The Role of Nutrition in the The Role of Nutrition in the Treatment of Chronic DiseaseTreatment of Chronic Disease

Norman Hord, PhD, MPH, RDNorman Hord, PhD, MPH, RDDepartment of Food Science and Human NutritionDepartment of Food Science and Human Nutrition

http://www.msu.edu/course/hnf/470http://www.msu.edu/course/hnf/470

OutlineOutline

Diet-Related Chronic Disease Risk Efficacy of Dietary Treatment of Chronic

Diseases Nutrients as Medicine Food As Social Currency

Introduction 1Introduction 1 The rise in the number and proportion of older

people has led to concern about societal consequences.

We associate age with: Increasing Loss of independence disability Functional impairments •Loss of mobility •Loss of sight •Loss of hearing

Introduction 2Introduction 2

Maximum life expectancy has not changed much; AVERAGE life expectancy HAS.

Major challenge: How can we maintain health and quality of life in an aging population?

The Framingham Heart StudyThe Framingham Heart Study

Risk Factors for CHD:Risk Factors for CHD:The Framingham Heart StudyThe Framingham Heart Study

Major Risk FactorsMajor Risk Factors “Important” Risk Factors“Important” Risk Factors

Cigarette SmokingCigarette Smoking Obesity*Obesity*Hypertension*Hypertension* Physical InactivityPhysical InactivityHigh Total Serum Cholesterol*High Total Serum Cholesterol* Family Hx of Premature CHDFamily Hx of Premature CHDLow HDL Cholesterol*Low HDL Cholesterol* Hypertriglyceridemia*Hypertriglyceridemia*Diabetes Mellitus*Diabetes Mellitus* Increased Lipoprotein [a]Increased Lipoprotein [a]

Increased serum homocysteine*Increased serum homocysteine*Abnormal levels of variousAbnormal levels of various

coagulation factorscoagulation factors

*Dietary factors contribute strongly to the control of or in the etiology*Dietary factors contribute strongly to the control of or in the etiology of these risk factors.of these risk factors.

Medical Nutrition Therapy has been integratedMedical Nutrition Therapy has been integratedinto the treatment guidelines for a number of into the treatment guidelines for a number of diseases, including:diseases, including:

•• Cardiovascular DiseasesCardiovascular Diseases•• Diabetes MellitusDiabetes Mellitus•• HypertensionHypertension•• ObesityObesity

Noncompliance with prescribed MNTNoncompliance with prescribed MNTand lifestyle changes:and lifestyle changes:

Negatively affect patient response to pharmacotherapy

May necessitate more intensive pharmacotherapy to achieve desired effect.

Diet Therapy and Risk Factor Diet Therapy and Risk Factor StratificationStratification

Dietary treatment strategies are Dietary treatment strategies are recommended by the National Institutes of recommended by the National Institutes of Health as the cornerstone for the treatment Health as the cornerstone for the treatment of all patients with:of all patients with:

• Cardiovascular Disease• Hypertension• Diabetes Mellitus• Obesity

Diet-Related Risk Factors for CHD

High LDL Cholesterol High LDL Cholesterol

Begin treatmentBegin treatment LDL CholesterolLDL Cholesterol (mg/dl)(mg/dl)

With CHD:With CHD: >100 >100Without CHD + one risk factor:Without CHD + one risk factor: >160 >160 Without CHD + > 2 risk factors:Without CHD + > 2 risk factors: >130 >130

Low HDL CholesterolLow HDL Cholesterol

HypertensionHypertension

Diabetes MellitusDiabetes Mellitus

Blood Lipid FractionBlood Lipid Fraction Desirable Borderline HighDesirable Borderline High

LDL Cholesterol (mg/dl)LDL Cholesterol (mg/dl) <130 <130 130-159 >160 130-159 >160

Total Cholesterol (mg/dl)Total Cholesterol (mg/dl) <200 <200 200-239 >240 200-239 >240

Triglycerides (Fasting; mg/dl) <200Triglycerides (Fasting; mg/dl) <200 200-400 200-400 >400 >400

HDL Cholesterol= “Low” (Bad) if 35 mg/dlHDL Cholesterol= “Low” (Bad) if 35 mg/dl

LDL:HDL ratio: > 5 indicates risk for menLDL:HDL ratio: > 5 indicates risk for men >4.5 indicates risk for women>4.5 indicates risk for women

Role of Diet in the Modification of Blood Cholesterol LevelsRole of Diet in the Modification of Blood Cholesterol Levels

Assumptions:Assumptions:

• • Blood cholesterol [ ] is an important and modifiable risk factorBlood cholesterol [ ] is an important and modifiable risk factor for coronary heart disease. for coronary heart disease.

• • Sustained reduction of total cholesterol [ ] of 1% is associatedSustained reduction of total cholesterol [ ] of 1% is associated with a 2-3% reduction in the incidence of coronary heart with a 2-3% reduction in the incidence of coronary heart disease.disease.

Role of Diet in the Modification of Blood Cholesterol Levels-3

Tang et al. (1998) BMJ 316: 1213-1220Systematic review of dietary intervention trials to lower blood total cholesterol in free-living subjects.

Efficacy of Dietary Intervention Trials to Lower Total Cholesterol

Diet Types % Reduction inTotal Cholesterol

AHA Step 2

Lower Total Fat 6.0

Raise PUFA:SFA Ratio

AHA Step 1 3.0

Role of Diet in the Modification of Blood Cholesterol Levels-2

Chief Determinants of Blood Cholesterol Levels

1. Certain saturated fatty acids cause a linear increasein low-density lipoprotein (LDL) cholesterol concentration.(Total SFA in U.S. Diet: 11-12 % of total energy)

2. Trans unsaturated fatty acids increase LDL cholesterol[ ]; not quite as atherogenic as certain SFA.(Total trans FA in U.S. Diet: ~ 3 % of total energy)

3. Polyunsaturated fatty acids derived from plant oils doNOT raise LDL cholesterol [ ].(Total PUFA in U.S. Diet: ~ 6 % of total energy)

4. Monounsaturated fatty acids derived from high oleic acid(cis-18:1) oils (e.g., olive, peanut, canola) do NOT raiseLDL cholesterol [ ].

Diabetes Mellitus (“passing through (the body)”; “honey sweet”)

Definition: a metabolic disorder characterizedby altered blood glucose regulationand utilization, usually caused byinsufficient or relatively ineffectiveinsulin.

Long-term hyperglycemia Cardiovascular Disease Microangiopathies

(Loss of kidney fxn; retinal degeneration)Neuropathy (may lead to gangrene; loss of feet or legs)

Goals for Control (not diagnosis!)

Fasting BG and before meals 80-120 mg/dl

One hour after meals <180 mg/dl

2 hours after meals <160 mg/dl

Bedtime 100-140 mg/dl

Hemoglobin A1c < 7 %

TAKE ACTION LEVELS 140 mg/dl / 8 or >%

Diet, Lifestyle and Diabetes

Key components in management:

Weight lossWeight loss

Diet adjustments to attenuate the Diet adjustments to attenuate the rise in blood glucose.rise in blood glucose.

Trial Participants:Trial Participants: 459 adults of which 133 had stage I HTN459 adults of which 133 had stage I HTN (B.P. 140-159/90-99)(B.P. 140-159/90-99)

49% women; 60% African-American49% women; 60% African-American

Acclimation Diet:Acclimation Diet: Low fruits (F), vegetables (V), dairy productsLow fruits (F), vegetables (V), dairy products~40% fat for 3 weeks~40% fat for 3 weeks

The Diets:The Diets: 1.1. Control Diet: average for fat, F&V consumptionControl Diet: average for fat, F&V consumption2.2. 8-10 servings of F&V, ~35+% fat8-10 servings of F&V, ~35+% fat3.3. Low-fat (<30% kcal), 8-10 servings of F&V,Low-fat (<30% kcal), 8-10 servings of F&V,

Rich in low-fat dairy foods.Rich in low-fat dairy foods.Duration:Duration: 8 weeks8 weeks

New Engl J Med (1997) 336: 1117-1124New Engl J Med (1997) 336: 1117-1124

Source: http://dash.bwh.harvard.edu/

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DASH CommentsDASH Comments

B.P. reductions occurred quickly (2 B.P. reductions occurred quickly (2 weeks) and were maintained throughout the weeks) and were maintained throughout the study.study.

Investigators estimated that incidence of Investigators estimated that incidence of CHD and strokes in U.S. could be reduced CHD and strokes in U.S. could be reduced by by 15%15% and and 27%,27%, respectively, if DASH diet respectively, if DASH diet were followed.were followed.

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The Obesity EpidemicThe Obesity Epidemic U.S.: 20% of men & 25% of women are obese.

97 million Americans are overweight or obese. (59.4% of men and 51% of women)

>10% of 4-5 year old children are obese.– ~2-fold increase over preceding decade

These increases have occurred despite successes in reducingThese increases have occurred despite successes in reducingdietary fat as % of kcal.dietary fat as % of kcal.

Source: NCHS, National Health and Nutrition Examination Survey,1997

Trends in Age-Adjusted Prevalence of Overweight in U.S.

05

10152025303540

1960-62

1971-74

1976-80

1988-91

Years

MenWomenGoal

Kuczmarski et al. National Health and Nutrition Examination Surveys, MMWR; 43: 818-821,1994.

Consequences of Modest Weight Consequences of Modest Weight GainGain

10% increase in weight results in:

Fasting Blood Glucose of 2-3 mg/dL

Systolic Blood Pressure of 6-7 mm Hg

Conditions Associated With Obesity (Relative Risk)

Obesity

Diabetes Mellitus Gall Bladder Disease Sleep Apnea (Type II) (RR>>3) (RR>>3) (RR>>3)

Stroke Hypertension(RR= 2-3) (RR>>3)

Coronary Heart Disease Gout Osteoarthritis (RR= 2-3) (RR=2-3) (RR=2-3)

Benefits of Modest Weight LossBenefits of Modest Weight Loss Normalizes high blood pressure Blood levels

LDL cholesterolInsulinGlycated hemoglobin (HbA1C)Blood glucoseUric acid

HDL Cholesterol Improved Quality of Life

Food as Social CurrencyFood as Social Currency Current interest in dietary factors centers on

nutrients or food components likely to decrease disease risk.

These beliefs betray the important social and psychological role food plays in most people’s lives.

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People eat food, notPeople eat food, notisolated nutrients.isolated nutrients.

Diets are made Diets are made of foods which of foods which are more than are more than mere collections mere collections of nutrients. of nutrients.

All the biological functions of food components All the biological functions of food components and their health effects have not been identified. and their health effects have not been identified.

If the focus is on a single nutrient, the benefits of If the focus is on a single nutrient, the benefits of the consuming these compounds in foods the consuming these compounds in foods may not may not be realized. be realized.

Why Not Focus on Just Nutrients?Why Not Focus on Just Nutrients?

Source:U.S. Department of Agriculture

Unlike Unlike nutrients, nutrients, foods and foods and diets have diets have cultural, cultural, ethnic, social ethnic, social and familyand familymeanings.meanings.

Source:Oldways Preservation & Exchange Trust

Asian Pyramid

Source:Oldways Preservation & Exchange Trust

MediterraneanPyramid

Source:Oldways Preservation & Exchange Trust

Latin AmericanPyramid

Dietary Patterns and Chronic Disease Risk Dietary Patterns and Chronic Disease Risk

• • Total diet, rather than nutrients or individualTotal diet, rather than nutrients or individualfoods, should be emphasized. foods, should be emphasized.

• • Dietary guidelines need to reflect Dietary guidelines need to reflect food food patternspatterns rather than numeric rather than numeric nutrient goals. nutrient goals.

• • Various dietary patterns can be consistent Various dietary patterns can be consistent with good health.with good health.

Evidence from animal, clinical and epidemiological Evidence from animal, clinical and epidemiological studies indicates that specific dietary patterns are studies indicates that specific dietary patterns are associated with reduced risk of specific diseases.associated with reduced risk of specific diseases.

Dietary Guidelines 2000 (ProposedDietary Guidelines 2000 (Proposed))Aim, Build, Choose--for Good HealthAim, Build, Choose--for Good Health

BBuild a Healthy Baseuild a Healthy Base

CChoose Sensiblyhoose Sensibly

AAim for Fitnessim for Fitness

Dietary Guidelines 2000 (proposed)Dietary Guidelines 2000 (proposed)

AimAim 1.1. Aim for a healthy weight.Aim for a healthy weight.2.2. Be physically active each day.Be physically active each day.

BuildBuild 3.3. Let the Pyramid guide your choices.Let the Pyramid guide your choices.4.4. Choose a variety of grains daily, Choose a variety of grains daily,

especially whole grains.especially whole grains.5.5. Choose a variety of fruits and Choose a variety of fruits and

vegetables daily.vegetables daily.6.6. Keep food safe to eat.Keep food safe to eat.

Choose SensiblyChoose Sensibly

7.7. Choose a diet that is low in saturatedChoose a diet that is low in saturatedfat and cholesterol and moderatefat and cholesterol and moderatein total fat.in total fat.

8.8. Choose beverages and foods that limitChoose beverages and foods that limityour intake of sugars.your intake of sugars.

9.9. Choose and prepare foods with lessChoose and prepare foods with lesssalt.salt.

10.10. If you drink alcoholic beverages, doIf you drink alcoholic beverages, doso in moderation.so in moderation.

Eat a variety of foods.Eat a variety of foods.

Choose most foods from plant sources.Choose most foods from plant sources.

Eat at least 5 servings of fruits and vegetables Eat at least 5 servings of fruits and vegetables every day.every day.

Eat at least 6 servings of whole grain foods Eat at least 6 servings of whole grain foods each day.each day.

Minimize the consumption of high-fat foods, especially Minimize the consumption of high-fat foods, especially those from animals.those from animals.

Choose low-fat, low-cholesterol foods.Choose low-fat, low-cholesterol foods.

Limit the amount of simple sugars in the diet.Limit the amount of simple sugars in the diet.

The Nutrition Checklist is based on the Warning The Nutrition Checklist is based on the Warning Signs described below. Use the word DETERMINE Signs described below. Use the word DETERMINE to remind you of the Warning Signs.to remind you of the Warning Signs.

DDISEASEISEASEEEATING POORLYATING POORLYTTOOTH LOSS/MOUTH PAINOOTH LOSS/MOUTH PAINEECONOMIC HARDSHIPCONOMIC HARDSHIPRREDUCED SOCIAL CONTACTEDUCED SOCIAL CONTACTMMULTIPLE MEDICINESULTIPLE MEDICINESIINVOLUNTARY WEIGHT LOSS/GAINNVOLUNTARY WEIGHT LOSS/GAINNNEEDS ASSISTANCE IN SELF CAREEEDS ASSISTANCE IN SELF CAREEELDER YEARS ABOVE AGE 80LDER YEARS ABOVE AGE 80------------------------------------------------------------------------------------------------------------------------------------------------The Nutrition Screening Initiative • 1010 Wisconsin Avenue, NW • Suite 800 • Washington, DC 20007The Nutrition Screening Initiative • 1010 Wisconsin Avenue, NW • Suite 800 • Washington, DC 20007

Interventions to improve health in later life Interventions to improve health in later life

InterventionIntervention Potential effectsPotential effects

No smoking No smoking Smoking increases risks of many cancers Smoking increases risks of many cancers including lung, stomach, larynx, including lung, stomach, larynx,

colon; cardiovascular disease andcolon; cardiovascular disease and thereby vascular dementia; respiratory thereby vascular dementia; respiratory

disease; osteoporotic fractures; disease; osteoporotic fractures; stomach ulcersstomach ulcers

DietDiet High fruit and High fruit and Protective for cardiovascular disease; Protective for cardiovascular disease; vegetable intake vegetable intake respiratory function; macular degeneration respiratory function; macular degeneration (5 or more servings (5 or more servings and cataracts; cancers including breast, and cataracts; cancers including breast, daily)daily) prostate, colorectal and stomach;prostate, colorectal and stomach; diverticular disease; diabetesdiverticular disease; diabetes

Other Dietary Strategies to Improve HealthOther Dietary Strategies to Improve Health

High complex carbohydrates, High complex carbohydrates, Protective for cardiovascular disease;Protective for cardiovascular disease; cancers including breast and colorectalcancers including breast and colorectal

Reduced saturated fat Reduced saturated fat (<15% of Kcal) and total fat (<15% of Kcal) and total fat (<35% food energy intake) (<35% food energy intake) High saturated fat intake increases High saturated fat intake increases risk of coronary heart disease; risk of coronary heart disease;

cancers including colorectal, prostate, cancers including colorectal, prostate, and breast; large bowel disease; and breast; large bowel disease;

osteoarthritisosteoarthritis

Reduced sodiumReduced sodium High sodium intake increases risk of High sodium intake increases risk of stroke, stomach cancer, osteoporosis, stroke, stomach cancer, osteoporosis, respiratory diseaserespiratory disease

Physical activityPhysical activity Protective for cardiovascular disease; Protective for cardiovascular disease;

diabetes; osteoporosis; cancers including diabetes; osteoporosis; cancers including colorectal and breast; depressioncolorectal and breast; depression

Summary pointsSummary points

Healthy life expectancy is influenced by a relatively Healthy life expectancy is influenced by a relatively limited number of chronic disabling conditions.limited number of chronic disabling conditions.

A substantial proportion of these chronic disabling A substantial proportion of these chronic disabling conditions can be prevented or postponed.conditions can be prevented or postponed.

A greater focus is needed on prevention and A greater focus is needed on prevention and health maintenance—much is already known about health maintenance—much is already known about the impact of modifiable influences such as diet, the impact of modifiable influences such as diet, physical activity, smoking, infection, pollution, physical activity, smoking, infection, pollution, and housing.and housing.