1. FirstLine Therapy TM Therapeutic Lifestyle Program

2. “Persons with lower health risks tend to live longer than those with higher health risks...” N Eng J Med 1998;338:1035-41

3. “Persons with high health risks... had twice the cumulative disability of those with low health risks.” N Eng J Med 1998;338:1035-41

4. “Not only do persons with better health habits survive longer, but in such persons, disability is postponed and compressed into fewer years at the end of life.”

6. Adult Treatment Panel III (ATP III) Guidelines National Cholesterol Education Program

7. “Everyone with elevated LDL cholesterol is treated with lifestyle changes that are effective in lowering LDL levels.”

8. “This approach is designated therapeutic lifestyle changes (TLC).”

9. “Lifestyle changes are the most cost- effective means to reduce risk for CHD.”

10. “ATP III recognizes the metabolic syndrome as a secondary target of risk-reduction therapy, after the primary target – LDL cholesterol.”

11. Metabolic Syndrome Synonyms Insulin resistance syndrome (Metabolic) Syndrome X Dysmetabolic syndrome Multiple metabolic syndrome

12. Benefit Beyond LDL Lowering: The Metabolic Syndrome as a Secondary Target of Therapy General Features of the Metabolic Syndrome Abdominal obesity Atherogenic dyslipidemia Elevated triglycerides Small LDL particles Low HDL cholesterol Raised blood pressure Insulin resistance (  glucose intolerance) Prothrombotic state Proinflammatory state

13. “First line therapies” in the Management of Metabolic Syndrome Weight reduction Increased physical activity “First line therapies” in the Management of Metabolic Syndrome Weight reduction Increased physical activity

14. Background Hypertension Type 2 diabetes Coronary heart disease Gallbladder disease Dyslipidemia Stroke Osteoarthritis Sleep apnea Certain cancers Approximately 108 million American adults are overweight or obese. Increased risk of: CDC/NCHS NHANES 1999

15. Diabetes Risk BMI Levels Incidence of New Cases per 1,000 Person-Years Knowler WC et al. Am J Epidemiol 1981;113:144-156.

16. Weight Gain and Diabetes Risk Body Mass Index at Age 21 Relative Risk Weight Change Since Age 21 Adapted from Chan JM et al. Diabetes Care 1994;17:960-969.

17. 26 -Year Incidence of Coronary Heart Disease in Men Incidence/1,000 BMI Levels Adapted from Hubert HB et al. Circulation 1983;67:968-977. Metropolitan Relative Weight of 110 is a BMI of approximately 25.

18. Hypertension BMI Percentage 2025303540 20 10 30 50 40 60 Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization. Brown WJ et al. Int J Obes 1998;22:520-528.

19. BMI Percentage 2025303540 5 10 15 25 20 Cholescystectomy Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization. Brown WJ et al. Int J Obes 1998;22:520-528.

20. BMI Percentage 2025303540 20 15 25 35 30 40 Hysterectomy Brown WJ et al. Int J Obes 1998;22:520-528. Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization.

21. BMI Percentage 2025303540 20 15 30 25 35 Back Pain Brown WJ et al. Int J Obes 1998;22:520-528. Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization.

22. BMI Percentage 2025303540 20 15 30 25 35 Constant Tiredness Brown WJ et al. Int J Obes 1998;22:520-528. Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization.

23. BMI Percentage 2025303540 15 10 20 25 30 More Than Five GP Consultations Brown WJ et al. Int J Obes 1998;22:520-528. Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization.

24. Relationship of BMI to Excess Mortality 300 Age at Issue Bray GA. Overweight is risking fate. Definition, classification, prevalence and risks. Ann NY Acad Sci 1987;499:14-28. 20-29 250 Mortality Ratio Body Mass Index (kg/[m 2 ]) 200 150 100 50 15 0 30-39 202530 Lo w Risk 4035 High Risk Moderat e Risk

26. “Weight and BMI do not evaluate body compartments and therefore do not reveal if weight changes result in loss of fat-free mass or gain in fat mass.” J Amer Diet Assoc 2002;102(7):944-955

27. “... we found that fat-free mass was lower and fat mass was higher in acutely ill and chronically ill patients than controls.” J Amer Diet Assoc 2002;102(7):944-955

28. “... no decline with age is as dramatic or potentially more significant than the decline in lean body mass. In fact, there may be no single feature of age-related decline more striking than the decline in lean body mass in affecting ambulation, mobility, energy intake, overall nutrient intake and status, independence and breathing.” J Nutr 127:990S-991S (1997)

29. Sarcopenia: “the Greek roots of the word are sarx for flesh and penia for loss.” J Nutr 127:990S-991S (1997)

30. “Sarcopenia is the backdrop against which the drama of disease is played out: a body already depleted of protein because of aging is less able to with stand the protein catabolism that comes with acute illness or inadequate protein intake.” JAMA 286(10) (2001)

31. “Muscle is the major source of protein for functions such as antibody production, wound healing, and white blood cell production during illness. If the body’s protein reserves are already depleted by sarcopenia, there is less to mobilize for illness.” JAMA 286(10) (2001)

32. Bioimpedance Analysis (BIA)

33. Women – Normal Reference Age25-3435-4445-5455-6465-7475-84 Body Fat 22.523.925.829.134.335.8 B. Cell Mass 37.136.334.531.527.725.7 Phase Angle 6.66.76.56.05.44.8

34. Men – Normal Reference Age25-3435-4445-5455-6465-7475-84 Body Fat 15.217.619.722.224.626.3 B. Cell Mass 43.541.139.636.834.131.5 Phase Angle 7.57.27.16.66.15.3

35. JAMA 286(10) (2001) “... the most important message is that sarcopenia exists in all older individuals. In the face of acute or chronic illness, maximizing muscle mass and protein stores through adequate nutritional support, aggressive physical therapy, and exercise programs becomes all the more important if muscle function and quality of life are to be preserved in the older population.”

37. Low-fat diet UltraMeal Progressive walking program Weekly group meeting Low-fat diet UltraMeal Progressive walking program Weekly group meeting J Amer Coll Nutr 1994;13(3):243-250

38. All Women: Lost Body weight 5.7 – 22 lbs Lost Fat mass2.0 – 22.9 lbs Average Fat Loss 14.1 lbs BMI declined0.55 – 3.86 kg/m 2 All Women: Lost Body weight 5.7 – 22 lbs Lost Fat mass2.0 – 22.9 lbs Average Fat Loss 14.1 lbs BMI declined0.55 – 3.86 kg/m 2 J Amer Coll Nutr 1994;13(3):243-250

39. 17 of 18 Showed: Decline in % body fat2.3 – 10.1% 12 of 18 Showed: Increase in fat free mass.2 – 7.7 lbs 17 of 18 Showed: Decline in % body fat2.3 – 10.1% 12 of 18 Showed: Increase in fat free mass.2 – 7.7 lbs J Amer Coll Nutr 1994;13(3):243-250

40. “No changes from baseline levels were found in the Pi/PCr ratio over 7 weeks... suggesting a preservation in muscle energy function over the course of the study while the subjects were losing fat mass and total body weight.” J Amer Col Nutr 1994;13(3):243-250

41. J Nutr Med 1992;3:285-93 10 week studyUltraMealOTC Total Weight Loss-11-13 Lean Body Mass+4-11 TSHNo Change+150%

42. “The difference may be due to... differential aspects of nutritional quality between the two programs.” J Nutr Med 1992;3:285-93

43. During weight loss, attention should be given to maintaining an adequate intake of vitamins and minerals. Maintenance of the recommended calcium intakes of 1,000 to 1,500 mg/day is especially important for women who may be at risk of osteoporosis. – NIH Guidelines Vitamins and Minerals

44. “The anabolic lean body mass effect noted in a majority of women, combined with the uniform improvements in fat mass, may offer new hope for health professionals and persons seeking to improve their body composition.” Int Clin Nutr Rev 1991;11(4):184-85

45. Unpublished Cholesterol Data 12 week program w/UltraMeal

46. Health Benefits of Weight Loss Decreased cardiovascular risk Decreased glucose and insulin levels Decreased blood pressure Decreased LDL and triglycerides, increased HDL Decreased severity of sleep apnea Reduced symptoms of degenerative joint disease Improved gynecological conditions

49. Am J Clin Nutr 2002;76(suppl):266S-73S “It has been postulated that obesity is related to glycemic index or glycemic load.... the lower the glycemic index and load of the first meal, the less food is consumed in the subsequent meal.”

52. Portion sizes & Eating Frequency Don’t skip meals Skipping meals leads to increased production of glucagon & gluconeogenesis resulting in muscle loss Eat frequently 3 small meals and 2-3 snacks daily To maintain stable blood sugar and insulin levels Use UltraMeal to: Achieve eating frequency goals increase quality nutrient intake while decreasing calorie intake

54. Ann NY Acad Sci 2002;957:250-59 “Insulin resistance often develops with advancing age, and may play a prominent role in the aging process...”

55. Ann NY Acad Sci 2002;957:250-59 “In summary, the current paper will encourage people to seek a better life style and use of appropriate dietary supplements, which may favorably affect life-span and reduce the incidence of advancing age-induced chronic disorders and improve deleterious symptoms of syndrome X.”

56. EPA/DHA – Omega 3 Fatty Acids You are what you eat The fat in your diet becomes part of your cell membranes Saturated fats and trans fats decrease membrane fluidity and decrease binding of insulin to cells When omega-3 fatty acids are substituted, insulin resistance may be prevented Other benefits of EPA & DHA Reduce chronic inflammation Inhibit platelet aggregation Lower triglycerides Reduce other risk factors for chronic disease

57. Med Sci sports Exerc 2001 Dec;33(12):2145-56 “It is recommended that weight loss programs target changing both eating and exercise behaviors, as sustained changes in both behaviors have been shown to result in significant long-term weight loss.”

58. Physical Activity: Why? Increases energy expenditure Protects and builds lean body mass Improves psychological factors Reduces risk of morbidity and mortality

59. Physical Activity: Effect on Health Enhances cardiorespiratory fitness Improves lipid profile – Including lower cholesterol Reduces blood pressure Increases insulin sensitivity Improves blood sugar control

60. Physical Activity Helps you feel better because it: Boosts energy Helps you cope with stress Improves self-image Increases resistance to fatigue Helps counter anxiety and depression Helps you relax and feel less tense Improves your ability to fall asleep and sleep well Provides an easy way to share time with friends or family and an opportunity to meet new friends

61. Physical Activity Helps you look better because it: Tones muscles Burns off calories to help lose extra pounds or to help you stay at your desirable weight--each pound requires you to burn off 3,500 more calories than you take in Helps control your appetite

62. Diet & Exercise Summary Low glycemic index foods (see FLT guide section 2) Small, frequent meals Medical food for body composition (UltraMeal) To increase intake of quality nutrients To improve insulin sensitivity To achieve meal frequency and size goals Quality omega 3 fatty acids (EPA, DHA) Exercise – progressively increase intensity Minimum – brisk walking, 30 min, 5X per week Additional supplementation as needed

63. Self-Monitoring Keep records of: Amount and types of foods eaten Frequency, intensity, and type of physical activity Time, place, and feelings

64. UltraMeal 1 serv 1 serv Cholarest SC1 1 EPA/DHA Extra Strength2 2 xx x x x x 2 Jane Patient 9/17/02 Lower Cholesterol, improve hot flushes, lose weight Complete diet diary and exercise log daily 30 min

65. Is This Program Expensive? FirstLine Therapy TM Testing Consultations Group sessions 2 meals per day EFA supplement McDonalds Big Mac Extra Value Meal$5.37 Carls Jr. Six Dollar Burger Value Combo$5.81 Starbucks Venti Latte$3.61 Frappuchino$4.26 per month: $329.60 per day: $11.77