Presentation on theme: "CURRENT ISSUES IN CLINICAL NUTRITION"— Presentation transcript:
1 CURRENT ISSUES IN CLINICAL NUTRITION Robert B. Baron MD MSProfessor and Associate DeanUCSF School of MedicineDeclaration of full disclosure: No conflict of interest
2 Vitamin, mineral and fish oil supplements Selected TopicsVitamin, mineral and fish oil supplementsLow-fat dietsDiet and lipid disordersDiet, exercise and weight loss
3 Case 153 year old woman in for check up. In good health. Exercises regularly. Eats low fat diet. Grandmother had hip fracture at age 86. Father with MI age 72. On no meds, but takes multivitamin and calcium daily. BMI 26. BP normal. LDL <100.What advice should you give about her diet and supplements?
4 CALCIUM, VITAMIN D AND FRACTURES 36,282 postmenopausal women, 50-79Randomized to 1000 mg calcium plus 400 IU ofvitamin D vs placebo, 7 year f/u.Calcium/D Placebo Hazard RatioHip ( )Vertebral ( )Arm/wrist ( )Total ( )Jackson, NEJM 2006
5 CALCIUM, VITAMIN D AND INVASIVE COLON CANCER 36,282 postmenopausal women, 50-79Randomized to 1000 mg calcium plus 400 IU ofvitamin D vs placebo, 7 year f/u.Calcium/D Placebo Hazard RatioCancer ( )Wactawski-Wende, NEJM 2006
6 LOW-FAT DIET AND INVASIVE BREAST CANCER 48,835 postmenopausal women, 50-79Randomized to dietary intervention or comparisonIntervention: reduce total fat to 20% of energy and increase fruits and vegetables to at least 6 servings per day; 8.1 year f/u.Intervention Comparison Difference Between Groups Year 1 Year Year Year 6Fat 24.3% % % %Calories 1500 kcals kcalsF and V 5.1 servings servingsWeight kg kg -1.3kg kgPrentice, NEJM 2006
7 LOW-FAT DIET AND INVASIVE BREAST CANCER (Cases, annualized per cent)Intervention Comparison HR pBreast CancerIncidence ( )Mortality ( )Total CancerIncidence ( ) .10Mortality (Total mortality ( )Prentice, NEJM 2006
8 LOW-FAT DIET AND INVASIVE COLON CANCER HR, 1.08 (95% Cl, )Weighted Log-Rank P=.29Cummulative HazardTime, yBeresford, S. A. A. et al. JAMA 2006;295:
9 LOW-FAT DIET AND CARDIOVASCULAR DISEASE All ParticipantsCummulative HazardTime, yParticipants Without a History of CVDCummulative HazardTime, yHoward, B. V. et al. JAMA 2006;295:
10 LOW-FAT DIET AND WEIGHT CHANGE OverallMean Difference, kgHoward, B. V. et al. JAMA 2006;295:39-49.
11 Case 263 year old man, with CAD, s/p angioplasty with stent placement, feels well, in for check up. Meds include ASA, beta blocker, ACE, statin, thiazide, vitamin E, beta-carotene.He asks whether he should start B vitamins and fish oil.
12 VITAMIN E AND CARDIOVASCULAR DISEASE Vitamin E vs placebo7 RCTs; 106,625 subjectsCV event CV death MI StrokeVit EPlaceboNS NS NS NSEidelman, JAMA, 2004
13 VITAMIN E, CARDIOVASCULAR EVENTS AND CANCER: HOPE TOO 3994 subjects, >55, vascular disease or diabetesRandomized to 400 IU vitamin E, or placebo, 7 year f/uVitamin E Placebo pCancerCancer deathsCV eventsHeart failureHosp for CHFHope and Hope-TOO Investigators, JAMA, 2005
14 VITAMIN E AND CARDIOVASCULAR DISEASE AND CANCER Women’s Health Study,Vitamin E 600 IU QOD vs placebo39,876 subjects, over 45 years old, 10.1 yrs f/uVitamin E Placebo pCV eventMIStrokeCV deathsInvasive cancerTotal mortalityLee, JAMA, 2006
15 Beta-CAROTENE AND CARDIOVASCULAR DISEASE Beta-carotene vs placebo8 RCTs; 138,113 subjectsMortality CV death StrokeCarotene % % 2.4%Placebo % % 2.3%NNH* NS* number needed to harmVivekananthan, Lancet, 2003
16 FOLATE AND RESTENOSIS AFTER STENTING 636 patients, post stentRandomized to folic acid, B6 and B12vs placebo, 6 month f/uRestenosis Lumen RevascB vitamins % mm 15.8%Placebo % mm 10.6%p= p= p=0.05Lange, NEJM, 2004
17 VITAMIN INTERVENTION FOR STROKE PREVENTION (VISP) 3680 adults, s/p strokeRandomized to:Mulitivit with low dose B6, B12, folic acidMultivit with high dose B6, B12, folic acidStroke CHD Death CombinedLow doseHigh dosep= p= p= p=0.61Toole, JAMA, 2004
18 HOMOCYSTEINE LOWERING AND CARDIOVASCULAR EVENTS (NORVIT) 3749 men and women post MIFolic acid (0.8 mg), B12 (0.4 mg), and B6 (40 mg) vs. placebo; 2 X2 factorial design; 40 month f/uB Vitamins/Placebo pCombined eventsMIStrokeCancerTotal mortalityBonaa, NEJM, 2006
19 HOMOCYSTEINE LOWERING AND CARDIOVASCULAR EVENTS (HOPE 2) 5522 men and women with vascular disease or diabetes55 and older; 5 year f/uFolic acid (2.5 mg), B12 (1 mg), and B6 (50 mg) vs. placeboB Vitamins/Placebo RR pCombined eventsCV DeathMIStrokeTotal mortalityHOPE 2, NEJM, 2006
20 FISH OIL AND SUDDEN DEATH Background: Observational data (Eskimos) and 4 RCTs suggest reduced sudden death with fish oils (diet or supplement)RCT, 200 patients with implantable defibrillators, fish oil 1.8g vs placebo, for two yearsRaitt, JAMA, 2005
21 Time to First Episode of ICD Therapy by Fish Oil vs Placebo Group Raitt, JAMA 2005
22 OMEGA-3 FATTY ACIDS AND CANCER Systematic review of 38 studies20 cohorts, 11 types of cancers:Breast: 1 increased, 3 decreased, 7 no associationColon: 1 decreased, 17 no associationLung: 1 increased, I decreased, 4 no associationProstate: 1 decreased, 15 no associationSkin: 1 increasedAerodigestive, bladder, lymphoma, ovarian, pacreatic, and stomach: no associationMacLean, JAMA, 2006
23 Case 2 63 year old man, with CAD, in for check up. Plan: DC vitamin E and caroteneDefer B vitamins and fish oilReinforce use of current meds, diet (including fish) and exercise
24 Case 353 year old woman, in good health, in for check up. No cardiovascular risk factors. Body mass index is BP 110/70. LDL-cholesterol is 170, HDL-cholesterol is 55, triglycerides 100. She exercises 5 days per week. Follows low fat, low cholesterol, mostly natural food diet.Framingham risk score 1% risk of CV event in next 10 yearsHow should we manage her LDL?
25 LDL Goal and Cutpoints Patients with 0–1 Risk Factor 2001 and 2004 190 mg/dL(160–189 mg/dL: LDL-lowering drug optional)160 mg/dL<160 mg/dLLDL Level at Which to Consider Drug TherapyLDL Level at Which to Initiate DietLDL Goal
26 Therapeutic Lifestyle Changes (TLC): Major features TLC DietReduced intake of cholesterol-raising nutrientsSaturated fats <7% of total caloriesDietary cholesterol <200 mg per dayLDL-lowering therapeutic optionsPlant stanols/sterols (2 g per day)Soluble fiber (10–25 g per day)Weight reductionIncreased physical activityATP III, NCEP 2001
27 TLC for patients with LDL-C = 160 Dietary Component LDL-C (mg/dL) Low saturated fat/dietary cholesterol–12Viscous fiber (10–25 g/d)–8Plant stanols/sterols (2 g/d)–16Total–36 mg/dlDietary adjunctsThis slide shows that in a hypothetical patient with an LDL-C of 160 mg/dL, average reductions in LDL-C obtained by a diet lower in saturated fat and dietary cholesterol and the addition of viscous fiber and plant stanol/sterol esters could reduce LDL-C to <130 mg/dL. This is the goal for many patients with multiple risk factors and may obviate the need for cholesterol-lowering drug therapy or an increase in dosage of cholesterol-lowering drug therapy.References:Walden CE, Retzlaff BM, Buck BL, McCann BS, Knopp RH. Lipoprotein lipid response to the National Cholesterol Education Program Step II diet by hypercholesterolemic and combined hyperlipidemic women and men. Arterioscler Thromb Vasc Biol 1997;17:Jenkins DJ, Kendall CW, Axelsen M, Augustin LS, Vuksan V. Viscous and nonviscous fibres, nonabsorbable and low glycaemic index carbohydrates, blood lipids and coronary heart disease. Curr Opin Lipidol 2000;11:49-56.Cato N. Stanol meta-analysis. Personal communication, 2000.
28 EFFECT OF A PLANT-BASED DIET 120 patients, LDL , 4 weeksLow fat vs. low fat plusEquivalent macronutrientsLow-fat plus had more vegetables, legumes, whole grainsGardner, Ann Intern Med, 2005
29 EFFECT OF PLANT-BASED DIET LDL mg/dlLow fatLow fat plusConclusion: current guidelines may underestimate potential LDL-lowering effectGardner, Ann Intern Med, 2005
30 Cholesterol-Lowering Foods vs Lovastatin 46 volunteers with hyperlipidemia, 1 month study,foods providedRandomized to control diet vs control diet andlovastatin vs “dietary portfolio”Control diet: vegetarian, very low in saturated fat,whole wheat cereals, low fat dairy foods“Portfolio” diet: also very low saturated fat,vegetarian diet, plus high in plant sterols, soyprotein, soluble fibers, almondsJenkins, Am J Clin Nutr, 2005
32 Cholesterol-Lowering Foods vs Lovastatin LDL CRPControl % -10.0%Control/statin % %Portfolio % %Jenkins, Am J Clin Nutr, 2005
33 Case 450 year old woman, in good health, in for check up. BMI 32 with metabolic syndrome.She says, “ I have to lose weight, and I am planning on doing that. I am about to try the South Beach diet.”
34 COMPARISON OF ATKINS, ORNISH, WEIGHT WATCHERS, AND ZONE 160 patients, randomly assignedIntention to treat at 1 yearAtkins Ornish WW ZoneWt Loss (kg)Completers (%)Completers at 1 yearWt Loss (kg)Dansinger, JAMA 2005
35 COMPARISON OF ATKINS, ORNISH, WEIGHT WATCHERS, AND ZONE Each group: 25% lost 5%, 10% lost 10% of initial weightEach diet reduced LDL/HDL by 10%No significant effects on BP or glucoseWeight loss associated with adherence, but not diet typeCRP and insulin reductions associated with weight loss, but not dietDansinger, JAMA, 2005
36 Dietary Guidelines for Americans, 2005 Adequate nutrients within calorie needs:limit saturated and trans fats, cholesterol, added sugars, salt and alcoholWeight management: balance intake and outputPhysical activity:to reduce risk of disease: 30 min moderate intensity most daysto prevent weight gain: 60 minutesto sustain weight loss: minutesFood groups encouraged:2 cups of fruit/day2.5 cups vegetables/day3 servings whole grains3 servings low-fat dairyDietary Guidelines for Americans, 2005