paul clayton sundevollen 20/5/07 - weight management - cardiovascular disease & diabetes
TRANSCRIPT
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Paul ClaytonSundevollen 20/5/07
- Weight Management
- cardiovascular disease & diabetes
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18971897
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19191919
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Korea 1951
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Fife 1953Fife 1953
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California 1955
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1957
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1957
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1957
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2001
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Ob / ob/ob normal
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1885: first automobile (Karl Benz)1885: first automobile (Karl Benz)
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1912: first traffic jams1912: first traffic jams
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1929: first parking problems
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Reduced energy expenditureReduced energy expenditure
1600
1800
2000
2200
2400
2600
2800
60 65 70 75 80 85 90 95Year
kcal per day
DoH ’98, USDA ’02, NIH ’03, NCHS ‘04
1940 50 60 70 80
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Positive energy balancePositive energy balance
1600
1800
2000
2200
2400
2600
2800
60 65 70 75 80 85 90 95Year
kcal per day
DoH ’98, USDA ’02, NIH ’03, NCHS ‘04
1940 50 60 70 80
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Obesogenic culture (AHA ’03)
Avge US adult sedentary 8 hours / day, < 2,000 steps / day (NYS Public Health Assocn ‘05)
Amish 16,000 steps /day: obesity 9% women, 0% men (Bassett et al ’04)
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Positive energy balancePositive energy balance
1600
1800
2000
2200
2400
2600
2800
60 65 70 75 80 85 90 95Year
kcal per day
DoH ’98, USDA ’02, NIH ’03, NCHS ‘04
1940 50 60 70 80 90 2000
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AHA 2002: ‘obesogenic culture’AHA 2002: ‘obesogenic culture’
Fewer bus-stops, remote parking
Exercise to be mandatory at all levels of educational system
No ‘junk foods’ to be sold / served in schools
‘baby bells’: constructive inconvenience
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Why is weight gain so easy?Why is weight gain so easy?
Multiple satiation mechanisms Protein: amino acids (fish > whey > casein)Protein: amino acids (fish > whey > casein)Fats: fatty acids (distal jejeunum)Fats: fatty acids (distal jejeunum)Carbs: glucose (Hoodia)Carbs: glucose (Hoodia)Fermentable carbs: SCFA (propionic)Fermentable carbs: SCFA (propionic)Insufficient calorific throughputInsufficient calorific throughputHigh calorific densityHigh calorific densityInstant gratificationInstant gratification
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Positive energy balancePositive energy balance
1600
1800
2000
2200
2400
2600
2800
60 65 70 75 80 85 90 95Year
kcal per day
DoH ’98, USDA ’02, NIH ’03, NCHS ‘04
1940 50 60 70 80
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Overweight but starvingOverweight but starving
W.H.O. ‘02: ‘Globally, overweight more of a health problem than underweight.’
U.N.O. ’06: ‘Overweight but malnourished’ (=Type B malnutrition)40-60% hospital admissions malnourished (US/UK)
And in the community (USDA and other surveys)
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MICRONUTRIENTSMICRONUTRIENTS CALORIESCALORIESMALNUTRITIONMALNUTRITION
TYPE A
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MICRONUTRIENTSMICRONUTRIENTS CALORIESCALORIESMALNUTRITIONMALNUTRITION
TYPE A
TYPE B
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Percentage of Population DepletedPercentage of Population DepletedIn Vitamins (USDA 1997)In Vitamins (USDA 1997)
C E A B1 B2 C E A B1 B2 NiacinNiacin Folate Folate B6 B12 B6 B12------------------------------------------------------------------------------------------------------------------------------------------37 68 55 32 31 27 34 54 1737 68 55 32 31 27 34 54 17
Vitamins
%
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* Gregory et al 2000. National Diet and Nutrition Surveys, HMSO
Iron from all sources (including supplements)% of children of all ages with intakes below RNI and LRNI
84
57
14
28
39
59 60
96
43
93
16
40 1 1 3 3
44
2
48
0
10
20
30
40
50
60
70
80
90
100
<4 >4 Boys Girls Boys Girls Boys Girls Boys Girls
1.5 - 4.5 Age 4-6 Age 7-10 Age 11-14 Age 15-18
% < RNI
% < LRNI
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* Gregory et al 2000. National Diet and Nutrition Surveys, HMSO
Vitamin A from food% of children of all ages with intakes below RNI and LRNI
0
10
20
30
40
50
60
70
80
<4 >4 Boys Girls Boys Girls Boys Girls Boys Girls
1.5 - 2.5 Age 4-6 Age 7-10 Age 11-14 Age 15-18
% < RNI
% < LRNI
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DIETARY SHIFTDIETARY SHIFT
Flavonoids 75%Vit C 50-60%Omega-3 50% Methyl groups 95%Carotenoids 40%Phospholipids 50% since 1900Selenium 50% ” 1960 (UK)Prebiotic fiber 50% ” 1960 (Fr)Sterols 66% ” 1960 (SA)
since Stone Age
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WHO Technical Report Series 916WHO Technical Report Series 916
‘Diet, Nutrition and the Prevention of Chronic Diseases’
Report of Joint FAO / WHO Expert Consultation
Geneva May 2003
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RSM 2005: Pathogenic culture?RSM 2005: Pathogenic culture?
Type 2 diabetes
Osteoporosis ARMD Neurodegenerative disease Lymphoma, leukaemia, melanoma, germ cell
tumours in teens & young adults ADD / ADHD / dysphasia / dyspraxia Allergy, asthma
heart disease, stroke, cancers, kidney disease, blindness, Alzheimer’s
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Type B Malnutrition worsens Type B Malnutrition worsens with agewith age
Reduced activity / calorie requirements
Institutional diet
Financial hardship
Poor dentition
Swallowing problems (xerostomia)
Loss of sense of taste
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Type B Malnutrition worsens Type B Malnutrition worsens with agewith age
Progressive depletion of anabolic factors
(vits C, B’s, D; Zn, Cu, Se, Fe, Ca, Mg; amino acids etc)
Progressive depletion of anti-catabolic factors
(vit E; Zn, Cu, Mn, Se; sterols, flavonoids, carotenoids etc)
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Type B Malnutrition worsens Type B Malnutrition worsens with agewith age
Progressive depletion of anabolic factors
decreased tissue repair, damage clearance etc
Progressive depletion of anti-catabolic factors
increased free radical activity, hexosylation, nitrosation, inflammation
= CATABOLIC DOMINANCE= CATABOLIC DOMINANCE
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Multiple agent interventionMultiple agent intervention
CDD’s have multiple patho-aetiology
CAD risk factors: hypertension, smoking, inactivity, obesity
LDL / HDL, LDL-ox.lag, HbA1c, hyperHc, ICAM-1, VCAM-1, VWF etc
Reduced risk: lycopene, quercitin, omega 3, methyl groups, alcohol, lutein, vitamin E, soy etc
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CVD: HOW DRUGS WORKCVD: HOW DRUGS WORK
LDL HDL LDL ox. Hc
V/CAM
I/CAM PLATELETS ACE
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CVD: HOW DRUGS WORKCVD: HOW DRUGS WORK
LDL HDL LDL ox. Hc
V/CAM
I/CAM PLATELETS ACE
Statins - - - - - -
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CVD: HOW DRUGS WORKCVD: HOW DRUGS WORK
LDL HDL LDL ox. Hc
V/CAM
I/CAM PLATELETS ACE
Statins - - - - - -
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CVD: HOW DRUGS WORKCVD: HOW DRUGS WORK
LDL HDL LDL ox. Hc
V/CAM
I/CAM PLATELETS ACE
Statins - - - - - -Ace
inhibitors - - - - - -
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CVD: HOW DRUGS WORKCVD: HOW DRUGS WORK
LDL HDL LDL ox. Hc
V/CAM
I/CAM PLATELETS ACE
Statins - - - - - -Ace
inhibitors - - - - - -
Beta
blockers - - - - - - -
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CVD: HOW SUPPLEMENTS WORKCVD: HOW SUPPLEMENTS WORK
LDL HDL LDL ox. Hc
V/CAM
I/CAM PLATELETS ACE
Statins - - - - - -Ace
inhibitors - - - - - -
Beta
blockers - - - - - - -
Nutrients
E,C, bC
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How PharmacoNutrition WorksHow PharmacoNutrition Works
LDL HDL LDL ox. Hc
V/CAM
I/CAM PLATELETS ACE
Statins - - - - - -Ace
inhibitors - - - - - -
eta
blockers - - - - - - -
Nutrients
RS Pl’s
E,C, bClycopene
B4, 6, 12, ’10’
flavonoids
Omega 3
flavonoids
flvd’s
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Prevention of (secondary) CADPrevention of (secondary) CAD
Lyon Heart Study (3 years, n=600)
Statins reduced risk of secondary infarct 18 – 23%
Dietary modification reduced risk 50-70% Dietary modification reduced risk 50-70%
de Lorgeril M et al Circulation ‘99:779-785
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NIDDM: Therapeutic StrategiesNIDDM: Therapeutic Strategies
The Pharmaceutical model
Expensive, adverse effects: palliative
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NIDDM: Therapeutic StrategiesNIDDM: Therapeutic Strategies
The Pharmaceutical model
Expensive, adverse effects: palliative
The Life-style model
Cheaper, other benefits: curative
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NIDDM: Life-Style ModelNIDDM: Life-Style Model
Weight loss
Exercise
Nutritional change
Pharmaco-nutritional programs
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NIDDM: the Tricameral modelNIDDM: the Tricameral model
1. Glycemic Load (whole diet)
2. Glucose sink(s)
3. Insulin – glucose uptake system
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1. Glycemic Load1. Glycemic Load
Log increase since Neanderthal period
Cooked root vegetables
Fine milling (17th C)
The potato (17th C)
Refined sugar (UK 30kg chocolate/year)
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2. Glucose sink(s)2. Glucose sink(s)
Skeletal muscle – physiological functionality and volume compromised
BAT – non-induced, therefore compromised
Affects glucose tolerance & plasma lipids
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3. Insulin–glucose uptake system3. Insulin–glucose uptake system
Dependent on:
Cr: Cr-oligopeptide insulin receptor kinase (via SH2 domain)
Inositol: phosphoglycans = insulin ‘second messengers’: activate GLUT-4
Mn: phosphoglycan co-factor
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Functional Insulin DepletionFunctional Insulin Depletion
Excessive glycation reactionsGlycated insulin and insulin receptors
Effective hypo-insulinaemia
Excessive GL dietDietary anti-glycosylants
(University of Coleraine in Ulster ’01-07)
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The Tricameral ModelThe Tricameral Model
Historically high GL diet
Sub-optimal glucose sinks
Impaired glucose handling
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Testing the Tricameral ModelTesting the Tricameral Model
Reduced GL foods
Structured exercise and/or cold exposure programme
Cr, D-chiro-inositol, Mn, anti-glycosylants
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Prevention of NIDDMPrevention of NIDDM
Diabetes Prevention Program (Mass Gen Hosp, IGT)
10 yr prospective trial: 7% weight loss + 150 mins exercise / week risk of progression to diabetes reduced by 60%
= 2x more effective than prophylactic = 2x more effective than prophylactic metforminmetformin
Knowler WC et al: N.Engl.J.Med 2002: 346:393-403
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Reversal of Metabolic SyndromeReversal of Metabolic Syndrome
180 patients ’Prudent’ or Mediterranean diet for 2 yearsM group: reduced weight, hs-CRP, IL-7, IL-18, insulin resistance; improved endothelial functionAt 2 years, 12% P had no features of metabolic syndromeM group: 55% had no featuresM group: 55% had no features
Esposito K et al JAMA 2004:292(12):1440-6
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Diabetic complicationsDiabetic complications
Cardiovascular: CAD, stroke, peripheral
Renal damage / failure
Visual impairment
Peripheral neuropathy
Dementia: Alzheimer’s disease, MI
Cancers
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Vascular Patho-aetiologyVascular Patho-aetiology
Atherogenic plasma lipid: pp TG, VLDLDirect insulin effects: ie vit CC uptake block, slowed tissue healingAntioxidant defences impairedGlycosylation / denaturation / AGEEndarterial inflammationEndarterial inflammationEssential hypertension Essential hypertension Platelet hyper-activityPlatelet hyper-activityCapillary fragilityCapillary fragility
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Renal Patho-aetiologyRenal Patho-aetiology
Depressed immune function + glycosylation of urinary tract epithelial cells + impaired bladder emptying due to nerve damage increased UTI
Glycosylation of glomerular capsular proteins & glycoproteins
Capillary fragility
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Neuronal Patho-aetiologyNeuronal Patho-aetiology
Oxidative stress
AGE stress (via RAGE): direct neurotoxicity
Capillary fragility
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Pharmaco-Nutritional ManagementPharmaco-Nutritional Management
Weight loss, exercise, reduced GL dietInsulin co-factors (Cr, Mn, D-chiro-inositol)
Phenolics: Vasotrophic, anti-inflammatory, vasodilator, anti-platelet, antioxidant, anti-glycosylant, anti-nitrosylationAntioxidants (C, E, ALA, Cu, Zn, others)Mixed phospholipids HDL, neuronal membrane
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DIET: Low sugar or low carbs?DIET: Low sugar or low carbs?
3 categories of carbs
Digestible (simple sugars, starches)
Fermentable (inulin, resistant starches)
Speciality (structural, metabolic poisons, intense sweeteners)
Low GI / GL
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The importance of low GLThe importance of low GL
Raised HbA1C increases risk of CAD, stroke etc
.
Brand et al (1991) Diabetes Care 14:95-101
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The importance of low GLThe importance of low GL
Raised HbA1C increases risk of CAD, stroke etc
15% reduced GL diet 12 weeks 2% reduced HbA1C (Type 2 diabetics) = 40% reduced risk of CAD, stroke etc
.
Brand et al (1991) Diabetes Care 14:95-101
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The importance of low GLThe importance of low GL
Raised HbA1C increases risk of CAD, stroke etc
15% reduced GL diet 12 weeks 2% reduced HbA1C (Type 2 diabetics) = 40% reduced risk of CAD, stroke etc
Benefit most noticeable in patients with raised HbA1C
Brand et al (1991) Diabetes Care 14:95-101
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The importance of low GLThe importance of low GL
Raised HbA1C increases risk of CAD, stroke etc
15% reduced GL diet 12 weeks 2% reduced HbA1C (Type 2 diabetics) = 40% reduced risk of CAD, stroke etc
Benefit most noticeable in patients with raised HbA1C
Many people have raised HbA1C without knowing itMany people have raised HbA1C without knowing it
Brand et al (1991) Diabetes Care 14:95-101
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Projected benefits of reducing CHO by 30gProjected benefits of reducing CHO by 30g
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1.2 % fall in 1.2 % fall in HbAHbA1c1c
1. De Vegt et al 1999; Khaw et al, 2001
≅ 30% 30% reduction in reduction in CHDCHD
1
Projected benefits of reducing CHO by 30gProjected benefits of reducing CHO by 30g
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1.2 % fall in 1.2 % fall in HbAHbA1c1c
1. De Vegt et al 1999; Khaw et al, 2001
2. Diabetes Control and Complications Trial, 1996
≅ 30% 30% reduction in reduction in CHDCHD
1.0 % fall in 1.0 % fall in HbAHbA1c1c
≅ 25% 25% reduction in reduction in retinopathyretinopathy
1
2
Projected benefits of reducing CHO by 30gProjected benefits of reducing CHO by 30g
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1.2 % fall in 1.2 % fall in HbAHbA1c1c
1. De Vegt et al 1999; Khaw et al, 2001
2. Diabetes Control and Complications Trial, 1996
3. Salmeron et al 1997ab; Meyer et al, 2000
≅ 30% 30% reduction in reduction in CHDCHD
1.0 % fall in 1.0 % fall in HbAHbA1c1c
≅≅ 25% 25%
reduction in reduction in retinopathyretinopathy
1
2
3>30% reduction >30% reduction in type-2 DMin type-2 DM
Projected benefits of reducing CHO by 30gProjected benefits of reducing CHO by 30g
<30g/d fall <30g/d fall in glycaemic in glycaemic
loadload
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Atkins and other low-GL dietsAtkins and other low-GL diets
Efficacy? (6 vs 12 months; 1 +ve vs 3 –ve)
High fat / protein, low fruit / veg diet increases risk of bowel & other cancer
Therapeutic index!1 in 3 adults have renal impairment; worsened by high protein diet Knight et al ’03
low phytate diet Curran et al ‘04
Who has renal impairment? Overweight, IGT
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Paul ClaytonSundevollen 20/5/07
- Weight Management
- cardiovascular disease & diabetes