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Nutrition MattersDietary Facts for Treatingand Preventing Disease

Debra G. Bell, M.D.

Obesity by country

Leading Causes of Death

•Four of 10 are diet related•Heart Disease, Cancer, Stroke and Diabetes

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Health Consequences ofObesity

• For BMI 25-30 and >30 the risks for the following conditionsincreases:

• Coronary heart disease• Type 2 diabetes• Cancers (endometrial, breast, and colon)• Hypertension• Dyslipidemia• Stroke• Liver and Gallbladder disease• Sleep apnea and respiratory problems• Osteoarthritis• Gynecological problems (abnormal menses, infertility)

NUTRITION MATTERS

Contributing Factorsto

Obesity

• Increased consumption of energy-dense, nutrient-poorfoods with high levels of sugar and saturated fats

• More sedentary• Genes are important in terms of susceptibility to weight

gain and we may be making that worse!

Energy balance is determined by calorieintake and physical activity.

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Standard American Diet

• S.A.D.• Why we have become more obese• Percentage of calories coming from sugars has increased to 20%.

Eating about 25% more calories/day than in 1970• This starts early. Childhood obesity tripled in past 30 years.• Industrialization• Packaged, processed, fast foods-many of which is NOT REAL FOOD!

Cost of Obesity

• Obesity-related conditions now account for 9.1 percent of all medicalspending, up from 6.5 percent in 1998.

• Obesity-related diseases currently account for a large portion of healthcare expenditure - $117-$147 billion/year, double what it was nearly adecade ago.

• Americans spent around 24% of their expenses on food in 1960/1961compared to only 12.4% in 2009. Conversely, in 1970 the US spent 7.2% of itsGDP on healthcare vs. 17.6% (projected) in 2009.

Food Politics

• Direct effect of food industry and American dietary trends• Can’t look at S.A.D. without considering food politics• Many changes have been fueled by agribusiness.• Food Bill, Farm Bill marketing - grains and dairy• Wheat Soy and Corn in everything• Commodity foods are hence artificially cheap. Cost to taxpayers

$19billion/year.• NOT REAL FOOD = NOT REALLY CHEAP

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Impact of Weight Loss

• Weight loss results in lower blood pressure, lower blood

sugar, and improved lipid levels. The Surgeon General's Call ToAction To Prevent and Decrease Overweight and Obesity

• Weight loss may improve survival in those who have an obesityrelated disease, especially type 2 diabetes

• Weight loss of 10% or less can improve the complications mostcommonly associated with obesity.

What to eat?

Review of basic nutritionSounds basic but has become complicated becauseof all the unhealthy choices in our cultureMust individualize depending on age, individualmetabolism and underlying health.

Types of foods

PROTEINS CARBOHYDRATES FATS

Copyright 2008 dgbell

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Types of food

• Three major classes used for energy:Carbohydrates, Fats, Proteins

• Protein differs from other 2 structurallybecause it contains nitrogen.

• Energy storage 1. Fat 2. Protein3.Carbohydrates (stored as glycogen - shortterm energy - a few hours)

Carbohydrates

An important source of energy for the bodyImportant in the regulation of blood sugarPrevent the breakdown of the bodies protein for useof energyImportant source of fiber and nutrients (vitamins,antioxidants and phytonutrients).

ALL CARBS ARE NOT CREATEDEQUAL

Simple Carbohydrates: starches and sugars.Complex Carbohydrates: whole grainsvegetables and fruits

Carbohydrates are necessary but what kinds?

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Glycemic index

• Highly sweet or very starchy foods - HIGH on theIndex: break down quickly and cause the release ofextra insulin, burdening our metabolism. More likelyto metabolize to fat.

• Low Index (below 55)- metabolized slower andprovide a steadier stream of glucose and othernutrients. As a result, they're less work and stress forthe body, and the energy can be better utilized. Tendto conserve insulin and hormones.

Glycemic Load

• High glycemic load can lead to large insulin release and can worseninsulin resistance

• The release of this large load if insulin can be rapid which canultimately lead to rebound hypoglycemia - lead to fatigue.

• Low foods - Body puts out less insulin, creates less stress on pancreasand other glands. May decrease risk of diabetes, heart disease andobesity.

• It’s the blast of insulin from high glycemic foods that drives hungercravings.

Most Common Carbohydrates eatenin US

#1 potatoes#2 white bread#3 Cold breakfast Cereal#4 Dark Bread#5 Orange Juice#6 Bananas#7 White Rice#8 Pizza#9 Pasta#10 Muffins

#11 Fruit Punch#12 Coca-cola#13 Apples#14 Skim Milk#15 Pancakes#16 Table Sugar#17 Jam#18 Cranberry Juice#19 French Fries#20 Candy

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Heart Disease and Carbs

• Harvard research - tracked role of starches and sugars inheart disease over 10-year period, monitoring the diet andhealth of over 75,000 women, ages 38 to 63 with nohistory of diabetes, stroke, or heart disease.

• The risk of heart disease was found to be "directlyassociated" with high carbohydrate foods.

• Over the course of the study, 761 cases of heart diseasedeveloped. Of those at risk for heart disease, eating a highcarbohydrate diet was found to double the risk of heartattack in the top 40%, with even greater risk among the top20%.

Heart Disease and Carbs

• Obesity also was part of this picture. Theresearchers reported that the link between highglycemic load and coronary heart disease risk wasmost often seen in subjects with "body weightsabove average." They concluded that a diet high inrefined carbohydrates increases the risk ofcoronary heart disease.

Proteins

Amino acids from dietary proteins are 1. Oxidized for energy 2. Incorporated into body proteins (muscle) 3. Used for other nitrogen containing compounds in

the body.

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Importance of Proteins

Support proper metabolismEssential for creation of hormonesBuilding blocks for the immune systemNeeded for growth and repair of all cellsPreserve and build muscle massEnergy source when carbohydrates not availableStabilize blood sugars and helps feel full

PROTEINS

Non- animal proteins: Legumes, beans, nuts and seeds. Whole grains have someprotein.Animal proteins: Fish, poultry, red meats, eggs, dairy

www.oceansalive.org website for fish safety information

We Need Fats

For skin, nails, hair and cell developmentFor hormone developmentInvolved in our neurological systems (brain andmood)Needed to keep cell membranes healthy somessages between cells can take place

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FATS

• Different from other macronutrients - not water soluble sorequire different processes of digestion, absorption, transportand utilization.

• Most common dietary lipid - Triglycerides• Cholesterol only found in foods of animal origin• Plant sterols=phytosterols

FAT

• Saturated Fats• Monounsaturated fats• Polyunsaturated fats• Trans Fats = Partially Hydrogenated Oils

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Fats

• “Good fats” – olive oil, nuts, avocado, fish• “Bad fats” – trans fatty acids, saturated fats

(animal fats -including dairy )in excess,overheated polyunsaturated fats.

“Low Fat”

• Low fat craze of the 70s proved to be bad for our health. Substitutedcarbs for fat

• The low fat craze caused some to replace real food with inventedsubstances and processed foods

• Low ratio of total cholesterol to HDL is important for heart health.Substitution of carbohydrate for saturated fat reduces HDL as well astotal chol and LDL so does not change the ratio

• Many low fat items have high sugar to add flavor.• Many low fat dairy products have additives to preserve texture.

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High Fructose Corn Syrup

Not only high glycemic index but because it is has beenchemically altered, it may cause even more strain on insulinand metabolism than even sugar.More carbohydrate and food cravings. Stimulatesneuropeptides (brain messengers) which causes hunger andcravings.Increases triglycerides and LDL.

DO NOT TELL PATIENTS TO EAT

A LOW FAT DIET!!!

Essential Fatty Acids

• Essential means we can not synthesize this from other things inour body and need to get it from the outside - our nutrition

• Omega-3 Flaxseed oil, walnut oil, Salmon, tuna, mackerel, sardines• Omega-6 canola oil, eggs, chicken, safflower oil, sunflower oil,

wheat germ oil, poultry

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Omega Fatty Acids

• Ratio of Omega 3, 6, 9 important.• Omega 6: Omega 3 fat intake ratio estimated as 1:1 in

prehistoric man and as 4:1 in 1900, and 20:1 in S.A.D.• Poor ratio is result of corn and soy added to packaged food and

baked goods and agricultural practices for raising meat, poultryand fish.

• Increase omega 3. Decrease omega 6 in diet.

Omega Fatty Acids

• Omega 3 - anti inflammatory• Too much omega 6 - pro inflammatory

Diabetes and HeartDisease

• Monounsaturated fats (compared to carbs) reducesblood sugar and triglycerides in type 2 DM.

• Fish consumption twice /week reduces risk of suddendeath

• Trans Fats increase risk of type 2 DM and heartdisease.

• Red meat may be associated with increase risk ofcolon and prostate cancer.

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A word or about DAIRY

• “Dairy foods are not a nutritional requirement.” Marion Nestle, What ToEat.

• Source of calcium and protein.• Healthful highly absorbable calcium sources: Beans and Greens, the

calcium they contain is absorbed nearly twice as well as the calcium incow's milk.

• Americans may require more calcium only because of high animalprotein and salt in diet.

• Many intolerances and problems for some consuming dairy such asconstipation, irritable bowel syndrome, lactose intolerance, allergies.

Dairy and Bone Health

• Bone Health? NO data to suggest that consuming dairy isrelated to bone health or that calcium in dairy is bio-available tobone after adolescence .

• Population studies show that countries with minimal or no dairyin diet have less osteoporosis and fewer bone fractures.

• Animal proteins (dairy, meat) have negative impact on bone.• Fruits and vegetables also good for bones• ACTIVITY, NO SMOKING OR SECOND HAND SMOKE,

Dairy and Bone Health

• In a 12-year Harvard study of 78,000 women, those who got the mostcalcium from dairy products received no benefit and actually brokemore bones than the women who got little or no calcium from dairy

• 1994 study of elderly men and women in Sydney, Australia,showed that those who consumed the most dairy products haddouble the hip fracture rate of those who consumed the least.

• Several studies of teenagers have found that their adult bonehealth is related to their physical activity level earlier in life, butnot to the amount of milk or calcium they consumed

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Whole Foods Diet

• A well-balanced whole-foods diet consists of vegetables, fruits,whole grains and legumes, nuts/seeds, with smaller amounts ofdairy, meat/poultry/fish/eggs. REAL FOOD!

• Foods that are eaten in close to their natural state• Example: a chicken breast instead of a chicken nugget

• Foods that are not processed or refined• Brown rice instead of Uncle Ben’s Minute Rice

• Foods that do not contain:• synthetic chemicals, additives, preservatives or artificial

colors

Mediterranean Diet

• Balanced diet of high-nutrient and low-caloriefoods=vegetables and fruits, whole grains, legumes.olive oil is principal fat.

• Positive impact on health: weight management, hearthealth, diabetes

• Research showed 33% reduction in risk of heartdisease, 24% lower death rate from cancer.

• Research showed worked better that low fat diet intreating metabolic syndrome

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Taking a Diet History

• Imperative component - must individualize.• No judgment• How often, how much, what time of day?• Must also know approximate energy expenditure - activity level.• FOCUS ON HEALTH not on weight.

DIET DIARYPlease write down EVERYTHING you have to eat or drink (including water) for 3 days. If your

weekends are very different from weekdays then record for 1 week.

DAY 3

DAY 2

DAY 1

Eveningsnack

SupperAfternoonsnack

LunchMorningsnack

Breakfast

Nutrition Counseling

• 4 W’s: what, when, why and aWare• Read labels, eat real food.• Paying attention to what one is putting in mouth,

hunger and satiety• Positive attitude (you deserve to be healthy) vs.

guilt, shame (should, “bad food”)

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Case #4• 56yo male, hypothyroid, dyslipidemia6/10: Wt. 209.8lbChol 213 HDL 36 TG 497 (no LDL can’t calc)Diet: bagel for breakfast, school lunch, snack foods cheetos,

meat, veg at supper, ice cream in evening. No exercise.

8/10: No bagel or ice cream, less bread, more whole grains and veggies. Exercising 4-6 days/week.Wt. 188lb Chol 148 HDL 48 LDLL 76 TG 133

Summary

• Take a diet history• Individualize- One size does NOT fit all• Be positive and realistic• Encourage to read labels• EAT REAL FOOD