5/3/2013

1

Nutrition Therapy inMetabolic Syndrome

Nicole RaimondoSodexo Dietetic Internship

Saint Joseph’s Medical Center

INTRODUCTION

• Increasing obesity has led to an increase in metabolic syndromeincrease in metabolic syndrome

• Affects ~32% of adults over the age of 20 and up to 45% over age 50

OUTLINE

Diagnostic Criteria

Overview

Critical Comments

Patient M

MNT

Medical Treatment

•Also known as…

METABOLIC SYNDROME

–Syndrome X–Insulin resistance syndrome–Obesity syndrome

• Group of risk factors that promote the de elo e t of

WHAT IS IT?

development of

–Atherosclerotic Cardiovascular Disease–Type II Diabetes

WHAT ARE THESE FACTORS?Abdominal

obesity

High triglycerides

Low HDLHigh blood pressure

High fasting blood sugar

5/3/2013

2

PATHOGENESIS

ADIPOSE

• Adipocytes

• Adipose tissue–Subcutaneous adipose tissue–Visceral adipose tissue

http://drpinna.com/wp-content/uploads/2010/10/1070397_f520.jpg

PATHOGENESIS PATHOGENESIS

PATHOGENESIS PATHOGENESIS

5/3/2013

3

PATHOGENESIS PATHOGENESIS

PATHOGENESIS PATHOGENESIS

Lancet 2005

•ObesityP di t

INCREASED RISK

•Genetics and inheritance•Poor diet

• Inactive• age

inheritance•Smokers•Antipsychotic meds

5/3/2013

4

• 47 million adults!

• Compared to an individual without the syndrome

RELEVANCE?

syndrome…–2 x as likely to develop heart disease–5 x as likely to develop diabetes

• Will soon be a bigger risk factor for heart disease than smoking

• Metabolic syndrome in psych disorders is 2 x more common

MENTALLY ILL PATIENTS

• Physical inactivity, stress, psychotropic drugs, altered glucose metabolism, dyslipidemia

• Leading cause of morbidity & mortality in those with schizophrenia

DIAGNOSTIC CRITERIA

Fasting blood sugar≥ 100 mg/dL or individual is taking a Rx for high glucose

Blood pressure≥ 130/85 mmHg or individual is taking an antihypertensive Rx

Waist circumference≥ 35 inches in women and ≥ 40 inches in men

HDL cholesterol<50 mg/dL in women and <40 mg/dL in men or the individual is taking a Rx for low HDL

Triglycerides≥ 150 mg/dL or the individual is taking a Rx for high triglycerides

•Blood Pressure Medications

MEDICAL TREATMENT

•Cholesterol Medications•Blood Sugar Medications

• Improve or correct the cardio-metabolic risk factors • Initial weight goal of 7-10%• Biochemical goal levels:

OVERALL GOALS OF MNT

gFasting plasma glucose <100 mg/dLTotal cholesterol <200 mg/dLLDL cholesterol <100 mg/dL

HDL cholesterolMen >40 mg/dLWomen >50 mg/dL

Triglycerides <150 mg/dLBlood pressure <130/80 mm Hg

• Abdominal obesity

W i t i f

MNT: PHYSICAL ASSESSMENT

• Waist circumference –Women ≥ 35 in–Men ≥ 40 in

• Estimate of body fat–BMI

5/3/2013

5

• Diagnostic criteria• C-reactive protein• Degree of impaired glucose regulation:

MNT: LAB VALUES

• Degree of impaired glucose regulation:Category FPG Test 2-hour PG Test HgA1C

Normal <100 mg/dL <140 mg/dL <5.7%

IFG 100-125 mg/dL Pre-diabetes:5.7-6.4%IGT 140-199 mg/dL

Diabetes ≥126 mg/dL ≥200 mg/dL ≥6.5%

• Mediterranean diet

DIETARY APPROACHES

• FirstLine Therapy Food Plan

• Dietary Approaches to Stop Hypertension (DASH)

MEDITERRANEAN DIET

• Improvements in • lipid profilelipid profile• waist circumference• blood pressure• glucose regulation

FIRSTLINE THERAPYFOOD PLAN

Food category Recommendation/dayLow GI vegetables (<55) ≥ 3 servings

Moderate GI vegetables (55-70) 1 servingModerate GI vegetables (55 70) 1 servingLegumes ≥1 servingsAnimal and vegetable proteins unlimitedNuts and seeds 1 servingLow GI fruits 2-3 servingsDairy 2-3 servings maxWhole grains 1 servingFats and oils 4 servings

DASH DIET

Food ServingsGrains 6-8 per dayFruits 4-5 per dayp yVegetables 4-5 per dayMeats, poultry, fish ≤ 6 per dayFat-free or low-fat dairy 2-3 per dayNuts, seeds, legumes 4-5 per weekFats and oils 2-3 per daySweets ≤5 per week

• Vitamin D• Vitamins A, C, E• Omega 3 fatty acids

SUPPLEMENTS

Omega 3 fatty acids• Conjugated linoleic acid• Magnesium• Cinnamon• Chromium• Green tea & Ginseng

5/3/2013

6

• Adequate intake improves glucose

l ti

VITAMIN D

regulation

• Inadequate intake increases insulin resistance and CRP

• In metabolic syndrome, people had low levels of it i A C d E

VITAMINS A, C, E

vitamins A, C, and E

• A, C, E improve oxidative stress levels

• EPA, DHA

• risk of sudden

OMEGA 3 FATTY ACIDS

cardiac death

• BP

• Improves dyslipidemia and inflammation

• CLA affects body fat mass and lean body

CONJUGATED LINOLEIC ACID

mass and lean bodymass

• Fat loss in humans by ~0.2 lbs per week

• In MetS- high levels of insulin circulating in the

MAGNESIUM

gbody stimulate Mg excretion leading to depletion

• Insulin sensitivity

CINNAMON

• Helps regulate blood glucose

5/3/2013

7

• Improves binding to insulin receptors

CHROMIUM

insulin receptors

• Drops in glucose and improvements in Hg A1C

• Polyphenols & caffeine

GREEN TEA & GINSENG

caffeine

• Ginsenosides

PHYSICAL ACTIVITY

• Moderate activity or greater intensity for 120 min/week• Triglycerides• HDL cholesterol

• Physical activity for 60 min/day at least 5 times/week

• Waist circumference

• Resistance training 2 days/week• Obesity, systolic blood pressure, and hemoglobin A1C

NUTRITION COUNSELING(IN PSYCHOTIC DISORDERS)

Cognitive-Behavioral Therapy

Transtheoretical Model

Health Belief Model

Social Cognitive Theory

• 44 year-old obese, unemployed, AA female

• Smoker

• Family history of mental illness

Past med hx:

PATIENT M

• Past med hx:– Type II diabetes– Hyperlipidemia– Hypertension– Anemia– Schizophrenia– Depression

MEDICAL & PSYCHIATRIC COURSE IN THE HOSPITAL

October 3rd, 2012

• Admitted with paranoid ideations and phallucinations

• Unsafe to be discharged into the community and admitted with schizoaffective disorder

5/3/2013

8

PATIENT M’S COURSE IN THE HOSPITAL

Admitting orders (10/03/2012):• cbc, lipid panel, HgA1C,

f ll hi t i t• full psychiatric assessment• OT for psychosocial functioning• group therapy• individual psychotherapy• psychopharmacotherapy• finger sticks BID• dietary consult

Zocor cholesterol and triglycerides

NovoLog regulate blood sugar levels

Levemir regulate blood sugar levels

Diovan blood pressure

MEDICATIONS

Diovan blood pressure

Clozaril schizophrenia

Prolixinpsychotic symptoms such as hallucinations and delusions

Depakote mania

Nicorette smoking cessation

Protonix gastroesophageal reflux

Zocor cholesterol and triglycerides

NovoLog regulate blood sugar levels

Levemir regulate blood sugar levels

Diovan blood pressure

MEDICATIONS

Diovan blood pressure

Clozaril schizophrenia

Prolixinpsychotic symptoms such as hallucinations and delusions

Depakote mania

Nicorette smoking cessation

Protonix gastroesophageal reflux

1. To provide safety and support to the patient

2. To encourage therapeutic relationships and assist the

INTERDISCIPLINARY PLAN FOR PATIENT M

patient in acclimating to the unit and psyc programs

3. To improve the patient’s symptoms of psychosis to a level that would allow her to be safely discharged back into the community

4. To improve the patient’s ability to care for herself so as to not neglect her health conditions

INITIAL NUTRITION ASSESSMENTOctober 4th, 2012

Assessment Diagnosis InterventionMonitoring

& Evaluation

ASSESSMENT

Glucose 291 HH/H 12.6/37.5 L

Height: 68 in

Weight: 295 lbsHgA1C 9.4 HTotal Cholesterol 233 HTriglycerides 293 HFinger Sticks 250-337 H

Weight: 295 lbs

BMI: 45 kg/m2, obesity grade III

Adjusted Body Weight: 189 lbs

Ideal Body Weight: 126-154 lbs

5/3/2013

9

• Mifflin-St. Jeor method – 500 kcal= ~2000 calories/day

ASSESSMENT

• Protein needs: 86 g of protein/day

• Fluid needs: ~2000 mL/day

METABOLIC SYNDROME IN PATIENT M

Blood sugar≥ 100 mg/dL or individual is taking a Rx for high glucose

HgA1C 9.4, Glucose 291Pt taking NovoLog, Levemir

Bl d ≥ 130/85 mmHg or individual is ≥ 130/85

Blood pressure/ g

taking an antihypertensive Rx Pt taking Diovan

Waist circumference

≥ 35 inches in women > 35 inches

HDL cholesterol

<50 mg/dL in women or the individual is taking a Rx for low HDL

unavailable

≥ 150 mg/dL or the individual is 293

M it iAssessment Diagnosis Intervention

Monitoring &

Evaluation

NUTRITION DIAGNOSESObesity (NC-3.3)

Excessive energy intake (NI-1.3)

Excessive oral intake (NI-2 2)Excessive oral intake (NI-2.2)

Inconsistent carbohydrate intake (NI-5.8.4)

Nutrition-related knowledge deficit (NB-1.1)

Undesirable food choices (NB-1.7)

Physical inactivity (NB-2.1)

Nutrition Diagnoses

Excessive energy intake related to a caloric intake greater than her calculated needs to promote weight loss as evidenced by a BMI of 45/Obesity Grade IIIloss as evidenced by a BMI of 45/Obesity Grade III.

Inconsistent and inappropriate carbohydrate intake related to a deficit in nutrition knowledge as evidenced by high glucose of 291 mg/dL, high HgA1Cof 9.4%, and high finger sticks of 250-337.

MonitoringAssessment Diagnosis Intervention

Monitoring &

Evaluation

5/3/2013

10

• Food and nutrient delivery–Modify diet to 2000 kcal CHO-consistent, fat, sodium

NUTRITION INTERVENTION

• Nutrition education–Nutrition relationship to health and disease– Educate on diet changes– Encourage attendance to monthly nutrition

class & psyc unit walking club– Encourage fish consumption for anemia

M it iAssessment Diagnosis Intervention

Monitoring &

Evaluation

MONITORING AND EVALUATION

• Diet order• Energy intake• CHO intake and timing

Intake

• Attendance of classesAttendance of classes• Level of nutrition

knowledgeNutrition knowledge

• Weight• BMIAnthropometrics

• Glucose profile• Lipid profileBiochemical data

• Diet order Δ to 2000 kcal CCD, low fat, 2 g Na

• Food and nutrient intake

FOLLOW-UP

• Food and nutrient intake

• Food and nutrition knowledge

• Anthropometrics• Weight: 266 lbs (120.9 kg)• BMI: 40 kg/m2

• Biochemical data

FOLLOW-UP

• Previous diagnosis of excessive energy intake being resol ed on inpatient dietresolved on inpatient diet

• Finger sticks <300, but still >200s at times so diagnosis relating to carbohydrate intake was still in effect

• Weight: 266 lbs

• BMI: 40 kg/m2

FOLLOW-UP #2

Glucose 260 H, ↓ from admHgA1C 8 1 H ↓ from admBMI: 40 kg/m

• Revise calorie needs based on new wt– Modify calorie

restriction to 1800

HgA1C 8.1 H, ↓ from admTotal Cholesterol 187 H, ↓ from admTriglycerides 204 H, ↓ from adm

Finger Sticks 150 to < 300

Blood Pressure 129/74

5/3/2013

11

CRITICAL COMMENTS

• Patients on clozapine gain an average of 11.7-13.9 lbs during the 1st yr of use– Reduce REE estimates by ~280 calories/day

• Multivitamin and vitamin D

• Schizoaffective disorder different nutrition counseling

Saint Joseph’s Medical Center nutritional care team!

Gayanne, Christina, and fellow interns!

Thank you to

References1. Mahan K, Escott-Stump S. Krause's Food and Nutrition Therapy. 12th ed. St. Louis, MO: Saunders Elsevier, 2008. 2. Thomas J, Walker D, K. A practical guide to metabolic syndrome. Clin Advis 2012;15:39-48. 3. Grundy SM, Cleeman JI, Daniels SR, et al. Diagnosis and Management of the Metabolic Syndrome: An American Heart Association/National

Heart, Lung, and Blood Institute Scientific Statement. Circulation 2005;112:2735-52. 4. Riordan H, J., Antonini P, Murphy M, F. Atypical Antipsychotics and Metabolic Syndrome in Patients with Schizophrenia: Risk Factors, Monitoring,

and Healthcare Implications. Am Health Drug Benefits 2011;4:292-301. 5. Elsevier. Clinical Key: Metabolic Syndrome. Version current 2012. Internet: https://www.clinicalkey.com/topics/internal-medicine/metabolic-

syndrome.html (accessed January 28 2013). 6. Opie LH. Metabolic Syndrome. Circulation 2007;115:e32-5. 7. Després J. Is visceral obesity the cause of the metabolic syndrome? Ann Med 2006;38:52-63. 8. Ibrahim MM. Subcutaneous and visceral adipose tissue: structural and functional differences. Obes Rev 2010;11:11-8. 9. Dodson MV, Mir PS, Hausman GJ, et al. Obesity, Metabolic Syndrome, and Adipocytes. Journal of Lipids 2011;2011: 10. Gropper S, Smith J, Groff J. Adipose Tissue. In: Advanced Nutrition and Human Metabolism. Belmont, CA: Thomson Wadsworth, 2005:143. 11. Pi-Sunyer FX. Pathophysiology and Long-Term Management of the Metabolic Syndrome. Obes Res 2004;12:174S-80S. 12 Oswal A Yeo G Leptin and the control of body weight: a review of its diverse central targets signaling mechanisms and role in the pathogenesis12. Oswal A, Yeo G. Leptin and the control of body weight: a review of its diverse central targets, signaling mechanisms, and role in the pathogenesis

of obesity. Obesity (Silver Spring) 2010;18:221-9. 13. Shu-Ju Chen, Chi-Hua Yen, Yi-Chia Huang, et al. Relationships between Inflammation, Adiponectin, and Oxidative Stress in Metabolic

Syndrome. PLoS ONE 2012;7:1-5. 14. Ouchi N, Parker JL, Lugus JJ, Walsh K. Adipokines in inflammation and metabolic disease. Nat Rev Immunol 2011;11:85-97. 15. Rizvi AA. Hypertension, obesity, and inflammation: the complex designs of a deadly trio. Metab Syndr Relat Disord 2010;8:287-94. 16. Assoumou HN, Barthelemy JC, Garet M, et al. Increased waist circumference is the component of metabolic syndrome the most strongly

associated with elevated C-reactive protein in elderly. Metab Syndr Relat Disord 2011;9:281-5. 17. Gade W, Schmit J, Collins M, Gade J. Beyond obesity: the diagnosis and pathophysiology of metabolic syndrome. Clin Lab Sci 2010;23:51-61. 18. Saddichha S, Manjunatha N, Ameen S, Akhtar S. Metabolic syndrome in first episode schizophrenia--A randomized double-blind controlled,

short-term prospective study. Schizophr Res 2008;101:266-72. 19. National Heart, Lung, and Blood Institute. Metabolic Syndrome. Version current November 3, 2011. Internet:

http://www.nhlbi.nih.gov/health/health-topics/topics/ms/ (accessed December 20 2012). 20. Mayo Foundation for Medical Education and Research. High Blood Pressure. Version current August 3, 2012. Internet:

http://www.mayoclinic.com/health/high-blood-pressure (accessed December 20 2012). 21. Academy of Nutrition and Dietetics. Nutrition Care Manual®. Metabolic Syndrome. Version current 2012. Internet:

http://nutritioncaremanual.org/topic.cfm?ncm_heading=Nutrition%20Care&ncm_toc_id=12829 (accessed January 3, 2013).

22. American Heart Association. What Your Cholesterol Levels Mean. Version current October 11, 2012. Internet: http://www.heart.org/HEARTORG/Conditions/Cholesterol/AboutCholesterol/What-Your-Cholesterol-Levels-Mean_UCM_305562_Article.jsp(accessed January 20, 2012).23. Tryzelaar J. ACE Inhibitors . Version current 2011. Internet: http://www.cardiachealth.org/heart-disease-treatment/heart-disease-medications/blood-pressure-medications/ace-inhibitors (accessed December 20, 2012). 24. Committee on Cardiovascular and Metabolic Diseases. Cardiovascular and Metabolic Diseases. Version current 2012. Internet: http://www.ccmdweb.org (accessed December 19, 2012). 25. Orchard TJ, Temprosa M, Goldberg R, et al. The effect of metformin and intensive lifestyle intervention on the metabolic syndrome: the Diabetes Prevention Program randomized trial. Ann Intern Med 2005;142:611-9. 26. Nieuwdorp M, Stroes ESG, Kastelein JJP. Normalization of metabolic syndrome using fenofibrate, metformin or their combination. Diabetes Obes Metab 2007;9:869-78. 27. Hedelin M, Löf M, Olsson M, et al. Dietary intake of fish, omega-3, omega-6 polyunsaturated fatty acids and vitamin D and the prevalence of psychotic-like symptoms in a cohort of 33,000 women from the general population. BMC Psychiatry 2010;10:38-. 28. Vrolix R, van Meijl ,L.E.C., Mensink RP. The metabolic syndrome in relation with the glycemic index and the glycemic load. Physiol Behav 2008;94:293-9. 29. Ridker PM. C-Reactive Protein: A Simple Test to Help Predict Risk of Heart Attack and Stroke. Circulation 2003;108:e81-5. 9 p p 3; 530. Baxter AJ, Coyne T, McClintock C. Dietary patterns and metabolic syndrome--a review of epidemiologic evidence. Asia Pac J Clin Nutr 2006;15:134-42. 31. Amini M, Esmaillzadeh A, Shafaeizadeh S, Behrooz J, Zare M. Relationship between major dietary patterns and metabolic syndrome among individuals with impaired glucose tolerance. Nutrition 2010;26:986-92. 32. Schiltz B, Minich DM, Lerman RH, Lamb JJ, Tripp ML, Bland JS. A science-based, clinically tested dietary approach for the metabolic syndrome. Metab Syndr Relat Disord 2009;7:187-92. 33. Kastorini CM, Milionis HJ, Esposito K, Giugliano D, Goudevenos JA, Panagiotakos DB. The effect of mediterranean diet on metabolic syndrome and its components a meta-analysis of 50 studies and 534,906 individuals. J Am Coll Cardiol 2011;57:1299-313. 34. Gouveri E, T., Tzavara C, Drakopanagiotakis F, et al. Mediterranean Diet and Metabolic Syndrome in an Urban Population: The Athens Study. Nutr Clin Pract 2011;26:598-606. 35. Lovejoy JC. The influence of dietary fat on insulin resistance. Curr Diab Rep 2002;2:435-40. 36. Aleixandre A, Miguel M. Dietary Fiber in the Prevention and Treatment of Metabolic Syndrome: A Review. Critical Reviews in Food Science & Nutrition 2008;48:905-12.37. Minich DM, Bland JS. Dietary management of the metabolic syndrome beyond macronutrients. Nutr Rev 2008;66:429-44. 38. Anonymous Your Guide to Lowering Your Blood Pressure with DASH. Your Guide to Lowering Your Blood Pressure with DASH 2006;64.

39. Azadbakht L, Mirmiran P, Esmaillzadeh A, Azizi T, Azizi F. Beneficial effects of a Dietary Approaches to Stop Hypertension eating plan on features of the metabolic syndrome. Diabetes Care 2005;28:2823-31. 40. Thomas GN, O Hartaigh ,B., Bosch JA, et al. Vitamin D Levels Predict All-Cause and Cardiovascular Disease Mortality in Subjects With the Metabolic Syndrome: The Ludwigshafen Risk and Cardiovascular Health (LURIC) study. Diabetes Care 2012;35:1158-64. 41. Lima MdL, Cruz T, Rodrigues LE, et al. Serum and intracellular magnesium deficiency in patients with metabolic syndrome--evidences for its relation to insulin resistance. Diabetes Res Clin Pract 2009;83:257-62. 42. Potenza MV, Mechanick JI. The Metabolic Syndrome: Definition, Global Impact, and Pathophysiology. Nutrition in Clinical Practice 2009;24:560-77. 43. Sharma P, Mishra S, Ajmera P, Mathur S. Oxidative stress in metabolic syndrome. Indian J Clin Biochem 2005;20:145-9. 44. Kamphuis MMJW, Lejeune MPGM, Saris WHM, Westerterp-Plantenga M. The effect of conjugated linoleic acid supplementation afterweight loss on body weight regain, body composition, and resting metabolic rate in overweight subjects. Int J Obes Relat Metab Disord 2003;27:840-7. 45. Racine NM, Watras AC, Carrel AL, et al. Effect of conjugated linoleic acid on body fat accretion in overweight or obese children. Am J Clin Nutr 2010;91:1157-64. 46. Whigham LD, Watras AC, Schoeller DA. Efficacy of conjugated linoleic acid for reducing fat mass: a meta-analysis in humans. Am J Clin 4 g , , y j g g y JNutr 2007;85:1203-11. 47. Bosak K. Managing Metabolic Syndrome: Focus on Physical Activity. J Nurse Pract 2012;8:206-11. 48. Academy of Nutrition and Dietetics. Nutrition Care Manual®. Schizophrenia. Version current 2012. Internet: http://nutritioncaremanual.org/topic.cfm?ncm_toc_id=144869 (accessed December 20, 2012). 49. Academy of Nutrition and Dietetics. Nutrition Care Manual®. Equations. Internet: http://www.nutritioncaremanual.org/topic.cfm?ncm_toc_id=255519#MSJ (accessed January 3, 2013). 50. Mayo Foundation for Medical Education and Research. Schizoaffective disorder. Version current December 21, 2010. Internet: http://www.mayoclinic.com/health/schizoaffective-disorder/DS00866 (accessed January 21, 2013).