Post on 17-Jan-2015
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Nutrition and the Metabolic Syndrome
Gail Underbakke, RD, MS
UW Preventive Cardiology Program
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 > 97th 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.
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.
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
MenWomen
>40 in >35 in
MenWomen
100 mg/dL or on medsFasting glucose130/85 mm Hg or on medsBlood pressure
HDL-C150 mg/dL or on medsTriglycerides
Abdominal obesity† (Waist circumference‡)
Defining LevelRisk Factor
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”)
Atherogenic Dyslipidemia
Risk of coronary heart disease
Despres J-P. Dyslipidemia and obesity. Baillere’s Clin Endocrinal Metab. 1994;8-636
Underlying Causes of Metabolic Syndrome
There are multiple underlying factors –
• abdominal obesity*
• insulin resistance*
• physical inactivity
• aging
• genetic or ethnic predisposition
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.
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
Daily Activity Reduces Post-Prandial Glucose
O’Keefe, et. al. JACC 2008; 51:249
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
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
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
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
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
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
Overall Lifestyle Recommendations for Metabolic Syndrome
• Exercise
• Weight Loss
• Total carbohydrate <60% of calories
• DASH diet
• Limit alcohol
• Smoking cessation
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
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
Copyright restrictions may apply.
Gardner, C. D. et al. JAMA 2007;297:969-977.
Which Diet Works?
Dansinger, JAMA 2005; 293:43-53
Ch
an
ge F
rom
Baselin
e (
%)
P<0.001
LDL-C
TG
Fish Sources of Omega-3 Fatty AcidsSalmon, Atlantic, farmed, 3 oz 1.09-1.83 gm
Herring, Atlantic, 3 oz 1.71
Sardines, canned, 3 oz 0.98-1.70
Mackerel, 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
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
Contains:
180 mg EPA
120 mg DHA
Per capsule
For more information:
Fish Oil Supplements
www.heartdecision.org
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.
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.
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.
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
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!
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
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
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)
Phytochemicals are measured in ORAC UnitsORAC 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.
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
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
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
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