Nutritional and Functional Medical Approach for Treating Metabolic Syndrome

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Nutritional and Functional Medical Approach for
Treating Metabolic Syndrome

• By William Rogers D.O.

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Definition of Metabolic Syndrome

• You are diagnosed with metabolic syndrome if you
  have three or more of the following
• A waistline of 40 inches or more for men and 35
  inches or more for women (measured across the
  belly)
• A blood pressure of 130/85 mm Hg or higher or are
  on blood pressure medications
• A triglyceride level above 150 mg/dl
• A fasting blood glucose (sugar) level greater
  than 100 mg/dl or are on glucose lowering
  medications
• A high density lipoprotein level (HDL) less than
  40 mg/dl (men) or under 50 mg/dl (women)

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Prevalence of Metabolic Syndrome

• Metabolic syndrome 47 million
• Type II diabetes 18 million
• Some degree of dysglycemia most likely affects
  more than 30of the adult U.S. population, and a
  rapidly increasing number of children
  adolescents

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Key Postulates

• Metabolic syndrome is the unifying theme for a
  related cluster of risk factors including insulin
  resistance, dysglycemia, dyslipidemia, excess
  visceral fat, high blood pressure, endothelial
  inflammation, hypercoagulability.
• These apparently diverse symptoms result from a
  common pathophysiologic process that typically
  develops over an extended period of time (from
  years to decades).
  
  

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Key Postulates

• The high prevalence spectrum of morbidity
  associated with this process makes it the biggest
  public health issue in this country.
• Lifestyle, dietary and nutraceutical support
  strategies offer many advantages to prescription
  drugs ,exogenous insulin or surgery for treatment
  of metabolic syndrome and prevention of diabetes.

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Stages of Dysglycemia andMetabolic Dysfunction

• Reactive Hypoglycemia
• Insulin Resistance
• Persistent Hyperglycemia Hyperinsulinemia
• Type II Diabetes

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Metabolic Syndrome Typical Progression

• Childhood Insulin Resistance
• 15 35 years Dyslipidemia
• 35 50 years Hypertension
• 40 55 years Impaired fasting glucose
• gt 55 years Type II diabetes
• Insulin resistance can be identified in children
  long before the appearance of dyslipidemia,
  hypertension and hyperglycemia
• Dr. Robert Roundtree 2007 Xymogen lecture series
  Austin, Texas

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James LaValle Cracking the Metabolic Code 2004
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Current Treatment Failing to Curb the Epidemic
Metabolic Syndrome

• Low fat, 55 carb diet since 1988 recommended to
  lower heart disease.
• 45 minutes daily exercise
• Treat cholesterol with statin/niacin ,
  statin/fishoil, statin/ fibrates
• Treat bp with ace, arbs, calcium channel
  blockers, selective beta blockers,thiazides
• Treat blood sugar with metformin, insulin, or
  other oral hypoglycemic agents

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ADAs revised Clinical Practice Recommendations

• In the recommended diet, 45 -65 of total
  calories come from carbohydrates, 20-35 from
  fats (lt7 from saturated fats), and 10 -35 from
  protein. The guidelines discourage
  low-carbohydrate diets for weight loss and give
  the use of glycemic index or glycemic load
  qualified endorsement for possibly providing a
  modest additional benefit for glycemic control.
  The 2007 recommendations note that there is
  insufficient evidence to recommend using the
  glycemic index for diabetes prevention. Diabetes
  Care (2007 30 Suppl. 1 S4-S4 1)

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Picture of the old improved food pyramid
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Picture of the new food mypyramid

• In general the Daily dietary recommendations
  consist of
• 3 to 5 servings of vegetables
• 2 to 4 servings of fruits
• 2 to 3 servings of milk, yogurt cheese
• 6 to 11 servings of bread, cereal, rice, pasta
• 2 to 3 servings of meat, poultry, fish, dry
  beans, eggs nuts
• Use fats, oils sweets sparingly

In general the Daily dietary recommendations
consist of 3 to 5 servings of vegetables 2 to 4
servings of fruits 2 to 3 servings of milk,
yogurt cheese 6 to 11 servings of bread,
cereal, rice, pasta 2 to 3 servings of meat,
poultry, fish, dry beans, eggs nuts Use fats,
oils sweets sparingly
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20 fat with 5 fruits and veggies/day and 6
grains vs. no dietary change

• NIH studied low fat, 5 fruits/vegetables and 6
  grains vs. no dietary change on 48,835 women
  spending 415 Million Dollars in an 8.1 year study
  (concluded in 2005) reported in JAMA 2006 found
• No clinically significant benefit of low fat
  diet concerning colorectal cancer
• No clinically significant benefit of low fat diet
  concerning pattern and risk of acquiring invasive
  breast cancer
• No clinical significant benefit in cardiac risk
  factors. CHD, Stroke, or CVD
• After following a healthy diet for 8.1 years the
  study group was .4kgs less in weight than
  control.
• Vol. 295 No. 6, February 8, 2006

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Houston We Have a Problem!
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Overweight/Obese Prevalence

• Data from the National Health and Nutrition
  Examination Survey (NHANES) have shown that more
  than 66 of the US population is now overweight
  or obese and the prevalence is rising at an
  alarming rate. www.cdc.gov/nchs/products/pubs/pubd
  /hestats/overweight/overwght_adult_03.htm
  Accessed September 15,2007

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Dietary strategies for improving
postprandialglucose, lipids, inflammation,
andcardiovascular health

• J Am Coll Cardiol. 2008 Jan 2251(3)249-55.
• a diet high in minimally processed, high-fiber,
  plant-based foods such as vegetables and fruits,
  whole grains, legumes, and nuts will markedly
  blunt the post-meal increase in glucose,
  triglycerides, and inflammation
• lean protein, vinegar, fish oil, tea, cinnamon,
  calorie restriction, weight loss, exercise, and
  low-dose to moderate-dose alcohol each positively
  impact post-prandial dysmetabolism
• eating patterns, such as the traditional
  Mediterranean or Okinawa diets, that incorporate
  these types of foods and beverages reduce
  inflammation and cardiovascular risk

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Diet Changes

• Since the onset of the low fat diet ,the USDA
  improved food pyramid of 1992, and mypyramid of
  2005, Obesity and Diabetes rates have rapidly
  expanded
• Harvard school of public health recommends the
  Healthy Eating Pyramid which includes calcium,
  multiple vitamins, low glycemic index
  carbohydrates, a small amount of alcohol,
  exercise, and no refined foods.
• Harvard School of Public Health claims the USDA
  was and is unduly influenced by political
  pressure exerted by food production associations.
• http//www.hsph.harvard.edu/nutritionsource/pyrami
  ds.html

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The USDA improved Pyramid of 1992

• Amazingly, the Food Pyramid was not developed by
  any of the federal agencies whose purpose is to
  promote health or any of the agencies concerned
  with nutritional or medical issues, but by the
  agency designed to promote agriculture and food
  consumption.
• Diet recommendations should be based on objective
  scientific medical research rather than the
  winners of competing economic self-interests. The
  USDA Food Pyramid serves its masters well, but
  the public suffers. "At best, the USDA Pyramid
  offers wishy-washy, scientifically unfounded
  advice on an absolutely vital topic - what to
  eat. At worst, the misinformation contributes to
  overweight, poor health, and unnecessary early
  death." Willett, Walter C., with the assistance
  of others.
• Eat, Drink, and Be Healthy The Harvard Medical
  School Guide to Healthy Eating. New York Simon
  Schuster, 2001.

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Harvard Public Health Food Pyramid
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Eat to Live Joel Fuhrman M.Ds Assessment of the
USDA Food Pyramid

• The USDA food pyramid does not encourage the
  consumption of nutrient dense plant foods. Anyone
  following the USDA guidelines eating 6 to 11
  daily servings of refined grains (breads,
  cereals, pastas), and 3 to 5 servings of animal
  products and dairy, is certain to obtain
  insufficient antioxidants and phytochemicals,
  depriving himself or herself to maximize
  prevention against common diseases. However, I do
  not recommend a grain-based diet. Potatoes, rice,
  and even whole grains do not contain the
  phytochemical power of fruits and vegetables.

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Eat to Live The revolutionary formula for Fast
and Sustained Weight Loss by Joel Fuhrman,M.D
Based on the China Study
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AHA Recommendation for Managing the Metabolic
Syndrome

• For managing both long- and short-term risk,
  lifestyle therapies are the first-line
  interventions to reduce the metabolic risk
  factors. These lifestyle interventions include
• Weight loss to achieve a desirable weight (BMI
  less than 25 kg/m2)
• Increased physical activity, with a goal of at
  least 30 minutes of moderate-intensity activity
  on most days of the week 
• Healthy eating habits that include reduced intake
  of saturated fat, trans fat and cholesterol

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High Protein-Low Carbohydrate Diet

• Apple shaped overweight people benefit from a
  high protein-low carbohydrate diet. They loose
  weight and keep it off. They improve their
  cardiac risk profile.
• JAMA May, 2007

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Kuwait Ketogenic Diet Study

• In this study, 64 healthy obese subjects with
  body mass index (BMI) greater than 30, having
  blood glucose level gt6.1 mmol/l (Group I n  31)
  and those subjects with normal blood glucose
  level (Group II n  33) were selected. Subjects
  with other complex medical histories were not
  included in this study. The body weight, blood
  glucose level, total cholesterol,
  LDL-cholesterol, HDL-cholesterol, triglycerides,
  urea, and creatinine were determined before and
  at 8, 16, 24, 48, and 56 weeks after the
  administration of the ketogenic diet.

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In a 56 Week Study, All Metabolic Syndrome
Parameters, Total Cholesterol and LDL-C Improve
with Ketogenic Diet

• Results  In the 64 subjects followed for 56
  weeks, the body weight, body mass index, the
  level of blood glucose, total cholesterol,
  LDL-cholesterol, triglycerides, and urea showed a
  significant decrease from week 1 to week 56
  (P lt 0.0001), whereas the level of
  HDL-cholesterol increased significantly
  (P lt 0.0001).
• Molecular and Cellular Biochemistry An
  International Journal for Chemical Biology in
  Health and Disease Beneficial effects of
  ketogenic diet in obese diabetic subjects
  Received 18 December 2006  Accepted
  7 March 2007  Published online 20 April 2007
  10.1007/s11010-007-9448-z

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Ketogenic Low Carb Diet

• The subjects exercised 45 minutes per day before
  the study and continued during the study.
• They took a daily Vitamin and Mineral preparation
  during the study.
• They were all between a BMI of 30 to 40 with
  normal renal and hepatic function.
• Subjects ate 20 grams Carbs /day x12weeks and 40
  grams Carbs /dayx44 weeks
• The median weight loss was 61 pounds.

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 Recommended and restricted food in ketogenic
diet

• Recommended food Proteins Fish Tuna, Sardine
  Prawns, Shrimps. Lobster Meat Kababs, Sausages,
  Minced     Poultry Chicken, Eggs     Cheese
  Full fat cheese     
• Vegetables/Fruits Spinach, Watercress, Eggplant,
  Parsley, Mulberry, Coriander, Mint, Artichoke,
  Okra, Cabbage, Mushroom, Avocado, Leek, Carrot,
  Radish, Celery, Cauliflower, Green pepper,
  Lettuce, Cucumber, Tomato, 1015 olives/ day,
  Lemon, Strawberry -6/day, Avocado, Berries-10/day
  20 grams12 w40grams46w Oil Olive oil (5
  tablespoon) added to the salad, Flax seed oil
• Fully restricted food Carbohydrates Flour,
  Potato, Macaroni Spaghetti, Noodles, Bread, Rice,
  Sugar, Sweets, Honey, Cakes
• Fruits/drinks All fruit juices, all soft drinks

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Carbohydrate restriction improves the features of
Metabolic Syndrome.
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The Atkins Hormone Found at Last?
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Starvation Hormone Found at Last?

• In the second study, scientists at the University
  of Texas Southwestern Medical Center, in Dallas,
  and colleagues found that FGF21 mobilizes fat in
  food- restricted mice and those with chronically
  elevated concentrations of the hormone (Inagaki T
  et al. Cell Metab. 2007 5 61415-425 JAMA,
  August 1, 2OO7Vo 298, No. 5 505

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Im Eating Diet Rat Food and Im Getting Fat
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Artificial Sweeteners Linked to Weight Gain

• According to the Calorie Control Council, the
  number of US residents who consume products
  containing sugar- free sweeteners grew from fewer
  than 70 million in 1987 to about 160 million in
  2000 (http//www.caloriecontrol .org). National
  survey data indicate that the incidence of
  obesity increased over that time from
  approximately 15 to 30 (Flegal KM. Physiol
  Behav. 2005
• 86 15 599-602).
• Scientists agree that while intensely sweet
  low-calorie sugar substitutes help lower the
  energy density of beverages and foods, these
  products also uncouple sweetness and energy,
  which may disrupt the bodys ability to
  accurately assess caloric intake.

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Artificial Sweeteners Part of the Problem

• For regular soft-drink drinkers, the risk of
  becoming overweight or obese was
• 26 for up to 1/2 can each day30.4 for 1/2 to
  one can each day32.8 for 1 to 2 cans each
  day47.2 for more than 2 cans each day.
• For diet soft-drink drinkers, the risk of
  becoming overweight or obese was
• 36.5 for up to 1/2 can each day37.5 for 1/2 to
  one can each day54.5 for 1 to 2 cans each
  day57.1 for more than 2 cans each day.
• For each can of diet soft drink consumed each
  day, a person's risk of obesity went up 41.
  Sources Daniel DeNoon, Fowler, S.P. 65th Annual
  Scientific Sessions, American Diabetes
  Association, San Diego, June 10-14, 2005

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Our Bodies Are Smarter Than We Think.

• . Fowler points to a recent study in which
  feeding artificial sweeteners to rat pups made
  them crave more calories than animals fed real
  sugar.
• "If you offer your body something that tastes
  like a lot of calories, but it isn't there, your
  body is alerted to the possibility that there is
  something there and it will search for the
  calories promised but not delivered," Fowler says.

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Adjustable Gastric Banding and Conventional
Therapy for Type 2 Diabetes

• Remission of type 2 diabetes was achieved by
  22(73) in the surgical group and 4(13) in the
  conventional-therapy group
• Participants randomized to surgical therapy were
  more likely to achieve remission of type 2
  diabetes through greater weight loss. JAMA.
  2008299(3)3 16-323 www.jama.com

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Bariatric Surgeries Dramatically Increase

• With a greater number of morbidly obese adults
  and higher demand for surgical solutions, it is
  not surprising that the number of bariatric
  surgical procedures performed in the United
  States swelled from 13,365 in 1998 to 72,177 in
  2002. In fact, an estimated 205,000 bariatric
  surgeries were performed in 2007 alone. However,
  with more bariatric procedures comes an upsurge
  in post surgical complications. JAOA Vol 108
  No 1 .January 2008 25

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Clinical Finding Associated with Obesity

• Increased adipose down regulates insulin receptor
  synthesis..
• Hyperinsulinemia in response to down regulation
  and glucose challenge stimulates increased
  adipose stores
• Hyperinsulinemia increases sodium retention
  leading to increase in plasma volume and raises
  blood pressure.
• Weight of adipose tissue compresses upper airways
  causing respiratory acidosis and obstructive
  sleep apnea with hypoxia.
• Degenerative arthritis in weight-bearing joints.
• Increased incidence of estrogen related cancers.
• Edward Goljan Rapid Review Pathology 2007

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Effects of Hyperinsulinemia

• Insulin blocks the enzyme lipoprotein lipase that
  inhibits the break down or fat for utilization in
  the liver and muscle tissue.
• Insulin stimulates the liver to increase free
  fatty acid production which are sent in serum to
  be deposited in the adipose tissue and increases
  fat stores.
• Insulin inhibits the production of glucagon.
• Insulin receptors become dysfunctional.
• Elevates Blood Pressure
• Alters lipid patterns
• Creates a pro inflammatory state.

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Increased BMI and Hyperinsulinemia Promote
Endothelial Dysfunction

• The Renin-Angiotensn-Aldosterone System (RAAS) is
  the pathophysiologic corner stone in the
  hypertensive disease process. www.JHASIM.com,
  2007, Vol.712 365-371
• The RAAS is controlled by the sympathetic nervous
  system (SNS).
• Excess weight, hyperinsulinemia, and an unhealthy
  diet have been shown by numerous investigators to
  elevate SNS activity (Curr. Dib. Rep.
  20077208-217) and activates RAAS.

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Renin-Angiotensin-Aldosterone System

• RAAS activation by the SNS leads to endothelial
  dysfunction and inflammation by promoting
  production of angiotensin II which induces
  vascular injury, vasoconstriction, cell growth,
  oxidative stress, and inflammation (Inducing
  release of cytokines and proinflammatory
  transcription factors) contributing to the
  prothrombotic state and plaque buildup and
  instability, and ultimately to plaque rupture.
  Clin. Sci 2007112375-384

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Elevated Blood SugarGlobal Impact on Health

• The predictive value of HbA1C for total
  mortality was stronger than that documented for
  cholesterol concentration, body mass index and
  blood pressure.
• Glycated haemoglobin, diabetes, and mortality in
  men in Norfolk cohort of European Prospective
  Investigation of Cancer and Nutrition. Khaw, K-T,
  et al, BMJ, 2001, Vol 322 1-6

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Weight Loss Improves HDL-C

• Now some researchers have turned their attention
  to boosting HDL-C levels. There is no question
  that the epidemiology is therethat HDL levels
  are inversely related to cardiovascular disease
  risk, said Steven E. Nissen, MD, chairman of the
  Department of Cardiovascular Medicine at the
  Cleveland Clinic Foundation. Secondly, theres
  evidence that raising HDL, by some mechanism, is
  beneficial. Lifestyle techniquesincluding
  exercise, weight loss, and smoking cessationhave
  been shown to modestly improve HDL-C levels. So
  have some medications, notably nicotinic acid
  (niacin or vitamin B3) and fibrates. JAMA,
  February 6, 2008Vol. 299, No. 5 509 .

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Exercise Impact on HgbA1c

• Ann Int Med 2007, Vol 147 357-369
• Systematic reviews show that structured exercise
  reduces hemoglobin A1c an average of 0.6
• Both aerobic resistance training had comparable
  effects
• In unblinded study of 251 adults with type
  II diabetes Combination of aerobic and
  resistance exercise training 45 minutes 3X per
  week) for 3 months resulted in an additional
  drop in Hgb A1c of 0.46-0.59 compared to either
  type alone (total drop of 0.97)

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NHANES-II

• 91 of Americans do not eat the suggested 2
  daily servings of fruits and 3 servings of
  vegetables
• 50 of Americans receive less than the RDA for
  Vit. A, C, Ca, Iron.
• Patterson BH, et al. Fruit and Vegetables in the
• American Diet Data from the NHANES-II survey.
• Am J Pub Health 80(2)1443-1449, 1990.

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USDANational Food Consumption Survey

• Evaluated food intake of 21,500 people over a
  three day period
• Results showed that not a single person consumed
  100 of the RDA for the 10 nutrients surveyed
• Source USDA National Food Consumption Survey
  1977-78

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USDA Nutritional Survey

• Nutrient Below RDA
• Vitamin B-6 80
• Magnesium 75
• Calcium 68
• Vitamin A 50
• Vitamin B-1 45
• Vitamin C 41
• Vitamin B-2, B-3, B-12 34
• Pao EM, Mickle SJ. Problem Nutrients in the
  United States.
• Food Technology 3558-62, 1981.

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My Preference of Supplement Form

• Liquid pharmaceutical grade cod liver oil each
  batch tested for heavy metals produced in a
  nitrogen rich environment in a small bottle and
  once opened refrigerated.
• Capsules of plant origin enzymes mixed with
  multiple probiotic bacteria with fos
  (fructooligosaccharides)
• Capsules of multiple vitamins from plant sources
  that do not make me nauseated.
• Gel caps of fat soluble vitamins that are low
  potency
• Capsules of multiple minerals bonded to an amino
  acid( chelated) for better absorption that
  doesnt make me sick.
• You can not get a one a day large enough to
  include everything you need.

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Optimal vitamin nutritional supplement
407 cracking the metabolic code by james b.
lavalle, r.ph,ccn,nd 2004
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Nutraceutical Candidatesfor Metabolic Syndrome

• Antioxidants
• Ascorbic acid
• Gamma tocopherol
• NAC
• Alpha Lipoic Acid
• Resveratrol
• CoQ10
• Magnesium
• Chromium
• Probiotics

• L-arginine
• DHEA
• Niacin
• Taurine
• DHA
• CLA
• Oat bran
• Whey protein
• Vitamin D
• Digestive Enzymes

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Botanicals for ManagingMetabolic Syndrome

• American Ginseng (12 extract) 750 mg
• Gurmar (Gymnema sylvestre) 400 mg
• Cinnamon (Cinnulin 201) 250 mg
• Green tea polyphenols 400 mg

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Digestive Enzymes

• If it wont spoil, dont eat it
• If it does spoil, eat it before it spoils
• If it wasnt available to eat 2000 years ago,
  dont eat it

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Digestive Enzymes

• Use after gallbladder surgery
• Use if you are having trouble digesting your food
• Signs and symptoms of poor digestion include
  belching, bloating, abdominal discomfort,
  constipation, and even heartburn.
• First try a product that includes a full range of
  digestive enzymes and contains pepsin, papain,
  and betaine.
• Avoid if active peptic ulcer disease exists
• Recommend one to three tablets with meals three
  times a day

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Probiotics

• Friendly bacteria in the G.I. tract
• Lactobacillus Acidophilus and Bifidobacterium
  bifidus
• Key players in maintaining GI function its
  interplay with the immune system
• When intestinal flora becomes imbalanced immune
  dysregulation and inflammation usually follow.
• Probiotics help with constipation, diarrhea,
  mucus in the stools, and are invaluable if you
  are going through radiation or chemotherapy.
• Synthesis of vitamins
• Recommend 5-10 billion CFU of dairy free
  probiotics a day. (keep refrigerated after
  opening)

Recommend l-glutamine 500mg three a day with
radiation and chemotherapy. Avoid with liver
failure
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Benefits of Cod Liver Oil

• Reduces susceptibility of the heart to
  ventricular arrhythmia
• Antithrombogenic
• Hypotriglyceridemic (fasting and postprandial)
• Retard growth of atherosclerotic plaque
• Reduce adhesion molecular expression
• Reduce platelet-derived growth factor
• Anti-inflammatory
• Promote nitric oxide-induced endothelial
  relaxation
• Mildly hypotensive

2750 circulation Nov19,2002
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OMEGA 3 FATTY ACIDS(DHA,EPA)NUTR Rev 20036163

• Anti-thrombotic
• Reduce sudden death, arrhythmias, Ml,CHD
• Inhibit cytokine-induced NFKB activation
• Inhibit cytokine-stimulated endothelial cell
  adhesion
• molecules VCAM, I-CAM and E-selectin
• Reduce blood pressure heart rate
• Dose
• DHA 600-1200 mg per day
• EPA 900-1800 mg per day

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Resveratrol improves health and survival of mice
on a high-calorie diet
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