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Cardiometabolic Syndrome
The Synergy of Diet and Exercise
A Continuing Education Program for Nursing and
Nutrition Professionals

• Roberta Anding, MS, RD/LD,CSSD, CDE
• Baylor College of Medicine
• ADA Media Spokesperson
• Sports Dietitian for the Houston Texans
• Director of Sports Nutrition, Texas Childrens
  Hospital

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Principles of MNT/Management for MetS

• Assessment of risk factors
• Diet and exercise patterns
• Weight management/calorie restriction
• Assessment of visceral fat
• Whole grains
• Magnesium
• Omega 3 fatty acids
• Calcium and vitamin D
• Plant sterols/stanols

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Nutrition Assessment

• Physical assessment nutrition analysis
• Acanthosis nigricans
• BMI/ Waist circumference
• EAL fair/imperative
• Dietary patterns
• Whole grains
• Low glycemic foods
• Omega 3
• Dairy
• Consumption of plant sterols

• Lab values
• Vitamin D
• Magnesium
• Lipid profile
• Liver enzymes

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Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metforminNEJM
346393, 2002

• Standard lifestyle recommendations
• Written information regarding food pyramid, NCEP
  step 1 diet and annual 30 min individual session
• Intensive lifestyle intervention
• 16 lesson individualized curriculum 11 during
  the first 24 wks, flexible, culturally sensitive
  group sessions

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Reduction in the incidence of type 2 diabetes
with lifestyle intervention or metforminNEJM
346393, 2002

• Average f/u 2.8 yrs
• Incidence of diabetes 11/100 p-yrs with placebo,
  7.8 with metformin (31 reduction) , 4.8 with
  lifestyle intervention (58 reduction)
• To prevent 1 case of diabetes, 6.9 persons would
  have to be treated with lifestyle modification,
  13.9 with metformin

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Prevalence of Metabolic Syndrome at 3 yrs in The
Diabetes Prevention ProgramOrchard et al, Ann
Intern Med 142611, 2005
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Changes in Body Fat Predict Diabetes Diabetes
Prevention Program (n758)1 year from baseline
Lifestyle InterventionFujimoto et al, Diabetes
561680, 2007
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Physical Assessment

• BMI
• Waist circumference
• gt 40 inches in men
• gt 35 inches in women
• Normal weight/metabolically obese
• Waist to hip ratio

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Physical Assessment

• Acanthosis nigricans
• Caused by the influence of insulin on the
  melanocytes
• Not a hygiene issue

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Waist circumference and 8 year incidence of
metabolic syndrome
8 year incidence of MetS
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Visceral fat the fat you cant see, or can you?
Visceral fat is white
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Calorie restriction

• Central to the treatment of metabolic syndrome
• Reduces hyperinsulinemic response
• Weight loss of 5-10 of initial weight can yield
  significant improvement of metabolic parameters
• Questions remain
• Should pathophysiology direct MNT
• Optimal macronutrient distribution
• Dietary patterns vs individual components
• Glycemic load
• Fortified foods with plant stanols
• 2 grams per day can lower LDL by 10

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How much weight loss will have an impact ?
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Does insulin status predict diabetes?
Low Insulin secretion, 15.9
Neither 1.5
Poor secretion and insulin resistance 54
Insulin resistant good secretion 28
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Caloric Restriction Acutely Lowers HDL-C Level

• Trials of very-low-calorie diets show that HDL-C
  levels decrease by 212 mg/dL during acute
  caloric restriction.
• After 12 wks, HDL-C returned to pretreatment
  range, and this trend was still apparent after 1
  year.
• Therefore, benefits of weight-loss programs
  should not be assessed during acute caloric
  restriction.

Rössner S, et al. Atherosclerosis.
198764125130.
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Weight and HDL-C

• Inverse correlation between body weight and HDL-C
  is consistently observed in both men and women.
• For every 3 kg (7 lb) of weight loss, HDL-C
  levels increase 1 mg/dL.

Dattilo AM, Kris-Etherton PM. Am J Clin Nutr.
1992 56320328
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Macronutrient Distribution

• Low carbohydrate diets(lt20 CHO)
• Some evidence of short term benefit(6 weeks)
• Ketogenic diets have no distinct advantages over
  lowering restriction of total carbohydrate
• Ketogenic diets may increase inflammatory risk
  and reduce exercise capacity
• 40 carbohydrate equally effective as traditional
  low carbohydrate diets in reducing body weight
  and insulin resistance

Am J Clin Nutr 2006 85238-9
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Definition GI-Quality of CHO

• the incremental area under the blood glucose
  response curve of 50 grams of available CHO from
  a test food, expressed as a percentage of the
  response to the same amount of CHO from a
  standard food (bread or glucose), taken by the
  SAME person
• Thomas M.S. Wolevar, DJA Jenkins

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Concept of Glycemic Load (GL)-Quantity of CHO

• GI refers to single CHO source
• Captures the quality of the CHO
• Glycemic Load
• GI x Amt of CHO in a serving
• GL captures the quantity of CHO

• Brown rice contains 18 gms CHO, GI 73
• GL for brown rice 18 x 73 or a glycemic load
  of 13
• Each GL 1 gram of glucose

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Not as simplistic as less processed foods are
low GI
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Glycemic load Weight loss or something else?

• Insufficient data in the Evidence Analysis
  Library to implement as a weight loss strategy.
• Are there benefits beyond weight control?
• Lowering the GI of a high carbohydrate diet
  improves beta cell function in those with IGT

Am J Clin Nutr 851169-1170
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Metabolic effects due to intake of high GI food
ß-cell
blood glucose
insulin response
Rapid uptake of nutrients by insulinresponsive
tissues
- glucagon
Glucose uptake
Glucose uptake
Lipogenesis
Glycogen synthesis
Glycogen synthesis
Lipolysis
Glucose output
NEFA release
Gluconeogenesis
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Epidemiologic studies reported on GI
disease Increasing GL associated with
Decreased HDL Increased TG Increased C-reactive protein Increased Risk of diabetes Increased Risk of CVD
Wolevar, 1992 Luscombe, 1999 Buyken, 2001 Liu, 2001 Ford, 2001 Frost, 1999 Liu, 2001 Liu, 2002 Hu, 2001 Salmeron, 1997 Salmeron, 1997 Schulze, 2004 Liu, 2000
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Glycemic load and liver steatosis

• Links between insulin resistance and liver
  steatosis
• High GI diets are associated with increasing
  prevalence of liver steatosis

Am J Clin Nutr 84136-42
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Framingham Offspring Cohort Study

• 2834 subjects assessed for carbohydrate related
  factors and the prevalence of metabolic syndrome.
• Total fiber, cereal fiber, fruit fiber and whole
  grains were were inversely associated with
  insulin resistance.
• Elevated glycemic index/glycemic load diets
  positively associated with IR
• Whole grains may reduce the risk of MetS

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Whole Grains, Fiber Magnesium

• Dietary patterns rich in whole grains provide 3
  nutrients linked with a decreased incidence of
  metabolic syndrome and improved biochemical
  parameters
• In a study of adults in Tehran, the higher the
  intake of whole grains the lower the prevalence
  of metabolic markers.
• Cereal fiber has been linked with a decrease in
  MetS

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Magnesium

• Recent studies have demonstrated the role of
  magnesium as a risk factor for MetS
• NHANES III and and the CARDIA study both
  demonstrated an inverse relationship between
  magnesium intake and MetS. Highest quartile of
  Mg intake reduced prevalence by 31
• No toxicity from whole food
• UL 350 mg

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AHA Recommendations for Omega-3 FA Intake
Population Recommendation
Patients without documented CHD Eat a variety of (preferably oily) fish at least twice a week. Include oils and foods rich in ?-linolenic acid (flaxseed, canola, and soybean oils flaxseeds and walnuts)
Patients with documented CHD Consume 1 g of EPADHA per day, preferably from oily fish. EPADHA supplements could be considered in consultation with the physician
Patients needing triglyceride lowering 24 grams of EPADHA per day provided as capsules under a physicians care
Kris-Etherton PM et al. Circulation
20021062747-2757.
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Vitamin D

• Vitamin D receptor are found on the nucleus of
  the cell and the cell membrane
• Essential in the function of the beta cell
• Adequate blood levels, not dietary intake can
  improve insulin sensitivity by 60
• A 30 year prevention program of Type 1 diabetes
  indicates an 80 reduction in disease with 2000
  IU of vitamin D
• Obesity is a risk factor for deficiency as it is
  sequestered in adipose tissue

Harris, SS J Nutrition 2005 135 (2)323-5
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Vitamin D

• Adequate blood levels are more effective than the
  diabetes medications metformin or TZDs
• A study of postmenopausal women taking
  bisphosphonates for osteoporosis and 400 IU of
  vitamin D
• 18 had levels less than 50 nmol/L and 52 had
  values lt 75nmol/L
• Serum 25(OH) levels above 80nmol/L considered
  optimal

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Cost of the Metabolic SyndromeResearch Options

• The Cardiovascular Health Study
• 10 year medical costs of individuals 65 and
  older
• NCEP definition
• Metabolic syndrome present in 47 of the sample
• Costs to Medicare 20 higher with metabolic
  syndrome
• Represents an outcome based intervention for
  RDs, nurses and other health care providers
• Adherence to 2005 Dietary Guidelines are
  effective for reducing MetS risk in women

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Summary

• Assessment patterns for RD/RN should include the
  following
• Visceral fat via waist circumference
• Dietary patterns
• Whole grains
• Magnesium, fiber
• Dairy products
• Calcium and vitamin D
• Glycemic load
• Plant stanols

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Women Cardiometabolic Syndrome
Question Answer Session
A Continuing Education Program for Nursing and
Nutrition Professionals
SPEAKERS
John D. Bisognano, MD, PhD
Roberta Anding, MS, RD/LD, CDE, CSSD
Lynne T. Braun, ANP, PHD, CNP, CLS
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This program is pre-approved for nursing and
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