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8/23/2016
1
The Importance of Calcium and the Role of Dairy
Monica Aggarwal, MD
Disclosures
• I have nothing to disclose
Calcium
• Calcium is necessary for bone growth and teeth
• Heart, muscle and nerve need calcium to work effectively
• The current RDA is 1000 mg in men and women until age 50
• Increases in women after menopause to 1200mg/day and in men greater than 70
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Calcium
• Cannot be made by the body
• Must be brought in from the diet
• Limestone rocks
• Nowadays:
– Cow’s milk
– Dark green leafy vegetables
– Soft shelled fish with soft, edible bones
– Fortified juices, milk alternatives (soy, almond)
Milk Does A Body Good?
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What do we Mean when Talk About Milk?
• Classically, considered milk that comes from the mammary gland of a mammal
.
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Breakdown of Milk
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Pasteurization
What do we Know About The Components of Milk?
Lactose
• D-galactose is associated with aging
– In a study of mice, the addition of D-galactose has been shown to induce signs of aging such as reduced cognitive and immune functions. At the same time in those mice, oxidative stress and chronic inflammation climbed.
– The amount of D-galactose given to the mice is the equivalent of 1-2 glasses of milk per day in humans.
Cui X, Zuo P, Zhang Q, Li X, Hu Y, Long J, Cui X, Packer L, Liu J. Chronic systemic D-galactose exposure induces memory loss, neurodegeneration, and oxidative damage in mice: protective effects of R-alpha-lipoic acid. J Neurosci Res; 2006; 83: 1584-90
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Lipopolysacchride
• Milk fat and cream have been associated with increased lipopolysacchride
• High fat diet triggers LPS production which is a byproduct of endotoxemia/dysbiosis
• LPS is found to be elevated in many chronic illnesses such as Autism and Alzheimer’s disease
Deopurkar R, Ghanim H, Friedman J, Abuaysheh S, Sia CL, Mohanty P, Viswanathan P, Chaudhuri A, Dandona P. Differential effects of cream, glucose, and orange juice on inflammation, endotoxin, and the expression of Toll-like receptor-4 and suppressor of cytokine signaling-3. Diabetes Care, May 2010; 33(5): 991-7.
IGF-1• IGF-1 and insulin are responsible for
anabolic/growth processes of the body
• IGF-1 levels are dependent on age, sex, food intake, sex hormones, smoking, Etohconsumption
• Energy or diet restriction lower IGF-1 levels
• Energy increase and excess IGF-1 in diet increase levels. Diet is more impactful than energy
IGF-1
• Correlation between higher levels of IGF-1 and most types of malignancies
• Animal proteins are associated with higher circulating IGF-1 levels
• Vegetable proteins such as legumes were not associated with increased IGF-1 levels
• Elevated IGF-1 levels noted in dietary calcium and milk
• Isolate out milk protein and still IGF-1 levels remain elevated
European Journal of Clinical Nutrition (2007) 61, 91–98. doi:10.1038/sj.ejcn.1602494; published online 9 August 2006
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rBGH
• Recombinant bovine growth hormone is a synthetic hormone that dairy farmers use to increase milk production
• Bovine growth hormone, similar to somatostatin
• rBGH treated cows have higher IGF-1 levels
Cow’s Milk And Cancer
• Studies suggest a correlation between milk intake and bladder and prostate cancer, as well as a potential link with colon cancer.
• There are connections between galactose and ovarian cancer. This association was found in women who drank more than three glasses of milk per day.
Lampe JW. Dairy products and cancer. J Am Coll Nutr 2011; 30(5 Suppl 1): 464S-70S.Genkinger JM, Hunter DJ, Spiegelman D, Anderson KE, Arslan A, Beeson WL, Buring JE, Fraser GE, Freudenheim JL, Goldbohm RA, Hankinson SE, Jacobs DR Jr. Dairy products and ovarian cancer: a pooled analysis of 12 cohort studies. Cancer Epidemio Biomarkers PRev. 2006; 15: 364-72.Giovannuvvi E, Rimm EB. Calcium and fructose intake in relation to risk of prostate cancer. Cancer Res 1998; 58: 442-447.
Physicians Health Study
• In a Harvard study of male professionals, men who drank more than two glasses of milk per day were at an increased risk of prostate cancer compared to those who did not drink milk.
• In another study, men who consumed more than 2000 mg of calcium suffered almost double the rate of fatal prostate cancer than those who did not.
Chan JM, Stampfer MJ, Ma J, Gann PH, Gaziano JM, Giovannucci E. Dairy products, calcium, and prostate cancer risk in the Physicians’ Health Study.Am J Clin Nutr. 2001;74:549–554.
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Dairy and Prostate
• Population-based prospective study in 43,435 Japanese men ages 45 to 74 years.
• During 7.5 years of follow-up
• Dairy products were associated with a dose-dependent increase in the risk of prostate cancer.
Kurahashi N, Inoue M, Iwasaki M, Sasazuki S, Tsugane AS. Dairy product, saturated fatty acid, and calcium intake and prostate cancer in a prospective cohort of Japanese men. Cancer Epidemiol Biomarkers Prev. 2008;17:930–937
Dairy and Breast Cancer
• Increased IGF-1 levels appear to be associated with Breast cancer in premenopausal women
Hankinson SE, Schernhammer ES. Insulin-like growth factor and breast cancer risk: Evidence from observational studies. Breast Dis. 2003;17:27-40.
Does Dairy Decrease Fracture Risk?
• >70000 post menopausal women were watched prospectively for fracture risk and association with Calcium and Vitamin D
• Total calcium consumption; i.e. 1200mg/day versus <600mg/day was no different in terms of fracture risk
• Milk Consumption was not associated with fewer fractures
• Only vitamin D consumption was associated with fracture risk
Feskanich D, Willett WC, Colditz GA. Calcium, vitamin D, milk consumption, and hip fractures: a prospective study among postmenopausal women. Am J Clin Nutr. 2003;77:504–511.
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Swedish Cohort, Observational
• 61,433 women (39-74 years at baseline) and one with 45,339 men
• Registry data
• Compared men and women who drank 3 glasses per day versus fewer than one glass per day
Michaëlsson K, Wolk A, Langenskiöld S, Basu S, Lemming EW, Melhus H, Byberg L. Milk intake and risk of mortality and fractures in women and men: cohort studies. BMJ; 2014; 349: g6015
Michaëlsson K, Wolk A, Langenskiöld S, Basu S, Lemming EW, Melhus H, Byberg L. Milk intake and risk of mortality and fractures in women and men: cohort studies. BMJ; 2014; 349: g6015.
Michaëlsson K, Wolk A, Langenskiöld S, Basu S, Lemming EW, Melhus H, Byberg L. Milk intake and risk of mortality and fractures in women and men: cohort studies. BMJ; 2014; 349: g6015.
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Milk, dietary calcium, and bone fractures in women: a 12-year prospective study
• No evidence that higher intakes of milk or calcium from food sources reduce fracture incidence.
• Women who drank two or more glasses of milk per day had relative risks of 1.45 for hip fracture when compared with women consuming one glass or less per week.
Feskanich D, Willett WC, Stamper MJ, Colditz GA. Milk, dietary calcium, and bone fractures in women: a 12-year prospective study. Am J Pub Health; June 1997, 87 (6): 992-7
Other additives that Decrease Calcium Absorption
• High sodium and high-protein diets absorb less calcium and excrete more calcium in their urine.
Weaver, C, Plawecki, K. Dietary calcium adequacy of a vegetarian diet. AJCN; 1994; 1238S-41S.Feskanich D, Willett WC, Stamper MJ, Colditz GA. Protein consumption and bone fractures in women. Am J Epidemiol. 1996;
143: 472–79.
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Around the World• If we look at countries such as India, Japan
and Peru, calcium intake is less than 1/3 of our daily recommended allowance (300mg per day) and their risk of fractures is extremely low.
Conclusions
• Calcium is necessary for bone growth but not the whole picture.
• We need vitamin D and vitamin K• Likely the amount of calcium needed is around
600mg/day• Eating more protein/sodium is associated with more
calcium losses• Drinking extra cow’s milk is associated with increased
fracture risk• Drinking cow’s milk is associated with increased
cancers such as prostate
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How Do we Keep Our Bones Strong?
• Fortified juice, soy milk
• Fruits and vegetables that are calcium rich
• Exercise is effective at increasing bone density
• Need Vitamins D and K
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Cutting Through the Cholesterol Confusion
Neal D. Barnard, MDGeorge Washington University School of MedicinePhysicians Committee for Responsible Medicine
Dietary Guidelines Advisory CommitteeFebruary 19, 2015
“…available evidence shows no
appreciable relationship between
consumption of dietary cholesterol and
serum cholesterol…. Cholesterol is not a nutrient of concern for overconsumption.”
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The New American Idea: Who Cares?
Gallup Poll, July 8-12, 20151,009 adults
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The New American Idea: Who Cares?
Gallup Poll, July 8-12, 20151,009 adults
Understanding Cholesterol
Chole = bile
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Cholesterol is a key part of cell membranes.
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Cholesterol is a raw material for building hormones.
4 rings in 6,6,6,5 pattern
8-carbon side chain
Cholesterol
↘↙
Cholesterol
Testosterone Estradiol
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Cholesterol Makes Vitamin D
7-Dehydrocholesterol Vitamin D3
→
Cholesterol contributes to cardiovascular disease.
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Coronary Heart Disease MortalityMultiple Risk Factor Intervention Trial
160 180 200 220 240 260 2800
1
2
3
4
5
Stamler J, Wentworth D, Neaton JD, et al. Is relationship betweenserum cholesterol and risk of premature death from coronary heartdisease continuous and graded? JAMA. 1986;256:2823-8.
Relative Risk
Serum Cholesterol (mg/dL)
Where Does Cholesterol Come From?
Produced in all animal cells, especially liver cells.
About 1,000 mg per day.
For comparison, 2 eggs = ~400 mg
Saturated Fat Increases Cholesterol Concentrations
1% ↑ saturated fat
Third Report of the National Cholesterol Education Program (NCEP) Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III) Final Report. NIH Publication No. 02-5215. September 2002.
2% ↑ LDL→
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There is no requirement for dietary
cholesterol.
40-60% of ingested cholesterol is
absorbed (proximal jejunum).
Chylomicrons escort cholesterol into the circulatory system.
Cholesterol from Food Products
Food → Blood
What is the relationship between cholesterol in foods and blood cholesterol levels?
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Early Studies
Ancel Keys, University of Minnesota Mark Hegsted, Harvard University
Curvilinear effect: Greatest effect at lower intakes.
Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for
Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002/2005.
Early Studies
At common intake levels, the relationship is linear.
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Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes
for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002/2005.
X × 0.0974 = Y
Linear Effect at Lower Intakes
X = dietary cholesterol change per 1000 kcal
Y = change in serum cholesterol in mg/dL
Hegsted M. Serum-cholesterol response to dietary cholesterol: a re-evaluation. Am J ClinNutr. 1986;44:299-305.
X × 0.1 = Y
100 mg cholesterol × 0.1 = 10 mg/dL
Example: 1 egg (~200 mg of cholesterol)
Assume a 2,000-calorie diet
Hegsted M. Serum-cholesterol response to dietary cholesterol: a re-evaluation. Am J ClinNutr. 1986;44:299-305.
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Harvard Study: Eggs and
Cholesterol
17 ovo-lacto-vegetarian students, previously averaging 3 eggs per week.
Adding 1 extra-large egg per day for 3 weeks:
Total: +11.6 mg/dL
LDL: +6.8 mg/dL (no effect on particle size)
HDL: -2.5 mg/dL
TG: +2.9 mg/dLSacks FM, Miller L, Sutherland M, et al. Ingestion of egg raises plasma low density lipoprotein in free-living subjects. Lancet. 1984 Mar 24;1(8378):647-9.
Roberts SL, McMurry MP, Connor WE. Am J Clin Nutr. 1981;34:2092-9.
Eggs vs Egg Substitute: Crossover Trial
EggsEggs
Substitute
Substitute
Meta-Analyses
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Meta-analysis: 27 Studies using Prepared Diets (Hopkins 1992)
Hopkins PN. Effects of dietary cholesterol on serum cholesterol: a meta-analysis and review. Am J Clin Nutr. 1992;55:1060-1070.
100 mg/d ↓ in
dietary
cholesterol
Meta-Analysis: 224 studies
(Howell 1997)
↓ 2.2 mg/dL
(57 µmol/L) in total cholesterol
→
WH, McNamara DJ, Tosca MA, Smith BT, Gaines JA. Plasma lipid and lipoprotein responses to dietary fat and cholesterol: a meta-analysis. Am J Clin Nutr. 1997;65:1747-1764.
Clarke R, Frost C, Collins R, Appleby P, Peto R. Dietary lipids and blood cholesterol: quantitative metaanalysis of metabolic ward studies. BMJ. 1997;314:112-117.
Meta-analysis: 395 Diet Experiments(Clarke 1997)
↓ Dietary cholesterol by 200 mg
↗TC ↓5.0 mg/dL(0.13 mmol/l)
LDL ↓3.9 mg/dL(0.10 mmol/l )
↘
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Weggemans RM, Zock PL, Katan MB. Dietary cholesterol from eggs increases the ratio of total cholesterol to high-density lipoprotein cholesterol in humans: a meta-analysis. Am J Clin Nutr 2001;73:885–91.
Meta-analysis: Cholesterol from Eggs (Weggemans 2001)
17 studies
100 mg dietary cholesterol
TC ↑2.2 mg/dL(0.056 mmol/L)
↗
↘ TC:HDL ratio↑ 0.02 units
↑ Dietary cholesterol
100 mg/d
Institute of Medicine
↑ LDL ~ 2 mg/dL
(0.05 mmol/L)→
Food and Nutrition Board, Institute of Medicine. Dietary Reference Intakes for
Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: National Academies Press; 2002/2005.
Sources of Cholesterol in the U.S. Diet Sales Eggs
Chicken
Beef
Cheese
Processed meat
Fish
Desserts
Mixed dishes
Pizza
Cold cuts
Reduced-fat milk
Pork
Shrimp
From the National Health and Nutrition Education Survey, 2005-2006. Cited in: National Cancer Institute. Sources of cholesterol among the U.S. population, 2005-2006. Risk Factor Monitoring and Methods Branch Website. Applied Research Program. http://riskfactor.cancer.gov/diet/foodsources, updated November 9, 2009.
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Animal Products
Cholesterol Saturated Fat
2 Large eggs 362 mg 3.1 g (19%)
Chicken with skin (100 g) 88 mg 3.8 g (14%)
without skin (100 g) 89 mg 2.0 g (10%)
Roast beef, lean only (100 g) 83 mg 3.4 g (17%)
Chinook salmon (100 g) 85 mg 3.2 g (13%)
Cheddar cheese (2 oz) 58 mg 11.0 g (43%)
http://ndb.nal.usda.gov/ndb/foods, accessed July 19, 2015
Plant Products
Cholesterol Saturated Fat
Black beans (100 g) 0 0.1 g (1%)
Brown rice (100 g) 0 0.2 g (1%)
Broccoli (100 g) 0 0.1 g (3%)
Sweet potato (100 g) 0 0.04 g (0.5%)
http://ndb.nal.usda.gov/ndb/foods, accessed July 19, 2015
Conclusions • Dietary cholesterol is absorbed into the
bloodstream and adds to plasma cholesterol.
• The increase is greatest at lower levels of baseline cholesterol intake.
• The increase is significant from a public health standpoint.
• Compensatory mechanisms do not prevent cholesterol elevations.
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Most current research on dietary cholesterol is industry-driven.
Industry Funding
2001 (Weggemans, AJCN):
(7/17)
2013 (Griffin, Curr Nutr Rep):
(11/12)
41%
92%
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Griffin and Lichtenstein 2013
Review of clinical trials 2003-2013
12 studies
“the effect on plasma lipid concentrations… is modest and appears to be limited to population subgroups.”
Griffin JD, Lichtenstein AH. Dietary cholesterol and plasma lipoprotein profiles:randomized-controlled trials. Curr Nutr Rep. 2013; 2: 274–282.
Author, year
Ballesteros 2004
Chakrabarty 2002
Greene 2005
Harman, 2008
Herron 2006
Isherwood 2010
Katz 2005
Knopp 2003
Mutungi 2008
Njike 2010
Pearce 2010
Vislocky 2009
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Author, year Funding
Ballesteros 2004 American Egg Board
Chakrabarty 2002 Indian Council of Medical
Research
Greene 2005 American Egg Board
Harman, 2008 British Egg Industry
Council
Herron 2006 American Egg Board
Isherwood 2010 European Fisheries Fund,
Sea Fish Industry Auth.
Katz 2005 American Egg Board
Knopp 2003 American Egg Board
Mutungi 2008 American Egg Board
Njike 2010 American Egg Board
Pearce 2010 Australian Egg Corp, Ltd
Vislocky 2009 American Egg Board
Author, year Funding Participants
Ballesteros 2004 American Egg Board 54 children
Chakrabarty 2002 Indian Council of Medical
Research
18
Greene 2005 American Egg Board 41
Harman, 2008 British Egg Industry
Council
45
Herron 2006 American Egg Board 91
Isherwood 2010 European Fisheries Fund,
Sea Fish Industry Auth.
25
Katz 2005 American Egg Board 49
Knopp 2003 American Egg Board 197
Mutungi 2008 American Egg Board 28
Njike 2010 American Egg Board 40
Pearce 2010 Australian Egg Corp, Ltd 82, diabetes
Vislocky 2009 American Egg Board 12
Author, year Funding Participants Intervention
Ballesteros 2004 American Egg Board 54 children Egg
Chakrabarty 2002 Indian Council of Medical
Research
18 Egg
Greene 2005 American Egg Board 41 Egg
Harman, 2008 British Egg Industry
Council
45 Egg, plus ↓ sat fat
and calories
Herron 2006 American Egg Board 91 Egg
Isherwood 2010 European Fisheries Fund,
Sea Fish Industry Auth.
25 Prawns
Katz 2005 American Egg Board 49 Egg
Knopp 2003 American Egg Board 197 Egg
Mutungi 2008 American Egg Board 28 Egg, plus a low-
carbohydrate diet
Njike 2010 American Egg Board 40 Egg
Pearce 2010 Australian Egg Corp, Ltd 82, diabetes Egg
Vislocky 2009 American Egg Board 12 Egg plus exercise
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Author, year Funding Participants Intervention TC change LDL change
Ballesteros 2004 American Egg Board 54 children Egg Not reportedU P<0.05 for some
Chakrabarty 2002 Indian Council of Medical
Research
18 EggU n.s. U n.s.
Greene 2005 American Egg Board 41 EggUP<0.05 U P<0.05
Harman, 2008 British Egg Industry
Council
45 Egg, plus ↓ sat fat
and calories F n.s. F n.s.
Herron 2006 American Egg Board 91 EggU P<0.01 U P<0.01
Isherwood 2010 European Fisheries Fund,
Sea Fish Industry Auth.
25 PrawnsU n.s. U n.s.
Katz 2005 American Egg Board 49 EggU n.s. U n.s.
Knopp 2003 American Egg Board 197 EggU sign. for some
groups
U sign. for some
groups
Mutungi 2008 American Egg Board 28 Egg, plus a low-
carbohydrate diet U n.s. U n.s.
Njike 2010 American Egg Board 40 Egg
U P<0.01 U P<0.01
Pearce 2010 Australian Egg Corp, Ltd 82, diabetes EggU n.s. U n.s.
Vislocky 2009 American Egg Board 12 Egg plus exercise Not reported Not reported
New Meta-Analysis: 18 Intervention Trials (Berger 2015)
87% of studies on LDL cholesterol were industry funded.
Even so….
New Meta-Analysis: 18 Intervention Trials (Berger 2015)
Increasing dietary cholesterol (combined result):
Total Cholesterol ↑ 11.2 mg/dLBerger S, Raman G, Vishwanathan R, Jacques PF, Johnson EJ. Dietary cholesterol and cardiovascular disease: a systematic review and meta-analysis. Am J Clin Nutr doi: 10.3945/ajcn.114.100305.
Funded by USDA agreement 1950-51000-073 and the American Egg Board, Egg Nutrition Center.
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Cutting Through the Cholesterol Confusion
Neal D. Barnard, MDGeorge Washington University School of MedicinePhysicians Committee for Responsible Medicine
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Reversing Coronary Artery Disease
Caldwell B. Esselstyn Jr., M.D.August 29, 2016
Dr Esselstyn reports no known financial conflicts.
Absence of Coronary Artery Disease
• Rural China
• Papua Highlanders
• Central Africa
• Tarahumara Indians
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Participants 1985 - 1988
23 men, 1 woman with severe triple vessel coronary artery disease – age range 44 - 68
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AVOID
• Oil
• Fish
• Fowl
• Meat
• Dairy
• Coffee with caffeine
Lecithin and Carnitine
Eggs Poultry
Milk Pork
Cream Duck
Dairy Lamb
Liver Venison
Red Meat Shell Fish
Fish
Foods to be Included
• Whole Grains
• Legumes, lentils
• Vegetables
• Fruit
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18 Patients Followed 12 Years
• 49 coronary events during 8 years prior to study
• None in 17 compliant patients during 12 years
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Treating The Cause
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GOOD CARBS / BAD CARBS:
James H O’Keefe, MDDirector Preventive CardiologyUniversity of Missouri-Kansas CitySaint Luke’s Mid America Heart Institute
SUPERFOOD VS CARBAGE
Fundamental Unit of Nutrition
• Not the nutrient: calcium
• But the food: unsweetened yogurt
Macronutrients & health
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Carbs are good
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Added Sugar : Evil Food
The Prevailing Dogma: Calorie-Focused Thinking
Cause of Obesity: Gluttony and Sloth
Treatment of Obesity:
Eating too much AND
Exercising too littleObesity
Reduce calories AND
Exercise moreNormal Weight
An Alternative View on Obesity
Refined carbohydrates and added sugars
Altered physiology/hormones
Internal starvation
Decreased exercise and increased food intake
Obesity
Leptin Resistance
Insulin Resistance
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Obesity and Refined Carbs
.Am J Clin Nutrition. 2004 May;79(5):774-9.
Sugar Intake: USA 1815 to 2000
O’Keefe, Cordain, Mayo Clin Proc Jan 1, 2004
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16 oz 32 oz 44 oz 52 oz 64 oz
48 Teaspoons Sugar
Sugar Causes Disease
High intake of added sugars:
Dementia
Diabetes
Obesity
High triglycerides + Low HDL
Hypertension
CV Death + CHD
Post Challenge Glucose Excursion
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Added Sugars = Added Risk for CV Death
NHANES. JAMA Intern Med. 2014;174(4):516-524.
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Carbage
Superfoods
Carbage
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Superfoods
Carbage
Summary: Avoid Refined Carbohydrates
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Exercise and Cardiac Rehabilitation: What's the Latest
Pam R. Taub MD, FACC
Director of Step Family Cardiac Wellness and Rehabilitation Center
Associate Professor of Medicine
UC San Diego Health System
Overview of Talk The current state of cardiac rehabilitation
• Outcome data supporting the use of cardiac rehabilitation
• Cellular mechanisms associated with exercise
• Intensive versus traditional cardiac rehabilitation
• Barriers to utilization of cardiac rehabilitation
Future directions in cardiac rehabilitation
• Extending cardiac rehabilitation to the home through digital and wearable technologies to reduce readmission rates
• Expanding scope of cardiac rehabilitation to HFPEF, POTS, PVD, and microvascular disease
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Currently Covered Indications for Cardiac Rehabilitation(CR)
Recent myocardial infarction (within 1 year)
Post Percutaneous coronary intervention (PCI)
Coronary artery bypass grafting (CABG)
Chronic stable angina
Cardiac transplantation
Heart valve repair or replacement
Stable, chronic heart failure (EF<35%)
Outcomes Associated with Cardiac Rehabilitation
Meta-analysis of 34 randomized controlled trials
showed that exercise-based CR programs are
associated with:• A lower risk of reinfarction (OR 0.53; 95% CI: 0.38 to 0.76)
• Decreased cardiac mortality (OR 0.64; 95% CI: 0.46 to 0.88)
• Decreased all-cause mortality (OR 0.74; 95% CI: 0.58 to 0.95)
• CR reduces 90 day hospital readmission rate after
acute MI or PCI
Class IA recommendation by AHA/ACC Guidelines
Am J Med 2004;116:682–92.
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Pleiotropic Effects of Cardiac Rehabilitation
(J Am Coll Cardiol 2015;65:389–95)
Cellular Mechanisms Associated with Exercise
Improved mitochondrial function
Increased nitric oxide production
Drexler Circulation 1992
Current Reimbursement for Cardiac Rehabilitation
With the affordable care act there is a focus on preventive services
There has been a gradual increase in reimbursement for cardiac rehabilitation
Currently in California
Medicare: $107 per session
Commercial Payers (e.g Anthem Blue Cross): $132 per session
For intensive cardiac rehab (ICR), 72 covered sessions
revenue is $7700 to $9500 per patient
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Ornish Versus PritikinOrnish Pritikin
Total Number of Sessions covered 72 (max per day is 6 sessions) over 18 weeks
72 sessions (divided into 18 sessions that are 4 hours each)
72 sessions(can customize how many sessions per day)
Diet 100% plant based Allows for lean meat and fish
Format All with live instructors:1 hour of exercise1 hour of nutrition counseling1 hour of yoga and1 hour of group therapy
Patients are in groups of 10-12 and stay with the same cohort throughout the program
Some parts are Video Instruction. Sessions duration can be customized over 18 weeks
Outcome Data The Lifestyle Heart Trial showed significant regression of coronaryatherosclerosis measured by angiography in the experimental group randomly assigned to intensive lifestyle changes.(5 year results reported by Ornish JAMA 1998)
Data from Pritikin residential treatment centers showed improvement in lipids, A1c, blood pressure and weight. (Barnard Am J Cardiol 1992)
New Paradigm For Cardiac Rehabilitation
“Living Lab” for research and secondary prevention
Ideal population to deploy new technologies to prevent readmission
Good outcome trials needed
Using devices/wearables to expand the length and scope of cardiac rehabilitation
Mayo Clinic Study (Apps + Cardiac Rehab )
• 44 patients
– 25 in the app +cardiac rehab arm
– 19 in cardiac rehabilitation without the app arm
• The app tracked and monitored patient weight, BP, blood sugar and physical activity and provided educational content
• The app group had 40% less readmissions and lower blood pressure and weight
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Date of download: 4/28/2016 Copyright © The American College of Cardiology. All rights reserved.
From: THE AUGMENTATION OF USUAL CARDIAC REHABILITATION WITH AN ONLINE AND SMARTPHONE-
BASED PROGRAM IMPROVES CARDIOVASCULAR RISK FACTORS AND REDUCES
REHOSPITALIZATIONS
J Am Coll Cardiol. 2014;63(12_S). doi:10.1016/S0735-1097(14)61296-1
Exercise Training for POTS Physical deconditioning (i.e., low stroke volume and
reduced LV mass ) and reduced standing stroke volume may be important to the pathophysiology of POTS
Physical reconditioning with short-term exercise training significantly increased :
peak oxygen uptake,
expanded blood and plasma volume,
improved POTS orthostatic intolerance symptoms,
and in most cases allowed these patients to be symptom free
Study of Exercise in POTS
103 patients completed the exercise program
Heart Rhythm 2016;13:943–950
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Exercise Training in PAD
The magnitude of functional benefit derived from exercise training exceeds that observed in drug therapy trials with both pentoxifylline and cilostazol (Circulation. 2011;123:87-97)
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Heart Failure with Preserved Ejection Fraction
No proven therapies
More common in women
Heterogeneous disease
Diastolic function is an energy-dependent process requiring ATP
It is estimated that relaxation of the myocardium requires up to 15% of the total energy cost of the cardiac cycle
In patients with HPEF, there is a decrease in the ratio of mitochondria to myofibrils and the function of the mitochondria is impaired
Microvascular Disease Mainly a disease of women
Data from WISE study shows it is also associated with poor outcomes
Associated with perfusion defect on SPECT/MRI
Underlying mechanisms include endothelial dysfunction
Studies underway to evaluate impact of exercise training
Conclusions New era in cardiac rehabilitation ushered in by
change in focus and reimbursement of our health care system
Appropriate use of cardiac rehabilitation can lead to improved outcomes
Expansion of cardiac rehabilitation to diseases such as HFPEF and POTS in the future
Many digital health devices/apps but need good outcome data