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The Role of Nutrition in the
Treatment of Chronic Disease
Norman Hord, PhD, MPH, RD
Department of Food Science and Human Nutrition
http://www.msu.edu/course/hnf/470
Outline
Diet-Related Chronic Disease Risk
 Efficacy of Dietary Treatment of Chronic
Diseases
 Nutrients as Medicine
 Food As Social Currency

Introduction 1
The rise in the number and proportion of
older people has led to concern about societal
consequences.
 We associate age with:
Increasing Loss of independence
disability
Functional impairments
•Loss of mobility
•Loss of sight
•Loss of hearing

Introduction 2
Maximum life expectancy has not changed
much; AVERAGE life expectancy HAS.
Major challenge: How can we maintain
health and quality of life in an aging
population?
The Framingham Heart Study
Risk Factors for CHD:
The Framingham Heart Study
Major Risk Factors
“Important” Risk Factors
Cigarette Smoking
Hypertension*
High Total Serum Cholesterol*
Low HDL Cholesterol*
Diabetes Mellitus*
Obesity*
Physical Inactivity
Family Hx of Premature CHD
Hypertriglyceridemia*
Increased Lipoprotein [a]
Increased serum homocysteine*
Abnormal levels of various
coagulation factors
*Dietary factors contribute strongly to the control of or in the etiology
of these risk factors.
Medical Nutrition Therapy has been integrated
into the treatment guidelines for a number of
diseases, including:
•
•
•
•
Cardiovascular Diseases
Diabetes Mellitus
Hypertension
Obesity
Noncompliance with prescribed MNT
and lifestyle changes:
Negatively affect patient response to
pharmacotherapy
 May necessitate more intensive
pharmacotherapy to achieve desired effect.

Diet Therapy and Risk Factor
Stratification

Dietary treatment strategies are
recommended by the National Institutes of
Health as the cornerstone for the treatment
of all patients with:
•
•
•
•
Cardiovascular Disease
Hypertension
Diabetes Mellitus
Obesity
Diet-Related Risk Factors for CHD
High LDL Cholesterol
Begin treatment
With CHD:
Without CHD + one risk factor:
Without CHD + > 2 risk factors:
Low HDL Cholesterol
Hypertension
Diabetes Mellitus
LDL Cholesterol
(mg/dl)
>100
>160
>130
Blood Lipid Fraction
Desirable Borderline
High
LDL Cholesterol (mg/dl)
<130
130-159
>160
Total Cholesterol (mg/dl)
<200
200-239
>240
Triglycerides (Fasting; mg/dl) <200
200-400
>400
HDL Cholesterol= “Low” (Bad) if 35 mg/dl
LDL:HDL ratio: > 5 indicates risk for men
>4.5 indicates risk for women
Role of Diet in the Modification of Blood Cholesterol Levels
Assumptions:
• Blood cholesterol [ ] is an important and modifiable risk factor
for coronary heart disease.
• Sustained reduction of total cholesterol [ ] of 1% is associated
with a 2-3% reduction in the incidence of coronary heart
disease.
Role of Diet in the Modification of Blood Cholesterol Levels-3
Efficacy of Dietary Intervention Trials to Lower Total Cholesterol
Diet Types
% Reduction in
Total Cholesterol
AHA Step 2
Lower Total Fat
6.0
Raise PUFA:SFA Ratio
AHA Step 1
3.0
Tang et al. (1998) BMJ 316: 1213-1220
Systematic review of dietary intervention trials to lower blood total cholesterol in free-living subjects.
Role of Diet in the Modification of Blood Cholesterol Levels-2
Chief Determinants of Blood Cholesterol Levels
1.
2.
3.
4.
Certain saturated fatty acids cause a linear increase
in low-density lipoprotein (LDL) cholesterol concentration.
(Total SFA in U.S. Diet: 11-12 % of total energy)
Trans unsaturated fatty acids increase LDL cholesterol
[ ]; not quite as atherogenic as certain SFA.
(Total trans FA in U.S. Diet: ~ 3 % of total energy)
Polyunsaturated fatty acids derived from plant oils do
NOT raise LDL cholesterol [ ].
(Total PUFA in U.S. Diet: ~ 6 % of total energy)
Monounsaturated fatty acids derived from high oleic acid
(cis-18:1) oils (e.g., olive, peanut, canola) do NOT raise
LDL cholesterol [ ].
Diabetes Mellitus
(“passing through (the body)”; “honey sweet”)
Definition:
a metabolic disorder characterized
by altered blood glucose regulation
and utilization, usually caused by
insufficient or relatively ineffective
insulin.
Long-term hyperglycemia
Cardiovascular Disease
Microangiopathies
(Loss of kidney fxn;
retinal degeneration)
Neuropathy
(may lead to gangrene;
loss of feet or legs)
Goals for Control
(not diagnosis!)
Fasting BG and before meals
One hour after meals
2 hours after meals
80-120 mg/dl
<180 mg/dl
<160 mg/dl
Bedtime
100-140 mg/dl
Hemoglobin A1c
<7%
TAKE ACTION LEVELS
140 mg/dl / 8 or >%
Diet, Lifestyle and Diabetes
Key components in management:
Weight loss
Diet adjustments to attenuate the
rise in blood glucose.
Trial Participants:
459 adults of which 133 had stage I HTN
(B.P. 140-159/90-99)
49% women; 60% African-American
Acclimation Diet:
Low fruits (F), vegetables (V), dairy products
~40% fat for 3 weeks
The Diets:
Duration:
1.
2.
3.
Control Diet: average for fat, F&V consumption
8-10 servings of F&V, ~35+% fat
Low-fat (<30% kcal), 8-10 servings of F&V,
Rich in low-fat dairy foods.
8 weeks
New Engl J Med (1997) 336: 1117-1124
Source: http://dash.bwh.harvard.edu/
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DASH Comments
B.P. reductions occurred quickly (2
weeks) and were maintained throughout the
study.
Investigators estimated that incidence of
CHD and strokes in U.S. could be reduced
by 15% and 27%, respectively, if DASH diet
were followed.
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The Obesity Epidemic

U.S.: 20% of men & 25% of women are obese.

97 million Americans are overweight or obese.
(59.4% of men and 51% of women)

>10% of 4-5 year old children are obese.
– ~2-fold increase over preceding decade
These increases have occurred despite successes in reducing
dietary fat as % of kcal.
Source: NCHS, National Health and Nutrition Examination Survey,1997
Kuczmarski et al. National Health and Nutrition Examination Surveys,
MMWR; 43: 818-821,1994.
Consequences of Modest Weight
Gain
10% increase in weight results in:
Fasting Blood Glucose of 2-3 mg/dL
Systolic Blood Pressure of 6-7 mm Hg
Conditions Associated With Obesity
(Relative Risk)
Diabetes Mellitus
(Type II)
(RR>>3)
Stroke
(RR= 2-3)
Gall Bladder Disease
(RR>>3)
Obesity
Coronary Heart Disease Gout
(RR= 2-3)
(RR=2-3)
Sleep Apnea
(RR>>3)
Hypertension
(RR>>3)
Osteoarthritis
(RR=2-3)
Benefits of Modest Weight Loss
Normalizes high blood pressure
 Blood levels
 LDL cholesterol
 Insulin
 Glycated hemoglobin (HbA1C)
 Blood glucose
 Uric acid

HDL Cholesterol
 Improved Quality of Life

Food as Social Currency
Current interest in dietary factors centers on
nutrients or food components likely to
decrease disease risk.
 These beliefs betray the important social
and psychological role food plays in most
people’s lives.

People eat food, not
isolated nutrients.
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Diets are made
of foods which
are more than
mere collections
of nutrients.
Why Not Focus on Just Nutrients?
All the biological functions of food components
and their health effects have not been identified.
If the focus is on a single nutrient, the benefits of
the consuming these compounds in foods may not
be realized.
Source:U.S. Department of Agriculture
Unlike
nutrients,
foods and
diets have
cultural,
ethnic, social
and family
meanings.
Asian Pyramid
Source:Oldways Preservation & Exchange Trust
Mediterranean
Pyramid
Source:Oldways Preservation & Exchange Trust
Latin American
Pyramid
Source:Oldways Preservation & Exchange Trust
Dietary Patterns and Chronic Disease Risk
• Total diet, rather than nutrients or individual
foods, should be emphasized.
• Dietary guidelines need to reflect food
patterns rather than numeric
nutrient goals.
• Various dietary patterns can be consistent
with good health.
Evidence from animal, clinical and epidemiological
studies indicates that specific dietary patterns are
associated with reduced risk of specific diseases.
Dietary Guidelines 2000 (Proposed)
Aim, Build, Choose--for Good Health
Aim for Fitness
Build a Healthy Base
Choose Sensibly
Dietary Guidelines 2000 (proposed)
Aim
1.
2.
Aim for a healthy weight.
Be physically active each day.
Build
3.
4.
Let the Pyramid guide your choices.
Choose a variety of grains daily,
especially whole grains.
Choose a variety of fruits and
vegetables daily.
Keep food safe to eat.
5.
6.
Choose Sensibly
7.
8.
9.
10.
Choose a diet that is low in saturated
fat and cholesterol and moderate
in total fat.
Choose beverages and foods that limit
your intake of sugars.
Choose and prepare foods with less
salt.
If you drink alcoholic beverages, do
so in moderation.
Eat a variety of foods.
Choose most foods from plant sources.
Eat at least 5 servings of fruits and vegetables
every day.
Eat at least 6 servings of whole grain foods
each day.
Minimize the consumption of high-fat foods, especially
those from animals.
Choose low-fat, low-cholesterol foods.
Limit the amount of simple sugars in the diet.
The Nutrition Checklist is based on the Warning
Signs described below. Use the word DETERMINE
to remind you of the Warning Signs.
DISEASE
EATING POORLY
TOOTH LOSS/MOUTH PAIN
ECONOMIC HARDSHIP
REDUCED SOCIAL CONTACT
MULTIPLE MEDICINES
INVOLUNTARY WEIGHT LOSS/GAIN
NEEDS ASSISTANCE IN SELF CARE
ELDER YEARS ABOVE AGE 80
-----------------------------------------------------------------------The Nutrition Screening Initiative • 1010 Wisconsin Avenue, NW • Suite 800 • Washington, DC 20007
Interventions to improve health in later life
Intervention
No smoking
Diet
High fruit and
vegetable intake
(5 or more servings
daily)
Potential effects
Smoking increases risks of many cancer
including lung, stomach, larynx,
colon; cardiovascular disease and
thereby vascular dementia; respiratory
disease; osteoporotic fractures;
stomach ulcers
Protective for cardiovascular disease;
respiratory function; macular degeneratio
and cataracts; cancers including breast,
prostate, colorectal and stomach;
diverticular disease; diabetes
Other Dietary Strategies to Improve Health
High complex carbohydrates,
Reduced saturated fat
(<15% of Kcal) and total fat
(<35% food energy intake)
Reduced sodium
Protective for cardiovascular disease;
cancers including breast and colorectal
High saturated fat intake increases
risk of coronary heart disease;
cancers including colorectal, prostate,
and breast; large bowel disease;
osteoarthritis
High sodium intake increases risk of
stroke, stomach cancer, osteoporosis,
respiratory disease
Physical activity
Protective for cardiovascular dis
diabetes; osteoporosis; cancers including
colorectal and breast; depression
Summary points
Healthy life expectancy is influenced by a relatively
limited number of chronic disabling conditions.
A substantial proportion of these chronic disabling
conditions can be prevented or postponed.
A greater focus is needed on prevention and
health maintenance—much is already known about
the impact of modifiable influences such as diet,
physical activity, smoking, infection, pollution,
and housing.