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A Continuing Education Program for Nursing and Nutrition Professionals

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

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A Continuing Education Program for Nursing and Nutrition Professionals

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  1. 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 Children’s Hospital

  2. 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 Principles of MNT/Management for MetS

  3. Lab values Vitamin D Magnesium Lipid profile Liver enzymes 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 Nutrition Assessment

  4. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metforminNEJM 346:393, 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 1:1 during the first 24 wks, flexible, culturally sensitive + group sessions

  5. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metforminNEJM 346:393, 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

  6. Prevalence of Metabolic Syndrome at 3 yrs in The Diabetes Prevention ProgramOrchard et al, Ann Intern Med 142:611, 2005

  7. Changes in Body Fat Predict DiabetesDiabetes Prevention Program (n=758)1 year from baseline: Lifestyle InterventionFujimoto et al, Diabetes 56:1680, 2007

  8. Physical Assessment • BMI • Waist circumference • > 40 inches in men • > 35 inches in women • Normal weight/metabolically obese • Waist to hip ratio

  9. Physical Assessment • Acanthosis nigricans • Caused by the influence of insulin on the melanocytes • Not a hygiene issue

  10. Waist circumference and 8 year incidence of metabolic syndrome 8 year incidence of MetS

  11. Visceral fat: the fat you can’t see, or can you? Visceral fat is white

  12. 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%

  13. ~5%Weight Loss 5%-10%Weight Loss HbA1c 1 1 2 2 Blood Pressure Total Cholesterol 3 3 HDL Cholesterol 3 3 4 Triglycerides How much weight loss will have an impact ?

  14. Does insulin status predict diabetes? Low Insulin secretion, 15.9% Neither 1.5% Poor secretion and insulin resistance 54% Insulin resistant good secretion ~ 28%

  15. Caloric Restriction Acutely Lowers HDL-C Level • Trials of very-low-calorie diets show that HDL-C levels decrease by 2–12 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. 1987;64:125–130.

  16. 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; 56:320–328

  17. Macronutrient Distribution • Low carbohydrate diets(<20% 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 85:238-9

  18. 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

  19. 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 Concept of Glycemic Load (GL)-Quantity of CHO

  20. Not as simplistic as “less processed” foods are low GI

  21. 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 85:1169-1170

  22. Metabolic effects due to intake of high GI food β-cell blood glucose insulin response Rapid uptake of nutrients by insulin–responsive tissues - glucagon Glucose uptake Glucose uptake Lipogenesis Glycogen synthesis Glycogen synthesis Lipolysis Glucose output NEFA release Gluconeogenesis

  23. Epidemiologic studies reported on GI & disease: Increasing GL associated with:

  24. 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 84:136-42

  25. 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

  26. 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

  27. 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

  28. 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

  29. Vitamin D • Adequate blood levels are more effective than the diabetes medications metformin or TZD’s • 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 < 75nmol/L • Serum 25(OH) levels above 80nmol/L considered optimal

  30. 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 RD’s, nurses and other health care providers Adherence to 2005 Dietary Guidelines are effective for reducing MetS risk in women

  31. 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

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

  33. To Access to the Course Evaluation and Obtain a CPE Certificate* • Click on LINK #5 in the LINKS BOX on the left of your screen before exiting this program today. • Or visitwww.thebeverageinstitute.org/CPEbetween today and March 26. • *This program is pre-approved for nursing and dietetic professional CPE. • Other professionals may obtain a Certificate of Attendanceby emailing pcna@commpartners.com or calling 1-800-274-9390

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