Nutrition and the Metabolic Syndrome

Gail Underbakke, RD, MS

UW Preventive Cardiology Program

Metabolic Syndrome in Children and Adolescents

Prevalence of metabolic syndrome is high among obese children and adolescents and it increases with worsening obesity.

439 subjects, ages 4-20, BMIs > 97th percentile

38.7% of moderately obese subjects had Met Syn

49.7% of severely obese subjects had Met Syn

New England Journal of Medicine 2004; 350:2362.

Definition:

The Metabolic Syndrome consists of multiple, interrelated risk factors of metabolic origin that appear to directly promote the development of atherosclerotic cardiovascular disease ( risk 2x), and are strongly associated with type 2 diabetes mellitus ( risk 5 x).

Metabolic risk factors include atherogenic dyslipidemia, elevated blood pressure, elevated plasma glucose, a prothrombotic state, and a proinflammatory state.

ATP III: The Metabolic Syndrome*

*Diagnosis is established when 3 of these risk factors are present.†Abdominal obesity is more highly correlated with metabolic risk factors than is BMI. ‡Some men develop metabolic risk factors when circumference is only marginally increased.Waist circumference measured at iliac crest.

<40 mg/dL or on meds<50 mg/dL or on meds

MenWomen

>40 in >35 in

MenWomen

100 mg/dL or on medsFasting glucose130/85 mm Hg or on medsBlood pressure

HDL-C150 mg/dL or on medsTriglycerides

Abdominal obesity† (Waist circumference‡)

Defining LevelRisk Factor

Country/Ethnic Values for Waist Circumference Defining Central Obesity,

International Diabetes Federation

Male Female

USA 102 cm (40”) 88 cm (35”)

Europids 94 (37”) 80 (31.5”)

South Asians 90 (35.5”) 80 (31.5”)

Atherogenic Dyslipidemia

Risk of coronary heart disease

Despres J-P. Dyslipidemia and obesity. Baillere’s Clin Endocrinal Metab. 1994;8-636

Underlying Causes of Metabolic Syndrome

There are multiple underlying factors –

• abdominal obesity*

• insulin resistance*

• physical inactivity

• aging

• genetic or ethnic predisposition

Post-prandial Dysmetabolism

• Inflammation plays a role in the development of chronic disease - heart disease, diabetes, dementia, and probably more

• High calorie, easily digestible, quickly absorbable foods and drinks lead to exaggerated post-prandial spikes in glucose and lipids (triglycerides)

• Exaggerated spikes in glucose and lipids generate excess free radicals and increase inflammation and endothelial dysfunction

• Fasting glucose and triglyceride values may be normal, while post-meal values are high.

Effects of a beverage containing 75 gm glucose with 75 gm fat as whipping cream. Nitrotyrosine indicates oxidant stress, CRP indicates inflammation, FMD = Flow-mediated dilation.

Ceriello et al, Circ 2005; 111:2518

Post Prandial Stress

Daily Activity Reduces Post-Prandial Glucose

O’Keefe, et. al. JACC 2008; 51:249

Inflammation

• Triggers include

– oxidized LDLs in artery intima

– low HDL levels (HDL inhibits inflammation)

– hypertension (via angiotensin)

– diabetes (via advance glycation end products)

– obesity (adipose produces cytokines)

– infection

• Testing? – HS (high sensitivity) C reactive protein

• Anti-inflammatory diet?

– More omega-3 fats, less omega-6, more antioxidants in food

Circulation. 2002; 105:1135-1143

AHA Recommendations for Management of the Metabolic Syndrome

Lifestyle First!

• Reduce weight by 7-10% during first year. Continue weight loss to goal of BMI < 25.

• 30-60 minutes moderate intensity aerobic activity, preferably daily, supplemented by daily lifestyle activity. Resistance training 2x per week.

• Saturated fat <7% of calories, dietary cholesterol <200 mg/day, total fat 25-35% of calories. Limit simple sugars.

Circulation 2005;112:2735-52

Lifestyle Recommendations to:

• Reduce Triglycerides

Weight loss, exercise, total carbohydrate <60% of calories, limit alcohol

• Increase HDL

Exercise, weight loss, smoking cessation, total carbohydrate <60% of calories

• Reduce blood pressure

Weight loss, exercise, DASH diet, limit alcohol

• Reduce blood sugar

Weight loss, exercise, consistent moderate carbohydrate

Carbohydrate and Triglycerides

• High carb diets can overwhelm normal metabolism, increase synthesis of fatty acids

• Sugar, especially fructose, has greatest effect, but all carbohydrates matter

• Goal <60% of calories from carbohydrate

– Fat intake should be 25-35% of calories. Cutting carbs may mean adding fat.

• Higher fiber diet can help minimize effects of carbohydrate

Effects of Lifestyle Modification to Manage Hypertension

Approximate Reduction in

Modification Systolic BP, mmHg

Weight reduction 5-20 w/ 10-kg wt loss

DASH Diet 8-14

2400 mg sodium/d 2-8

Physical activity 4-9

Moderate alcohol 2-4

JNC 7, May 2003

Dietary Approaches to Stop Hypertension (DASH and DASH-Sodium)

• Moderate sodium use (2400 mg per day or less)

• Maintain a healthy weight

• Increase intake of fruits and vegetables to 8-10 servings per day and include 2-3 servings of low-fat dairy products per day

• Emphasize whole grains, poultry and fish, lean red meats, vegetarian proteins and some nuts

• SBP decreased 11 mm Hg, DBP 6 mm Hg

NEJM 1997;336;1117-24

Overall Lifestyle Recommendations for Metabolic Syndrome

• Exercise

• Weight Loss

• Total carbohydrate <60% of calories

• DASH diet

• Limit alcohol

• Smoking cessation

The Continuum of Diets to Reduce CVD Risk

Total Fat 30-40% 34% <30% <30% <10%

Sat Fat < 7% 11% <10% <7% --

Cholesterol < 200 256 <300 <200 <5 mg

MUF 15-20% -- 10-15% 10-15% --

PUF <10% -- <10% <10% --

CHO 45-55% 50% 55-65% 55-65% 75%

“Mediterranean” Current AHA AHA Ornish,

Average Step TLC Pritikin

American One

One Diet for All?

Case # 1

62 y.o. male

CAD

BMI - 24

Waist circumference - 34”

Cholesterol - 285

Triglycerides - 78

HDL - 47

LDL - 222

Fasting Glucose – 87

Saturated and trans fat

Soluble fiber

Add plant sterols

Case #2

62 y.o. male

CAD

BMI - 31

Waist circumference - 42”

Cholesterol - 217

Triglycerides - 283

HDL - 30

LDL - 130

Fasting Glucose – 122

Control carbohydrates and calories

Saturated and trans fat

Soluble fiber

Copyright restrictions may apply.

Gardner, C. D. et al. JAMA 2007;297:969-977.

Which Diet Works?

Dansinger, JAMA 2005; 293:43-53

Ch

an

ge F

rom

Baselin

e (

%)

P<0.001

LDL-C

TG

Fish Sources of Omega-3 Fatty AcidsSalmon, Atlantic, farmed, 3 oz 1.09-1.83 gm

Herring, Atlantic, 3 oz 1.71

Sardines, canned, 3 oz 0.98-1.70

Mackerel, Atlantic, 3 oz 0.34-1.57

Salmon, Atlantic, wild, 3 oz 0.9-1.56

Tuna, fresh, 3 oz 0.24-1.28

Salmon, pink, 3 oz 1.09

Rainbow trout, farmed, 3 oz 0.98

Rainbow trout, wild, 3 oz 0.84

Salmon, sockeye or chum, 3 oz 0.68

Tuna, canned, white, 3 oz 0.73

Tuna, canned, light, 3 oz 0.26

Cod, Atlantic, 3 oz 0.24

Catfish, wild, 3 oz 0.2

Kris –Etherton. Circulation 2002; 106:2747

Plant Sources of Omega-3 Fatty Acids,Per gram of fat

Flax seed oil 0.66

Fish body oil 0.3

Cod liver oil 0.19

Canola oil 0.12

Walnuts 0.11

Soybean oil 0.08

Contains:

180 mg EPA

120 mg DHA

Per capsule

For more information:

Fish Oil Supplements

www.heartdecision.org

Facts about the Glycemic Index• Defined as the area under the blood glucose curve for a test

food, compared to the area under the curve for a carbohydrate equivalent amount of a reference food.

• Starches higher in amylose (some varieties of barley and corn) are more resistant than those higher in amylopectin.

• Food processing - gelatinization of starch increase GI (most breads and cereals), crystallization of starch reduces GI.

• Organic acids (sourdough bread, fermentation of water-soluble fiber) reduce GI.

• GI affected by fat, protein, and fiber in the current meal, content of previous meal.

Glycemic Index of Selected Foods

Potatoes 80-100 Baked beans 48

Corn flakes 84 Orange, Grapes 43

Whole Wheat bread 72 Pumpernickel bread 41

White bread 70 Apple 36

Rice, brown and white 70 M & Ms, peanut 33

Spaghetti, 20 min. 61 Yogurt with fruit 33

Ice Cream 61 Spaghetti, 5 min. 34

Basmati rice 60 Lentils 28

Sweet potato 54 Peach 28

Sourdough bread 54 Barley 25

Banana 53 Soybeans 18

Glucose = 100, 50 gram carbohydrate dose. AJCN 2002; 76:5-56.

Glycemic Index of Mixed Foods

White rice 100

with pickled cucumber 73

with yogurt 72

with fermented soy 68

with whole milk 59

with ice cream 57

Sushi (rice, vinegar, sea algae) 67

50 gm carbohydrate test food, European J Clin Nutr (2003) 57, 743-752.

Alcohol – What’s a serving?

12 oz beer

5 oz of wine

1.5 oz of 80 proof liquor

Size of typical wine glass - 10-14 oz.

Recommendations:

No more than 2 drinks per day for men

No more than 1 drink per day for women

Benefits of Nuts

• Low in saturated fat, good source of monounsaturated fat

• No cholesterol

• Convenient source of protein

• Rich in the amino acid arginine, may improve vasodilation

• Rich in Vitamin E, folic acid, copper, and magnesium

A handful, not a can full!

Nuts - Fat Content, 1 ounce Calories Total Sat. MUF PUF

Almonds, 24 170 14.5 1.5 10 3.0

Brazil, 8 190 19 5.0 7.0 7.0

Cashews, 18 160 13 2.5 8.0 2.5

Filberts, 12 180 18 1.0 15.0 2.0

Macadamia, 12 200 20 3.0 16.5 1.0

Peanuts, 35 pcs 160 13.5 2.0 7.0 4.5

Pecans, 15 hlvs. 190 19 2.0 12.0 5.0

Pistachios, 47 160 14 2.0 9.5 2.0

Walnuts, 14 hlvs. 180 17 2.0 4.0 11.0

Soy nuts, 3 Tbsp 129 6 0.9 1.4 3.5

Oxidative Stress

An imbalance of pro-oxidants and antioxidants results in

– generation of reactive oxygen species (free radicals)

– increased inflammation

Pro-oxidants

– Saturated and trans fats

– High glycemic index carbohydrates

– Excessive alcohol intake

Foods / Nutrients with Antioxidant Effects

• Omega-3 fatty acids

• Dietary fiber

• Moderate alcohol intake

• Antioxidants from food

– Vitamin C

– Vitamin E

– Vitamin D?

– Carotenoids

– Selenium

– Polyphenols (phytochemicals)

Phytochemicals are measured in ORAC UnitsORAC per 100 grams ORAC per calorie

Cloves, ground 125,549 389

Turmeric, ground 15,679 44

Dark Chocolate 13,120 22

Milk Chocolate 6740 13

Prunes 5770 24

Pomegranate 3307 40

Raisins 2830 9

Blueberries 2400 43

Blackberries 2036 47

Kale 1770 35

Strawberries 1540 48

Spinach 1260 55

Raspberries 1220 24

ORAC = Oxygen Radical Absorbance Capacity, AJCN 2006;84:95.

To Minimize Post-Prandial Dysmetabolism

• Minimally processed, high-fiber, plant-based foods (whole grains, vegetables, fruits, nuts, legumes)

• Lean protein, fish

• Moderate calorie intake

• Regular physical activity

Sample Mediterranean Menu

B - Cooked cracked wheat cereal with walnuts

and yogurt Melon

Snack - Orange 2 handfuls sunflower seeds

L - Lentil spinach soup Tomato cucumber salad Whole Wheat bread with olive oil

Snack - 2 oz Camembert cheese 1 mango

D - Spaghetti w/ tomato, peppers, Parmesan, mussels, and olive oil,

Lettuce salad with V and O dressing

Baked figs Red wine

DASH - Sample Menu (2000 calories)

Breakfast Dinner

Orange Juice Baked cod

Oatmeal, 1 t. sugar Rice pilaf

1 c. 1% milk 1/2 c. broccoli

Banana 1/2 c. stewed tomatoes

WW toast, soft margarine 1 c. green salad w/ dressing Dinner roll, soft margarine

Lunch Melon

Chicken salad, pita half

Part-skim Farmer’s cheese Snack

Lettuce leaves 1/4 c. dried apricots

Raw carrots, celery 1/3 c. mixed nuts

1 c. 1% milk 3/4 c. pretzel sticks

Canned fruit

Resources

American Institute for Cancer Research - Veggies

• http://www.aicr.org/site/PageServer?pagename=pub_new_amer_plate_veg

DASH diet

• http://www.nhlbi.nih.gov/health/public/heart/hbp/dash/index.htm

MyPyramid from USDA

• http://www.mypyramid.gov

National Heart Lung and Blood Institute publications

• http://www.nhlbi.nih.gov/health/index.htm