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Episode 10 - Diseases and Chronic Conditions

  • EBE
  • Jan 6, 2020
  • 10 min read

According to the World Health Organization There is a significant relationship between what we eat, our physical activity and chronic diseases (Diabetes, Heart Disease, osteoarthritis, cancer, dental disease). We are going to address the nutritional advice for Obesity, Diabetes, Heart Disease (hypertension and hyperlipidemia), and Cancer. Because of the complex and interconnected relationship between obesity and Diabetes, Heart Disease, and Cancer I will be addressing it within each one of those specific conditions.


Obesity and physical inactivity are the two most significant causes of Type 2 Diabetes. As previously mentioned in Episode 3 about genetics, there are many genetic factors that underlie obesity and type 2 diabetes; however, even in individuals who have genetic predisposition it is possible to prevent Type 2 Diabetes with exercise and nutrition. Complications of diabetes are numerous and devastating. The best way to avoid type 2 diabetes and the complications of diabetes (such as vision loss, limb loss, kidney disease, stroke, hypertension) is to control your blood sugar through nutrition and exercise.

Exercise increases your bodies tissues receptiveness for blood sugar and thus significantly decreases one's risk of type 2 diabetes even in the setting of obesity (Obesity Action Coalition). "Two randomized trials each found that lifestyle interventions including ∼150 min/week of physical activity and diet-induced weight loss of 5–7% reduced the risk of progression from impaired glucose tolerance (IGT) to type 2 diabetes by 58% " (Dr. Ronald Sigal, Diabetes Care, 2006)


How does diet change our risk of Obestity, Diabetes (DM), Heart Disease (HD), and Cancer?


Diabetes

Type 1 Diabetes: At this time we do not know of any nutritional factors that are causative to type 1 diabetes, the best way to navigate nutrition after the diagnosis of type 1 diabetes is to work with a registered dietitian who has specialized in type 1 diabetes.


Type 2 Diabetes: Diet, exercise, and environment play a very significant role in your risk of acquiring type 2 diabetes. When we talk about risk factors for type 2 diabetes there are modifiable and unmodifiable risk factors. Modifiable risk factors are what you eat and how much you exercise. Unmodifiable risk factors are your genetics. For some income & environment are unmodifiable risk factors and there is currently a strong relationship with low income and obesity /type 2 diabetes. The relationship between income and diabetes risk is due to accessibility of fruits and vegetables. If you are a patient affected by food scarcity, please talk with your physician about your challenges accessing food.

Obesity and physical inactivity are the two most significant causes of Type 2 Diabetes. As previously mentioned in Episode 3 about genetics (unmodifiable risk factor), there are many genetic factors that underlie obesity and type 2 diabetes; however, even in individuals who have genetic predisposition it is possible to prevent Type 2 Diabetes with exercise and nutrition. Complications of diabetes are numerous and devastating. The best way to avoid type 2 diabetes and the complications of diabetes (such as vision loss, limb loss, kidney disease, stroke, hypertension) is to control your blood sugar through nutrition and exercise.


Diet and Exercise have both been significantly evaluated for their role in Type 2 Diabetes. In a 2017 Cochrane review found that diet + physical activity reduces or delays the incidence of type 2 diabetes in those with impaired glucose tolerance (pre-diabetes).

Healthy A1C less than 5.6

Pre diabetes = A1C of 5.7 - 6.4

Type 2 Diabetes = A1C of greater than 6.5

Thus the most important thing to focus on, especially if you have a strong family history of type 2 diabetes (parents, grandparents, siblings have type 2 diabetes), is starting early on incorporating exercise and nutrition lifestyle changes. Adding in exercise maintains peripheral tissue utilization of insulin = your muscles and fat cells will take the sugar insulin brings to them. Remember, type 2 diabetes is based on insulin resistance at peripheral tissues and exercise is the best way to avoid peripheral tissue glucose resistance; meaning your organs, muscle, and fat cells stop accepting glucose from your blood and this is called glucose intolerance or impaired glucose tolerance. Because, exercise increases your bodies tissues receptiveness for blood sugar it significantly decreases one's risk of type 2 diabetes even in the setting of obesity (Obesity Action Coalition, AAFP, ADA). "Two randomized trials each found that lifestyle interventions including ∼150 min/week of physical activity and diet-induced weight loss of 5–7% reduced the risk of progression from impaired glucose tolerance (IGT) to type 2 diabetes by 58% " (Dr. Ronald Sigal, Diabetes Care, 2006). Although the aforementioned 2017 Cochrane review found that there was not enough evidence that diet or physical activity alone was sufficient to prevent Type 2 Diabetes, it did find that when diet and physical activity were modified simultaneously there was a 26% reduction in Type 2 Diabetes. So in summary, for individuals with elevated unmodifiable risk factors (genetics) or impaired glucose tollerance the best way to prevent Type 2 Diabetes is to exercise and modify diet.


Diet for prevention of Type 2 Diabetes: the best way to prevent type 2 diabetes or avoid long-term complications related to diabetes is to keep your A1C <7% this means following a diet that keeps your blood sugar average below 150ug/dL. For many people the means following a low glycemic index diet, but everyone is unique so I encourage you to incorporate a lifestyle change that allows you to manage your blood sugar. Diets that have demonstrated good clinical evidence in Type 2 Diabetes:

Diabetic Nephropathy is a very common complication of prolonged type 1 and type 2 diabetes. Of course the best way to avoid complication with diabetes is to have excellent blood sugar control (A1C <7), and the best way to avoid diabetic nephropathy is to take your ACE inhibitor or ARB if it was prescribed to you. In addition to maintaining good blood sugar control, there are 2 dietary interventions that we wanted to investigate with regard to diabetic nephropathy. Below we address both the role of sodium and protein in diabetic nephropathy:


1) Should I reduce my protein intake if I have diabetic nephropathy? Cochrane Review: “The results show that reducing protein intake appears to slightly slow progression to renal failure but not statistically significantly so”


2) Should I reduce my sodium if I have diabetic nephropathy? Cochrane Review: “this meta-analysis shows a large fall in BP with salt restriction, similar to that of single drug therapy. All diabetics should consider reducing salt intake at least to less than 5-6 g/day in keeping with current recommendations for the general population and may consider lowering salt intake to lower levels”



Heart disease

Heart Disease which can be congenital (not covered here) or acquired is the leading cause of death in the USA and is due to hypertension and hyperlipidemia.


Hypertension is defined by the American Heat Association as a blood pressure that is higher than 120/80. The number on top (120) is called the systolic pressure and is the force your heart has to pump against. The bottom number is the diastolic number (80) and is the force blood exerts on your vessels when the heart is between beats. Typically both systolic and diastolic pressure increases simultaneously as your blood vessels become stiff (atherosclerosis). Atherosclerosis is a normal part of aging but can occur at earlier ages because of lifestyle factors. Additionally, high blood pressure can occur from other causes such as diabetes, obesity, chronic kidney disease and these states also increase your rate of atherosclerosis thereby increasing your blood pressure further. NIH states that the risk factors for Atherosclerosis are high blood cholesterol levels (hyperlipidemia), high blood pressure (from diabetes, chronic kidney disease, high sodium diet), smoking, obesity, lack of physical activity, unhealthy diet (high saturated fats, high sodium, high sugar).


There are significant relationships between obesity, hypertension, and hyperlipidemia. Diabetes, Hypertension, and Hyperlipidemia also have significant genetic causes and predispositions as well. Because Hyperlipidemia is a complex chronic disease I have included below more details about specific genetic factors implicated in it's pathology. Outside of those genetic factors The recommendations to avoid hypertension (blood pressure greater than 120/70) and hyperlipidemia/high cholesterol is to:

  • Eat a low sodium diet (less than 5g of sodium per day)

  • Eat a low saturated fat diet

“ The best diet for preventing heart disease is one that is full of fruits and vegetables, whole grains, nuts, fish, poultry, and vegetable oils; includes alcohol in moderation, if at all; and goes easy on red and processed meats, refined carbohydrates, foods and beverages with added sugar, sodium, and foods with trans fat.” (Harvard)


“A diet rich in fruits, vegetables, and low-fat dairy foods and with reduced saturated and total fat can substantially lower blood pressure. This diet offers an additional nutritional approach to preventing and treating hypertension. “ (NEJM)


For evaluation of specific diets with regard to HD:

Should I decrease my saturated fat intake if I have heart disease?

Cochrane "found that cutting down on saturated fat led to a 17% reduction in the risk of cardiovascular disease (including heart disease and strokes), but no effects on the risk of dying. The review found no clear health benefits of replacing saturated fats with starchy foods or protein. Changing the type of fat we eat, replacing saturated fats with polyunsaturated fats, seems to protect us better, reducing our risk of heart and vascular problems. The greater the decrease in saturated fat, and the more serum total cholesterol is reduced, the greater the protection. People who are currently healthy appear to benefit as much as those at increased risk of heart disease or stroke (people with high blood pressure, high serum cholesterol or diabetes, for example), and people who have already had heart disease or stroke. There was no clear difference in effect between men and women.”


Should I decrease my sodium intake if I have high blood pressure?

Yes, especially if you have black or hispanic ancestry, as there is a greater reduction of blood pressure in low sodium diets in these groups. However, a low sodium diet does not improve blood lipid levels (no decrease in cholesterol or triglycerides). (Cochrane)


Resources for low sodium diets



Genetics for hyperlipidemia (high blood cholesterol & triglycerides)

Familial hypercholesterolaemia is an inherited disorder characterised by a raised blood cholesterol and premature ischaemic heart disease. Changing diet is an important management option to reduce low‐density lipoprotein cholesterol (LDL = the bad cholesterol) levels. Recently, certain lipid‐lowering drugs have shown to be safe and effective for the treatment of children with familial hypercholesterolaemia.


Management of FH aims at lowering LDL by ≥ 50% or to < 3.36 mmol/l (130mg/dL). Statins are the most preferred pharmacological agents recommended for the treatment of FH along with diet and physical activity management in all age groups (Avis 2007; Shafiq 2007).


in 2014 Cochrane review reviewed diet interventions in familial hypercholesterolemia and found: that plant protien (soy), dietary fibers, plant sterols, and omega 3 fatty acids were able to lower total cholesterol levels greater than a cholesterol-lowering diet. They also found that guar gum when given in addition to bezafibrate reduced total cholesterol and LDL better than bezafibrate alone.


Medications for FH: Four statins (lovastatin, simvastatin, pravastatin and atorvastatin) have also been approved by U.S. Food and Drug Administration (US FDA) for use in children with familial hypercholesterolaemia. Children who do not achieve the LDL cholesterol goal after prescribed initial statin dosing need higher dose of statin or addition of another lipid lowering agent. Ezetimibe, a cholesterol absorption inhibitor, is recommended as a monotherapy or in combination with statins in children and adolescents (Yeste 2009). Bile acid sequestrants cholestyramine and cholestipol are not recommended for use in pediatric age group due to severe gastrointestinal side effects and poor palatability. Colesvelam, another bile acid sequastrant, can be used in boys aged 7 to 10 years and in postmenarchal girls as monotherapy or as adjuvant to statins. Niacin and fibrates are not recommended in the pediatric age group due to their adverse effects (O'Connor 1990; Tonstad 1997a)



Cancer:

There are familial cancers (not covered here) and there are spontaneous cancers w/ genetic underpinnings. The cancers that are the most influenced by diet are GI/GU tract cancers (liver, pancreas, stomach, colon cancer, bladder cancer).


“While diet and weight loss are central for cancer prevention, combining a good diet with other healthy habits can further lower your risk, according to a study in the May 2016 issue of JAMA Oncology.


Harvard researchers examined four main lifestyle areas that are associated with health status: smoking, drinking, weight, and exercise. They looked at 46,000 men over 26 years and classified about 12,000 as a low-risk group because they engaged in defined healthy behavior in all four areas—they did not smoke, drank moderate amounts of alcohol (no more than two servings per day), had a body mass index of 18.5 to 27.5, and engaged in 150 minutes of moderate-intensity exercise per week. When they compared these men with others who did not meet these standards, the researchers discovered that men could avert or delay 67% of cancer deaths and prevent 63% of new malignancies each year. In terms of specific cancers, men could reduce incidence of bladder cancer by 62%, prostate cancer by 40%, and kidney cancer by 36%.”


A 2014 study in The Lancet found that a higher body mass index increases the risk of developing some of the most common cancers. Scientists discovered that among five million people studied, gain of 34 pounds was linked with a 10% or higher risk for colon, gallbladder, kidney, and liver cancers. The connection? Experts say body fat produces hormones and inflammatory proteins that can promote tumor cell growth.


Cocrane 11/02/19 examined dietary interventions for adult cancer survivors. They found that dietary interventions did not significantly change the risk of mortality (death) and did not make a difference in the occurrence of secondary malignancies (another cancer). Co‐morbidities were not measured in any included trials. The dietary interventions they evaluated did not make a difference in energy intake (total calories eaten per day remained the same between study groups); but the dietary interventions did increase participants fruit and vegetable servings. They found that most participants did not have a change in waist -to-hip ratio.


Resources for current clinical trials, fact sheets, etc https://www.nal.usda.gov/fnic/cancer

 
 
 

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