Applying Functional Nutrition for Chronic Disease Prevention and Management:

Transcription

1 FUNCTIONAL NUTRITON COURSE Applying Functional Nutrition for Chronic Disease Prevention and Management: Bridging Nutrition and Functional Medicine in 21st Century Health Care Final Follow Up Webinar # 4 January 27, 2011 Mary Willis RD,CDE Common Conditions Managed Through Functional Nutrition Overweight/Obesity and Dyslipidemia

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4 Functional Nutrition Protocols Overweight/Obesity/Gastric Bypass Care Dyslipidemia Mary Willis RD, CDE

5 Overweight/Obesity Gastric Bypass Care

6 Overweight Obesity

7 Obesity as an Inflammatory Disorder One of the more interesting discoveries of the past decade has been the recognition that the adipocyte produces inflammatory cytokines Obesity, therefore, may be viewed as a low grade systemic inflammatory disease

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10 The basis for the current obesity epidemic is controversial. However the simplistic idea that obesity is can be explained by two factors: energy intake and energy expenditure, is now being challenged due the lack of success in decreasing obesity. Heindel et al. Molecular and Cellular Endo 2009;304:90-96

11 Epigenetics Ex: of epigenetic stimuli: Diet, Stress, Xenobiotics Various chemicals called epigenetic markers sit on genes and offer basic instructions to them telling them to switch on or off.

12 Bray et al JADA 2005;105:S18

13 Recent research implicates environmental risk factors including nutrient quality, stress, fetal environment and pharmaceutical or chemical exposure evidence points to endocrine disrupting chemicals that interfere with the adipose tissue biology, endocrine hormone systems or central hypothalamicpituitary-adrenal axis as suspects in derailing the homeostatic mechanisms important to weight control Grun et al. Molecular and Cell Endo 2009;

14 OBESOGENS chemicals that inappropriately regulate and promote lipid accumulation Grun et al. Rev Endocrin Metab Disord 2007;8:161- Heindel 171 et al. Molecular and Cellular Endo 2009;304:90-96

15 Endocrine Disrupters Organochlorinated pesticides Industrial chemicals Plastics and plasticizers Fuels

16 Chronic administration of ATZ decreased BMR and increased body weight, intra-abdominal fat and insulin resistance without changing food intake or physical activity level. ATZ blocked oxidative phosphorylation of complex I and III, resulting in decreased oxygen consumption. These results suggest that long term exposure to the herbicide ATZ might contribute to insulin resistance and obesity Lim et al. PloS ONE 2009;4(4):5186-

17 Weight loss- Where Do Stored Toxins Go? Weight loss has been shown to increase blood concentration of potentially toxic organochlorine compounds Concerns that undesired and potentially harmful side effect of weight loss in some obese patients who show high organochlorine body burden

18 Gastric Bypass-Increased Plasma Concentrations of EDCs 3 groups studied: control lean subjects BMI < 25 n=15, obese BMI n=14 ( at beginning and then plateau), Morbidly obese n=13 ( before and 3 and 12 mos after bypass) Plasma organochlorine concentration increased with weight loss and was related to magnitude Significant increase of 23.8% in obese, 51.8% in morbidly obese After surgery, 388.2% increase after 1 year Hue et al. Obesity Surgery 2006;16:

19 Bariatric Surgery/ Gastric Bypass Care

20 Bariatric Surgery

21 Malabsorbtive Bariatric Surgery Guidelines Consequences of Bariatric Surgery 1. Benefits: Documented improvement in metabolic management of Metabolic Syndrome/Type 2 DM. Weight. 2. Costs: Permanent alteration in the ability to absorb macro and micro nutrients. High risk of abdomenal surgery. Koch TR. Et al. Gasteroenterol Clin North Am. 2010;39:

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23 Vitamin and Mineral Supplement recommendations post malabsorptive bariatric sugery

24 ADIME Assess Diagnose Intervene Monitor & Evaluate

25 The ABCDs Of Nutritional Assessment A C B D Anthropometric Biomarkers & Labs Clinical Indicators Diet and Lifestyle Assessment

26 Overweight obesity Anthropometrics BMI, waist and hip measurements % lean body mass and fat mass-bia testing Visual of body type, android, gynoid, mixed Biomarkers Assess basic health lab markers along with additional labs specific to body type, health history and clinical indicators. Hormone: thyroid, adrenal, insulin markers. - Nutrigentic testing- emerging options Clinical Indicators Nutrition focused physical exam Body Composition Status Remember overweight/undernourished Diet/Lifestyle Assessment Quantity and Quality of diet intake & Lifestyle. Toxic chemical Exposure Questionnaire History of Yo-Yo dieting/disordered eating Overweight/Obesity A D I M E

27 Bioelectrical Impedance Analysis Anthropometrics Screening Exam Vitals Blood Pressure Height and Weight Body Mass Index Waist to Hip Ratio Waist Circumference Hip Circumference

28 POM FAB Protein CBC and CMP for Total Protein, albumin and other markers Oils- Functional testing- RBC Fatty acids, Omega 3 index. Minerals RBC magnesium if IR and RLS or on certain medication. (IF GBP add ferritin, serum Zinc and copper, 24 hr urine calcium) Fat Soluble Vitamins 25-OH vitamin D, (If GBP add Vit A and Vit E) Antioxidants - Fruit and Vegetable intake, Functional testing-spectra Cell B Vitamins MMA, B 12, homocyteine, Folate if mood disorders, (IF GBP add whole blood thiamine) Overweight/Obesity A D I M E

29 Functional Testing Food Allergy/Sensitivity testing Saliva Cortisol Stool Testing for dysbiosis- CDSA Organic Acids/Ion profiles RBC Fatty Acids Endocrine Disruptor Evaluation: detoxification panel, pesticide levels, organochlorine baseline, RBC micronutrients RMR resting metabolic rate if history of disordered eating and chronic low calorie dieting. Nutrigenetic testing: Weight management panel + Overweight/Obesity A D I M E

30 Current Nutrigenetic Test Panels Cardiovascular health Lipids Hypertension Coagulation Detoxification Phase I and Phase II Inflammation Major inflammation genes Female hormones Weight management Overweight/Obesity A D I M E

31 ADIME Assess Diagnose Intervene Monitor & Evaluate

32 BMI Ranges Normal BMI Overweight BMI Obese BMI Morbidly Obese BMI SuperMorbid Obesity BMI >50

33 Health Risk Based on Waist to Hip Ratio Male Female Health Risk Based Solely on WHR = or < 0.90 = or < 0.80 Low Risk 0.90 to to 0.85 Moderate Risk >1.0 >0.85 High Risk Ford ES, Giles WH, Dietz WH (2002). Prevalence of metabolic syndrome among US adults: findings from the third National Health and Nutrition Examination Survey. JAMA 287(3):

34 Apple Body Type vs Pear Body Type Mixed Body Type

35 Android Body Type Common Biomarker Patterns to Recognize Increased Inflammation Through Adipocytokine Communication Insulin Resistance/Hyperinsulinemia Coupled with Increased Secretion of Resistin and Reduced Adiponectin Hum. Reprod. (2006) 21 (9): PNAS July 26, 2005 vol. 102 no Obesity Research (2003) 11,

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37 Android Obesity Pattern (Incr WHR) Should Know Objective Findings Bioelectrical Impedance Analysis Body Composition Fluid Distribution/intra vs. extracellular Lipid profile Triglyceride/HDL Ratio- Apolipoproteins A1 and B High Sensitivity C-Reactive Protein Glucose and Insulin Fasting and 2 Hour HgbA1C 25 OH Vitamin D3

38 Gynoid Body Type Common Functional Biomarker Patterns to Recognize Increased Risk for HPATG Dysfunction Infecto-obesity Risks Detoxification Abnormalities Gastrointestinal Concerns and Allergies Based on clinical experience

39 Gynoid Obesity Patterns Functional Assessments to Consider HPATG Axis Concerns Orthostatic BP-Adrenal Insufficiency Salivary Adrenal Endocrine Testing Thyroid panel-tsh, Free T4, Free T3, rt3 Thyroid Antibodies Liver and Detoxification Concerns ALT, AST, GGT Homocysteine Methylmalonic Acid Estrogen Metabolites Gastrointestinal Concerns Infection-Dysbiosis, SIBO, Candidiasis, Parasites Food Sensitivities, Intolerances, and Allergy Intestinal Permeability

40 A D I M E A D I M E A D I M E A D I M E A D I M E

41 Key Foundations to Lasting Diet and Lifestyle Change

42 2 week Jump Start Healthy weight loss starts with a good hormone balance. Insulin: glycemic control, smaller freq. meals, slow down rate of eating. Cortisol: Fight or flight Stress to control blood sugar. Leptin: signals the body to stop eating when full. Ghrelin: signals the body when to feed. Balance Thyroid, estrogen, progesterone and testosterone. EAT WHOLE FOODS: I use a Modified Elimination Diet- Whole food based insulin- controlling plan that emphasizes protein, anti-inflammatory fruits and vegetables, nuts, seeds and fiber. Removes simple carbohydrate, dairy, soy and grains short term. Limited servings of legumes and GI fruits. GOOD HYDRATION: Remove soda s/coffee. Use diluted juice waters/teas. MOVE: moderate walking 30 min most days. SLEEP: aim for 7-8 hours most nights CHECK YOUR STRESS: Keep a symptom journal RELAX: Boost those endorphins! (Exercise, physical touch, laughter!)

43 IFM Tool Kit

44 Core Food Plan How are the Macronutrients Distributed? 60/20/20 Balanced 50/20/30 40/30/30 50% Carbohydrate 20% Protein 30% Fat Macronutrient distributions are selected based on the individuals body-type, genotype and health status

45 Core Food Plan Modifications Lipid Management: Fat Controlled Anti-inflammatory: Flavonoids / EFAs Elimination Diet(s): Gluten-free Dairy-free Nut-free Egg-free Soy-free Corn-free Yeast-free Osteoporosis- Core Food Plan with bone support exercise /nutrients. Individualized Weight Management: Android/Gynoid/Mixed Body Type Impaired Glucose Tolerance/DM: Carb Controlled/ Glycemic Load GI Support: Fiber/ Fiber 5 R approach Respiratory Conditions: Asthma/COPD Anti inflammatory CFP Detoxification: Liver supporting whole foods Blood Pressure Management: Sodium Controlled, Potassium Rich, High Fiber

46 Dyslipidemia

47 Dyslipidemia

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49 Risk Factors for Heart Disease Dyslipidemia: Elevated Total Cholesterol Elevated LDL Elevated VLDL Low HDL Elevated Triglycerides Elevated TC/ HDL Ratio 1. Cigarette smoking 2. Hypertension(BP 140/90 or above, or on high BP meds) 3. Diabetes 4. Family history of premature CHD (CAD in father, brother or son before 55 ; CAD in mother sister or daughter before Age: Men 45 yrs. or older; women 55 yrs. or older 6. Obesity or Overweight 7. Physical Inactivity 8. High Sat/trans Fat Intake 9. Low Fiber Intake 10. High Stress Lifestyle Emerging risk factors: hscrp, homocysteine, Vitamin D, and use of Expanded Lipid profiles.

50 Janet-Fatigue/MS - PMH: Multiple sclerosis Fatigue Coronary Spasm - nitro Hypothyroid - Hashimoto s Thyroiditis - 20s Hypercholesterolemia-on statin HTN Asthma Chronic sinus issues Osteoarthritis Overweight/obesity-BMI 34, W/H-0.9. IBS GERD Pain Infertility - fertility meds for years, BCPs for years for hot flashes and irregular periods Irregular Periods in the past Depression Family History: Father CHD, died at 49. Mother HTN, ETOH, died at 68.

51 Advanced Lipids Lipoprotein Particle Analysis(LPP):Spectracell; Berkley Heart Lab (BHL) VAP: Atherotec NMR: Liposcience Give an expanded view of lipid size, density, particle number, lipoprotein(a), apoa, apob and other genetic and helpful markers.

52 In the IFM Toolkit

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55 Particle Size Cholesterol - on Lipitor

56 Particle Size Testing on Lipitor Large VLDL is more atherogenic. LDL particle number and size drives CVD risk. Large LDL is less atherogenic and small dense LDL is high risk. HDL 3 is less protective for CHD than HDL 2. Large HDL 2 is most protective. IF HDL is less than 50 and Trig. are over 125 then the LDL particle number increases faster. If LDL is reduced to 60 then the effects of HDL and Trig are less atherogenic. Statins are not effective in reducing LDL particle size, number or APO B.

57 A D I M E A D I M E A D I M E A D I M E A D I M E

58 Fat Control not Low Fat- Displace animal source Sat Fat /Trans Fat with MUFA s. and PUFA s.

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61 Janet s Intervention Supplemental Support: Glucomannan fiber- 2 with each meal Omega-3 fish oil 2000mg+ of DHA+EPA Vitamin D 5000IU per day Vit. D3 Rice protein anti-inflammatory medical food as part of elimination diet Magnesium citrate 150mg 1-6 per day depending on bowel tolerance Probiotics 30 billion twice a day Policosanol 10 mg BID Diet and Lifestyle Changes: Carb Controlled/Cardiometabolic weight reduction plan. Life long gluten free diet after 2-4 week elimination diet. 7-9 hours sleep most nights. Stress Reduction.

62 Improved Outcome: Janet 4 months later Symptoms of puffiness, bloating, constipation, sinuses pressure, GERD, chest pain ALL GONE. Fasting Insulin from to 18 to 4 Hs-CRP from 6.0 to 1.3 LDL particle size increased in size from 18.4 to 20.4 LFTs normal, BP normal off medication Lost 30 lbs MSQ from 137 to 22 Off all medications except thyroid Symptoms of MS relieved signs of optic neuritis gone while off of MS medication

63 References/Resources Bariatric Surgery- Koch TR, Finelli FC, Postoperative metabolic and nutritional complications of bariatric surgery. Gastroenterol Clin North Am. 2010:39: Mechanick JI, et al. American Assoc. of Clinical Endocrinologists, the Obesity Society, and American Society for Metabolic & Bariatric Surgery Medical Guidelines for Clinical Practice for the Perioperative Nutritional, metabolic & Nonsurgical support of the Bariatric Surgery Patient. Endocrine Prac. Vol. 14(Suppl 1) July/August Dyslipidemia- Integrative Approach Houston MC, et al. Nonpharmacologic Treatment of Dyslipidemia. Progress in Cardiovascular Disease 2009;52: Bradley R, et al. Integrative Treatments to Reduce Risk of Cardiovascular Disease. Integrative Med 2009; Feb/Mar. Vol.8, No. 1:26-34.

64 Protocols

65 In Your IFM Toolkit

66 Follow Up Webinars Common Conditions Managed through Functional Nutrition 1. Michael Stone - Inflammatory and Respiratory Conditions and Depression/Anxiety 2. Ruth DeBusk - Hypertension and GERD 3. Elizabeth Boham - Osteoporosis & Food Allergies/Intolerances 4. Mary Willis - Overweight/Obesity and Dyslipidemia All are archived and will be available on the course materials page next week ent/files/functionalnutritionprogramdec2010/