Michigan Occupational Health Conference
2012
Preventive Nutrition in the Insulin Resistance Era:
Lifestyle Medicine: The Most Powerful “Drug”!
Sept 29, 2012
Presenter: Tom Rifai MD (DrTomRifai.com)
Medical Director - Metabolic Nutrition & Weight Management
St Joseph Mercy Oakland, Pontiac MI
Course Director, Harvard Medical School Online Lifestyle Medicine CME:
“Nutrition and the Metabolic Syndrome” (cmeonline.med.harvard.edu)
A Metabolic Doc Can’t Do It
Without a Great Team!
Tom Rifai, MD
Medical Director and Lifestyle Coach
Certified Physician Nutrition Specialist & Internist, Group and Nutrition Class Leader
Larissa Shain, RD
Chief Dietitian, Group and Nutrition Class Leader
Denise Simpson, MA
Educator, Clinical and Front Desk Coordinator
Tova Spring, RN
Patient Assessment, Triage, Counseling and Educator
Don Deering, PhD
Behavior Modification Coach and CBT specialist
SJMO Physical Therapy
As well as Certified Exercise Trainers
Objectives we will try our best to meet
• Understand insulin resistance, how to detect it early and
what lifestyle factors contribute
• Better understanding your patient’s lifestyle contributors and
the need for realistic expectations in terms of your
capabilities and desires versus theirs
• Add goals & insight to the challenges and risks of excess
salt
• Add insight into biological issues re: protein, carbohydrate
fats
• Understand appropriate role of medical foods and when to
refer to comprehensive medical metabolic/behavior mod
programs
• Understand the use of metformin in pre-diabetes
Why a try for a lifestyle with a 20-30%
calorie reduction?
Calorie Reduction is THE most
powerful evidence based tool to
prolong life & avoid type 2 diabetes!
(Journal: Science vol 325: 201,2009)
After 20 years….
- 80% of lower cal animals alive
- 50% of high cal were alive/dead!
Vast majority of the higher cal group
died of heart attack, stroke, diabetes
or cancer….
Less than 15% of the low cal group
died of a “modern chronic disease”
and not one developed diabetes!
“But Doc - What Precisely is Obesity ?”
• Most commonly used definition is “BMI ”
Body Mass Index > 30 (wt/in2 x 703)
• However, assesses only height & weight, so not optimal
• BMI’s ease for large studies, not accuracy in detecting
metabolic risks, made it popular
• Abdominal Circumference is the most clinically useful,
practical, simple & reproducible technique in a busy practice
• DEXA Scan is considered the Medical Gold Standard by many
for assessing how body composition affects health and to best
estimate ideal weight based on body fat %, body fat
distribution and lean/muscle composition
(Journal of Preventive Cardiology, Summer 2004)
Total Body:
% Fat
percent
ACTUAL DXA RESULTS =
Projected Weight* Age Matched
Low % Fat
Projected Weight* Age Matched
Hi % Fat
Projected Weight* Young Normal
Low % Fat
Projected Weight* Young Normal
Hi % Fat
Fat
Lbs.
Lean
Lbs.
47.
73.8
78.74
4.59
157.14
31.4
38.14
78.74
4.59
121.48
44.2
66.01
78.74
4.59
149.34
24.4
26.9
78.74
4.59
110.23
34.8
Projected Weight* for X% Fat
2
Current BMI (kg/m ) is 26.2
X
Bone
Lbs.
78.74
4.59
44.48
X* Total Body
78.74
4.59
100
Weight at BMI = 18 would be =
Weight at BMI = 24.9 would be =
Total Body
Lbs.
127.81
8333
(100-X)
107.94
149.92
* Projected weights are based on assuming that lean and bone tissue are constant over time although lean tissue can indeed
change with training.
Scan measurements by Limbs:
Fat (lb) Lean (lb) Bone (lb)
Right
Arm
Left
Arm
Total (lb)
2.19
3.64
0.22
6.05
2.73
4.53
0.283
7.55
Fat (lb) Lean (lb) Bone (lb) Total (lb)
Right
Leg
Left
Leg
11.49
11.94
0.56
23.99
12.31
12.8
0.804
25.91
Scan measurements by Body Region:
Arms
Legs
Trunk
% Fat
36.2
47.7
51.4
Fat (lb) Lean (lb)
4.92
8.18
23.79
24.74
42.4
38.47
Bone (lb)
0.503
1.364
1.577
Total (lb)
13.6
49.9
82.44
Central fat measure (trunk fat/total fat) = % truncal fat = 57.4
Age matched normal range for % truncal fat (42.8 - 51.2 )
Young Adult (20-29 years) normal range for % truncal fat (36.8 - 45.2 )
What is “Insulin Resistance”
PRACTICALLY speaking?
• A physiological state, inducible to some degree or another in
most humans, resulting in higher insulin requirements to
maintain glucose levels and resulting largely from extensive
time periods of an imbalance between movement (low) &
calorie intake (high)….. DM2 reflects insulin resistance PLUS
beta-cell burnout…
• May begin with epigenetic contributions during pregnancy
(smoking, GDM, macrosomia or low birth weight)
• Next you’ll see kids who eat minimal fruit & veggies and lots
of: high calorie/high salt added grains (breads, cereals,
desserts, baked goods/bake sales) instead for “carbs”, with
lots of cured meats, fast food pizza, burgers, fries, pop and
sitting, playing video games in summer (kids gain more weight
in summer) & sitting most of day in school, etc etc
What is “Insulin Resistance”
PRACTICALLY speaking?
• Prior to Metabolic Syndrome you may see < 2 of
5 plus other related metabolic findings
(hyperferritinemia – Diabetes Care Vol 28; #8
2005; hyperuricemia, elevated ALT/fatty liver,
higher than optimal fasting insulin – e.g., >7)
• Prior to “pre-diabetes” most have “Metabolic
Syndrome” (3 of 5 IDF criteria - see next slide)
• Prior to DM2 we have “pre-diabetes” – now most
practically detected with A1c & FBG. (Gold Std,
2hr OGTT, is impractical on large scale)
Metabolic Syndrome as defined by
International Diabetes Federation
Metabolic Syndrome by IDF standards REQUIRES:
Meeting Abdominal Circumference Criteria
>37 inches in Caucasians, Arab and African American men
For Asian (also consider Latinos, American Indians & other
high risk groups, including +FH) male threshold drops to
>35”
and
>31.5 in ALL women
AND at least 2 of the following 4
• Fasting TG level: > 150 mg/dL or on specific treatment for
this
• HDL cholesterol: < 40 mg/dL in men, < 50 mg/dL in women
or on specific treatment for this
• BP >130/85 mm Hg, or on treatment for BP or with BP drug
• Fasting plasma glucose > 100 mg/dL on more than one
occasion or treatment for this (OGTT is strongly recommended but
is not needed to define presence of the syndrome)
…consider A1c?)
*Risks of poor body composition induced insulin resistance*
Excess visceral/liver/muscle fat plus below average amount/use of
muscle mass or a combination of BOTH (most common)
Dementia
• Stroke & Depression
Pulmonary Disorders
• Obstructive sleep apnea
• Asthma
More CVD
• Heart Attack
• Heart Failure
• Metabolic Syndrome
• Type 2 Diabetes
Liver Disorders
• NAFLD*>NASH**>Cirrhosis>Cancer
• High Blood Pressure
• Kidney Failure
Reproductive/Sexual Abnormalities
Cancers
• Abnormal periods
• Infertility / PCOS***
• Erectile Dysfunction (CVD)
DVT
Osteoarthritis
• Breast, ovarian, uterus
• Colon**
• Prostate
Gout
* NAFLD=Non-Alcohol Fatty Liver Disease **NASH = nonalcoholic steatohepatitis
4083.NIH/NHLBI. September 1998; NIH publication no. 98
*** PCOS = polycystic ovarian syndrome
“So you “see” insulin
<-- resistance….now what?
Lifestyle change/Behavior modification
is THE gold standard….BUT HARD!
And you know that genetics are certainly a contributor…
…but you KNOW human genes are the virtually the same
now as 10,000 years ago!…
So genetics are a minor issue (especially for diseases
encountered after age of 50) on a population scale,
though EPIGENETIC modifications (e.g., smoking during
pregnancy and macrosomic babies) are SCARY…yet still
it’s really more about…..
The Perfect Storm for Calorie Excess
Based Diseases
•
The most sedentary society in history!
– 80-90% of average Americans’ daytime is spent sitting!
– Why? Because we can! Couldn’t sit too long 10,000 years
ago!
•
The most “food toxic” environment in history!
– Hyper-palatable foods with ADDICTIVE PROPERTIES
(high sugar/starch plus salt plus saturated fat = HEROIN
EQUIVALENT) are WAY too convenient
– Irrational “finish your plate” attitude has led to huge portion
expectations along with OVER-using food as cultural focus
– Using food too often for stress & mood management
Where are the excess, age inducing/free radical
promoting, excess calories mostly coming from?
• Excessive Thin, sugar/fat/alcohol based liquid
calories: non-satiating (not “sensed” by brain/body)
• Excessive Calorie Dense/Refined Carbs: Grains,
most refined & baked/dry grain (flour, rice, corn, oats
like: breads/bagels, pies, donuts, cookies, pastries,
dry cereals, chips, popcorn, pizza dough, tortillas,
wraps, granola bars, muffins), are biggest source
of increase in solid food calorie intake since
1980 AND many are mixed with:
• Excessive non-essential fats: Oils, non-skim dairy,
cheeses/butter, margarines, feed-lot fed animals
Complementing the “excesses” from
previous slide are:
SITTING/SEDENTARY TIME INCREASING
MEAL SKIPPING AND ERRATIC EATING PATTERNS
POOR INTAKE OF WHOLE FRUIT n VEGETABLES
POOR DISTRIBUTION THROUGHOUT THE DAY OF
QUALITY PROTEIN SOURCES
All together leading to: Increase in not only food volume,
but increased calories PER BITE (calorie density),
overcompensation of calorie intake at night,
muscle/bone loss with fat gain in liver/viscera and
marbled/weaker muscle 
PHENOTYPIC INSULIN RESISTANCE
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI
No Data
<10%
10%–14%
30, or ~ 30 lbs. overweight for 5’ 4” person)
15%–19%
20%–24%
Source: CDC Behavioral Risk Factor Su rveillance System.
25%
Obesity Trends* Among U.S. Adults
BRFSS, 2006
(*BMI
No Data
<10%
30, or ~ 30 lbs. overweight for 5’ 4” person)
10%–14%
15%–19%
20%–24%
Source: CDC Behavioral Risk Factor Su rveillance System.
25%–29%
30%
Obesity Trends* Among U.S. Adults
BRFSS, 2008
(*BMI
No Data
<10%
30, or ~ 30 lbs. overweight for 5’ 4” person)
10%–14%
15%–19%
20%–24%
Source: CDC Behavioral Risk Factor Su rveillance System.
25%–29%
30%
Obesity Trends* Among U.S. Adults
BRFSS, 2010
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
URGENT: “Adult” Diseases in Kids – “In U.S….type 2 diabetes accounts for up
to 46% of all new cases of diabetes referred to pediatric centers. The
magnitude of type 2 diabetes is probably underestimated” CDC
As of 2010, about 20% of preadolescents in US are now
obese or overweight.. likely
many of the “normals” suffering
poor (i.e., Insulin Resistance
prone) body composition
The Impotence of “Willpower”
HELP PATIENTS RETIRE SOME GUILT:
“WILLPOWER SUCKS” FOR GOOD REASONS!
• Human tendency to gain fat is protective against the frequent
lack of calories of most of human history (“Obesity Paradox”)
• Tendency towards obesity is a “good thing gone awry” due to
our mismatch of genes to modern environment
• Leningrad World War 2 observation – The food deprivation of
the Nazi onslaught actually caused more deaths than
bombing…and more body fat at the beginning of siege was
observed to be associated with lower risk of death.
• The point is: Wisdom and environmental management beats
“willpower” and guilt-based “dieting” as a tool for real lifestyle
change! But MUST try to make it MINDLESS to eat
healthier to win the battle against our internal tendencies!
The Basics in achieving “Optimal” Nutrition:
Be a Motivational Interviewer
• Accept that even basics can be difficult to achieve
since the US food environment is currently, overall,
VERY poor at supporting healthy choices!
• Therefore: BE PERSISTENT but PATIENT and
MOTIVATIONAL PARTNER/COACH. Inform patient
risks of poor lifestyle choices & help reconcile their
understanding with facts…. but also ENGAGE them in
respectful conversation of what makes it difficult for
them? What motivates them to be healthier? What
sabotages their efforts? Go with THEIR flow,
“contract” with them, follow up frequently if needed
(note USPSTF rec. on visit frequency for obesity mgt)!
The Basics in achieving “Optimal” Nutrition:
Be a Motivational Interviewer
• STEP 1 – TEMPTATION CONTROL: MUST
emphasize home environment be a
“HEALTHY FOOD ONLY ZONE” as much
as reasonably possible
• While indulgences are OK on occasion
(and a fact of life), they should generally
be left OUTSIDE THE HOME!
• Need proof? Read: Mindless Eating
(Professor Brian Wansink PhD)
Stimulus Control for Long Term
Calorie Control
FIRST - REMOVE TEMPTATIONS FROM AS MANY
ENVIRONMENTS AS POSSIBLE !
Emphasize that “don’t worry, there will be more than enough
opportunities for indulgences in a lifetime without having them in
our faces (i.e., homes/work) tempting us constantly day in & day out!”
• Removing calorie dense/hi-salt “comfort foods” from home/work does
NOT at all mean “removing them from your life”
• HABIT ALERT: Success comes with accepting frequently bringing
healthy food with you far more often than before (e.g., work/vacations)
• Will still have to contend with restaurants and outside sources of
“food”, of course – Using a menu as an “ingredients list”
• CSPINET.org (order “Nutrition Action” Healthletter); LoseIt.com & app
• Tips for mind re-training for comfort food overeaters:
 Book: “Eating the Moment” - Pavel Somov PhD
 Website: “www.ShrinkYourself.com” - Roger Gould MD
The “Anti-Salt Vault ”
•
AHA, IOM, NIH, CDC all generally agree on reduction (e.g., low
sodium “DASH”) - Excellent review: American Journal of
Medicine, May 2012 (In kids it can have long lasting benefit!)
•
Ancient human intake likely less 500mg/day and natural
sodium content of modern intake around 400mg/day (Evolution
of the Human Diet, Peter Ungar PhD – Univ of Arkansas)
•
Truth is that it’s dietary potassium to sodium ratio (and more
likely the dietary potassium+mag+calcium to sodium ratio) that
really matters in terms of mortality/morbidity risks
•
Such risks include all those associated with HTN (stroke, CHF,
MI) but also osteoporosis, kidney stones & gastric C/A, asthma
and the fact that CVD RISK IS RELATED TO SALT INTAKE
INDEPENDENT OF ITS EFFECT ON BLOOD PRESSURE!
•
Exceptions: when on salt depleting diuretics, heavy sweating
The “Anti-Salt Vault”
Upshot: Educate on 2 major points
1. Ideally, DECREASE sodium to < 1500 mg/day - MUST look @
labels & restaurant info! “Lose It!” smart phone app
www.LoseIt.com can track sodium too; www.NutritionData.com;
www.HealthyDiningFinder.com site has a “sodium savvy” option
2. INCREASE fresh vegetables, whole fruits and (low sodium)
legumes in trade for grains (esp refined/sodium added ones –
e.g., breads/cereals – unfortunately even many “whole grain”
products have substantial salt added) to enhance dietary
potassium intake for less overall calories than grains. Keep grain
intake to true whole grain and in range of 2-4 (not 6-11) svgs/day
Saturated Fat vs Cholesterol
•
Overall saturated fat is more important driver of atherogenic
particles (LDL, IDL, VLDL) than dietary cholesterol since
most of us down regulate hepatic LDL receptor under
influence of saturated fat leading to decreased clearance of
serum LDL/non-HDL
•
About 1/4 of us DO respond to dietary cholesterol which can
be detected by seeing a significant difference between
fasting and non-fasting cholesterol
•
Non-fasting cholesterol more useful if using standard lipid
panel since “non-HDL” more predictive than LDL for CVD
events…you can also see non-fasting triglycerides which
are may add insight when fasting are “OK”
Saturated Fat vs Cholesterol
Biggest saturated fat sources:
1.
Fat containing dairy (2% milk “ain’t so great”, fat-free Greek
yogurt IS great !) …. hard cheese (aka “dairy meat”) being a
HUGE US issue and WAY over-rated as a “healthy food”
2.
Fatty animal “flesh and skin” components (most, including
“90% lean” beef; skin of poultry; most pork cuts thanks to grainbased CFOs See Movie: “FOOD INC.”)
3.
Biggest non-animal sources: Palm Oil, Palm Kernel Oil (what
makes the chocolate mint chips so hard, solid and “crunchy” –
like your arteries will be if you eat too much chocolate mint ice
cream), Coconut Oil, Cocoa butter (full disclosure: the stearic
acid of cocoa butter is “less bad” saturated fat since liver can
convert to oleic acid/monounsaturated fat)
Saturated Fat Education: Theory vs
Reality (Reality Meets Science!)
• AHA: For secondary prevention and
“Mediterranean Diet” concept: <7% of
calories
• Reality: NO ONE IS REALLY GOING TO
CALCULATE “7%” of their calories so, IMO,
a more practical goal for saturated fat is
“shooting for < 10g/day”
A moment on “healthy” fats
•
•
•
Small amounts, ½ to 1 ½ oz/day, of un-salted nuts
(caveat: high, CD). Probably the “best high fat food” choice
Monounsaturated “less bad” Olive, Safflower, Canola oils
Polyunsaturated – 4 types: long vs short and Omega 3 vs 6
1. Long w3 (EPA) – fish and supplements good!
2. Short w3 (LNA) – good if replacing saturated but not a
replacement for long (walnuts, flaxseed)
3. Short w6 (LA) – looks good if replacing saturated and may act
on small bowel to decrease cholesterol absorp (Sunflower,
Soybean, Corn, Cottonseed, Peanut oils)
4. Long w6 (AA) – may be pro-inflammatory (major source is
CFO grain fed land animal fat, including fatty dairy)
FIBER FACTS and an “Inconvenient
Truth” on “whole” grains
• Intact Fiber intake of >30g/day - Recent NIH-AARP data
says intake seems related to reduced CVD, cancers and
infections and total mortality. BUT CAREFUL WHEN
FIBER COMING FROM WHOLE GRAINS due to added
salt and high calorie density which may overwhelm the
fiber benefit (note: BREADS/GRAINS are the biggest
contributor to US sodium intake).
• New processed (NON-intace) fibers: inulin (Fiber One
bars), aka “chicory root fiber”, maltodextrin, polydextrose,
oat fiber, wheat fiber (these are FDA approved to be listed
as fiber but not approved in Europe or Canada as such.
• Excess grains contribute to Renal Acid Load and bone loss
“Optimal” Nutrition:
PROTEIN - a Controversial Area!
• …Recent data, including NIH Omni-Heart Trial comparing
standard DASH (15% protein, 60% carb, 25% fat) to “High
Protein DASH” (shifting protein up to 25% and carbs down
to 50%) found FAR better results in Metabolic Syndrome
(aka AMERICAN) subjects for lipid control and overall CVD
risk factors (especially triglycerides)
• IOM describes a “healthy range” from 15-35% of total daily
calories (30% of 1800 cal is 540 = 135 grams)
• Overall, protein suppresses appetite hormone ghrelin and
better than Carbs/Fat so let’s not demonize protein in and
of itself!
“Optimal” Nutrition:
PROTEIN - a Controversial Area!
• “Low Protein Diets”, despite common misconception, have
NEVER been shown to reduce progression to dialysis, does
not mitigate diabetic nephropathy (AJCN, 2008)
• RDA for protein (0.8g per kg, whatever THAT means in
the REAL world!) is defined as a MINIMUM intake to meet
the requirement of “most” “healthy” adults! But THAT may
describe less than 10% of Americans!…Yet protein RDA is
commonly promoted as an “optimum” intake. But it is
frequently recognized as inadequate for many and certainly
not optimal for most as low protein can = muscle loss and
muscle loss can = increased risk for insulin resistance &
total mortality risk!
• Good review on misconceptions re: Protein and the RDA JAMA June 25, 2008 pgs 2891-2893
“Optimal” Nutrition:
PROTEIN - a Controversial Area!
• Protein has caveats, such as it’s Renal Acid Load and that
many sources come with “unwanted passengers” (saturated
and excess total fat…as in feed-lot fed animal cuts;
sodium…like cured meats, iron…as in red meat) BUT!……
• Adequate protein at most meals, especially breakfast (and NO,
Cheerios and most dry cereals are NOT a significant source of protein,
nor a very overall good food source! Some exceptions of course) and
many snacks
• Combine “clean, high-protein” sources with low calorie density (or at
least unrefined) higher fiber quality sources of lower protein
ALKALINE foods (vegetables & fruit). Legumes are great and
basically neutral on RAL….whole grains caveats aforementioned
“Optimal” Nutrition:
PROTEIN - a Controversial Area!
• Protein is critical for maintaining lean tissue mass as we
age and is NOT harmful to bone AS LONG AS
VEGETABLE AND FRUIT INTAKE is high enough, and
grain intake low enough, to address protein’s (and grains’)
acidity (hence, advantage of “Paleo Diet” vs other “low carb”
diets is that it is low in salt/high in fruits & vegetables)
• Protein Intake ideally should be SPREAD throughout the
day (e.g., total daily intake for women ~80-100g/day and men
~100-150g) with several 20-35 gram meals/snacks…using
medical protein supplements if necessary. Older people need
at least 25-30 grams in a “meal” to substantially effect protein
synthesis! Not likely going much higher will help though…
BASIC EXAMPLES OF HEALTHY PROTEIN
SOURCES
• Lean, low sodium fish, fowl, egg whites, “Greek” yogurts,
pork tenderloin, certain higher protein legumes (e.g.,
soybeans/edamame/tofu & lentils)
• Must consider high quality, high protein
“Medical Meal Replacements” for appetite control and
muscle loss prevention as evidenced by the NIH
LookAHEAD ongoing trial of Type 2 Diabetes showing
remarkable results considering the subjects’ PCP’s are
generally still loading up their patients on weight gain
promoting diabetic medications instead of shifting towards
more weight loss friendly/neutral options.
Countering the acidity concern of protein: important
basics on dietary acid-base balance
• WHOLE FRUITS and VEGETABLES MUST LEAD THE WAY!
(More than just low cal/high potassium! Alkaline too!)
• Legumes - The Unsung Heroes - great “grain alternative”!
(lentils! beans and peas…generally Acid-Base neutral)
• BE MODERATE on grains (e.g., wheat, rice, corn, oats, etc),
including “whole grains” as they are still acidic like refined grains
so should NOT displace vegetables/fruits/legumes. Also, the MASS
majority of dry whole grains (e.g., breads, cereals) in this country
are HIGH SODIUM ADDING more bone risk over and above
acidity issue & CD!
• Nuts (except almonds) mildly acidic too, but the amount eaten
is small so mitigates risk of their acidity
Metabolic Medicine with Multidisciplinary
Weight and Lifestyle Management
• State-of-the-art metabolic medical program and its power in
treatment/prevention of diabetes, high blood pressure,
cholesterol problems, fatty liver, obstructive sleep apnea and
other insulin resistance related issues.
• Combining the following 3 proven tools for the first 12-16
weeks (aka – “intensive behavior modification phase”)
• Temporary use of medical formula foods as PART of food
• 12 weekly, intensive group education course (“Lifestyle U”)
• Frequent clinical follow up in the first 3-4 months then
progressively less to complete at least one year
For the patient needing to get lean, weight loss is only
part of achieving total wellness and health
• In addition to medical weight management:
– Management of INSULIN RESISTANCE (the root of
diabetes…it’s NOT necessarily “gone” when sugar is “normal”)
– Screen meds for weight gain risk
– Expert supplement advice (avoid those that have no benefit
and those that may do harm)
– State-of-the-art cholesterol management (“Normal” cholesterol
by standard testing is NOT enough!)
– Evaluation of important nutrient levels
including : Vitamin D deficiency, B12 & Iron excess
– Screening for obstructive sleep apnea
– Optimal preparation for bariatric surgery, if needed
“Optimal” Nutrition:
Basic Eating Questions
•
•
•
•
•
•
•
•
•
•
Since relatively non-controversial eating will include calorie, sodium
and saturated fat control, ask if these risky eating patterns occur:
“Never”(<1x/mo), “Sometimes”(1x/mo-1x/wk) or “Often” (>2x/wk):
Do you skip breakfast go longer than one hour of awakening?
Do you ever go more than 3-4 hrs w/o eating?
Do you drink any of your calories? Do you eat out (sit down or fast food)?
Do you eat calorie dense sweets (grain based, hard chocolates, ice cream)?
Do you eat calorie dense starches (breads, cereals, chips, wraps, etc)?
Do you purposefully add non-essential fats (butter, mayo, dressings, oil)?
Do you eat cheese (alone, on salad/pizza, in sandwiches)? nuts?
ADDITIONALLY, FOR HEALTHY EATING PATTERN CHOICES ASK:
Do you eat unfried fish at least twice weekly?
Do you eat at least 2-3 pieces of whole fruit?
Do you eat some fresh vegetables daily?
SJMO Metabolic Nutrition
Weight Management Program
• Our program model is based on the most proven medical evidence:
–
–
National Institutes of Health Landmark “Look Ahead” Study
The Harvard/Joslin Diabetes center “Why WAIT” program
• Initial part of program includes 3 major components:
1. “Lifestyle University” - a 3 month intensive education package to
prepare for seamless transition to longevity lifestyle:
12 lifestyle change support groups and 6 nutrition classes,
2 RD visits, an MD or RD led grocery shopping tour:
2.
3.
Frequent metabolic physician monitoring for safety
• Approximately two times per month for the first three months, then
progressively less thereafter ….your primary care doc gets updates!
DATA PROVEN Medical Grade Meal Replacements mixed with foods
known to help treat disease, promote body fat loss & improve health
**Medical foods prescribed MUST be purchased from clinic
during first 3 months**
Initial Evaluation: Attention to building safe,
enjoyable, physical activity
Regular Physical Activity starts with NOT SITTING so much!
Even STANDING more and sitting less gives measurable
benefits! (Diabetes Care, 2012)
Critical to weight maintenance, better weight loss maintenance potential,
muscle retention and quality of life.
Multiple options
*Physical Therapy – TIP: an underutilized tool! Find a good
PT and “partner” with them on your goals then prescribe PT
for patients as appropriate (which are many!)
Certified Exercise Specialists/Physiologists
Phase III Cardiac Rehab
Metformin – a wonder drug?
• Well known first line in DM2 and should stay if on insulin!
• Now used frequently in PCOS, GDM and recently endorsed
by ADA for high risk pre-type 2 diabetics to lower DM2 31%
• Excellent safety profile (likely acceptable up to Cr 1.8)
• Also associated with lower CVD and Cancer (in trials now)
• NEWS FLASH! 10yr follow up to Diabetes Prevention
Program shows TLC cost effective while metformin cost
SAVING! Only 10% of medical tx is actually cost SAVING!
• IMO, B12 should be supplemented (1000mcg PO QD)
• IMO, in pre-diabetics where healthy weight loss is
CRITICAL - best to use metforminER at LUNCH, adjusting
dose up to 1500-2500mg based on GI tolerance
Supplements worth an Honorable Mention
• D3 (IMO - target dose to 25D between ~50ng/dL)
• B12 (IMO - target dose to keep level >500pg/mL with MMA <0.2 umol/L
& Homocysteine <14umol/L; Neurology Sept 27, 2011
• Omega 3 (caveat: 1000mg fish oil doesn’t = 1000mg w3)
Look for “Triple Strength” Fish Oils or use prescription form
• Re others: DO NO HARM! Best is HEALTHY LIFESTYLE! Failures:
Vitamin E, Selenium, Beta-Carotene, Folic Acid for CVD
• Magnesium Citrate/Glycinate? PPI (use ICD-9 995.2)
• Multivitamin? NO EVIDENCE OF BENEFIT FOR GENERAL POP.!
Careful w/ Fe (check ferritin with IR - code 263.0; ferritin levels
>100ng/mL should prompt thought of body iron excess), folate;
Consider QOD? www.naturalmedicinesdatabase.com
“Hot Topics”
• Recent controversies regarding sodium and blood pressure
control
• Alcohol and heart disease
• Resveratrol
• Omega 3 vs. 6; krill oil vs. fish oil
• Recent controversies re: Vitamin D regarding how much is
enough; should we be measuring levels? who needs
supplementation? what kind of supplementation?
• Other vitamin or mineral supplementation
• Calcium supplementation & osteoporosis prevention
• Coffee/caffeine
• Soy products; Phytoestrogens
• Nutrient density (Whole Food's ANDI) & Joel Fuhrman's
perspective on nutrition
• Chocolate
Testimonials
REAL RESULTS FROM SJMO
Metabolic Nutrition & Weight Mgt Program
• Average weight loss for first 3 months 7.2%
(many losing more than 10%)
• Average weight loss for 12 months 11%
(many losing more than 15%)
• Average 6 month cholesterol/trig decrease 31 points –
many achieving such with LESS medicine
• A1C/glucose levels improved in 93% with virtually all doing
so with LESS medicine
What Might Your Newly Reprogrammed Modern
Hunter-Gatherer Patient Be Doing?
• Eating a healthy breakfast within 1 hr of awakening or meal replacement
with about 20-30g of quality protein, moderate amount of unrefined
healthy carbs (whole fruit, veg in omelet, small amt of whole grain)
• Eating SEVERAL pieces of whole fruit & vegetables throughout the day
and quality sources of “clean, lean” (clean=low sodium; lean=low sat fat)
protein with fish happening >2x/wk
• For weight mgt look at “carbs” like this: low starch veggies over starchy
veggies/fruit/legumes over cooked whole grains over dry whole grains,
over anything refined.
• For weight mgt look at “fats” like this: moderate ALWAYS with unsalted
nuts leading the way followed by high fat whole foods (avocado) and
lastly touches of “healthy” oils (canola, olive)
• Mindful of Environment and re-engineered home so they can “give their
willpower a break!” (Book Rec: Mindless Eating – Brian Wansink PhD)
• Eating out less and more wisely/informed when so doing
• SITTING MUCH LESS and INTEGRATING EXERCISE ALSO
Just in case all else fails,
consider bariatric surgery…..
OR ...