Nutrition and Disease Prevention

Dr. David L. Gee

FCSN 245 Basic Nutrition

Leading Causes of Death

#1 - Heart Disease 280 deaths/100,000/yr

#2 - Cancers 210 deaths/100,000/yr

#3 - Strokes 60 deaths/100,000/yr

#8 - Diabetes 20 deaths/100,000/yr

Incidence of early heart disease (under age 65)

Males: 300/100,000 fatal MI 80/1,000 MI

Female: 125/100,000 fatal MI 45/1,000 MI

History of a Heart Attackearly stages

Fatty StreaksFactors that contribute to fatty streak

formation hypertension cigarette smoke inflammation other causes?

Low-grade Systemic Inflammation in Overweight Children

Pediatrics, Jan. 2001 cross-sectional epidemiological study 3,561 children, 8-16 yrs old C-reactive protein (a marker of

inflammation) linked with development of heart disease in overweight adults

C-reactive Protein in Overweight Children

Other factors (smoking by parents, inactivity) have also been Associated with increased CRP in children.

History of a Heart AttackProgression of the disease

Atherosclerosis “Hardening of the arteries”

Accumulation of lipids (LDL-C) by macrophages forming foam cells

Growth of fibrous cells on inner wall of coronary arteries

Calcification of endothelium of coronary arteries Results in coronary arteries that are narrowed and

stiff causing reduced blood flow.

CHOLESTEROL BUILDSToo much fat in the blood can build up as plaque within heart vessel

walls. Its presence triggers the inflammation alarm, attracting immune cells such as monocytes, which seek out and attach to the plaque.

INFLAMMATION SETS INThe monocytes mature into macrophages, which begin engulfing the

fatty plaque. The immune activity alerts the liver to produce CRP, which floods in to attack the growing plaque.

A HEART ATTACK OCCURSAs immune cells pile onto the plaque, it becomes increasingly

unstable and eventually ruptures. Debris from the lesion can cause a blood clot or trigger a heart attack.

History of a Heart AttackEnd stage of the disease

AnginaMyocardial Infarction

Thrombosis: growth of stationary clot

Embolism: sudden closure by loose clot

IschemiaLocal deficiency of blood supply

History of a Heart Attack

Warning signs Angina & shortness of breath Often no warning!

Treatment of late-stage CHDSecondary Prevention of CHD

Testing Stress test Angiogram

Angioplasty Balloon angioplasty stents

Coronary Bypass Surgery Grafting of healthy veins around diseased coronary

arteries

Primary Prevention of CHD

Know your risk factorsMake dietary changesStart/continue exerciseStop smokingStress reductionUse medication if necessary

CHD Risk Factors( * modifiable)

High LDL-cholesterol * Low HDL-cholesterol * High blood pressure * Family history of early CHD Current cigarette smoking * Diabetes * (Obesity *)

Risk Factors for CHD

High Total Blood Cholesterol >200 mg/dl: borderline high risk >240 mg/dl: high risk

High LDL-C >130 mg/dl: borderline high >160 mg/dl: high risk

© 2002 Wadsworth Publishing / Thomson Learning™

Lowering your LDL-C

Decrease dietary saturated fat < 10% calories (dietary guidelines) < 7% calories (AHA diet)

Decrease dietary cholesterol < 300 mg/day (dietary guidelines) < 200 mg/day (AHA diet)

Lowering your LDL-C

Replacing dietary SFA with MUFA Canola oil, olive oil

Increase dietary fiber (soluble) Whole grains, oats, fruits, vegetables

Pectins (fruits)Beta-glucans (oatmeal)

Lowering your LDL-C

Decrease dietary Trans-FADecrease dietary Trans-FA Reduce consumption of foods containing

hydrogenated fats

Lowering your LDL-C Medications

Plant stanols/sterolsBenecol, Take Control Inhibits absorption of dietary cholesterol

“Statin” drugs Zocor, Lipitor Inhibits cholesterol synthesis in liver

Bile acid binding resins Questran Prevents reabsorption of bile acids and forces liver to make more from

cholesterol

Niacin (pharmacological doses) Prevents synthesis of VLDL and LDL

Risk Factors for CHD

Low HDL-C< 40mg/dl : high risk> 65mg/dl : protective

Increasing your HDL-C

ExerciseAlcohol (chronic low dosages)

1-2 servings/d males1 serving/d females

Acute high dosages can cause dyslipidemia

Risk Factors for CHD

HypertensionDiabetes

lose weight if overweight (type 2) control blood sugar

Cigarette smoking quit/don’t start

When you stop smoking, your body begins a series of changes that continue for years:

Source: Centers for Disease Control and Prevention 20 minutes after quitting

Your heart rate drops. 12 hours after quitting

The carbon monoxide level in your blood drops to normal. 2 weeks to 3 months after quitting

Your heart attack risk begins to drop. Your lung function begins to improve.

1 to 9 months after quitting Your coughing and shortness of breath decrease.

When you stop smoking, your body begins a series of changes that continue for years:

Source: Centers for Disease Control and Prevention

1 year after quitting Your added risk of heart disease is half that of a smoker's.

5 years after quitting Your stroke risk is reduced to that of a non-smoker's five to 15 years

after quitting. 10 years after quitting

Your lung cancer death rate is about half that of a smoker's. Your risk of cancers of the mouth, throat, esophagus, bladder, kidney and pancreas decreases.

15 years after quitting Your risk of heart disease is back to that of a non-smoker's.

Non-modifiable Risk FactorsAge

males over 45 female post-menopause

Family History premature CHD

males under 55females under 65

Risk Reduction

0

20

40

60

80

100

smoke, hiBP, hiTC

hiBP, hiTC

hiTC

none

Is heart disease reversible?

Dean Ornish: Reversing Heart Disease Very low fat (<10% of Calories)

Minimal saturated fatSemi-vegetarian, whole grains

Exercise & Stress Reduction Randomized Controlled Trials

Angiograms show regression of lesions

Copyright restrictions may apply.

Nissen, S. E. et al. JAMA 2006;0:295.13.jpc60002-10.

Example of Regression of Atherosclerosis in a Patient in the Trial

Regression with 2 year use of high dosage of cholesterol-lowering medication

May is American Stroke Month, but strokes happen year-round. Each year 700,000 people have a new or recurrent stroke. On average every three minutes someone dies of a stroke. There are currently 4.8 million stroke survivors.

What causes a stroke?

Stroke: when part of the brain does not blood and oxygen it needs and cells begin to die within minutes

Ischemic Stroke: blockage of blood vessels Cerebral thrombosis: growth of stationary clot Cerebral embolism: wandering clot

Hemorrhagic Stroke: bleeding in brain Ruptured aneurysm

Risk Factors For Stroke

High blood pressure Smoking Diabetes Carotid Artery disease Some blood disorders (sickle cell disease) High blood cholesterol Physical inactivity High alcohol consumption

Hypertension

Definition Diastolic Blood Pressure

> 90 mm Hg Systolic Blood Pressure

> 140 mm Hg Desirable < 120/80 New 2003 definition:

DBP: 80-90 or SBP: 120-140 Prehypertension

Hypertension and Disease

Stroke 2/3rds with first stroke have HPT 7 times more likely than normal

Coronary heart disease 1/2 with first MI have HPT 3 times more likely than normal

End-stage Renal FailureBlindness

Hypertension

Prevalence 50 million > one quarter of adults

Of people with hypertension 30% are unaware of it 34% are on medication and have it under control 25% are on medication and still have hypertension 11% are not on medication

Risk Factors

Age Risk increases with age

Ethnicity Risk higher among African-Americans

Family HistoryObesity

Risk higher in overweight and obese

Dietary Treatment for Hypertension

Weight LossModerate weight lossRegular exercise

Weight Loss vs. Medication

-40

-35

-30

-25

-20

-15

-10

-5

0

5

Weight Loss Medication Placebo

SBP

DBP

LVM

Dietary Treatment for Hypertension

Salt and Sodium NaCl is 40% Na

Is the (recommended) amount in mg sodium mg sodium chloride

~50% responsive Salt restriction doesn’t work for everybody

Salt restriction and prevention of hypertension debate

Diet and Hypertension

Salt Recommendations WHO: < 6 g/day (2400mg Na/d)

` 1 tsp salt

Salt Intake US: 8 g/day (3200mg Na/d) Asia: 30-40 g/day

Sources of Salt

10% unprocessed foods15% added by consumer75% in processed foods

Salt in Processed Foods

Foods prepared in brine Pickles (1700mg/pickle), sauerkraut (940mg/c)

Smoked and cured meats Ham (1200mg/3oz), bacon (300mg/3 slices)

Salty snacks Chips (170mg/oz)

Highly processed foods Fast foods (950mg/BigMac) Sauces and condiments (180mg/Tcatsup) Canned and instant soups (1100mg/c CNS)

How do you eat a low sodium diet (<1800 mg/day) ????

Teriyaki sauce: 700 mg/T BBQ sauce: 425 mg/ 2T Polish sausage: 2000 mg Italian salad dressing: 200 mg/T Pepperoni pizza: 880 mg/slice Apple pie: 330 mg/slice Canned pasta w/ sauce: 800 mg/serving Frozen buttermilk pancakes: 370 mg/serving

Other Dietary Treatments for Hypertension

Alcohol < 1-2 servings per day >2 servings increases risk of hpt

Potassium fruits and vegetables

Fish Oils Calcium

The DASH Dietp 410-411

Dietary Approaches to Stop Hypertension 1997 DASH trial -NHLBI Diet rich in

fruit vegetable grain products

Low/non fat dairy, fish and meats

DASH-Na TrialNEJM (1/4/01)

412 mild hypertensive adults30 day intervention

DASH vs Control Diet Low, Intermediate, High Sodium

(1200, 2300, 3500 mg Na/d)

The DASH Diet

For 2000 Calorie/day diet:Grain products: 8 servings (6-11)Vegetables: 5 servings (3-5)Fruits: 5 servings (2-4)LF/NF Dairy: 3 servings (2-3)LF Meats: 2 servings (2-3)Nuts, seeds, legumes: 1 serving

DASH-Na Conclusions

DASH diet lowers BP Sodium reduction lowers BP Combination of DASH and Na reduction

effects greater than separately DASH+low-Na reduced Systolic BP by:

11.5mm Hg in Hpt subjects7.1 mm Hg in borderline Hpt subjects

DASH-Na Conclusions

Benefits seen with men and women blacks and non-blacks hypertensive and borderline hypertensive

A 2 mm Hg drop in DBP results in: 17% reduction in Hpt 6% reduction in CHD risk 15% reduction in stroke risk

http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm

DASH has also been shown to:

Reduce risk of heart disease by-reducing blood pressure-Decreasing LDL-C

-Reduce body weight in -overweight subjects

-Improve glucose control -In diabetics

-Contain dietary components that -Reduce risk of cancer

Diet and Cancer

Definitions Cancer: uncontrolled growth and spread of

abnormal cells Tumor: mass of cancer cells

benign tumor (non-harmful, non- invasive) malignant tumor (harmful, invasive)

Metastatic Cancer: spreading to other tissues

Cancer Facts

US men have a 1 in 2 lifetime risk US women have a 1 in 3 lifetime risk 1,220,000 new malignant cancer cases in

2000 552,000 cancer deaths in 2000

Cancer TrendsJNCI, 1999

1990-1996All cancer incidence declined by

2.2% -4.1% males -0.5% females

US Male Cancer Death Rates by Site

US Women Cancer Death Rate by Site

Cancer in Women

020406080

100120140160180200

Lung Colon Pancreas Uterus

Deaths

New Cases

Cancer RatesRacial Differences

0

50

100

150

200

250

300

350

400

450

Blacks Cauc. Hisp. Asian Indian

Incidence

Mortality

The Cancer Development Process

Initiation Alterations in DNA/gene mutation

Multiple genes must be altered for cancer to occur minutes - days Causes: Exposure to Carcinogens

radiation chemical viruses

The Cancer Development Process

Promotion “locking in” DNA alterations/gene mutations

Genes affecting cell differentiation Cancer cells are de-differentiated from cells they come from

Genes affecting cell division Cancer cells divide uncontrollably

failure of DNA repair mechanisms cancerous cells begin to divide months - years

The Cancer Development Process

Cancer ProgressionUncontrolled growth of cancer

cellsmalignancy and metastasisweeks to years

Diet and Cancer Development

Initiation Dietary sources of carcinogens & pre-

carcinogensaflatoxin mold from peanutsbenzopyrene from charbroiled meatsnitrosamine from cured meats

Dietary Protection antioxidants dietary fiber

Diet and Cancer Development

Promotion Dietary promoters of cancer

Fat and PUFAexcess alcohol

Dietary anti-promoters of cancervitamins & phytochemicals

Progression Dietary factors increasing cancer progression

excess Fat and calories

Diet and CancerACS 2000

One third of cancer deaths in US is due to cigarette smoking

One third of cancer deaths in US is due to diet

5-10% of cancers are hereditary

Folate and Colon Cancer

Harvard Nurses’ Health Study 1998 89,000 women

If consumed >400 ug folate -> 30% lower risk than those consuming <200 ug folate

If consume folate supplements daily for 15 years -> 75% lower risk supplements more bio-available consumed more total folate

1999 ACS Dietary Guidelines

Choose most of the foods you eat from plant sources. Five A Day low in fat and calories high in folic acid, vitamin C, beta-carotene high in fiber high in phytochemicals

ACS Dietary Guidelines

Limit your intake of high-fat foods, particularly from animal sources dietary fats are cancer promoters colon, prostate, endometrial cancers linked to high

intake of animal fats cured and smoked meats contain carcinogens

Nitrosaminesbenzopyrenes

ACS Dietary Guidelines

Be Physically Active: achieve and maintain a healthy weight

Obesity associated with most cancers

Exercise and Dietary Modifications

Overweight, Obesity, and Mortality from Cancer in a

Prospectively Studied Cohort of U.S. Adults NEJM 348:1625(April 2003)

900,000 adults Prospective study, free of cancer

Self reported height/body weight in beginning 16 year follow up ~57,000 cancer deaths

Obesity and Mortality from CancerNEJM April 2003

ACS Dietary Guidelines

Limit consumption of alcoholic beverages, if you drink at all.

Associated with: Breast cancer Mouth and throat cancers Liver cancer

Effect of smoking and alcohol are more than additive (synergistic)

Dietary GuidelinesAmerican Heart Association

Heart disease and strokeAmerican Cancer Society

CancersAmerican Diabetes Association

General Agreement !