Transcript Document

Dr. Jeffrey Tucker
Presents
The Program For Total Health
The gold standard is health span
Of American women ages 45 – 54
• 33% suffer from hypertension
• 32% have lower back pain
• 20% have elevated blood pressure
• 22% have knee pain
• 21% have neck pain
• 12% have shoulder pain
• 11% have finger pain
The gold standard is health span
Of American men ages 45 – 54:
• 30% suffer from hypertension
• 27% have lower back pain
• 20% have elevated blood pressure
• 19% have knee pain
• 15% have neck pain
• 13% have shoulder pain
• 7% have finger pain
• American diet: about 72% of the calories in the average
American's diet come from foods that were not
consumed by our recent hunter-gatherer ancestors.
Consider that 23% come from grains (20.4% from
refined grains), 18.6% from refined sugars, 17.6% from
refined omega-6 seed oils (corn, soybean, sunflower,
cottonseed, safflower, peanut, etc.), 10.6% from dairy,
and about 1.4% from alcohol.
• Cordain L, Eaton SB, Sebastian A, et al. Origins and
evolution of the Western diet: health implications for the
21st century. Am J Clin Nutr, 2005;81(2):341-54.
• The remaining 28% come from a marginal intake
of fruits, vegetables, nuts and legumes, and a
substantial intake of domestic, feedlot, grain-fed
meat. We know wild game is about 2% to 4% fat
by weight, while modern feed-lot meat is 20% to
24% fat by weight. Essentially, this means we
are eating unhealthy, obese animals.
• Seaman DR. The diet-induced pro-inflammatory
state: a couse of chronic pain and other
degenerative diseases. J Manip Physiol Ther,
2002;25:168-79.
• In short, our diet in America today consists of
grains, sugars, omega-6 fatty acids, trans
fats, and obese meat, and is substantially
deficient in fruits and vegetables. The outcome
of this pattern of eating is the typical inflamed,
swollen-looking, overweight American, who is
prone to osteoporosis, osteoarthritis, chronic
pain, and other chronic diseases.
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Dr. Tucker’s Therapeutic Lifestyle
Program
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Diet
Exercise
Supplement
Rest
The Program Will Address
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Making healthy food choices
Preventing chronic disease formation
Improving body composition
Reducing body fat storage
Increasing lean muscle mass
Reducing inflammation
Improving blood sugar management
Reducing hyperinsulinemia and hyperglycemia
Increasing exercise & physical activity = gentle
movement therapy & strength training
Charting Office Visits
SOAP Note Format
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Subjective
Objective
Assessment/Diagnosis
Functional abnormalities
Plan (diet modifications, exercise program,
supplementation recommendations,
relaxation techniques)
Office Flow Algorithm
1. The doctor prescribes the program to the
patient
2. Patient assessment (BIA, blood, FMS)
3. Patient consultation (ROF, establish
goals, individualize the program)
4. Follow up visits
5. Retest
BIA = Bioelectrical impedance analysis
FMS = Functional Movement Screen
ROF = report of findings
Retest
• Program goals are
achieved
• Prescribe
maintenance program
• Send re-evaluation
reminder card in 6-12
months
• Program goals are
not achieved
• Return to step 3
previous slide
Timing of Return Visits
Recommended Follow Up
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2.
Medical Doctor (weeks)
Forms/Assessment (blood, etc.)
Consultation/Refer to Tucker for
Total Health program
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Tucker
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Tucker/Follow up visit MD
5.
Tucker
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Tucker
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Tucker
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Tucker/MD
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Tucker
10. Tucker
11. Tucker
12. Re-evaluation MD
• Tucker (weeks)
1. Forms/Assessment/BIA
2. Diet/meal plan/supplements
3. Functional Movement Screen
4. Education/exercise
5. Education/exercise/BIA
6. Education/exercise
7. Exercise
8. Exercsie
9. Retest FMS/BIA
10. Exercise
11. Retest FMS/BIA
12. Re-evaluate Tucker/MD
FMS = Functional Movement Screen
BIA = Bioimpedance Analysis
Charging for Programs
• Determine what method of payment will
work best for patients.
• Determine cost of services.
• Supplements are charged for separately.
Counseling For Patients With NO
Medical Illness or Symptoms
Insurance codes:
• 99401 15 Minutes
• 99402 30 Minutes
• 99403 45 Minutes
• 99404 60 Minutes
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Patients can call there own insurance company and ask them how much
they will reimburse for these services.
Individual and Group Counseling
WITH Medical Illness or Symptoms
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For counseling GROUPS of patients 99078
For counseling INDIVIDUALS
99213 Consultation 15 min
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99214
25 min
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99215
40 min
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99244
60 min
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99245
90 min
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99354 Prolonged Care
$150
Bioimpedance Analysis (BIA)
• A4556 BIA Electrodes (2 sets @ 15 each)
• $30
• Provides: Body composition, fluid
distribution, phase angle
• This test can be performed as often as
necessary to document changes in body
fat and lean muscle mass.
BIA may be used
To assess:
- Body composition (estimate)
- Fluid balance
- Cellular performance (cellular health
analysis)
Body composition - BCM
• Loss of BCM (sarcopenia) is associated
with a reduced quality of life, poor immune
response, increased biological age,
osteoporosis, and impaired healing.
Body Composition - BCM
• It takes three times longer to accumulate
BCM as to deplete it.
• To increase BCM you must remove
catabolic factors (stress, anxiety,
sedentary behaviors, insulin resistance,
etc.), increase protein calories, and
introduce resistance training.
Trunkal Obesity/Central Adiposity
• Waist Circumference
• Waist to Hip Ratio
Vital Signs
• BP
• Pulse
• Temp
Hypertension Staging
• Pre-hypertension
– Systolic BP: 120-139 mm Hg; diastolic BP: 80-89 mm
Hg
• Stage I
– Systolic BP: 140-159 mm HG; diastolic BP: 90-99 mm
Hg
• Stage II
– Systolic BP: 160-179 mm HG; diastolic BP: 100-109
mm Hg
• Stage III
– Systolic BP: 180+ mm HG; diastolic BP: 110+ mm Hg
Hypertension
• Stress – Adrenal hyper/hypo function
i.e: addison/cushings or other adrenal tumor. Test with urine cortisol or 24
hour urine test for vanillylmandelic acid and catecholamines (severe
HTN)
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Renal function (U/A)
Congestive heart failure/atherosclerosis
Hyperinsulinemia
Hypothyroid
Lymphatic congestion
Drug interaction/reaction
– Especially contraceptive pills, steroids, decongestants, appetite
suppressants
• Lifestyle
– Alcohol, obesity, smoking, high sodium, lead toxicity (soft water),
caffeine
Lab: Cardiovascular
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Lipids, fractionated lipid profile
Hs-CRP
Fibrinogen
Homocysteine
Highly Sensitive C-reactive Protein
• C-reactive protein – is an important independent
marker for inflammation.
• High levels reflect over activity of inflammatory
cytokines linked to coagulation and vascular
endothelium damage.
• Evidence suggests that previous infection with
pathogens such as Chlamydia pneumoniae or
Helicobactor pylori may act as an initiating
trigger for this chronic inflammation.
C-Reactive Protein
• Marker of inflammation, infection and cell injury
– Aspirin’s reduction of MI risk appears to be related to
CRP levels
– CRP activates complement which injures the inner
layer of blood vessels leading to constriction of
vessels, arrhythmia
• Strong predictor of the risk of future MI
– Study of 2,037 healthy middle-aged men from the
Quebec Cardiovascular Study:
– 105 first cardiac events during 5 years of follow-up
lead to 1.8 fold increased risk of ischemic heart
disease when CRP was at least 1.77 mg/L
hs-CRP
• Is helpful in assessing risk for unstable
plaque, myocardial infarction, and
diabetes.
• Elevated levels of CRP and IL-6 predict
the development of type 2 DM. these data
support a possible role for inflamation in
diabetogenesis.
• JAMA, 2001, Vol 286: 327-334
Diseases Associated With
Defective Methylation Capacity
• Atheroscelosis, coronary artery disease,
deep vein thrombosis, stroke
• Neural tube defects, spontaneous
abortion, placental abruption
• Cervical dysplasia, cervical cancer
• Colon cancer
• Cognitive impairment, depression, senility,
Alzheimer’s disease
• Osteoporosis, RA, diabetes
MTHFR
Methylenetetrahydrofolate reductase
• MTHFR is involved in the conversion of
homocysteine to methionine via the
remethylation pathway
• Polymorphism associated with increased
levels of homocysteine and defective
methylation
MTHFR – Intervention
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Folic acid/5-MTHFR
Vitamin B12/Methylcobalamin
Vitamin B6
Roboflavin: precursor for FMN (flavin
mononucleotide) (B6 to p-5-p), precursor
for FADH2 (flavin dinuceotide), coenzyme
for MTHFR
• Betaine/TMG
Fibrinogen
• Plays a key role in arterial occlusion by
promoting thrombus formation, endothelial
injury, and hyperviscosity.
• Increased fibrinogen levels are seen with:
smoking, oral contraceptive use, obesity, stress,
inflammation, insulin resistance, and aging.
• Higher risk: elevated fibrinogen with high total
cholesterol or elevated LDL; elevated fibrinogen
with high CRP.
Lab: Metabolic Syndrome/DMII
• Glucose-fasting and two hour
• Insulin-fasting and two hour
• HgbA1C
Lab: Altered Endocrinology
• Adrenal Stress Profile – salivary cortisol
• Thyroid
Lab: Objective Goals
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Total cholesterol – under 200
Triglyerides – under 150
HDL – over 50 (male) and over 60 (female)
LDL – under 130 (under 100 if blood risks are
present)
• Trig/HDL ratio – under 3.0
Adults 3+ screen for IR
Children 2+ screen for IR
• Lipoproteins
A1 and B
American Cholesterol education program expert panel’s
current policy on fasting blood triglyceride levels in adults:
Less than 150 mg/dl
(<1.7 mmol/L)
Normal
150 -199 mg/dl (1.7-2.3
mmol/L)
Boderline-high
200 – 499 mg/dl (2.35.64 mmol/L)
High
Higher than 500 mg/dl
(>5.64 mmol/L)
Very high
How to Make the Program Flow
• Where I begin with a new patient:
– Initial consultation
– Charting the Subjective Intake
– Establishing the patient’s health goals to start
their Lifestyle Change Program
– Objective findings: ordering or collecting data
– Review of findings (first or second visit)
– Developing their unique program
– Follow up appointments
Complete the Health Profile
Questionnaire (HPQ)
• Anyone scoring over 50 points total or 10
or more in any one section would benefit
from a detoxification program.
• Even individuals scoring as low as 25-30
will experience greater energy, clarity,
vitality and find that nagging symptoms of
unknown origin often get better.
• Go to www.DrJeffreyTucker.com to
complete this form.
The Initial Health Consultation
• Subjective interview
– HCP Prescription
– Health History
– Health Profile Questionnaire (HPQ)
– Diet/Exercise/Sleep/Stress Diary
– Client’s Health Goals
– Assessing Readiness to Change
The Initial Health Consultation
• Objective Data Collection
– BIA and vitals
• Review of Findings
• Begin Education and Health Coaching
Lifestyle Change – How?
• It takes 45 days to change a habit or
incorporate a new one.
Diet Diary/Exercise log
• Are you filling yours out daily?
• Keep track of:
– Everything you eat
– Everything you drink
– Your Activity/Exercise
• People who self-monitor both eating and
exercise behaviors, are more successful at
reaching and maintaining their ideal
weight.
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The American College of Sports Medicine. (Med Sci Sports Exerc 2001 Dec;33(12):2145-56)
Portion sizes & eating frequency
• Don’t skip meals
- Skipping meals leads to increased production of
glucagon & gluconeogenesis resulting in muscle loss
• Eat frequently
- 3 small meals and 2-3 snacks daily
- To maintain stable blood sugar and insulin levels
- Use high quality meal replacement to:
Achieve frequency goals
Increase nutrient intake while decreasing calorie
intake
Do the body composition analysis to find out your body fat
percent and lean muscle mass.
Identifying the clients that will
benefit from this program:
• Altered Body Composition
– Sacropenic obesity
– Weakness and Fatigue
• Inflammatory Conditions
• Abnormal Blood Sugar Regulation
– Insulin Resistance/Hyperinsulinemia
– Metabolic Syndrome
– Type II Diabetes
• Cardiovascular Risks
– Hypertension
– Hyperlipidemia
Inflammatory Related Chronic
Disorders
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Obesity (Adipocyte)
Sarcopenia (Muscular)
Atherosclerosis (Cardiovascular)
Type II Diabetes (Endocrine)
Osteo- and Rheumatoid Arthritis (Skeletal)
Inflammatory Bowel Disease
(Gastrointestinal)
Lifestyle Modifications and
Preventing Disease
• 3,234 non-diabetic subjects with elevated fasting and
post-load plasma glucose concentrations were
randomized to placebo, Metformin (850 mg twice daily),
or lifestyle-modification program. Program goals of at
least a 7 percent weight loss and at least 150 minutes of
physical activity per week. Initial average BMI = 34.
• At average follow up of 2.8 years, the lifestyle
intervention reduced the incidence of progression to
diabetes by 58 percent vs. the Metformin reduction of 31
percent (as compared with placebo).
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Knowler, W.C. et al., Reduction in the incidence of Type 2 Diabetes with lifestyle intervention or Metformin. N Engl
J Med. 2002. 346(6): p. 393-403
The goals of the diet are
• Decrease insulin stimulation via dietary changes which
decrease insulin release
- ‘Good’ (vs ‘bad’) carbohydrates
- Fiber
- Moderate protein
- ‘Good’ (vs ‘bad’) fat
- Portion size & meal frequency
• Increase cellular responsiveness to insulin:
Chromium
Green tea
Lipoic acid
Cinnamon
Magnesium
Definition of Glycemic Index
• Glycemic Index (GI) is defined as the
incremental area under the blood glucose
curve in response to a standardized
carbohydrate load. It is therefore an index
of the blood glucose raising potential of
the available carbohydrate in a food.
Obesity as an Inflammatory
Disorder
• Obesity reduces a lifespan by 8 to 20
years.
• One of the most interesting discoveries of
the past decade has been the recognition
that the adipocytes produces inflammatory
cytokines.
• Obesity, therefore, may be viewed as a
low grade systemic inflammatory disease.
What does the Adipocyte secrete?
• Resistin is an adipose tissue-specific
factor inducing insulin resistance linking
DM to obesity.
• Adiponectin is an anti-inflammatory, insulin
sensitizing adipocytokine.
• Adiposity is a form of chronic, low-grade
inflammation.
Mid-line trunkal obesity (VAT
deposition)
• Cushingoid appearance –increased deposition
in the visceral adipose tissue enhanced by
increased levels of
 Insulin
 Glucocorticoids (cortisol)
• VAT contributes to:
- Production of the release of TNFa, IL-1, IL-6
- Altered insulin sensitivity and glucose
tolerance
-Thyroid hormone activity alterations
LIPOPSUCTION
The New England Journal of Medicine June
17, 2004
Liposuction (avg of 20 lbs) did not
significantly alter the insulin sensitivity of
muscle, liver, or adipose tissue; did not
significantly alter plasma concentrations of
CRP, IL-6, TNFa, and adiponectin; and did
not significantly affect other risk factors for
coronary heart disease.
General Features of Metabolic
Syndrome
• Abdominal obesity
o Men – waist > 40 inches, or waist is larger than hips
o Women – waist > 35 inches, or waist is greater than 80% the size of
hips
• Altered blood lipids (fats)
o High triglycerides , trig/HDL ratio
o Small LDL cholesterol particles
o Low HDL cholesterol
• Raised blood pressure
• Insulin resistance (+ glucose intolerance)
• Pro-thrombotic state (blood clotting tendency)
- Increased fibrinogen and PAI-1
• Pro-inflammatory state
- Increased IL-6 and hs-CRP
Clinical Identification of the Metabolic
Syndrome
Risk Factor
Abdominal obesity
Men
Women
Triglycerides
HDL cholesterol
Men
Women
Blood pressure
Fasting glucose
Adult Dx: 277.7
Defining Level
Waist Circumference
>102 cm (>40 in)
>88 cm (>35 in)
>150 mg/dl
<40 mg/dl
<50 mg/dl
>130/>85 mmHg
>100
NCEP ATP III
Metabolic Syndrome Patients
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Increased blood fat
Increased body fat
Increased muscle fat
Increased liver fat
Increased pancreatic fat
Do you know someone at risk?
• Approximately 90 million Americans have
insulin resistance.
• 18.2 million Americans have diabetes.
• Over 5 million undiagnosed diabetes.
• Average time from onset to diagnosis is 4
to 7 years due to insidious nature in early
stages.
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National Institutes of Health and Centers for Disease Control and Prevention
Insulin Resistance Syndrome
Metabolic Syndrome
• Overweight or a waist circum.>40 inches for
men, >35 inches for women.
• Elevated BP, blood glucose, blood lipids
(triglycerides).
• Sedentary lifestyle.
• Family history of type 2 diabetes, hypertension
or cardiovascular disease.
• A history of glucose intolerance or gestation
diabetes.
• Polycystic ovary syndrome.
• Sleep apnea.
Almost half of severely obese
children have metabolic syndrome
• “The overall prevalence of the metabolic
syndrome was…
49.7 percent in severely obese subjects”
• N Engl J Med 2004;350:2362-74
Conditions related to insulin
resistance (program candidates)
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Cardiovascular disease
Type 2 diabetes
Hypertension
Hyperlipidemia
Polycystic Ovary Syndrome
Overweight/Obesity
Cancer (colon, breast, prostate)
Sarcopenia
Accelerated aging
Sleep apnea
Alzheimers disease
Inflammatory Cytokines, Hyperinsulinemia, and Atherosclerosis
• A number of studies have domonstarted
that increases in inflammatory mediators
like IL-6 and hs-CRP are associated with
insulin resistance and metabolic
syndrome.
• Metabolic syndrome is strongly associated
with the onset of endothelial dysfunction,
which may explain why type-2 diabetes is
a risk factor for atherosclerosis.
American College of Cardiology
53rd Scientific Sessions - March 9, 2004
• National clinical guidelines recommend
therapeutic lifestyle changes (TLC) as a
standard of care in the management of CVD risk
factors.
• The value of TLC in actual practice is often
discounted by clinicians and health insurers who
instead frequently turn to widely available
pharmacotherapeutic agents.
• Emory University Health Sciences Center
American College of Cardiology
53rd Scientific Sessions - March 9, 2004
• “Many patients with classic cardiovascular
disease risk factors can achieve risk
reduction goals without medications within
only three months of initiating therapeutic
lifestyle changes (TLC).”
• Emory University Health Sciences Center
Weight loss does not always lead
to better health
• “Weight and BMI do not evaluate body
compartments and therefore do not reveal
if weight changes result in loss of fat-free
mass or gain in fat mass.”
• J Amer Diet Assoc 2002;102(7):944-955
• BIA is a reliable resource for assessing
body composition and tissue
differentiation.
Why body composition and BMI are
associated with increased risks
• Muscle mass is the #1 Bio-Marker of aging
• Hence, the higher the muscle mass the greater
the longevity
• Important for preventing
Sarcopenia
Obesity
Heart disease
Type II diabetes
Osteoporosis
Body Mass Index
• Commonly used index of body
composition
• Not useful for measuring percentage of
body fat or lean body mass
• Patients with normal BMI may have
sarcopenia or sarcopenic obesity
One in every six of your patient’s
children are now obese
• The American Obesity Association uses a
reference point of -85th percentile of BMI
as overweight
• -95th percentile for obesity
• The American Obesity Association
estimates that over 30% of America’s
children can be classified as “overweight”
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US Department of Health and Human Services
Developmental Origins of Health
and Disease
• As compared with members of the cohort
in whom heart disease outcomes did not
develop, those who were hospitalized for
or died from coronary heart had relatively
small body size during the first two years
of life, then grew more rapidly through 11
years of age.
• Developmental Origins of Health and Disease, N Engl J
Med;2005:353(17):1848
Trajectories of Growth Among Children Who
Have Coronary Events as Adults
• On average, adults who had a coronary
event had been small at birth and thin at
two years of age and thereafter put on
weight rapidly. This pattern of growth
during childhood was associated with
insulin resistance in later life. The risk of
coronary events was more strongly related
to the tempo of childhood gain in BMI than
to the BMI attained at any particular age.
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New England Journal of Medicine
Clinical Importance of Obesity Versus the Metabolic Syndrome in
Cardiovascular Risk in Women
A Report From the Women’s Ischemia Syndrome Evaluation
• The metabolic syndrome but not BMI
predicts future cardiovascular risks in
women.
• The prevalence exceeds 20% on
individuals > 20 years of age and 40% of
the population > 40 years of age.
Waist Circumference Predicts
Metabolic Risk
• Men with a waist circumference greater
than 40” and woman with a waist
circumference greater than 35” are at
increased risk for metabolic diseases.
• Klein S. The case of visceral fat: argument
for the defense. J Clin. Invest. 2004; 113
(11): 1530-1532.
Obesity & Cancer
• 14% of obese patients will go on to have
cancer.
• In 2020 1 in 26 people will get cancer.
• 5lbs of body fat looks like a loaf of bread.
Essential Fatty Acids (EFA’s)
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…are called essential because we MUST
ingest them.
• Basically two types:
1. Omega-3’s found in cold water fish, nuts,
canola oil and flaxseed.
2. Omega-6’s found in meat, cheese, nuts,
seeds, grains, leafy vegetables, corn,
safflower & soybean oil.
Clinical importance of EFAs
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Structural: all animals’ cell membranes.
-membrane stability.
-membrane fluidity.
-membrane-bound enzyme activities.
-receptor action.
-Permeability.
-ion-channel modulation.
Eicosanoid formation.
Cholesterol transport and oxidation.
Regulation of gene expression: FAs ‘talk to our genes.”
Classification of Fatty Acids
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Saturated (SFA)
Monounsaturated (MUFA)
Polyunsaturated (PUFA)
Highly unsaturated fatty acids (HUFAs)
Trans fatty acids (TFAs)
Classification of Fatty Acids
• Essential
-Linoleic acid (LA; omega 6)
-Alpha-linoleic acid (ALA; omega 3)
• Non-essential
-SFA, MUFAs, TFAs, few PUFAs.
What do EFA’s do?
• Modulate the inflammatory responses.
• Dilate or constrict blood vessels, stomach,
intestines, bronchial tree, uterus.
• Components of cell membranes:
• -involved in cell-to-cell communication
• -keep cell walls rigid or fluid
• -control the flow of nutrients in & out of cells
• Required for the production of RBC’s
Suggested therapeutic effects of
EFAs
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Modulate autoimmune conditions.
Improve insulin resistance.
Improve lipids.
Reduce CAD.
Reduce arrhythmia.
CNS: depression, vision, possibly ADHD.
Cancer-prevention, metastases control,
and adjunct to RX.
Signs of EFA deficiency…
• All patients on the
Standard American
Diet
• Dermatitis – dry, scaly
skin, follicullar
hyperkeratosis
• Dry hair, dandruff
• Brittle nails
• Decreased memory
and mental abilities
• Psychological
disturbances
• Impaired or increased
immune responses
• Neuropathy
• Reduced visual acuity
• Increased
cholesterol/HDL ratio
Likely markers of EPA deficiency
• CVD
• Arthritis
• Syndrome X and
Insulin resistance
• Inflammatory bowel
disease
• Irritable Bowel
Disease
• Diabetes
• Cancer
• Skin diseases
• Autoimmune disease
In general omega – 6’s…
• Are derived from linoleic acid and produce
inflammatory prostaglandins that are
associated with heart disease, cancer and
other inflammation associated diseases.
-Enhance growth of precancerous cells
-Initiate tumor growth
-Increases rates of tumor growth
-Promotes metastasis via PGE2 promotion
-PGE1 from DGLA is protective
In general omega-3’s
• Are derived from alpha-linolenic acid and are
associated with anti-inflammatory properties.
-Smooth muscle relaxation (lower BP).
-Relaxation of intestines (enhances nutrient
absorption).
-Enhanced ability for hormones to communicate
with target cells, decreasing the need for total
hormone.
-Enhanced cell-to-cell communication (decreases
rate o cell growth).
Dietary sources of EFAs
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FoodOmega-3 (grams per 100g)
Flax 20.3
Hemp seeds 7.0
Pumpkin seeds 3.2
Salmon 3.2
Walnuts 3.0
Rape seed 2.1
Herring 2.0
Soybeans 1.2
Butter 1.2
Olive oil 0.6
Wheat germ 0.5
Sunflower seeds 0
Almond 0
Olives 0
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Omega-6 (grams per 100g)
4.9
21.0
23.4
0.7
30.6
9.0
0.4
8.6
1.8
7.9
5.5
30.7
9.2
1.6
Other References
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Metabolism 1998;47:106-112
Br J Nutr 2000;83:S59-S66
Annu Rev Nutr 1999;19:63-90
J Biol Chem 2000;275:30749-30752
J Nutr 1998;128:923-926
Am J Clin Nutr 1999;70:566-571
Biochimie 1998;79:95-99
Int J Obes 1997;21:637-643
J Nutr 1997;127:2142-2150
Am J Clin Nutr 1999;69:890-897
Am J Clin Nutr 1999;70:817-825
J Nutr 1990;120:544-552
J Biol Chem 1998;278:5678-5684
J Biol Chem 1999;274:23577-23583
J Biol Chem 1999;274:471-477
J Biol Chem 1999;274:37335-37339
J Biol Chem 2000;275:32379-32282
Natl Acad Sci USA 1999;96:1041-1048
Scand J Med Sci Sports, 7(1): 25-31, 1997
Eur J Appl Physiol, 87(3): 193-201, 2002
J Appl Physiol, 80(2): 464-71, 1997
J Nutr, 127(9): 1752-7, 1997
Am J Clin Nutr: 1991, 54:438-463
Food Standards Agency ‘Manual of Nutrition’ 10th edition
Omega-3 & Healthy Cardiovascular
Function
• Omega 3 EFAs from fish support shortterm as well as long-term cardiovascular
health.
• “Our findings contradict the current belief
in the medical community that increasing
the intake of omega-3 fatty acids produces
only long term cardiac benefits.”
– Dr. Fernando Holguin
• Chest 127/4/April 2005
Omega-3s reduce the risk of heart
attacks by up to 90%
• Siscovich et al. JAMA. 1995;274:13631367
Omega-3 and healthy body
composition
• Fish oil concentrates not only caused weight
reduction in the mice but also appeared to stop
the animals from gaining weight when given free
access to food.
• Additionally, omega-3 concentrate reduced the
number of fat cells, especially in the abdominal
region.
• Researchers showed that concentrated fish oil
increased oxidation of fat by activating genes
that break down fat in the mitochondria and
peroxisomes.
•
Lipids, Vol. 39, no 12 (2004)
EFA imbalances predispose to
chronic inflammatory conditions
• The inflammatory based chronic diseases that
are increasing in incidence in menopausal age
women and are statistically most likely to kill
them:
 Arthritis
 IBD
 Auto-immune diseases
 Asthma
 Atherosclerosis
 Cardiovascular disease
 Cancer
DHA Supports Mitochondrial
Function & Energy Production
• Mitochondria, have a substantial
concentration of DHA-containing
phospholipids, suggesting that these are
essential for the functional assembly of the
respiratory chain complexes.
•
Infante JP, Hiszagh VA, secondary carnitine deficiency and impaired
docosahexaenoic acid synthesis: a common demoninator in the
pathophysiology of diseases of oxidative phosphorylation and betaoxidation. FEBS Lett. 2000 Feb 18:468(1):1-5
Omega-3s reduce “silent inflammation”
A primary cause of chronic disease
Problem
• 75% of Americans may have “silent” inflammation
• Underlying cause of conditions such as Alzheimer’s and
cardiovascular diseases
Solution
• Increase EPA-DHA consumption (AA/EPA 1.5 to 3):
-Displace inflammatory compounds such as PGE2
-Increase formation of anti-inflammatory compounds such
as PGE1
• Reduce body fat; insulin increases stored AA which is
pro-inflammatory
Omega-3 and healthy brain
function
• “People who eat oily fish or take fish oil
supplements score 13 percent higher in IQ tests
and are prone to healthier brain aging.”
• “The results suggest that fish oil users have
younger brains than non-users. The aging of the
brain is being slowed down by a year or two.”
• Dr. Lawrence Whalley (AM J Clinic Nutrition,
2004)
•
American J Clin Nut Vol, 80, no 6, pp 1650-1657
Omega-3 fatty acids and
neuropsychiatry
“Epidemiological evidence suggests that dietary
consumption of the long chain omega-3 fatty
acids EPA and DHA, commonly found in fish or
fish oil, may modify the risk for certain
neuropsychiatric disorders. As evidence,
decreased blood levels of omega-3 fatty acids
have been associated with several
neuropsychiatric conditions, including Attention
Deficit (Hyperactivity) Disorder, Alzheimer’s
Disease, Schizophrenia and Depression…”
Young, G et al: Reprod Nutr Dev. 2005 Jan-Feb;445(1):1-28
Adult Attention and Focus may be
aggravated by stress
Effect of randomized supplementation with high dose olive, flax or fish oil on
serum phospholipid fatty acid levels in adults with attention deficit
hyperactivity disorder. Young, GS et al Reprod Nutr Dev. 2005 SepOct;45(5):549-58
These data suggest that in order to increase levels of EPA
and DHA in adults with ADHD, and decrease the
AA/EPA ratio to levels seen in high fish consuming
populations, high dose fish oil may be preferable to high
dose flax oil. Future study is warranted to determine
whether correction of low levels of long-chain omega-3
fatty acids is of therapeutic benefit in this population.
DHA and Psychological Stress
DHA deficiency has been shown to
-reduce catecholamine production
-lower serotonin binding affinity
-reduce the number of synaptic vessels
Administration of DHA influences behavior
and plasma catecholamine levels at times
of psychological stress.
Hamazaki T et al: Lipids. 1999;34 Suppll:S33-7
Anti-stress effects of DHA
Hamazaki T et al: Biofactors. 2000;13(1-4):41-5.
Anti-Stress Effects of DHA
• In a similar double blind two month study (study 2), we measured
plasma catecholamines and cortisol of students (3 females and 4
males for the DHA group and the same numbers for the control) at
the start and end of the study. In study 2 the students were under a
continuous stress of final exams that lasted for two months
throughout the whole study period.
• The plasma cortisol did not change in either group, but the
norepinephrine concentration was significantly decreased in the
DHA group (-31%), whereas it stayed at the same level in the
control group. These effects of DHA intake may be applied to people
under psychological stress.
• Hamazaki T et al. Biofactors 2000; 13(1-4): 41-45.
What about depression?
• Severity of depression correlates directly
with the AA:EPA ratio.
• DHA deficiency has been shown to:
-reduce catecholamine production
-lower serotonin binding affinity
-reduce the number of synaptic vessels
• DHA supplementation dramatically
increases the number of synaptic vessels
in nerves.
OB/GYNs are recommending
EPA/DHA
•
•
•
•
Promotes brain and eye development
Encourages fetal weight gain
Prevents perterm labor and preeclampsia
Increases the nutritional value of breast
milk
• Stabilizes mood and prevent depression
during and after delivery – “baby blues”
DHA Reduces Post-natal Depression and
May Promote Restful Sleep
•
•
Without sufficient dietary intake, mothers
become depleted of DHA and may
increase their risk of suffering major
depressive symptoms in the postpartum
period.
How much? – 500 mg/day preconception, 1st & 2nd Trimester
-1000 mg/day 4rd & 4th Trimester
1.
American journal of clinical nutrition 2002;76(3):608-13
•
EPA-DHA Reduces Pediatric
Asthma
• Maternal oily-fish intake during pregnancy
was associated with reduced asthma risk
among children whose mothers had a
history of asthma.
• Among children of asthmatic mothers,
maternal intake of oily-fish during
pregnancy reduced asthma risk by 71%.
• M.T. Salam et al, Prevention Medicine
USC 5/25/04
Change your oil, improve your
health!
• Goal: to achieve minimum 8-10% cellular
EPA/DHA level
• Achieve by supplementing 1 gram EPADHA per day
EPA-DHA Dosing
• Application:
• Daily Levels:
Adult Maintenance
Cardiovascular Health
Healthy Blood Fat Levels
Inflammation
Mental Function
Prenatal Health
Children
Adults under chronic stress
Blood sugar balance
1-2 grams EPA-DHA
1-2 grams EPA-DHA
2-4 grams EPA-DHA
2-7 grams EPA-DHA
2-10 grams EPA-DHA
1-2 grams EPA-DHA
100 mg – 400 mg DHA
1000 mg – 2000 mg DHA
Individual diet plan
Functional Medicine
“Functional medicine focuses on the early
warning recognition and intervention to improve
physical, mental and physiological function prior
to the onset of acute disease.” Gazela, KA: “Jeffrey S. Bland,
PhD, FACN, CNS: Functional Medicine Pioneer”, Alternative Therapies in Health and
Medicine, Sept/Oct 2004, VOL. 10, NO. 5.
Medical foods are designed to restore function
during early phases of declining health as well
as manage a variety of chronic conditions and
disorders by addressing underlying causes.
What is a Medical Food?
• A specific combination of whole food
macronutrient derivatives, micronutrients
and botanical extracts designed with a
specific therapeutic goal in mind.
WHY SOY?
•
•
•
•
•
•
•
•
•
Healthy body composition
Insulin resistance
Favors “Good estrogen”
Body recognizes as safe, weak estrogen
Cardiovascular health
Bone health
Antioxidant protection
Cognitive function
Hot flashes, sweats, dryness, mood, etc.
I support the use of soy
• Do to the large amount of reported safety and
efficacy studies.
• Its long history of safe consumption by Asian
populations.
• The FDA health claim regarding soy protein and
its potential to reduce the risk of heart disease.
• Substantial data regarding the benefits of soy in
cardiovascular health, prostate health,
menopausal symptom relief, and bone health as
well as other important areas.
Understanding Soy
• Soy has been consumes by Asian culture for
thousands of years.
• Soy is a legume that is so nutritionally complete
that it sustained Eastern populations through
drought and famine.
• Composed of:
- Protein
- Carbohydrates
- Fat
- Fiber
- Phytonutrients
- Isoflavones
- Other isoflavone rich foods include garbonzo
beans and sprouts (Red Clover).
The Forms of Soy
• Soy has been used and studied in various
forms:
-Whole soybeans - raw and cooked
-Protein isolates - with balanced and
unbalanced isoflavone content
-Balanced isoflavone isolates
-Single isoflavone isolates
• The more imbalanced the isoflavones the
greater the chance for negative affects.
Phytosterols and Human Lipid
Metabolism
“Plant sterols have been known for several
decades to reduce plasma cholesterol
levels. These plant materials have been
granted a health claim by the FDA
regarding their effects in the general
prevention of cardiovascular disease”.
Marie-Pierre
Soy & Plant Sterol Research
“At a dosage of 1.8 g/day, LDL Cholesterol
concentrations were 11.3% lower in the
plant sterol group, and cholesterol
absorption efficiency was 56% lower in the
plant sterol group.”
Am J Clin Nutr 2002;76:1272-78
Soy
“…Moreover, it has been estimated…that
introducing 2 g of plant sterols daily might
reduce the risk of coronary heart disease
by 25%...low dose of soy protein (8g)
added in beta-sitosterol (2g) seems to be
a practical and safe alternative for patients
seeking reductions in LDL cholesterol
(<15%).”
Effects of a Dietary Portfolio of Cholesterol –
Lowering Foods vs Lovastatin on Serum
Lipids and C-Reactive Protein
“In this study, diversifying cholesterollowering components in the dietary
portfolio by use of a soy protein-based,
plant sterol fortified diet was as effective in
lowering LDL cholesterol as was the use
of lovastatin…reductions in hsCRP were
significant with this dietary regime”.
JAMA 2003;290:502-10.
Is soy beneficial for breast health?
• Research is far from conclusive on this
issue and researchers are urging women
to be cautious
• However, a distinction should be made
between the clear benefit of soy protein for
cardiovascular health and the inconclusive
role of isoflavones for breast tissue health.
Does soy benefit menopausal
women?
• YES. The research shows a great correlation
with reducing hot flashes and other menopausal
issues by consuming soy products.
• Consumption of soy protein containing
isoflavones decreased the intensity of hot
flashes.
• The majority of studies in menopausal women
have shown improvement of hot flashes
following soy consumption.
Do soy products compromise male
reproduction?
• NO. Studies done with balanced soy isoflavones
do not show negative impact on male
reproduction.
• Negative studies are done with one isoflavone or
by injecting isoflavones directly into the blood
create much of the negative concern on soy.
• Genistein was shown in cell cultures to
negatively impact human sperm’s ability to
fertilize the female egg.
• Only when plant estrogens are injected, leading
to high blood levels are adverse effects seen in
research animals.
Do soy products compromise male
reproduction?
• Four published clinical trials investigating the
effects of soy isoflavone consumption in men
and reported that there are no adverse effects of
soy isoflavone consumption on sperm quality.
• Consumption of isoflavone supplements at the
level of 40mg daily had no effect on semen
quality.
• There is no evidence of increased rates of
fertility disorders among the Asian population
due to soy consumption.
• Medical foods with soy deliver 17mg of balanced
isoflavones per serving.
Should soy be used for prostate
health?
• YES. Research shows overwhelming evidence
of the positive benefits in supporting prostate
health without adverse effects.
•
•
•
•
Nagata C, Takatsuka N, Shimizu H, Hayashi H, Akamatsu T, Murase K. Effect of
soymilk consumption on serum estrogen and androgen concentrations in Japanese
men. Cancer Epidemiol Biomarkers Prev 2001;10(3);179-84.
Habito RC, Montaito J, Leslie E, Ball MJ, Effects of replacing meat with soyabean in
the diet on sex hormone concentrations in healthy adult males. Br J Nutr
2000;84(4):557-63.
Mitchell JH, Cawood E, Kinniburgh D, Provan A, Collins AR, Irvine DS. Effects of a
phytoestrogen food supplement on reproductive health in normal males. Clin Sci
2001;100(6):613-18.
Hussain M et al. soy isoflavones in the treatment of prostate cancer Nutr Cancer
2003;47(2):111-7.
Does soy inhibit thyroid function?
• Well designed human clinical studies have
demonstrated that soy has a minimal
effect on overall thyroid function in healthy
individuals.
• Ultrameal Medical Food Program:
Containing soy protein (15 grams) with a
comprehensive vitamin/mineral blend
• Patients using the Ultrameal product had no change in their TSH
levels after 10 weeks. Patients using the popular retail product
showed a significant elevation (150% above baseline) in their TSH
levels.
Does soy inhibit thyroid function?
• Amounts greater than 200mg of isoflavones per
day may inhibit thyroid hormone synthesis in
susceptible people. (thyroid issues/low iodine)
• Certain studies suggest that soy and soy
isoflavones inhibit the production of thyroid
hormones in individuals with thyroid issues.
• Approximately 10 million Americans or 3% of the
population have thyroid issues.
• Alternatives to soy based medical foods are
available for these individuals (rice and whey,
etc.)
Is soy beneficial for bone health?
• YES. Studies have shown that the
isoflavones that are found in soy stimulate
bone formation and reduce bone
breakdown.
• Soy isoflavones have been found to have
a positive effect on bone health.
• Isoflavones stimulate osteoblastic bone
formation and inhibit osteoclastic bone
breakdown.
Metagenics options to benefit every
type of person
• Thyroid issues & soy
allergy clients:
UltraMeal WHEY
UltraMeal RICE
UltraClear
UltraClear Plus
UltraInflamX
• Breast tissue health
options:
Estrium
UltraMeal WHEY
UltraMeal RICE
UltraClear
UltraClear Plus
UltraInflamX
Is soy beneficial for tissue health?
• YES. Soy contains various beneficial
agents for tissue health.
• Cultures that eat soy have shown an
improvement in colon and specific
hormone-related tissue health issues.
• Human trials involving post-menopausal
women demonstrate a significant shift in
healthy estrogen metabolism.
Isn’t it better to use a more
complete protein?
• Early studies suggested that soy was not a
complete protein source. These early
findings have been shown to be
inaccurate.
• Soy has the same “protein digestibility”
score as egg white and milk protein.
• Sarwar G, McDonough FE, Evaluation of protein digestibilitycorrected aꎜ’no’’acid score method for assessing protein quality of
foods. J Assoc Off Anal Chem 1990;73(3):347-56.
Isn’t soy more allergenic than other
proteins?
• Soy proteins tend to be less reactive than
many other food proteins. In fact, soy has
been used as an alternative for infants
with allergies to cow’s milk.
• A meta-analysis of 17 studies of allergy
patterns in high risk infants revealed soy
allergy occurs in 3% to 4% of subjects
versus 25% for cow’s milk.
Do I have to use fermented soy products to
achieve therapeutic benefits?
• No. The majority of studies around the
world show beneficial effects of soy.
• Our research studies support those
findings for areas including:
Blood sugar
Body composition
Preserving muscle mass during weight
loss
Cardiovascular risk reduction
Improve health with
• UltraMeal
-Altered Body Composition
-Early Onset Metabolic Syndrome with Altered Body Composition
• Central body obesity
• Insulin resistance
• Altered body composition
• UltraMeal Plus
-Metabolic Syndrome with Cardiovascular Syndrome
• Elevated Cholesterol
• Increased Triglycerides
• Hypertension
UltraMeal Plus
• Combined with a low-glycemic-index
dietary program and exercise regimen,
provides nutritional support for the
management of conditions associated with
cardiovascular disease, including:
• Hypercholesterolemia
• Hypertriglyeridemia
• Metabolic Syndrome
• Altered Body Composition
UltraMeal
• Combined with a low-glycemic-index
dietary program and exercise regimen,
provides nutritional support for the
management of conditions associated with
altered body composition, including:
• Dyslipidemia
• Metabolic Syndrome
• Hypertension
• Estrogen imbalance
UltraMeal Plus 360
•
Multi-mechanistic nutritional support for metabolic syndrome and CVD, with
the added benefit of Selective Kinase Response Modulators (SKRMs).
• Clinically tested results: The UltraMeal Plus 360 Medical Food Program was
recently shown to improve important CVD risk factors in patients with
metabolic syndrome. In this clinical study, patients assigned to treatment
with UltraMeal Plus 360 Medical Food Program, exercise regimen, and lowgylcemic-load (GL) diet vs. the same low-GL diet and exercise regimen
alone showed:
• Statistically greater reductions in lipid parameters
• Statisitcally greater reduction in serum homocysteine
• Significant increase in HDL (“good”) cholesterol
• Persistent lowering effects on apoB and apoB/apoA1 ratio
o ApoB may be a better indicator of CVD risk than total cholesterol or LDL
o ApoB/apoA1 ratio is a newly recognized, increasingly significant indicator of
CVD risk
Dynamic Combination for Overall
Cardiovascular Health
•
•
•
•
•
Patient Profile
Patients on statin therapy
Patients 35-64 under
preventative care for CVD
Increased triglyerides
High C-reactive protein
High cholesterol
– Increased LDL
– Low HDL
UltraMeal Plus
2 scoops BID along with a
low glycemic diet
EPA/DHA
Recommended: 1 to 3
grams daily
CoQ10
Recommended: 100 – 300
mg daily
Children & Young Adults
(soy and whey combination)
• Ultracare FIRST START Medical Food
Program
UltraGlycemX Medical Food
• Nutritional support for individuals with
Type 2 Diabetes and Hypoglycemia
UltraGlycemX
• Combined with a low-glycemic-index dietary
program and exercise regimen, provides
nutritional support for the management of
conditions associated with insulin insensitivity
and elevated blood sugar levels, including:
• Type 2 diabetes
• Insulin resistance
• Hypoglycemia
• Hypertension
Blood sugar
• Blood sugar refers to levels of glucose in
the blood.
• Blood sugar concentration, or serum
glucose level, is tightly regulated in the
human body.
• Glucose transported via the bloodstream
is the primary source of energy for the
body’s cells.
Fasting & 2 hr postprandial glucose
following a 75 gram glucose load
• Fasting
• 80-90 optimal
• 105 and above =
DMII
• 2 hour postprandial
• 80-120 optimal
• Below 80 =
hypoglycemia
• 120 and above =
DMII
Glucose levels
•
•
•
•
35 = extremely low, danger of unconsciousness
75 = slightly low, first symptoms of lethargy etc.
80-90 = optimal pre-prandial in non-diabetics
80-120 = ooptimal 2 hour post-prandial in nondiabetics
• Above 100 = look for Metabolic Syndrome
criteria
• 400 = max mg/dl for some meters & strips
• 600 = high danger of severe electrolyte
imbalance
Blood sugar important points
1) “high fructose corn syrup,” which is simply a
Pure fructose (what we use) is NOT the same
as replacement for table sugar. Fructose is
“natural” and is the typical carbohydrate found
in fruits and sone vegetables.
2) The fructose in UltraMeal and UltraGlycemX is
nutritive (ie, food) and is NOT used as a
sweetener. It is there for its therapeutic benefit.
3) “Moderate” consumption of fructose is
associated with POSITIVE blood sugar,
triglyceride, and body composition benefits.
Blood sugar important points con’t
1) Data from animal studies use fructose levels
far higher than a human would consume in a
day – the equivalent of up to 700 calories in a
day from fructose alone.
2) We have the clinical proof in numerous studies
that moderate fructose consumption shows
health benefits.
3) The obvious problem is poor diet – one FULL
of empty calories from processed foods and
beverages and NOT from a quality, balanced,
meal such as UltraMeal or UltraGlycemX.
Definition of Glycemic Index
• Glycemic index (GI) is defined as the
incremental area under the blood glucose
curve in response to a standardized
carbohydrate load. It is therefore an index
of the blood glucose raising potential of
the available carbohydrate in a food.
Many factors affect GI of a food:
• Carbohydrate type
-Simple: glucose, fructose, maltose
-Complex: amylose, amylopectin
• Fiber content and type
• Processing (the higher the processing, the
higher the GI load)
• Physical nature
• Other macronutrients in food
-Protein
-Fat
Glycemic Index
• The GI for a particular food is derived by
expressing the individual glycemic index
as a percent of a reference food, typically
white bread or glucose.
Glycemic Index and Obesity
Low GI foods control appetite and delay hunger.
Low GI diets reduce insulin levels and insulin resistance.
- High-carb, low-fat diets increase postprandial
hyperglycemia and hyperinsulinemia.
Several human studies found that energy restricted low-GI
diets produced greater weight loss than did equivalent
diets based on high GI foods.
Brand-Miller JC et al. Glycemic index and obesity. AM J
Clin Nutr, 2002. 76(1): p. 281S-5S.
Glycemic Index and HDLCholesterol
• Conclusion: dietary GI is a stronger
predictor than dietary fat intake of serum
HDL-cholesterol concentration.
•
Frost G et al. Glycaemic index as a determinant of serum HDL-cholesterol
concentration. Lancet, 1999. 353(9158): p. 1045-8.
A meta-analysis of Low-GI Diets in the
Management of Diabetes
• 14 studies that met inclusion criteria
• Conclusions:
-Low GI diets have a clinically useful effect on
medium-term glycemic control in patients with
diabetes.
-The benefit is similar to that offered by
pharmacological agents that also target
postprandial hyperglycemia.
*Without drugs they get “similar” results on
low GI diet
Brand-Miller et al. Low-Glycemic Index Diets in the Management of Diabetes: A meta-analysis of
randomized controlled trials. Diabetes Care, 2003 26(8): 2261-2267
Glycemic Index
Low GI
55 or less
Medium GI
56 to 69
High GI
70 or more
Glycemic Index of Selected Foods
(referenced to glucose)
•
•
•
•
•
•
•
•
Watermelon
Pearled barley
White flour bread
Carrot
Cornflakes
Baked potato
Apple
Apple juice
72
25
70
47
72
85
38
40
Glycemic Load
• The amount of carbohydrate often differs in a
typical serving of a food.
• A measure termed ‘glycemic load’ (GL) has
been introduced.
(Salmeron J, Ascherio A, et al. Dietary fiber,
glycemic load, and risk of NIDDM in men.
Diabetes Care, 1997. 20(4): 545-50.
• The dietart glycemic load is defined as the
product of a food’s glycemic index and its
carbohydrate content.
GL=(GI divided by 100) x available
carb
• Example: Watermelon (GL=4)
- Glycemic index = 72. A typical serving
(120 grams or ¾ cup) has 6 grams of
available carbohydrate.
- Glycemic load = (72 / 100) x 6 = 4.32
(rounded to 4).
Glycemic Load
Low GL
10 or less
Medium GL
11 to 19
High GL
20 or more
GL=(GI/100) x available carb
(available carbohydrate content of typical serving)
• Example: Carrot (GL = 3)
- Glycemic index = 47. A typical serving (80
grams or ½ cup cooked) has 6 grams of
available carbohydrate.
- Glycemic load = (47/100) x 6 = 2.82
(rounded to 3)
GI/GL Comparisons
FOOD
GI
GL
Baked potato
85
26
Watermelon
72
4
Apple
38
6
Apple juice
40
11
Carrot
47
3
GI & GL values of hundreds of
foods have been determined
• On the web:
www.glycemicindex.com
www.mendosa.com
Effects of a Low-Glycemic Load
Diet
“Resting energy expenditure decreased less with the lowglycemic load diet than with the low-fat diet…participants
receiving the low-glycemic load diet reported less
hunger…”
“Insulin resistance, serum triglycerides, C-reactive protein,
and blood pressure improved more with the low-glycemic
load diet.”
“In conclusion, we found that the physiologic adaptations to
a weight loss diet thought to antagonize weight loss,
involving energy expenditure and hunger, can be
modified by dietary composition.”
JAMA 2004:292(20)2482-2490
High Glycemic Index Foods,
Overeating, and Obesity
“Voluntary energy intake after the high-GI
meal…81% greater than after the low-GI
meal.”
Pediatrics 1999; 103(3):E26
GI Meals
“high-glycemic index meals produce an initial
period of high blood glucose and insulin levels,
followed in many individuals by reactive
hypoglycemia, counter-regulatory hormone
secretion, and elevated serum free fatty acid
concentrations. These events may promote
excessive food intake, beta cell dysfunction,
dyslipidemia, and endothelia dysfunction.”
JAMA 2002:287(18);2414-2423
Fiber
• Two isocalorically equal diets varying only in
amount and type of fiber (50 g at 1:1
soluble/insoluble vs 24 g at 1:2 soluble vs.
insoluble) for 6 weeks in non-insulin diabetes
patients.
• The high-fiber diet lowered the area under the
curve for 24-hour plasma glucose and insulin
concentrations by 10 percent and 12 percent
respectively.
•
Chandala, M., et al., Beneficial effects of high dietary fiber intake in patients with type 2 diabetes
mellitus. N Engl J Med, 2000. 342(19):1392-8.
FAT
• High-monounsaturated-fat diets reduced fasting
triglycerides (19%) and VLDL-cholesterol (22%),
and caused a modest increase in HDLcholesterol concentrations with no adverse affect
on LDL-cholesterol.
• No evidence that high-monounsaturated fat diets
induce weight gain in patients with diabetes
mellitus provided that energy intake is
controlled.
•
Garg, A., high monounsaturated fat diets for patients with diabetes mellitus: a meta-analysis. AM J
Clin Nutr, 1998. 67(3 Suppl): p. 577S-582S.
Healthy vs Unhealthy
• Normal Metabolism
 Healthy body
composition
 Great energy
 Healthy attitude
 Great mental function
• Metabolic Syndrome
 Mental fogginess
 Low energy
 Depression
 Increased fat
 Decreased muscle
mass
Detoxification & Inflammation
UltraClear UltraClear Plus
•
•
•
•
•
Fatigue
Food allergies
Environmental toxicity
Liver function
Health maintenance
Elimination of Toxins
• UltraClear Plus
Nutritional Support Is required for
Proper Clearance of Toxins
• “Diets restricted in calories, protein, … as well as
those having low quality protein or high sugar
content, can affect the component enzymes,
ctochrome P-450 and the cytochrome P-450
reductase, … In addition, deficiencies of specific
vitamins (riboflavin, ascorbic acid, and Vitamins
A and E) and minerals (iron, copper, zinc, and
magnesium) affect the components and
activities of the system.”
•
Bidlack WR, Brown RC, Mohan C. Fed Proc. 1986 Feb;45(2):142-8.
Detoxification
• UltraClear
• UltraClear Plus
• UltraClear Plus pH
• AdvaClear
These help with chemical toxicity, food
allergies, liver function, fatigue
GI Dysfunction: Increasing liver
stress
• Patients with leaky gut, mediated food allergies,
inflammation may have hepatic (liver) stress.
• In these scenarios, the liver is constantly
burdened by toxins and allergens arriving from
the gut.
• These patients will benefit from a program to
restore normal gut barrier function to relieve the
burden on the liver before they can become well.
How the environment affects
genetic expression
•
•
•
•
•
•
Poor diet
Stress
Fatigue
Lack of exercise
Drugs, alcohol, tobacco
Chemical exposure
UltraClear Plus
•
A clinically tested detoxification program
to:
1. Reduce toxic load (external sources of
toxins)
2. Improve Biotransformation (supports
cytochrome p450 phase 1 and
conjugation phase 2 pathways
3. Support elimination (optimal excretion of
toxins)
AdvaClear
• This formula is particularly valuable in patients
who score over 100 on the MSQ as they often
have overactive Phase 1 activity and depleted
conjugation pathways. Ingredients include
- Pomegranate
- Watercress
- Artichoke
- Milk thistle
- Green tea
Estrium
Scientifically designed to:
• Promotes healthy hormone cycles
• Relieves symptoms of PMS
• Promotes healthy estrogen metabolism
and excretion
• Modifies the effects of circulating
estrogens
Estrium
Patient Benefits
• Reduction in PMS symptoms
• Case studies show effective for symptoms
associated with menstrual tension,
menstruation and endometriosis
• Easy to use – 2 scoops one to two times
daily mixed with juice, milk or milk
substitute as meal replacement or snack
Ideal Foods That Modify Estrogen
Metabolism
• Cruciferous vegetables:
broccoli, cabbage,
brussel sprout
• Fresh greens and
vegetables (assorted
colors)
• Fresh fruit: berries,
melons, citrus
• Legumes: soy – tofu,
soymilk, miso, tempeh,
steamed soy beans
(edamane), garbanzo
• Beans
• Raw seeds and nuts: flax
seeds
• Whole grain: oats, whole
wheat or rye berries
• Quality proteins: fish,
(tuna, salmon, haddock),
hormone free chicken,
beef
• Oils: flax seed (ALA,
Omega-3), olive, sesame
If you have Inflammation
Use UltraInflamX
•
•
•
•
•
Rheumatoid arthritis
Inflammatory bowel disease
Fibromyalgia
Eczema & psoriasis
Asthma
Additional Inflammatory Support
•
•
•
•
•
•
•
Estrium
Kaprex
Kaprex AI
Inflavinoid
Inflavinoid Intensive Care
ChondroCare
Essential Fatty Acids
Inflammatory Cytokines,
Hyperinsulinemia & Atherosclerosis
• A number of studies have demonstrated
that increases in inflammatory mediators
like IL-6 and hs-CRP are associated with
insulin resistance and metabolic
syndrome.
• Metabolic syndrome is strongly associated
with the onset of endothelial dysfunction,
which may explain why type-2 diabetes is
a risk factor for atherosclerosis.
If you have
• Altered body composition
• Abnormal blood sugar regulation
• Cardiovascular risks (atherosclerosis)
Consider UltraMeal Plus, UltraInflamX
Nitric Oxide prevents Atherosclerosis and
Promotes Circulatory Health
• Dilating the arteries and increasing blood
flow support circulatory function for a
healthy heart.
Support healthy blood pressure,
circulation & heart muscle function
• Arginine
• 5-MTHF
• Magnesium Bonito Peptides
Arginine Imperative for Heart
Health
• Is an amino acid
• Is naturally found in red meat, poultry, fish, and
diary
• Supports the production of nitric oxide, which is
used to dilate blood vessels
• Maintain health of the circulatory system
• Is used for cardiovascular conditions:
– Congestive heart failure
– Hypertension
– Coronary artery disease
Magnesium & Folate
most researched ingredients for the heart
•
•
•
•
•
•
Magnesium
Supports healthy
endothelial cells
Alleviates arrhythmias &
heart palpitations
Essential for proper heart
muscle function
Lowers triglyerides
Raises HDL
Lowers cholesterol
•
•
•
•
•
5-MTHF
Improves nitric oxide
status
Lowers blood levels of
homocysteine
Crucial for methylation
Reduces risk of heart
disease
Influences endothelial
function
New Atherosclerosis Concepts
• Understanding the impact on the vascular
tissue through inflammatoryimmunological mediated trauma
• The association with the abnormal
lipid/cholesterol panel and risks for MI
• The presence of inflammatory cytokines
Ornish D et al: JAMA. Vol. 280, No.
23, pp. 2001, dec. 16, 1998
• Intensive lifestyle changes (10% fat, whole
foods vegetarian diet, aerobic exercise,
stress management training, smoking
cessation and group psychosocial support)
resulted in regression of coronary
atherosclerosis over a five year period,
whereas for those in the control group
using the traditonal AHA approach CHD
continued to progress and more than twice
as many coronary events occurred.
Using medical food shakes twice
daily
• Predictability – clinically tested and utilized
in thousands of clinics worldwide
• Well tolerated by the most sensitive client
– easily digested and low allergy potential
• Convenient – good taste and easy to
follow programs
Cardiovascular support
•
•
•
•
-
EPA/DHA
Cardiogenic (CV Wellness Essential)
CoQ10
Lipid support
Lipogen
Meta sitosterol 2.0
Lipotain
Cholarest
Therapeutic dosing levels for
cardiovascular health
• Arginine
• Magnesium
• ActiFolate
3000 – 6000 mg
200 – 400 mg
400 – 800 mcg
CoQ10
• Ubiquinone (CoQ10) is a vitamin-like fat-soluble
antioxidant found in all cells in the body.
• Statin therapy for cholesterol, lowers the body’d
production of CoQ10.
• CoQ10 deficiency may cause increase risk of
heart disease and high blood pressure.
• Adequate CoQ10 intake is vital for organs such
as the heart, liver, kidney and pancreas.
• As you age the CoQ10 is depleted.
• CoQ10 is key for mitochondrial function.
CoQ10: Dosage Range
100-300 mg daily
• Protects patients on Statin therapy
• Effective nutritional treatment for
congestive heart failure
• Antihypertensive effects
• High doses may reduce functional decline
in early Parkinson’s disease
• May prevent migraine headaches
• Master antioxidant-may support breast
tissue health
Dr. Jeffrey Tucker’s Program
• Simple lifestyle changes
• Facilitates transition to healthy, whole food
diet
• Replaces problem meals with a healthy
shake
• Understand the relationship of health and
food
• Food choices from every category (meats,
vegetables, fruit, grains, etc)
Dr. Jeffrey Tucker’s Program
Diet & Exercise
• Low gylcemic index foods
• Small, frequent meals
• Medical food for body composition
• Quality EFAs, esp. omega 3 (EPA, DHA)
• Exercise –progressive body movement
-CORE, Gymstick, free weight training
• Additional supplementation as needed
Why is this the most effective
program?
•
•
•
•
•
•
Better appetite control
Delayed hunger
Less cravings
Better blood sugar control
Improved insulin sensitivity
Better reduction of elevated blood lipids,
blood pressure & blood sugar
• The most specific exercise training
Clients that will benefit from Dr.
Tucker’s program
• Altered body composition (come in to the office
and do a BIA test)
• Abnormal blood sugar regulation
• Cardiovascular risks (atherosclerosis,
hyperlipidemia, dyslipidemia)
Consider: UltraMeal Plus for increased cholesterol
and LDL.
UltraMeal + MetaglycemX/Insinase or
UltraGylcemX + Insinase for increased Trig/HDL
ratio
Illness and Muscle Loss
• “…we found that fat-free mass was lower
and fat mass was higher (Sarcopenia) in
acutely ill and chronically ill patients than
controls.”
•
J Amer Diet assoc 2002;102(7):944-955
•
The over-fat “ill” with sarcopenia include those with fatigue, arthritis, back
pain, metabolic syndrome, cardiovascular disease, hypertension, diabetes
and other health problems.
Sarcopenia – understanding the
Dynamics of Aging Muscle
• The damage caused by high glycemic
meals insulin resistance, inflammatory
immune factors and hormone changes
acting primarily in the postprandial state
are implicated as an important cause of
sarcopenia.
• JAMA 2001:286(10):1230-31.
10 week Doctor Supervised Program
vs.
Un-supervised Program
Total
weight
Lean Body
Mass
Change In
Fat Weight
Dr.
-11 LBS
Supervised
+4 LBS
-15 LBS
Over The
Counter
-11 LBS
-.91 LBS
-13 LBS
10 week Doctor Supervised Program
vs.
Un-supervised Program
“Two statistically significant differences
between the groups were changes in
thyroid stimulating hormone (TSH) and
body composition (BC). No change in TSH
was observed in the DSP group pre- and
post-intervention. Whereas a significant
increase (150%) was observed in the OTC
group. In addition, participants in the DSP
group last significantly more fat than the
OTC group.”
UltraMeal has the science…
All Women:
• Lost body weight
• Decline in % body at
• Lost fat mass
• Average fat loss
• 12 of 18 showed
increase in lean body mass
5.7-22 lbs
up to 10.1%
up to 22.9 lbs
14.1 lbs
.2 – 7.7 lbs
Robert Hackman, PhD Associate Professor of Nutrition University of Oregon
250 Esslinger Hall Eugene, OR.
UltraMeal Soy Protein Source
• Conditions associated with
Metabolic Syndrome
• Delicious Flavors & Variations
- Banana Blast
- Dutch Chocolate
- Strawberry Supreme
- Vanilla
- Country Peach
- Raspberry
- Mocha
- Also available in Rice & Whey
Protein
• UltraMeal in
convenient Bar Form
-Chocolate Raspberry
-Lemon Zinger
-Chocolate Fudge
-Apple Cinnamon
-Chocolate Banana
UltraMeal: Additional Facts
• Glycemic Index of 31
• Optimal, foundation nutrition with all
essential vitamins and minerals
• Dairy-free source of calcium for bone
health (500mg per serving = 2 scoops)
• Features ActiFolate, a proprietary blend of
active floates for healthy methylation
Cardiovascular Disease Facts
• Cardiovascular disease is the #1 killer in U.S.
• Nearly 62 million have at least one type of CVD
• More Dr. office visits for hypertension or high
blood pressure, than for any other reason
• Economic cost of CVD is approximately 298
Billion, more than 28 Billion was spent on CVD
Drugs.
Soy & Plant Sterol Research
“At a dosage of 1.8 g/day, LDL cholesterol
concentrations were 11.3% lower in the
plant sterol group, and cholesterol
absorption efficiency was 56% lower in the
plant sterol group.”
Am J Clin Nutr 2002;76:1272-78
UltraMeal Plus Program Better Than AHA Diet For
Reducing 14 Cardiovascular Risk Factors
• Human Clinical Trial Demonstrates…
Trial conducted at the Functional Medicine research Center, a research
arm of Metagenics.
UltraMeal Plus & Dr. Tucker’s Workout Program in
Reducing 14 Cardiovascular Disease Risk Factors
• UltraMeal Plus
tChol
-16%
LDL-C
-15%
HDL-C
+6%
Trig
-45%
tChol/HDL-C
-20%
TG/HDL-C
-45%
Body weight
-14.8lb
% Lean Mass
+2.8%
Hs CRP
-34%
HbA1C
-3.4%
Fasting Insulin -26%
BP systolic
-4.6
BP dyastolic
-8.3
• AHA Diet
-1%
-2%
+1%
-24%
-4%
-24%
-7.5lb
+1.23%
-7%
-1.5%
-10%
-2.3
-6.0
UltraMeal Plus & Dr. Tucker’s
Program
• Reduction in 14 important cardiovascular
disease risk factors including cholesterol,
HDL, triglyerides, blood pressure.
• 97% greater weight loss tha aleading diet
used by doctors worldwide (ADA diet).
• 110% greater fat loss than a leading diet
used by doctors worldwide (AHA diet).
UltraMeal Plus
• Patients lost weight while maintaining
muscle, resulting in improved body
composition.
• Promotes healthy blood sugar balance –
low glycemic index meal.
• Preserves lean body mass – unlike most
diet and weight loss programs, patients
lose fat and maintain muscle.
The Truth About Type 2 Diabetes
•
•
•
20.8 million children and adults have diabetes
14.6 million diagnosed
6.2 million are unaware
Results from insulin resistance
The body’s cells are resistant to the actions of
insulin
• Pancreas produces too little insulin
• Diabetics usually develop the condition after age
45
• About 18% of U.S. population 65 and older has
diabetes.
UltraGlycemX
Glycemic Index of 36
• Nutritional support for individuals with Type 2
Diabetes & Hypoglycemia
• Provides enhanced levels of:
-Cinnamon
-Vitamin E, biotin, vanadium, magnesium,
chromium, and alpha-lipoic acid
• High quality protein, carbohydrates, and fat in
shake form
• Inclusion of specific fibers
• Is free of dairy, lactose, wheat, gluten
UltrGlycemX supportive vitamins &
minerals
•
•
•
•
-
Alpha-lipoic Acid
Stimulation of Glucose Transport Proteins
Improves insulin receptor sensitivity
Increases glucose metabolism in mitochrondria
Zinc and Chromium Combination
Reduces oxidative stress in patients with blood sugar
concerns
Vanadium
Activates cellular insulin receptor pathways
Taurine
Protects the beta cells in the pancreas
Stimulates insulin sensitivity
Cinnamon in UltraGlycemX
“This study demonstrates that intake of 1, 3,
6 g of cinnamon per day reduces serum
glucose, triglyerides, LDL cholesterol and
total cholesterol in people with Type 2
diabetes and suggests inclusion of
cinnamon in the diet of people with type 2
diabetes will reduce the risk factors
associated with diabetes and CVD.”
Green Tea Therapy for
Insulin Resistance
Green Tea in UltraGlycemX
• Antioxidant
• Appetite regulation
• Leptin receptor independent pathway
• Stimulates respiration and energy
expenditure
• Stimulates adipose tissue thermogenisis
• Fat burning
Green Tea in UltraGlycemX
“Epigallacatechin gallate (EGCG), a major
ingredient in green tea…was reported to
functionally act as antidiabetic. Injection of
EGCG into lean and obese Zucker rats
significantly lowered blood glucose and
insulin levels, and green tea extract
increased glucose metabolism in
adipocytes (fat cells).”
Experimental and molecular Medicine Vol. 35, No 2, 136-139 April 2003
UltraGlycemX supportive vitamins
& minerals
•
•
•
-
Biotin
Supports metabolism of glucose without increased insulin secretion
Improves beta cell function
Enhances post-prandial glucose uptake by the liver and skeletal
muscle
Alpha-lipoic Acid
Stimulation of Glucose Transport proteins
Improves insulin receptor sensitivity
Increases glucose metabolism in mitochrondria
Chromium
Enhances cell membrane fluidity
Stimulates glucose uptake
Allows for proper binding of insulin to receptors
UltraGlycemX supportive vitamins
& minerals con’t
• Zinc & chromium combination
- Reduces oxidative stress in patients with Type 2
diabetes.
• Vanadium
- Activates cellular insulin receptor pathways
• Taurine
- Protects the beta cells in the pancreas
- Stimulates insulin sensitivity
UltraGlycemX
•
•
•
•
Hypoglycemia
Dizzy after skipping a meal
Sugar cravings
Low energy
Parameters:
• Fasting glucose >100mg/dl and <110mg/dl
• Triglycerides >150mg/dl and <175mg/dl
• BP < 140/90
Which Medical Food To Use
• BODY COMPOSITION MANAGEMENT
UltraMeal, First Start
• CARDIOVASCULAR DISEASE & BODY
COMPOSITION
UltraMeal Plus
• DYSGLYCEMIA & INSULIN RESISTANCE
UltraGlycemX, UltraMeal 360
• INFLAMMATION
UltraInflamX, UltraInflamX 360
• DETOXIFICATION
UltraClear, UltraClear Plus, UltraClearPlus pH, Estrium
UltraGlycemX
Type 2 Diabetes
Insulin resistance
Hypoglycemia
Hypertension
UltraMeal Plus
Hypercholesterolemia
Hypertriglyceridemia
Metabolic
Syndrome
Altered body
composition
UltraMeal
Dyslipidemia
Metabolic
syndrome
Hypertension
Estrogen
imbalance
Biochemical
Challenge
Wellness
Essentials
Maintenance
General
Wellness
Original,
Woman’s,
Pregnancy, Men’s
Body
composition
Original
Blood Sugar
UltraMeal
Insulin
resistance
Blood Sugar
UltraMeal Plus (pH),
Metabolic
Syndrome
Blood Sugar
Dyslipidemia
Cardiovascular
Blood Sugar
UltraMeal Plus (pH),
Original, Joint
Inflammation
Medical Food
Micronutrients
Supportive
supplements
Ceralin forte
EPA/DHA
MetaGlycemX EPA/DHA,
UltraGlycemX
UltraMeal Plus (pH),
Insinase, Ceriva
MetaGlycemX EPA/DHA,
UltraGlycemX
Insinase, Ceriva
UltraGlycemX
Metasitosterol
2.0
EPA/DHA,
CoQ10, Lipotain
UltraInflamX
Inflavinoid
EPA/DHA, Kaprex,
Kaprex AI, IsoD3,
Trancor, Ceralin Forte
Inflavinoid Int. Care
Biotransformation
(Detoxification)
Original
UltraClear Plus
(pH), UltraInflamX
AdvaClear
Silymarin,
Chloraclear
Methylation
Original
UltraMeal Plus (pH),
Estrium
AdvaClear
Glycogenic
EstroFactors/Testralin
Female
Hormones
Women’s
Estrium
EstroFactors
MetaI3C,
Ceriva
Male Hormones
Men’s
UltraMeal Plus
Metasitosterol
Tribulus synergy,
Testralin
Why Stress Reduction?
• Stress accounts for 75-90% of all primary care visits in
the US (National Inst for Occupational Safety and Health)
• Almost all illness is stress-related
- caused by stress
- aggravated by stress
- causes stress
• #1 reason why people eat poorly and quit healthy life
style programs
• Conserves energy
• Restores sense of control
• Supports good choices
• Reduces cortisol
What do people do to manage mental
stress
Self-medicate through…
• Drug or alcohol abuse
• Tobacco use
• Abnormal patterns
• Passive activities (couch potato, video games)
• Over-eating, over-working, over-sleeping
• Stimilants, e.g. coffee
- Four or five cups daily can cause changes in blood
pressure and stress hormone levels similar to those
produced by chronic stress
(self-perpetuating the stress cycle)
Or, go to their Doctors for Rx
to manage mood or stress-related illness
•






•
•
•
•
•
Anti-depressants
SSRIs
SNRIs
NDRIs
Tricyclic antidepressants
Receptor blockers
MAOIs
Anti-anxiety medications
Anti-inflammatory
Anti-ulcerant
Cholesterol reducers
Anti-hypertensives
Depression & Anxiety Disorders
National Institute of Mental Health, Information Resources and Inquires Branch
website:
www.nimh.nih.gov
• Depression
In an given 1 year period, 9.5% of the population,
or 18.8 million American adults suffer from a
depressive disorder.
Affects about 12.4 million women and over 6
million men in the US each year
• Anxiety Disorders
Approximately 19 million American adults
Chronic, relentless and grows progressively worse
if not treated
North America Top Selling Drug
Category
• Central nervous system category
(anti-anxiety, antidepressants, antipsychotics)
2005 retail sales: $43.3 billion
Growth: 23.0%
12.2% of all drug sales
www.imshealth.com
FDA Warning:
• Anti-depressants linked to suicidal behavior in
depressed children and adolescents.
• The warning applies to both children and adults
and includes the following drugs:
Prozac
Lexapro
Zoloft
Wellbutrin
Paxil
Effexor
Luvox
Serzone
Celexa
Remeron
What is Stress?
• A physiologic response to a demand for
change
• “Fight or Flight” response
• General Adaptation Syndrome
• Sympathetic Nervous system Dominance
Stress Physiology
Hans Selye, M.D., Ph.D.
• “Without stress, there would be no life”
• “Stress = nonspecific response of the body
to any demand.”
How can stress cause so much
damage?
Selye’s General Adaptation Syndrome
The 3 Stages of Stress
• Arousal
Rapid increases in catecholamines (alarm molecules)
Slower increases of corticosteroids (stress steroids)
• Adaptation
Characterized by sustained increased levels of corticosteroids and
alarm molecules
Altered glucose tolerance, blood pressure, thyroid hormone and sex
hormone metabolism
• Exhaustion
Degenerative diseases characterized by the adverse influence of
corticosteroids and alarm molecules
Stress versus the
Relaxation Response
Fight or Flight Response
• Sympathetic State
 Inc. Heart Rate
 Inc. Blood Pressure
 Inc. Respiratory Rate
 Dilated Pupils
 Muscle Tension
 Inhibits Digestion
Relaxation Response
• Parasympathetic State
 Dec. Heart Rate
 Dec. Blood Pressure
 Dec. Respiratory Rate
 Constricted Pupils
 Muscle Relaxation
 Enhances Digestion
Stress
• The basis for human stress related
disease is the high percentage of time
spent in the sympathetic dominant state.
Sympathetic Dominance:
Long-term Effects of Elevated Cortisol & Catecholamines
• GI distress: IBS, ulcers
• Cardiovascular symptoms:
rapid pulse, pounding heart,
weakness, dizziness, chest
pain, high BP
• Mood changes: general
irritability, floating anxiety,
depression, impulsive
behavior, nervous laughter,
increase startle response
• Hyper-kinesis or –excitation
• Sleep disturbances:
nightmares, insomnia
• Brain architecture changes:
Lower hippocampal volume
(inc cortisol)
• Cognitive impairment:
inability to concentrate, poor
memory
• Neuromusculoskeletal
complaints: TMJ, bruxism,
trembling, nervous ticks, back
and muscle ache
• Energy level: Fatigue of
unknown origin
• Adrenal architecture
changes: Adrenal hyperplasia
“burnout”: dryness of mouth,
sweating, salt cravings
• Immune impairment:
increased susceptibility to viral
infections, autoimmune
disorders
Stress…Not Just An Adrenal
Problem
• Stress triggers psycho-neuroendocrineimmune imbalances
Applied Nutrition Science Reports No. 576
Emotional trauma  Limbic system 
Hypothalums
Locus Coenuleus Primary Afferent
Nociceptor  Noxious Stimulus
Emotional trauma Limbic system  Hypothalums 
Norepinephine (NE)
Sympathetic
Nervous System
Corticotrophin
Releasing Hormone
(CRH)  Anterior
Pitutiary 
Adrenocorticotrophin
Adrenal
cortexCortisol
Cortisol
• Increases with age and can elevate blood
glucose by up to 50%, contributing to
insulin resistance and inflammation.
Cortisol Influences Neuroendocrine
Function
• Inc. Epinephrine (E) &
Norepinephrine
• Inc. Cortisol
• Inc. Insulin (due to inc.
glucose)
• Inc. visceral fat deposition
• Dec. TSH, T4, T3
• Dec. estrogen,
Testosterone,
Progesterone
• Altered neurotransmitter
balance
• Inc. oxidative stress
• Inc. inflammation
• Inc. need for
detoxification
• Impaired immunity
- Dec. Secretory IgA
- Inc. Antigen penetration
- Inc. IgG
- Dec. NK cell activity
- Dec. IL-2
- Inc. bone loss
Sympathetic Dominance Can Trigger
HPA Hypoactivation
•
Glucocorticoid receptor insensitivity or under production of cortisol (adrenal
insufficiency)
Symptoms and conditions
Fatigue/malaise
Risk of inflammatory conditions
Risk of autoimmune disease
Myocardial infarction
Unable to perform routine tasks
Inability to cope
Apathy
Anorexia
Weight loss
Restless sleep
Weakness
Chronic pain
Reduced libido
Sympathetic Dominance Can Trigger
HPA Hyperactivation
•
Cortisol and catecholamine
excess and imbalance
Symptoms and conditions
Anxiety
Agitation/irritability
Restless sleep
Increased cholesterol
Increased triglyerides
Increased blood pressure
Insulin resistance
Reduced libido
Fatigue
Depression
Impaired memory learning
Gastrointestinal disorders
Central obesity
Neurologic disorders
Loss of muscle tone
Decreased growth
Protein wasting
Bone loss
Skin disorders
Reduced immune defense
Poor injury/illness recovery
Reduced sex hormone levels
Reduced reproductive function
Functional renal problems
Sympathetic Dominance Can Trigger…
• HPA Hypoactivation
• HPA hyperactivation
• Adrenal Exhaustion – adrenal gland
hyperplasia and failure to respond.
Stress Physiology
Conditions Linked with Overproduction & Underproduction of Cortisol
•
•
•
•
•
•
•
•
Overproduction
Cushing’s Syndrome
Depression & OCD
Diabetes
Sleep deprivation
Anorexia nervosa
Excessive exercise
Childhood abuse
Hyperthyroidism
•
•
•
•
•
•
•
Underproduction
Seasonal depression
CFIDS
Fibromyalgia
Hypothyroidism
Tobacco withdrawal
Allergies/Asthma
Rheumatoid arthritis
B. McEwen. The End of Stress as We Know It.
2002, p.64
Identify Antecedents, Triggers &
Biological Mediators
• Antecedents: genetics, experiences, past
illnesses, occupational exposure, nutrition,
lifestyle
• Triggers: psychosocial, work relations,
trauma
• Biological Mediators: cortisol, insulin,
catecholamines, cytokines, sex steroids
Recognize signs of physical and
mental stress
•
•
•
•
•
•
•
•
•
Anxiety
Back pain
Constipation
Diarrhea
Depression
Exhaustion
Fatigue
Headaches
High blood pressure
• Insomnia (disturbed
sleep)
• Relationship problems
(i.e. loss of sexual desire)
• Shortness of breath
• Stiff neck
• Upset stomach
• Weight gain
• Weight loss
• Worrying
Identify Stress Arousal Triggers
Psychological Stressors
-Divorce
-Unemployment
-Death
-Children, etc.
-Self-esteem
Environmental Stressors
-Chemical/toxic
-Infection
-Endobiosis
-Noise
-Light
-Vibration
Metabolic Stressors
-Nutritional (need beyond supply,
supply beyond need)
-Oxidative
-Inflammatory
Physiological stressors
-Structural
-Traumatic
-Pain
-Excess exercise
-Poor sleep
Stressors have different effects
depending on…
•
•
•
•
Dose
Pattern
Duration
Gender: Fight vs. Flight contrasted with
Tend & Befriend
Subclinical Hypothyroidism
• Subclinical hypothyroidism is more
common than overt hypothyroid in elderly,
especially women
• Subclinical hypothyroidism (inc. TSH in the
presence or normal T concentrations)
• Increasing evidence to suggest a
predisposing factor for depression,
cognitive impairment and dementia
Davis JD et al: Current Psychiatry Reports (2003)S:384-390
Stress & Immunity
Dynamic Balance = Health
• Th1 dominance = tissue/organ specific
autoimmune disorders, delayed
hypersensitivity reactions
• Th2 dominance = allergic & atopic
conditions, systemic autoimmune
disorders
• Th3 imbalance = immunosuppression in
allergies and autoimmunity
Th1, Th2, Th3
Th1
•
•
•
•
IL-12
lL-2
TNF-alpha
IFN-y
Th3
• Gut mucosal cells
• Balance Th1 & Th2
Th2
•
•
•
•
•
•
IL-4
IL-5
IL-6
IL-9
IL-10
IL-13
Th1 and Th2
•
•
•
•
•
•
•
•
•
•
Th1 Dominant Responses (Tissue
specific)
Hashimoto’s thyroiditis
Multiple sclerosis
Type 1 diabetes
Acute allograft rejection
Vitilligo
Alopecia
Crohn’s disease
Psoriasis
Sjogrens syndrome
Unexplained recurrent abortions
•
•
•
•
•
•
•
•
•
•
•
•
•
Th2 Dominant Responses
(systemic)
Allergies, hayfever
Rhinitis, Urticaria
Systemic Lupus Erythaematosis
Haemolytic anaemia,
Thrombocytopenia
Scleroderma, Sarcoidosis
Chronic Fatigue
IBS
Graves disease
Asthma
Eczema
Infections
Tumors
Successful pregnancy
Stress Hormones, Th1/Th2 patterns,
Pro/Anti-inflammatory Cytokines and
Susceptibility to Disease
• “Acute stress might induce proinflammatory activities of certain tissues
through the neural activation of the
corticotropin-releasing hormone-mast cellhistamine axis”
Ilia J. Elenkov and George P. Chrousos
Cytokine Hypothesis of Depression
“There is growing evidence that depression
can directly stimulate the production of
proinflammatory cytokines that influence a
spectrum of conditions associated with
aging…”
Kiecolt Glaser JK et al. Depression & immune Fnction. J Psychomsom Res.
2002;53(4):873-6
“The ‘cytokine hypothesis of depression’ implies that proinflammatory
cytokines represent the key factor in …depressive disorders.”
Schiepers OJ, et al. cytokines and Major Depression. Prog Neuropsycho Biol Psychiatry.
2005;29(2):201-17
Depressed Healing, Cytokines and
Hostility
“Couples who demonstrated consistently
higher levels of hostile behaviors across
both their interactions healed at 60% of
the rate of low-hostile couples.’
Kiecolt-glaser JK, et al Hostile marital interactions, proinflammatory cytokine production,
and wound healing. Arch Gen psychiatry. 2005;62(12):1377-84
“Even a modest number of depressive symptoms may sensitize the
inflammatory response in older adults and produce amplified and
prolonged inflammatory responses.”
Glaser R et al. Mild depressive symptoms are associated with amplified and prolonged inflammatory responses after
influenza vaccination in older adults. Arch Gen Pstch. 2003;60(10):1009-14
Balanced Biological Mediators
With Personalized Therapeutic Lifestyle Change
Programs
1. Dec. total load of HPA/HPT triggering factors
2. Reduce HPA/HPT hyper-reactivity
3. Improve detoxification of glucocorticoids and
catecholamines
4. Improve cortisol sensitivity
5. Improve insulin sensitivity
6. Support thyroid hormone production,
metabolism and tissue sensitivity manage
cholesterol levels
Reducing stress hormones affects
mood
• Antagonizing CRF (corticotrophin
releasing factor) and glucocorticoid
receptors may be effective in treating
depression.
• Mechanism – interruption of reverberating
neuroendocrine loops involving the HPA
axis and several areas of the brain
(prefrontal cortex, amygdala,
hippocampus, and hypothalamus)
Obesity and moods
• Obesity is associated with an approximately
25% increase in odds of mood and anxiety
disorders and an approximately 25% decrease
in odds of substance use disorders. Variation
across demographic groups suggests that social
or cultural factors may moderate or mediate the
association between obesity and mood disorder.
• Arch Gen Psychiatry. 2006;63:824-830
Manage stress naturallycore functional approach
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Eating habits
Diet
Specific nutrients
Plant adaptogens
Cognitive techniques to alter stress
perception
• Exercise
Food Improves Mood by Buffering
the Stress Response
• Skipping meals, GI Dietlow blood
sugarHungry brain=inc. Cortisolinc.
hepatic glucagon, inc. muscle
breakdowninc. sugar, inc. insulin, inc.
fats
Food Improves Mood by Buffering
the Stress Response
Reactive hypoglycemia
Carbohydrate cravings
Mood swings
Shakiness, fainting, etc.
Inc. VAT (sarcopenia)
Inc. Blood pressure
Inc. Blood sugar
Inc. Triglyerides
Inc. Inflammation
Altered sex hormones
Cognitive function
Short term: Energy
Long term: CVD, Metabolic
Syndrome, Obesity,
Diabetes, Cancer
Recurring Micronutrient Themes &
Stress Hormone Management
• Specific Nutrients
-EPA/DHA
-MVM
-B complex Vitamins B6, B12, Folate
-Magnesium
Omega-3 fatty Acids and
Neuropsychiatric Disorders
“…decreased blood levels of omega-3 fatty
acids have been associated with several
neuropsychiatric conditions, including
Attention Deficit (Hyperactivity) disorder,
Alzheimer’s Disease, Schizophrenia and
Depression…”
Young, G et al: Reprod Nutr Dev. 2005 JanFeb:454(1);1-28
Anti-Stress Effects of DHA
• In a double blind two month study, we measured plasma
catecholamines and cortisol of students (3 females and 4
males for the DHA group and the same numbers for the
control) at the start and end of the study. Students were
under continuous stress of final exams that lasted for two
months throughout the whole study period.
• The plasma cortisol did not change in either group, but
the norepinephrine concentration was significantly
decreased in the DHA group (-31%), whereas it stayed
at the same level in the control group. These effects of
DHA intake may be applied to people under
psychological stress.
•
Hamazaki T et al. Biofactors 2000; 13(1-4):41-45
Consequences of Magnesium deficiency on the Enhancement of Stress
Reactions; Preventive and Therapeutic Implications (A Review)
• Mg deficiency intensifies adverse
reactions to stress
• Such reactions are mediated by excess
release of catecholamines and
corticosteroids
• Low Mg and high Ca levels increase
release of stress hormones, which further
lower tissue Mg
J Am Coll nutr 1994; 13(5):429-446
Magnesium
Metabolic Syndrome & Inflammation
• Mg intake is inversely associated with systemic
inflammation and the prevalence of metabolic
syndrome in middle-aged and older women
• Participates in reducing risks to top health
challenges facing women: CVD, cancer, stroke,
diabetes, obesity
• N=11,686 women > 45 yo participated in
Women’s Health Study initially free of
cardiovascular disease and cancer and had no
use of postmenopausal hormones
Stress Has Many Faces
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Stressed & overworked
Stressed & tired
Stressed & wired
Stressed & inflexible
Stressed & hot
Stressed & cold
Stressed & depleted
Stressed & immune challenged
Disturbed sleep & mood
How Adaptogenic Herbs Buffer Stress
Molecules and Protect the Nervous System
• Non-toxic – no change in normal
physiology
• Helps the body adapt to stress
• Normalizes body function
Plant Adaptogens
• Balance the way your brain and endocrine
system process stress thereby reducing the
damaging effects of prolonged exposure to
catecholamines and glucocorticoids
• Increase the non-specific resistance of an
organism without disturbing normal biological
parameters
• Act as a nootropic – a substance that enhances
cognition, protects the brain and has low toxicity
and few side effects
Disturbed sleep & mood
• 60 million Americans suffer from disturbed
sleep, characterized by functional
impairments during the day.
• Today, the widespread practice of “burning
the candle at both ends” in western
industrialized societies has created so
much sleep deprivation that what is really
abnormal sleep is now almost the norm
Expressions of sleep disturbances
www.cdc.gov/niosh/stresswk.html
• Difficulty falling asleep
• Difficulty waking up in the
morning
• Waking up tired
• Microsleeps - very brief
episodes of sleep, such
as “nodding off”
• “zoning out” in the middle
of a conversation or task
• Preferring a late bedtime
– 2-3 AM and waking up
late, around 10 AM
• Preferring an early
bedtime – 8 PM and
waking up early, around 5
AM
• Clumsy and/or slower
reactions times
• Snoring (sleep apnea)
• Routinely falling asleep
within 5 minutes after
lying down
• Waking up frequently
during the night with
difficulty returning to
sleep
FDA Warning:
Commonly used RX for sleep disorders can disrupt
performance and be addictive
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Valium
Dalmane
Ambien
Restoril
Halcion
Natural sleep cycle
Light sleep: Body movement decreases. Spontaneous
awakening may occur.
Stage 1: dec. serotonin
Intermediate sleep: Most of the night is spent in this stage.
Helps refresh the body.
Stage 2: dec. Melatonin
Deep sleep: Difficult to arouse. Most restorative stage,
lasting 30-40 minutes in first few cycles, less in later
cycles.
Stage 3 & 4: dec. Serotonin
REM: Dreaming occurs. Heart rate increases. Lasts about
10 minutes in first cycle, 20-30 minutes in later cycles
Stage 5: inc.Acetycholine, dec. GABA, dec. Dopamine
REM-NREM Balance
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REM=Ergotrophic
On-line, engaged
Externalized
Hypermetabolic
Cholinergic
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NREM=Restorative
Off line, Autistic
Internalized
Hypometabolic
Serotonergic and
GABAergic
Neurotransmitters Involved in
Sleep
• Serotonin-NREM
• Acetylcholine-REM
• GABA-inhibits brain arousal centers,
reduces REM
• Histamine-stimulates brain arousal
centers, “wake promoting
neurotransmitter”
Healthy Sleep Hygiene
• Create a relaxing bedtime routine:
Read a book
Listen to music
Practice a relaxation technique
Take a warm bath
Keep the temperature in your bedroom at a
comfortable level: extremes can disrupt your
sleep
• Go to sleep and wake at the same time each
day – helps to develop a sleep-wake rhythm that
encourages better sleep
Healthy Sleep Hygiene
No daytime naps
Go to bed only when sleepy
Set a bed routine
Get out of bed if you are not sleeping. Get up
after 15 to 20 minutes if unable to fall asleep.
Get back into bed only if you are sleepy.
Maintain a consistent wake up time, no matter
how much sleep obtained.
Use bed for sex and sleep only.
More Ways To Sleep Better
• Watch your diet – a heavy meal or spicy foods before
bedtime can lead to nightime discomforts; fluids can
require disruptive trips to the bathroom. A light snack can
prevent hunger pangs and help you sleep better.
• Eat no closer than 2 hours before bedtime.
• Avoid caffeine (tea, cola, chocolate and coffee) and
cigaraette smoking 4 to 6 hours before bedtime.
• Have no more than one serving of alcohol consumed 2
hours or more before bedtime.
• Exercise regularly – exercising in the morning or
afternoon – at least three hours before bedtime, so you
won’t get too revved up – may help you get a deeper,
more restful sleep.
Larzelere M. wiseman P. Anxiety, depression, and insomnia. Prim Care Clin Office Pract 2002;29:339-360
Melatonin
• Reduced sleep onset
• Increased REM sleep compared to
placebo
• Effective in children and adolescents with
ADHD and insomnia
• Improves tinnitus
• Improvement in behavioral symptoms in
dementia patients
• Cluster headaches
Melatonin
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Short half life (approx 1 hour)
Metabolized by P450 cytochromes
Physiologic range between 8 to 3 mg
Modest decrease in sleep latency
Melatonin has thermoregulatory effects
that assist in its sophoric effects, reduces
core body temperature
Melatonin: Human Studies
• Analysis of 17 different studies involving 284 pts;
melatonin demonstrated reduced sleep onset
latency, increased sleep efficiency, and
increased total sleep duration (Wurtman et al.
Sleep Med Review 2005(9);41-50)
• Two randomized studies demonstrated
increased REM sleep percentage (J Clinical
Endocrinology 2004; 89:128-134)
• Useful in patients with delayed sleep phase
syndrome (Sleep 2005(10);1271-1278)
Melatonin: Safety
• Generally regarded as safe with little risk of
toxicity especially in short term use
• Side effects may include fatigue and dizziness
• High doses ( 8 mg or above) associated with
reduced sperm motility
• Should not be used in pregnancy or breast
feeding
• May reduce effectiveness in patients taking
warfarin
Recommended Use of Melatonin
• Administer 30 minutes to 1 hour prior to
bedtime
• Dosing varies by age
• Administration of melatonin to older adults
results in substantially higher blood levels
“less is more”
• Exposure to light will inhibit the sleep
promoting effects of melatonin
Passionflower: Overview
• Traditional herb used for its sedative and
anxiolytic properties
• Two biologically active flavanoids isolated;
Apigenin and Chrysin which bind to
benzodiazepine receptors
• Both Apigenin and Chrysin reduce behavioral
measures of anxiety in animals in a manner
similar to benzodiazepines (Pharmacol Biochem
Behav 1994, 47(1):697-706
What is Casein Tryptic Hydrolsate?
• Pure tryptic hydrolysate from milk
anxiolytic like profile (on label: “casein
hydrolsate”)
• Standardized to 2.2% casein decapetide
with molecular mass 1267 Da,
corresponds to the peptide 91 to 100 of
alphas1 casein by enzymatic hydrolysis
using trypsin
• Can be concentrated or isolated by HPLC
Casein Tryptic Hydrolysate
• Demonstrated to be efficacious for stress reduction using
conditioned defensive burying test and elevated plusmaze in rats
• Aids sleep
• Helps to reduce cortisol
• Helps to keep blood pressure levels within the normal
range (modify)
• Helps to control symptoms of physiological and
psychological stress
• Casein tryptic hydrolysate produces a noticeable effect
in as little as one hour and optimal results can be
observed after 10 days of treatment.
Mind-Body & Cognitive Approaches
• Journaling
• Belly breathing
• Relaxation techniques
Stress & Relaxation
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EVERYTHING to do with health
Worry is the most common effect
Type II stress is exhausting
80% serious illnesses preceded by high
stress levels in previous year
• Animal research (Vernon Riley)
Stress & Relaxation
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NOTHING to do with health
Stress ‘tolerance’ is key
‘Stress hardiness’ – Kobasa
Expand capacity reduce physiologic toll,
connect with Inner Resources
• Improve problem-solving abilities
Breath & Back Pain
“Patients suffering from chronic low back pain
improved significantly with breath therapy.
Changes in standard low back pain measures of
pain and disability were comparable to those
resulting from high quality, extended physical
therapy. Qualitative data suggested improved
coping skills and new insight into the effect of
stress on the body as a result of breath therapy.”
Mehling WE, et al. RCT of Breath Therapy for Patients with chronic low back pain. Altern Ther Health
Med. 2005;11(4)44-52.
Imagery
Physiological Effects
• Heart rate, blood pressure, respiratory rate
& rhythm
• Oxygen consumption, CO2 & lactic acid
elimination
• Gastrointestinal motility and secretions
• Sexual arousal and function
• Muscle relaxation and function
• Immune system responsiveness
Marketing Opportunities
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Existing patients
Referrals
Events/local presentations
Media outreach
Corporate wellness
JAMA 2005:294;2010-2011
“…what we do agree on is reduction of risk
factors for heart disease and diabetes
through lifestyle changes first, is an
appropriate treatment.”
Comparison
Our Program
Triglycerides
-95 mg/dl
AHA Step 1
Diet
-49 mg/dl
T-chol
-43 mg/dl
-2.6 mg/dl
LDL-C
-28 mg/dl
+3.2 mg/dl
HDL-C
+2.8 mg/dl
-.5 mg/dl
Weight
-14.8 lbs
-7.8 lbs
The Cost Effectiveness of Lifestyle Modification or Metformin in
Preventing Type 2 Diabetes in Adults with Impaired Glucose Tolerance
“The lifestyle intervention, compared with
the metformin intervention, provided
greater health benefits at lower costs and,
from the prospective of a fiscally prudent
policymaker, represents the intervention of
choice.”
Annals of internal Medicine 2005; 142:323-332
TLC is more effective, less expensive than
Medication
Delay in
development of
diabetes
Reduced
incidence of
disease
Cost (per
QALY)
Lifestyle
Metformin
11 years
3 years
20%
8%
$1,100
$31,000