The Role of Nutrition in the

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The Role of Nutrition in the Treatment of
Chronic Disease Norman Hord, PhD, MPH,
RD Department of Food Science and Human Nutrition
http//www.msu.edu/course/hnf/470
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Outline

• Diet-Related Chronic Disease Risk
• Efficacy of Dietary Treatment of Chronic Diseases
• Nutrients as Medicine
• Food As Social Currency

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Introduction 1

• The rise in the number and proportion of older
  people has led to concern about societal
  consequences.
• We associate age with Increasing Loss of
  independence disability Functional impairments
  Loss of mobility Loss of sight
  Loss of hearing

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Introduction 2

• Maximum life expectancy has not changed much
  AVERAGE life expectancy HAS.
• Major challenge How can we maintain health and
  quality of life in an aging population?

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Causes of Death
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Risk of Death From CVD and Cancer Increases with
Age
Data from American Heart Association (1997)
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Data from the American Heart Association (1997)
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The Framingham Heart Study
The Best 50 Million the U.S. government ever
spent!
50 Years of Medical Discovery
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Framingham Findings
Cigarette Smoking Causes Coronary Heart Disease!
Diabetes is an Underlying Cause of Heart Disease
Physical Exercise Lowers Risk of Heart Disease
Obesity Increases Risk of Heart Disease
Serum Cholesterol Heart Disease Risk
Hypertension Stroke Risk
Estrogen Replacement Therapy Lowers Risks of Hip
Fracture
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Risk Factors for CHD The Framingham Heart Study
Major Risk Factors Important Risk
Factors Cigarette Smoking Obesity Hypertension
Physical Inactivity High Total Serum
Cholesterol Family Hx of Premature CHD Low HDL
Cholesterol Hypertriglyceridemia Diabetes
Mellitus Increased Lipoprotein
a Increased serum homocysteine Abnorm
al levels of various coagulation
factors Dietary factors contribute strongly to
the control of or in the etiology of these risk
factors.
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Medical Nutrition Therapy has been
integrated into the treatment guidelines for a
number of diseases, including Cardiovascular
Diseases Diabetes Mellitus Hypertension Obes
ity
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Noncompliance with prescribed MNTand lifestyle
changes

• Negatively affect patient response to
  pharmacotherapy
• May necessitate more intensive pharmacotherapy to
  achieve desired effect.

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Diet Therapy and Risk Factor Stratification

• Dietary treatment strategies are recommended by
  the National Institutes of Health as the
  cornerstone for the treatment of all patients
  with

Cardiovascular Disease Hypertension Diabetes
Mellitus Obesity
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Diet-Related Risk Factors for
CHD High LDL Cholesterol Begin
treatment LDL Cholesterol
(mg/dl) With CHD
gt100 Without CHD one risk factor
gt160 Without CHD gt 2 risk factors
gt130 Low HDL Cholesterol Hypertension Di
abetes Mellitus
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CVD Risk Factor Standards
Blood Lipid Fraction Desirable Borderline
High LDL Cholesterol (mg/dl) lt130
130-159 gt160 Total Cholesterol (mg/dl)
lt200 200-239 gt240 Triglycerides
(Fasting mg/dl) lt200 200-400
gt400 HDL Cholesterol Low (Bad) if 35
mg/dl LDLHDL ratio gt 5 indicates risk for
men gt4.5 indicates risk for women
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Role of Diet in the Modification of Blood
Cholesterol Levels Assumptions Blood
cholesterol is an important and modifiable
risk factor for coronary heart disease.
Sustained reduction of total cholesterol of
1 is associated with a 2-3 reduction in the
incidence of coronary heart disease.
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Role of Diet in the Modification of Blood
Cholesterol Levels-3
Efficacy of Dietary Intervention Trials to Lower
Total Cholesterol
Diet Types Reduction in Total
Cholesterol AHA Step 2 Lower Total Fat
6.0 Raise PUFASFA Ratio AHA Step
1 3.0
Tang et al. (1998) BMJ 316 1213-1220 Systematic
review of dietary intervention trials to lower
blood total cholesterol in free-living subjects.
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Role of Diet in the Modification of Blood
Cholesterol Levels-2
Chief Determinants of Blood Cholesterol
Levels 1. Certain saturated fatty acids cause a
linear increase in low-density lipoprotein (LDL)
cholesterol concentration. (Total SFA in U.S.
Diet 11-12 of total energy) 2. Trans
unsaturated fatty acids increase LDL
cholesterol not quite as atherogenic as
certain SFA. (Total trans FA in U.S. Diet 3
of total energy) 3. Polyunsaturated fatty acids
derived from plant oils do NOT raise LDL
cholesterol . (Total PUFA in U.S. Diet 6
of total energy) 4. Monounsaturated fatty acids
derived from high oleic acid (cis-181) oils
(e.g., olive, peanut, canola) do NOT raise LDL
cholesterol .
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Diabetes
Mellitus (passing through (the body)
honey sweet) Definition a metabolic
disorder characterized by altered blood
glucose regulation and utilization, usually
caused by insufficient or relatively
ineffective insulin. Long-term hyperglycemia
Cardiovascular Disease
Microangiopathies (Loss of kidney
fxn retinal degeneration) Neuropath
y (may lead to gangrene loss
of feet or legs)
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Goals for Control
(not diagnosis!) Fasting BG and
before meals 80-120 mg/dl One hour after
meals lt180 mg/dl 2 hours after meals lt160
mg/dl Bedtime 100-140 mg/dl Hemoglobin
A1c lt 7 TAKE ACTION LEVELS 140 mg/dl /
8 or gt
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Pathological Sequelae in Type 2 Diabetes Mellitus
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Diet, Lifestyle and Diabetes Key
components in management Weight loss Diet
adjustments to attenuate the rise in blood
glucose.
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Trial Participants 459 adults of which 133 had
stage I HTN (B.P. 140-159/90-99) 49
women 60 African-American Acclimation
Diet Low fruits (F), vegetables (V), dairy
products 40 fat for 3 weeks The
Diets 1. Control Diet average for fat, FV
consumption 2. 8-10 servings of FV, 35
fat 3. Low-fat (lt30 kcal), 8-10 servings of
FV, Rich in low-fat dairy foods. Duration 8
weeks
New Engl J Med (1997) 336 1117-1124
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Source http//dash.bwh.harvard.edu/
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(No Transcript)
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DASH Comments B.P.
reductions occurred quickly (2 weeks) and were
maintained throughout the study. Investigators
estimated that incidence of CHD and strokes in
U.S. could be reduced by 15 and 27,
respectively, if DASH diet were followed.
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The Obesity Epidemic

• U.S. 20 of men 25 of women are obese.
• 97 million Americans are overweight or obese.
  (59.4 of men and 51 of women)
• gt10 of 4-5 year old children are obese.
• 2-fold increase over preceding decade

These increases have occurred despite
successes in reducing dietary fat as of kcal.
Source NCHS, National Health and Nutrition
Examination Survey,1997
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Kuczmarski et al. National Health and Nutrition
Examination Surveys, MMWR 43 818-821,1994.
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Consequences of Modest Weight Gain
10 increase in weight results
in Fasting Blood Glucose of 2-3
mg/dL Systolic Blood Pressure of 6-7 mm Hg
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Conditions Associated With Obesity
(Relative Risk)
Diabetes Mellitus Gall Bladder Disease
Sleep Apnea (Type II)
(RRgtgt3) (RRgtgt3) (RRgtgt3) Stroke
Hypertension (RR 2-3)
(RRgtgt3) Coronary Heart Disease Gout
Osteoarthritis (RR 2-3)
(RR2-3) (RR2-3)
Obesity
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Benefits of Modest Weight Loss

• Normalizes high blood pressure
• Blood levels
• LDL cholesterol
• Insulin
• Glycated hemoglobin (HbA1C)
• Blood glucose
• Uric acid
• HDL Cholesterol
• Improved Quality of Life

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Food as Social Currency

• Current interest in dietary factors centers on
  nutrients or food components likely to decrease
  disease risk.
• These beliefs betray the important social and
  psychological role food plays in most peoples
  lives.

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People eat food, not isolated nutrients.
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Diets are made of foods which are more than mere
collections of nutrients.
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All the biological
functions of food components and their health
effects have not been identified. If the focus
is on a single nutrient, the benefits of the
consuming these compounds in foods may not be
realized.
Why Not Focus on Just Nutrients?
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SourceU.S. Department of Agriculture
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Unlike nutrients, foods and diets have cultural,
ethnic, social and family meanings.
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Asian Pyramid
SourceOldways Preservation Exchange Trust
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Mediterranean Pyramid
SourceOldways Preservation Exchange Trust
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Latin American Pyramid
SourceOldways Preservation Exchange Trust
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Dietary Patterns and Chronic Disease Risk
Total diet, rather than nutrients or
individual foods, should be emphasized.
Dietary guidelines need to reflect food
patterns rather than numeric nutrient
goals. Various dietary patterns can be
consistent with good health.
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Evidence from animal, clinical and
epidemiological studies indicates that specific
dietary patterns are associated with reduced
risk of specific diseases.
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Dietary Guidelines 2000 (Proposed) Aim,
Build, Choose--for Good Health
Build a Healthy Base
Aim for Fitness
Choose Sensibly
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Dietary Guidelines 2000 (proposed) Aim 1. Aim
for a healthy weight. 2. Be physically active
each day. Build 3. Let the Pyramid guide your
choices. 4. Choose a variety of grains daily,
especially whole grains. 5. Choose a
variety of fruits and vegetables
daily. 6. Keep food safe to eat.
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Choose Sensibly 7. Choose a diet that is low
in saturated fat and cholesterol and
moderate in total fat. 8. Choose beverages
and foods that limit your intake of
sugars. 9. Choose and prepare foods with
less salt. 10. If you drink alcoholic
beverages, do so in moderation.
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The Unified Dietary Guidelines
Eat a variety of foods. Choose most
foods from plant sources. Eat at
least 5 servings of fruits and vegetables
every day. Eat at least 6 servings
of whole grain foods each day.
Minimize the consumption of high-fat foods,
especially those from animals.
Choose low-fat, low-cholesterol foods.
Limit the amount of simple sugars in the diet.
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The Nutrition Checklist is based on the Warning
Signs described below. Use the word DETERMINE
to remind you of the Warning Signs. DISEASE EATI
NG POORLY TOOTH LOSS/MOUTH PAIN ECONOMIC
HARDSHIP REDUCED SOCIAL CONTACT MULTIPLE
MEDICINES INVOLUNTARY WEIGHT LOSS/GAIN NEEDS
ASSISTANCE IN SELF CARE ELDER YEARS ABOVE AGE
80 -----------------------------------------------
------------------------- The Nutrition Screening
Initiative 1010 Wisconsin Avenue, NW Suite
800 Washington, DC 20007
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Interventions to improve health
in later life Intervention
Potential effects No
smoking Smoking increases
risks of many cancers including lung,
stomach, larynx, colon
cardiovascular disease and
thereby vascular
dementia respiratory disease
osteoporotic fractures stomach
ulcers Diet High fruit and Protective
for cardiovascular disease vegetable intake
respiratory function macular
degeneration (5 or more servings and
cataracts cancers including breast,
daily) prostate, colorectal and
stomach
diverticular disease diabetes



From Khaw, K.-T. (1997) British Medical Journal
315 1090-1096.
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• Other Dietary
  Strategies to Improve Health
• High complex carbohydrates, Protective for
  cardiovascular disease
• cancers including breast and colorectal
• Reduced saturated fat
• (lt15 of Kcal) and total fat
• (lt35 food energy intake) High saturated
  fat intake increases
• 
  risk of coronary heart disease
• cancers including colorectal, prostate,
• 
  and breast large bowel disease
• osteoarthritis
• Reduced sodium High sodium intake increases
  risk of
• stroke, stomach cancer, osteoporosis,
• respiratory disease
• Physical activity

From Khaw, K.-T. (1997) British Medical Journal
315 1090-1096.
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Summary points
Healthy life expectancy is influenced by a
relatively limited number of chronic disabling
conditions. A substantial proportion of
these chronic disabling conditions can be
prevented or postponed. A greater focus
is needed on prevention and health
maintenancemuch is already known about the
impact of modifiable influences such as diet,
physical activity, smoking, infection,
pollution, and housing.
From Khaw, K.-T. (1997) British Medical Journal
315 1090-1096.