Michigan Occupational Health Conference 2012 Preventive Nutrition in the Insulin Resistance Era:

1. Michigan Occupational Health Conference 2012 Preventive Nutrition in the Insulin Resistance Era: Lifestyle Medicine: The Most Powerful “Drug”! Sept 29, 2012 Presenter: Tom Rifai MD (DrTomRifai.com) Medical Director - Metabolic Nutrition & Weight Management St Joseph Mercy Oakland, Pontiac MI Course Director, Harvard Medical School Online Lifestyle Medicine CME: “Nutrition and the Metabolic Syndrome” (cmeonline.med.harvard.edu)

2. A Metabolic Doc Can’t Do It Without a Great Team! Tom Rifai, MD Medical Director and Lifestyle Coach Certified Physician Nutrition Specialist & Internist, Group and Nutrition Class Leader Larissa Shain, RD Chief Dietitian, Group and Nutrition Class Leader Denise Simpson, MA Educator, Clinical and Front Desk Coordinator Tova Spring, RN Patient Assessment, Triage, Counseling and Educator Don Deering, PhD Behavior Modification Coach and CBT specialist SJMO Physical Therapy As well as Certified Exercise Trainers

3. Understand insulin resistance, how to detect it early and what lifestyle factors contribute Better understanding your patient’s lifestyle contributors and the need for realistic expectations in terms of your capabilities and desires versus theirs Add goals & insight to the challenges and risks of excess salt Add insight into biological issues re: protein, carbohydratefats Understand appropriate role of medical foods and when to refer to comprehensive medical metabolic/behavior mod programs Understand the use of metformin in pre-diabetes Objectives we will try our best to meet

4. Why a try for a lifestyle with a 20-30% calorie reduction? Calorie Reduction is THE most powerful evidence based tool to prolong life & avoid type 2 diabetes! (Journal: Science vol 325: 201,2009)After 20 years…. - 80% of lower cal animals alive - 50% of high cal were alive/dead!Vast majority of the higher cal group died of heart attack, stroke, diabetes or cancer….Less than 15% of the low cal group died of a “modern chronic disease” and not one developed diabetes!

5. Most commonly used definition is “BMI ” Body Mass Index > 30 (wt/in2 x 703) However, assesses only height & weight, so not optimal BMI’s ease for large studies, not accuracy in detecting metabolic risks, made it popular Abdominal Circumference is the most clinically useful, practical, simple & reproducible technique in a busy practice DEXA Scan is considered the Medical Gold Standard by many for assessing how body composition affects health and to best estimate ideal weight based on body fat %, body fat distribution and lean/muscle composition (Journal of Preventive Cardiology, Summer 2004) “But Doc - What Precisely is Obesity ?”

7. A physiological state, inducible to some degree or another in most humans, resulting in higher insulin requirements to maintain glucose levels and resulting largely from extensive time periods of an imbalance between movement (low) & calorie intake (high)….. DM2 reflects insulin resistance PLUS beta-cell burnout… May begin with epigenetic contributions during pregnancy (smoking, GDM, macrosomia or low birth weight) Next you’ll see kids who eat minimal fruit & veggies and lots of: high calorie/high salt added grains (breads, cereals, desserts, baked goods/bake sales) instead for “carbs”, with lots of cured meats, fast food pizza, burgers, fries, pop and sitting, playing video games in summer (kids gain more weight in summer) & sitting most of day in school, etc etc What is “Insulin Resistance” PRACTICALLY speaking?

8. Prior to Metabolic Syndrome you may see < 2 of 5 plus other related metabolic findings (hyperferritinemia – Diabetes Care Vol 28; #8 2005; hyperuricemia, elevated ALT/fatty liver, higher than optimal fasting insulin – e.g., >7) Prior to “pre-diabetes” most have “Metabolic Syndrome” (3 of 5 IDF criteria - see next slide) Prior to DM2 we have “pre-diabetes” – now most practically detected with A1c & FBG. (Gold Std, 2hr OGTT, is impractical on large scale) What is “Insulin Resistance” PRACTICALLY speaking?

9. Metabolic Syndrome by IDF standards REQUIRES: Meeting Abdominal Circumference Criteria >37 inches in Caucasians, Arab and African American men For Asian (also consider Latinos, American Indians & other high risk groups, including +FH) male threshold drops to >35” and >31.5 in ALL women Metabolic Syndrome as defined by International Diabetes Federation

10. Fasting TG level: > 150 mg/dL or on specific treatment for this • HDL cholesterol: < 40 mg/dL in men, < 50 mg/dL in women or on specific treatment for this • BP >130/85 mm Hg, or on treatment for BP or with BP drug Fasting plasma glucose > 100 mg/dL on more than one occasion or treatment for this (OGTT is strongly recommended but is not needed to define presence of the syndrome) …consider A1c?) AND at least 2 of the following 4

11. *Risks of poor body composition induced insulin resistance* Excess visceral/liver/muscle fat plus below average amount/use of muscle mass or a combination of BOTH (most common) • Dementia • Stroke & Depression Pulmonary Disorders • Obstructive sleep apnea • Asthma • More CVD • Heart Attack • Heart Failure Liver Disorders • NAFLD*>NASH**>Cirrhosis>Cancer • Metabolic Syndrome • Type 2 Diabetes • High Blood Pressure • Kidney Failure Reproductive/Sexual Abnormalities Cancers • Abnormal periods • Infertility / PCOS*** • Breast, ovarian, uterus • • Erectile Dysfunction (CVD) • Colon** DVT • Prostate Osteoarthritis Gout * NAFLD=Non-Alcohol Fatty Liver Disease **NASH = nonalcoholic steatohepatitis *** PCOS = polycystic ovarian syndrome 4083.NIH/NHLBI. September 1998; NIH publication no. 98

12. Lifestyle change/Behavior modification is THE gold standard….BUT HARD! “So you “see” insulin <-- resistance….now what? And you know that genetics are certainly a contributor… …but you KNOW human genes are the virtually the same now as 10,000 years ago!… So genetics are a minor issue (especially for diseases encountered after age of 50) on a population scale, though EPIGENETIC modifications (e.g., smoking during pregnancy and macrosomic babies) are SCARY…yet still it’s really more about…..

13. The most sedentary society in history! 80-90% of average Americans’ daytime is spent sitting! Why? Because we can! Couldn’t sit too long 10,000 years ago! The most “food toxic” environment in history! Hyper-palatable foods with ADDICTIVE PROPERTIES (high sugar/starch plus salt plus saturated fat = HEROIN EQUIVALENT) are WAY too convenient Irrational “finish your plate” attitude has led to huge portion expectations along with OVER-using food as cultural focus Using food too often for stress & mood management The Perfect Storm for Calorie Excess Based Diseases

14. Excessive Thin, sugar/fat/alcohol based liquid calories: non-satiating (not “sensed” by brain/body) Excessive Calorie Dense/Refined Carbs: Grains, most refined & baked/dry grain (flour, rice, corn, oats like: breads/bagels, pies, donuts, cookies, pastries, dry cereals, chips, popcorn, pizza dough, tortillas, wraps, granola bars, muffins), are biggest source of increase in solid food calorie intake since 1980 AND many are mixed with: Excessive non-essential fats: Oils, non-skim dairy, cheeses/butter, margarines, feed-lot fed animals Where are the excess, age inducing/free radical promoting, excess calories mostly coming from?

15. SITTING/SEDENTARY TIME INCREASING MEAL SKIPPING AND ERRATIC EATING PATTERNS POOR INTAKE OF WHOLE FRUIT n VEGETABLES POOR DISTRIBUTION THROUGHOUT THE DAY OF QUALITY PROTEIN SOURCES All together leading to: Increase in not only food volume, but increased calories PER BITE (calorie density), overcompensation of calorie intake at night, muscle/bone loss with fat gain in liver/viscera and marbled/weaker muscle  PHENOTYPIC INSULIN RESISTANCE Complementing the “excesses” from previous slide are:

20. Obesity Trends* Among U.S. AdultsBRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person) No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

21. As of 2010, about 20% of pre-adolescents in US are now obese or overweight.. likely many of the “normals” suffering poor (i.e., Insulin Resistance prone) body composition URGENT: “Adult” Diseases in Kids – “In U.S….type 2 diabetes accounts for up to 46% of all new cases of diabetes referred to pediatric centers. The magnitude of type 2 diabetes is probably underestimated” CDC

23. HELP PATIENTS RETIRE SOME GUILT: “WILLPOWER SUCKS” FOR GOOD REASONS! Human tendency to gain fat is protective against the frequent lack of calories of most of human history (“Obesity Paradox”) Tendency towards obesity is a “good thing gone awry” due to our mismatch of genes to modern environment Leningrad World War 2 observation – The food deprivation of the Nazi onslaught actually caused more deaths than bombing…and more body fat at the beginning of siege was observed to be associated with lower risk of death. The point is: Wisdom and environmental management beats “willpower” and guilt-based “dieting” as a tool for real lifestyle change! But MUST try to make it MINDLESS to eat healthier to win the battle against our internal tendencies! The Impotence of “Willpower”

24. Accept that even basics can be difficult to achieve since the US food environment is currently, overall, VERY poor at supporting healthy choices! Therefore: BE PERSISTENT but PATIENT and MOTIVATIONAL PARTNER/COACH. Inform patient risks of poor lifestyle choices & help reconcile their understanding with facts…. but also ENGAGE them in respectful conversation of what makes it difficult for them? What motivates them to be healthier? What sabotages their efforts? Go with THEIR flow, “contract” with them, follow up frequently if needed (note USPSTF rec. on visit frequency for obesity mgt)! The Basics in achieving “Optimal” Nutrition:Be a Motivational Interviewer

25. STEP 1 – TEMPTATION CONTROL: MUST emphasize home environment be a “HEALTHY FOOD ONLY ZONE” as much as reasonably possible While indulgences are OK on occasion (and a fact of life), they should generally be left OUTSIDE THE HOME! Need proof? Read: Mindless Eating (Professor Brian Wansink PhD) The Basics in achieving “Optimal” Nutrition:Be a Motivational Interviewer

26. FIRST - REMOVE TEMPTATIONS FROM AS MANY ENVIRONMENTS AS POSSIBLE ! Emphasize that “don’t worry, there will be more than enough opportunities for indulgences in a lifetime without having them in our faces (i.e., homes/work) tempting us constantly day in & day out!” Removing calorie dense/hi-salt “comfort foods” from home/work does NOT at all mean “removing them from your life” HABIT ALERT: Success comes with accepting frequently bringing healthy food with you far more often than before (e.g., work/vacations) Will still have to contend with restaurants and outside sources of “food”, of course – Using a menu as an “ingredients list” CSPINET.org (order “Nutrition Action” Healthletter); LoseIt.com & app Tips for mind re-training for comfort food overeaters: Book: “Eating the Moment” - Pavel Somov PhD Website: “www.ShrinkYourself.com” - Roger Gould MD Stimulus Control for Long Term Calorie Control

27. AHA, IOM, NIH, CDC all generally agree on reduction (e.g., low sodium “DASH”) - Excellent review: American Journal of Medicine, May 2012 (In kids it can have long lasting benefit!) Ancient human intake likely less 500mg/day and natural sodium content of modern intake around 400mg/day (Evolution of the Human Diet, Peter Ungar PhD – Univ of Arkansas) Truth is that it’s dietary potassium to sodium ratio (and more likely the dietary potassium+mag+calcium to sodium ratio) that really matters in terms of mortality/morbidity risks Such risks include all those associated with HTN (stroke, CHF, MI) but also osteoporosis, kidney stones & gastric C/A, asthma and the fact that CVD RISK IS RELATED TO SALT INTAKE INDEPENDENT OF ITS EFFECT ON BLOOD PRESSURE! Exceptions: when on salt depleting diuretics, heavy sweating The “Anti-Salt Vault ”

28. Upshot: Educate on 2 major points Ideally, DECREASE sodium to < 1500 mg/day - MUST look @ labels & restaurant info! “Lose It!” smart phone app www.LoseIt.com can track sodium too;www.NutritionData.com;www.HealthyDiningFinder.com site has a “sodium savvy” option INCREASE fresh vegetables, whole fruits and (low sodium) legumes in trade for grains (esp refined/sodium added ones – e.g., breads/cereals – unfortunately even many “whole grain” products have substantial salt added) to enhance dietary potassium intake for less overall calories than grains. Keep grain intake to true whole grain and in range of 2-4 (not 6-11) svgs/day The “Anti-Salt Vault”

29. Overall saturated fat is more important driver of atherogenic particles (LDL, IDL, VLDL) than dietary cholesterol since most of us down regulate hepatic LDL receptor under influence of saturated fat leading to decreased clearance of serum LDL/non-HDL About 1/4 of us DO respond to dietary cholesterol which can be detected by seeing a significant difference between fasting and non-fasting cholesterol Non-fasting cholesterol more useful if using standard lipid panel since “non-HDL” more predictive than LDL for CVD events…you can also see non-fasting triglycerides which are may add insight when fasting are “OK” Saturated Fat vs Cholesterol

30. Biggest saturated fat sources: Fat containingdairy (2% milk “ain’t so great”, fat-free Greek yogurt IS great !) …. hard cheese (aka “dairy meat”) being a HUGE US issue and WAY over-rated as a “healthy food” Fatty animal “flesh and skin” components (most, including “90% lean” beef; skin of poultry; most pork cuts thanks to grain-based CFOs See Movie: “FOOD INC.”) Biggest non-animal sources: Palm Oil, Palm Kernel Oil (what makes the chocolate mint chips so hard, solid and “crunchy” – like your arteries will be if you eat too much chocolate mint ice cream), Coconut Oil, Cocoa butter (full disclosure: the stearic acid of cocoa butter is “less bad” saturated fat since liver can convert to oleic acid/monounsaturated fat) Saturated Fat vs Cholesterol

31. AHA: For secondary prevention and “Mediterranean Diet” concept: <7% of calories Reality: NO ONE IS REALLY GOING TO CALCULATE “7%” of their calories so, IMO, a more practical goal for saturated fat is “shooting for < 10g/day” Saturated Fat Education: Theory vs Reality (Reality Meets Science!)

32. Small amounts, ½ to 1 ½ oz/day, of un-salted nuts (caveat: high, CD). Probably the “best high fat food” choice Monounsaturated “less bad” Olive, Safflower, Canola oils Polyunsaturated – 4 types: long vs short and Omega 3 vs 6 Long w3 (EPA) – fish and supplements good! Short w3 (LNA) – good if replacing saturated but not a replacement for long (walnuts, flaxseed) Short w6 (LA) – looks good if replacing saturated and may act on small bowel to decrease cholesterol absorp (Sunflower, Soybean, Corn, Cottonseed, Peanut oils) Long w6 (AA) – may be pro-inflammatory (major source is CFO grain fed land animal fat, including fatty dairy) A moment on “healthy” fats

33. Intact Fiber intake of >30g/day - Recent NIH-AARP data says intake seems related to reduced CVD, cancers and infections and total mortality. BUT CAREFUL WHEN FIBER COMING FROM WHOLE GRAINS due to added salt and high calorie density which may overwhelm the fiber benefit (note: BREADS/GRAINS are the biggest contributor to US sodium intake). New processed (NON-intace) fibers: inulin (Fiber One bars), aka “chicory root fiber”, maltodextrin, polydextrose, oat fiber, wheat fiber (these are FDA approved to be listed as fiber but not approved in Europe or Canada as such. Excess grains contribute to Renal Acid Load and bone loss FIBER FACTS and an “Inconvenient Truth” on “whole” grains

34. …Recent data, including NIH Omni-Heart Trial comparing standard DASH (15% protein, 60% carb, 25% fat) to “High Protein DASH” (shifting protein up to 25% and carbs down to 50%) found FAR better results in Metabolic Syndrome (aka AMERICAN) subjects for lipid control and overall CVD risk factors (especially triglycerides) IOM describes a “healthy range” from 15-35% of total daily calories (30% of 1800 cal is 540 = 135 grams) Overall, protein suppresses appetite hormone ghrelin and better than Carbs/Fat so let’s not demonize protein in and of itself! “Optimal” Nutrition:PROTEIN - a Controversial Area!

35. “Low Protein Diets”, despite common misconception, have NEVER been shown to reduce progression to dialysis, does not mitigate diabetic nephropathy (AJCN, 2008) RDA for protein (0.8g per kg, whatever THAT means in the REAL world!) is defined as a MINIMUM intake to meet the requirement of “most” “healthy” adults! But THAT may describe less than 10% of Americans!…Yet protein RDA is commonly promoted as an “optimum” intake. But it is frequently recognized as inadequate for many and certainly not optimal for most as low protein can = muscle loss and muscle loss can = increased risk for insulin resistance & total mortality risk! Good review on misconceptions re: Protein and the RDA - JAMA June 25, 2008 pgs 2891-2893 “Optimal” Nutrition:PROTEIN - a Controversial Area!

36. Protein has caveats, such as it’s Renal Acid Load and that many sources come with “unwanted passengers” (saturated and excess total fat…as in feed-lot fed animal cuts; sodium…like cured meats, iron…as in red meat) BUT!…… Adequate protein at most meals, especially breakfast (and NO, Cheerios and most dry cereals are NOT a significant source of protein, nor a very overall good food source! Some exceptions of course) and many snacks Combine “clean, high-protein” sources with low calorie density (or at least unrefined) higher fiber quality sources of lower protein ALKALINE foods (vegetables & fruit). Legumes are great and basically neutral on RAL….whole grains caveats aforementioned “Optimal” Nutrition:PROTEIN - a Controversial Area!

37. Protein is critical for maintaining lean tissue mass as we age and is NOT harmful to bone AS LONG AS VEGETABLE AND FRUIT INTAKE is highenough, and grain intake low enough, to address protein’s (and grains’) acidity (hence, advantage of “Paleo Diet” vs other “low carb” diets is that it is low in salt/high in fruits & vegetables) Protein Intake ideally should be SPREAD throughout the day (e.g., total daily intake for women ~80-100g/day and men ~100-150g) with several 20-35 gram meals/snacks…usingmedical protein supplements if necessary. Older people need at least 25-30 grams in a “meal” to substantially effect protein synthesis! Not likely going much higher will help though… “Optimal” Nutrition:PROTEIN - a Controversial Area!

38. Lean, low sodium fish, fowl, egg whites, “Greek” yogurts, pork tenderloin, certain higher protein legumes (e.g., soybeans/edamame/tofu & lentils) Must consider high quality, high protein “Medical Meal Replacements” for appetite control and muscle loss prevention as evidenced by the NIH LookAHEAD ongoing trial of Type 2 Diabetes showing remarkable results considering the subjects’ PCP’s are generally still loading up their patients on weight gain promoting diabetic medications instead of shifting towards more weight loss friendly/neutral options. BASIC EXAMPLES OF HEALTHY PROTEIN SOURCES

39. WHOLE FRUITS and VEGETABLES MUST LEAD THE WAY! (More than just low cal/high potassium! Alkaline too!) Legumes - The Unsung Heroes - great “grain alternative”! (lentils! beans and peas…generally Acid-Base neutral) BE MODERATEon grains (e.g., wheat, rice, corn, oats, etc), including “whole grains” as they are still acidic like refined grains so should NOT displace vegetables/fruits/legumes. Also, the MASS majority of dry whole grains (e.g., breads, cereals) in this country are HIGH SODIUM ADDING more bone risk over and above acidity issue & CD! Nuts (except almonds) mildly acidic too, but the amount eaten is small so mitigates risk of their acidity Countering the acidity concern of protein: important basics on dietary acid-base balance

40. Metabolic Medicine with Multidisciplinary Weight and Lifestyle Management • State-of-the-art metabolic medical program and its power in treatment/prevention of diabetes, high blood pressure, cholesterol problems, fatty liver, obstructive sleep apnea and other insulin resistance related issues. • Combining the following 3 proven tools for the first 12-16 weeks (aka – “intensive behavior modification phase”) • Temporaryuse of medicalformula foodsas PART of food • 12 weekly, intensive group education course (“Lifestyle U”) • Frequent clinical follow up in the first 3-4 months then progressively less to complete at least one year

41. In addition to medical weight management: Management of INSULIN RESISTANCE (the root of diabetes…it’s NOT necessarily “gone” when sugar is “normal”) Screen meds for weight gain risk Expertsupplement advice(avoid those that have no benefit and those that may do harm) State-of-the-art cholesterol management (“Normal” cholesterol by standard testing is NOT enough!) Evaluation of important nutrient levels including : Vitamin D deficiency, B12 & Iron excess Screening for obstructive sleep apnea Optimal preparation for bariatric surgery, if needed For the patient needing to get lean, weight loss is only part of achieving total wellness and health

42. Since relatively non-controversial eating will include calorie, sodium and saturated fat control, ask if these risky eating patterns occur: “Never”(<1x/mo), “Sometimes”(1x/mo-1x/wk) or “Often” (>2x/wk): Do you skip breakfast go longer than one hour of awakening? Do you ever go more than 3-4 hrs w/o eating? Do you drink any of your calories? Do you eat out (sit down or fast food)? Do you eat calorie dense sweets (grain based, hard chocolates, ice cream)? Do you eat calorie dense starches (breads, cereals, chips, wraps, etc)? Do you purposefully add non-essential fats (butter, mayo, dressings, oil)? Do you eat cheese (alone, on salad/pizza, in sandwiches)? nuts? ADDITIONALLY, FOR HEALTHY EATING PATTERN CHOICES ASK: Do you eat unfried fish at least twice weekly? Do you eat at least 2-3 pieces of whole fruit? Do you eat some fresh vegetables daily? “Optimal” Nutrition:Basic Eating Questions

43. Our program model is based on the most proven medical evidence: National Institutes of Health Landmark “Look Ahead” Study The Harvard/Joslin Diabetes center “Why WAIT” program Initial part of program includes 3 major components: 1. “Lifestyle University” - a 3 month intensive education package to prepare for seamless transition to longevity lifestyle: 12 lifestyle change support groups and 6 nutrition classes, 2 RD visits, an MD or RD led grocery shopping tour: 2. Frequent metabolic physician monitoring for safety Approximately two times per month for the first three months, then progressively less thereafter ….your primary care doc gets updates! 3. DATA PROVEN Medical Grade Meal Replacements mixed with foods known to help treat disease, promote body fat loss & improve health **Medical foods prescribed MUST be purchased from clinic during first 3 months** SJMO Metabolic Nutrition Weight Management Program

44. Initial Evaluation: Attention to building safe, enjoyable, physical activity Regular Physical Activity starts with NOT SITTING so much! Even STANDING more and sitting less gives measurable benefits! (Diabetes Care, 2012)Critical to weight maintenance, better weight loss maintenance potential, muscle retention and quality of life. Multiple options *Physical Therapy – TIP: an underutilized tool! Find a good PT and “partner” with them on your goals then prescribe PT for patients as appropriate (which are many!) Certified Exercise Specialists/Physiologists Phase III Cardiac Rehab

45. Well known first line in DM2 and should stay if on insulin! Now used frequently in PCOS, GDM and recently endorsed by ADA for high risk pre-type 2 diabetics to lower DM2 31% Excellent safety profile (likely acceptable up to Cr 1.8) Also associated with lower CVD and Cancer (in trials now) NEWS FLASH! 10yr follow up to Diabetes Prevention Program shows TLC cost effective while metformin cost SAVING! Only 10% of medical tx is actually cost SAVING! IMO, B12 should be supplemented (1000mcg PO QD) IMO, in pre-diabetics where healthy weight loss is CRITICAL - best to use metforminER at LUNCH, adjusting dose up to 1500-2500mg based on GI tolerance Metformin – a wonder drug?

46. D3 (IMO - target dose to 25D between ~50ng/dL) B12 (IMO - target dose to keep level >500pg/mL with MMA <0.2 umol/L & Homocysteine <14umol/L; Neurology Sept 27, 2011 Omega 3 (caveat: 1000mg fish oil doesn’t = 1000mg w3) Look for “Triple Strength” Fish Oils or use prescription form Re others: DO NO HARM! Best is HEALTHY LIFESTYLE!Failures: Vitamin E, Selenium, Beta-Carotene, Folic Acid for CVD Magnesium Citrate/Glycinate? PPI (use ICD-9 995.2) Multivitamin? NO EVIDENCE OF BENEFIT FOR GENERAL POP.!Careful w/ Fe (check ferritin with IR - code 263.0; ferritin levels >100ng/mL should prompt thought of body iron excess), folate; Consider QOD? www.naturalmedicinesdatabase.com Supplements worth an Honorable Mention

47. Recent controversies regarding sodium and blood pressure control Alcohol and heart disease Resveratrol Omega 3 vs. 6; krill oil vs. fish oil Recent controversies re: Vitamin D regarding how much is enough; should we be measuring levels? who needs supplementation? what kind of supplementation? Other vitamin or mineral supplementation Calcium supplementation & osteoporosis prevention Coffee/caffeine Soy products; Phytoestrogens Nutrient density (Whole Food's ANDI) & Joel Fuhrman's perspective on nutrition Chocolate “Hot Topics”

48. Testimonials

50. REAL RESULTS FROM SJMO Metabolic Nutrition & Weight Mgt Program • Average weight loss for first 3 months 7.2% (many losing more than 10%) • Average weight loss for 12 months 11% (many losing more than 15%)  • Average 6 month cholesterol/trig decrease 31 points – many achieving such with LESS medicine • A1C/glucose levels improved in 93% with virtually all doing so with LESS medicine