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11/1/2016 1 Diet Strategies Versus Supplementation Do they exist alone or in concert James B. LaValle R.Ph.,M.T. C.C.N. Chairman Metabolic Intelligence Academic Co-Chair A4M/ MMI Fellowship Adjunct Faculty George Washington School of Medicine and Health Sciences 2015 59% of adults attempted weight loss (2015 IFIC) Only 36% of Americans describe themselves as overweight (2013 Gallup Poll) Weight loss is a 42 billion plus industry. Despite huge expenditures and participation in weight loss programs, only 5 - 10% achieve sustained weight loss (90% gain wt back in 5 yrs or less) Weight Loss Statistics 2015 59% of adults attempted weight loss (2015 IFIC) Only 36% of Americans describe themselves as overweight (2013 Gallup Poll) Weight loss is a 42 billion plus industry. Despite huge expenditures and participation in weight loss programs, only 5 - 10% achieve sustained weight loss (90% gain wt back in 5 yrs or less) Weight Loss Statistics Strategies for Post Prandial Glucose, Lipids, Inflammation and CV Health Study looked at factors to reduce ds risk and recommended a diet dubbed the anti inflammatory diet : Focused on quality of foods eaten - high in minimally processed foods (low in processed) vegetables, fruits, whole grains, legumes, nuts/seeds Looked at all factors that lowered post meal glycemic response OKeefe et al J Am Coll Cardiol, 2008; 51:249-255. Anti-Inflammatory Diet Select high-fiber carbohydrates with low glycemic index, including vegetables, fruits, whole grains, legumes, and nuts. At all 3 meals, consume lean protein, specifically mentioned high biologic value protein (animal protein) Eat approximately 1 handful of nuts daily (using a closed fist), consumed with vegetables, grains, berries, or other fruits. Eat salad daily, consisting of leafy greens with dressing of vinegar and virgin olive oil. Avoid highly processed foods and beverages, particularly those containing sugar, high-fructose corn syrup, white flour, or trans fats. Limit portion sizes to modest quantities. Other things that positively impact post-prandial dysmetabolism: vinegar, fish oil, tea, cinnamon Anti Inflammatory Diet Maintain normal weight and avoid overweight or obesity. Waist circumference should be less than one half of height in inches. Perform physical activity for at least 30 minutes or more daily, of at least moderate intensity. For those with no history of substance abuse, consuming 1 alcoholic beverage before or with an evening meal may be considered.

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Page 1: Diet Strategies Versus Supplementation - Avera Health · Diet Strategies Versus Supplementation ... Cell 163, 1079–1094, November 19, 2015. Elsevier Inc. Improvement in Microcirculation

11/1/2016

1

Diet Strategies Versus Supplementation

Do they exist alone or in concert James B. LaValle R.Ph.,M.T. C.C.N.

Chairman Metabolic Intelligence

Academic Co-Chair A4M/ MMI Fellowship

Adjunct Faculty George Washington School of Medicine and Health Sciences

• 2015 59% of adults attempted weight loss (2015 IFIC)

• Only 36% of Americans describe themselves as overweight (2013 Gallup Poll)

• Weight loss is a 42 billion plus industry.

• Despite huge expenditures and participation in weight loss programs, only 5 - 10% achieve sustained weight loss (90% gain wt back in 5 yrs or less)

Weight Loss Statistics

• 2015 59% of adults attempted weight loss (2015 IFIC)

• Only 36% of Americans describe themselves as overweight (2013 Gallup Poll)

• Weight loss is a 42 billion plus industry.

• Despite huge expenditures and participation in weight loss programs, only 5 - 10% achieve sustained weight loss (90% gain wt back in 5 yrs or less)

Weight Loss Statistics Strategies for Post Prandial Glucose, Lipids, Inflammation and CV Health

• Study looked at factors to reduce ds risk and recommended a diet dubbed the anti inflammatory diet : • Focused on quality of foods eaten - high in minimally

processed foods (low in processed) vegetables, fruits, whole grains, legumes, nuts/seeds

• Looked at all factors that lowered post meal glycemic response

O’Keefe et al J Am Coll Cardiol, 2008; 51:249-255.

Anti-Inflammatory Diet • Select high-fiber carbohydrates with low glycemic index, including

vegetables, fruits, whole grains, legumes, and nuts.

• At all 3 meals, consume lean protein, specifically mentioned high biologic value protein (animal protein)

• Eat approximately 1 handful of nuts daily (using a closed fist), consumed with vegetables, grains, berries, or other fruits.

• Eat salad daily, consisting of leafy greens with dressing of vinegar and virgin olive oil.

• Avoid highly processed foods and beverages, particularly those containing sugar, high-fructose corn syrup, white flour, or trans fats.

• Limit portion sizes to modest quantities.

• Other things that positively impact post-prandial dysmetabolism: vinegar, fish oil, tea, cinnamon

Anti Inflammatory Diet

• Maintain normal weight and avoid overweight or obesity. Waist circumference should be less than one half of height in inches.

• Perform physical activity for at least 30 minutes or more daily, of at least moderate intensity.

• For those with no history of substance abuse, consuming 1 alcoholic beverage before or with an evening meal may be considered.

Page 2: Diet Strategies Versus Supplementation - Avera Health · Diet Strategies Versus Supplementation ... Cell 163, 1079–1094, November 19, 2015. Elsevier Inc. Improvement in Microcirculation

11/1/2016

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Low Carb and Metabolic Syndrome • Low carb/high fat diet improved BP, increased HDL, lowered trig,

reduced bl glu and insulin, and reduced weight.

• Low fat/high carb diet exacerbated Metabolic Syndrome

• Authors discussed the persistence of AHA/NHBL in recommending low fat diets as being in error for Met Syndrome

Volek J, Feinman R. Nutr and Metab 2005,2:31

Low Carb in Type 2 Diabetes

• Type 2 Diab. given 25% carb diet for 8 wks., then 55% carb calorie equiv diet

• 25% diet - signif decreased wt., bl. glu and HbA1c, also BP decreased from 136/83 to 133/77, sulfonylureas D/C

• 55% carb - HbA1C increased, wt incr.

• Concl 1.6% A1C reduction of low carb diet comparable to that seen with acarbose, can achieve same benefit without exposure to an additional drug

Guiterrez, et al. JACN 1998;17(6) 595-600.

Low Carb in Diabetes

• 10 obese pts - low carb diets led to spontaneous lower kcal intake, wt. loss, much improved bl glu, HbA1C, trig and chol.

• HbA1C 7.3 to 6.8 % in 2 weeks

Ann Intern Med 2005 Mar 15;142(6):469-70

• Contrast with ACCORD trial - which intensive arm was D/C due to incr. risk of death. Goal of study was HbA1C under 7% with intensive meds

20% Carb Diet

• 16 obese type 2 diab. Put on 20% carb (LC) diet compared to 15 in control group on 60% carb (HC) for six months

• Results - bl glu - 3.4 mmol/l vs. -.6 mmol/l, HbA2c -1.4% vs -.6 %, wt -11.4 kg vs -1.8 kg, BMI -4.1 kg/m vs -.7 kg/m

• Follow up at 1 yr and 2 yr cont’d to show HbA1c under 6.5 % for majority of pts. And 1 pt. came out of renal failure

Upsala J Med Sci 109: 179-184, 2005

Low Carb Diet Prevents End Stage Renal Failure

• Case study - 60 y.o., Type 2 diab, retinopathy, BP 125/90, on glimipiride, quinapril, metaprolol, simvastatin, aspirin. Developed albuminuria and incr creatinine. Started on insulin. Wt incr. from 85 to 89 kg avg. to 94 kg. Started on 20% carb diet.

• In 2 weeks - was off insulin, in 3 mo HbA1 c decr. To 6.5%, in 6 mo lost 19 kg., steady incr. in creatinine stopped and remained stable through 2 1/2 yr f/u. Retinopathy stabilized.

Nutr Metab (Lond). 2006; 3: 23.Published online 2006 June 14. doi: 10.1186/1743-7075-3-23.

Low Carb for Insulin Resistance • Am Diab Assoc would not recommend them (Sheard et al. Diab Care 27:2266-

2271, 2004) In 2008, finally acknowledged low carb diets were as effective as calorie restr/low fat diets for weight loss, but recommended people staying on low carb for no more than 1 yr. due to possible risks (Diab Care Jan 2008 Volume 31: S61-S78

• Westman et al. Provide an excellent review of low carb diets for wt. mgmt, CVD, diab. (Am J of Clin Nutr, Vol. 86, No. 2, 276-284, August 2007)

Page 3: Diet Strategies Versus Supplementation - Avera Health · Diet Strategies Versus Supplementation ... Cell 163, 1079–1094, November 19, 2015. Elsevier Inc. Improvement in Microcirculation

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Low Carb and Lipids

• Low carb diets lowered trig, increased HDL and lowered apoB even in absence of wt. loss or presence of higher sat fat when compared to low fat diets

Krauss, et al. AJCN 2006;83:1025-1031

Low Carb and Hypertension

• Obese subjects placed on low carb, high fat diet. No kcal restriction. Sodium intake went from 2 g to 20 g

• Lost 5% of body wt in 6 wks, had signif reductions in fasting insulin and mean aterial pressure

• Auth conclusions - we need to stop paying so much attn to sodium and start paying attn to fasting insulin

Hays JH Mayo Clin Proc 2003:78;1331-1336

Low Carb Studies

• Low Carb High Protein (HP)diets were compared to high fat (HF) and High Carb High Fiber (HC) diets in 96 overweight women. 16 weeks

• Participants were given general weight loss counseling during first 8 weeks, cont’d diets on their own during second 8 weeks.

McAuley, et al. Diabetologia (2005) 48:8-16

High vs. Low Carb Results

• Authors concl. - HP diet best overall approach for ¯risk of CVD and Type II Diab in insulin resistant people

HC HF HP

Weight - 5 kg - 7 kg -7 kg

Waist - 7 cm. -10.5 cm -9.7 cm

Trig - .32

mmol/L 13% had

incr. LDL

-.56 mmol/L

LDL signif lower, but

25% had 10% incr

LDL

-.63 mmol/L

-LDL signif lower, but 7% had incr

LDL

Insulin -4.2

mU/L

-5.9 -3.8

Low Carb and Macular Degeneration

• 4100 adults age 55-80 completed surveys of dietary habits

• High intakes of high GI and GL were associated with greatest risk of developing AMD in at least one eye

Chiu C, et al. AJCN July 2007;vol 86:180-188

Red Meat

• Each svg red meat eat daily increased risk of death by 13%, processed meats raised it 20% for ea svg.

• Substituting red meat with fish, poultry beans, nuts, lowered risk Pan A, et al. Arch Int Med 172 (7)p.555-63.

• Red meat consumption raised risk of Type2 Diab Pan, A., et al.,. Am J Clin Nutr, 2011. 94(4): p. 1088-96.

• Including lean red meat in an otherwise healthy diet (8 frt/veg, 4 oz whole grain etc) still led to decreased chol and triglycerides. Am J Clin Nutr

• doi: 10.3945/ajcn.111.016261.

Page 4: Diet Strategies Versus Supplementation - Avera Health · Diet Strategies Versus Supplementation ... Cell 163, 1079–1094, November 19, 2015. Elsevier Inc. Improvement in Microcirculation

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Risk of Overcooked Meats • Cooking meats at high heats causes formation of

heterocyclic amines, which are carcinogenic.

• Reduce HCA’s by marinating meat in spices (Basil, mint, rosemary, oregano, thyme and sage) and microwaving meat for a minute before cooking (HCA’s come out in the liquid)

• Cook at lower heats (under 375) and don’t cook to well done.

Zheng W, Lee SA. Well-done meat intake, heterocyclic amine exposure, and cancer risk. Nutr Cancer. 2009;61(4):437–446.

University of Arkansas, Food Safety Consortium. "Brush On The Marinade, Hold Off The Cancerous Compounds." ScienceDaily. ScienceDaily, 28 June 2007. <www.sciencedaily.com/releases/2007/06/070627124111.htm>.

Saturated Fat • Large meta analysis from 2014 determined intake

of saturated fats does not elevate risk of heart disease

• Dairy fat was inversely associated with risk for heart disease.

• Monounsaturated fats had a null association for risk.

• Omega 3 fats lowered risk.

• Trans fats increased risk. Chowdhury R, Warnakula S, Kunutsor S, Crowe F, Ward HA, Johnson L, et al. Association of Dietary, Circulating, and Supplement Fatty Acids With Coronary Risk: A Systematic Review and Meta-analysis. Ann Intern Med. 2014;160:398-406.

Side Effect of Low Carb Diet?

• Constipation - http://www.webmd.com/diet/down-low-on-low-carb-diets

• Effects of diet on gut flora, production of short chain fatty acids, regulation of appetite and blood sugar impacted by dietary intake (fat and plant foods/fiber/resistant starches)

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3601187/

Vegetarian Diet

• High rates of diabetes being seen in United Arab Emirates (18%) Asian countries and India, as well as U.S. (10%)

• Veg diet must be calorie and glycemic controlled

• Glycemic control affects heart disease risk and gut flora balance

http://www.idf.org/latest-diabetes-figures-paint-grim-global-picture

Hu, Frank, Diabetes Care http://care.diabetesjournals.org/content/34/6/1249.full

Vegetarian Diet Study • A low carb vegan diet (Eco Atkins) was compared to low fat, kcal

controlled lacto ovo veg diet. 39 people

• Vegan 26% carb, 31 % pro (wheat gluten = seitan and soy), 43% fat

• High carb, Low pro – 58% carb, 16% pro, 25% fat

• Low carb vegan diet – lost 6.9 kg in 6 mo had 10% reduction in lipids, High carb veg lost 5.8 kg

• 10 yr calculated risk CHD was reduced in both groups, greater decreases in LDL, TC, and, ApoB in low carb.

• Slight drops in trig’s on low carb group. HDL about same.

• Attrition rates were high 50% low carb veg, 30% high carb group Wong J, Kendall C, Jenkins D. Effect of a 6-month vegan low-carbohydrate (‘Eco-Atkins’) diet on cardiovascular risk factors and body weight in hyperlipidaemic adults: a randomised controlled trial. BMJ Open. 2014.

Macronutrients and Microbiome • Proteobacteria and enterobacteriaceae are positively associated with PPGR (post prandial glycemic response), obesity, metabolic syndrome, impaired lipid profiles. Complex carbs decrease enterobacteriaceae

• Actinobacteria – associated with PPGR

• High fat/low fiber diet – leads to increased bacteroides and actinobacteria, high fat diets reduce bifidobacterium and increase LPS.

• High fiber low fat diet – prebiotic fibers and resistant starch feed beneficial flora promoting improved enterocyte maintenance and function and mucin layer. Increases Prevotella enterotype bacteria – correlates with enhanced susceptibility to RA

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4303825/

Page 5: Diet Strategies Versus Supplementation - Avera Health · Diet Strategies Versus Supplementation ... Cell 163, 1079–1094, November 19, 2015. Elsevier Inc. Improvement in Microcirculation

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Individual Response to Carbs

• Study finds what we have observed clinically

• 800 person study, given standardized meals of different composition 1meal per day, put on continuous glucose monitor

• Wide variations among individuals to same glucose/mixed meal load

• Bread and butter – 15 mg/dl – 79 mg/dl

Cell 163, 1079–1094, November 19, 2015. Elsevier Inc.

Improvement in Microcirculation by Garlic

Before

After

AGE Placebo AGE Placebo

The optimum time of the effect is around 90-120 min, which is similar time with the one of SAC blood level.

Okuhara, T. Jpn. Pharmacol. Therapeut. 22(8): 3695-3701, 1994

Aged Garlic Extract improves Coronary Calcium and Endothelial Function in Asymptomatic

Adults with Subclinical Atherosclerosis

Matthew Budoff, Naser Ahmadi, Khurram Nasir, Fereshteh Hajsadeghi, Khawer Gul, Sandy Liu, Ferdinand Flores, Nagatoshi Ide, Morteza Naghavi

Division of Cardiology, Harbor-UCLA Medical Center, Torrance, CA

Conflict: Grant Support: Wakunaga of America

Second Clinical Study using Aged Garlic Extract w/ B-vitamins AGE and Endothelial Health

Absolute Changes in Thermal Vascular

Function and Coronary Artery

0

20

40

60

AGE

Placebo

CAC TMP AUC

P value =0.02

P value =0.03

Ab

solu

te C

han

ge

Fat Around the Heart

Page 6: Diet Strategies Versus Supplementation - Avera Health · Diet Strategies Versus Supplementation ... Cell 163, 1079–1094, November 19, 2015. Elsevier Inc. Improvement in Microcirculation

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Association of AGE and Cardiac Fat Ahmadi IJC 2013 Third Study - FAITH

Results

• Calcium progression slowed by 53%

• (58 in placebo vs 27 in AGE+CoQ)

• Endothelial Function improved by over 90%

• 29.49±10.47 vs. -1.79±9.9, p=0.02

• CRP was reduced by 1.31 mg/L in AGE-CoQ10 compared to placebo

Bone Mineral Density and AGE

CAC and BMD

Likelihood of AGE to improve endothelial health, decrease homocysteine and slow progression of osteoporosis and coronary atherosclerosis

Page 7: Diet Strategies Versus Supplementation - Avera Health · Diet Strategies Versus Supplementation ... Cell 163, 1079–1094, November 19, 2015. Elsevier Inc. Improvement in Microcirculation

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Non-Alcoholic Fatty Liver Disease under the influence of Aged Garlic Extract therapy

• Liver and spleen are visible at the bottom of the heart, allowing measures of fat in the liver

• Fatty liver is a precursor to diabetes and liver failure

Liver Benefits

Fatty Liver Disease

No patients on active therapy formed NAFLD, while 9% of patients on placebo developed CT evidence of NAFLD (p<0.001).

AGE on Advanced Lipid profile

• AGE is significantly associated with reduction of apoB/apoA-1. In sub-analysis, AGE independently reduced LDL-C and apoB/apoA-1 among patients with ASCVD risk<7.5%

• This study indicates that AGE may have a beneficial effect with respect to reducing LDL-C and apoB/apoA-1 levels in patients with Mets, especially those

• categorized with relatively low cardiovascular risk

Garlic Study #4

• 72 patients randomized to Kyolic or placebo

• Evaluation of non-calcified plaque (CT angiography)

• Evaluation of Carotid Intimal Media Thickness

• Coronary calcium, biomarkers, blood pressure, etc..

Garlic 4–REGRESSION OF PLAQUE

Page 8: Diet Strategies Versus Supplementation - Avera Health · Diet Strategies Versus Supplementation ... Cell 163, 1079–1094, November 19, 2015. Elsevier Inc. Improvement in Microcirculation

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CONCLUSIONS

• Garlic significantly slowed the atherosclerosis process (Coronary Calcium) when added to statin and aspirin therapy

• The benefit of Garlic is most likely multifactorial: • Cholesterol Benefit

• Anti-oxidant

• Blood Pressure

• Homocysteine

• Direct Anti-atherosclerotic Effect

• Garlic Effects extend beyond the heart: bone, liver, vascular health and fat

Thank you for Your Attention

James B. LaValle www.jimlavalle.com metaboliccode.com