Dose Response to Exercise in Women aged 4575 yearsDREW - PowerPoint PPT Presentation

Title: Dose Response to Exercise in Women aged 4575 yearsDREW


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Cardiometabolic Syndrome
The Synergy of Diet and Exercise
A Continuing Education Program for Nursing and
Nutrition Professionals

• Roberta Anding, MS, RD/LD,CSSD, CDE
• Baylor College of Medicine
• ADA Media Spokesperson
• Sports Dietitian for the Houston Texans
• Director of Sports Nutrition, Texas Childrens
  Hospital

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Principles of MNT/Management for MetS

• Assessment of risk factors
• Diet and exercise patterns
• Weight management/calorie restriction
• Assessment of visceral fat
• Whole grains
• Magnesium
• Omega 3 fatty acids
• Calcium and vitamin D
• Plant sterols/stanols

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Nutrition Assessment

• Physical assessment nutrition analysis
• Acanthosis nigricans
• BMI/ Waist circumference
• EAL fair/imperative
• Dietary patterns
• Whole grains
• Low glycemic foods
• Omega 3
• Dairy
• Consumption of plant sterols

• Lab values
• Vitamin D
• Magnesium
• Lipid profile
• Liver enzymes

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Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metforminNEJM
346393, 2002

• Standard lifestyle recommendations
• Written information regarding food pyramid, NCEP
  step 1 diet and annual 30 min individual session
• Intensive lifestyle intervention
• 16 lesson individualized curriculum 11 during
  the first 24 wks, flexible, culturally sensitive
  group sessions

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Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metforminNEJM
346393, 2002

• Average f/u 2.8 yrs
• Incidence of diabetes 11/100 p-yrs with placebo,
  7.8 with metformin (31 reduction) , 4.8 with
  lifestyle intervention (58 reduction)
• To prevent 1 case of diabetes, 6.9 persons would
  have to be treated with lifestyle modification,
  13.9 with metformin

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Prevalence of Metabolic Syndrome at 3 yrs in The
Diabetes Prevention ProgramOrchard et al, Ann
Intern Med 142611, 2005
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Changes in Body Fat Predict Diabetes Diabetes
Prevention Program (n758)1 year from baseline
Lifestyle InterventionFujimoto et al, Diabetes
561680, 2007
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Physical Assessment

• BMI
• Waist circumference
• gt 40 inches in men
• gt 35 inches in women
• Normal weight/metabolically obese
• Waist to hip ratio

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Physical Assessment

• Acanthosis nigricans
• Caused by the influence of insulin on the
  melanocytes
• Not a hygiene issue

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Waist circumference and 8 year incidence of
metabolic syndrome
8 year incidence of MetS
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Visceral fat the fat you cant see, or can you?
Visceral fat is white
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Calorie restriction

• Central to the treatment of metabolic syndrome
• Reduces hyperinsulinemic response
• Weight loss of 5-10 of initial weight can yield
  significant improvement of metabolic parameters
• Questions remain
• Should pathophysiology direct MNT
• Optimal macronutrient distribution
• Dietary patterns vs individual components
• Glycemic load
• Fortified foods with plant stanols
• 2 grams per day can lower LDL by 10

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How much weight loss will have an impact ?
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Does insulin status predict diabetes?
Low Insulin secretion, 15.9
Neither 1.5
Poor secretion and insulin resistance 54
Insulin resistant good secretion 28
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Caloric Restriction Acutely Lowers HDL-C Level

• Trials of very-low-calorie diets show that HDL-C
  levels decrease by 212 mg/dL during acute
  caloric restriction.
• After 12 wks, HDL-C returned to pretreatment
  range, and this trend was still apparent after 1
  year.
• Therefore, benefits of weight-loss programs
  should not be assessed during acute caloric
  restriction.

Rössner S, et al. Atherosclerosis.
198764125130.
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Weight and HDL-C

• Inverse correlation between body weight and HDL-C
  is consistently observed in both men and women.
• For every 3 kg (7 lb) of weight loss, HDL-C
  levels increase 1 mg/dL.

Dattilo AM, Kris-Etherton PM. Am J Clin Nutr.
1992 56320328
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Macronutrient Distribution

• Low carbohydrate diets(lt20 CHO)
• Some evidence of short term benefit(6 weeks)
• Ketogenic diets have no distinct advantages over
  lowering restriction of total carbohydrate
• Ketogenic diets may increase inflammatory risk
  and reduce exercise capacity
• 40 carbohydrate equally effective as traditional
  low carbohydrate diets in reducing body weight
  and insulin resistance

Am J Clin Nutr 2006 85238-9
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Definition GI-Quality of CHO

• the incremental area under the blood glucose
  response curve of 50 grams of available CHO from
  a test food, expressed as a percentage of the
  response to the same amount of CHO from a
  standard food (bread or glucose), taken by the
  SAME person
• Thomas M.S. Wolevar, DJA Jenkins

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Concept of Glycemic Load (GL)-Quantity of CHO

• GI refers to single CHO source
• Captures the quality of the CHO
• Glycemic Load
• GI x Amt of CHO in a serving
• GL captures the quantity of CHO

• Brown rice contains 18 gms CHO, GI 73
• GL for brown rice 18 x 73 or a glycemic load
  of 13
• Each GL 1 gram of glucose

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Not as simplistic as less processed foods are
low GI
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Glycemic load Weight loss or something else?

• Insufficient data in the Evidence Analysis
  Library to implement as a weight loss strategy.
• Are there benefits beyond weight control?
• Lowering the GI of a high carbohydrate diet
  improves beta cell function in those with IGT

Am J Clin Nutr 851169-1170
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Metabolic effects due to intake of high GI food
ß-cell
blood glucose
insulin response
Rapid uptake of nutrients by insulinresponsive
tissues
- glucagon
Glucose uptake
Glucose uptake
Lipogenesis
Glycogen synthesis
Glycogen synthesis
Lipolysis
Glucose output
NEFA release
Gluconeogenesis
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Epidemiologic studies reported on GI
disease Increasing GL associated with
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Glycemic load and liver steatosis

• Links between insulin resistance and liver
  steatosis
• High GI diets are associated with increasing
  prevalence of liver steatosis

Am J Clin Nutr 84136-42
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Framingham Offspring Cohort Study

• 2834 subjects assessed for carbohydrate related
  factors and the prevalence of metabolic syndrome.
• Total fiber, cereal fiber, fruit fiber and whole
  grains were were inversely associated with
  insulin resistance.
• Elevated glycemic index/glycemic load diets
  positively associated with IR
• Whole grains may reduce the risk of MetS

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Whole Grains, Fiber Magnesium

• Dietary patterns rich in whole grains provide 3
  nutrients linked with a decreased incidence of
  metabolic syndrome and improved biochemical
  parameters
• In a study of adults in Tehran, the higher the
  intake of whole grains the lower the prevalence
  of metabolic markers.
• Cereal fiber has been linked with a decrease in
  MetS

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Magnesium

• Recent studies have demonstrated the role of
  magnesium as a risk factor for MetS
• NHANES III and and the CARDIA study both
  demonstrated an inverse relationship between
  magnesium intake and MetS. Highest quartile of
  Mg intake reduced prevalence by 31
• No toxicity from whole food
• UL 350 mg

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AHA Recommendations for Omega-3 FA Intake
Kris-Etherton PM et al. Circulation
20021062747-2757.
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Vitamin D

• Vitamin D receptor are found on the nucleus of
  the cell and the cell membrane
• Essential in the function of the beta cell
• Adequate blood levels, not dietary intake can
  improve insulin sensitivity by 60
• A 30 year prevention program of Type 1 diabetes
  indicates an 80 reduction in disease with 2000
  IU of vitamin D
• Obesity is a risk factor for deficiency as it is
  sequestered in adipose tissue

Harris, SS J Nutrition 2005 135 (2)323-5
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Vitamin D

• Adequate blood levels are more effective than the
  diabetes medications metformin or TZDs
• A study of postmenopausal women taking
  bisphosphonates for osteoporosis and 400 IU of
  vitamin D
• 18 had levels less than 50 nmol/L and 52 had
  values lt 75nmol/L
• Serum 25(OH) levels above 80nmol/L considered
  optimal

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Cost of the Metabolic SyndromeResearch Options

• The Cardiovascular Health Study
• 10 year medical costs of individuals 65 and
  older
• NCEP definition
• Metabolic syndrome present in 47 of the sample
• Costs to Medicare 20 higher with metabolic
  syndrome
• Represents an outcome based intervention for
  RDs, nurses and other health care providers
• Adherence to 2005 Dietary Guidelines are
  effective for reducing MetS risk in women

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Summary

• Assessment patterns for RD/RN should include the
  following
• Visceral fat via waist circumference
• Dietary patterns
• Whole grains
• Magnesium, fiber
• Dairy products
• Calcium and vitamin D
• Glycemic load
• Plant stanols

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Women Cardiometabolic Syndrome
Question Answer Session
A Continuing Education Program for Nursing and
Nutrition Professionals
SPEAKERS
John D. Bisognano, MD, PhD
Roberta Anding, MS, RD/LD, CDE, CSSD
Lynne T. Braun, ANP, PHD, CNP, CLS
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