firstline therapy tm therapeutic lifestyle program

FirstLine TherapyTM

Therapeutic Lifestyle Program

“Persons with lower health risks tend to live longer than those with higher health risks. . .”

“Persons with lower health risks tend to live longer than those with higher health risks. . .”

N Eng J Med 1998;338:1035-41

“Persons with high health risks . . . had twice the cumulative disability of those with low health risks.”

“Persons with high health risks . . . had twice the cumulative disability of those with low health risks.”

N Eng J Med 1998;338:1035-41

N Eng J Med 1998;338:1035-41

“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.”

“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.”

Adult Treatment Panel III

(ATP III) Guidelines

National Cholesterol Education Program

“Everyone with elevated LDL cholesterol is treated with lifestyle changes that are

effective in lowering LDL levels.”

“Everyone with elevated LDL cholesterol is treated with lifestyle changes that are

effective in lowering LDL levels.”

“This approach is designated therapeutic lifestyle changes

(TLC).”

“This approach is designated therapeutic lifestyle changes

(TLC).”

“Lifestyle changes are the most cost-effective means to reduce risk

for CHD.”

“Lifestyle changes are the most cost-effective means to reduce risk

for CHD.”

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

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

Metabolic SyndromeSynonyms

Insulin resistance syndrome (Metabolic) Syndrome X Dysmetabolic syndrome Multiple metabolic syndrome

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

“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

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

Diabetes Risk

0

20

40

60

80

100

<20 20-25 25-30 30-35 35-40 >40

BMI Levels

Inci

den

ce o

f N

ew C

ases

p

er 1

,000

Per

son

-Yea

rs

Knowler WC et al. Am J Epidemiol 1981;113:144-156.

Weight Gain and Diabetes Risk

2.11.01.0

5.33.6

2.5

21.1

9.1

6.3

0

5

10

15

20

25

<22 22-23 24+

<5 kg 5-10 kg 11+ kg

Body Mass Index at Age 21

Rel

ativ

e R

isk

Weight Change Since Age 21

Adapted from Chan JM et al. Diabetes Care 1994;17:960-969.

26 -Year Incidence of Coronary Heart Disease in

Men

177

255

350333366

440

0

100

200

300

400

500

600

<25 25-<30 30+

<50 years 50+ years

Inci

den

ce/1

,000

BMI LevelsAdapted from Hubert HB et al. Circulation 1983;67:968-977. Metropolitan Relative Weight of 110 is a BMI of approximately 25.

Hypertension

BMI

Per

cen

tag

e

20 25 30 35 40

20

10

30

50

40

60

Relationship between BMI and crude percentage of women reportingmedical problems, surgical procedures, symptoms, and health care utilization.

Brown WJ et al. Int J Obes 1998;22:520-528.

BMI

Per

cen

tag

e

20 25 30 35 40

5

10

15

25

20

Cholescystectomy

Relationship between BMI and crude percentage of women reporting medical problems, surgical procedures, symptoms, and health care utilization.


BMI

Per

cen

tag

e

20 25 30 35 40

20

15

25

35

30

40

Hysterectomy



BMI

Per

cen

tag

e

20 25 30 35 40

20

15

30

25

35

Back Pain



BMI

Per

cen

tag

e

20 25 30 35 40

20

15

30

25

35

Constant Tiredness



BMI

Per

cen

tag

e

20 25 30 35 40

15

10

20

25

30

More Than Five GP Consultations



Relationship of BMI to Excess Mortality

300Age at Issue

Bray GA. Overweight is risking fate. Definition, classification, prevalence and risks. Ann NY Acad Sci 1987;499:14-28.

20-29250

Mo

rtal

ity

Rat

io

Body Mass Index (kg/[m2])

200

150

100

50

150

30-39

20 25 30

LowRisk

4035

High

Risk

ModerateRisk

“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.”

“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

“. . . we found that fat-free mass was lower and fat mass was higher in acutely ill and chronically ill patients than controls.”

“. . . 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

“. . . 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.”

“. . . 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)

Sarcopenia: “the Greek roots of the word are sarx for flesh and penia for loss.”

Sarcopenia: “the Greek roots of the word are sarx for flesh and penia for loss.”

J Nutr 127:990S-991S (1997)

“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.”

“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)

“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.”

“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)

Bioimpedance Analysis (BIA)

Women – Normal Reference

Age25-34

35-44

45-54

55-64

65-74

75-84

Body Fat

22.5 23.9 25.8 29.1 34.3 35.8

B. Cell

Mass37.1 36.3 34.5 31.5 27.7 25.7

Phase

Angle6.6 6.7 6.5 6.0 5.4 4.8

Men – Normal Reference

Age25-34

35-44

45-54

55-64

65-74

75-84

Body Fat

15.2 17.6 19.7 22.2 24.6 26.3

B. Cell

Mass43.5 41.1 39.6 36.8 34.1 31.5

Phase

Angle7.5 7.2 7.1 6.6 6.1 5.3

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.”

“. . . 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.”

• 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

All Women:• Lost Body weight 5.7 – 22 lbs• Lost Fat mass 2.0 – 22.9

lbs•Average Fat Loss 14.1 lbs

• BMI declined 0.55 – 3.86 kg/m2

All Women:• Lost Body weight 5.7 – 22 lbs• Lost Fat mass 2.0 – 22.9

lbs•Average Fat Loss 14.1 lbs

• BMI declined 0.55 – 3.86 kg/m2

J Amer Coll Nutr 1994;13(3):243-250

17 of 18 Showed:• Decline in % body fat 2.3 – 10.1%12 of 18 Showed:• Increase in fat free mass .2 – 7.7 lbs

17 of 18 Showed:• Decline in % body fat 2.3 – 10.1%12 of 18 Showed:• Increase in fat free mass .2 – 7.7 lbs

J Amer Coll Nutr 1994;13(3):243-250

“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.”

“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

J Nutr Med 1992;3:285-93

10 week study UltraMeal

OTC

Total Weight Loss

-11 -13

Lean Body Mass +4 -11

TSH No Change

+150%

“The difference may be due to . . . differential aspects of nutritional quality between the two programs.”

“The difference may be due to . . . differential aspects of nutritional quality between the two programs.”

J Nutr Med 1992;3:285-93

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

“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.”

“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

Unpublished Cholesterol Data12 week program w/UltraMeal

Total Cholesterol Change % ChangeStarting TC > 225 -56 22.7%Starting TC 200 - 225 -51 23.4%Starting TC < 200 -22 13.3%Average -40 18.9%

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

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.”

“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.”

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

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 . . .”

“Insulin resistance often develops with advancing age, and may play a prominent role in the aging process . . .”

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.”

“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.”

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

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.”

“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.”

Physical Activity: Why?

• Increases energy expenditure

• Protects and builds lean body mass

• Improves psychological factors

• Reduces risk of morbidity and mortality

Physical Activity: Effect on Health• Enhances cardiorespiratory fitness

• Improves lipid profile– Including lower cholesterol

• Reduces blood pressure

• Increases insulin sensitivity

• Improves blood sugar control

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

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

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

Self-Monitoring

Keep records of:

Amount and types of foods eaten

Frequency, intensity, and type of physical activity

Time, place, and feelings

UltraMeal 1 serv 1 servCholarest SC 1 1EPA/DHA Extra Strength 2 2

x xx xxx 2

Jane Patient 9/17/02Lower Cholesterol, improve hot flushes, lose weightComplete diet diary and exercise log daily

30 min

Is This Program Expensive?

FirstLine TherapyTM

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 $4.26per month: $329.60

per day: $11.77

firstline therapy tm therapeutic lifestyle program

Documents

int j obes

health care utilization

j epidemiol

low health risks

lower health risks

higher health risks

high health risks

n eng j med