Obesity Diabetes and Complications[1]

Obesity, Diabetes & Obesity, Diabetes & ComplicationsComplications

COPE #7999COPE #7999--GOGOStuart Richer, OD, PhD, FAAOStuart Richer, OD, PhD, FAAO

DVA Medical Center DVA Medical Center

Chief, Optometry SectionChief, Optometry Section

Associate Professor, Associate Professor,

Family & Preventive Medicine, Family & Preventive Medicine, RFUMS, North Chicago, ILRFUMS, North Chicago, IL

9 November 2008Jackson , MI

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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

ocular (and systemic) disease?ocular (and systemic) disease?

�� Clinical EntitiesClinical Entities

�� Epidemiology & DefinitionsEpidemiology & Definitions

�� Biological Rationale for Specific Biological Rationale for Specific

MacronutrientsMacronutrients

�� Rationale for Specific Rationale for Specific

Micronutrients & Micronutrients & NutraceuticalsNutraceuticals

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Course ConsiderationsCourse Considerations

�� Specific Patient RecommendationsSpecific Patient Recommendations•• ExerciseExercise

•• DietDiet

•• SupplementsSupplements

•• Effective CommunicationEffective Communication

�� ConclusionConclusion•• keeping the overflowing bath from keeping the overflowing bath from ruining the bathroom floorruining the bathroom floor

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Battling the systemic & ocularcomplications of obesity is analogousto keeping an overflowing bathtubfrom ruining the bathroom floor

Turn Offthe Faucet

Pull the Plug Mop Up the Floor

Bail the Tub

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Why is Obesity Associated With Why is Obesity Associated With Ocular & Systemic Disease?Ocular & Systemic Disease?

�� An Unholy TriumvirateAn Unholy Triumvirate

••InflammationInflammation

••HypertensionHypertension

••HypoxiaHypoxia

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InflammationInflammation�� Fat cells (Fat cells (adipocytesadipocytes) are ) are

endocrine cells, secreting endocrine cells, secreting

hormones regulating insulin hormones regulating insulin

sensitivity & satiety, and are sensitivity & satiety, and are

associated with elevated markers associated with elevated markers

of inflammationof inflammation

PAI-1Factor VIIiNOS

CRPICAMsIL-6FibrinogenTNF-αααα

ResistanAdiponectinLeptin

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Subcutaneous vs.

Visceral Fat

Fat Cells Are Endocrine Cells!!Fat Cells Are Endocrine Cells!!

Reactive Oxygen Species & Inflammation

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Inflammation & Oxidative StressInflammation & Oxidative Stress

�� 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

�� Increased oxidativeIncreased oxidative stress causes stress causes inflammation & endothelial dysfunctioninflammation & endothelial dysfunction

Diabetes. 2005 Jun;54(6): 1615-25Circulation. 2007 Sep;116(11): 1234-41

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Oxidative StressOxidative Stress……

““ an imbalance between tissue an imbalance between tissue

oxidants (free radicals or reactive oxidants (free radicals or reactive

oxygen species) and antioxidants oxygen species) and antioxidants

may be a unifying mechanism in the may be a unifying mechanism in the

development of majordevelopment of major--obesityobesity--

related co morbidities such as related co morbidities such as

cardiovascular disease and diabetescardiovascular disease and diabetes””

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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Oxidative Stress Endothelial Dysfunction

Disease

HypercoaguabilityVasoconstrictionInflammation

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Inflammation Inflammation –– iron metabolismiron metabolism

�� Iron (FeIron (Fe2+2+) overload also ) overload also

promotes inflammation & ROSpromotes inflammation & ROS

•• Metabolic (common in T2DM and Metabolic (common in T2DM and

the metabolic syndrome)the metabolic syndrome)**

•• Genetic (Genetic (haptoglobinhaptoglobin genotype)**genotype)**

•• DietaryDietary

*Diabetes 2002;51: 2348-54**Arterioscler Thromb Vasc Biol. 2007, Nov 21

JAMA 2000 Sep 13;284(10):1244-5

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Obesity

VAT

InflammatoryCytokines

TNF-ααααPAI-1ICAMsCRPFFAs

Adipokines

IronOverload

MetabolicHp Genotype

Diet

Insulin Resistance

Skeletal MuscleLiver

Hypothalamus

IncreasedOxidativeStress

BluntedSatiety Receptors

Hunger &Increased

Caloric Intake

Disease

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HypertensionHypertension�� Obesity & BMI are clear and Obesity & BMI are clear and

continuous risk factors for HTNcontinuous risk factors for HTN

•• IR activates the IR activates the reninrenin--angiotensinangiotensin systemsystem

�� Weight loss results in reduced BP in Weight loss results in reduced BP in

large clinical trialslarge clinical trials

�� HTN is a definitive risk factor for CVD HTN is a definitive risk factor for CVD

and myriad ocular diseases (and myriad ocular diseases (RVOsRVOs, ,

AION, DR)AION, DR)

Blood Press. 2007;16(1): 13-19Am J Hyperten. 2006 Nov;19(11): 1103-9

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HypoxiaHypoxia

�� Obesity is Obesity is THETHE major risk factor for major risk factor for

obstructive sleep apnea syndrome obstructive sleep apnea syndrome

(OSAS)(OSAS)

�� OSAS causes hypoxic stress and OSAS causes hypoxic stress and

elevates blood pressureelevates blood pressure

�� OSAS is associated with endothelial OSAS is associated with endothelial

dysfunction and several eye diseasesdysfunction and several eye diseases

J Clin Sleep Med. 2007 Jun 15;3(4): 409-15Exp Physiol. 2007 Jan;92(1): 51-65

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Inflammation

ROS

Endothelial Dysfunction

Hypertension

Hypoxia


Clinical Entities: Clinical Entities: Eye Disease Eye Disease Associated with ObesityAssociated with Obesity

�� CataractCataract

�� AMDAMD

�� GlaucomaGlaucoma

�� Diabetic RetinopathyDiabetic Retinopathy

�� NAIONNAION

�� Floppy Eyelid Syndrome (FES)Floppy Eyelid Syndrome (FES)

�� PseudotumorPseudotumor cerebricerebri (PTC)(PTC)

�� Venous Occlusive DiseaseVenous Occlusive Disease

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CataractCataract

�� BMI > 30 increased risk of PSC and BMI > 30 increased risk of PSC and

cortical cataract cortical cataract ((Blue Mountains Eye Study. Blue Mountains Eye Study.

Ophthalmic Ophthalmic EpidemiolEpidemiol. 2003;10(4):227. 2003;10(4):227--4040))

�� Metabolic Syndrome increases risk Metabolic Syndrome increases risk

of cataract by 30of cataract by 30--40% 40% ((EurEur J J OphthalOphthal. .

2007;17(4): 6052007;17(4): 605--1414))

�� Risk of PSC 2.5X higher for women Risk of PSC 2.5X higher for women

with waist circumference > 89cm with waist circumference > 89cm ((Am J Am J ClinClin NutrNutr 2003;78:4002003;78:400--55))

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Did you know all of these are Did you know all of these are associated with associated with Obstructive Obstructive

Sleep Apnea (OSAS)?Sleep Apnea (OSAS)?•• Glaucoma prevalence estimated Glaucoma prevalence estimated --27%27% (Eye. (Eye. 2007, May 42007, May 4))

•• Floppy Eyelid Syndrome prevalence Floppy Eyelid Syndrome prevalence -- 25%25%(Ophthalmology. 2006;113(9):1669(Ophthalmology. 2006;113(9):1669--74)74)

•• PseudotumorPseudotumor CerebriCerebri ((1515--40%)40%) J J NeuroophthalNeuroophthal2001 21(3):2001 21(3):235235))

•• 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)

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AMDAMD

�� Increased risk with increasing BMI & Increased risk with increasing BMI & waist sizewaist size (Arch (Arch OphthalmolOphthalmol. 2003;121(6): 785. 2003;121(6): 785--92)92)

�� 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

Intern Med. 1997;122:481Intern Med. 1997;122:481--6)6)

�� Marked obesity increases the risk Marked obesity increases the risk

of DRof DR ((Diabetes Care. 1986;9(4): 961Diabetes Care. 1986;9(4): 961--9)9)

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Venous Occlusive DiseaseVenous Occlusive Disease

�� Risk of RVO and arterial emboli is Risk of RVO and arterial emboli is

3.8 fold higher for BMI > 303.8 fold higher for BMI > 30(Ophthalmology. 2005;112(4): 540(Ophthalmology. 2005;112(4): 540--7)7)

�� Highest risk of CRVO if patient Highest risk of CRVO if patient

has HTN, DM or OHTNhas HTN, DM or OHTN

�� High risk of BRVO reported when High risk of BRVO reported when

BMI > 25 kg/mBMI > 25 kg/m22 at 25 years of at 25 years of

ageage ((Ophthalmology. 1996;114(5): 545Ophthalmology. 1996;114(5): 545--54)54)

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Epidemiology and DefinitionsEpidemiology and Definitions

�� In 2006, 60.5% of Americans were In 2006, 60.5% of Americans were

overweight, 23% were obese, and overweight, 23% were obese, and

3% were morbidly obese3% were morbidly obese

1990 1998 2006

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

BMI > 30

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““1 in 3 Children 1 in 3 Children Born in 2000 will Born in 2000 will

develop Diabetesdevelop Diabetes””

Ben Szirth, PhD

New Jersey Medical College

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Classic DefinitionClassic Definition

�� BMI > 25BMI > 25 overweightoverweight

�� BMI > 30BMI > 30 obeseobese

�� BMI > 35BMI > 35 severely obeseseverely obese

�� BMI > 40BMI > 40 morbidly obesemorbidly obese

BMI = Weight (kg)/Height (m)2

or

Weight (pounds)/Height (inches)2 x 703

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Children & TeensChildren & Teens�� Overweight BMI > 85% percentileOverweight BMI > 85% percentile

�� Obese BMI > 95% percentileObese BMI > 95% percentile

Girls Boys

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Other measures of obesityOther measures of obesity

�� Abdominal AdiposityAbdominal Adiposity

••Waist Circumference > 102 cm Waist Circumference > 102 cm

(40 inches) in men(40 inches) in men

••Waist Circumference > 88 cm Waist Circumference > 88 cm

(35 inches) in women(35 inches) in women

••Waist:HipWaist:Hip Ratio >1.0 for menRatio >1.0 for men

> 0.8 for women> 0.8 for women

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“There is a charm about the forbidden that makes it unspeakably desirable” -Mark Twain

“My doctor told me to stop havingintimate dinners for four. Unless there are three other people” -Orson Welles

Nutritional Management

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Biologic Rationale For Specific Biologic Rationale For Specific MacronutrientsMacronutrients

�� Dietary Macronutrients are Dietary Macronutrients are

nutrients needed in relatively nutrients needed in relatively

large quantitieslarge quantities

•• Fats (glycerin + 3 fatty acids)Fats (glycerin + 3 fatty acids)

•• Carbohydrates (sugars)Carbohydrates (sugars)

•• Proteins (amino acids joined by Proteins (amino acids joined by

peptide bonds)peptide bonds)

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Dietary FatDietary Fat

�� Saturated Fat:Saturated Fat:

•• High intake unquestionably linked to High intake unquestionably linked to

increased CV risk & inflammationincreased CV risk & inflammation (J Lipid Res. (J Lipid Res.

2006;47: 16612006;47: 1661--7)7)

•• Intake > 10% of calories worsens insulin Intake > 10% of calories worsens insulin

sensitivity and LDLsensitivity and LDL--CC ((HepatologyHepatology. 2003;37: 909. 2003;37: 909--16)16)

•• But intake < 7% of calories has little effect But intake < 7% of calories has little effect

on LDLon LDL--C and C and significantly lowers significantly lowers

protective HDLprotective HDL--CC, especially in patients , especially in patients

with insulin resistancewith insulin resistance ((ObesObes Surg. 2005;15: 502Surg. 2005;15: 502--5)5)

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Dietary FatDietary Fat

�� Trans Fat Trans Fat

•• Multiple isomers with varying metabolic Multiple isomers with varying metabolic

effectseffects

•• transtrans--10,cis10,cis--12 conjugated 12 conjugated linoleiclinoleic acid acid

from partially hydrogenated oils from partially hydrogenated oils ((corn corn

oil &oil & vegetable oilvegetable oil) ) significantly significantly

increases inflammation and CV riskincreases inflammation and CV risk (N (N

EnglEngl J Med. 1997;337: 1491J Med. 1997;337: 1491--99)99) and induces and induces

endothelial dysfunctionendothelial dysfunction ((AtherosclerAtheroscler Supp. Supp.

2006;7: 292006;7: 29--32)32)

Note: trans fats < 0.5 g are reported as “0” on food labels

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Monounsaturated Fats Monounsaturated Fats -- MUFAMUFA�� Decrease triglycerides, LDLDecrease triglycerides, LDL--C C and oxidized LDLand oxidized LDL--C without C without decreasing HDLdecreasing HDL--CC (J (J NutrNutr BiochemBiochem. . 2006;17: 6452006;17: 645--58)58)

�� Decrease Decrease ICAMsICAMs & improve & improve endothelial dysfunctionendothelial dysfunction (Ann Intern (Ann Intern Med. 2001;134: 1115Med. 2001;134: 1115--19)19)

�� 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.

2001;414:8132001;414:813--20; Circulation. 2002;106: 206720; Circulation. 2002;106: 2067--72)72)

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Production of reactive oxygen species Production of reactive oxygen species

(Superoxide) by mitochondria (Superoxide) by mitochondria

exposed to any glucoseexposed to any glucose

IntracellularGlucose & FFAs

ATP + ��Superoxide (O2

-)Mitochondrian

Inflammatory Cytokines

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HFCS and Obesity?HFCS and Obesity?�� Fructose is metabolized by Fructose is metabolized by hepatocyteshepatocytes to to

produce produce triacylglyceroltriacylglycerol and uric acidand uric acid

�� Uric acid reduces NO levelsUric acid reduces NO levels

�� NO is requisite for insulin receptor functionNO is requisite for insulin receptor function

�� HFCS elevates triglycerides and fosters HFCS elevates triglycerides and fosters

hyperuricemiahyperuricemia--induced insulin resistanceinduced insulin resistance

�� HFCS contributes to the Metabolic HFCS contributes to the Metabolic

Syndrome Syndrome (Am J (Am J PhysiolPhysiol Renal Renal PhysiolPhysiol 2006; 2006;

290(3):f625290(3):f625--31)31)

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Uric Acid & Metabolic SyndromeUric Acid & Metabolic SyndromeMetabolism. 2008 Jun;57(6):845Metabolism. 2008 Jun;57(6):845 --5252

6 7 8 9 10

Serum Uric Acid (mg/dl)

Prevalence of

Metabolic Syndrome

%

Per NCEPATP-IIICriteria

100

80

60

40

20

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FPG > 110 HDL < 40 (male) or < 50 (female)

BP > 130/85 TG > 150

Waist > 40 inches (male) or 36 inches (female)

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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)

•• Rich in antioxidantsRich in antioxidants

•• High in fiberHigh in fiber

�� Fiber increases insulin sensitivityFiber increases insulin sensitivity (Diabetes (Diabetes Care 2005;28: 1022Care 2005;28: 1022--28)28)

�� Fiber reduces CRP and TNFFiber reduces CRP and TNF--αα (Diabetes Care (Diabetes Care 2006;29(2): 2072006;29(2): 207--21)21)

�� 25 gm fiber reduces BP 6mm/4mm in 25 gm fiber reduces BP 6mm/4mm in hypertensive patientshypertensive patients (J (J HypertenHyperten. 2005;23(3): . 2005;23(3): 475475--81)81)

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The Case for Pomegranates??The Case for Pomegranates??•• Juice, seeds and extract all reduce Juice, seeds and extract all reduce

biomarkers of oxidative stressbiomarkers of oxidative stress (J Agric Food (J Agric Food

Chem. 2007;55(24): 10050Chem. 2007;55(24): 10050--4)4)

•• PJ reduced systolic BP 21% and oxidized PJ reduced systolic BP 21% and oxidized

LDLLDL--C by 90% in patients with CASC by 90% in patients with CAS

•• PJ decreased carotid PJ decreased carotid intimaintima media media

thickness by an average of 30% at one thickness by an average of 30% at one

yearyear ((ClinClin NutrNutr. 2004;23(3): 423. 2004;23(3): 423--33)33)

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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?

Good Good CarbCarb: Bad : Bad CarbCarbPD

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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

caloric intakecaloric intake (Lipids. 2003;38(2): 117(Lipids. 2003;38(2): 117--21)21)

�� 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)

�� dGLdGL specifically influences CV risk in obese specifically influences CV risk in obese patientspatients (Am J (Am J ClinClin NutrNutr. 2007;85(3): 724. 2007;85(3): 724--34)34)

�� 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)

& AMD (large & AMD (large drusendrusen, GA, CNVM), GA, CNVM) (Am J (Am J ClinClin

NutrNutr. 2007;86(1): 180. 2007;86(1): 180--8)8)

�� 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

(Am J (Am J ClinClin NutrNutr. 2007;86(1): 180. 2007;86(1): 180--8)8)

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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Eat

Drin

k &

Be

Hea

lthy,

Wal

ter

Will

ett


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

•• Increases Increases thermogenesisthermogenesis 22--3X (body 3X (body heat)heat)

BUTBUT

�� 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 ��

cholesterol absorption & synthesischolesterol absorption & synthesis

�� Reduces Reduces FFAsFFAs and improves insulin and improves insulin

sensitivitysensitivity (Br J (Br J NutrNutr. 2006;96: 469. 2006;96: 469--75)75)

�� Improves endothelial function and Improves endothelial function and

inflammatory markersinflammatory markers ((Am J Am J ClinClin NutrNutr.. 2003 2003

Jul;78(1):123Jul;78(1):123--30; Diabetes Care. 2007 Apr;30(4):96730; Diabetes Care. 2007 Apr;30(4):967--73)73)

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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

plentiful fiber, favoring cold water, plentiful fiber, favoring cold water,

fatty fish, fatty fish, lean grass fed meatlean grass fed meat and and

some soy protein, with minimal, some soy protein, with minimal,

regular alcohol consumption (1/2 regular alcohol consumption (1/2

glass of red wine daily)glass of red wine daily)

Modify based on clinical history

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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))

JAMA. 2008 Sep 17;300(11):1303-10. Epub 2008 Sep 16

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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

�� 20:1 imbalance W6:W3 fatty acids20:1 imbalance W6:W3 fatty acids

�� 55--10 % calories from 10 % calories from trans fatstrans fats

�� GrainGrain--fed & fattened cows, pigs, chickens fed & fattened cows, pigs, chickens --and stable, and stable, (perhaps slightly lower %) saturated fat consumption(perhaps slightly lower %) saturated fat consumption

�� Progressive increase in calories to 3700/capita in 1990s Progressive increase in calories to 3700/capita in 1990s (fast food , meal super(fast food , meal super--sizing & nocturnal 24/7 eating)sizing & nocturnal 24/7 eating)

�� Lack of Variety in Food SupplyLack of Variety in Food Supply

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““Modern NutritionModern Nutrition”” and Ocular and Ocular DiseaseDisease

�� Excess Carbohydrates & Low MicronutrientsExcess Carbohydrates & Low Micronutrients

•• Obesity and increased risk of CVD, HTN and +/Obesity and increased risk of CVD, HTN and +/-- CANCERCANCER

•• Obesity and increased risk of AMD & CATARACT Obesity and increased risk of AMD & CATARACT

•• Obesity, Diabetes and increased risk of RETINOPATHYObesity, Diabetes and increased risk of RETINOPATHY

•• Obesity and increased inflammationObesity and increased inflammation

�� Insufficient NutritionInsufficient Nutrition

•• induced by average plant food consumption of only 3 induced by average plant food consumption of only 3 servings/dayservings/day

•• induced by individual pharmaceuticals & induced by individual pharmaceuticals & polypharmacypolypharmacy

•• induced by an RDA for ascorbic acid that is too lowinduced by an RDA for ascorbic acid that is too low

•• induced by recommendations to avoid fish induced by recommendations to avoid fish –– omega IIIomega III

•• induced by recommendations to avoid sunlight induced by recommendations to avoid sunlight –– vitamin Dvitamin D

•• Induced by mixed message Induced by mixed message ““nutrinutri phobiaphobia””

�� MalMal--nutritionnutrition

---- TRANS fats from soy oilsTRANS fats from soy oils

---- high fructose corn syruphigh fructose corn syrup

---- aspartameaspartame

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US Public Health & Primary US Public Health & Primary PreventionPrevention

�� 90 % of Americans will develop HTN 90 % of Americans will develop HTN

80 % of CVD in western culture is a 80 % of CVD in western culture is a

direct consequence of diet & lifestyle.direct consequence of diet & lifestyle.

�� 70 % of Americans are 70 % of Americans are

overweight or obese. overweight or obese.

�� 36 % of Americans have diabetes 36 % of Americans have diabetes

or preor pre--diabetes.diabetes.

�� CVD disease kills almost half of us.CVD disease kills almost half of us.

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Alzheimer's in AmericaAlzheimer's in America

�� 72.8 years average age of onset (1 72.8 years average age of onset (1

study).study).

�� AlzheimerAlzheimer’’s affects 1 in 10 people s affects 1 in 10 people

over age 65, the rate is closer to over age 65, the rate is closer to 50 % 50 %

for Americans over age 85. for Americans over age 85.

�� 66--8 % develop symptoms before age 8 % develop symptoms before age

65 (~300,000 people). 65 (~300,000 people).

�� Few people experience symptoms Few people experience symptoms

between ages 30 and 40.between ages 30 and 40.

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Is ALZ Type 3 Diabetes ?Is ALZ Type 3 Diabetes ?WeiWei--QuinQuin Zhao et al, Zhao et al, AmyloidAmyloid beta beta oligomersoligomers

induce impairment of neuronal insulin receptors, induce impairment of neuronal insulin receptors, FASEB, 24 Aug 2007.FASEB, 24 Aug 2007.

1.1. AmyloidAmyloid beta diffusible beta diffusible ligandligand(ADDL) initiates deterioration of (ADDL) initiates deterioration of dendrite synapse function, dendrite synapse function, composition & structurecomposition & structure

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

�� Promote ExercisePromote Exercise

�� Promote Dietary KnowledgePromote Dietary Knowledge

••2005 USDA Food Triangle2005 USDA Food Triangle

�� Rx Comprehensive MultivitaminsRx Comprehensive Multivitamins

••Omega fatty AcidsOmega fatty Acids

�� Rx Targeted antioxidantsRx Targeted antioxidants

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3 EXERCISE GOALS3 EXERCISE GOALS

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

congestive heart failure)congestive heart failure)

1.1. Premature sudden death Premature sudden death -- 4x the MI risk4x the MI risk

2.2. Irregular heart beatsIrregular heart beats

3.3. Failure to nourish heartFailure to nourish heart

4.4. Difficulty with BP and cholesterol controlDifficulty with BP and cholesterol control

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Cafeteria Food Fight Cafeteria Food Fight ““ 77--eleven with bookseleven with books ”” ??

Vending machines Vending machines

43 % of elementary schools43 % of elementary schools

74 % of middle schools74 % of middle schools

* nearly all high schools* nearly all high schools

•• National School Lunch Program National School Lunch Program –– 27 27 million meals/daymillion meals/day

•• $ 2.09 meal subsidy (break even)$ 2.09 meal subsidy (break even)

•• 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)

•• Exercise promotes SIRT1Exercise promotes SIRT1 (Rejuvenation Res. (Rejuvenation Res. 2007)2007)

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CA

LOR

IC

RE

ST

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N

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ISE


AD

A

2005 ADA Scientific Session

Courtesy of Steven Freed, RPh, CDE


Okinawa Centenarian StudyOkinawa Centenarian StudyNIH/ Japan Ministry of HealthNIH/ Japan Ministry of Health

M M SukukiSukuki, MD, PhD Principal Investigator, MD, PhD Principal InvestigatorB Wilcox, MD, B Wilcox, MD, MScMSc CoCo--PIPI

D Wilcox, PhD, D Wilcox, PhD, MHScMHSc CoCo--PIPI

Key Findings of this 28 year diet studyKey Findings of this 28 year diet study

1) Lifestyle trumps genes1) Lifestyle trumps genes

2) Energy Balance is crucial for healthy 2) Energy Balance is crucial for healthy

weightweight

3) Macronutrient balance is key to healthy 3) Macronutrient balance is key to healthy

weight maintenance and lossweight maintenance and loss

4) Biomarkers show health benefits4) Biomarkers show health benefits

5) Fights stress and inflammation5) Fights stress and inflammation

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The Diabetes Prevention The Diabetes Prevention ProgramProgram

A Randomized A Randomized Clinical TrialClinical Trial

to Prevent Type to Prevent Type 2 Diabetes2 Diabetesin Persons at in Persons at High Risk High Risk

�� Northwestern Northwestern UnivUniv School of School of MedicineMedicine

�� Massachusetts General Massachusetts General HospitalHospital

�� UnivUniv of California, San Diegoof California, San Diego

�� St St LukesLukes--RosseveltRossevelt HospitalHospital

�� Indiana Indiana UnivUniv School of School of MedicineMedicine

�� MedstarMedstar Clinical Research Clinical Research CenterCenter

�� Washington Washington UnivUniv ScoolScool of of MedicineMedicine

�� John Hopkins UniversityJohn Hopkins University

�� University of New Mexico University of New Mexico School of MedicineSchool of MedicineNEJM 346:393-403, 2002

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-8

-6

-4

-2

0

0 1 2 3 4

Years from Randomization

Weig

ht

Ch

an

ge (

kg

) Placebo

Metformin

Lifestyle

Mean Weight ChangeMean Weight Change

The DPP Research Group, NEJM 346:393-403, 2002

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0 1 2 3 4

0

10

20

30

40Placebo (n=1082)Metformin (n=1073, p<0.001 vs. Plac)Lifestyle (n=1079, p<0.001 vs. Met , p<0.001 vs. Plac )

Percent developing diabetes

All participants

All participants

Years from randomization

Cum

ulat

ive

inci

denc

e (%

)

Placebo (n=1082)

Metformin (n=1073, p<0.001 vs. Placebo )Lifestyle (n=1079, p<0.001 vs. Metformin ,

p<0.001 vs. Placebo )

Incidence of Diabetes Incidence of Diabetes

Risk reductionRisk reduction31% by metformin31% by metformin58% by lifestyle58% by lifestyle


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Mean Change in Fasting Plasma Mean Change in Fasting Plasma GlucoseGlucose

100

105

110

115

0 1 2 3 4


FP

G (

mg

/dl)

Placebo

MetforminLifestyle


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Mean Change in HbAMean Change in HbA1c1c

5.8

5.9

6.0

6.1

0 1 2 3 4


H

bA

1c (

%)

Placebo

MetforminLifestyle


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Loren Loren CordaineCordaine, PhD, PhD

1.1. GlycemicGlycemic loadload2.2. Fatty acid Fatty acid compositioncomposition

3.3. Macronutrient Macronutrient compositioncomposition

4.4. Micronutrient Micronutrient densitydensity

5.5. AcidAcid--base base balancebalance

6.6. SodiumSodium--potassium ratiopotassium ratio

7.7. Fiber contentFiber content

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Chronic pancreatic Chronic pancreatic HyperHyper--insulinemiainsulinemia

(The last 180 years)(The last 180 years)

�� Increased StatureIncreased Stature

�� Decreased age of MenarcheDecreased age of Menarche

�� Acne Acne

�� PolyscysticPolyscystic Ovary SyndromeOvary Syndrome

�� Epithelial Cancers (breast, colon, lung, prostate) Epithelial Cancers (breast, colon, lung, prostate) via via ↑↑ hepatic IGFhepatic IGF--1 & 1 & ↓↓ hepatic IGFBPhepatic IGFBP--11

�� Skin tagsSkin tags

�� AcanthosisAcanthosis NigricansNigricans

�� Male Vertex BaldingMale Vertex Balding

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AG

ING

ST

AR

T W

ITH

A G

OO

D D

IET


Foods Deficient in the Foods Deficient in the Standard American Diet (SAD)Standard American Diet (SAD)

�� FruitsFruits

�� VegetablesVegetables

�� FishFish

�� Whole GrainsWhole Grains

�� LegumesLegumes

�� Nuts & SeedsNuts & Seeds

Percentage of Individuals Not Consuming the Recommended number of Pyramid Servings Per Day

63%58%

73%

84%

72%

35%40%

72% 73%

37%

48%

55%

72% 73%

59%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Grain Vegetables Fruit Dairy Meat

Female 20+ Males 20+ All Individuals 2+

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Anatomy of Anatomy of www.MyPyramid.govwww.MyPyramid.gov2005 for Americans (over age 2)2005 for Americans (over age 2)

OOne Size Doesnne Size Doesn ’’ t Fit Allt Fit All

�� ActivityActivity

�� ModerationModeration

�� PersonalizationPersonalization

�� ProportionalityProportionality

�� VarietyVariety

�� Gradual ImprovementGradual Improvement

Age ; Gender ; Activity; 12 tailored diet plans

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USDA /HHS USDA /HHS Key RecommendationsKey Recommendations

�� EAT FEWER EAT FEWER

CALORIESCALORIES

�� BE MORE ACTIVEBE MORE ACTIVE

�� WISER FOOD WISER FOOD

CHOICESCHOICES

�� * compatible with * compatible with

DASHDASH

((DDietary ietary AApproaches to pproaches to

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.

�� 4 4 HLCsHLCs (Healthy Lifestyle Characteristics)(Healthy Lifestyle Characteristics)

�� 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"

RDA = Recommended Daily AllowanceRDA = Recommended Daily Allowance--””prevent 97% of deficienciesprevent 97% of deficiencies””RDI = Recommended Dietary IntakeRDI = Recommended Dietary Intake

* J Pharmacol Exp Ther. 2005 Apr 15; [Epub ahead of print]

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Wha

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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

•• QuercetinQuercetin –– prevents prevents sorbitolsorbitol BV damageBV damage

•• Bilberry (160Bilberry (160--320 mg 25% 320 mg 25% stndstnd xtractxtract))

•• GenisteinGenistein ––multiple MOAmultiple MOA

•• Ginkgo Ginkgo BilobaBiloba –– BV healthBV health

�� CarotenoidsCarotenoids i.e. i.e. LuteinLutein (6(6--20 mg) 20 mg)

•• Protects Eye & Cardiovascular Protects Eye & Cardiovascular BVsBVs

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Additional SupplementsAdditional Supplements�� B Vitamin ComplexB Vitamin Complex

•• B1 Thiamin B1 Thiamin –– better carbohydrate metabolismbetter carbohydrate metabolism

•• B3 Niacin B3 Niacin –– improves HDL statusimproves HDL status

•• B6 B6 Pyridoxine(sPyridoxine(s) ) –– better protein metabolismbetter protein metabolism

•• Folic acid Folic acid –– healing; healing; ↓↓homocysteinehomocysteine

•• B12 B12 MethylcarbolamineMethylcarbolamine –– for nerve cell functionfor nerve cell function

�� Biotin Biotin –– better fatty acid metabolismbetter fatty acid metabolism

�� Zn/Cu & manganese Zn/Cu & manganese –– better immune system & better immune system & healing response healing response

�� VanadylVanadyl Sulfate Sulfate –– better glucose tolerancebetter glucose tolerance

�� Selenium Selenium –– ““insulin mimicinsulin mimic””

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Andrew Weil, MD top 4 Andrew Weil, MD top 4 GTF (GTF (glucose tolerance factorglucose tolerance factor) chromium () chromium (picolinatepicolinate))

200 mcg 200 mcg –– 1000mcg / day1000mcg / day

Helps insulin transport glucose into cellsHelps insulin transport glucose into cells

Alpha Alpha LipoicLipoic Acid Acid –– 600 600 –– 1200 mg1200 mg

Helps insulin transport glucose into cellsHelps insulin transport glucose into cells

Inhibits Inhibits glycosylatedglycosylated attachment of sugar to proteinattachment of sugar to protein

Maintains eye and nerve health (Maintains eye and nerve health (↓↓peripheral neuropathy)peripheral neuropathy)

Also AcetylAlso Acetyl--LL--CarnosineCarnosine (2 recent studies)(2 recent studies)-- 500 & 500 & 1000mg1000mg

Magnesium (citrate or Magnesium (citrate or tauratetaurate) ) –– 400mg400mg

Insulin productionInsulin production

COQ10COQ10-- 100 mg100 mg

Maintains cardiac functionMaintains cardiac function

Protects against high dose Protects against high dose statinsstatins, AMD & Parkinson, AMD & Parkinson’’s s DzDz

31% drop in blood sugar in 1 study31% drop in blood sugar in 1 study

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Diabetes and Diabetes and ↑↑CVDzCVDz�� ↑↑ CVDzCVDz 2 2 -- 5X over general population5X over general population

�� 55 % prevalence rate among adults55 % prevalence rate among adults

•• Compared with 2 Compared with 2 --4% of the general 4% of the general

populationpopulation

�� 75 % of all deaths from DM I and DM II75 % of all deaths from DM I and DM II

�� 35 % die from 35 % die from CVDzCVDz before age 55before age 55

�� ““Hyperglycemia is a necessary but not Hyperglycemia is a necessary but not

sufficient condition for the development of sufficient condition for the development of

diabetic vascular diseasediabetic vascular disease””

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

�� Vitamin C/E and lysineVitamin C/E and lysine

�� BioflavanoidsBioflavanoids

•• 4 ounces frozen berries / day4 ounces frozen berries / day

•• 2 ounces pomegranate juice / day2 ounces pomegranate juice / day

�� B VitaminsB Vitamins

�� MagnesiumMagnesium

�� Omega III and Omega III and FlaxSeedFlaxSeed (omega III & IP6)(omega III & IP6)�� Rice Bran: Rice Bran:

•• IP6 CA++ & Fe++ chelating agentsIP6 CA++ & Fe++ chelating agents

�� Vitamin D and KVitamin D and K

�� ArginineArginine

�� CondrointinCondrointin SulfateSulfate�� ResveratrolResveratrol

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Vita

min

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& E

toge

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–

Pro

tect

ive

Syn

ergy

aga

inst

Ath

eros

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Supportive Synergy of Vitamin C & E Supportive Synergy of Vitamin C & E Randomized Control TrialsRandomized Control Trials

The Antioxidant Supplementation in Atherosclerosis The Antioxidant Supplementation in Atherosclerosis

Prevention (ASAP) StudyPrevention (ASAP) Study

VitsVits. C & E: 500 mg; 182 mg. C & E: 500 mg; 182 mg

Harvard Intravascular Harvard Intravascular UltrasonographyUltrasonography (IVUS) Study(IVUS) Study


HDLHDL--Atherosclerosis Treatment Study (HATS) Atherosclerosis Treatment Study (HATS)


*Multi*Multi--Vitamins and Vitamins and ProbucolProbucol (MVP) Study(MVP) Study

RestenosisRestenosis s/p balloon angioplasty; s/p balloon angioplasty; VitVit C, E, C, E,

& & ββ--carotenecarotene-- 500 mg, 700 IU (637 mg), 30000 IU500 mg, 700 IU (637 mg), 30000 IU

*Heart Protection Study*Heart Protection Study

Mortality; Mortality; VitVit C, E & C, E & ββ--carotenecarotene-- 250 mg, 600 250 mg, 600

mg, 20 mgmg, 20 mg

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Veterinarians know “Cavies should receive between 25-50mg of vitamin C daily” Fresh fruits and vegetables high in vitamin C are a great source

1 kg guinea pig

70 kg human equivalent is 1,750 mg to 3,500 mg / day

Maybe that’s why we need those 13 portions of fruits and vegetables

per day, The average American consumes only 3 portions.

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Simplify thru Rx of Comprehensive Simplify thru Rx of Comprehensive Multivitamin / Multivitamin /

(Ocular) Multi(Ocular) Multi --Mineral SupplementsMineral Supplements

•• www.PurityProducts.comwww.PurityProducts.com ““Perfect Perfect MultiGreensMultiGreens FormulaFormula””

••11--800800--281281--77817781

•• www. www. MedOp.comMedOp.com ““Whole Body FormulaWhole Body Formula””

••11--800800--358358--77977797

•• www. www. Lef.comLef.com ““Two per dayTwo per day”” ––superior to superior to CentrumCentrum®®

••11--800800--544544--44404440

•• www.drwhitaker.comwww.drwhitaker.com –– ““ForwardPlusForwardPlus””

••11--800800--722722--80088008

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Mul

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betic

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mal

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DO YOU ASK YOUR PATIENTS IF DO YOU ASK YOUR PATIENTS IF THEY CONSUME FISH / FISH OIL ???THEY CONSUME FISH / FISH OIL ???

�� ↑↑ HDLHDL�� ↓↓ triglyceridestriglycerides�� ↓↓ Blood pressureBlood pressure�� ↓↓ Heart Beat rateHeart Beat rate�� ↓↓ arrhythmias arrhythmias

•• (studies show as effective as a pacemaker)(studies show as effective as a pacemaker)•• ↓↓ sudden death heart attacksudden death heart attack

↓↓ Violent Behavior; Violent Behavior; ↑↑ MoodMood

↑↑ Cognitive functionCognitive function

�� ↓↓ MI, CVA, CA & AMDMI, CVA, CA & AMD

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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Imag

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AA

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UT

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↑↑ Comprehensive Multivitamin Comprehensive Multivitamin Dose w AgeDose w Age

(or extent of health challenge)(or extent of health challenge)

0

0.5

1

1.5

2

2.5

3

3.5

4

Age 20 Age 40 Age 60 Age 80

# Capsules

SERIAL INTAKE IF POSSIBLE

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A90

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Fiscal & Fiscal & Nutritional CostNutritional Cost of of PharmaceuticalsPharmaceuticals

DRUGSDRUGS

�� 2001: $120 Billion2001: $120 Billion

�� 2006: $200 Billion 2006: $200 Billion

�� 2008 $300 Billion 2008 $300 Billion estimateestimate

AVERAGE age 65 y/oAVERAGE age 65 y/o

�� 4 medications4 medications

�� 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

Obesity / DiabetesObesity / Diabetes

�� FiberFiber

�� Resveratrol/QuercetinResveratrol/Quercetin

••red wine red wine

�� BenfotiamineBenfotiamine

�� LipoicLipoic acid acid

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Oxidative Stress & DiabetesOxidative Stress & DiabetesCausesCauses

�� HyperglycemiaHyperglycemia

�� HyperleptinemiaHyperleptinemia

�� ↑↑ tissue lipidstissue lipids

�� ↑↑ AGEsAGEs

�� ↑↑ protein protein kinasekinase CC

�� ↓↓ antioxidant defensesantioxidant defenses

�� ↑↑ free radical formationfree radical formation

�� Chronic inflammationChronic inflammation

EffectsEffects

1.1. Cellular Insulin Cellular Insulin ResistanceResistance

2.2. Pancreatic Beta Pancreatic Beta Cell DysfunctionCell Dysfunction

3.3. Accelerated Accelerated arterioarterio--sclerosis & sclerosis & arteriolarsclerosisarteriolarsclerosis

4.4. NeuropathyNeuropathy

5.5. RetinopathyRetinopathy

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

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Fiber Supplement Fiber Supplement Benefits: Benefits:

�� Controls & balances blood sugar Controls & balances blood sugar

levelslevels

�� Lowers Lowers glycemicglycemic index of meals by index of meals by

up to 50%up to 50%

�� Supports healthy weight loss Supports healthy weight loss

�� Promotes satiety & Promotes satiety & ↓↓ food cravingsfood cravings�� ↓↓ total and LDL total and LDL cholesteraolcholesteraol

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SteviaStevia ®® for diabetics ?for diabetics ?Better than aspartame Better than aspartame

A no calorie herbal natural sweetenerA no calorie herbal natural sweetener

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Oral Medications to Treat Type 2 Oral Medications to Treat Type 2 DiabetesDiabetes

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Combination Therapy for Type 2 Diabetes

Combination Therapy Combination Therapy for Type 2 Diabetesfor Type 2 Diabetes

BiguanidesBiguanides

InsulinInsulin

SulfonylureasSulfonylureas

Alpha-glucosidaseInhibitors

Alpha-glucosidaseInhibitors

MeglitinideMeglitinide ThiazolidinedionesThiazolidinediones

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““Diabetes Defeated Diabetes Defeated ®”®”7 Herbal Formula7 Herbal Formula((GlucatorGlucator v.2 to v.2 to ↑↑ sugar metabolism)sugar metabolism)

�� HSI.COM Panelist Jon Barron HSI.COM Panelist Jon Barron

�� Reviewed 44 herbs used in 2500 Reviewed 44 herbs used in 2500 y/oy/o AyurvedicAyurvedic Medicine Medicine

1.1. FenugreekFenugreek –– ↑↑ pancreatic fn & pancreatic fn & ↓↓ 54% urine BS54% urine BS

2.2. GymnemaGymnema SylvestaSylvesta –– ↓↓ BSBS craving and craving and increase pancreatic regeneration.increase pancreatic regeneration.

3.3. KonjacKonjac ManninMannin –– 52% 52% ↓↓ BSBS

4.4. NopalNopal CactusCactus (prickly pear)(prickly pear)–– 15% 15% ↓↓ BSBS5.5. BanabaBanaba Leaf ExtractLeaf Extract: : ↓↓BS by 30%BS by 30%6.6. Bitter MelonBitter Melon: 3 components acting on BS: 3 components acting on BS

7.7. CinnulinCinnulin PFPF: : ↑↑ insulin receptivityinsulin receptivity

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Phase 1 Clinical Trial Phase 1 Clinical Trial of 7 Herbal Formula in patients of 7 Herbal Formula in patients

with T2DMwith T2DM�� ↓↓ BS by 54.4 ptsBS by 54.4 pts

�� ↑↑ 52% in BS utilization & optimization52% in BS utilization & optimization

�� ↓↓ carbohydrate metabolismcarbohydrate metabolism

�� 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

of diabetesof diabetes

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Increasing Insulin SensitivityIncreasing Insulin Sensitivity

�� PharmacologicPharmacologic•• TZD (TZD (ActosActos, , AvandiaAvandia) AKA ) AKA glitizonesglitizones

�� Environmental Environmental •• Decreasing iron overloadDecreasing iron overload

•• Decreasing HFCSDecreasing HFCS

•• Decreasing visceral fat (i.e. FFA)Decreasing visceral fat (i.e. FFA)�� Exercise to decrease VATExercise to decrease VAT

�� PolyphenolsPolyphenols

•• Decreasing glucose stormDecreasing glucose storm

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↓↓IInsulin Resistancensulin Resistancecourtesy Bill courtesy Bill SardiSardi

�� IP6 IP6 phytatephytate**

�� ResveratrolResveratrol

�� QuercetinQuercetin

�� TaurineTaurine

*Rice bran, *Rice bran, chiachia seed powder or flaxseed meal seed powder or flaxseed meal --all contain all contain phytatephytate

Iron overload = > increased ferritin = > inflammatio n = insulin resistance = > hunger = >caloric intake = obesity

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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

i.e. i.e. nephropathynephropathy

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www.diabetesincontrol.comwww.diabetesincontrol.com

�� ““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

Inflammation promotes oxidative Inflammation promotes oxidative stressstress

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16 Ways to 16 Ways to Decrease Inflammation: Steve Pratt, MDDecrease Inflammation: Steve Pratt, MD

1.1. Ave 7Ave 7--8 8 qualityquality hrs sleep/nighthrs sleep/night

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

5.5. Adequate quantities dietary fiberAdequate quantities dietary fiber

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

10.10. Fasting blood sugar 75 mg/Fasting blood sugar 75 mg/dLdL

11.11. 2 Tbsp extra2 Tbsp extra--virgin cold pressed olive oil most virgin cold pressed olive oil most

daysdays

12.12. High High carotenoidcarotenoid dietdiet

13.13. Spice it upSpice it up

14.14. PrebioticsPrebiotics / / probioticsprobiotics

15.15. Fruits & veggies Fruits & veggies –– ““unlimitedunlimited””

16.16. Dark chocolate Dark chocolate

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CommunicationCommunication

�� 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

•Targeted Antioxidants•Targeted micronutrients• Anti-inflammatory Diet

•Caloric restriction•Exercise•Pharmacotherapy

•Sibutramine, Orlistat, rimonabant

•Bariatric Surgery

TURN OFF the FAUCET

MOP UP the FLOOR

BAIL the BATH/Pull the Plug

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A Society Whose Time Has A Society Whose Time Has

ComeCome

www.optometricnutritionsocietywww.optometricnutritionsociety

.org.org

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Obesity Diabetes and Complications[1]

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Transcript of Obesity Diabetes and Complications[1]