1. The Role of Nutrition in the Treatment of Chronic Disease Norman Hord, PhD, MPH, RD Department of Food Science and Human Nutrition http://www.msu.edu/course/hnf/470

2. Outline l Diet-Related Chronic Disease Risk l Efficacy of Dietary Treatment of Chronic Diseases l Nutrients as Medicine l Food As Social Currency

3. Introduction 1 l The rise in the number and proportion of older people has led to concern about societal consequences. l We associate age with: Increasing Loss of independence disability Functional impairments Loss of mobility Loss of sight Loss of hearing

4. Introduction 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?

8. The Framingham Heart Study

10. Risk Factors for CHD: The Framingham Heart Study Major Risk Factors“Important” Risk Factors Cigarette SmokingObesity* Hypertension*Physical Inactivity High Total Serum Cholesterol*Family Hx of Premature CHD Low HDL Cholesterol*Hypertriglyceridemia* Diabetes Mellitus*Increased Lipoprotein [a] Increased serum homocysteine* Abnormal levels of various coagulation factors *Dietary factors contribute strongly to the control of or in the etiology of these risk factors. of these risk factors.

11. Medical Nutrition Therapy has been integrated into the treatment guidelines for a number of diseases, including: Cardiovascular DiseasesCardiovascular Diseases Diabetes MellitusDiabetes Mellitus HypertensionHypertension ObesityObesity

12. Noncompliance with prescribed MNT and lifestyle changes: l Negatively affect patient response to pharmacotherapy l May necessitate more intensive pharmacotherapy to achieve desired effect.

13. Diet Therapy and Risk Factor Stratification l Dietary treatment strategies are recommended by the National Institutes of Health as the cornerstone for the treatment of all patients with: Cardiovascular Disease Hypertension Diabetes Mellitus Obesity

14. Diet-Related Risk Factors for CHD High LDL Cholesterol Begin treatmentLDL Cholesterol (mg/dl) (mg/dl) With CHD: >100 Without CHD + one risk factor: >160 Without CHD + > 2 risk factors: >130 Low HDL Cholesterol Hypertension Diabetes Mellitus

15. Blood Lipid FractionDesirable Borderline High LDL Cholesterol (mg/dl) 160 Total Cholesterol (mg/dl) 240 Triglycerides (Fasting; mg/dl) 400 HDL Cholesterol= “Low” (Bad) if 35 mg/dl LDL:HDL ratio: > 5 indicates risk for men >4.5 indicates risk for women >4.5 indicates risk for women

16. Role of Diet in the Modification of Blood Cholesterol Levels Assumptions: Blood cholesterol [ ] is an important and modifiable risk factor Blood cholesterol [ ] is an important and modifiable risk factor for coronary heart disease. for coronary heart disease. Sustained reduction of total cholesterol [ ] of 1% is associated Sustained 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.

17. Role of Diet in the Modification of Blood Cholesterol Levels-3 Tang et al. (1998) BMJ 316: 1213-1220 Systematic 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 in Total Cholesterol AHA Step 2 Lower Total Fat 6.0 Raise PUFA:SFA Ratio AHA Step 1 3.0

18. 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 increase in 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 do NOT 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 raise LDL cholesterol [ ].

19. Diabetes Mellitus (“passing through (the body)”; “honey sweet”) Definition:a metabolic disorder characterized by altered blood glucose regulation and utilization, usually caused by insufficient or relatively ineffective insulin. Long-term hyperglycemia Cardiovascular Disease Microangiopathies (Loss of kidney fxn; retinal degeneration) Neuropathy (may lead to gangrene; loss of feet or legs)

20. 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 Bedtime100-140 mg/dl Hemoglobin A1c< 7 % TAKE ACTION LEVELS 140 mg/dl / 8 or >%

22. Diet, Lifestyle and Diabetes Key components in management: Weight loss Diet adjustments to attenuate the rise in blood glucose.

23. Trial Participants:459 adults of which 133 had stage I HTN (B.P. 140-159/90-99) (B.P. 140-159/90-99) 49% women; 60% African-American Acclimation Diet:Low fruits (F), vegetables (V), dairy products ~40% fat for 3 weeks The Diets:1.Control Diet: average for fat, F&V consumption 2.8-10 servings of F&V, ~35+% fat 3.Low-fat (<30% kcal), 8-10 servings of F&V, Rich in low-fat dairy foods. Duration:8 weeks New Engl J Med (1997) 336: 1117-1124

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

26. DASH Comments DASH Comments B.P. reductions occurred quickly (2 weeks) and were maintained throughout the study. Investigators estimated that incidence of CHD and strokes in U.S. could be reduced by 15% and 27%, respectively, if DASH diet were followed.

28. The Obesity Epidemic l U.S.: 20% of men & 25% of women are obese. l 97 million Americans are overweight or obese. (59.4% of men and 51% of women) l >10% of 4-5 year old children are obese. –~2-fold increase over preceding decade These increases have occurred despite successes in reducing dietary fat as % of kcal. Source: NCHS, National Health and Nutrition Examination Survey,1997

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

30. Consequences of Modest Weight Gain 10% increase in weight results in: Fasting Blood Glucose of 2-3 mg/dL Systolic Blood Pressure of 6-7 mm Hg

31. 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)

32. Benefits of Modest Weight Loss l Normalizes high blood pressure l Blood levels l LDL cholesterol l Insulin l Glycated hemoglobin (HbA1C) l Blood glucose l Uric acid l HDL Cholesterol l Improved Quality of Life

33. Food as Social Currency l Current interest in dietary factors centers on nutrients or food components likely to decrease disease risk. l These beliefs betray the important social and psychological role food plays in most people’s lives.

34. People eat food, not isolated nutrients.

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

36. All the biological functions of food components and their health effects have not been identified. If the focus is on a single nutrient, the benefits of the consuming these compounds in foods may not be realized. Why Not Focus on Just Nutrients?

37. Source: U.S. Department of Agriculture

38. Unlike nutrients, foods and diets have cultural, ethnic, social and family meanings.

39. Source: Oldways Preservation & Exchange Trust Asian Pyramid

40. Source: Oldways Preservation & Exchange Trust Mediterranean Pyramid

41. Source: Oldways Preservation & Exchange Trust Latin American Pyramid

42. Dietary Patterns and Chronic Disease Risk Total diet, rather than nutrients or individual Total diet, rather than nutrients or individual foods, should be emphasized. Dietary guidelines need to reflect food Dietary guidelines need to reflect food patterns rather than numeric nutrient goals. Various dietary patterns can be consistent Various dietary patterns can be consistent with good health.

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

44. Dietary Guidelines 2000 (Proposed) Dietary Guidelines 2000 (Proposed) Aim, Build, Choose--for Good Health Build a Healthy Base Choose Sensibly Aim for Fitness

45. Dietary Guidelines 2000 (proposed) Aim1.Aim for a healthy weight. 2.Be physically active each day. Build3.Let the Pyramid guide your choices. 4.Choose a variety of grains daily, especially whole grains. 5.Choose a variety of fruits and vegetables daily. 6.Keep food safe to eat.

46. Choose Sensibly Choose Sensibly 7.Choose a diet that is low in saturated fat and cholesterol and moderate in total fat. 8.Choose beverages and foods that limit your intake of sugars. 9.Choose and prepare foods with less salt. 10.If you drink alcoholic beverages, do 10.If you drink alcoholic beverages, do so in moderation.

47. 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. Eat at least 6 servings of whole grain foods Eat at least 6 servings of whole grain foods each day. Minimize the consumption of high-fat foods, especially Minimize the consumption of high-fat foods, especially 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.

48. The Nutrition Checklist is based on the Warning Signs described below. Use the word DETERMINE to remind you of the Warning Signs. DISEASE EATING POORLY TOOTH LOSS/MOUTH PAIN ECONOMIC HARDSHIP REDUCED SOCIAL CONTACT MULTIPLE MEDICINES INVOLUNTARY WEIGHT LOSS/GAIN NEEDS ASSISTANCE IN SELF CARE ELDER YEARS ABOVE AGE 80 ------------------------------------------------------------------------ The Nutrition Screening Initiative 1010 Wisconsin Avenue, NW Suite 800 Washington, DC 20007

49. Interventions to improve health in later life Intervention Potential effects Intervention Potential effects No smoking Smoking increases risks of many cancers No smoking Smoking increases risks of many cancers including lung, stomach, larynx, colon; cardiovascular disease and colon; cardiovascular disease and thereby vascular dementia; respiratory thereby vascular dementia; respiratory disease; osteoporotic fractures; disease; osteoporotic fractures; stomach ulcers stomach ulcersDiet High fruit and Protective for cardiovascular disease; High fruit and Protective for cardiovascular disease; vegetable intake respiratory function; macular degeneration vegetable intake respiratory function; macular degeneration (5 or more servings and cataracts; cancers including breast, (5 or more servings and cataracts; cancers including breast, daily) prostate, colorectal and stomach; daily) prostate, colorectal and stomach; diverticular disease; diabetes diverticular disease; diabetes

50. Other Dietary Strategies to Improve Health High complex carbohydrates, Protective for cardiovascular disease; cancers including breast and colorectal Reduced saturated fat (<15% of Kcal) and total fat (<35% food energy intake) High saturated fat intake increases risk of coronary heart disease; risk of coronary heart disease; cancers including colorectal, prostate, and breast; large bowel disease; and breast; large bowel disease;osteoarthritis Reduced sodiumHigh sodium intake increases risk of stroke, stomach cancer, osteoporosis, respiratory disease Physical activity Protective for cardiovascular disease; Protective for cardiovascular disease; diabetes; osteoporosis; cancers including colorectal and breast; depression

51. Summary points Summary points Healthy life expectancy is influenced by a relatively Healthy life expectancy is influenced by a relatively 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. A greater focus is needed on prevention and A greater focus is needed on prevention and health maintenance—much is already known about the impact of modifiable influences such as diet, physical activity, smoking, infection, pollution, and housing.