1. Nutrition and Chronic Illness Kathaleen Briggs Early, PhD, RD, CDE Assistant Professor of Biochemistry and Nutrition kearly@pnwu.org

2. Learning Objectives o Upon completion of this module, the student will be able to: 1.Explain the severity of the worldwide obesity epidemic 2.Identify how chronic diseases can be prevented by proper nutrition and lifestyle 3.Identify what dietary regimens are beneficial for chronic disease management 4.Explain why breastfeeding is the best choice for infant feeding 2

3. Chronic Disease o A long-term condition – e.g., obesity, diabetes, and cardiovascular disease o May be prevented or delayed with lifestyle changes – e.g., healthier eating and more physical activity o According to the WHO “…by 2020, chronic diseases will account for almost three-quarters of all deaths worldwide, and that 71% of deaths due to ischaemic heart disease (IHD), 75% of deaths due to stroke, and 70% of deaths due to diabetes will occur in developing countries. The number of people in the developing world with diabetes will increase by more than 2.5-fold, from 84 million in 1995 to 228 million in 2025. On a global basis, 60% of the burden of chronic diseases will occur in developing countries.” 3

4. Nutrition for Chronic Disease Prevention and Treatment o Nutrition is a widely accepted tool for prevention of chronic diseases o Nutrition is also very important for management and treatment of a chronic diseases o This presentation will discuss cardiovascular diseases (e.g., heart disease and stroke), obesity and diabetes, and how they can be prevented and treated with nutrition 4

5. Classification BMI(kg/m � ) Principal cut-off pointsAdditional cut-off points Underweight<18.50 Severe thinness<16.00 Moderate thinness16.00 - 16.99 Mild thinness17.00 - 18.49 Normal range18.50 - 24.99 18.50 - 22.99 23.00 - 24.99 Overweight≥25.00 Pre-obese25.00 - 29.99 25.00 - 27.49 27.50 - 29.99 Obese≥30.00 Obese class I30.00 - 34-99 30.00 - 32.49 32.50 - 34.99 Obese class II35.00 - 39.99 35.00 - 37.49 37.50 - 39.99 Obese class III≥40.00 http://apps.who.int/bmi/index.jsp?introPage=intro_3.html 5

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7. Value of waist circumference o Location of excess fat is important o If excess fat is mainly around midsection = more likely to develop health problems than if excess fat is mainly around hips and thighs Apple vs. Pear shapes True even if BMI falls within the normal range o Women: waist measurement of more than 35 inches (88 cm) o Men: waist measurement of more than 40 inches (102 cm) 7 Higher risk body shape Lower risk body shape

8. Use BMI and Waist Circumference o Use it with every patient visit o Can identify those patients at risk for chronic disease with confidence o Should be incorporated into vital signs and patient check-in procedures o Quick, cheap, and easy to do! 8

9. The role of genetics in body weight o Epidemiological evidence shows that obesity, excess energy (Calorie) intake, and sedentary lifestyle are primary contributors to the chronic disease epidemic o 40% of BMI is attributable to independent genetic influences 9

10. Obesity and Nutrition Transition “Obesity in the developing world can be seen as a result of a series of changes in diet, physical activity, health and nutrition, collectively known as the 'nutrition transition.' As poor countries become more prosperous, they acquire some of the benefits along with some of the problems of industrialized nations.” 10

11. Worldwide Obesity Epidemic o 2.5 million deaths can be attributed to overweight/obesity worldwide o Nearly 70% of cases of CVD are associated with obesity o Worldwide, more than 1.1 billion overweight adults At least 312 million of them are clinically obese By the end of 2010, an estimated 43 million children under five will be overweight o Obesity levels range from 20-30% in European countries, to over 70% in Polynesia o By 2015, the worldwide obese population will reach 1.5 BILLION 11

12. Diabetes o Characterized by increased blood glucose (sugar) levels o Due to 1.a lack of insulin (a hormone), which controls blood glucose levels And/Or 2.an inability of the body’s tissues to respond properly to insulin (a state called insulin resistance) o The most common type of diabetes is type 2 o Diabetes can benefit from good nutrition 12

13. Types of Diabetes – Type 1 diabetes an autoimmune condition resulting in the need for lifelong insulin therapy – Type 2 diabetes Progressive disease related to insulin resistance May be managed with just diet and exercise, or may require oral medication and/or insulin injections Most commonly seen in overweight/obese people, but can also develop in normal weight people – Gestational Diabetes Diabetes that develops during pregnancy 13

14. Nutrition for Diabetes o Goal of nutrition therapy – To help people with diabetes learn how to make healthy food choices, which will optimize glycemic control and prevent complications – A healthy, well-balanced diet – There is no one “diabetic diet” Healthy eating for diabetes includes whole grain cereals, lean protein foods, fruits, generous portions of non-starchy vegetables Ideally, a person with diabetes receives an individualized meal plan from a nutritionist or dietitian 14

15. Nutrition for Diabetes – Questions to ask patients: What are the food-related factors that increase one’s chance of developing diabetes? – Answer: Obesity (in part due to excess food intake) is the only food-related cause of diabetes. Eating too much sugar does not cause diabetes. What are the factors that influence eating habits? – There are many factors that influence food choices and eating habits. Economic and family situation, geography and cultural all contribute to food choices. 15

16. Nutrition for Diabetes Questions to ask patients: – What types of foods do you normally eat? This allows identification of healthy vs. less healthy eating patterns – What types of foods do you eat after waking? Carbohydrate foods are less well-tolerated in the morning hours during pregnancy – Are you able to monitor your blood sugar? If patients have access to a glucometer and test strips, monitoring post-meal blood sugars can be a useful tool in assessing dietary factors Elevated post-meal blood sugars may indicate too much carbohydrate is being consumed, or inadequate medication or insulin is being provided 16

17. Managing Type 2 Diabetes o Glycemic Control – Self-monitoring should only be considered when the person with diabetes and their health care team is prepared to learn the skill, record the findings, understand the data, and act appropriately on the data – Desired plasma glucose levels are <6.0 mmol/l (<110 mg/dl) before meals, and <7.8 mmol/l (<140 mg/dl) 2 h after meals. Allow higher targets for patients on insulin or sulfonylureas at risk for hypoglycemia 17

18. Managing Type 2 Diabetes o Provide dietary counseling that optimizes a healthy weight and reduces cardiovascular risk profile (e.g., low fat, low salt) o Using the plate method is one way to instruct lower-literacy patients on a healthy diabetes meal plan 18

19. The Plate Method o Easy to teach o Easy to understand o Based on dividing portions onto a standard 9” plate 19

20. 20 http://www.dlife.com/diabetes/information/inspiration_expert_advice/expert_columns/Pr escriptionSolutionsPlatePlannerEnglish_LetterSize_3-09.pdf

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22. Cardiovascular Disease o Caused by disease of the blood vessels (atherosclerosis) of the heart, usually as part of the process which affects blood vessels more generally o Stroke and heart disease are the main cardiovascular diseases – Stroke is the main cardiovascular disease in many east Asian countries 22

23. Nutrition for Cardiovascular Disease o Eat a diet rich in fruits, vegetables and whole cereal grains – This provides potassium and fiber, both clearly linked to reduced chronic disease risk o Don’t add salt during food preparation o Limit use of processed and pre-prepared food items – They are typically very high in salt o Cook with no or very minimal added fats and oils – If fat or oil is used, unsaturated is healthiest option (canola, olive, etc) o Maintain a healthy body weight o Control blood pressure and blood sugar 23

24. Successful Long-term Weight Control o Long-term behavioral treatment, whatever form it takes, encourages patients to practice four key behaviors 1.Exercise regularly 2.Consume a lower-calorie diet 3.Monitor weight regularly 4.Record food intake and physical activity 24

25. Preventing Chronic Diseases o Maintain a healthy body weight – The WHO goals are For an adult median BMI of 21 to 23 kg/m 2 For individuals, the recommendation is to maintain a BMI in the range 18.5 to 24.9 kg/m 2 and to avoid a weight gain greater than 5 kg (11 pounds) during adult life 25

26. Preventing Chronic Diseases: Physical Activity o Stay physically active – The WHO goal is for all people to get one hour per day on most days of the week of moderate-intensity activity, such as brisk walking 26

27. Preventing Chronic Diseases: Breastfeeding o Infants should be breastfed for at least 6 months o Breastfeeding is convenient – Food is readily available for the infant, and requires no special preparation or equipment o Provides the best balance and quantity of nutrients ideal for the human infant o Both colostrum and breastmilk have anti-infective constituents that help limit infectious disease o Bottle feeding increases risk of infections from contamination with pathogenic organisms in the milk, the formula and the water used in preparation, as well as in bottles, teats (bottle nipples) and other items used for infant feeding 27

28. Preventing Chronic Disease: Breastfeeding o More economical than bottle-feeding – Bottle feeding involves costs for infant formula the bottles and teats and the fuel necessary for bottle sterilization o Prolongs the duration of post-partum anovulation, helping mothers to space their children o Enhances bonding and relationship between mother and infant o Seems to reduce the risk of allergies, obesity and certain other health problems 28

29. Preventing Chronic Diseases: Summary Points o Chronic diseases can be prevented with lifestyle changes – Lifestyle changes include healthier eating, increasing physical activity, and smoking cessation o Very active populations with diets rich in vegetables, legumes, fruits and whole grains may have a total fat intake of up to 35% of total calories without the risk of unhealthy weight gain. WHO, 2003 29

30. Contact Information Kathaleen Briggs Early, PhD, RD, CDE kearly@pnwu.org