Clinical Guidance to Help Your Patients Make Healthier Food Choices

October 27, 2011

Webinar sponsored by the American Medical Association, in partnership with Health Care Without Harm, Kaiser Permanente, and Physicians for Social Responsibility

Moderator: Robert M. Gould, MD, Associate Pathologist, Kaiser Hospital, San Jose and President, San Francisco-Bay Area Chapter of Physicians for Social Responsibility

Presenter: Ted Schettler, MD, MPH is Science Director of the Science and Environmental Health Network (www.sehn.org). He also serves as science director of the Collaborative on Health and Environment (www.healthandenvironment.org). He has a medical degree from Case Western Reserve University and a masters in public health from Harvard University. Schettler has addressed the connections between human health and the food, chemical, built, and social environments in numerous publications and presentations. He has served on advisory committees of the US EPA and National Academy of Sciences. and practiced medicine primarily in New England for many years.

This webinar is being recorded for archiving and available for CME credit for one year. Individual PowerPoint presentations will also be available for download when approved by presenters. For more information on this

webinar series, including CMEs for physicians, and to view past events, please visit http://www.healthyfoodinhealthcare.org.

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Clinical Guidance to Help Your Patients Make

Healthier Food Choices

Ted Schettler, MD, MPHScience Director, Science and Environmental Health Network

Scope of the Presentation

Rationale for Food Matters Webinar Series

Ecological and Lifecycle Approach

Scope of Obesity Epidemic and Role of Western Diet

Drivers of the Western Diet and Diseases

Healthy Diet – First Foods and Beyond

Helping Your Patients Make Healthier Choices

Guiding Rationale A Food Systems Approach

Our current food system:

Produces large quantities of calorie-rich, nutrient-poor food

Is a major driver of obesity, diabetes, cardiovascular disease, some kinds of cancer, malnutrition, and other chronic diseases

Substantially contributes to environmental degradation with impacts on public health, including air and water pollution, climate change, and loss of biodiversity

Guiding Rationale Child & Maternal Health

Good nutrition is an essential requirement of healthy human development,

Developing humans are uniquely vulnerable to toxic environmental exposures, and

The health impacts of in-utero and early life nutrition and toxic exposures have consequences across an individual’s lifespan.

Guiding Rationale Healthcare Responsibilities

What is the responsibility of the healthcare sector to address the nutritional and environmental origins of the diseases they treat?

What role can the healthcare sector play in reversing the epidemics of today, and envisioning a healthier future?

Food Matters to Pregnant Women, Children and Future Generations

Nutrition MattersGood nutrition is an

essential requirement of healthy human development

Vulnerability MattersDeveloping fetus and

human are uniquely vulnerable

to environmental exposures

Timing MattersHealth consequences of in-

utero and early life exposures can manifest across an

individual’s lifespan

Developmental Origins of Adult Disease

“It is suggested that poor nutrition in early life increases susceptibility to the effects of an affluent diet. . .”

Barker DJ, Osmond C. Infant mortality, childhood nutrition, and ischaemicheart

disease in England and Wales. Lancet. 1986 May 10;1(8489):1077-81.

Timing Matters

Exposure in early gestation: three-fold increase in coronary heart disease, more obesity

Exposure in mid-gestation: increase in obstructive airways disease

Exposure in late gestation: impaired glucose tolerance

Painter RC, Roseboom TJ, Bleker OP. Prenatal exposure to the Dutch famine and disease in later life: an overview. Reproductive Toxicology. 2005 Sep-Oct;20(3):345-52.

Early Life Experiences Can Influence Later-life Health and Disease

Toxic exposuresMaternal nutrition

Psychosocial stressors

Obesity, hypertension,Cardiovascular disease,

diabetes

Alzheimer’s, dementia,

Parkinson’sLow birth weight

Aging begins at conception

An Ecological Health Framework: The individual in the context of family, community, society and ecosystem

Public Health Impact of Environmentally-Driven Western Disease Cluster is Profound

Obesity/overweight2/3 US adults, prevalence X2 in ~25 yrs

Pre/Diabetes 40% US adults. Prevalence DM ~X2 over 20 yrsType 2 diabetes now appearing in children, adolescents; usually associated with obesity

Cardiovascular disease Still leading cause of death

Metabolic syndrome Early signs of other cluster diseases; 35% adults, ~55%>60 yrs

Metabolic syndrome in childhood increases the risk of cardiovascular disease in adulthood 15 fold

Chronic Disease: Nutrition and Health

Soda and fast food consumption linked to increased risk of weight gain and diabetes.

Average consumption of high fructose corn syrup has increased by over 25% in the last 30 years.

High-sugar or high-fat foods comprise almost 30 percent of all calories consumed by Americans.

Increase in daily calories over the last 20 years (men 168, women 300).

Food Environments Drive Chronic Disease

Altered PathwaysNutritional/

Environmental Factors

Chronic Disease

Mechanisms of ActionInflammationInflammation

Disrupted Insulin SignalingDisrupted Insulin Signaling

Oxidative StressOxidative Stress

Inflammation

Inflammation is a dimension of:

Diabetes

Metabolic syndrome

Obesity (in most but not all individuals)

CVD

Some neurodegenerative disorders

Other chronic illnesses (e.g. various malignancies)

Insulin Signaling = Normal Metabolism

Insulinsignaling

• ↓ blood sugar• ↓ artery disease• ↓ triglycerides

Disrupted Insulin Signaling = Inflammatory Metabolism

Some Nutrients Are Increasingly Pervasive and Promote Inflammatory Metabolism

What’s Changed in the Western Diet?

Year

% o

f cal

orie

s fr

om fa

t

mg/

day

High Glycemic Carbohydrates Increase the Risk of Chronic Disease

High glycemic carbohydrates break down quickly during digestion, rapidly releasing glucose (sugar) into the

bloodstream.

ΔPl

asm

a In

sulin

,mg/

dl

Time, mins

INSULINEMIC RESPONSE

Low glycemic food

High glycemic food

Properties of Fatty Acids

Omega-3 Omega-6 Saturated

• Perishable • Durable Increased inFood • Short shelf life • Long shelf life factory-farmed

System • Increased in • Processed foods animalspasture-fed animals

Immune Anti-inflammatory Inflammatory & InflammatoryProperties Anti-inflammatory

Evolutionary Recent marked Recent marked Recent markedContext decline increase increase

Nutrient Influences on Insulin Signaling, Inflammatory Metabolism

Saturated fat ↓ Antioxidants

High Glycemic Carbohydrates

Fructose

The Importance of Early Nutrition: In the Womb & Infancy

Growth

Developmental programming Epigenetic: DNA methylation, histone modification,

RNA interference

Establish “set points” of various phenotypic traits; program immune system, etc.

Influence susceptibility to adult disease; e.g. obesity, metabolic syndrome, diabetes, cancer, neurodegenerative disease, etc.

Pilot Study: Impact of low glycemic load diet in overweight/obese pregnant women

n=46

Low-GL Diet:Longer pregnancy duration (delivery <38 weeks 13% vs. 48%)

Greater Infant Head Circumference

Lower maternal triglycerides and cholesterol

Dietary interventions may help prevent premature births and other adverse maternal and infant outcomes

This study needs to be repeated with larger numbers

Maternal High Glucose and Increased Risk of Diabetes in Children

Prenatal exposure to high levels of maternal blood glucose reduces insulin sensitivity in infants

Gestational diabetes associated with increased risk of Type 2 diabetes in children; not entirely explained by BMI

Rationale for focus on healthy food in pregnant women as a driver of health of future generations

Breast Feeding Advantages: Infant

Reduced infectious disease pneumonia, gastroenteritis, otitis media, other

Lower risk of type 1 diabetes; type 2 diabetes if mother does not have diabetes

> 6 mo. decreases the risk of childhood cancerleukemia, Hodgkins, neuroblastoma

Lower risk of inflammatory bowel disease

Improved neurological development and lower asthma risk (inconsistent evidence)

Breast Feeding Advantages: Maternal

Less postpartum bleeding

Earlier return to pre-pregnancy weight

Improved bone strength; decreased risk of hip fracture later in life

Reduced ovarian and pre-menopausal breast cancer

Birth control

Women who don’t breastfeed have increased risk of type 2 diabetes

Influence of Nutrition on Chronic Disease

Increase risks saturated and trans fatshigh glycemic carbohydrateslack of fruits/vegetables/omega 3sexcess omega 6s?

Reduce risks fruits, vegetables, nutsomega 3slow glycemic carbohydrate“Mediterranean-type” diet

Benefits of Mediterranean-Type Diet on Chronic Disease Risk

Clinical intervention studies

70% ↓ heart attacks, cardiac death & total mortality DeLogeril, 94

60%↓ cardiac events in CVD patients* Ornish, 98

~50% ↓ metabolic syndrome Esposito, 04

39% ↓ in CRP Esposito, 04

↓ insulin resistance Esposito, 04

↓ weight Esposito. 04

*10% low fat, vegetarian diet + exercise, stress reduction

Benefits of Mediterranean-Type Diet on Chronic Disease Risk

Prospective observation studies

80% ↓ diabetes Martinez-Gonzalez, 08

~31% ↓ all-cause & cardiovascular mortality

22% ↓ cancer mortality** calculated from Sofi, 08

73% ↓ Alzheimer’s mortality Scarmeas, 07

25-30% ↓ Parkinson’s disease Gao, 07

Systemic Drivers of Diet and Food Choices 33

Advertising & Media

Access & AvailabilityFast food restaurants, food deserts

Education, social psychology, and early life experiences

Cost

Food Advertising

$25-30 billion per year Twice the amount needed to provide health and nutrition for everyone in the world. -UNDP 1998

$12 billion per year Aimed at marketing to children.

Subsidies: Abundant, low-priced corn and soybeans foster cheap junk foods

Economic Drivers of Food Choice

Interconnections Between Nutrition and Environment

Helping Your Patients Make Healthier Choices

Summary: What is a healthy diet?

Observations are applicable for your patients at every age

Early life nutrition affects health status, chronic disease risklater in life

Food system, including production, distribution, and advertising have strong influences on the diets of individuals

References

Barker DJ, Osmond C. Infant mortality, childhood nutrition, and ischaemicheart disease in England and Wales. Lancet. 1986 May 10;1(8489):1077-81.

Painter RC, Roseboom TJ, Bleker OP. Prenatal exposure to the Dutch famine and disease in later life: an overview. Reproductive Toxicology. 2005 Sep-Oct;20(3):345-52.

De Logeril et al. Med. diet, traditional risk factors, and the rate of cardiovascular complications after myocardial infarction: final report of the Lyon Diet Heart Study. Circulation. 1999 Feb 16;99(6):779-85.

Barzi F et al. Mediterranean diet and all-causes mortality after myocardial infarction: results from the GISSI Prevenzione trial European Journal of Clinical Nutrition (2003) 57, 604–611

Estruch R, Martínez-González MA, Corella D, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med. 2006 Jul 4;145(1):1-11.

Serra-Majem et al. Scientific evidence of interventions using the Mediterranean diet: a systematic review. Nutr Reviews 2006 Feb;64(2 Pt 2):S27-47.

Vincent-Baudry S, et al..The Medi-RIVAGE study: reduction of cardiovascular disease risk factors after a 3-mo intervention with a Mediterranean-type diet or a low-fat diet.Am J Clin Nutr. 2005 Nov;82(5):964-71.

Esposito, K et al. Effect of a Med-style diet on endothelial dysfunction and markers of vascular inflammation in the metabolic syndrome. Random. Trial. JAMA 292(2):1440-6, 2004.

Estruch R, Martínez-González MA, Corella D, et al. Effects of a Mediterranean-style diet on cardiovascular risk factors: a randomized trial. Ann Intern Med. 2006 Jul 4;145(1):1-11.

References40

Shai I, Schwarzfuchs D, Henkin et al. Weight loss with a low-carbohydrate, Mediterranean, or low-fat diet. N Engl J Med. 2008 Jul 17;359(3):229-41.

Brunner EJ. Dietary patterns and 15-y risks of major coronary events, diabetes, and mortality.Am J Clin Nutr. 2008 May;87(5):1414-21.

Martínez-González MA et al. Adherence to Mediterranean diet and risk of developing diabetes: prospective cohort study. BMJ. 2008 Jun 14;336(7657):1348-51. Epub 2008 May 29.

van Dam RM, Dietary patterns and risk for type 2 diabetes mellitus in U.S. men. Ann Intern Med. 2002 Feb 5;136(3):201-9.

Benetou V et al. Conformity to traditional Mediterranean diet and cancer incidence: the Greek EPIC cohort. Br J Cancer. 2008 Jul 8;99(1):191-5.

Sofi F, Adherence to Mediterranean diet and health status: meta-analysis. BMJ. 2008 Sep 11;337.

Rhodes, et al. Effects of a low–glycemic load diet in overweight and obese pregnant women: a pilot randomized controlled trial. American Journal of Clinical Nutrition. 2010. 92 (6): 1306-1315.

Clinical Guidance to Help Your Patients Make Healthier Food Choices

October 27, 2011

Webinar sponsored by the American Medical Association, in partnership with Health Care Without Harm, Kaiser Permanente, and Physicians for Social Responsibility

Upcoming webinars:

This webinar is being recorded for archiving and available for CME credit for one year. Individual PowerPoint presentations will also be available for download when approved by presenters. For more information on this

webinar series, including CMEs for physicians, and to view past events, please visit http://www.healthyfoodinhealthcare.org.