Dr Catherine Itsiopoulos PhD APD AN

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would you trade in a meal of chargrilled octopus
and souvlaki for a slow-cooked lentil soup and
chicken and broadbean casserole? The impact of
cooking methods on the AGE content of a healthy
Cretan Mediterranean Diet

• Dr Catherine Itsiopoulos PhD APD AN
• Fellow of University of Melbourne
• Diabetes CCRE

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Acknowledgements

• Professor Kerin ODea
• Dr Laima Brazionis
• Dr Karen Walker
• Dr Allison Hodge
• Dr Marno Ryan
• Dr Andrew Wilson
• Dr Andrzej Januszewski, Connie Karshimkus
• AMS Students
• Nor Fadhilla Shahril (Dee)
• Nor Sadaah Idris

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Mediterranean DietWhich One?What are Health
Benefits?
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Epidemiological EvidenceThe Diet and 15-year
Death Rate in the Seven Countries Study

• 15 year death rates of men aged 40-59 yrs at
  entry into the cohort indicated that Greek men
  form Crete had less than half the all-cause
  mortality and less than one tenth the CHD
  mortality compared to other countries in the
  study.
• Mortality was positively related to saturated fat
  intake and negatively related to mono-
  unsaturated fat intake (ie Olive oil).

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The Cretan Mediterranean Diet became the
archetypal Mediterranean Diet

• Food Consumption of Greek Men from Crete in the
• Seven Countries Study
• (Greek men aged 40-59 years 1960-65)
• Food group g/day
• N 31 persons
• Bread 380
• Cereals 30
• Potatoes 190
• Legumes 30
• Vegetables 191
• Fruit 464
• Meat 35
• Fish 18
• Eggs 25
• Cheese 13
• Milk 235
• Sugars 20
• Pastries 0

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What is so special about the Greek diet?

• A more balanced intake of essential fatty acids
  from vegetable, animal and marine sources,
  omega-6omega-3 ratio of about 21 instead of
  101 or 201 as it is in Europe and the U.S.,
  respectively.
• Bioactive phytochemicals high amounts of vitamin
  C, vitamin E, beta-carotene, glutathione,
  phytoestrogens, and phytochemicals from green
  leafy vegetables, phenolic compounds from wine
  and olive oil high intakes of tomatoes, onions,
  garlic and herbs, especially oregano, mint,
  rosemary, parsley and dill that contain lycopene,
  allylthiosulfinates, salicylates, carotenoids,
  indoles, monoterpenes, polyphenols, flavonoids,
  and other phytochemicals, used in cooking
  vegetables, meat and fish.

Simopoulos and Sidosis, World Rev Nutr Diet 2000,
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Clinical EvidenceThe Lyon Diet Heart Study
Can a Mediterranean-type diet reduce the rate of
recurrence after a first MI?

• 605 patients randomly assigned to
  Mediterranean-type diet or control group (AHA
  Step 1 diet) after 1st myocardial infarct
• Mediterranean Intervention All added fats
  replaced with high n3 canola oil and spread more
  fruits/ vegies/ fish and less meat.
• AHA Step 1 diet low fat (30 energy with lt10
  SATF), high n6 PUFAs
• Major findings (after 27 months)
• gt 70 reduction in cardiac deaths and non-fatal
  MI
• 55 reduction in all-cause mortality

de Lorgeril et al, Circulation 99 779-85, 1999
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Mediterranean diet in the management of MetabS

• Randomised trial investigating impact of the Med
  diet on MetabS
• 180 patients with MetabS randomised to Med diet
  or prudent diet (LF, HCHO)
• At 2 yrs patients on Med diet had
• greater weight loss (-4kg vs -1kg)
• greater reduction in inflammatory markers (CRP,
  IL-6)
• greater reduction in IR
• At 2 yrs 40/90 on Med diet still had MetabS
  whereas 78/90 on prudent diet still had MetabS

Esposito et al. JAMA 2004292(12)1440-1446
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Weight change at 2 yrs LF vs LCHO vs Med diet
Med diet more effective on Glycaemic control In
T2DM subjects
Shai N Engl J Med, Volume 359(3).July 17,
2008.229241
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High Monounsaturated fat diet improves glucose
control better than Western diet and Low Fat Diet

• Randomised trial investigating impact of 3 diets
  (MUFA, Western, Low Fat) on insulin resistance
  and glucose tolerance in 46 obese (non-diab)
  subjects
• After 6 months MUFA diet
• 3 FGluc (p0.015)
• 9.4 insulin (p0.035)
• 12.1 HOMA score (p0.020)
• Low fat diet and Western diet increased glycaemic
  variables

Due et al. Am J Clin Nutr 200887855-62.
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Adherence to Med diet and Health Status
meta-analysis

• Systematic review of prospective cohort studies
  on Med diet and mortality and health outcomes
• 12 studies - 1,574,299 subjects (1966-2008 3-18
  yrs duration)
• Greater adherence to med diet associated with
• 9 reduction in overall mortality
• 9 reduction in cardiovascular mortality
• 6 reduction in cancer mortality
• 13 reduction in Parkinsons Alzheimers

Sofi et al, Adherence to Mediterranean diet and
health status meta-analysis. BMJ 20083371344.
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Characteristics of the traditional Cretan
Mediterranean diet
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Olive Oil as the major source of fat
60mls/day
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Vegetables with every meal include leafy greens
and tomatoes

• Include
• 100g leafy greens
• 100g tomatoes
• 200g other veggies

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HortaWild Edible GreensTry these..
raw
cooked
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Purslane Contains n3 FAs
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Legumes at least twice a week

• 250g serve
• 2 x per week

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Fish at least twice per week

• 150-200g serves
• 2 x per week
• Include oily fish

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Meat less often

• Less meat -
• Beef, lamb, pork, chicken
• Not more than once per week

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Fresh fruit every day
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Dried fruit and nuts as snacks
Walnuts are high in ALA
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Yoghurt everyday
Cheese in moderation
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Wholegrain breads and cereals
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Wine in moderation and always with meals

• 1-2 glasses/day
• Always with meals
• Dont get drunk

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Sweets for special occasions only!
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Practical Applications

• Use olive oil as the main added fat (60 mls
  /day)
• Eat vegetables with every meal (include 100g
  leafy greens and 100g tomatoes, and 200g other
  vegetables/day)
• Include at least two legumes meals (250g serve)
  per week)
• Eat at least two servings of fish (150-200g
  serves) per week and include oily fish
• Eat meat (beef, lamb, pork and chicken) less
  often and not more than once per week
• Fresh Fruit everyday and dried fruit and nuts as
  snacks or dessert
• Eat yoghurt everyday and cheese in moderation
• Include wholegrain breads and cereals with meals
• Consume wine in moderation (1-2 glasses per day)
  and always with meals and dont get drunk
• Have sweets or sweet drinks for special occasions
  only.

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Advanced Glycation EndproductsAGEs

• What are they?
• How is Diet Involved?

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What are AGEs?

• AGEs are classically formed by the Maillard
  Reaction (c1912) a non-enzymatic reaction between
  reducing sugars and proteins and fats
  endogenously OR exogenously
• Endogenous AGEs
• Early glycation of proteins e.g. HbA1c
• Early lipoxydation of lipids e.g. LDL, ApoB
• Later glycation of long lived proteins e.g.
  collagen, lens crystalline
• AGE formation accelerated with ageing and
  oxidative stress and diabetes (hyperglycaemia)
• Exogenous AGEs
• Formed in foods by Maillard reaction e.g.
  browning of foods through toasting/ BBQ/ grilling
  at high temperatures.

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AGEs Browning of tissues
Changes of colour of tooth root
surfaces http//www.forsci.cz/podrobnosti/prehled.
jpg
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Age-Related Cataract
Yellowing and opacification of crystalline lens
with ageing
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AGE Formation
HbA1c
CML
http//www.vrp.com/graphics/OCT04BENFOfig1.jpg
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Fate of dietary AGEs
AGE protein
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Health Impact of AGEs
Vascular stiffening
Renal Disease
AGEs
Myocardial dysfunction
Accelerated Ageing
Accelerated Diabetes Complications
Retinopathy
Nephropathy
Neuropathy
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Metabolic Pathways of AGEs

• Chemical nature of AGEs largely unknown
• Pentosidine and CML most commonly found
• AGE intermediates in humans

Carboxyl methyl lysine (CML).
Fluorophore P (Pentosidine).
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Low Molecular Weight Fluorophores and T1 DM

• 37 patients with T1 DM and 112 healthy controls
• LMW F levels measured at 12 and 60 months
• Relative to controls LMW-F were higher in
  diabetes at 12 and 60 months
• 5.4 /- 1.9 vs 3.8/- AU/ml (p0.0001)

Andrzej Januszewski, M Thomas, C Karschimkus et
al., 2008
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Dietary AGEs Studies

• 20 MF with T2DM fed Low and high AGE diets over
  6 day period in randomised cross-over study.
• HAGE diet
• reduced FMD by 36
• Increased serum AGEs and inflamm. (Negrean et al,
  2007).
• 38 MF with T1 T2 DM fed egg white fructose
  (high AGE) vs control.
• HAGE meal
• increased serum AGE and AGE cross-linking.
  (Koschinsky et al, 1999).

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Dietary AGEs Database

• AGEs are deceptive as they give food a desirable
  taste and smell Vlassara Mt Sinai School of
  Medicine
• Databases limited
• Sprite 475 AGE U / 250ml
• Orange juice 600 AGE U/ 250ml
• Tea/ coffee 2,200 AGE U/250ml
• Normal coke 8,500 AGE U/250ml
• Diet coke 9,500 AGE U/250ml
• Effect of cooking
• Doughnut pre 2,590 post 60,820 AGE U/g PRO
• Duck skin pre 2,350 post 236,180 AGE U/ g PRO

Koschinsky et al, 1997
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Why is the Mediterranean Diet Low in AGEs?

• Low in saturated fat
• Moderately low in protein
• Focus on slow and moist method of cooking
• Highly plant based

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The Impact of Cooking Method on the AGE Content
of a Healthy Greek Diet

• Nor Fadhilla Shahril Dee AMS Student
• Supervisors
• Dr Karen Walker
• Dr Catherine Itsiopoulos

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Low and High AGE Randomised Cross-Over
Intervention Study
4 week wash out
Week 8
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AMS Project Effect of Cooking Method on AGE
content of healthy Greek diet
AMS Student Nor Fadhilah Shahril Dee
Randomised cross-over 12 week study in healthy
young people
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Chicken and Broad Bean Casserole
Low AGE 1011 kU/ serve
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Charcoal Chicken and Chips
High AGE 5418 kU / serve
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Baked Snapper
LOW AGE 827 kU / serve
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Fish and Chips
High AGE 7897 kU / serve
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Char-Grilled Octopus
High AGE
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Octopus Casserole
Low AGE
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Souvlaki
HIGH AGE 2,441 kU / serve
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Cooking Team

• Nor Fadhilla Shahril Dee
• Theano Itsiopoulos
• Paraskevi Koutsis
• Karen Walker
• Allison Hodge
• Laima Brazionis
• Catherine Itsiopoulos

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Participant Characteristics

• Healthy, non-smokers
• 5 males and 5 females
• Age 33 /- 6 years
• BMI 25.3 /- 4.6
• Fasting Glucose 5.1 /- 0.5

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Dietary Compliance

• Assessed by 7-day diet diary in last 7 days of
  each diet (days 21-28)
• Analysis of diet records (Foodworks) indicated
  good compliance with prescribed diets
• Overall subjects reported enjoying both diets
• Some subjects reported feeling unwell lethargic/
  heavy feeling/ low energy on HAGE diet
• No effect on mood detected using the WHO-5
  questionnaire.

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Change in serum AGEs (as CML) following low
and high AGE diets


P lt 0.05 ELISA
PRELIMINARY DATA Nor Fadhilla Shahril et al.
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Other Findings

• No change in glycemic parameters
• No change in lipids
• No change in blood pressure
• No change in inflammatory markers (CRP)
• No change in body weight (on either diet)
• Some weight gain observed during washout

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Conclusions

• Elevated plasma AGEs are detrimental to health
  leading to increased markers of inflammation.
• Elevated plasma AGEs are accelerated in diabetes
  and kidney failure due to increased endogenous
  production of AGEs and reduced urinary excretion
  of AGEs (endogenous and from diet).
• A traditional Cretan Mediterranean diet that
  adopts slow cooking methods may provide a lower
  dietary AGEs thus leading to lower plasma AGEs
  and protect against inflammation, particularly in
  diabetes and renal disease.

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Current and Proposed Studies
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AGE Content of Cretan Diet

• Prepare 7 day menu
• High and Low AGE (n14 days)
• Homogenise
• Sample x 3
• Analyse whole days for CML
• Analyse specific dishes (high and low AGE) for
  CML

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Impact of Cretan Diet on Body Fat Distribution in
MetabS and NAFLDMarno Ryan, Allison Hodge,
Catherine Itsiopoulos

• Subjects with Metabolic Syndrome and NAFLD
• Randomise to 6 weeks Cretan diet and cross over
  to 6 weeks low fat diet (NHF)
• Measure impact of Cretan diet on
• Body fat distribution (incl. liver)
• Glycemic parameters
• Lipids
• Inflammatory markers
• Insulin resistance

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Impact of Fish vs Fish Oil on CVD Risk Markers
and Vascular Health Post AMILaima Brazionis,
Andrew Wilson, Catherine Itsiopoulos AMS student
Nor Sadaah Idris

• 20 M and F post AMI to be recruited
• Randomised to fish (2 salmon per week)
• or fish oils (2 capsules per day) for 3 months
• Impact of fish v fish oil on
• body weight
• BP and HR
• Lipids and Glucose
• HDI (small artery elasticity)
• Erythrocyte omega 3 index

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TELOS

• Kalh Ugeia