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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 Zocor, Lipitor Inhibits cholesterol synthesis in liver Bile acid binding resins 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 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: 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 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 Ham (1200mg/3oz), bacon (300mg/3 slices) Salty snacks Chips (170mg/oz) Highly processed foods 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) ???? 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 < 1-2 servings per day >2 servings increases risk of hpt Potassium fruits and vegetables Fish Oils Calcium The DASH Diet p 410-411 Dietary Approaches to Stop Hypertension 1997 DASH trial -NHLBI Diet rich in 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 men and women blacks and non-blacks hypertensive and borderline hypertensive A 2 mm Hg drop in DBP results in: 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 !