The Nutrition Consultation in Age Management Medicine

There are three critical omega-3-fatty acids: Alpha-linolenic acid (ALA), Eicosapentaenoic acid (EPA), and Docosahexanoic acid (DHA). ALA is obtained from grain and vegetable sources. Flaxseed contains the highest amount of ALA. However, ALA is a short-chain omega-3 fatty acid and is only converted into the longer chain, anti-inflammatory EPA and DHA in the body. This conversion rate is quite low, making flaxseeds a less desirable source of omega-3. Slide23

EPA and DHA are found in seafood. The best source for EPA and DHA are fatty cold-water fish, such as salmon, steel head trout, tuna, sardines, and mackerel. “Atlantic” salmon is the new label for farm-raised salmon, which contains more contaminants and less omega-3 than wild salmon. Avoid farm-raised salmon and only consider healthy sources of wild salmon. A French study of fish oils recom1ends oily fish 1 to 2 times a week for the primary and secondary prevention of CHD⁵⁰.

How much omega-3 is needed? Slide24 The recommendation is 1 gm per day of EPA and DHA for cardio-protection. De Leiris recommends this amount can be safely taken without adjustment of other medications. To reduce elevated triglycerides and to reduce morning stiffness, 2 to 4 gm per day is recommended; 3 gm are needed to reduce tender joints in patients with rheumatoid arthritis⁵².

A study done by Veldink, et al, (2006), showed people who had a high intake of polyunsaturated fatty acids (PUFA) and vitamin E had a significantly reduced risk of developing amyleomyotic lateral sclerosis (ALS) (odds ratio for each, 0.4, 95% confidence interval, 0.2 to 0.7, P= 0.001). The finding that a higher intake of PUFAs appeared to decrease the risk of developing ALS may be in accordance with the results of studies in patients with other neurodegenerative disorders, such as Alzheimer's disease and Parkinson's disease. A conclusion of the researchers was, "Omega 3 PUFAs—eicosapentanoic acid, docosahexanoic acid and alpha-linolenic acid, in particular—have been shown to protect against cardiovascular disease and Alzheimer's disease. In contrast, omega 6 fatty acids—linoleic acid—have opposite mechanisms of action."⁵³

Protein should be 20% to 30% of total calories. Proteins low in saturated fat minimizes inflammation. A diet that limits intake of dark meat chicken and turkey, lean cuts of beef, ham, pork, and lean Canadian bacon is desirable. Avoid fatty cuts of meat (hot dogs, bacon, sausage, liver, and hard cheeses). Increasing soy protein to 25 gm per day with a low-fat diet reduce CVD by reducing inflammation. Eat more soybeans, legumes, nuts and seeds.

Eating To Reduce Inflammation: Slide25

Plenty of omega-3 fatty acids
Plenty of monounsaturated fats
Low amounts of polyunsaturated fats (omega-6 FA)
Plenty of dietary fiber (25 gms to 35 gms/day)
Protein sources that are low in saturated fat (41)
Low-glycemic CHOs (7 + servings of fruits and vegetables/day, proved to be associated with a lower risk of CVD, stroke, and cancer)

Glycemic Index & Glycemic Load

The glycemic index (GI) is a ranking of carbohydrates, based on the immediate effect on blood glucose levels. It compares carbohydrates gram for gram. Carbohydrates that break down quickly during digestion have the highest GI; the blood glucose response is fast and high. Carbohydrates breaking down slowly, release glucose gradually into the blood stream, and have low GI.

The GI is the integrated increase in blood glucose level in a 2-hour period after the ingestion of a known quantity of a test food (50g CHO) x 100 = GI. Slide26

The GI is significant because a low GI means a smaller rise in blood glucose levels after meals. Low GI = 45 or less. Low GI diets can help people lose weight and improve the body’s sensitivity to insulin. Low GI can improve diabetes control and lipids. Low GI foods keep you satiated for longer, eliminate cravings, and prolong physical endurance. Slide27

High GI foods promote inflammation. High GI = 64 or more. Medium GI = 46 – 63. Carrots have a slightly high GI 49, but only minimal CHOs per serving (8 gm of absorbable CHO in 1 cup). Therefore, the glycemic load for carrots is low, making them an acceptable CHO. Slide28

The glycemic load of the American diet has significantly increased due to an increase in CHO with fat reduction and increased consumption of foods with a higher GI, due to more refinement in food processing. Glycemic load = (GI) x [gms of absorbable CHO (total CHO – fiber)]. The slides list foods that are low, medium or high GI/GL foods Slide29 Slide30

Slide31

Willett, et al, compiled a list of the 20 most consumed sources of carbohydrate in the American diet Slide32 Slide33 Slide34 plus the glycemic index and loads of the common breakfast cereals. ^53,54 Slide35 As the GI/GL of your diet increases, so do hunger, cravings, binge eating, and over eating. All are promoted by high glycemic foods. Slide36 . There are ways to decrease GI and GL: Slide37 Eat 4 to 6 small meals daily; Eat healthy fat and protein with your carbohydrates; Eat fiber with your carbohydrates; Eat slowly.

Glycation

Glycation is the non-enzymatic bonding of glucose to proteins. Glycation renders the protein non-functional. The higher blood glucose, the more glycation occurs. HgA1c is our best measure of glycation. Glycation is an excellent biomarker for aging and risk for degenerative diseases. Sugar is added to prepared foods to make food taste good. It is important to know the percentage of added sugar, when trying to avoid it.

Slide38

Teaching Patients To Switch To A Low-Glycemic Diet

Enjoy all types of fruit and vegetables (except potatoes)
Eat plenty of salad vegetables with vinaigrette dressing
Avoid sugar and sugar products
Use oats, barley, and bran as breakfast cereals
Use darker grains, such as rye or pumpernickel, rather than wheat
Use "grainy" breads made with whole seeds (3 gm to 5 gm fiber/slice)

Is your patient’s insulin and blood sugars controlled? Look at the laboratory results and behaviors to know: Slide39

· Fasting serum insulin levels—Goal = <5 uU/ml

TG/HDL ratios—goal = <1.5
Hg A1c—goal = <5%
Resolution of hunger, cravings, binge eating, uncontrolled eating and mood swings
High energy levels

Mediterranean Diet

The Mediterranean-style diet is “…a nutritional program that will effectively reduce the markers of inflammation and promote weight loss ⁵⁶.” It reduces body fat, improves glucose and insulin utilization, lowers blood pressure and triglycerides; lowers total cholesterol and LDL, improves HDL with an overall improvement in endothelial function. It reduces CRP, IL-6, and other pro-inflammatory cytokines.

The Mediterranean diet was studied in Italy from 2001-2004 during which time 90 persons diagnosed with the MetS were fed the Mediterranean diet while 90 similar persons served as controls. The Mediterranean diet participants experienced a significantly greater weight loss (4.0 kg vs. 1.2 p <0.001), improved insulin sensitivity (P< 0.001), along with significant reductions in serum insulin and lipid levels (all P< 0.001)⁵⁷.

In a more recent 2-year trial, 322 moderately obese subjects (mean age,52 years; mean BMI 31 and 86% male) were assigned to one of three diets: low-fat, restricted-calorie; Mediterranean, restricted-calorie; or low-carbohydrate, non–restricted-calorie. Mediterranean-diet group consumed the largest amounts of dietary fiber and had the highest ratio of monounsaturated to saturated fat (P<0.05 for all comparisons among treatment groups). The low-carbohydrate group consumed the smallest amount of carbohydrates and the largest amounts of fat, protein, and cholesterol and had the highest percentage of participants with detectable urinary ketones (P<0.05 for all comparisons among treatment groups). The mean weight loss was 2.9 kg for the low-fat group, 4.4kg for the Mediterranean-diet group, and 4.7 kg for the low-carbohydrate group (P<0.001) for the interaction between diet group and time); among the 272 participants who completed the intervention, the mean weight losses were 3.3 kg, 4.6 kg, and 5.5 kg, respectively. In concluding, researchers found that Mediterranean and low-carbohydrate diets may be effective alternatives to low-fat diets⁵⁸. The more favorable effects on lipids (with the low-carbohydrate diet) and on glycemic control (with the Mediterranean diet) suggest that personal preferences and metabolic considerations might individualize dietary interventions

The Mediterranean diet has 30%-35% fat; 20%-30% protein; 40%-50% CHOs. It is a plant-based diet, high in soluble and insoluble dietary fiber . Protein comes from both animal and vegetable sources. It is low in saturated fats, trans fats and cholesterol, yet is high in omega-3 fatty acids. The Mediterranean diet is low in refined sugars and refined grains (breads and pasta), the high-glycemic carbohydrates.

The typical Mediterranean diet: Slide40

Fruits and vegetables – at least 7 servings a day

Fish (cold water) – 3 to 4 times a week
Fiber – consume at least 25 gms to 35 gms per day. Slide41
Dairy – nonfat and low fat, only in limited amounts and up to 4 eggs per week
Grains, starches, legumes and nuts – whole grain, fiber-rich cereals, breads, pasta. Slide42 At least 3 servings per day of whole grains. “Multi-grain” or “high fiber” does not necessarily mean whole grain. Whole grains reduce risk of cardiovascular disease, T2DM and obesity. Whole grains contain all three parts of the grain kernel: Slide43 fiber-rich bran, the starchy endosperm and the nutrient–packed germ. Whole grains can play a significant role in weight management and weight loss. Whole grains lower hs-CRP and IL-6 levels
Meat – limit red meat to 1 to 2 times per month; consume mostly lean meats in limited quantities (e.g. chicken and turkey) Alcohol – limit intake – especially for those with high triglycerides. None for individuals who have a problem with alcohol (30% of all drinkers)

If weight reduction is a goal, avoid refined white flour, baked goods and breads, limit nuts and nut butters. Slide44

Print Slide45 Slide46 to help your patients make healthy choices when grocery shopping.

Physical Activity

Evidence-based decisions help make choices when treating nutritional issues. Exercise as treatment is based on a survey by the American College of Sports Medicine (ACSM) that showed 25% of patients seek advise on exercise and physical activity from their physician. Additionally, the survey showed that 65% of patients would be more interested in exercise programs as disease prevention and treatment, if the physician recommended programs and resources⁵⁹. ACSM and the American Medical Association have launched a physician and patient awareness program to encourage physical activity.

A study to look at how much exercise should be recommended to decrease the prevalence of MetS and its complications, determined that a modest amount of moderate-intensity exercise without dietary changes significantly improved MetS and supported the recommendation that adults get 30 minutes of moderate-intensity exercise daily. However, exercise alone will not make changes to the nutritional status of the individual⁶⁰.

Older adults should maintain as high a functional status as possible and regularly engage in physical activity. Many older adults can follow the same recommendations for younger adults. Weight-supporting activities such as stationary bicycling, deep-water walking, and floor exercises may be more appropriate in older adults with compromised bone health, although with proper supervision and training these individuals can safely engage in resistance exercises as well. Individualized programs devised by physical therapists or physiatrists can safely improve strength, mobility, and functional capacity in vulnerable older adults. Physical therapists can also train individuals in specific postural exercises to strengthen back extensor muscles, which may relieve pain and slow development or progression of kyphosis.

Patients with spinal fractures should avoid activities that flex the spine and increase pressure on compromised vertebral bodies. In addition, activities such as golf, bowling, tennis, and horseback riding place significant force on the spine and should be avoided in patients with compromised bone health. People with osteoporosis of the spine should avoid use of exercise machines that involve trunk rotation or forward bending, as these movements can cause a fracture in individuals with osteoporosis. Machines to avoid include abdominal exercisers, biceps, rowing, and cross-country ski machines, stationary bicycles with moving handlebars, or upper body ergometers.

Physical therapists play an important role in both fracture prevention and treatment. They can evaluate balance and the risks of falling and teach specific exercises and techniques to minimize that risk. Since nearly all hip fractures are associated with a fall, preventing falls in older individuals is fundamental to preventing fractures. Occupational therapists can evaluate the home environment and make modifications that minimize the risks of falling, including eliminating loose rugs; installing hand rails, shower chairs, and hand-held nozzles in the bathroom; installing bedside lamps, nightlights in hallways and bathrooms, and strips of contrasting tape on stair treads; and recommending the use of canes and walkers as appropriate as well as the avoidance of certain types of clothing, including long robes, loose belts, and scarves.

Exercise and high-protein/reduced-carbohydrate and -fat diets have each been shown separately, or in combination with an energy-restricted diet to improve body composition and health in sedentary, overweight (BMI > 25) adults. A current study, instead, examined the physiological response to 10 weeks of combined aerobic and resistance exercise (EX) versus exercise + minimal nutrition intervention designed to alter the macronutrient profile, in the absence of energy restriction, using a commercially available high-protein/low-carbohydrate and low-fat, nutrient-dense food supplement (EXFS); versus control (CON)⁶¹ Previously sedentary, overweight subjects (female = 19; male = 19) were randomly assigned to either CON (n = 10), EX (n = 14) or EXFS (n = 14). EX and EXFS participated in supervised resistance and endurance training (2× and 3×/wk, respectively); EXFS consumed 1 shake/d (weeks 1 and 2) and 2 shakes/d (weeks 3–10).. The researchers concluded that absent energy restriction or other dietary controls, provision of a high-protein/low-carbohydrate and -fat, nutrient-dense food supplement significantly, 1) modified ad libitum macronutrient and energy intake (behavior effect), 2) improved physiological adaptations to exercise (metabolic advantage), and 3) reduced the variability of individual responses for fat mass, muscle mass and time-to-exhaustion – all three variables improving in 100% of EXFS subjects. Virtually all of the available information pertaining to the use of food supplement interventions in overweight and obese populations is not related to controlled exercise. Total cholesterol-to-HDL ratio, however, decreased significantly (p < 0.017) in both exercise groups

Inflammation & Dental Health

Periodontal disease may increase the risk of cardiovascular disease by approximately 20%. Consequently, the dentist plays a key role in helping control and prevents cardiovascular disease. Patient history should include “last dental examination” and the name of the patient’s dentist. Other contributors to oral inflammation are aggressive teeth brushing, aggressive flossing, and plaque. Counter-rotational and oscillating-rotating electric brushes have shown to reduce levels of gingival bleeding and inflammation.

Anti-Inflammatory Herbs & Supplements

Turmeric and ginger are anti-inflammatory herbs, which should be included in the diet. Ginger can be grated or sliced thin to complement raw vegetables. One tablespoon turmeric, diluted in water can be added to vegetables to cook. Cook with added soymilk and sweetener, then drink. (Caution—can interact with blood thinners, coumadin and heart medicines.) Boswelia and White Willow Bark (aspirin). Combination formulas are found in Ziaflammend and Kaprex .

Omega-3 fish oil: 4 gms of omega-3s are recommended for the anti-inflammatory effect when treating medical conditions, such as asthma, arthritis, depression. It is difficult to reach this dose with diet alone. These are considered safe sources of omega-3 fish oil because they have been molecularly filtered to remove mercury and PCPs. Don’t be confused – most fish oils come in a 1,000mg (1gm) sized capsule, but the amount of EPA and DHA varies and should be as high as possible. Some examples are: Slide47

Sears/Zone Labs Omega Rx Fish Oil
Nordic Natural Omega-3 Fish Oil
Spectra Fish Oil
Eskimo 3 Fish Oil

Antioxidants

There is evidence that cells within the joint produce reactive oxygen species (ROS) or free radicals, and that oxidative damage has been implicated in the development of chronic disease, including arthritis and cancer. Therefore, it is recommended to eat a diet rich in antioxidants: eat plenty of antioxidant-rich fruits and vegetables, such as berries and cherries to help modify the body's inflammatory response.

Some choose to take antioxidant supplements for extra protection such as vitamin C, vitamin E, or selenium. Dark chocolate has flavonoids and antioxidants. A typical serving is ½ oz. http://www.consumerhealthjournal.com/articles/chocolate.html.

Hydration

Inflammation produces heat and dehydrates the body, which can decrease synovial fluid in the joints and cause desiccation of the vertebral discs. Therefore, advise patients to stay hydrated. What is adequate hydration? That will depend upon the activity and the weather, but urinating every 3 to 4 hours and drinking sufficient water to keep the urine a light yellow with no odor is usually sufficient. No evidence based findings are available for the amount of water that is to be drunk daily, nor are there findings that recommend bottled water in preference to the usual household drinking water. Bottled water is most appropriate for travel to areas where the water purity is questionable or the taste is bad.

Hormones

Hormone studies abound in the laboratory and include a variety of animal species from frat to elk and cow. It is difficult to transfer finding from these studies to humans, and even more difficult to provide large cohorts for evidence-based guidelines for hormone use. However, clinical evidence, and increasing success with hormonal modulation is filling the gap of information. New studies, which can pique your particular interests, include those on hormones that affect appetite, vitamin D, thyroid, and the role of the grape. ⁶²

Appetite is affected by many factors including the hormones leptin, ghrelin and adiponectin. Ghrelin stimulates hunger, leptin promotes satiety, and adiponectin affects insulin response. The biochemical mechanisms that account for differences in appetite hormones among individuals with varying body size and adiposity should aid in appropriate treatment strategies. In a small Utah study to test whether the pre- and postprandial response of key appetite hormones differs in normal weight and severely obese women, significant differences in both pre- and selected post- prandial levels of leptin, ghrelin, adiponectin and insulin existed between NW and SO women.

Substantial evidence supports a relationship between vitamin D status and insulin sensitivity.

The growing incidence of prediabetes and T2DM is a critical health problem with consequent devastating QOL and health-care costs. In epidemiological studies, Vitamin D status ( assessed by serum 25-hydroxyvitamin D levels) is inversely associated with diabetes. Several clinical intervention studies also support that vitamin D, or its active metabolite 1,25-dihydroxyvitamin D (1,25(OH)2D), improves insulin sensitivity, even in subjects with glucose metabolism parameters within normal ranges. The mechanisms which may underlie this effect include potential relationships with increased lean mass, regulation of insulin release, altered insulin receptor expression, and specific effects on insulin action. These actions may be mediated by systemic or local production of 1,25(OH)2D or by suppression of parathyroid hormone, which may function to negatively affect insulin sensitivity. ⁶³

Since rapid weight loss is associated with a decrease of TSH and T3, the resulting decrease in resting energy may contribute towards the difficulties maintaining weight loss. Leptin seems to be a promising link between obesity and alterations of thyroid hormones since leptin concentrations influence TSH release. A moderate elevation of TSH concentrations associated with T3 values in or slightly above the upper normal range, is frequently found in obese humans. These alterations seem a result of, and not a cause of, obesity since weight loss leads to a normalization of elevated thyroid hormone levels. Reinehr T. Obesity and thyroid function, Mol Cell Endocrinol. 2009 Jun 18. PubMed ahead of print.

Any review of dietary modifications to improve health would be incomplete without a comment on red wine, grape seeds or other grapevine (Vitis vinifera) products, as grape and grape juice, that represent a valuable source of bioactive phytochemicals, synthesized by three secondary metabolic pathways (phenylpropanoid, isoprenoid and alkaloid biosynthetic routes) and stored in different plant tissues. The Italian authors reviewed studies from the last decades, to conclude that there is compelling evidence suggested that regular consumption of these products may contribute to reducing the incidence of chronic illnesses, such as cancer, cardiovascular diseases, ischemic stroke, neurodegenerative disorders and aging, in a context of the Mediterranean dietary tradition. The health benefits arising from grape product intake can be ascribed to the potpourri of biologically active chemicals occurring in grapes. Among them, the recently discovered presence of melatonin adds a new element to the already complex grape chemistry. Melatonin, and its possible synergistic action with the great variety of polyphenols, contributes to further explaining the observed health benefits associated with regular grape product consumption. ⁶⁴

Daily Guidelines for Patients

Never skip meals: The body enters starvation mode, causing metabolism to slow down, hoarding whatever calories are eaten. Rather, eat smaller meals more frequently. Think of food as fuel for the body and brain.

Base each meal around a lean protein source: Fish, chicken, turkey, lean beef (occasionally), cheese, cottage cheese, legumes, or yogurt (plain, unsweetened). The serving size of protein should be about the size of the palm of your hand.

Eliminate high-glycemic carbohydrates: Bread, pasta, rice, cereals, candy, baked goods, pretzels, sweets (often, anything white in color). The processing of these foods leaves them devoid of nutrients and increases the glycemic index and load. This is especially important to achieve the full benefit of your hormone replacement program.

Eat at least 3 to 5 servings of fresh vegetables, and 1 to 2 servings of fresh fruit every day. Vegetables are an excellent source of phyto-nutrients and fiber. Choose whole fruits instead of fruit juice because juicing removes the fiber and increases the glycemic index. Limit starchy and root veggies (potatoes, corn, beets, parsnips, etc.), dried and tropical fruits (raisins, dates, pineapple, mango, papaya, melons, etc.).

Add healthy fats to your diet: Essential omega-3 and omega-9 fatty acids are crucial for the prevention of heart disease, arthritis, joint problems and immune system weakness. Good sources include wild salmon and other ocean fish, almonds, walnuts, avocados, ground flaxseeds, olive oil, and fish oil supplements (with EPA/DHA).

Drink lots of water: Drink 6 to 8 eight-ounce glasses of water daily. Drink one extra glass for every caffeinated beverage, and if exercising.

Keep alcohol intake to a minimum. While 4 to 8 ounces of red wine daily provides health benefits, more than that can increase health risk. Dry red wine is the best choice. Hard alcohols are also low glycemic. Everything in moderation.

Choose natural products. Avoid refined foods, hydrogenated oils, artificial colors, flavors, sweeteners, and preservatives. Avoid fat-free products, which usually make up for a lack of taste by adding artificial ingredients and sugar. Shop the perimeter of your grocery store.

Take your supplements daily. Studies show reduced calorie diets without supplementation lowers metabolism; but with supplementation, the metabolism is unchanged.

The nutrition guidance outlined for young and middle-aged adults also applies to older individuals and to the elderly. Specific additional recommendations pertinent to this age group are discussed below.

Aging is inevitable, but there is no reason to surrender to Old Age. Healthy habits in eating, physical exercise, socialization, and family ties are aids to growing older with class. The key for patients is “Moderation in all things.”

References

Post Test