Transcript Nutrition and Disease Prevention

Nutrition and Disease Prevention
Dr. David L. Gee
FCSN 245 Basic Nutrition
Leading Causes of Death
 #1 - Heart Disease

280 deaths/100,000/yr
 #2 - Cancers

210 deaths/100,000/yr
 #3 - Strokes

60 deaths/100,000/yr
 #8 - Diabetes

20 deaths/100,000/yr
Incidence of early heart disease
(under age 65)
Males:


300/100,000 fatal MI
80/1,000 MI
Female:


125/100,000 fatal MI
45/1,000 MI
History of a Heart Attack
early stages
Fatty Streaks
Factors that contribute to fatty
streak formation
hypertension
 cigarette smoke
 inflammation
 other causes?

Low-grade Systemic Inflammation
in Overweight Children
 Pediatrics, Jan. 2001
 cross-sectional epidemiological study
 3,561 children, 8-16 yrs old
 C-reactive protein (a marker of
inflammation) linked with development of
heart disease in overweight adults
C-reactive Protein in
Overweight Children
Other factors (smoking by parents, inactivity) have also been
Associated with increased CRP in children.
History of a Heart Attack
Progression of the disease
 Atherosclerosis

“Hardening of the arteries”
 Accumulation of lipids (LDL-C) by macrophages
forming foam cells
 Growth of fibrous cells on inner wall of coronary
arteries
 Calcification of endothelium of coronary arteries
 Results in coronary arteries that are narrowed and
stiff causing reduced blood flow.
CHOLESTEROL BUILDS
Too much fat in the blood can build up as plaque within heart vessel
walls. Its presence triggers the inflammation alarm, attracting immune
cells such as monocytes, which seek out and attach to the plaque.
INFLAMMATION SETS IN
The monocytes mature into macrophages, which begin engulfing the
fatty plaque. The immune activity alerts the liver to produce CRP,
which floods in to attack the growing plaque.
A HEART ATTACK OCCURS
As immune cells pile onto the plaque, it becomes increasingly
unstable and eventually ruptures. Debris from the lesion can cause a
blood clot or trigger a heart attack.
History of a Heart Attack
End stage of the disease
Angina
Myocardial Infarction

Thrombosis:


Embolism:


growth of stationary clot
sudden closure by loose clot
Ischemia

Local deficiency of blood supply
History of a Heart Attack
 Warning signs
Angina & shortness of breath
 Often no warning!

Treatment of late-stage CHD
Secondary Prevention of CHD
 Testing


Stress test
Angiogram
 Angioplasty


Balloon angioplasty
stents
 Coronary Bypass Surgery

Grafting of healthy veins around diseased coronary
arteries
Primary Prevention of
CHD
 Know your risk factors
 Make dietary changes
 Start/continue exercise
 Stop smoking
 Stress reduction
 Use medication if necessary
CHD Risk Factors
( * modifiable)
 High LDL-cholesterol *
 Low HDL-cholesterol *
 High blood pressure *
 Family history of early CHD
 Current cigarette smoking *
 Diabetes *
 (Obesity *)
Risk Factors for CHD
High Total Blood Cholesterol
>200 mg/dl: borderline high risk
 >240 mg/dl: high risk

High LDL-C
>130 mg/dl: borderline high
 >160 mg/dl: high risk

© 2002 Wadsworth Publishing / Thomson Learning™
Lowering your LDL-C
Decrease dietary saturated fat
< 10% calories (dietary guidelines)
 < 7% calories (AHA diet)

Decrease dietary cholesterol
< 300 mg/day (dietary guidelines)
 < 200 mg/day (AHA diet)

Lowering your LDL-C
Replacing dietary SFA with MUFA

Canola oil, olive oil
Increase dietary fiber (soluble)

Whole grains, oats, fruits, vegetables
 Pectins
(fruits)
 Beta-glucans (oatmeal)
Lowering your LDL-C
Decrease dietary Trans-FA

Reduce consumption of foods containing
hydrogenated fats
Lowering your LDL-C
Medications
Plant stanols/sterols
Benecol, Take Control
 Inhibits absorption of dietary cholesterol

 “Statin” drugs
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Zocor, Lipitor
Inhibits cholesterol synthesis in liver
 Bile acid binding resins

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Questran
Prevents reabsorption of bile acids and forces liver to make more
from cholesterol
 Niacin (pharmacological doses)

Prevents synthesis of VLDL and LDL
Risk Factors for CHD
Low HDL-C
< 40mg/dl : high risk
> 65mg/dl : protective

Increasing your HDL-C
Exercise
Alcohol (chronic low dosages)
1-2
servings/d males
1 serving/d females

Acute high dosages can cause
dyslipidemia
Risk Factors for CHD
Hypertension
Diabetes
lose weight if overweight (type 2)
 control blood sugar

Cigarette smoking

quit/don’t start
When you stop smoking, your body begins
a series of changes that continue for years:
Source: Centers for Disease Control and Prevention
 20 minutes after quitting

Your heart rate drops.
 12 hours after quitting

The carbon monoxide level in your blood drops to
normal.
 2 weeks to 3 months after quitting

Your heart attack risk begins to drop. Your lung function
begins to improve.
 1 to 9 months after quitting

Your coughing and shortness of breath decrease.
When you stop smoking, your body begins
a series of changes that continue for years:
Source: Centers for Disease Control and Prevention
 1 year after quitting

Your added risk of heart disease is half that of a smoker's.
 5 years after quitting

Your stroke risk is reduced to that of a non-smoker's five to 15 years
after quitting.
 10 years after quitting

Your lung cancer death rate is about half that of a smoker's. Your risk
of cancers of the mouth, throat, esophagus, bladder, kidney and
pancreas decreases.
 15 years after quitting

Your risk of heart disease is back to that of a non-smoker's.
Non-modifiable Risk Factors
Age
males over 45
 female post-menopause

Family History

premature CHD
 males
under 55
 females under 65
Risk Reduction
100
80
60
40
20
0
smoke, hiBP, hiTC
hiBP, hiTC
hiTC
none
Is heart disease reversible?
 Dean Ornish: Reversing Heart
Disease

Very low fat (<10% of Calories)
Minimal saturated fat
 Semi-vegetarian, whole grains


Exercise & Stress Reduction
 Randomized Controlled Trials

Angiograms show regression of
lesions
Example of Regression of Atherosclerosis in a Patient in the Trial
Nissen, S. E. et al. JAMA 2006;0:295.13.jpc60002-10.
Regression with 2 year use of high dosage of cholesterol-lowering medication
Copyright restrictions may apply.
May is American Stroke Month, but strokes happen yearround. Each year 700,000 people have a new or recurrent
stroke. On average every three minutes someone dies of a
stroke. There are currently 4.8 million stroke survivors.
What causes a stroke?
 Stroke: when part of the brain does not blood and
oxygen it needs and cells begin to die within
minutes
 Ischemic Stroke: blockage of blood vessels


Cerebral thrombosis: growth of stationary clot
Cerebral embolism: wandering clot
 Hemorrhagic Stroke: bleeding in brain

Ruptured aneurysm
Risk Factors For Stroke

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High blood pressure
Smoking
Diabetes
Carotid Artery disease
Some blood disorders (sickle cell disease)
High blood cholesterol
Physical inactivity
High alcohol consumption
Hypertension
Definition
 Diastolic Blood Pressure

> 90 mm Hg
 Systolic Blood Pressure
> 140 mm Hg
 Desirable < 120/80
 New 2003 definition:

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
DBP: 80-90 or SBP: 120-140
Prehypertension
Hypertension and Disease
 Stroke
2/3rds with first stroke have HPT
 7 times more likely than normal

 Coronary heart disease
1/2 with first MI have HPT
 3 times more likely than normal

 End-stage Renal Failure
 Blindness
Hypertension
 Prevalence
50 million
 > one quarter of adults
 Of people with hypertension
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30% are unaware of it
34% are on medication and have it under control
25% are on medication and still have
hypertension
11% are not on medication
Risk Factors
 Age

Risk increases with age
 Ethnicity

Risk higher among African-Americans
 Family History
 Obesity

Risk higher in overweight and obese
Dietary Treatment for
Hypertension
Weight Loss
Moderate weight loss
Regular exercise

Weight Loss vs. Medication
5
0
-5
-10
SBP
DBP
LVM
-15
-20
-25
-30
-35
-40
Weight Loss
Medication
Placebo
Dietary Treatment for
Hypertension
 Salt and Sodium

NaCl is 40% Na
 Is
the (recommended) amount in
 mg sodium
 mg sodium chloride
 ~50% responsive

Salt restriction doesn’t work for everybody
 Salt restriction and prevention of
hypertension debate
Diet and Hypertension
Salt Recommendations

WHO: < 6 g/day (2400mg Na/d)
`
1 tsp salt
Salt Intake
US: 8 g/day (3200mg Na/d)
 Asia: 30-40 g/day

Sources of Salt
10% unprocessed foods
15% added by consumer
75% in processed foods
Salt in Processed Foods
 Foods prepared in brine

Pickles (1700mg/pickle), sauerkraut (940mg/c)
 Smoked and cured meats
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Ham (1200mg/3oz), bacon (300mg/3 slices)
 Salty snacks
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Chips (170mg/oz)
 Highly processed foods
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Fast foods (950mg/BigMac)
Sauces and condiments (180mg/Tcatsup)
Canned and instant soups (1100mg/c CNS)
How do you eat a low sodium diet
(<1800 mg/day) ????
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Teriyaki sauce: 700 mg/T
BBQ sauce: 425 mg/ 2T
Polish sausage: 2000 mg
Italian salad dressing: 200 mg/T
Pepperoni pizza: 880 mg/slice
Apple pie: 330 mg/slice
Canned pasta w/ sauce: 800 mg/serving
Frozen buttermilk pancakes: 370 mg/serving
Other Dietary Treatments for
Hypertension
 Alcohol
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< 1-2 servings per day
>2 servings increases risk of hpt
 Potassium
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fruits and vegetables
 Fish Oils
 Calcium
The DASH Diet
p 410-411
Dietary Approaches to Stop Hypertension
 1997 DASH trial -NHLBI
 Diet rich in
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
fruit
vegetable
grain products
 Low/non fat dairy, fish and meats
DASH-Na Trial
NEJM (1/4/01)
412 mild hypertensive adults
30 day intervention
DASH vs Control Diet
 Low, Intermediate, High Sodium

(1200,
2300, 3500 mg Na/d)
The DASH Diet
 For 2000 Calorie/day diet:
 Grain products: 8 servings (6-11)
 Vegetables: 5 servings (3-5)
 Fruits: 5 servings (2-4)
 LF/NF Dairy: 3 servings (2-3)
 LF Meats: 2 servings (2-3)
 Nuts, seeds, legumes: 1 serving
DASH-Na Conclusions
 DASH diet lowers BP
 Sodium reduction lowers BP
 Combination of DASH and Na reduction
effects greater than separately

DASH+low-Na reduced Systolic BP by:
11.5mm Hg in Hpt subjects
 7.1 mm Hg in borderline Hpt subjects

DASH-Na Conclusions
 Benefits seen with
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men and women
blacks and non-blacks
hypertensive and borderline hypertensive
 A 2 mm Hg drop in DBP results in:
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17% reduction in Hpt
6% reduction in CHD risk
15% reduction in stroke risk
http://www.nhlbi.nih.gov/health/public
/heart/hbp/dash/index.htm
DASH has also been shown to:
Reduce risk of heart disease by
-reducing blood pressure
-Decreasing LDL-C
-Reduce body weight in
-overweight subjects
-Improve glucose control
-In diabetics
-Contain dietary components that
-Reduce risk of cancer
Diet and Cancer
 Definitions
 Cancer: uncontrolled growth and spread of
abnormal cells
 Tumor: mass of cancer cells


benign tumor (non-harmful, non- invasive)
malignant tumor (harmful, invasive)
 Metastatic Cancer: spreading to other tissues
Cancer Facts
 US men have a 1 in 2 lifetime risk
 US women have a 1 in 3 lifetime risk
 1,220,000 new malignant cancer cases in
2000
 552,000 cancer deaths in 2000
Cancer Trends
JNCI, 1999
1990-1996
All cancer incidence declined by
2.2%


-4.1% males
-0.5% females
US Male Cancer Death Rates by Site
US Women Cancer Death Rate by Site
Cancer in Women
200
180
160
140
120
100
80
60
40
20
0
Deaths
New Cases
Lung
Colon
Pancreas
Uterus
Cancer Rates
Racial Differences
450
400
350
300
250
Incidence
Mortality
200
150
100
50
0
Blacks
Cauc.
Hisp.
Asian
Indian
The Cancer Development
Process
 Initiation
 Alterations in DNA/gene mutation

Multiple genes must be altered for cancer to occur
 minutes - days
 Causes: Exposure to Carcinogens



radiation
chemical
viruses
The Cancer Development
Process
Promotion
 “locking in” DNA alterations/gene mutations

Genes affecting cell differentiation


Cancer cells are de-differentiated from cells they come from
Genes affecting cell division

Cancer cells divide uncontrollably
 failure of DNA repair mechanisms
 cancerous cells begin to divide
 months - years
The Cancer Development
Process
Cancer Progression
Uncontrolled growth of cancer
cells
malignancy and metastasis
weeks to years
Diet and Cancer Development
Initiation
 Dietary sources of carcinogens & precarcinogens
 aflatoxin
mold from peanuts
 benzopyrene from charbroiled meats
 nitrosamine from cured meats
 Dietary Protection


antioxidants
dietary fiber
Diet and Cancer Development
 Promotion

Dietary promoters of cancer
Fat and PUFA
 excess alcohol


Dietary anti-promoters of cancer

vitamins & phytochemicals
 Progression

Dietary factors increasing cancer progression

excess Fat and calories
Diet and Cancer
ACS 2000
 One third of cancer deaths in US is due
to cigarette smoking
 One third of cancer deaths in US is due
to diet
 5-10% of cancers are hereditary
Folate and Colon Cancer
 Harvard Nurses’ Health Study 1998

89,000 women
 If consumed >400 ug folate -> 30% lower
risk than those consuming <200 ug folate
 If consume folate supplements daily for 15
years -> 75% lower risk


supplements more bio-available
consumed more total folate
1999 ACS Dietary Guidelines
Choose most of the foods you
eat from plant sources.





Five A Day
low in fat and calories
high in folic acid, vitamin C, beta-carotene
high in fiber
high in phytochemicals
ACS Dietary Guidelines
Limit your intake of high-fat
foods, particularly from animal
sources



dietary fats are cancer promoters
colon, prostate, endometrial cancers linked to
high intake of animal fats
cured and smoked meats contain carcinogens
Nitrosamines
 benzopyrenes

ACS Dietary Guidelines
Be Physically Active: achieve
and maintain a healthy weight
Obesity associated with most
cancers
Exercise and Dietary Modifications
Overweight, Obesity, and Mortality from Cancer in a
Prospectively Studied Cohort of U.S. Adults
NEJM 348:1625(April 2003)
 900,000 adults

Prospective study, free of cancer



Self reported height/body weight in beginning
16 year follow up
~57,000 cancer deaths
Obesity and Mortality from Cancer
NEJM April 2003
ACS Dietary Guidelines
Limit consumption of alcoholic
beverages, if you drink at all.
 Associated with:



Breast cancer
Mouth and throat cancers
Liver cancer
 Effect of smoking and alcohol are more than
additive (synergistic)
Dietary Guidelines
 American Heart Association

Heart disease and stroke
 American Cancer Society

Cancers
 American Diabetes Association
General Agreement !