clinical guidance to help your patients make …...clinical guidance to help your patients make...
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Clinical Guidance to Help Your Patients Make Healthier Food Choices
October 27, 2011
Webinar sponsored by the American Medical Association, in partnership with Health Care Without Harm, Kaiser Permanente, and Physicians for Social Responsibility
Moderator: Robert M. Gould, MD, Associate Pathologist, Kaiser Hospital, San Jose and President, San Francisco-Bay Area Chapter of Physicians for Social Responsibility
Presenter: Ted Schettler, MD, MPH is Science Director of the Science and Environmental Health Network (www.sehn.org). He also serves as science director of the Collaborative on Health and Environment (www.healthandenvironment.org). He has a medical degree from Case Western Reserve University and a masters in public health from Harvard University. Schettler has addressed the connections between human health and the food, chemical, built, and social environments in numerous publications and presentations. He has served on advisory committees of the US EPA and National Academy of Sciences. and practiced medicine primarily in New England for many years.
This webinar is being recorded for archiving and available for CME credit for one year. Individual PowerPoint presentations will also be available for download when approved by presenters. For more information on this
webinar series, including CMEs for physicians, and to view past events, please visit http://www.healthyfoodinhealthcare.org.
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Clinical Guidance to Help Your Patients Make
Healthier Food Choices
Ted Schettler, MD, MPHScience Director, Science and Environmental Health Network
Scope of the Presentation
Rationale for Food Matters Webinar Series
Ecological and Lifecycle Approach
Scope of Obesity Epidemic and Role of Western Diet
Drivers of the Western Diet and Diseases
Healthy Diet – First Foods and Beyond
Helping Your Patients Make Healthier Choices
Guiding Rationale A Food Systems Approach
Our current food system:
Produces large quantities of calorie-rich, nutrient-poor food
Is a major driver of obesity, diabetes, cardiovascular disease, some kinds of cancer, malnutrition, and other chronic diseases
Substantially contributes to environmental degradation with impacts on public health, including air and water pollution, climate change, and loss of biodiversity
Guiding Rationale Child & Maternal Health
Good nutrition is an essential requirement of healthy human development,
Developing humans are uniquely vulnerable to toxic environmental exposures, and
The health impacts of in-utero and early life nutrition and toxic exposures have consequences across an individual’s lifespan.
Guiding Rationale Healthcare Responsibilities
What is the responsibility of the healthcare sector to address the nutritional and environmental origins of the diseases they treat?
What role can the healthcare sector play in reversing the epidemics of today, and envisioning a healthier future?
Food Matters to Pregnant Women, Children and Future Generations
Nutrition MattersGood nutrition is an
essential requirement of healthy human development
Vulnerability MattersDeveloping fetus and
human are uniquely vulnerable
to environmental exposures
Timing MattersHealth consequences of in-
utero and early life exposures can manifest across an
individual’s lifespan
Developmental Origins of Adult Disease
“It is suggested that poor nutrition in early life increases susceptibility to the effects of an affluent diet. . .”
Barker DJ, Osmond C. Infant mortality, childhood nutrition, and ischaemicheart
disease in England and Wales. Lancet. 1986 May 10;1(8489):1077-81.
Timing Matters
Exposure in early gestation: three-fold increase in coronary heart disease, more obesity
Exposure in mid-gestation: increase in obstructive airways disease
Exposure in late gestation: impaired glucose tolerance
Painter RC, Roseboom TJ, Bleker OP. Prenatal exposure to the Dutch famine and disease in later life: an overview. Reproductive Toxicology. 2005 Sep-Oct;20(3):345-52.
Early Life Experiences Can Influence Later-life Health and Disease
Toxic exposuresMaternal nutrition
Psychosocial stressors
Obesity, hypertension,Cardiovascular disease,
diabetes
Alzheimer’s, dementia,
Parkinson’sLow birth weight
Aging begins at conception
An Ecological Health Framework: The individual in the context of family, community, society and ecosystem
Public Health Impact of Environmentally-Driven Western Disease Cluster is Profound
Obesity/overweight2/3 US adults, prevalence X2 in ~25 yrs
Pre/Diabetes 40% US adults. Prevalence DM ~X2 over 20 yrsType 2 diabetes now appearing in children, adolescents; usually associated with obesity
Cardiovascular disease Still leading cause of death
Metabolic syndrome Early signs of other cluster diseases; 35% adults, ~55%>60 yrs
Metabolic syndrome in childhood increases the risk of cardiovascular disease in adulthood 15 fold
Chronic Disease: Nutrition and Health
Soda and fast food consumption linked to increased risk of weight gain and diabetes.
Average consumption of high fructose corn syrup has increased by over 25% in the last 30 years.
High-sugar or high-fat foods comprise almost 30 percent of all calories consumed by Americans.
Increase in daily calories over the last 20 years (men 168, women 300).
Food Environments Drive Chronic Disease
Altered PathwaysNutritional/
Environmental Factors
Chronic Disease
Mechanisms of ActionInflammationInflammation
Disrupted Insulin SignalingDisrupted Insulin Signaling
Oxidative StressOxidative Stress
Inflammation
Inflammation is a dimension of:
Diabetes
Metabolic syndrome
Obesity (in most but not all individuals)
CVD
Some neurodegenerative disorders
Other chronic illnesses (e.g. various malignancies)
Insulin Signaling = Normal Metabolism
Insulinsignaling
• ↓ blood sugar• ↓ artery disease• ↓ triglycerides
Disrupted Insulin Signaling = Inflammatory Metabolism
Some Nutrients Are Increasingly Pervasive and Promote Inflammatory Metabolism
What’s Changed in the Western Diet?
Year
% o
f cal
orie
s fr
om fa
t
mg/
day
High Glycemic Carbohydrates Increase the Risk of Chronic Disease
High glycemic carbohydrates break down quickly during digestion, rapidly releasing glucose (sugar) into the
bloodstream.
ΔPl
asm
a In
sulin
,mg/
dl
Time, mins
INSULINEMIC RESPONSE
Low glycemic food
High glycemic food
Properties of Fatty Acids
Omega-3 Omega-6 Saturated
• Perishable • Durable Increased inFood • Short shelf life • Long shelf life factory-farmed
System • Increased in • Processed foods animalspasture-fed animals
Immune Anti-inflammatory Inflammatory & InflammatoryProperties Anti-inflammatory
Evolutionary Recent marked Recent marked Recent markedContext decline increase increase
Nutrient Influences on Insulin Signaling, Inflammatory Metabolism
Saturated fat ↓ Antioxidants
High Glycemic Carbohydrates
Fructose
The Importance of Early Nutrition: In the Womb & Infancy
Growth
Developmental programming Epigenetic: DNA methylation, histone modification,
RNA interference
Establish “set points” of various phenotypic traits; program immune system, etc.
Influence susceptibility to adult disease; e.g. obesity, metabolic syndrome, diabetes, cancer, neurodegenerative disease, etc.
Pilot Study: Impact of low glycemic load diet in overweight/obese pregnant women
n=46
Low-GL Diet:Longer pregnancy duration (delivery <38 weeks 13% vs. 48%)
Greater Infant Head Circumference
Lower maternal triglycerides and cholesterol
Dietary interventions may help prevent premature births and other adverse maternal and infant outcomes
This study needs to be repeated with larger numbers
Maternal High Glucose and Increased Risk of Diabetes in Children
Prenatal exposure to high levels of maternal blood glucose reduces insulin sensitivity in infants
Gestational diabetes associated with increased risk of Type 2 diabetes in children; not entirely explained by BMI
Rationale for focus on healthy food in pregnant women as a driver of health of future generations
Breast Feeding Advantages: Infant
Reduced infectious disease pneumonia, gastroenteritis, otitis media, other
Lower risk of type 1 diabetes; type 2 diabetes if mother does not have diabetes
> 6 mo. decreases the risk of childhood cancerleukemia, Hodgkins, neuroblastoma
Lower risk of inflammatory bowel disease
Improved neurological development and lower asthma risk (inconsistent evidence)
Breast Feeding Advantages: Maternal
Less postpartum bleeding
Earlier return to pre-pregnancy weight
Improved bone strength; decreased risk of hip fracture later in life
Reduced ovarian and pre-menopausal breast cancer
Birth control
Women who don’t breastfeed have increased risk of type 2 diabetes
Influence of Nutrition on Chronic Disease
Increase risks saturated and trans fatshigh glycemic carbohydrateslack of fruits/vegetables/omega 3sexcess omega 6s?
Reduce risks fruits, vegetables, nutsomega 3slow glycemic carbohydrate“Mediterranean-type” diet
Benefits of Mediterranean-Type Diet on Chronic Disease Risk
Clinical intervention studies
70% ↓ heart attacks, cardiac death & total mortality DeLogeril, 94
60%↓ cardiac events in CVD patients* Ornish, 98
~50% ↓ metabolic syndrome Esposito, 04
39% ↓ in CRP Esposito, 04
↓ insulin resistance Esposito, 04
↓ weight Esposito. 04
*10% low fat, vegetarian diet + exercise, stress reduction
Benefits of Mediterranean-Type Diet on Chronic Disease Risk
Prospective observation studies
80% ↓ diabetes Martinez-Gonzalez, 08
~31% ↓ all-cause & cardiovascular mortality
22% ↓ cancer mortality** calculated from Sofi, 08
73% ↓ Alzheimer’s mortality Scarmeas, 07
25-30% ↓ Parkinson’s disease Gao, 07
Systemic Drivers of Diet and Food Choices 33
Advertising & Media
Access & AvailabilityFast food restaurants, food deserts
Education, social psychology, and early life experiences
Cost
Food Advertising
$25-30 billion per year Twice the amount needed to provide health and nutrition for everyone in the world. -UNDP 1998
$12 billion per year Aimed at marketing to children.
Subsidies: Abundant, low-priced corn and soybeans foster cheap junk foods
Economic Drivers of Food Choice
Interconnections Between Nutrition and Environment
Helping Your Patients Make Healthier Choices
Summary: What is a healthy diet?
Observations are applicable for your patients at every age
Early life nutrition affects health status, chronic disease risklater in life
Food system, including production, distribution, and advertising have strong influences on the diets of individuals
References
Barker DJ, Osmond C. Infant mortality, childhood nutrition, and ischaemicheart disease in England and Wales. Lancet. 1986 May 10;1(8489):1077-81.
Painter RC, Roseboom TJ, Bleker OP. Prenatal exposure to the Dutch famine and disease in later life: an overview. Reproductive Toxicology. 2005 Sep-Oct;20(3):345-52.
De Logeril et al. Med. diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999 Feb 16;99(6):779-85.
Barzi F et al. Mediterranean diet and all-causes mortality after myocardial infarction: results from the GISSI Prevenzione trial European Journal of Clinical Nutrition (2003) 57, 604–611
Estruch R, Martínez-González MA, Corella D, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med. 2006 Jul 4;145(1):1-11.
Serra-Majem et al. Scientific evidence of interventions using the Mediterranean diet: a systematic review. Nutr Reviews 2006 Feb;64(2 Pt 2):S27-47.
Vincent-Baudry S, et al..The Medi-RIVAGE study: reduction of cardiovascular disease risk factors after a 3-mo intervention with a Mediterranean-type diet or a low-fat diet.Am J Clin Nutr. 2005 Nov;82(5):964-71.
Esposito, K et al. Effect of a Med-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome. Random. Trial. JAMA 292(2):1440-6, 2004.
Estruch R, Martínez-González MA, Corella D, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med. 2006 Jul 4;145(1):1-11.
References40
Shai I, Schwarzfuchs D, Henkin et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008 Jul 17;359(3):229-41.
Brunner EJ. Dietary patterns and 15-y risks of major coronary events, diabetes, and mortality.Am J Clin Nutr. 2008 May;87(5):1414-21.
Martínez-González MA et al. Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study. BMJ. 2008 Jun 14;336(7657):1348-51. Epub 2008 May 29.
van Dam RM, Dietary patterns and risk for type 2 diabetes mellitus in U.S. men. Ann Intern Med. 2002 Feb 5;136(3):201-9.
Benetou V et al. Conformity to traditional Mediterranean diet and cancer incidence: the Greek EPIC cohort. Br J Cancer. 2008 Jul 8;99(1):191-5.
Sofi F, Adherence to Mediterranean diet and health status: meta-analysis. BMJ. 2008 Sep 11;337.
Rhodes, et al. Effects of a low–glycemic load diet in overweight and obese pregnant women: a pilot randomized controlled trial. American Journal of Clinical Nutrition. 2010. 92 (6): 1306-1315.
Clinical Guidance to Help Your Patients Make Healthier Food Choices
October 27, 2011
Webinar sponsored by the American Medical Association, in partnership with Health Care Without Harm, Kaiser Permanente, and Physicians for Social Responsibility
Upcoming webinars:
This webinar is being recorded for archiving and available for CME credit for one year. Individual PowerPoint presentations will also be available for download when approved by presenters. For more information on this
webinar series, including CMEs for physicians, and to view past events, please visit http://www.healthyfoodinhealthcare.org.