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The Cell

Leading Causes of Death vs Actual Causes of Death http://www.clivir.com/lessons/show/stroke-statistics-information-charts-and-graphs.html

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Journal of Clinical Pharmacy and Therapeutics (2010) 35, 11–48

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Expensive Urine? http://www.newstarget.com/021393.html

© Rakowski 2008

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The Actual Deadly Quartet

Toxins

Malnutrition Laziness

Multi-Center Trial

University of Connecticut, Storrs

University of Florida, Jacksonville

University of California, Irvine:

HSM4 Study

Entrance Criteria 12 weeks

Provided with baseline diet instructions; booklet and DVD;

Randomized into 2 arms

Non-blinded

Females only

Age: 20-75 y

BMI: >25 kg/m2

LDL: >100 mg/dL

TG: >150 mg/dL

Meet criteria for MetS

Total body weight

Between-arm P value

Unadjusted Adjusted for sites

V5-V1 0.537 0.498

V7-V1 0.427 0.379

Intervention Control

202.7 192.3 189.5

200.4 190.8 188.6

0

20

40

60

80

100

120

140

160

180

200

220

V1 V5 V7 V1 V5 V7

lbs

(mea

n ±

SE)

P<.001 P<.001 P<.001 P<.001

-6.8% vs. -6.2%

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Cholesterol

Between-arm P value

Unadjusted Adjusted for sites

V5-V1 0.031 0.032

V7-V1 0.026 0.037

Intervention Control

218.4

182.6 187.2

220.6

197.6 202.3

0.0

50.0

100.0

150.0

200.0

250.0

V1 V5 V7 V1 V5 V7

mg/

dl (

mea

n ±

SE

)

P<.001 P<.001 P<.001 P<.001

-14.6% vs. -8.8% LDL

Between-arm P value

Unadjusted Adjusted for sites

V5-V1 0.100 0.117

V7-V1 0.030 0.039

Intervention Control

133.6

109.4 112.0

131.1

115.3 119.7

0.0

20.0

40.0

60.0

80.0

100.0

120.0

140.0

160.0

V1 V5 V7 V1 V5 V7

mg/

dl (

mea

n ±

SE)

P<.001 P<.001 P<.001 P=.001

-16.7% vs. -9.3%

Among individuals aged 70 to 90 years, adherence to a Mediterranean diet and healthful lifestyle is associated with a more than 50% lower rate of all-causes and cause-specific mortality. JAMA. 2004;292:1433-1439

The Actual Deadly Quartet

Toxins

Malnutrition Laziness

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Dan Buettner Blue Zone Author

lifestyle is 90%, genetics is 10%

‘The average American Leaves 12 good years on the table.’ Blue Zone Average American Leaves 12 good Years on the table

The Actual Deadly Quartet

Toxins

Malnutrition Laziness

“Women successful in maintaining normal weight and gaining fewer than 2.3 kg over 13 years averaged approximately

60 minutes a day of moderate-intensity activity”

JAMA. 2010;303(12):1173-1179

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DSHEA (1994) Dietary supplements were defined in a law passed by

Congress in 1994 called the Dietary Supplement Health and Education Act (DSHEA).

A dietary supplement is a product that: ◦ Is intended to supplement the diet ◦ Contains one or more dietary ingredients (including

vitamins, minerals, herbs or other botanicals, amino acids, and certain other substances) or their constituents

◦ Is intended to be taken by mouth, in forms such as tablet, capsule, powder, soft gel, gel cap, or liquid

◦ Is labeled as being a dietary supplement

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Federal regulations for dietary supplements are very different from those for prescription and over-the-counter drugs. For example, a dietary supplement manufacturer does not have to prove a product’s safety and effectiveness before it is marketed.

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Pearls for Safety If you are thinking about using a dietary supplement,

1) Get information on it from reliable sources.

2) Keep in mind that dietary supplements may interact with medications or other dietary supplements and may contain ingredients not listed on the label.

3) Tell your health care providers about any therapies you use, including dietary supplements.

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Vitamin D

Am J Clin Nutr 2008;88(suppl):491S–9S

Vitamin D Deficiency World wide incidence of rickets is rising

At a level of 32 ng/ml, 90% of the UK population is insufficient

Certain populations are at higher risk: Elderly, home bound, critically ill, obese, pregnant women,

restricted diets

51% pts in VAH extended care facility were deficient (37%) or insufficient (14%) in VD

Increased attention to prevention skin cancer

Prentice A. Nutr Rev Vol 66 (Suppl 2): S153-S164; Braddy KK et al. J Am Med Dir Assoc 2009; 10:653-7.

Am J Clin Nutr 2008;88(suppl):491S–9S

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Am J Clin Nutr 2008;88(suppl):491S–9S

Metanalysis Vitamin D and all cause mortality

ARCH INTERN MED/VOL 167 (NO. 16), SEP 10, 2007

Risk factors for Vitamin D Deficiency

Age > 65

Dark skin

Insufficient sunlight exposure (house bound or northern latitude during winter)

Medication (Anticonvulsants, Steroids)

Obesity

Sedentary lifestyle

Malabsorption

Chronic kidney disease

Liver Failure Bordelon B et al. Am Acad Fam Phys 2009; 80:841-6; Holick M. NEJM

2007; 357:266-81.

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Vitamin D Dosage Test Vitamin D (VD) level

Prefer to use cholcalciferol VD3

Adequate Ca++ intake may positively affect VD level

Adult dose w/o other risk factors should be at least 1000 IU VD3 although 2000 IU is well tolerated.

Choose higher level of VD initially for at risk pts.

Follow serum levels every two months after dose adjustment

If treating mainly for osteoporosis prevention 32-40 ng/ml should be sufficient

For cancer reduction, 50 ng/ml is a appropriate minimum.

Contraindications to VD

Granulomatous disease TB: evidence exists for improvement of outcome

Sarcoidosis

Metastatic bone disease

Williams syndrome

Symptoms of toxicity

Nephro calcinosis

Vascular calcinosis

Pancreatitis

Hypercalcemia Bordelon B et al. Am Acad Fam Phys 2009; 80:841-6.

Safety Doses of up to 10,000IU/ day have not shown

significant toxicity

Levels >200 ng/ml (500 nmol/L) toxicity possible

Modest increase in kidney stones (17%) reported in WHI

One CR severe hypocalcemia w/ IV bisphosphonate and occult VD deficiency

One CR noted VD toxicity at extremely high doses (>2 million IU)

Inflammation In Many Chronic Diseases an inflammatory process is

at the center or significantly worsens the condition.

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FOOD AS MEDICINE

AN ANTI-INFLAMMATORY DIET

Rationale:

Inflammation is emerging as a core of many chronic disease states not limited to musculoskeletal dysfunction ◦ Alzheimer’s Disease ◦ Rheumatoid arthritis ◦ IBD ◦ CAD ◦ Colon cancer ◦ Autoimmune diseases

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Common inflammatory triggers: Age (related to wear & tear)

Physical injuries

Infections

Environmental stressors

Allergies & food sensitivities

Dietary imbalances, deficiencies

Adipose tissue in obesity

Hypertension

Diabetes (Hyperglycemia & Insulin resistance)

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Anti-inflammatory measures

Antioxidants (Multivitamin; mineral)

Foods:

most colorful fruits and vegetables, oily fish and certain nuts, seeds, herbs and spices such as ginger.

Steroids

NSAIDs

Essential Fatty Acids (EFA)

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Mediterranean Diet The Mediterranean diet isn't actually a single diet, it is

a 'style' of eating from Spain, Italy, and Greece.

It is full of healthy, low fat food choices,

rich in fruits, vegetables, whole grains, nuts, beans, and seeds

provides thousands of micronutrients, antioxidants, vitamins, and minerals that can help protect against cancer, heart disease, and Alzheimer’s disease, among other conditions

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Mediterranean Diet A higher degree of adherence to the Mediterranean

diet was associated with:

Reduction in total mortality (0.75 [95% CI, 0.64 to 0.87]).

An inverse association with

Death due to coronary heart disease (OR 0.67 [95% CI 0.47 to 0.94]) and

Death due to cancer (OR0.76 [95% CI 0.59 to 0.98].

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N Engl J Med. 2003 Jun 26;348(26):2595-6

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Adherence to Mediterranean diet and health status: meta-analysis. Eight cohorts 1996 -2008

514,816 subjects and 33,576 deaths

Greater adherence to a Mediterranean diet is associated with a significant improvement in health status, as seen by significant reduction in : ◦ Overall mortality (9%),

◦ Mortality from cardiovascular diseases (9%),

◦ Incidence of or mortality from cancer (6%),

◦ Incidence of Parkinson's disease & Alzheimer's disease (13%).

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BMJ. 2008 Sep 11;337:a1344

Essential Fatty Acids Omega 3 & 6

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Signs of EFA Deficiency Atopic dermatitis-

generalized & scaly

Brittle nails

Course & dry hair

Follicular keratosis

Slow wound healing

Cerumen impaction

Alopecia

Excessive Thirst & urination

Kidney damage

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Omega 6 Fatty Acid (Linoleic Acid)

Omega 3 Fatty Acids (alpha-linolenic acid)

Δ6-Desaturase

Gamma-linoleic acid (GLA)

Evening Primrose Oil

Borage Oil

Black Current Oil

Arachidonic Acid

Leukotrienes Prostaglandins (PGE2)

(Inflammatory)

Lipoxygenase

Cyclo-oxygenase

(COX)

Eicosapentaenoic Acid

(EPA)

Prostaglandins PGE1, PGE3

(Favorable)

Less Inflammatory

Leukotrienes

Lipoxygenase

Docosahexaenoic acid

(DHA)

COX Δ5-Desaturase

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Arachidonic Acid

(in cell membrane)

Free AA

Phospholipase A-2

Cyclo-oxygenase

Pathway

Lipoxygenase

Pathway

Prostaglandins

&

Thromboxanes Leukotrienes

Onions/Apples Quercetin

Turmeric Curcumin, Feverfew Perthenolides

Onions/ Apples Quercetin

Turmeric Curcumin

Rosemary Ursolic acid

Red Pepper Capsaicin

Ginger

Onions/Apples Quercitin

Boswellia Bosellic Acid

Rosemary Carnosol

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Fish Oil Major lipid effects are reduction of TG (25-40%)

and increase in HDL(1-3%). Reduces absorption and synthesis of cholesterol,

VLDL, Chylomicrones but may produce an increase in LDL due to down-regulation of LDL receptors (5-10%).

1 fatty fish meal = 900mg of EPA + DHA Dose: 1-4 gm of EPA + DHA daily Avoid high doses of Cod Liver oil due to risk of

high vitamin A. Caution due to increased risk of bleeding with high dose.

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TAKE HOME MESSAGE Eat more fish, fruits, vegetables, nuts, seeds and whole

grains

Increase omega-3 fatty acids and decrease omega-6 fatty acids

Eat less saturated & trans fats - processed foods, whole milk dairy products, and red meat

Consider a Mediterranean concept for your diet

It's Okay to eat most everything in Moderation.

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Communication

Hostility and Coronary Artery Calcification in Young Adults (The CARDIA Study)

Prospective cohort study followed over 10 years

374 adults aged 18 - 30 years at baseline

Presence of any detectable coronary artery calcification (coronary calcium score >0), and coronary artery calcium scores of 20 or higher.

OR of having any coronary calcification was 2.57 (95% CI, 1.31-5.22), and the OR of having a calcium score of 20 or higher was 9.56 (95% CI, 2.29-65.9) after adjusting for multiple variables.

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JAMA. 2000;283(19):2546-2551

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Depression and Heart Disease Metanalysis

Eleven studies met the inclusion criteria

Relative risk [RR] for the development of CHD in depressed subjects was 1.64 (95% confidence interval [CI]=1.29–2.08, p<0.001).

A sensitivity analysis showed that clinical depression (RR=2.69, 95% CI=1.63–4.43, p<0.001) was a stronger predictor than depressive mood (RR=1.49, 95% CI=1.16–1.92, p=0.02).

American Journal of Preventive Medicine, 2002,23 (1):51-61

SHEEP Study Self-selected use of low dose multivitamin supplements

and the risk of myocardial infarction. 1296 cases (910 men, 386 women) with a first nonfatal MI

and 1685 controls (1143 men, 542 women) frequency-matched

to the cases by sex, age and hospital catchment area. Subjects aged 45–70 y residing in Sweden, Among controls, 57% of the women and 35% of the men

used dietary supplements Of those taking supplements, 80% used multivitamin

preparations. OR of MI comparing regular users of supplements with

nonusers were 0.79 (95% CI 0.63–0.98) for men and 0.66 (95% CI 0.48–0.91) for women.

J. Nutr. 133: 2650–2654, 2003.

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Cardiac Risk Reduction Happiness: Depression in CAD pts.

better predictor of future cardiac events than severity of CAD, cholesterol & smoking

(Carney RM et al. Psychosom Med 1988)

Marital Satisfaction: Divorce equivalent to smoking 1 pack cig /day

(Morowitz Irish Med J. 1975)

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Cardiac Risk Reduction Education: Higher level of education is associated

with < 50% cardiac risk after controlling for smoking, HTN, obesity & Hypercholesterolemia. (Mulcahy Ir. Med J. 1984)

Humor: MI pts treated with 30 mins./day humor video had fewer irreg rhythms, lower BP, less medication, and 1/5 rate of recurrent MI. (Tan, Can

J Cardiol 1997).

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Cardiac Risk Reduction

PETS: After MI, pet owners had 1/5 rate of recurrence (Friedmann 1980)

Alcohol: 1-2 drinks /day associated with 1/3 reduction in risk of heart disease. (Doll BMJ, 1997)

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Cardiac Risk Reduction Vacations: The frequency of annual vacations by

middle-aged men at high risk for CHD is associated with a reduced risk of all-cause mortality and, more specifically, mortality attributed to CHD (30%). (Gump B, Psychosom Med 2000).

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Short Sleep Duration and Incident Coronary Artery Calcification

Observational cohort (CARDIA)

healthy middle-aged population of 495 participants

5 year follow-up

Coronary artery calcification was measured by computed tomography

Longer measured sleep duration was significantly associated with reduced calcification incidence (adjusted OR 0.67 per hour [95% CI 0.49-0.91 per hour]; P=.01).

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Cardiac Risk Reduction Siestas: Men taking a siesta were 30-

50% less likely to have a heart attack. (Trichopoulas 1987)

Siesta in apparently healthy individuals is inversely associated with coronary mortality, and the association was particularly evident among working men. (Naska 2007)

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Cardiac Risk Reduction

Sexual Activity: Men having 100 orgasms/year compared with < 1/month had 50% lower risk of death (Davey Smith G. BMJ, 1997)

A graded relation with fatal CHD events was observed in events recorded up to 10 years. The age adjusted relative risk of fatal coronary heart disease contrasting low frequency of sexual intercourse (<1 monthly) with the highest group (at least 2X/ week) was 2.80 (CI 1.13 to 6.96) which was not attenuated by adjustment for a wide range of potential confounders. (Ebrahim S, J

Epidemiol Community Health, 2002)

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Live Longer, Live Better!

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Use it or Lose it

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Get Enough Sleep

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Keep Your Teeth Healthy

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Color your food

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Wellness Requires Following An Anti-Inflammatory Diet For A Lifetime Basis

Eat small meals

Have some protein at every meal

Eat primarily fruits and vegetables

Take your fish oil

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Circle of Friends

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Relax

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SSCIM Clinic

20072 SW Birch Street

Suite 190

Newport Beach, CA 92660

(949) 757-0443 83