink QOD), consumption (1 drink QOD), preferably red wine, 3 oz. preferably red wine, 3 oz. pomegranate juice daily and a small pomegranate juice daily and a small square of dark chocolate twice/weeksquare of dark chocolate twice/week
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Dietary ProteinDietary Protein�� Increased protein intake results in Increased protein intake results in heightened satiety and weight lossheightened satiety and weight loss(J (J NutrNutr. 2004;134:975S. 2004;134:975S--979S; Cell 979S; Cell MetabMetab. 2006;4:223. 2006;4:223--33)33)
•• Triggers release of gut hormones Triggers release of gut hormones ((adiponectinadiponectin, GLP, GLP--1) that 1) that ��appetiteappetite
�� Appears to worsen insulin sensitivity Appears to worsen insulin sensitivity and may contribute to kidney diseaseand may contribute to kidney disease((AnnuAnnu Rev Rev NutrNutr. 2007;27:293. 2007;27:293--310; 310; ClinClin J Am Soc J Am Soc NephrolNephrol. . 2006;1(6): 12932006;1(6): 1293--9)9)
�� ��IGF which may shorten lifespanIGF which may shorten lifespan((Aging Cell. 2008;7(5): 681Aging Cell. 2008;7(5): 681--7)7)
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Iron Iron –– ItIt’’s Whats What’’s For Dinners For Dinner�� Strong association between T2DM & Strong association between T2DM & consumption of ironconsumption of iron--rich red meat as rich red meat as well as serum levels of nonwell as serum levels of non--transferrintransferrin--bound iron (bound iron (NTBI)NTBI)(Diabetes(DiabetesCare. 2007;30: 1926Care. 2007;30: 1926--33)33)
•• Suggests FeSuggests Fe2+2+ overload & abnormal iron overload & abnormal iron metabolism in diabetesmetabolism in diabetes
•• Hp genotype may exacerbate the risk of Hp genotype may exacerbate the risk of retinopathyretinopathy
�� Iron overload also has been Iron overload also has been implicated in the pathogenesis of implicated in the pathogenesis of AMDAMD (Retina. 2007;27(8):997(Retina. 2007;27(8):997--1003)1003)
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Benefits of Soy ProteinBenefits of Soy Protein
�� An increasing body of literature suggests An increasing body of literature suggests
benefits in obesitybenefits in obesity
�� Reduces TC, LDL and Reduces TC, LDL and TGsTGs by by ��
Take Home on ProteinTake Home on Protein�� Increased protein consumption Increased protein consumption decreases appetite and assists in decreases appetite and assists in weight lossweight loss
�� These benefits must be weighed These benefits must be weighed against the against the possible riskpossible risk of kidney of kidney dysfunction & worsened insulin dysfunction & worsened insulin resistanceresistance
•• ((but see but see SkovSkov AR 1999; 528AR 1999; 528--36 36 International J of Diabetes) International J of Diabetes)
�� Increased consumption of cold water, Increased consumption of cold water, fatty fish, and some fermented soy fatty fish, and some fermented soy protein may be is preferableprotein may be is preferable
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Dietary Recommendations for Dietary Recommendations for Overweight & Obese PatientsOverweight & Obese Patients
�� Eat an antiEat an anti--inflammatory, calorie inflammatory, calorie
restricted diet consisting of a restricted diet consisting of a
variety of low GL fruits & variety of low GL fruits &
vegetables, nuts, whole grains and vegetables, nuts, whole grains and
The Mediterranean DietThe Mediterranean Diet�� Nurses Health Study showed reduced Nurses Health Study showed reduced biomarkers of inflammation & endothelial biomarkers of inflammation & endothelial dysfunctiondysfunction (Am J (Am J ClinClin NutrNutr. 2005;82: 163. 2005;82: 163--73)73)
�� Lyon Heart Study showed a 70% reduction Lyon Heart Study showed a 70% reduction in MI and unstable anginain MI and unstable angina
�� EPIC showed an inverse correlation EPIC showed an inverse correlation between adherence to a Med style diet between adherence to a Med style diet and deathand death (N (N EnglEngl J Med. 2003;348: 2599J Med. 2003;348: 2599--2608)2608)
�� The NIHThe NIH--AARP study (n= 380,000) AARP study (n= 380,000) showed a 20+% reduction in CVD & showed a 20+% reduction in CVD & Cancer mortalityCancer mortality ((Arch Intern Med. 2007 Dec Arch Intern Med. 2007 Dec 10;167(22):246110;167(22):2461--88 ))
�� 83% reduced risk of T2DM over 4 years83% reduced risk of T2DM over 4 years((BMJ 2008, May 29 BMJ 2008, May 29 –– EPubEPub June 1June 1))
Little proof of ocular benefit – but good probability
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Killer Containers?Killer Containers?�� BisphenolBisphenol A (BPA): a polymer A (BPA): a polymer
additive commonly lining bottles, additive commonly lining bottles, cans and food containerscans and food containers
�� ¾¾ of BPA in the US is found in of BPA in the US is found in polycarbonate polycarbonate
�� Higher urinary BPA Higher urinary BPA concentartionsconcentartionsassociated with a 39% increased risk associated with a 39% increased risk of both CV of both CV dxdx and diabetesand diabetes
�� Early BPA exposure may trigger fat Early BPA exposure may trigger fat cell growth (cell growth (DiabesityDiabesity))
USA Dietary Patterns USA Dietary Patterns (1890(1890--2008)2008)
�� High simple carbohydrate consumptionHigh simple carbohydrate consumption
Soda Soda --3.5 cans/day (only 25 % diet) 3.5 cans/day (only 25 % diet) -- started in started in 18901890
85% is White Flour Baked goods 85% is White Flour Baked goods -- started in 1890started in 1890
Potatoes Potatoes -- French Fries as #1 French Fries as #1 ““vegetablevegetable””
�� Low Fruit & Vegetable (micronutrient/fiber) Low Fruit & Vegetable (micronutrient/fiber) consumption consumption –– 3 servings per day is average3 servings per day is average
2.2. Insulin resistance in the AD brain Insulin resistance in the AD brain exists.exists.
3.3. May be reversible and some DM May be reversible and some DM meds likely helpful.meds likely helpful.
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…… abdominal fat in midabdominal fat in mid --life life ↑↑risk risk for dementia, study suggests.for dementia, study suggests.
�� Being overweight / obese nearly doubles Being overweight / obese nearly doubles one's risk of dementia in old age one's risk of dementia in old age
�� "abdominal fat is a bigger risk factor than "abdominal fat is a bigger risk factor than even family historyeven family history““
�� Highest amount of abdominal fat Highest amount of abdominal fat between ages 40 and 45 are 3X more between ages 40 and 45 are 3X more likely to develop dementialikely to develop dementia than those than those with the lowest amount of abdominal fat with the lowest amount of abdominal fat whereas having a parent or sibling w ALZ whereas having a parent or sibling w ALZ only doubles the risk" only doubles the risk"
R Whitmer et al, Neurology, 3-26-2008
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in 2008,in 2008,
Only 2% of Medical Only 2% of Medical
Students are Entering Students are Entering
Primary Care Primary Care ––
Family and Preventive Family and Preventive
Medicine Medicine
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Primary Care OD Primary Care OD INTERVENTIONINTERVENTION
1.1. MAINTAIN MUSCLE MAINTAIN MUSCLE MASS (Resistance)MASS (Resistance)
2.2. JOINT FLEXIBILITY & JOINT FLEXIBILITY & Bone HealthBone Health
3.3. CARDIOVASULAR CARDIOVASULAR STATUS & Weight STATUS & Weight MaintenanceMaintenance
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Overweight Children Overweight Children --10 % between age 2 to 510 % between age 2 to 5
15 % between age 6 and1915 % between age 6 and19
�� 20 hours of TV/Computer/week20 hours of TV/Computer/week
(LESS EXERCISE)(LESS EXERCISE)
�� Fast Food Consumption and ToysFast Food Consumption and Toys
�� Drink soda (Liquid Candy Bars)Drink soda (Liquid Candy Bars)
�� Fat and sugary snacks (ice cream, Fat and sugary snacks (ice cream,
donuts, muffins, candy)donuts, muffins, candy)
�� Sugary cereals for breakfast (make Sugary cereals for breakfast (make triglycerides & cholesterol)triglycerides & cholesterol)
�� Effect on Family Effect on Family depression? ; hostility?, depression? ; hostility?, ADD? ; $40 per week extra on food bill.ADD? ; $40 per week extra on food bill.
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American College of American College of Cardiology Study, 3/20/2002Cardiology Study, 3/20/2002
�� 575 females with normal BP575 females with normal BP
�� average age = 20 years; average age = 20 years; from parochial & from parochial &
public schools in Cincinnati, Ohiopublic schools in Cincinnati, Ohio
�� 20 % of students with left 20 % of students with left
ventricular hypertrophyventricular hypertrophy (precursor to (precursor to
•• Fast Food Fast Food –– higher profit margins higher profit margins of 50%of 50%
•• 20 % of schools serve branded foods20 % of schools serve branded foods
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Physical ActivityPhysical Activity�� Get 30 minutes of moderate Get 30 minutes of moderate exercise most days of the weekexercise most days of the week•• Exercise with or without weight loss Exercise with or without weight loss reduces abdominal fatreduces abdominal fat ((ObesObes Res. Res. 2004;12(5): 7892004;12(5): 789--98)98)
•• Reduces insulin secretion 40%, BP 15%, Reduces insulin secretion 40%, BP 15%, and mortality by 27%and mortality by 27% (Arch Intern Med. 2007 (Arch Intern Med. 2007
Dec 10;167(22):2461Dec 10;167(22):2461--8)8)
•• Both the Both the Finnish Diabetes StudyFinnish Diabetes Study and the and the Diabetes Prevention ProgramDiabetes Prevention Program showed a showed a 60% reduction in T2DM 60% reduction in T2DM DxDx in atin at--risk risk patientspatients (N (N EnglEngl J Med. 2004;346:393J Med. 2004;346:393--403; Diabetes. 403; Diabetes. 2005;54(1):1582005;54(1):158--65)65)
SStop top HHypertension)ypertension)Doctors: Think about reading this important book, from the Chairman, Harvard School of Public Health
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But only 3% of Americans But only 3% of Americans follow 4 basic health practicesfollow 4 basic health practices�� MJ Reeves, AP Rafferty, Healthy lifestyle MJ Reeves, AP Rafferty, Healthy lifestyle
characteristics among adults in the US, 2000, characteristics among adults in the US, 2000,
Arch Intern Med 2005;165:854Arch Intern Med 2005;165:854--7. 7.
�� 153,000 adults, random household telephone 153,000 adults, random household telephone surveyssurveys
1.1. Nonsmoking (76 %)Nonsmoking (76 %)
2.2. BMI 18.5 BMI 18.5 –– 25 (40%)25 (40%)
3.3. 5 or more F &V daily5 or more F &V daily (23%)(23%)
4.4. > 30 minutes physical activity 5 times > 30 minutes physical activity 5 times per week (22%)per week (22%)
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What are What are NutraceuticalsNutraceuticals ??
��NutraceuticalNutraceutical can be defined as, "a food (or part of a can be defined as, "a food (or part of a food) that provides medical or health benefits, food) that provides medical or health benefits, including the prevention and/or treatment of a including the prevention and/or treatment of a disease.disease.““ However, the term However, the term nutraceuticalnutraceutical as as commonly used in marketing has no regulatory commonly used in marketing has no regulatory definition.definition.
��* * ““Prescription drugsPrescription drugs are approved through the are approved through the rigorous new drug application process (NDA). In rigorous new drug application process (NDA). In contrast, dietary supplements are regulated as foods contrast, dietary supplements are regulated as foods and the FDA must determine that a dietary and the FDA must determine that a dietary supplement ingredient poses a "significant or supplement ingredient poses a "significant or unreasonable risk of illness or injury" unreasonable risk of illness or injury"
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14 14 SuperFoodsSuperFoods ®® Handout Handout
�� Spinach BlueberriesSpinach Blueberries
�� Sardines CitrusSardines Citrus
�� Turkey Breast PumpkinTurkey Breast Pumpkin
�� Broccoli YogurtBroccoli Yogurt
�� Walnuts OatsWalnuts Oats
�� TomatoTomato LegumesLegumes
�� SoySoy Green TeaGreen Tea
Daily sunlight and/or 1000 IU vitamin D twice per day daily also is very important for general health
www.mypyramid.gov
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ProPro --Oxidants vs. Oxidants vs. AntiAnti --oxidantsoxidants in Obesity & in Obesity & DiabetesDiabetes
Figure 1 : HK Vincent and AG Taylor, Biomarkers and potential mechanisms of obesity-induced oxidant stress in humans, International Journal of Obesity, 30 p 400-18, 2006
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A plethora of helpful supplementsA plethora of helpful supplements�� Vitamin E (natural dVitamin E (natural d--alpha & mixed isomers)alpha & mixed isomers)
•• BV & nerve sheath healthBV & nerve sheath health
�� Vitamin CVitamin C
•• 500 mg to as much as 2500 mg but serially 500 mg to as much as 2500 mg but serially doseddosed
•• BV health & BV health & ↓↓ insulin resistance, cataract & insulin resistance, cataract & cancercancer
�� FlavonoidsFlavonoids @70% of vitamin C dose@70% of vitamin C dose
R Asieh, AP Levy, In vivo & in vitro studies establ ishing haptoglobin as a major susceptibility gene for diabetic vascular dis ease, Vasc Health & Risk Management, 2005:1(1) 19-28.
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A plethora of nutrients for better A plethora of nutrients for better blood Vesselsblood Vessels
Fish (sardines, herring, salmon, tuna) 3x per Fish (sardines, herring, salmon, tuna) 3x per week or 1000mg cod liver oil BID daily week or 1000mg cod liver oil BID daily
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Reversing Diabetes, Revised and Reversing Diabetes, Revised and Updated, by Julian Whitaker, M.D.Updated, by Julian Whitaker, M.D.
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↑↑ Comprehensive Multivitamin Comprehensive Multivitamin Dose w AgeDose w Age
(or extent of health challenge)(or extent of health challenge)
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2
2.5
3
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4
Age 20 Age 40 Age 60 Age 80
# Capsules
SERIAL INTAKE IF POSSIBLE
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Fiscal & Fiscal & Nutritional CostNutritional Cost of of PharmaceuticalsPharmaceuticals
�� Growing % of Growing % of healthcare budget healthcare budget with political aspectswith political aspects
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Even OTC Pharmaceuticals can induce Even OTC Pharmaceuticals can induce nutritional deficiencies which are often nutritional deficiencies which are often treated with additional pharmaceuticalstreated with additional pharmaceuticals
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Examples of Additional Examples of Additional Targeted Supplementation in Targeted Supplementation in
HK Vincent and AG Taylor, Biomarkers and potential mechanisms of obesity-induced oxidant stress in humans, International Journal of Obesity, 30 p400-18, 2006
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Controlling the Glucose Flash Flood Controlling the Glucose Flash Flood --upon Blood Vesselsupon Blood Vessels
““Obesity creates Obesity creates
the oxidant the oxidant
conditions of a conditions of a
““breeding breeding
groundground”” for for
diseases such as diseases such as
diabetes, heart diabetes, heart
disease, HTN disease, HTN
and and CVDzCVDz””
Image from Life Enhancement Inc, Petaluma, CA
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Hyperglycemia & Vascular Hyperglycemia & Vascular Complications from Complications from ↑↑ bloodblood sugarsugar
Professor Thomas C Washer, Karl-Franzens University of Graz, Austria, Understanding Diabetes, Oxidative Stress and Vascular Complications in type 2 diabetes
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Lowers Insulin Resistance by 40%Lowers Insulin Resistance by 40%when taken before mealswhen taken before meals
Proprietary Fiber blendof koniac root, Na alginate & xanthum
gum
3-5X better effect on cholesterol than oats or psyllium (↓total & LDL-C
by 19/29%)
May lessen need for insulin or other diabetic
medications
Talk with your doctor University of Toronto & Canadian Center for Functional Medicine
�� 5.5 pounds average weight loss5.5 pounds average weight loss
www.HSIBaltimore.com
www.baselinenutritionals.com
800-695-5995
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Oxidative Stress is implicated in both Oxidative Stress is implicated in both the etiology & long term complications the etiology & long term complications
Tart Cherry Extract for Tart Cherry Extract for �������� VATVAT•• Dahl rats were fed whole tart cherry or Dahl rats were fed whole tart cherry or isocoloricisocoloricplacebo. placebo.
•• After 90 days, the cherryAfter 90 days, the cherry--enriched diet was enriched diet was associated with reduced FBS, associated with reduced FBS, hyperlipidemiahyperlipidemia, , hyperinsulinemiahyperinsulinemia, and fatty liver.. , and fatty liver..
•• Physiologically relevant tart cherry Physiologically relevant tart cherry consumption reduced several phenotypic risk consumption reduced several phenotypic risk
factors that are associated with risk for factors that are associated with risk for metabolic syndrome and Type 2 diabetes. Tart metabolic syndrome and Type 2 diabetes. Tart cherries may represent a whole food research cherries may represent a whole food research model of the health effects of model of the health effects of anthocyaninanthocyanin--rich rich foods and may possess foods and may possess nutraceuticalnutraceutical value value
against risk factors for metabolic syndrome and against risk factors for metabolic syndrome and its clinical its clinical sequelaesequelae..
��
Altered Altered hyperlipidemiahyperlipidemia, hepatic , hepatic steatosissteatosis, and hepatic , and hepatic
peroxisomeperoxisome proliferatorproliferator--activated receptors in rats with intake of activated receptors in rats with intake of
tart tart cherry.cherry.SeymourSeymour EMEM et al et al Department of Food Science and Human Department of Food Science and Human
Nutrition, Michigan State UniversityNutrition, Michigan State University
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The FDA against the USDA The FDA against the USDA & 29 Cherry Marketers& 29 Cherry Marketers
(Oct 2006)(Oct 2006)
“Eat 9 – 13 portions of
Fruits & Vegetables per
day”
“20 cherries reduces inflammation in a similar manner as aspirin or Cox-2 inhibiting drugs without the lethal side effects of gastric bleeding or vitamin depletion associated with these drugs” The molecules in cherries, called anthocyanins, work to reduce inflammation at ten times less dosage than aspirin. [Journal Natural Products 1999 Feb; 62(2): 294–6]
Warning letter threatening regulatory action if scientific “drug like” claims are not removed from the web.
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Figure 2: HK Vincent and AG Taylor, Biomarkers and potential mechanisms of obesity-induced oxidant stress in humans, International Journal of Obesity, 30 p400-18, 2006
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BenfotiamineBenfotiamine(natural (natural lipid formlipid form of Vitamin B1) of Vitamin B1)
that prevents agethat prevents age--related cellular damagerelated cellular damage
1.1. Blocks formation of harmful sugar Blocks formation of harmful sugar
products products
2.2. Prevents and protect tissue structure Prevents and protect tissue structure
and function and function
i.e. i.e. retinal damageretinal damage
i.e. i.e. nerve function damagenerve function damage
�� ““benfotiaminebenfotiamine was shown to was shown to block at least 3 pathways of block at least 3 pathways of hyperglycemia mediated hyperglycemia mediated vascular damage vascular damage
1. 1. hexosaminehexosamine pathway pathway (increased PAI 1 & (increased PAI 1 & clotting)clotting)
2.2. protein protein kinasekinase C and C and vascvasc leakage and VEGF leakage and VEGF
3. 3. AGEsAGEs & & crosslinkingcrosslinking
4. 4. PolyolPolyol ((sorbitolsorbitol))
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Diabetes: A Systemic DiseaseDiabetes: A Systemic Disease
DiabeticRetinopathy
Leading causeof blindness
in working ageadults
DiabeticNephropathy
Leading cause of end-stage renal disease
CardiovascularDisease
DiabeticNeuropathy
Stroke
Leading cause of non-traumatic lower extremity amputations
2- to 4- fold increase in cardiovascular mortality and stroke
National Diabetes Information Clearinghouse. Diabetes StatisticsNational Diabetes Information Clearinghouse. Diabetes Statistics––Complications of Diabetes. (website) Complications of Diabetes. (website) http://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.hthttp://www.niddk.nih.gov/health/diabetes/pubs/dmstats/dmstats.htm#comp.m#comp.
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LipoicLipoic AcidAcid
Helps insulin transport glucose into Helps insulin transport glucose into
cellscells
Inhibits Inhibits glycosylatedglycosylated attachment of attachment of
sugar to proteinsugar to protein
Maintains eye and nerve health Maintains eye and nerve health
((↓↓ peripheral neuropathy)peripheral neuropathy)
Also AcetylAlso Acetyl--LL--CarnosineCarnosine (2 recent (2 recent
studies)studies)-- 500 & 1000mg500 & 1000mg
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Nutrients against VEGF & Nutrients against VEGF & neovascularizationneovascularization (in DM & AMD)(in DM & AMD)
Genistein
Curcumin
EGCG
Bioflavanoids
Vitamin D
Learn To Love Indian Cuisine!
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Tertiary (Add-On) Treatment for very High Risk & Active AMD Retinal
Patients in place of Fish Oil Capsules (contains fish oil)
↓ Inflammation
↓ Oxidation ↓ Neovascularization
•Soy (genistein), Tumeric and & Vitamin D against neovascularization (wet AMD)
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Figure 5: HK Vincent and AG Taylor, Biomarkers and potential mechanisms of obesity-induced oxidant stress in humans, International Journal of Obesity, 30 p400-18, 2006
2.2. 10% 10% ↓↓↓↓↓↓↓↓ weight if BMI over 25weight if BMI over 25
3.3. Min 30 min/d moderate exercise most days Min 30 min/d moderate exercise most days Better = 60Better = 60--90 min/d exercise most days90 min/d exercise most days
4.4. Weight training 2Weight training 2--3x /wk3x /wk
6.6. Eat high nEat high n--3 fatty acid fish 4x/wk, 3.5 3 fatty acid fish 4x/wk, 3.5 oz/serving, (i.e. Wild Salmon best, then oz/serving, (i.e. Wild Salmon best, then sardines, herring, tuna) & take 1sardines, herring, tuna) & take 1--3 g fish oil 3 g fish oil capsules daily.capsules daily.
7.7. 2 Tbsp ground flaxseed meal most days2 Tbsp ground flaxseed meal most days
8.8. 1 1 -- 11½½ oz walnuts 5x/wkoz walnuts 5x/wk
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16 Ways to 16 Ways to Decrease InflammationDecrease Inflammation
9.9. 1 c berries, cherries or purple grapes, or 41 c berries, cherries or purple grapes, or 4--8 oz 8 oz
100% pomegranate juice (or purple grape 100% pomegranate juice (or purple grape
juice) dailyjuice) daily----better yet, bathe each meal with better yet, bathe each meal with
berries, cherries, grapes, pomegranate juiceberries, cherries, grapes, pomegranate juice
�� Physicians face numerous barriers when Physicians face numerous barriers when counseling patients on weight loss and counseling patients on weight loss and risks, including how, when and with whom risks, including how, when and with whom to have discussionsto have discussions
�� Obese patients find the terms Obese patients find the terms ‘‘fatfat’’ and and ‘‘obeseobese’’ highly derogatory, preferring highly derogatory, preferring ‘‘excess weightexcess weight’’ or or ‘‘high BMIhigh BMI’’ ((ObesObes Res. Res. 2003;11(9): 11402003;11(9): 1140--6)6)
�� The vast majority of overweight (84%) The vast majority of overweight (84%) and obese patients (97%) believe they and obese patients (97%) believe they need to lose weight, but fewer than 25% need to lose weight, but fewer than 25% had discussed weight loss with their PCPshad discussed weight loss with their PCPs(J (J FamFam PractPract. 2001;50(6): 513. 2001;50(6): 513--18)18)
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Effective Patient CommunicationEffective Patient Communication�� Ask for permission to discuss weight Ask for permission to discuss weight statusstatus•• Be careful to distinguish between the weight Be careful to distinguish between the weight problem and the personproblem and the person
•• Focus on specific health risks (AMD, DR, Focus on specific health risks (AMD, DR, cataract, CHD and cancer)cataract, CHD and cancer)
�� Assess motivation, current dietary and Assess motivation, current dietary and exercise statusexercise status
�� Build a partnership by helping patients set Build a partnership by helping patients set a few realistic goalsa few realistic goals•• Walk 5,000 steps daily, lose 7% of weight, Walk 5,000 steps daily, lose 7% of weight, reduce BP by 10/5, increase MPOD, etc.reduce BP by 10/5, increase MPOD, etc.
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ConclusionConclusion�� Battling ocular & systemic complications of Battling ocular & systemic complications of obesity is analogous to keeping an obesity is analogous to keeping an overflowing bathtub from ruining the overflowing bathtub from ruining the bathroom floor bathroom floor --
•• Turn off the faucetTurn off the faucet: : reduce calories, reduce calories, increase exercise, control blood glucose & increase exercise, control blood glucose & blood pressure, treat any OSASblood pressure, treat any OSAS
•• Bail the water and pull the plugBail the water and pull the plug: : lose lose weight, especially VAT that drives IR, weight, especially VAT that drives IR, HTN, ROS and inflammationHTN, ROS and inflammation
•• Mop up the floorMop up the floor: : eat an antieat an anti--inflammatory diet, use synergistic inflammatory diet, use synergistic antioxidants & micronutrients to target antioxidants & micronutrients to target the metabolic abnormalities of obesitythe metabolic abnormalities of obesity
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•Caloric restriction•Increase energy expenditure•BG and BP control•CPAP for OSAS