the importance of calcium and the role of dairy · 8/23/2016 1 the importance of calcium and the...

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The Importance of Calcium and the Role of Dairy

Monica Aggarwal, MD

Disclosures

• I have nothing to disclose

Calcium

• Calcium is necessary for bone growth and teeth

• Heart, muscle and nerve need calcium to work effectively

• The current RDA is 1000 mg in men and women until age 50

• Increases in women after menopause to 1200mg/day and in men greater than 70

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Calcium

• Cannot be made by the body

• Must be brought in from the diet

• Limestone rocks

• Nowadays:

– Cow’s milk

– Dark green leafy vegetables

– Soft shelled fish with soft, edible bones

– Fortified juices, milk alternatives (soy, almond)

Milk Does A Body Good?

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What do we Mean when Talk About Milk?

• Classically, considered milk that comes from the mammary gland of a mammal

.

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Breakdown of Milk

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Pasteurization

What do we Know About The Components of Milk?

Lactose

• D-galactose is associated with aging

– In a study of mice, the addition of D-galactose has been shown to induce signs of aging such as reduced cognitive and immune functions. At the same time in those mice, oxidative stress and chronic inflammation climbed.

– The amount of D-galactose given to the mice is the equivalent of 1-2 glasses of milk per day in humans.

Cui X, Zuo P, Zhang Q, Li X, Hu Y, Long J, Cui X, Packer L, Liu J. Chronic systemic D-galactose exposure induces memory loss, neurodegeneration, and oxidative damage in mice: protective effects of R-alpha-lipoic acid. J Neurosci Res; 2006; 83: 1584-90

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Lipopolysacchride

• Milk fat and cream have been associated with increased lipopolysacchride

• High fat diet triggers LPS production which is a byproduct of endotoxemia/dysbiosis

• LPS is found to be elevated in many chronic illnesses such as Autism and Alzheimer’s disease

Deopurkar R, Ghanim H, Friedman J, Abuaysheh S, Sia CL, Mohanty P, Viswanathan P, Chaudhuri A, Dandona P. Differential effects of cream, glucose, and orange juice on inflammation, endotoxin, and the expression of Toll-like receptor-4 and suppressor of cytokine signaling-3. Diabetes Care, May 2010; 33(5): 991-7.

IGF-1• IGF-1 and insulin are responsible for

anabolic/growth processes of the body

• IGF-1 levels are dependent on age, sex, food intake, sex hormones, smoking, Etohconsumption

• Energy or diet restriction lower IGF-1 levels

• Energy increase and excess IGF-1 in diet increase levels. Diet is more impactful than energy

IGF-1

• Correlation between higher levels of IGF-1 and most types of malignancies

• Animal proteins are associated with higher circulating IGF-1 levels

• Vegetable proteins such as legumes were not associated with increased IGF-1 levels

• Elevated IGF-1 levels noted in dietary calcium and milk

• Isolate out milk protein and still IGF-1 levels remain elevated

European Journal of Clinical Nutrition (2007) 61, 91–98. doi:10.1038/sj.ejcn.1602494; published online 9 August 2006

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rBGH

• Recombinant bovine growth hormone is a synthetic hormone that dairy farmers use to increase milk production

• Bovine growth hormone, similar to somatostatin

• rBGH treated cows have higher IGF-1 levels

Cow’s Milk And Cancer

• Studies suggest a correlation between milk intake and bladder and prostate cancer, as well as a potential link with colon cancer.

• There are connections between galactose and ovarian cancer. This association was found in women who drank more than three glasses of milk per day.

Lampe JW. Dairy products and cancer. J Am Coll Nutr 2011; 30(5 Suppl 1): 464S-70S.Genkinger JM, Hunter DJ, Spiegelman D, Anderson KE, Arslan A, Beeson WL, Buring JE, Fraser GE, Freudenheim JL, Goldbohm RA, Hankinson SE, Jacobs DR Jr. Dairy products and ovarian cancer: a pooled analysis of 12 cohort studies. Cancer Epidemio Biomarkers PRev. 2006; 15: 364-72.Giovannuvvi E, Rimm EB. Calcium and fructose intake in relation to risk of prostate cancer. Cancer Res 1998; 58: 442-447.

Physicians Health Study

• In a Harvard study of male professionals, men who drank more than two glasses of milk per day were at an increased risk of prostate cancer compared to those who did not drink milk.

• In another study, men who consumed more than 2000 mg of calcium suffered almost double the rate of fatal prostate cancer than those who did not.

Chan JM, Stampfer MJ, Ma J, Gann PH, Gaziano JM, Giovannucci E. Dairy products, calcium, and prostate cancer risk in the Physicians’ Health Study.Am J Clin Nutr. 2001;74:549–554.

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Dairy and Prostate

• Population-based prospective study in 43,435 Japanese men ages 45 to 74 years.

• During 7.5 years of follow-up

• Dairy products were associated with a dose-dependent increase in the risk of prostate cancer.

Kurahashi N, Inoue M, Iwasaki M, Sasazuki S, Tsugane AS. Dairy product, saturated fatty acid, and calcium intake and prostate cancer in a prospective cohort of Japanese men. Cancer Epidemiol Biomarkers Prev. 2008;17:930–937

Dairy and Breast Cancer

• Increased IGF-1 levels appear to be associated with Breast cancer in premenopausal women

Hankinson SE, Schernhammer ES. Insulin-like growth factor and breast cancer risk: Evidence from observational studies. Breast Dis. 2003;17:27-40.

Does Dairy Decrease Fracture Risk?

• >70000 post menopausal women were watched prospectively for fracture risk and association with Calcium and Vitamin D

• Total calcium consumption; i.e. 1200mg/day versus <600mg/day was no different in terms of fracture risk

• Milk Consumption was not associated with fewer fractures

• Only vitamin D consumption was associated with fracture risk

Feskanich D, Willett WC, Colditz GA. Calcium, vitamin D, milk consumption, and hip fractures: a prospective study among postmenopausal women. Am J Clin Nutr. 2003;77:504–511.

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Swedish Cohort, Observational

• 61,433 women (39-74 years at baseline) and one with 45,339 men

• Registry data

• Compared men and women who drank 3 glasses per day versus fewer than one glass per day

Michaëlsson K, Wolk A, Langenskiöld S, Basu S, Lemming EW, Melhus H, Byberg L. Milk intake and risk of mortality and fractures in women and men: cohort studies. BMJ; 2014; 349: g6015

Michaëlsson K, Wolk A, Langenskiöld S, Basu S, Lemming EW, Melhus H, Byberg L. Milk intake and risk of mortality and fractures in women and men: cohort studies. BMJ; 2014; 349: g6015.

Michaëlsson K, Wolk A, Langenskiöld S, Basu S, Lemming EW, Melhus H, Byberg L. Milk intake and risk of mortality and fractures in women and men: cohort studies. BMJ; 2014; 349: g6015.

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Milk, dietary calcium, and bone fractures in women: a 12-year prospective study

• No evidence that higher intakes of milk or calcium from food sources reduce fracture incidence.

• Women who drank two or more glasses of milk per day had relative risks of 1.45 for hip fracture when compared with women consuming one glass or less per week.

Feskanich D, Willett WC, Stamper MJ, Colditz GA. Milk, dietary calcium, and bone fractures in women: a 12-year prospective study. Am J Pub Health; June 1997, 87 (6): 992-7

Other additives that Decrease Calcium Absorption

• High sodium and high-protein diets absorb less calcium and excrete more calcium in their urine.

Weaver, C, Plawecki, K. Dietary calcium adequacy of a vegetarian diet. AJCN; 1994; 1238S-41S.Feskanich D, Willett WC, Stamper MJ, Colditz GA. Protein consumption and bone fractures in women. Am J Epidemiol. 1996;

143: 472–79.

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Around the World• If we look at countries such as India, Japan

and Peru, calcium intake is less than 1/3 of our daily recommended allowance (300mg per day) and their risk of fractures is extremely low.

Conclusions

• Calcium is necessary for bone growth but not the whole picture.

• We need vitamin D and vitamin K• Likely the amount of calcium needed is around

600mg/day• Eating more protein/sodium is associated with more

calcium losses• Drinking extra cow’s milk is associated with increased

fracture risk• Drinking cow’s milk is associated with increased

cancers such as prostate

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How Do we Keep Our Bones Strong?

• Fortified juice, soy milk

• Fruits and vegetables that are calcium rich

• Exercise is effective at increasing bone density

• Need Vitamins D and K

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Cutting Through the Cholesterol Confusion

Neal D. Barnard, MDGeorge Washington University School of MedicinePhysicians Committee for Responsible Medicine

Dietary Guidelines Advisory CommitteeFebruary 19, 2015

“…available evidence shows no

appreciable relationship between

consumption of dietary cholesterol and

serum cholesterol…. Cholesterol is not a nutrient of concern for overconsumption.”

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The New American Idea: Who Cares?

Gallup Poll, July 8-12, 20151,009 adults

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The New American Idea: Who Cares?

Gallup Poll, July 8-12, 20151,009 adults

Understanding Cholesterol

Chole = bile

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Cholesterol is a key part of cell membranes.

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Cholesterol is a raw material for building hormones.

4 rings in 6,6,6,5 pattern

8-carbon side chain

Cholesterol

↘↙

Cholesterol

Testosterone Estradiol

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Cholesterol Makes Vitamin D

7-Dehydrocholesterol Vitamin D3

→

Cholesterol contributes to cardiovascular disease.

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Coronary Heart Disease MortalityMultiple Risk Factor Intervention Trial

160 180 200 220 240 260 2800

1

2

3

4

5

Stamler J, Wentworth D, Neaton JD, et al. Is relationship betweenserum cholesterol and risk of premature death from coronary heartdisease continuous and graded? JAMA. 1986;256:2823-8.

Relative Risk

Serum Cholesterol (mg/dL)

Where Does Cholesterol Come From?

Produced in all animal cells, especially liver cells.

About 1,000 mg per day.

For comparison, 2 eggs = ~400 mg

Saturated Fat Increases Cholesterol Concentrations

1% ↑ saturated fat

Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. NIH Publication No. 02-5215. September 2002.

2% ↑ LDL→

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There is no requirement for dietary

cholesterol.

40-60% of ingested cholesterol is

absorbed (proximal jejunum).

Chylomicrons escort cholesterol into the circulatory system.

Cholesterol from Food Products

Food → Blood

What is the relationship between cholesterol in foods and blood cholesterol levels?

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Early Studies

Ancel Keys, University of Minnesota Mark Hegsted, Harvard University

Curvilinear effect: Greatest effect at lower intakes.

Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for

Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002/2005.

Early Studies

At common intake levels, the relationship is linear.

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Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes

for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002/2005.

X × 0.0974 = Y

Linear Effect at Lower Intakes

X = dietary cholesterol change per 1000 kcal

Y = change in serum cholesterol in mg/dL

Hegsted M. Serum-cholesterol response to dietary cholesterol: a re-evaluation. Am J ClinNutr. 1986;44:299-305.

X × 0.1 = Y

100 mg cholesterol × 0.1 = 10 mg/dL

Example: 1 egg (~200 mg of cholesterol)

Assume a 2,000-calorie diet

Hegsted M. Serum-cholesterol response to dietary cholesterol: a re-evaluation. Am J ClinNutr. 1986;44:299-305.

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Harvard Study: Eggs and

Cholesterol

17 ovo-lacto-vegetarian students, previously averaging 3 eggs per week.

Adding 1 extra-large egg per day for 3 weeks:

Total: +11.6 mg/dL

LDL: +6.8 mg/dL (no effect on particle size)

HDL: -2.5 mg/dL

TG: +2.9 mg/dLSacks FM, Miller L, Sutherland M, et al. Ingestion of egg raises plasma low density lipoprotein in free-living subjects. Lancet. 1984 Mar 24;1(8378):647-9.

Roberts SL, McMurry MP, Connor WE. Am J Clin Nutr. 1981;34:2092-9.

Eggs vs Egg Substitute: Crossover Trial

EggsEggs

Substitute

Substitute

Meta-Analyses

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Meta-analysis: 27 Studies using Prepared Diets (Hopkins 1992)

Hopkins PN. Effects of dietary cholesterol on serum cholesterol: a meta-analysis and review. Am J Clin Nutr. 1992;55:1060-1070.

100 mg/d ↓ in

dietary

cholesterol

Meta-Analysis: 224 studies

(Howell 1997)

↓ 2.2 mg/dL

(57 µmol/L) in total cholesterol

→

WH, McNamara DJ, Tosca MA, Smith BT, Gaines JA. Plasma lipid and lipoprotein responses to dietary fat and cholesterol: a meta-analysis. Am J Clin Nutr. 1997;65:1747-1764.

Clarke R, Frost C, Collins R, Appleby P, Peto R. Dietary lipids and blood cholesterol: quantitative metaanalysis of metabolic ward studies. BMJ. 1997;314:112-117.

Meta-analysis: 395 Diet Experiments(Clarke 1997)

↓ Dietary cholesterol by 200 mg

↗TC ↓5.0 mg/dL(0.13 mmol/l)

LDL ↓3.9 mg/dL(0.10 mmol/l )

↘

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Weggemans RM, Zock PL, Katan MB. Dietary cholesterol from eggs increases the ratio of total cholesterol to high-density lipoprotein cholesterol in humans: a meta-analysis. Am J Clin Nutr 2001;73:885–91.

Meta-analysis: Cholesterol from Eggs (Weggemans 2001)

17 studies

100 mg dietary cholesterol

TC ↑2.2 mg/dL(0.056 mmol/L)

↗

↘ TC:HDL ratio↑ 0.02 units

↑ Dietary cholesterol

100 mg/d

Institute of Medicine

↑ LDL ~ 2 mg/dL

(0.05 mmol/L)→

Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for

Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002/2005.

Sources of Cholesterol in the U.S. Diet Sales Eggs

Chicken

Beef

Cheese

Processed meat

Fish

Desserts

Mixed dishes

Pizza

Cold cuts

Reduced-fat milk

Pork

Shrimp

From the National Health and Nutrition Education Survey, 2005-2006. Cited in: National Cancer Institute. Sources of cholesterol among the U.S. population, 2005-2006. Risk Factor Monitoring and Methods Branch Website. Applied Research Program. http://riskfactor.cancer.gov/diet/foodsources, updated November 9, 2009.

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Animal Products

Cholesterol Saturated Fat

2 Large eggs 362 mg 3.1 g (19%)

Chicken with skin (100 g) 88 mg 3.8 g (14%)

without skin (100 g) 89 mg 2.0 g (10%)

Roast beef, lean only (100 g) 83 mg 3.4 g (17%)

Chinook salmon (100 g) 85 mg 3.2 g (13%)

Cheddar cheese (2 oz) 58 mg 11.0 g (43%)

http://ndb.nal.usda.gov/ndb/foods, accessed July 19, 2015

Plant Products

Cholesterol Saturated Fat

Black beans (100 g) 0 0.1 g (1%)

Brown rice (100 g) 0 0.2 g (1%)

Broccoli (100 g) 0 0.1 g (3%)

Sweet potato (100 g) 0 0.04 g (0.5%)

http://ndb.nal.usda.gov/ndb/foods, accessed July 19, 2015

Conclusions • Dietary cholesterol is absorbed into the

bloodstream and adds to plasma cholesterol.

• The increase is greatest at lower levels of baseline cholesterol intake.

• The increase is significant from a public health standpoint.

• Compensatory mechanisms do not prevent cholesterol elevations.

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Most current research on dietary cholesterol is industry-driven.

Industry Funding

2001 (Weggemans, AJCN):

(7/17)

2013 (Griffin, Curr Nutr Rep):

(11/12)

41%

92%

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Griffin and Lichtenstein 2013

Review of clinical trials 2003-2013

12 studies

“the effect on plasma lipid concentrations… is modest and appears to be limited to population subgroups.”

Griffin JD, Lichtenstein AH. Dietary cholesterol and plasma lipoprotein profiles:randomized-controlled trials. Curr Nutr Rep. 2013; 2: 274–282.

Author, year

Ballesteros 2004

Chakrabarty 2002

Greene 2005

Harman, 2008

Herron 2006

Isherwood 2010

Katz 2005

Knopp 2003

Mutungi 2008

Njike 2010

Pearce 2010

Vislocky 2009

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Author, year Funding

Ballesteros 2004 American Egg Board

Chakrabarty 2002 Indian Council of Medical

Research

Greene 2005 American Egg Board

Harman, 2008 British Egg Industry

Council

Herron 2006 American Egg Board

Isherwood 2010 European Fisheries Fund,

Sea Fish Industry Auth.

Katz 2005 American Egg Board

Knopp 2003 American Egg Board

Mutungi 2008 American Egg Board

Njike 2010 American Egg Board

Pearce 2010 Australian Egg Corp, Ltd

Vislocky 2009 American Egg Board

Author, year Funding Participants

Ballesteros 2004 American Egg Board 54 children


Research

18

Greene 2005 American Egg Board 41


Council

45

Herron 2006 American Egg Board 91



25

Katz 2005 American Egg Board 49

Knopp 2003 American Egg Board 197

Mutungi 2008 American Egg Board 28

Njike 2010 American Egg Board 40

Pearce 2010 Australian Egg Corp, Ltd 82, diabetes

Vislocky 2009 American Egg Board 12

Author, year Funding Participants Intervention

Ballesteros 2004 American Egg Board 54 children Egg


Research

18 Egg

Greene 2005 American Egg Board 41 Egg


Council

45 Egg, plus ↓ sat fat

and calories

Herron 2006 American Egg Board 91 Egg



25 Prawns

Katz 2005 American Egg Board 49 Egg

Knopp 2003 American Egg Board 197 Egg

Mutungi 2008 American Egg Board 28 Egg, plus a low-

carbohydrate diet

Njike 2010 American Egg Board 40 Egg

Pearce 2010 Australian Egg Corp, Ltd 82, diabetes Egg

Vislocky 2009 American Egg Board 12 Egg plus exercise

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Author, year Funding Participants Intervention TC change LDL change

Ballesteros 2004 American Egg Board 54 children Egg Not reportedU P<0.05 for some


Research

18 EggU n.s. U n.s.

Greene 2005 American Egg Board 41 EggUP<0.05 U P<0.05


Council

45 Egg, plus ↓ sat fat

and calories F n.s. F n.s.

Herron 2006 American Egg Board 91 EggU P<0.01 U P<0.01



25 PrawnsU n.s. U n.s.

Katz 2005 American Egg Board 49 EggU n.s. U n.s.

Knopp 2003 American Egg Board 197 EggU sign. for some

groups

U sign. for some

groups

Mutungi 2008 American Egg Board 28 Egg, plus a low-

carbohydrate diet U n.s. U n.s.

Njike 2010 American Egg Board 40 Egg

U P<0.01 U P<0.01

Pearce 2010 Australian Egg Corp, Ltd 82, diabetes EggU n.s. U n.s.

Vislocky 2009 American Egg Board 12 Egg plus exercise Not reported Not reported

New Meta-Analysis: 18 Intervention Trials (Berger 2015)

87% of studies on LDL cholesterol were industry funded.

Even so….

New Meta-Analysis: 18 Intervention Trials (Berger 2015)

Increasing dietary cholesterol (combined result):

Total Cholesterol ↑ 11.2 mg/dLBerger S, Raman G, Vishwanathan R, Jacques PF, Johnson EJ. Dietary cholesterol and cardiovascular disease: a systematic review and meta-analysis. Am J Clin Nutr doi: 10.3945/ajcn.114.100305.

Funded by USDA agreement 1950-51000-073 and the American Egg Board, Egg Nutrition Center.

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Cutting Through the Cholesterol Confusion

Neal D. Barnard, MDGeorge Washington University School of MedicinePhysicians Committee for Responsible Medicine

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Reversing Coronary Artery Disease

Caldwell B. Esselstyn Jr., M.D.August 29, 2016

Dr Esselstyn reports no known financial conflicts.

Absence of Coronary Artery Disease

• Rural China

• Papua Highlanders

• Central Africa

• Tarahumara Indians

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Participants 1985 - 1988

23 men, 1 woman with severe triple vessel coronary artery disease – age range 44 - 68

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AVOID

• Oil

• Fish

• Fowl

• Meat

• Dairy

• Coffee with caffeine

Lecithin and Carnitine

Eggs Poultry

Milk Pork

Cream Duck

Dairy Lamb

Liver Venison

Red Meat Shell Fish

Fish

Foods to be Included

• Whole Grains

• Legumes, lentils

• Vegetables

• Fruit

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18 Patients Followed 12 Years

• 49 coronary events during 8 years prior to study

• None in 17 compliant patients during 12 years

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Treating The Cause

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GOOD CARBS / BAD CARBS:

James H O’Keefe, MDDirector Preventive CardiologyUniversity of Missouri-Kansas CitySaint Luke’s Mid America Heart Institute

SUPERFOOD VS CARBAGE

Fundamental Unit of Nutrition

• Not the nutrient: calcium

• But the food: unsweetened yogurt

Macronutrients & health

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Carbs are good

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Added Sugar : Evil Food

The Prevailing Dogma: Calorie-Focused Thinking

Cause of Obesity: Gluttony and Sloth

Treatment of Obesity:

Eating too much AND

Exercising too littleObesity

Reduce calories AND

Exercise moreNormal Weight

An Alternative View on Obesity

Refined carbohydrates and added sugars

Altered physiology/hormones

Internal starvation

Decreased exercise and increased food intake

Obesity

Leptin Resistance

Insulin Resistance

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Obesity and Refined Carbs

.Am J Clin Nutrition. 2004 May;79(5):774-9.

Sugar Intake: USA 1815 to 2000

O’Keefe, Cordain, Mayo Clin Proc Jan 1, 2004

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16 oz 32 oz 44 oz 52 oz 64 oz

48 Teaspoons Sugar

Sugar Causes Disease

High intake of added sugars:

Dementia

Diabetes

Obesity

High triglycerides + Low HDL

Hypertension

CV Death + CHD

Post Challenge Glucose Excursion

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Added Sugars = Added Risk for CV Death

NHANES. JAMA Intern Med. 2014;174(4):516-524.

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Carbage

Superfoods

Carbage

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Superfoods

Carbage

Summary: Avoid Refined Carbohydrates

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Exercise and Cardiac Rehabilitation: What's the Latest

Pam R. Taub MD, FACC

Director of Step Family Cardiac Wellness and Rehabilitation Center

Associate Professor of Medicine

UC San Diego Health System

Overview of Talk The current state of cardiac rehabilitation

• Outcome data supporting the use of cardiac rehabilitation

• Cellular mechanisms associated with exercise

• Intensive versus traditional cardiac rehabilitation

• Barriers to utilization of cardiac rehabilitation

Future directions in cardiac rehabilitation

• Extending cardiac rehabilitation to the home through digital and wearable technologies to reduce readmission rates

• Expanding scope of cardiac rehabilitation to HFPEF, POTS, PVD, and microvascular disease

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Currently Covered Indications for Cardiac Rehabilitation(CR)

Recent myocardial infarction (within 1 year)

Post Percutaneous coronary intervention (PCI)

Coronary artery bypass grafting (CABG)

Chronic stable angina

Cardiac transplantation

Heart valve repair or replacement

Stable, chronic heart failure (EF<35%)

Outcomes Associated with Cardiac Rehabilitation

Meta-analysis of 34 randomized controlled trials

showed that exercise-based CR programs are

associated with:• A lower risk of reinfarction (OR 0.53; 95% CI: 0.38 to 0.76)

• Decreased cardiac mortality (OR 0.64; 95% CI: 0.46 to 0.88)

• Decreased all-cause mortality (OR 0.74; 95% CI: 0.58 to 0.95)

• CR reduces 90 day hospital readmission rate after

acute MI or PCI

Class IA recommendation by AHA/ACC Guidelines

Am J Med 2004;116:682–92.

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Pleiotropic Effects of Cardiac Rehabilitation

(J Am Coll Cardiol 2015;65:389–95)

Cellular Mechanisms Associated with Exercise

Improved mitochondrial function

Increased nitric oxide production

Drexler Circulation 1992

Current Reimbursement for Cardiac Rehabilitation

With the affordable care act there is a focus on preventive services

There has been a gradual increase in reimbursement for cardiac rehabilitation

Currently in California

Medicare: $107 per session

Commercial Payers (e.g Anthem Blue Cross): $132 per session

For intensive cardiac rehab (ICR), 72 covered sessions

revenue is $7700 to $9500 per patient

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Ornish Versus PritikinOrnish Pritikin

Total Number of Sessions covered 72 (max per day is 6 sessions) over 18 weeks

72 sessions (divided into 18 sessions that are 4 hours each)

72 sessions(can customize how many sessions per day)

Diet 100% plant based Allows for lean meat and fish

Format All with live instructors:1 hour of exercise1 hour of nutrition counseling1 hour of yoga and1 hour of group therapy

Patients are in groups of 10-12 and stay with the same cohort throughout the program

Some parts are Video Instruction. Sessions duration can be customized over 18 weeks

Outcome Data The Lifestyle Heart Trial showed significant regression of coronaryatherosclerosis measured by angiography in the experimental group randomly assigned to intensive lifestyle changes.(5 year results reported by Ornish JAMA 1998)

Data from Pritikin residential treatment centers showed improvement in lipids, A1c, blood pressure and weight. (Barnard Am J Cardiol 1992)

New Paradigm For Cardiac Rehabilitation

“Living Lab” for research and secondary prevention

Ideal population to deploy new technologies to prevent readmission

Good outcome trials needed

Using devices/wearables to expand the length and scope of cardiac rehabilitation

Mayo Clinic Study (Apps + Cardiac Rehab )

• 44 patients

– 25 in the app +cardiac rehab arm

– 19 in cardiac rehabilitation without the app arm

• The app tracked and monitored patient weight, BP, blood sugar and physical activity and provided educational content

• The app group had 40% less readmissions and lower blood pressure and weight

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Date of download: 4/28/2016 Copyright © The American College of Cardiology. All rights reserved.

From: THE AUGMENTATION OF USUAL CARDIAC REHABILITATION WITH AN ONLINE AND SMARTPHONE-

BASED PROGRAM IMPROVES CARDIOVASCULAR RISK FACTORS AND REDUCES

REHOSPITALIZATIONS

J Am Coll Cardiol. 2014;63(12_S). doi:10.1016/S0735-1097(14)61296-1

Exercise Training for POTS Physical deconditioning (i.e., low stroke volume and

reduced LV mass ) and reduced standing stroke volume may be important to the pathophysiology of POTS

Physical reconditioning with short-term exercise training significantly increased :

peak oxygen uptake,

expanded blood and plasma volume,

improved POTS orthostatic intolerance symptoms,

and in most cases allowed these patients to be symptom free

Study of Exercise in POTS

103 patients completed the exercise program

Heart Rhythm 2016;13:943–950

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Exercise Training in PAD

The magnitude of functional benefit derived from exercise training exceeds that observed in drug therapy trials with both pentoxifylline and cilostazol (Circulation. 2011;123:87-97)

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Heart Failure with Preserved Ejection Fraction

No proven therapies

More common in women

Heterogeneous disease

Diastolic function is an energy-dependent process requiring ATP

It is estimated that relaxation of the myocardium requires up to 15% of the total energy cost of the cardiac cycle

In patients with HPEF, there is a decrease in the ratio of mitochondria to myofibrils and the function of the mitochondria is impaired

Microvascular Disease Mainly a disease of women

Data from WISE study shows it is also associated with poor outcomes

Associated with perfusion defect on SPECT/MRI

Underlying mechanisms include endothelial dysfunction

Studies underway to evaluate impact of exercise training

Conclusions New era in cardiac rehabilitation ushered in by

change in focus and reimbursement of our health care system

Appropriate use of cardiac rehabilitation can lead to improved outcomes

Expansion of cardiac rehabilitation to diseases such as HFPEF and POTS in the future

Many digital health devices/apps but need good outcome data

the importance of calcium and the role of dairy · 8/23/2016 1 the importance of calcium and the...

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