Dietary Approaches to Management of Metabolic Syndrome

1
Dietary Approaches to Management of Metabolic
Syndrome

• Frank M. Sacks, MD
• Professor of Cardiovascular Disease Prevention,
  Nutrition Department, Harvard School of Public
  Health
• Professor of Medicine, Harvard Medical School

2
Macronutrients (Fat, Carb, Protein)Effects on
Blood Pressure, Blood Lipids, Glucose, Diabetes,
Obesity, Cardiovascular Disease

• Blood pressure control DASH diet, sodium,
  Mediterranean diet
• Blood lipids amount of fat, type of fat
• Blood glucose fat vs carb type, amount fiber
• Overweight and obesity protein, carb, fat

3
Blood Pressure Patterns Worldwide
Japan, UK, Jamaica, USA
Systolic BP
Rural Thailand, Africa, Amazon
Age (yr)
Epstein FH. Epidemiology of Hypertension, 1967
4
Characteristics of Populations with Low Blood
Pressure

• Very low salt intake (10-50 mmol/d)
• Vegetable products are staples
• Low meat intake
• Low prevalence of overweight

5
The DASH Dietary Pattern Foods
Emphasizes Fruits, Vegetables, Low-fat Dairy
Foods Includes Whole Grains, Nuts, Poultry,
Fish Reduced in Fats (27), Red Meat, Sweets,
and Sugar-containing Beverages. Low sodium 65
mmol (1.5 g)
6
70

• Age group

164
Age
Age group
108
70
Vollmer, Sacks et al. Ann Intern Med 20011351019
Vollmer, Sacks et al. Ann Intern Med 20011351019
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Olive Oil, Mediterranean Diet, and Blood Pressure

• Mediterranean diet Reduction in BP
• Strazullo P et al. J Hypertens 19864407
• Esposito K..Giugliano G. JAMA Sept 22/29, 2004
• Olive Oil
• Reduction in BP and reduced BP meds
• Ferrara L et al. Arch Intern Med 2000160
• Olive oil and Mediterranean diet Greek EPIC
  Study
• Both associated with decreased BP
• Psaltopoulou TTrichopolou A. Am J Clin Nutr
  October 4, 2004.
• Cereal intake associated with higher BP
• High Monounsaturated Fat vs High Carb in NIDDM
• Reduced BP Rasmussen OW et al. Diabetes Care
  1993161565
• Large trial near completion (OmniHeart Appel,
  Sacks)

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Increased Dietary Protein

• Higher dietary protein associated with lower
  blood pressure in populations
• Association stronger for vegetable than animal
• Problem of confounding by other nutrients, e.g.
  potassium, fiber
• Small trials show reduced LDL-C and TG (B Wolfe)
• High total dietary protein predictive of reduced
  incidence of coronary heart disease and diabetes
• Direct (causal) effect of increased protein vs
  reduced carb unclear
• Large trial near completion (OmniHeart Appel,
  Sacks)

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Dietary Fats, Lipoproteins and CHD
10
Predicted changes in plasma cholesterol and
triglyceride concentrations caused by three types
of diet treatment
Sacks Katan. Am J Med, 2002113(9B)13s
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Carbohydrate and Blood Triglycerides and HDL

• VLDL TG, apoB and apoCIII concentrations increase
• Increased TG production by liver and reduced
  clearance from the circulation
• Huff Nestel. Metabolism 198231493 Parks
  Hellerstein. AJCN 200071412
• Long-lasting effect, 2 yr (Retzlaff et al. AJCN
  199562988)
• Worse in overweight or obese
• Not eliminated by modest weight loss (Knopp et
  al. JAMA 19972781509)
• Apo A-I production decreases, clearance increases
  
• Brinton, Eisenberg, Breslow. J Clin Invest
  199085144
• These mechanisms may be detrimental

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Randomized Clinical Trials of Polyunsaturated Fats
CVD
N
Fat
Yrs
Cholesterol
6 5 4 8
34 39 46 39
Finnish Hospital Oslo MRC Soy Oil Los
Angeles (Dayton)
676 412 393 846
-15 -14 -15 -13
-43 -25 -12 -34
Linoleic was the major fat that replaced
saturated, but alpha linolenic acid also
increased.
P lt 0.05
Sacks Katan. Am J Med. 2002 Dec 30 supplement.
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DiabetesDietary Fats, Carbohydrates, Fiber
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Effect of Dietary Carbohydrate and
Monounsaturated Fat on Glucose and Insulin Levels
in Type 2 Diabetes
? High Carb 55 carb, 30 fat ? High Mono 40
carb, 45 fat
? Meals
N42, Crossover, 6 weeks
Garg et al. NEJM 1994 2711421
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Polyunsaturated Fat Improves Insulin Sensitivity
Polyunsaturated Fat
Saturated Fat
N17, P0.02
Euglycemic hyperinsulinaemic clamp
SummersFrayn. Diabetologia 200245369
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Glycemic index of High-Carb Diet Affects Plasma
Glucose and Insulin in Type 2 Diabetes
Both Diets Carb 55, Starch 210g, Sugars 32g,
Fiber 36g, Fat 28
? High Glycemic Index ?Low Glycemic Index
N20, Crossover, 24 days
Jarvi..Vessby. Diab Care 19992210
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High Fiber Diet Improves Plasma Glucose and
Insulin Concentrations in Type 2 Diabetes
Glucose
Fiber Content ? ADA diet 24 g ? High Fiber 50 g
Both Diets Carb 55, Fat 30
Insulin
N13, Crossover, 6 weeks
Chandalia et al., 2000 NEJM 3421395.
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Effect of peas vs potatoes in mixed meals on
glucose and insulin in type 2 diabetes
Plasma Glucose
Serum Insulin
?Potatoes Peas and Potatoes ?Peas
?Potatoes Peas and Potatoes ?Peas
Schafer et al. AJCN 20037899
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Diet Type and ObesityThree Viewpoints
Low-fat, High-carb
Moderate-fat Calorie Reduced
Low-Carb, High Protein

• Low energy density
• High satiety
• Less flavor
• Metabolism of carb is less efficient than fat.
  Less fat deposition during overfeeding

• Highest satiety
• Ketosis
• Low glycemic load
• Appetite suppression
• Reduced food intake

• Food intake reduced by portion control
• More flavors increase satisfaction and long-term
  adherence
• Low glycemic load reduces late-day intake

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Low-Fat, High-Carbohydrate Diets That Caused
Weight Loss

• Strict Vegetarians in Boston
• 73 men, 43 women, mostly in their 20s, adherent
  for 3 years
• Fat 22, Carb 65, Protein 13, High Fiber
• Whole grains only no sugar
• Matched for age and sex with nonvegetarians in
  Framingham
• Body weight 128 lb (58 kg) vs 161 lb (73 kg)

Sacks FM et al. N Engl J Med 19752921148
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Low-Fat, High-Carbohydrate Diets That Caused
Weight Loss

• 20 Coronary Disease Patients, San Francisco
• Fat lt10, meals provided
• Body weight
• Baseline 200 lb (91 kg)
• After 1 year 178 lb (81 kg)
• After 5 years 183 lb (83 kg)
• Control group increased 5 lb (2 kg)

Gould KL et al. JAMA 1995274894 Ornish D et al.
Lancet 1990336129
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Diet Type and Weight Loss

• Low-Fat Diets caused substantial weight loss in
  highly motivated, supervised people
• What does a low-fat diet do in more
  representative, less supervised groups?
• How do low-fat diets compare with reduced calorie
  moderate-fat diets?

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26.062
24
Moderate Unsaturated Fat vs Low-Fat Diet Weight
Loss
Months
McManus, Antinoro, Sacks. Int J Obesity 200125
1503-11
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Moderate Unsaturated Fat vs Low-Fat Diet
Participation Rates
McManus, Antinoro, Sacks. Int J Obesity 200125
1503-11
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Dietary Intake on the Moderate-Fat Compared to
the Low-Fat Diet

• Increases in beneficial nutrients
• Polyunsaturated fat
• Fiber
• Protein
• Increases in vegetable intake

27
Low-Carb Diet vs Low-Fat Diet for Weight Loss
Stern LSamaha F. Ann Intern Med 2004140769
28
Conventional Diet vs Atkins Low Carbohydrate Diet
0
Conventional Diet
-4
NS
P .001
P .02
Change in Weight ()
-8
Low Carbohydrate Diet
-12
0
6
3
9
12
Month
Foster GD, et al. N Engl J Med.
20033482082-2090.
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How Much Fat, Carb, and Protein for Weight
Loss? A New Trial with NHLBI

• Aim is to determine the optimal proportions of
  fat, protein, and carbohydrate for weight loss
  and maintenance.
• There will be 800 overweight or obese people to
  participate in Boston (Harvard School of Public
  Health) and Baton Rouge (Pennington, LSU)
• Duration of treatment is 2 years

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Weight Loss Trial

• These diets will be taught
• 1. Low-fat (20), average protein (15), high
  carb (65)
• 2. Low-fat (20), high protein (25), average
  carb (55)
• 3. Moderate fat (40), average protein (15), ave
  carb (45)
• 4. Moderate fat (40), high protein (25), low
  carb (35)

All dietary approaches will be consistent with
what we know about diet and cardiovascular
disease and cancer.
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Dietary Treatment and the Metabolic Syndrome

• Hypertension
• DASH diet, Mediterranean diet, low sodium
• Improved lipids, prevention of CHD
• More unsaturated fats, less saturated and trans
• Less carbohydrate
• Improved glycemic control in NIDDM or MetSyn
• More unsaturated fat, less carb
• Lower glycemic index of carb (whole grains,
  beans)
• High fiber
• Treatment of overweight and obesity
• Lower carb, higher unsat fat and protein is
  probably better for weight loss and lipids