Writing The Nutrition Prescription

Primary Care Nutrition
Writing the Nutrition Prescription

http://taylorandfrancis.com
Writing the Nutrition Prescription
David Heber
Zhaoping Li
CRC Press
Taylor & Francis Group
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Library of Congress Cataloging‑in‑Publication Data
Names: Heber, David, author. | Li, Zhaoping, 1962- author.

Title: Primary care nutrition : writing the nutrition prescription / David Heber, Zhaoping Li.
Description: Boca Raton : Taylor & Francis, 2017. | Includes bibliographical references and index.
Identifiers: LCCN 2016056394 | ISBN 9781498748339 (hardback : alk. paper)
Subjects: | MESH: Diet Therapy | Primary Health Care | Overweight--diet therapy |
Nutritional Physiological Phenomena | Health Promotion
Classification: LCC RA784 | NLM WB 400 | DDC 613.2--dc23
LC record available at https://lccn.loc.gov/2016056394
Visit the Taylor & Francis Web site at

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Contents
Preface............................................................................................................................................ xiii
Authors............................................................................................................................................xvii
Chapter 1 Incorporating Nutrition into the Primary Care Practice............................................... 1

1.1 Introduction........................................................................................................1
1.2 Survey Your Practice Population’s Nutrition Status and Lifestyle..................... 1
1.2.1 The Global Nutrition Transition and Your Practice.............................. 2
1.2.2 Food Insecurity and Low Socioeconomic Status.................................. 3
1.2.3 Relative Food Costs and Calories per Bite............................................ 4
1.3 Identifying Medical, Nutritional, Behavioral, and Exercise Resources
Available............................................................................................................. 5
1.4 Obtaining the Equipment Needed for Primary Care Nutrition Practice............ 6
1.5 Outfitting Your Office to Accommodate Obese Patients................................... 7
1.6 Training Your Staff to be Empathetic and Have Supportive Interactions.......... 7
1.7 Modifying Routines to Maintain Efficient Patient Flow.................................... 9
1.8 Providing Internet Resources for Self-Monitoring and Reporting
Progress to Your Practice...................................................................................9
1.9 Establish Methods to Obtain Reimbursement for Your Services..................... 10
1.10 Primary Care Algorithm.................................................................................. 11
References................................................................................................................... 11
Chapter 2 Personalization of Nutrition Advice............................................................................ 15

2.1 Introduction...................................................................................................... 15
2.2 Understanding the Dietary Guidelines and Government Advice..................... 16
2.2.1 Personalization of Dietary Guidelines................................................ 17
2.2.2 Recommended Dietary Allowances: A Brief History........................ 18
2.2.3 Dietary Reference Intakes................................................................... 19
2.2.4 The 2015–2020 Dietary Guidelines....................................................20
2.2.5 Dietary Patterns Recommended by the 2015–2020 U.S. Dietary
Guidelines........................................................................................... 21
2.2.6 Physical Activity Guidelines............................................................... 21
2.2.7 Daily Values and Label Reading......................................................... 22
2.3 Body Composition and Personalization of the Nutrition Prescription............. 22
2.3.1 Rationale for a Balanced Diet Based on Supplemented
Personalized Protein............................................................................26
2.3.2 Protein Quantity and Quality.............................................................. 31
2.3.3 Carbohydrates and Fibers.................................................................... 32
2.3.4 Simple Sugars and Complex Carbohydrates....................................... 32
2.3.5 Glycemic Index, Glycemic Load, and Calories.................................. 33
2.3.6 Fats and Oils........................................................................................ 37
2.3.7 Dietary Pattern That Prevents Weight Gain........................................40
2.4 Optimizing Vitamin, Mineral, and Micronutrient Intake from Foods
and Supplements............................................................................................... 41
2.4.1 Fat-Soluble Vitamins: A, D, E, and K................................................. 42
2.4.1.1 Vitamin A............................................................................ 42
v
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2.4.1.2 Vitamin D............................................................................ 43

2.4.1.3 Vitamin E............................................................................. 45
2.4.1.4 Vitamin K............................................................................46
2.4.2 Water-Soluble Vitamins...................................................................... 47
2.4.2.1 Vitamin B1 (Thiamin)......................................................... 47
2.4.2.2 Vitamin B2 (Riboflavin)...................................................... 47
2.4.2.3 Vitamin B6 (Pyridoxine)..................................................... 47
2.4.2.4 Niacin................................................................................... 48
2.4.2.5 Folic Acid............................................................................. 48
2.4.2.6 Vitamin B12......................................................................... 48
2.4.2.7 Choline................................................................................. 49
2.4.2.8 Pantothenic Acid and Coenzyme A..................................... 50
2.4.2.9 Biotin................................................................................... 50
2.5 Writing the Exercise Prescription and Evaluating Fitness............................... 51
2.6 Leveraging Dietetic and Nursing Support........................................................ 52
2.7 Issues Around Botanical Dietary Supplements................................................ 52
2.8 Enabling Patient Choice in Nutrition for Diets and Supplements.................... 52
References................................................................................................................... 53
Chapter 3 Nutrition and the Immune System.............................................................................. 57

3.1 Introduction...................................................................................................... 57
3.2 The Fat Cell as an Endocrine and Immune Cell.............................................. 57
3.3 Malnutrition and Immune Function................................................................. 58
3.4 Immune Function in Obesity............................................................................ 58
3.5 Immune Function and Vitamin and Mineral Balance..................................... 59
3.6 Interaction of Omega-3 Fatty Acids and Macrophage.....................................60
3.7 Caloric Restriction without Malnutrition and Immune Function..................... 61
3.8 Gut Microbiota and Immune Function............................................................. 62
3.9 Practical Considerations for Modulating Immune Function............................ 65
References...................................................................................................................66
Chapter 4 Nutrition and Gastrointestinal Disorders.................................................................... 71

4.1 Introduction...................................................................................................... 71
4.2 Food Addiction or Simply Craving?................................................................. 72
4.3 Eating Disorders: From Bulimia to Anorexia Nervosa.................................... 73
4.4 Treatment of Eating Disorders......................................................................... 73
4.5 Food Intolerance and Food Allergy................................................................. 74
4.6 Irritable Bowel Syndrome................................................................................ 75
4.7 Gluten Enteropathy and Gluten Sensitivity...................................................... 76
4.8 Inflammatory Bowel Diseases.......................................................................... 77
4.8.1 Malnutrition......................................................................................... 77
4.8.2 Enteral and Parenteral Nutrition......................................................... 77
4.8.3 Breastfeeding....................................................................................... 77
4.8.4 Specific Carbohydrate Diet................................................................. 78
4.8.5 FODMAP Diet.................................................................................... 78
4.8.6 Western Diet and Obesity.................................................................... 78
4.8.7 Omega-3 Polyunsaturated Fatty Acids................................................ 79
4.8.8 Vitamin D............................................................................................ 79
4.9 Summary.......................................................................................................... 79
References...................................................................................................................80
Contents vii
Chapter 5 Approach to the Overweight and Obese Patient: The Elephant in the Room............. 85
5.1 Introduction...................................................................................................... 85
5.2 Pathophysiology of Obesity.............................................................................. 85
5.2.1 Genetic and Environmental Interactions in Obesity........................... 87
5.2.2 Biological Signals Regulating Food Intake......................................... 88
5.2.3 Protein Is the Most Satiating Macronutrient.......................................90
5.2.4 Drugs for Obesity................................................................................90
5.2.5 Surgical Approaches to Obesity.......................................................... 91
5.3 Impact of Excess Body Fat on Health..............................................................92
5.3.1 Type 2 Diabetes Mellitus....................................................................92
5.3.2 Hypertension and Renal Disease.........................................................92
5.3.3 Cardiovascular Diseases: Coronary Artery Disease and Stroke......... 93
5.3.4 Obesity and Cancer............................................................................. 93
5.3.5 Obesity and Depression.......................................................................94
5.3.6 Obesity and Infertility.........................................................................94
5.3.7 Obesity and Pulmonary Diseases: Sleep Apnea and Asthma............. 95
5.3.8 Obesity in Aging and Brain Health.....................................................96
5.3.9 Obesity and Musculoskeletal Disorders.............................................. 96
5.3.10 Obesity and Fatty Liver Disease.........................................................96
5.3.11 Gallstones and Gout............................................................................96
5.3.12 Bottom Line on Obesity and Health...................................................96
5.4 Determining the Obesity Phenotype................................................................96
5.5 Estimating Energy Expenditure and Protein Requirements............................ 98
5.6 Providing Structured Diet Programs that Include Choice................................99
5.7 Leisure Time Physical Activity and Exercise................................................. 100
5.8 Behavioral Strategies that Work..................................................................... 103
5.8.1 Widely Accepted Behavioral Strategies............................................ 103
5.9 Follow-Up and Social Support....................................................................... 106
References................................................................................................................. 109
Chapter 6 Evolution of Type 2 Diabetes Mellitus...................................................................... 119

6.1 Introduction.................................................................................................... 119
6.2 Social and Economic Determinants of Risk.................................................. 119
6.3 Minority Health Disparities and Risk Factors in the United States............... 120
6.4 Adaptation to Starvation Sets the Stage for T2DM........................................ 121
6.5 Pancreatic β-Cell Exhaustion and the Development of T2DM...................... 121
6.6 Genetics of T2DM Linked to Multiple Risk Factors...................................... 124
6.6.1 Gestational Diabetes Mellitus........................................................... 125
6.6.2 Gene–Environment Interaction and Risk for T2DM........................ 125
6.6.3 Prediabetes........................................................................................ 126
6.7 Conclusion...................................................................................................... 127
References................................................................................................................. 127
Chapter 7 Managing Diabetes without Weight Gain................................................................. 135

7.1 Introduction.................................................................................................... 135
7.2 Diagnosis of T2DM........................................................................................ 135
7.3 Pharmacological Treatment of Diabetes: A Brief History............................. 136
7.4 Diabetes and Obesity...................................................................................... 138
viii Contents
7.5 Nutrition and Diabetes Management.............................................................. 138

7.5.1 Weight Management and Weight Reduction in T2DM..................... 139
7.5.2 Typical Modern Management of T2DM........................................... 140
7.5.3 Use of Metformin in T2DM.............................................................. 141
7.5.4 Meal Replacements as a Tool for Planning Weight Management
Diets.................................................................................................. 142
7.5.5 Physical Activity, Including Resistance Exercise, to Increase
Muscle Mass...................................................................................... 143
7.5.6 Low-GI Foods, Fiber, and Resistant Starches in T1DM and T2DM.... 144
7.5.7 Monounsaturated Fats....................................................................... 145
7.5.8 Omega-3 Fatty Acids......................................................................... 146
7.5.9 Spices and Glucose Control............................................................... 146
7.5.10 Micronutrients................................................................................... 146
7.6 Conclusion...................................................................................................... 147
References................................................................................................................. 147
Chapter 8 Fatty Liver Disease.................................................................................................... 155

8.1 Introduction.................................................................................................... 155
8.2 Pathophysiology of NAFLD........................................................................... 155
8.3 NAFLD and Metabolic Syndrome................................................................. 157
8.4 NAFLD and Cirrhosis.................................................................................... 157
8.5 NAFLD and Hepatocellular Cancer............................................................... 157
8.6 Fatty Liver Interactions with Alcoholic and Viral Hepatitis.......................... 159
8.7 Diagnostic Dilemmas..................................................................................... 160
8.8 Clinical Presentation of Significant Liver Damage........................................ 160
8.9 Nutritional Approaches to Liver Disease....................................................... 161
8.9.1 Fructose and Fatty Liver................................................................... 161
8.9.2 Vitamin E, Fish Oils, Phytonutrients, and Overall Nutrition
for Liver Disease............................................................................... 162
8.9.3 Management of Protein Malnutrition in Advanced Liver Disease..... 164
8.10 Conclusion...................................................................................................... 165
References................................................................................................................. 166
Chapter 9 Lipid Disorders and Management............................................................................. 173

9.1 Introduction.................................................................................................... 173
9.2 Lipoproteins and Lipid Metabolism............................................................... 174
9.3 Disorders of Cholesterol Metabolism and Transport..................................... 174
9.4 Differentiating Common and Rare Lipid Disorders....................................... 175
9.4.1 Familial Hypertriglyceridemia and Secondary
Hypertriglyceridemia........................................................................ 175
9.4.2 Hypercholesterolemia and Familial Hypercholesterolemia.............. 177
9.5 Hypertriglyceridemia and the Unrecognized Impact of Visceral Fat............ 177
9.6 Control of LDL Cholesterol for Prevention of Atherosclerotic
Cardiovascular Diseases................................................................................. 178
9.7 Impact of Nutrition on Lipid Disorders.......................................................... 180
References................................................................................................................. 182
Contents ix
Chapter 10 Nutrition and Coronary Artery Disease.................................................................... 187

10.1 Introduction.................................................................................................. 187
10.2 Coronary Artery Disease, Unstable Plaques, and Myocardial Infarction.... 188
10.2.1 Cellular Basis of Atherosclerosis and Inflammation...................... 189
10.2.2 Endothelial Dysfunction and Nitric Oxide in CAD........................ 191
10.2.3 Coronary Artery Calcification........................................................ 192
10.3 Type 2 Diabetes and CAD............................................................................ 192
10.4 Effects of Statin Drugs in CAD Beyond Lipid Lowering............................ 192
10.5 Dietary Recommendations for Patients with Coronary Artery Disease...... 193
10.6 Weight Management through Nutrition and Exercise to Reduce
Visceral Fat................................................................................................... 193
10.6.1 Dietary Pattern and CAD................................................................ 193
10.6.2 Nitrate-Rich Foods Defend Endothelial Health under Hypoxic
Conditions....................................................................................... 196
10.6.3 Refined Carbohydrates and Sugar versus Fruits and Vegetables
in Low-Glycemic-Index Diets......................................................... 197
10.6.4 Phytonutrients, Potential Role in Stabilizing Atherosclerotic
Plaques............................................................................................ 198
10.7 Conclusion....................................................................................................200
References.................................................................................................................200
Chapter 11 Hypertension and Obesity.........................................................................................207

11.1 Introduction..................................................................................................207
11.2 Epidemiology of Obesity and Hypertension.................................................208
11.3 Diet in Obesity and Hypertension................................................................208
11.4 Mechanisms Mediating Obesity-Related Hypertension............................... 211
11.5 Nutrition Approaches to Obesity-Associated Hypertension
and the Metabolic Syndrome........................................................................ 214
11.5.1 Sodium Restriction in Therapy of Hypertension and Obesity........ 214
11.5.2 Pharmacological Adjunctive Treatment May Be Necessary.......... 215
11.6 Summary and Overall Treatment Recommendations.................................. 216
References................................................................................................................. 217
Chapter 12 Nutrition, Chronic Kidney Disease, and Kidney Failure.......................................... 223

12.1 Introduction.................................................................................................. 223
12.2 Obesity, Fatty Kidney, and Chronic Kidney Disease...................................224
12.3 Renal Insufficiency and Chronic Kidney Disease........................................ 225
12.4 Nutrition and Prevention of Chronic Kidney Disease.................................. 228
12.5 Nutrition in Chronic Kidney Disease and End-Stage Renal Disease........... 228
12.6 Summary...................................................................................................... 232
References................................................................................................................. 232
Chapter 13 Nutrition and Heart Failure....................................................................................... 237

13.1 Introduction.................................................................................................. 237
13.2 Etiology and Clinical Classification of Heart Failure.................................. 237
13.3 Diagnosis and Medical Treatment of Heart Failure..................................... 238
13.3.1 Heart Failure with Preserved Ejection Fraction.............................. 238
13.3.2 Pharmacotherapy of Heart Failure with Reduced Ejection Fraction... 239
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13.3.3 Sodium Restriction in Low-Output Heart Failure..........................240

13.3.4 Heart Failure Treatment: Medical Therapy.................................... 241
13.3.4.1 ACE Inhibitors and Angiotensin Receptor Blockers.... 241
13.3.4.2 β-Blockers...................................................................... 241
13.3.4.3 Aldosterone Antagonists............................................... 242
13.3.4.4 Digoxin.......................................................................... 242
13.3.4.5 Diuretics........................................................................ 242
13.3.4.6 ADH Antagonists.......................................................... 242
13.3.4.7 Nesiritide....................................................................... 242
13.3.4.8 Hydralazine and Nitrates............................................... 243
13.3.5 Heart Failure Treatment: Mechanical, Revascularization,
and Heart Transplant....................................................................... 243
13.4 BMI Paradox in Heart Failure...................................................................... 243
13.5 Macronutrients..............................................................................................244
13.5.1 Protein in Sarcopenia and Cardiac Cachexia..................................244
13.5.2 Balancing Omega-3 and Omega-6 Fats in the Diet........................ 245
13.6 Micronutrients...............................................................................................246
13.6.1 Coenzyme Q10 Supplementation....................................................246
13.6.2 Thiamine......................................................................................... 247
13.7 Conclusion.................................................................................................... 247
References.................................................................................................................248
Chapter 14 Pulmonary Function, Asthma, and Obesity.............................................................. 255

14.1 Introduction.................................................................................................. 255
14.2 Pulmonary Function in Obesity.................................................................... 255
14.3 Asthma and Obesity..................................................................................... 256
14.4 Obstructive Sleep Apnea and Hypoventilation Syndrome........................... 257
14.5 Effects of Poor-Quality Sleep in Obesity..................................................... 258
14.6 Primary Care Sleep Hygiene Recommendations......................................... 259
14.7 Summary......................................................................................................260
References.................................................................................................................260
Chapter 15 Frailty, Nutrition, and the Elderly............................................................................. 265

15.1 Introduction.................................................................................................. 265
15.2 Nature of Aging............................................................................................266
15.3 Epidemiology of Frailty................................................................................ 267
15.4 Sarcopenia.................................................................................................... 269
15.5 Muscle Protein Synthesis.............................................................................. 270
15.6 Protein Requirements................................................................................... 271
15.7 Smell and Taste Changes with Aging........................................................... 271
15.8 Prevention and Treatment of Frailty............................................................. 272
15.9 Summary...................................................................................................... 274
References................................................................................................................. 274
Chapter 16 Nutrition in Neurodegenerative Disorders and Cognitive Impairment..................... 281

16.1 Introduction.................................................................................................. 281
16.2 Epidemiology................................................................................................ 281
16.3 Diagnosis of Dementia................................................................................. 283
Contents xi
16.4 Age-Related Changes in the Brain............................................................... 285

16.5 Inflammation, Oxidative Stress, and the Brain............................................ 286
16.6 Healthy Lifestyle and the Brain.................................................................... 286
16.6.1 Exercise and Brain Health.............................................................. 286
16.6.2 Omega-3 Fatty Acids and Fish Oils................................................ 287
16.6.3 Antioxidant-Rich Foods.................................................................. 288
16.6.4 Coffee, Caffeine, and the Brain...................................................... 289
16.6.5 Alcohol and the Brain..................................................................... 289
16.6.6 Dietary Supplements and the Brain................................................290
16.7 Diabetes, Visceral Fat, Inflammation, and Alzheimer’s Disease.................290
16.8 Primary Care Physician and Case Manager Collaboration in Dementia
Patients.......................................................................................................... 291
16.9 Summary...................................................................................................... 291
References................................................................................................................. 292
Chapter 17 Gene–Nutrient Interaction........................................................................................ 297

17.1 Introduction.................................................................................................. 297
17.2 Human Nutrition and Gene–Nutrient Interaction......................................... 298
17.3 Nutrigenetics................................................................................................. 298
17.4 Nutrigenomics: Effects of Nutrients on Gene Expression............................300
17.5 Epigenetics and Diet.....................................................................................300
17.6 Gene–Nutrient Interactions in Cancer and Aging........................................302
17.7 Genome-Wide Scanning and Disease Risk.................................................. 303
17.8 The Microbiome and the Metagenome.........................................................304
17.9 Case Study of Clinical Application in Primary Care of Gene–Nutrient
Interactions...................................................................................................304
17.10 Summary...................................................................................................... 305
References.................................................................................................................306
Chapter 18 Nutrition and the Risk of Common Forms of Cancer...............................................309

18.1 Introduction..................................................................................................309
18.2 Nutrition and Physical Activity as Risk Factors........................................... 310
18.3 Risk Factors versus Statistical Bad Luck and Cancer Risk........................... 311
18.3.1 Obesity and Cancer......................................................................... 314
18.3.2 Alcohol............................................................................................ 315
18.4 Phytonutrients from Fruits, Vegetables, and Spices...................................... 316
18.5 Antioxidant Supplements.............................................................................. 316
18.5.1 Folic Acid........................................................................................ 318
18.5.2 Lycopene......................................................................................... 318
18.5.3 Glucosinolates from Cruciferous Vegetables.................................. 318
18.5.4 Green Tea Polyphenols.................................................................... 319
18.6 Spices............................................................................................................ 320
18.7 Microbiota Metabolism of Phytonutrients and Immune Function............... 321
18.8 Summary...................................................................................................... 322
References................................................................................................................. 322
xii Contents
Chapter 19 Nutrition and the Cancer Patient............................................................................... 329

19.1 Introduction.................................................................................................. 329
19.2 Primary Care Oncology................................................................................ 329
19.3 Changing Face of Cancer............................................................................. 330
19.4 Cancer Survivors in Primary Care............................................................... 331
19.5 Malnutrition and Cancer............................................................................... 333
19.5.1 Protein–Energy Malnutrition.......................................................... 333
19.5.2 Carbohydrate Metabolism............................................................... 334
19.5.3 Host–Tumor Interactions and Metabolic Abnormalities
in the Cancer Patient....................................................................... 335
19.6 Nutrition Screening...................................................................................... 336
19.7 Selecting Appropriate Methods of Nutrition Care....................................... 337
19.7.1 Oral Nutrition Support.................................................................... 337
19.7.2 Enteral Nutrition............................................................................. 339
19.7.3 Parenteral Nutrition.........................................................................340
19.8 Diet and Cancer Prevention: The Role of Colorful Fruits and Vegetables..... 340
19.9 Complementary and Alternative Medicines................................................. 342
References................................................................................................................. 342
Chapter 20 Writing the Nutrition Prescription............................................................................ 349

20.1 Introduction.................................................................................................. 349
20.2 Nutrition Prescriptions by Chapter............................................................... 349
20.3 Engaging with Patients Using Wearable Devices and Social Media............ 357
20.3.1 Wearable Devices............................................................................ 358
20.3.2 Social Media................................................................................... 359
20.4 Managing Information Overload to Keep Up with Nutrition Research....... 359
20.5 Information Management Strategies............................................................ 360
20.6 Continuing Education and Certification.......................................................360
20.6.1 American Board of Nutrition Physician Specialists.......................360
20.6.2 American Board of Obesity Medicine............................................ 362
20.6.3 Specialist Certification of Obesity Professional Education............ 362
Reference................................................................................................................... 363
Index............................................................................................................................................... 365
Preface
The time is now for this textbook on primary care nutrition. Had it been written at any time during
the last 30 years, it would have been thought to be totally irrelevant and an unnecessary diversion
from the serious work of primary care practitioners. How could nutrition be important to a medical
profession schooled in drugs and surgery for the prevention and treatment of disease?
Nutrition was an afterthought for most physicians that had nothing to do with medicine
but was a supportive function delegated to dietitians. Dietitians functioned in limited ways in
hospitals to help patients choose which menu items they would like to eat from the limited,
cost-driven choices provided by most hospital kitchens. Some administrative dietitians came
to control hospital kitchen budgets and were named directors of nutrition departments in major
medical centers. Out in the world, dietitians struggled to develop private practices and were
always driven by food industry–directed information that they were urged to deliver to patients.
The American Dietetic Association had more members in one large state than the total number
of certified by.
The creative energy in medical research funded by the National Institutes of Health in the post-
war 1950s through the 1970s was directed at understanding the cellular and molecular basis of dis-
ease. This understanding revolutionized medicine into a science-based endeavor for optimal health.
Subspecialties divided on the basis of organ systems sprouted in the 1970s to incorporate the large
amount of special technical information that was emerging. Subspecialty divisions, including pul-
monary and intensive care, nephrology, and endocrinology and metabolism, were established from
what was formerly simply a division of metabolism.
As this process proceeded to become more highly specialized, the utilization of expensive and
targeted treatments recommended by specialists was the main focus of patient care. The primary
care physician conducted annual physical exams and analyzed routine laboratory values in an
attempt to detect diseases at an early stage. Primary care doctors were called general practitioners
to indicate that they really had the limited expertise of a generalist. It was much more prestigious to
be a specialist during the age of expanding discoveries in the 1970s and 1980s.
Ultimately, the United States developed the most advanced and highly technical medical solu-
tions in the world, but the distribution of that care was not cost-effective. Renal dialysis was begun
to deal with the tragedy of young people dying of kidney failure due to autoimmune diseases and
other rare conditions. With the advent of Medicare, dialysis expanded to include patients with type
2 diabetes, who now make up a significant portion of the hundreds of thousands of patients receiv-
ing this care in preparation for renal transplant or simply as a last resort. Cardiology has undergone
a major expansion with the addition of interventional cardiologists who revascularize coronary
arteries that would previously have required open-heart surgery, accompanied by cracking open the
chest to reach the heart.
The advent of statins and drugs for hypertension gave patients the impression that they were
protected from advanced disease solely through medication. Diet and exercise were largely not part
of the medical model. Nonetheless, adherence to medications was poor. Often, this resulted from
unacceptable side effects, such as muscle pain in patients taking statin drugs. In other cases, it was
simply due to poor adherence that was in line with poor lifestyle habits and inattention to medical
advice. In the 1970s and 1980s, the hospital was the place that care was delivered. The primary
care doctor was simply a bystander and patient advocate as specialists swirled around the patient,
consulting separately on each organ system. Procedures and tests that were often unnecessary were
simply performed to defend against the risk of malpractice suits. Fear of omission or making a mis-
take drove much of this behavior without regard to costs.
Attitudes about outpatient nutrition in primary care began to change as the result of the detec-
tion of the obesity epidemic in the United States in the early 1990s. This was followed by the
xiii
xiv Preface
identification of the Global Nutrition Transition, where countries throughout the world had both
malnutrition and obesity coexisting in societies that had only known malnutrition and underweight
until recent years. The World Health Organization declared that for the first time in human history,
there were more overweight than underweight people. While fast food and a sedentary lifestyle were
identified as major factors in this global epidemic, there was little innovation in medical practice
against these driving forces. Medical care continued as usual based on the molecular and cellular
research engine that moved more slowly, and now more of the research was based within the drug
industry, which has a vested interest in promoting their solutions over nutrition and lifestyle changes.
Over a period of 20 years, numerous hormones and peptides regulating food intake and energy expen-
diture were discovered in laboratories and moved to drug companies. All these drugs designed to address
a bonanza of potential drug sales to the 50% of Americans who were overweight or obese failed.
The most informative example was the discovery of leptin. This was the most promising protein
to emerge from the molecular revolution, whose very name is taken from the Greek root for the word
that means “thinning.” The full story is repeated in Chapter 5, but the point is that a basic observa-
tion in rodents that a protein could both correct a rare human genetic defect associated with obesity
and prevent mice from becoming obese on a high-fat snack food-based diet called a “cafeteria diet”
gained tremendous attention both at the National Institutes of Health and in the drug industry as
Amgen invested $20 million to license leptin’s intellectual property from the Rockefeller University
in New York and many millions more to test this drug in humans. It turned out that leptin had little
effect on the garden-variety obesity that was becoming increasingly common in the United States,
but it worked as predicted in the genetic defect of leptin deficiency, which only occurred in a rela-
tively small number of individuals from the Middle East and Scotland.
At the same time as these drugs were failing, many consumers were having success with meal
replacements, the practice of substituting protein-rich shakes for typical cereal and milk breakfasts
or high-calorie eggs, bacon, and potatoes served at restaurants and as weekend breakfasts at home.
The reaction of the food industry and dietitians to this phenomenon was one of almost total rejec-
tion. In the late 1970s, extreme very low-calorie diets made from poor-quality protein and admin-
istered without medical supervision led to the deaths of about 80 women in the United States. The
perception that these diets were dangerous persisted despite the development of high-quality shakes
using milk protein and supplemented with vitamins and minerals. Research funded by industry
demonstrated in more than 500 publications that these protein shakes were a successful modality
within a healthy diet to promote weight management.
Our group at the University of California, Los Angeles (UCLA) published a multisite study in
1994 in which a minimal intervention of supplying meal replacements and paying participants to
be weighed weekly in six different centers around the United States led to significant weight loss
in the range of 5% of body weight. However, the weight loss required adherence to diet, and the
meal replacements merely simplified the process by removing some complexity from daily nutri-
tion plans. The next accomplishment was to show that meal replacements could be safely used in
patients with type 2 diabetes, led to better weight loss than food-based diets, and were safe. While
there were ongoing improvements in the taste and convenience of protein shakes, there were many
people who could not accept the idea that a shake would be a meal. In our research studies, we
conducted a run-in phase and often up to half of recruited subjects for a randomized study would
refuse to consume shakes. The LOOK Ahead Trial was the first large multisite study funded by the
National Institutes of Health to use meal replacements. There were three predictors of weight loss
in participants over the first year: use of meal replacements, recording food intake, and physical
activity. The more shakes an individual consumed, the greater the observed weight loss. Today,
meal replacements are used around the world within a diet plan that emphasizes adequate protein
and physical activity, including a healthy active lifestyle and resistance exercises.
Despite being the most easily understood variable in the obesity drug and various nutrition
approaches, weight loss alone is not necessarily a good thing. Full-day symposia were held by the
American Society for Nutrition differentiating unintentional weight loss, which was often associated
Preface xv
with cancers and other chronic diseases, from the deliberate weight loss achieved by overweight
and obese patients. Our group was the first to use the term sarcopenic obesity, which combined the
idea of an increase in body fat together with a reduction in muscle mass as a clinical subtype of obe-
sity. Incorporating resistance exercise into recommended weight management regimens for men and
women to optimize body composition became the predominant philosophy of our UCLA Risk Factor
Obesity Program. As described in Chapter 5, resistance exercise and protein supplementation work
together to change body composition. However, the target of that supplementation was individualized
optimal protein intake based on the lean body mass measured by bioelectrical impedance. The rec-
ommended amount of protein was almost twice the minimum 0.8 g/kg that was derived from a 1973
research study that identified that number as the minimum for positive nitrogen balance.
The emergence of the metabolic syndrome as a collection of risk factors for diabetes, heart dis-
ease, and even common forms of cancer led to a reassessment of body composition again. While the
idea that abdominal fat was important was first proposed in the 1950s, modern research not only
identified the health implications of this common condition through epidemiological observations,
but also established through molecular and cellular investigations that visceral fat is an inflamma-
tory organ releasing cytokines into the systemic circulation.
Age-related chronic diseases are not simply commonly observed conditions, but conditions with
a common origin in poor diets and lifestyles. Primary care was thrown into the limelight with the
development of diagnosis-related compensation from the government and private insurers. The pri-
mary care practice was invested with the function of a gatekeeper appropriately rationing inpatient
care, diagnostic tests, and expensive interventions prior to the involvement of specialists. These
proposed cost-cutting measures did not result in control of overall health care costs in the United
States, as growth in the number of people with diabetes, heart disease, and other costly age-related
chronic diseases continued to increase. As expected, ministries of health around the world have
identified similar increases in poor health. Chief among these countries was Mexico, which nearly
rivals the United States in the prevalence of overweight, obesity, metabolic syndrome, and type 2
diabetes. However, the largest coming wave of patients will originate in China, where 120 million
people have diagnosed diabetes, and prediabetes affects about 500 million people.
Our key mission in writing this textbook is to provide primary care practices with the informa-
tion and tools to address this global epidemic of obesity and nutrition-related diseases. After initial
chapters on integrating nutrition into your primary care practice, there is a revealing look at the
process of developing dietary guidelines and how the guidelines have slowly evolved to incorpo-
rate new findings in nutritional science and medicine. In the chapters that follow, the messages go
beyond the dietary guidelines that are for healthy people and not for disease conditions. The chap-
ters cover obesity, eating disorders and food intolerance, lipid disorders, heart disease and heart
failure, renal disease, pulmonary disease, cancer prevention, and cancer survival.
We want to acknowledge the support of Dr. Jieping Yang, who assisted in editing and formatting the
text, as well as setting the framework for our writing schedules over the last year. We also want to thank
Randy Brehm at CRC Press, whose vision resulted in the development of the concept for this book.
David Heber, MD, PhD, FACP, FASN

Professor Emeritus of Medicine and Public Health
Founding Director, UCLA Center for Human Nutrition
David Geffen School of Medicine at UCLA
Zhaoping Li, MD, PhD

Professor of Medicine
Lynda and Stewart Resnick Chair in Human Nutrition
Chief, Division of Clinical Nutrition
and Director, UCLA Center for Human Nutrition
David Geffen School of Medicine at UCLA
Authors
David Heber, MD, PhD, FACP, FASN, is a professor emeritus of medicine and public health
at the David Geffen School of Medicine at University of California, Los Angeles (UCLA) and
is internationally prominent in the fields of nutrition, metabolism, and obesity and its associated
complications. He is also the founding director of the UCLA Center for Human Nutrition and the
founding chief of the Division of Clinical Nutrition in the UCLA Department of Medicine where
he directed multiple National Institutes of Health-funded research programs, including the UCLA
Clinical Nutrition Research Unit, the UCLA Dietary Supplements Research Center: Botanicals and
the UCLA Nutrition and Obesity Training Grant. Dr. Heber is the founding chair of the Herbalife
Nutrition Institute, and is a member of the McCormick Science Institute.
Dr. Heber is board certified in internal medicine, and endocrinology and metabolism by the
American Board of Internal Medicine and is a certified physician nutrition specialist. He earned his
MD at Harvard Medical School and his PhD in physiology at the UCLA. Dr. Heber served as chair
of the Medical Nutrition Council of the American Society for Nutrition and, in 2014, was elected as
a fellow of the American Society for Nutrition, the highest honor of the society. He has been listed
multiple times since 2000 as one of the Best Doctors in America including 2015–2016 based on a
survey of over 35,000 physicians in the United States. In 2014, according to Reuters News Agency,
he was in the top 1% of cited authors in the field of agricultural sciences and was listed as one of the
most influential scientific minds of 2014.
Dr. Heber’s primary areas of research are obesity treatment and prevention, and the role of nutri-
tion, phytonutrients, and botanical dietary supplements in the prevention and treatment of com-
mon forms of cancer and cardiovascular disease. He has published seminal research articles on the
causes of obesity, weight loss strategies, and the relationship of obesity to cancer and cardiovascu-
lar disease, and is the author of over 250 peer-reviewed scientific articles, over 50 book chapters,
several professional texts, and four books for the public including “What Color Is Your Diet?” and
“The LA Shape Diet.”
Zhaoping Li, MD, PhD, FACP, FACN is the director of the Center for Human Nutrition, chief of
the Division of Clinical Nutrition, and the Lynda and Stewart Resnick Endowed Chair in Human
Nutrition at David Geffen School of Medicine at the University of California, Los Angeles (UCLA).
Currently, she is the vice president of the National Board of Physician Nutrition Specialists, the
president of the World Association of Chinese Doctors in Clinical Nutrition, and a member of the
American Society for Nutrition Medical Nutrition Council.
Dr. Li is board certified in internal medicine and a physician nutrition specialist. She completed
her MD and PhD in physiology at Beijing University, China and has been a faculty member at
UCLA. She is leading the Center for Human Nutrition to have vigorous research programs in nutri-
tion, microbiome, and metabolism; providing mentorship and didactic and informal training for
young scientists, premed, medical students, medical residents, fellows, and clinicians; and directing
clinical programs that specialize in metabolic diseases, bariatric medicine, gastrointestinal dis-
eases, and cancer prevention/treatment.
For nearly three decades, Dr Li’s research interest has focused on translational research in the
role of macronutrients and phytochemicals in the prevention and treatment of obesity-related chronic
diseases. She has been a principal investigator for over 50 investigator-initiated National Institutes
of Health- and industry-sponsored clinical trials and published over 150 peer-reviewed papers in
journals such as JAMA, Annals of Internal Medicine, American Journal of Clinical Nutrition, and
Journal of American Dietetic Association.
xvii
1 Incorporating Nutrition into
the Primary Care Practice
1.1 INTRODUCTION
You can make a significant difference through your efforts in a world challenged by an international
epidemic of chronic diseases fueled by rapidly spreading unbalanced nutrition and sedentary life-
styles. Primary care has typically presided over the relentless progress of common chronic diseases
while providing palliative drugs that control blood sugar, blood pressure, and blood lipids. In this
book, you will learn how to prescribe nutrition and lifestyle change for the prevention and palliation
of such common diseases as type 2 diabetes mellitus, heart disease, and common forms of cancer.
It is very clear that physicians do not have the time or training to sit with patients and discuss
the details of their breakfast, lunch, and dinner, or the details of their exercise program. Moreover,
they do not have the time to follow up in adequate detail with patients to see if they are complying
with their nutrition and exercise prescription. Previous efforts to make primary care physicians
competent in all aspects of exercise and nutritional counseling have not been successful, as amply
documented in studies of physicians in the United States and around the world. The only exception
is the relatively small number of physician nutrition specialists in academic centers and in private
practice who have a commitment to practice nutrition and weight management as a specialty.
This chapter and the balance of the book aim to arm you with the necessary tools to incorporate
nutrition into your primary care practice, utilizing nurses, registered dietitians, psychologists, and
physical therapists, whether within your practice or by referral to the community. In addition, there
are commercial weight loss programs, Internet weight loss programs, and smartphone apps that are
all available to help patients improve their diet and lifestyle.
Surveying your patient population, organizing the office staff, taking advantage of printed and
Internet resources, obtaining proper office equipment, and becoming conversant in global nutrition
issues affecting different populations will prepare you to incorporate nutrition into your practice. As
a result of these efforts, you will begin the process of providing an environment where your patient’s
nutritional issues can be addressed.
While you are not expected to deliver the care, your knowledge base must be at a level where
you feel comfortable endorsing the importance of diet and lifestyle as a legitimate component of
primary care practice.
1.2 SURVEY YOUR PRACTICE POPULATION’S

NUTRITION STATUS AND LIFESTYLE
Dietary patterns, physical activity, and lifestyle are inseparable, and the first step in understand-
ing your practice population is to realize that nutrition is more than diet alone and encompasses
all aspects of exercise and lifestyle that affect metabolism and age-related chronic diseases on an
individual basis.
Practice populations differ in their demographic, socioeconomic, and cultural backgrounds, all
of which affect their nutrition and lifestyle habits. Profiling your practice population is not some-
thing you have to do personally, but your office staff can build a database so that you can spend
your time most efficiently in encouraging diet and lifestyle changes that are culturally, socially, and
1
2 Primary Care Nutrition
economically feasible with those individuals in your practice at highest risk, including those with
the metabolic syndrome, hypertension, prediabetes, and type 2 diabetes.
A one-size-fits-all approach to nutrition intervention is not effective, and waiting to deliver ser-
vices only to those patients who request nutrition consultation is an outdated and likely a wasted
effort for your primary care practice. On the other hand, once you identify the at-risk groups in your
practice, which will be a significant fraction of your patient population, you can survey and encour-
age readiness to change so that your efforts will have the greatest impact on the overall quality of
care you can provide individually, within your practice, and within your community. By the way,
this is not something that every primary care doctor will want to do. However, you can become an
example to your patients and a resource to your colleagues and your community by taking on this
challenge.
1.2.1 The Global Nutrition Transition and Your Practice

While poor nutritional habits and sedentary lifestyle are global problems, the world leader in estab-
lishing this unhealthy combination has been the United States over the past 40 years. It was only
in the last years of the twentieth century that the U.S. Centers for Disease Control and Prevention
identified sedentary lifestyle and unhealthy nutritional habits as causal factors that increase the risk
of heart disease and common forms of cancer, the two leading killers of all adults in the United
States (U.S. Department of Health and Human Services 1996).
On a global scale, 5 million deaths worldwide have been attributed to unhealthy nutritional
habits, including sedentary lifestyle, making these habits among the 10 leading global causes of
death and disability (Booth et al. 2000; Lees and Booth 2005; Lee et al. 2012). The World Health
Organization has recognized that for the first time in human history, there are more overweight than
underweight individuals in the world today, and this applies to your practice.
One of the most striking examples of this global shift is Mexico (Figure 1.1) (Romieu et al.
1997). Mexico has documented an increase in obesity in urban areas and continued malnutrition in
some rural areas (Chávez et al. 1993). The Global Nutrition Transition is marked by the prevalence
of overweight and obesity surpassing malnutrition and an increase in deaths from noncommuni-
cable chronic diseases (NCDs) in low- and middle-income countries (Chávez et al. 1993; Popkin
2004; Caballero 2005; Doak and Popkin 2008). The nutrition transition often precedes or occurs in
tandem with demographic, epidemiological, and socioeconomic changes resulting from globaliza-
tion, urbanization, and development (Popkin and Gordon-Larsen 2004; Omran 2005; Satia 2010).
For example, Brazil, Chile, Ecuador, Mexico, Peru, and the Dominican Republic are considered to
Percentage (%)
1960 1992
16 14 12 10 8 6 4 2 0 0 2 4 6 8 10 12 14 16
CVD
Cancer
Accidents
Diabetes
Perinatal
Cirrhosis
Pneumonia
Violent deaths
Diarrhea
FIGURE 1.1 Principal causes of death in Mexico in 1960 and 1992. CVD, cardiovascular disease; perinatal,
perinatal diseases. (Reprinted from Romieu, I. et al., Am. J. Clin. Nutr., 65(4 Suppl.), 1159S–1165S, 1997.)
Incorporating Nutrition into the Primary Care Practice 3
be advancing in the nutrition transition because, since 2000, these countries have had an increasing
prevalence of obesity, increased proportion of dietary intake from fat, reduced prevalence of infant
mortality and stunting, and increasing mortality from NCDs (Albala et al. 2001; Uauy et al. 2001;
Ford and Mokdad 2008; Barquera et al. 2009, 2013; Bonvecchio et al. 2009; Abrahams et al. 2011;
Rojas-Martínez et al. 2012).
African American and Latino adults in the United States have a higher prevalence of obesity
than non-Hispanic whites (Flegal et al. 2010; Ogden et al. 2012). The relationship between accul-
turation to an American or Western diet pattern and overweight and obesity among Latino immi-
grants has been well documented in the literature (Schaffer et al. 1998; Aldrich and Variyam 2000;
Bermudez et al. 2000; Edmonds 2005; Akresh 2007; Bowie et al. 2007; Ayala et al. 2008), but is
clearly not restricted to that ethnic group.
1.2.2 Food Insecurity and Low Socioeconomic Status

In diverse populations in both developed and developing countries, studies have found a mild to
strong relationship between food insecurity and obesity (Carlson et al. 1999; Adams et al. 2003;
Hawkes 2006; Velásquez-Melendez et al. 2011). Food insecurity is a state in which the availability
of nutritionally adequate foods is reduced where the ability to obtain acceptable foods is limited or
uncertain.
Ethnic or racial minority status and low socioeconomic status (SES), whether conceptualized
at the individual or neighborhood level, are both associated with an increased risk of morbidity
and mortality for numerous age-related chronic diseases seen commonly in primary care practices
(Coogan et al. 2010; Lantz and Pritchard 2010). For example, African American patients and oth-
ers of lower SES are more likely than other groups to have two or more cardiovascular disease risk
factors (Sharma et al. 2004), and these groups also have higher rates of hypertension (Flegal et al.
2002), poorly controlled diabetes (Romieu et al. 1997), and obesity (Chávez et al. 1993). They also
exhibit low rates of meeting recommendations for fruit and vegetable intake (Popkin 2004) and, in
some studies, poorer dietary profiles (Caballero 2005; Doak and Popkin 2008).
High-fat, high-salt, high-sugar foods are often the lowest-cost options available to consumers in
low-income neighborhoods, as they are more affordable than healthier diet options (Omran 2005).
African American neighborhood markets often have less store space devoted to fresh and frozen
fruits and vegetables than markets in upper-scale neighborhoods, but similar space devoted to high-
calorie energy-dense snacks with low nutrient density (Satia 2010).
Individuals with lower income and those living in ethnic minority neighborhoods have greater
access to fast-food restaurants (Abrahams et al. 2011) and less access to supermarkets with fresh
produce (Albala et al. 2001) than people in higher-income and majority neighborhoods. A higher
frequency of fast-food consumption has been reported in African Americans (Uauy et al. 2001;
Ford and Mokdad 2008) and persons of lower SES (Caballero 2005; Bonvecchio et al. 2009; Rojas-
Martínez et al. 2012), and a growing body of literature shows that fast-food consumption is associ
ated with poorer dietary habits. Studies have compared the diet composition of adults, based on
dietary recalls, on days in which fast food was consumed versus days it was not. It is no surprise
that overall dietary parameters on days when fast-food consumption occurs demonstrate higher total
calories, total fat, saturated fat, carbohydrates, added sugar, and sugar-sweetened carbonated bever-
ages, and lower fiber, vitamins and minerals, milk, nonstarchy vegetables, and fruit intake (Ford and
Mokdad 2008; Rojas-Martínez et al. 2012). Other studies have used food frequency questionnaires
or dietary screeners and more general questions about average or typical fast-food consumption
with similar findings (Uauy et al. 2001; Barquera et al. 2009, 2013), including in African Americans
(Uauy et al. 2001; Flegal et al. 2010). In addition to specific dietary parameters, studies have also found
that more frequent fast-food consumption is associated with poorer overall dietary quality, as measured
by eating indices (Uauy et al. 2001; Ogden et al. 2012), as well as weight gain and poor metabolic
health outcomes (Aldrich and Variyam 2000; Uauy et al. 2001; Akresh 2007; Ayala et al. 2008).
30 30
Men Women Men Women
25 25
Obesity, BMI>30 (%)
20 20
15 15
10 10
5 5
0 0
<100 100–199 200–399 >400 <12 12 12–16 16 >16
Income (% of poverty) Education (y)
FIGURE 1.2 Obesity as a function of income and education. (Reprinted from Drewnowski, A., and Specter,
S. E., Am. J. Clin. Nutr., 79(1), 6–16, 2004.)
The global nutrition transition also occurs as the result of acculturation to American dietary habits
with immigrants from multiple cultural and ethnic backgrounds (Schaffer et al. 1998; Carlson et al.
1999; Bermudez et al. 2000; Adams et al. 2003; Sharma et al. 2004; Edmonds 2005; Hawkes 2006;
Bowie et al. 2007; Coogan et al. 2010; Lantz and Pritchard 2010; Velásquez-Melendez et al. 2011).
Among women, higher obesity rates tend to be associated with low incomes and low education
levels (Kumanyika 1999; Flegal et al. 2002; Paeratakul et al. 2002; Wardle et al. 2002). The associa-
tion of obesity with low SES has been less consistent among men (Flegal et al. 2002; Paeratakul et al.
2002). Minority populations, other than Asian Americans, exhibit higher rates of obesity and over-
weight than do U.S. whites based on body mass index (BMI) (Flegal et al. 2002). Studies of body
composition have not been done in Asian American populations, but our own studies in Asian col-
lege students show a high incidence of sarcopenic obesity, where there is increased body fat despite
normal BMI. Analyses of data for 68,556 U.S. adults in the National Health Interview Survey by the
Centers for Disease Control and Prevention showed that the highest obesity rates were associated
with the lowest incomes and low educational levels (Schoenborn et al. 2002). The relation between
obesity and education and income, based on charts published by the Centers for Disease Control and
Prevention (Schoenborn et al. 2002), is shown separately for men and women in Figure 1.2.
1.2.3 Relative Food Costs and Calories per Bite

Over the past 40 years, there has been a progressive global market-driven development of food
technology used to make high-fat, high-sugar, high-salt snack foods and commodities used in foods
available to consumers at very low cost while retaining profit margins (Bowman 1997; Maillot et al.
2007; Townsend et al. 2009). In order to determine whether the relative low cost of processed foods
and ingredients in fast foods promotes poor eating habits and the global epidemic of obesity and
diabetes, a number of researchers led by Dr. Adam Drewnowski of the University of Washington
School of Public Health have examined the cost of foods relative to their energy density (Figure 1.3)
(Darmon and Drewnowski 2015). These studies also have an impact on understanding the relation-
ships between SES, diet quality, and health.
Using energy density values from Rolls and Barnett (2000), Drewnowski collected the energy
costs of foods from supermarkets in Seattle in the winter of 2003. The concept he demonstrated is
1000
R2 = 0.4112
Energy density (kcal/100 g)
100
10
1
0.01 0.1 1 10 100
Energy cost (euro/100 kcal)
FIGURE 1.3 Energy density (kcal/100 g) and energy cost (euro/100 kcal) of foods (n = 1117) in the French
food database, based on 2007 national food prices. (Reprinted from Darmon, N., and Drewnowski, A., Nutr.
Rev., 73(10), 643–660, 2015.)
that you get more calories per dollar with junk foods than healthy foods. The energy cost of cookies
or potato chips was about 1200 kcal/dollar, whereas that of fresh carrots was only 250 kcal/dollar.
The energy cost of soft drinks was 875 kcal/dollar, whereas that of orange juice from concentrate
was 170 kcal/dollar. Fats and oils, sugar, refined grains, potatoes, and beans represented some of the
lowest-cost options and provided dietary energy at lower cost than healthy foods. The differential
in energy costs between sugar and strawberries was on the order of several thousand percent. The
hierarchy of food prices is such that dry foods with a stable shelf life are generally less costly per
kilocalorie than are perishable meats or fresh produce with high water content. As a rule, potato
chips, chocolate, and locally bottled soft drinks provide dietary energy at a lower cost than do natu-
rally hydrated lean meats, fish, and fresh vegetables and fruit. Energy-dense foods may contain a
relatively high proportion of refined grains, added sugars, and vegetable fats.
The U.S. diet has been shown to derive close to 50% of energy from added sugars and fat (Bowman
1997; Maillot et al. 2007). Data from the Economic Research Service of the U.S. Department of
Agriculture (USDA) (Townsend et al. 2009) show that the per capita availability of caloric sweeten-
ers and fats and oils increased by 20% for each between 1977 and 1997. Retail price increases dur-
ing that time were much lower for sweets and fats than for vegetables and fruit. Other studies have
shown that foods identified as accounting for the greatest increase in energy intake by Americans
during that time were salty snacks, desserts, soft drinks, fruit drinks, hamburgers, and cheeseburg-
ers. For the most part, many such foods are composed of refined grains, added sugars, and fats.
1.3 IDENTIFYING MEDICAL, NUTRITIONAL, BEHAVIORAL,

AND EXERCISE RESOURCES AVAILABLE
The American Society for Nutrition (ASN), with more than 4100 members, is the premier research
society dedicated to improving the quality of life through the science of nutrition. The society
fulfills its mission by fostering and enhancing research in animal and human nutrition, and provid-
ing opportunities for sharing, disseminating, and archiving peer-reviewed nutrition research results
at its annual meeting and in its publications, the American Journal of Clinical Nutrition and the
Journal of Nutrition. The society also fosters quality education and training in nutrition through its
annual continuing medical education conference, Advances and Controversies in Clinical Nutrition.
The society welcomes primary care physicians with an interest in nutrition. Its Medical Nutrition
Council sponsors a number of Research Interest Sections, the largest of which, with more than 500
members, is the Research Interest Section on Obesity.
The Obesity Society (TOS) is a scientific and educational organization dedicated to expanding
research, prevention, and treatment of obesity and reduction in stigma and discrimination affecting
persons with obesity. The society has more than 2500 members. About 39% are PhDs, 35% MDs,
and 2% RDs. Physician specialties include endocrinology, internal medicine, psychology, psychia-
try, pediatrics bariatric surgery, and family practice. Members work in universities, hospitals, indi-
vidual or group practices, medical schools, government, and other fields. The society publishes two
journals, including the leading peer-reviewed scientific journal in the field, Obesity. The society’s
annual meeting, Obesity Week, is cohosted with the American Society for Metabolic and Bariatric
Surgery (ASMBS) and brings in more than 5000 obesity professionals. Obesity Week is the pre-
mier annual scientific and educational conference bringing together the world’s experts in obesity
research, treatment, and prevention—from clinicians and surgeons to educators and policy makers.
TOS members are organized into various interest groups by specialty, known as sections, includ-
ing Bariatric Surgery, Basic Science, Bio-Behavioral Research, Clinical Management, Diversity,
eHealth/mHealth, Epidemiology, Health Services Research, Latin American Affairs, Obesity &
Cancer, and Pediatric Obesity.
The Academy of Nutrition and Dietetics is the world’s largest organization of food and nutrition
professionals, founded in Cleveland, Ohio, in 1917, by a visionary group of women dedicated to help-
ing the government conserve food and improve the public’s health and nutrition during World War I.
Today, the academy has more than 75,000 members—registered dietitian nutritionists, dietetic tech-
nicians, registered and other dietetics professionals holding undergraduate and advanced degrees
in nutrition and dietetics, and students—and is committed to improving the nation’s health and
advancing the profession of dietetics through research, education, and advocacy. This is an excellent
resource for nutritional publications and information for dietitians. There are sections for dietitians
interested in sports nutrition, research, or other areas of dietetics.
With more than 50,000 members and certified professionals, the American College of Sports
Medicine (ACSM) is the largest sports medicine and exercise science organization in the world. For
more than 60 years, the ACSM has advanced and translated scientific research to provide educa-
tional and practical applications of exercise science and sports medicine. ACSM and its members
are dedicated to promoting well-being, sport safety, fitness, and physical activity through research,
education, and public health efforts that positively impact quality of life for athletes. Primary care
physicians interested in sports nutrition and medicine can obtain scientific information through
position papers and attending meetings of this society.
This is not an exhaustive list, but these organizations provide well-vetted information that is
accurate. Many popular authors and websites advertising nutritional products contain information
that is not reliable.
1.4 OBTAINING THE EQUIPMENT NEEDED

FOR PRIMARY CARE NUTRITION PRACTICE
In order to be able to classify patients by body weight for height, it is vital to have a stadiometer, as
well as an accurate scale in your practice. The scales should be certified within 0.1 kg, and I prefer
the electronic scales that automatically register weight, as opposed to the traditional doctor’s scale,
which requires balancing a counterweight. This takes more time and is often not as accurate. It
is important to weigh patients consistently, with or without shoes, and ask them to remove heavy
clothing as well.
Pamphlets with nutritional information and DVD presentations on televisions in the waiting
room can be an excellent source of nutrition education for patients.
1.5 OUTFITTING YOUR OFFICE TO ACCOMMODATE OBESE PATIENTS

It is helpful to have industrial-capacity electronic scales that are able to accurately weigh patients
up to 400 pounds if you intend to see obese patients in your practice. It is also important to have
armless chairs in the waiting room and corridors able to accommodate obese patients. A number of
pieces of hospital equipment have been redesigned, including MRI machines, to be able to accom-
modate obese patients up to 650 pounds. The need for this redesign of equipment is a sad comment
on the extent of the obesity epidemic and its growth in this country over the last 40 years. TOS is a
good source for specific recommendations on equipment manufacturers for a primary care practice
that plans to accommodate severely obese patients.
1.6 TRAINING YOUR STAFF TO BE EMPATHETIC

AND HAVE SUPPORTIVE INTERACTIONS
It is vital to identify staff members with an interest in nutrition and an empathetic attitude to the
obese. Staff who believe that obesity is a moral failing are likely to mistreat obese patients or make
them feel uncomfortable. Office staff without special training that dietitians or nurses typically have
can welcome and encounter patients with nutritional issues, including obesity. Medical assistants
and even receptionists who have a strong personal interest in nutrition can be encouraged to obtain
valid information on the nutrition status of patients and record it appropriately in a practice record.
Questionnaires can be placed in the waiting room to help you determine the nutritional status
and interests of your patients. These can be collected by the office staff and utilized to profile the
concerns and habits of your patients. The Society for Behavioral Medicine has recommended the
questionnaires listed in Table 1.1 for use in primary care practices. It also recommends including
these in the electronic health record (Glasgow and Emmons 2011).
Note that many of the scales in Table 1.1 survey behavioral issues and physical activity, which
are part of the nutrition landscape. Isolating food environment information alone often misses the
real motivation for existing poor nutritional and lifestyle habits. Which of the above scales and
questionnaires you incorporate into your practice will depend on your particular interests and the
focus of your practice. In Chapters 2 and 5, on optimum nutrition and the assessment of overweight
and obese patients, further suggestions for analytical tools are given. However, it is not likely
you will choose to use all these. Instead, select those that make the most sense for your practice
population.
Despite the epidemic of overweight and obesity in the United States today, there are still some
groups at risk for nutritional deficiencies. These groups include (1) pregnant women, (2) the
elderly, and (3) individuals who smoke, drink excess amounts of alcohol, or abuse drugs. While
the nutritional supplementation of pregnant women is well established, including the use of
prenatal vitamins, in lower socioeconomic groups, there are still many women who fail to get
prenatal nutritional counseling. In clinics seeing a large number of alcoholics and drug abusers,
nutrition is given little attention. Similarly, in primary care practices seeing geriatric patients,
most attention is directed at chronic diseases such as diabetes, dementia, and cardiovascular
diseases.
The assessment of risk of nutritional deficiency is straightforward and can be used to determine
which patients require consideration for nutritional support, as described in Box 1.1.
TABLE 1.1
Recommended Domains and Example Measures
Domain Example Measures
Smoking/tobacco use SRNT items; one Fagerstrom item for smokers
Physical activity BRFSS, IPAQ, or pedometer readings
Eating patterns Starting the conversation or NCI fat and fruit/vegetable screeners
Risky drinking 2 items from AUDIT or BRFSS
Medication taking Hill–Bone Adherence Scale
Optional items Customized to site priorities—e.g., salt intake, sleep patterns
Psychosocial and Patient/Environmental Characteristics
Depression/anxiety PHQ 2 or 4
Quality of life PROMIS questions
Stress/distress Distress scale or distress thermometer
Health literacy/numeracy Chin and Fagerlin health literacy and numeracy items
Patient goals Free text on specific measurable goal and goal attainment
Demographic characteristics Race, ethnicity, zip code for GIS coding
Optional characteristics Customized to setting: patient priorities and preferences (e.g.,
preferred level of participation in medical decision making,
mode of contact—e-mail vs. phone)
Issue patient most wants to discuss during next
contact
Source: Reprinted from Glasgow, R., and Emmons, K. M., Transl. Behav. Med., 1(1), 108–109, 2011.
Note: AUDIT: Alcohol Use Disorder Identification Test; BRFSS: Behavioral Risk Factor Surveillance System; GIS:
Geographic Information Systems; IPAQ: International Physical Activity Questionnaire; NCI: National Cancer
Institute; PHQ: Patient Health Questionnaire; PROMIS: Patient-Reported Outcomes Measurement Information
System; SRNT: Society for Research on Nicotine and Tobacco.
BOX 1.1 SIGNS AND SYMPTOMS OF MALNUTRITION

The presence of any of the following criteria should motivate the primary care physician to conduct
a complete nutritional assessment with consideration of appropriate forms of nutritional therapy:
• Recent involuntary weight loss of greater than 5% in 1 month or more than 10% in
6 months, especially when associated with anorexia, fatigue, or weakness
• History of recent significant physiological stresses, such as organ dysfunction, major
surgery, infection, or illness within the last 3 months
• Absolute lymphocyte count of <1200 cells/mm3 or serum albumin of <3.2 g/dL.
While the above criteria are simple, it is important that these signs and symptoms are taught to
your office staff, as often the vital signs of weight, blood pressure, and temperature are taken with
no regard for nutrition status.
While classic vitamin deficiency diseases are rare today in the United States, except in certain
high-risk groups (e.g., alcoholics, pregnant teenagers, and institutionalized elderly), there are a vari-
ety of individuals whose dietary intake is inadequate to maintain optimal health. For instance, it
is recommended that Americans eat 25 g of fiber/day, but the average intake is only about 10 g. In
California, only about one in five people consume five servings a day of fruits and vegetables, as
recommended by the USDA. As a result, there are a number of micronutrient vitamins and min-
erals that are deficient, but not at levels that would cause disease. Examples include carotenoids,
vitamin E, vitamin C, folate, and selenium. While the nutrient levels that constitute deficiency are
established, there is little information on what is suboptimal or what types of responses can be
expected following nutritional intervention. It is also unclear why there are individual variations in
the absorption of a beta-carotene oral load, the effects of dietary fiber eaten at the same time, or the
effects of various fats in the diet on absorption of micronutrients.
While patients look to the physician for advice, this is the point where a practice should employ
a well-trained dietitian or refer to an affiliated dietitian with a modern perspective and open mind
to follow the practices that you establish in your practice for nutritional counseling beyond simple
nutrition deficiencies.
1.7 MODIFYING ROUTINES TO MAINTAIN EFFICIENT PATIENT FLOW

In today’s environment of high patient volumes, especially in capitated care practices, it is essential
to design efficient patient flow while obtaining nutritional information. There are a number of strate-
gies available to accomplish this.
It goes without saying that there must be a carefully designed appointment schedule so that
follow-up visits do not turn into lengthy encounters in an unplanned fashion. Being able to refer
patients with nutrition questions to a practice-based resource can help to reduce this problem.
One of the most efficient and least costly strategies is to establish group education classes when
the office space is not being used in the evenings or weekends. Groups of up to 20 people can attend
education and behavior modification sessions. Professionals can be paid an hourly wage to conduct
these sessions, and patients can be charged a nominal fee. It is important to ask patients to pay in
advance for a set number of sessions. This puts the burden on the patient and not the practice when a
patient decides to drop out of the program. Setting up a careful budget can create a win–win for the
patients, the professionals conducting the groups, and the practice itself as it obtains a reputation in
the medical community of providing nutrition and behavior education for nutrition-related issues.
Making e-mail contact available for questions on nutrition can be a real time saver as well.
Similar questions are often asked repeatedly, and a library of frequently asked questions can be
established for patients in the practice.
1.8 PROVIDING INTERNET RESOURCES FOR SELF-MONITORING

AND REPORTING PROGRESS TO YOUR PRACTICE
There are a number of free apps available that can help maintain compliance.
MyFitnessPal is a free smartphone app and website that tracks diet and exercise to determine
optimal calorie intake and nutrients set to the users’ goals and provides e-mail and website mes-
sages to motivate users. The user may enter the name of the food or scan the barcode to find the item
in a large database of more than 5 million foods or may select foods from a list of most frequently
eaten foods. In 2015, the company had 80 million users.
Another popular one is Lose It. This app is a way to record both nutrition and exercise infor-
mation. The food library is extensive and includes name brands plus generic categories, like fruit,
coffee, and chicken. Each food type includes accurate calorie, carbohydrate, fat, and protein values,
which you can track on a separate page. Daily exercises can be added, including the intensity and
hours spent. The app then calculates how many calories are eaten and burned. During the day, it
keeps track of how much has been eaten and how much more can be eaten within the targeted pro-
tein or calories for the day. A graph based on data over time displays the weight lost. These records
can be brought to routine visits and shared with your practice. This review provides an opportunity
to applaud progress or solve problems around obstacles to compliance. Apps require a lot of data
entry. Smartphones are passively collecting numbers of steps taken each day, and Fitbit counts steps
and interacts with a home computer each night to record progress and provide encouragement.
It is wise to discourage your patients from trying to learn about nutrition on the general Internet.
Most of the information available distorts the science or makes outright false claims for various
nutritional approaches and supplements. Your practice should be the ultimate resource for informa-
tion that is endorsed by you once you have the background you need.
1.9 ESTABLISH METHODS TO OBTAIN REIMBURSEMENT FOR YOUR SERVICES

In the course of treating common diseases influenced by nutrition and obesity, it is your prerogative
as a primary care physician to use nutrition alone or in combination with medication to treat com-
mon diseases, including hypertension, hyperlipidemia, hyperglycemia, and obesity.
By law, Medicare covers specified, medically necessary services for illness and injury. The prior
legal language, because it stated that obesity was not an illness, prevented Medicare from covering
treatments for diseases related to obesity.
As of August 2015, according to Medicare coverage, the question is no longer whether obesity
is a disease or a risk factor. What matters is whether there is scientific evidence that an obesity-
related medical treatment improves health. Essential to this process is the submission of published,
clinical trial data that demonstrate that obesity-related treatments improve the health of Medicare
beneficiaries.
In addition to billing for comorbid diseases where obesity or nutrition is addressed, Medicare
provides coverage for intensive behavioral therapy. There is a limit of 22 individual and/or group
visits (any combination) in the initial 12-month period, counted from the date of the first claim. This
can be repeated annually. Face-to-face weekly visits are reimbursed in the first month. In months
2–6, visits are reimbursed twice per month, and then in months 7–12, monthly visits are reimbursed.
However, in order to qualify, the patient must lose more than 3 kg (6.6 pounds) in months 2–6, and
this must be documented in the medical record. As of January 2015, Medicare covers group inten-
sive behavioral counseling using a new group code, G0473. Face-to-face behavioral counseling for
groups of 2–10 individuals lasting 30 minutes is approved.
Another approach is to simply create behavioral group programs for a reasonable charge, for
which patients are responsible. They can be given a master bill to submit to their insurance, or in
other cases, where they use a health savings account, a brief letter to their accountant will suffice.
Hyperlipidemia Hypertension
and CVD Assess and treat and renal disease
nutrition and lifestyle-
related chronic
disease risk factors
Fatty liver and Common

metabolic cancers
syndrome
Pulmonary
Excess visceral fat and
Diabetes and distribution sleep apnea
Dementia Sarcopenia
and frailty
PCP Referral to community

PCP collaborative care
lifestyle counseling programs, commercial
RD, RN, practice
and medication programs, websites, etc.
FIGURE 1.4 This algorithm describes the interaction of primary care practice and chronic age-related dis-
eases where nutrition and lifestyle play a major role (see text). CVD, cardiovascular disease; PCP, primary
care physician; RD, registered dietitian; RN, registered nurse.
1.10 PRIMARY CARE ALGORITHM

To conclude this chapter, an overview of the primary care practice paradigm is presented in Figure 1.4.
The integration of nutrition into primary care practice begins with the assessment and treat-
ment of the nutrition- and lifestyle-related risk factors associated with common chronic diseases.
The primary care physician has the primary responsibility for endorsing the nutrition and lifestyle
prescription. Of equal importance are the primary care practice health care providers, including
registered dietitians, nurses, exercise physiologists, psychologists, nurse practitioners, and physician
assistants, as well as the referral to community resources, websites, and commercial programs, as
described in this chapter. The chronic diseases included in the algorithm in Figure 1.4 are among
the most common encountered in primary care practice. Excess visceral fat and obesity are primary
factors in most of these conditions.
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2 Personalization of
Nutrition Advice
2.1 INTRODUCTION
The interest of the public in nutrition, health, and longevity is something you will encounter fre-
quently in your primary care practice. Often, this information is presented as strong opinions and
preconceived misconceptions. Much of the misinformation about nutrition in the public arena is
found on the Internet, and your patients will bring this misinformation to your attention. In addi-
tion to information that makes no physiological sense, there is a great deal of information that your
patients will find confusing or conflicting, such as the controversy around dietary fats and sugars.
Official governmental and nongovernmental advisory groups, in an effort to reach a political con-
sensus meeting the needs of various vested interests, often issue generalized guidelines that are of
little practical value to you in responding to a patient’s specific questions.
Government guidelines are based on established but incomplete nutrition science. They fail to
account for the many aspects of the emerging science of nutrition, including phytonutrients, anti-
oxidants, the microbiome, and the wealth of information emerging on the role of the microbiome in
intermediary metabolism. Humans evolved on a plant-based diet eating animals that were also plant
eaters on land and at sea. Processing and food production has made food plentiful and enabled the
feeding of the world’s hungry in unprecedented ways.
There is also “hidden hunger,” a term popularized by Dr. Hans Biesalski of the University of
Hohenheim in Germany. This is the intracellular and sometimes localized deficiency of vitamins
and minerals that is not easily diagnosed using the usual clinical methods.
A key example of hidden hunger is the well-known need for vitamin C or ascorbic acid, an impor-
tant dietary antioxidant and stimulant of collagen synthesis. The amounts of vitamin C needed to
prevent scurvy are minimal, but the optimum intake of vitamin C for antioxidant protection in the
body is much higher. Humans do not synthesize vitamin C, so it must come from the diet. Ironically,
it is believed that the genetic machinery for making vitamin C evolved due to the vitamin C-rich
environment in the ancient plant-based diet in Africa. A single fruit contains more vitamin C than
the amount needed to prevent scurvy. Nonetheless, scurvy was common among sailors until the
middle of the eighteenth century.
The fictional captain of a Portuguese ship sailing to Japan in the novel Shogun, set in the 1700s,
would take a tiny slice of apple each day and squeeze its juice onto a spoon and drink it to prevent
scurvy. Today, while scurvy is uncommon, the intakes of vitamin C are still too low in many popu-
lation groups in the United States and globally.
While, along with scurvy, beriberi, pellagra, and the other classical vitamin deficiencies are
no longer common, suboptimal intakes of vitamins, minerals, and phytonutrients from fruits and
vegetables have been associated with increased incidences of heart disease and common forms of
cancer.
Often, the information in dietary guidelines that set the basis for healthy nutrition is ignored by
the public, but these guidelines are used by industry and government to modify the food supply. The
many assumptions underlying dietary guidelines and government advice are that they are meant for
healthy people. Unfortunately, we live in an era where two-thirds of all Americans are overweight
or obese, and many more have excess body fat due to a sedentary lifestyle and an unhealthy diet.
Fat-soluble vitamins such as vitamin D and phytonutrients such as lutein, which are fat soluble,
15
distribute into fat tissue, lowering circulating and cellular levels of these substances and other lipid-
soluble vitamins and phytonutrients.
The information and recommendations in this book will remain within the dietary guidelines,
but focus them to go beyond what can be observed in an epidemiology study to what can be pre-
scribed to an individual patient to achieve healthy results. As a primary care physician, you may be
called upon for an instant consensus decision on a nutritional issue that is controversial. Partnering
with dietitians, nurses, and other health care personnel will be a vital way to make your nutrition
endorsement and prescription of balanced nutrition and healthy active lifestyles effective. However,
it will be important that you and your dietitians and health care personnel are aligned on the advice
being given. Even minor inconsistencies in advice can undermine the confidence of patients in the
validity of the information you are providing. Education of the staff in your practice, along with
discussions of any disagreements on approach, is critical to establishing a viable nutrition focus in
your practice.
Federal regulations in the United States, as part of the Dietary Supplements Health Education
Act, mandate that a dietary supplement may not “prevent, cure, treat, or mitigate” any disease. It
also cleverly excludes tobacco, which contains nicotine and could in the broadest sense be consid-
ered a drug or botanical. Clearly, humans should meet their needs from the hundreds of thousands
of substances found in plant-based foods, spices, and herbs, as ancient man defined the genetics of
our metabolism. Eating a variety of foods, spices, and herbs can approximate what we need for opti-
mal health, but no diet is perfect, and reasonable supplementation has demonstrated benefits. Many
benefits cannot be demonstrated in clinical trials since they are an integral part of combined effects
that we cannot study with presently available methods. However, individuals with certain genetic
polymorphisms demonstrate the need for supplementation in terms of reduced risks of chronic
diseases, such as heart disease and cancer. These examples are discussed in greater detail in this
chapter. The risks of dietary supplements have been overemphasized by those sectors of the medi-
cal and scientific communities that prefer drugs and surgery over nutrition for the treatment and
prevention of disease.
It is important to realize that nutrition is both an applied science and a political science. The
advice emerging from government advisory committees in many countries reflects the concerns
of individual food lobbying groups and many other stakeholders. Once the Dietary Guidelines
Advisory Committee summarized the science in the 2015–2020 guidelines and submitted them to
the U.S. Department of Agriculture (USDA) and the Department of Health and Human Services, the
guidelines underwent congressional review, where the inputs of commodity groups were considered.
At the level of congressional review, one of the recommendations of the Scientific Advisory
Committee on eating less meat protein, which they based on extensive review of the scientific litera-
ture, was removed following complaints from the beef industry interests. In addition, recommen-
dations on developing sustainable food sources reflecting environmental concerns were removed
during congressional review. Nonetheless, the content of the guidelines is constantly improving
decade by decade, and the next set of guidelines, after 2020, may well overcome some or all of the
objections raised in the 2015–2020 guidelines. This process is a progressive one that ultimately
leads the nation and the world to a better understanding of healthy diet and lifestyle. However, the
slow rate of evolution is a strong rationale for providing nutrition advice that is both within and in
some aspects beyond the current dietary guidelines.
2.2 UNDERSTANDING THE DIETARY GUIDELINES

AND GOVERNMENT ADVICE
Many in the food industry and the dietetic community view the dietary guidelines issued by the
government as laws that must not be violated. Clearly, they behave like laws for the marketing and
regulatory departments of food companies and public agencies. However, these guidelines are not
unchanging laws, but have evolved over many decades, largely based on data derived from the field
Personalization of Nutrition Advice 17
of nutritional epidemiology (Willett 1998). This field depends on self-reported dietary intake, and
measurement of a limited number of biomarkers, such as height and weight. Nutritional epidemiol-
ogy has resulted in some of the most influential publications in nutrition science in humans. While
there is a large nutrition science literature in animal nutrition, the data on human intervention stud-
ies are usually conducted on small numbers of people, with the exceptions of a few large studies,
such as the Women’s Health Initiative (WHI) and the Dietary Approaches to Stop Hypertension
(DASH) (Sacks et al. 1995; Howard et al. 2006; Prentice et al. 2006).
Today, the guidelines are still a work in progress, as combinations of foods eaten together in
dietary patterns have evolved from the epidemiological data, including the Healthy Eating Index
(Kennedy et al. 1995) and the Mediterranean diet (Trichopoulou et al. 2003). Nutritional scientists,
physicians, and dietitians who volunteer to do the hard work of examining large epidemiological
evidence bases for the development of nutrition advice are often faced with too little information or
even conflicting information. Further analysis of the same data sets led to the expected conclusion
that those who adhered to the dietary guidelines had a reduced risk of chronic disease compared
with those who did not (McCullough et al. 2000a,b, 2002).
As a result, many dietary guidelines are meant to be broad in nature and not too far out in
front of the science. Others are compromises that do not reflect the science that is known. There
is also a natural bias toward foods and against dietary supplements, which does not reflect the
knowledge, attitudes, and behaviors of the public or the extensive body of data on micronutrient
supplementation.
Dietary supplements are meant to be an addition to the diet, and they do not substitute for a
poor dietary pattern. It is also true that obtaining all the micronutrients that have been implicated
in a healthy lifestyle by simply eating a healthy dietary pattern (formerly the four or five basic food
groups) is no longer possible given the explosion of nutrition knowledge. Supplements can be a use-
ful way to adhere to the dietary guidelines, even though they are only beginning to receive minimal
mention in the guidelines. Fears of toxicity are overblown, and safe levels of supplements are dis-
cussed further in this chapter.
2.2.1 Personalization of Dietary Guidelines

As stated above, government advice on diet and physical activity is well meaning, but it is too gen-
eral to be very useful in advising individual patients. In this chapter, we describe not only the guide-
lines and how to stay within them broadly, but also how to personalize them to help your patients
achieve a better diet and lifestyle that meets their individual goals for health and quality of life.
Once again, it is important to remember there has been a positive evolution of the dietary guidelines
over the last few decades, and this chapter is not an attack on the dietary guidelines or a criticism of
the dedicated professionals who developed recommendations.
The process of evolution of dietary guidelines will continue, always following and not leading
science, but you do not need to wait for approval from these government bodies before instituting
the advice that you think is best for your patients. Since nutrition advice does not participate in
the costly aspects of the health care system and may help prevent age-related chronic diseases,
physician-led teams should retain the liberty to give individualized advice for many years to
come. Arrayed against this freedom are several powerful stakeholders, including the food indus-
try and the regimenting systems of primary care that threaten to control physician behavior,
through direct regulation or indirectly by controlling government reimbursement for services
rendered.
In the United States, the American Dietetic Association has changed its name to the Academy
for Nutrition and Dietetics. Beginning in 2017, dietitians will be required to have a master’s degree
in nutrition to be registered dietitians. These changes will enhance the communication and coopera-
tion between physicians and dietitians to ideally form a functioning nutrition expert team within
primary care medical practices.
2.2.2 Recommended Dietary Allowances: A Brief History

The National Research Council issued the first recommended dietary allowances (RDAs) for vitamins,
minerals, protein, and energy in 1941. These recommendations were intended to serve as a guide for
good nutrition. In early 1977, after years of discussion, scientific review, and debate, the U.S. Senate
Select Committee on Nutrition and Human Needs, led by Senator George McGovern, recommended
dietary goals for the American people (U.S. Congress 1977). The goals consisted of complementary
nutrient-based and food-based recommendations. The first goal focused on energy balance and recom-
mended that, to avoid overweight, Americans should consume only as much energy as they expended.
Overweight Americans should consume less energy and expend more energy. For the nutrient-based
goals, the Senate committee recommended that Americans make the following modifications:
1. Increase consumption of complex carbohydrates and naturally occurring sugars

2. Reduce consumption of refined and processed sugars, total fat, saturated fat, cholesterol,
and sodium
3. Increase consumption of fruits, vegetables, and whole grains
4. Decrease the consumption of refined and processed sugars and foods high in such sugars
5. Decrease the consumption of foods high in total fat and animal fat, while partially replac-
ing saturated fats with polyunsaturated fats
6. Decrease intake of eggs, butter fat, and other high-cholesterol foods
7. Decrease salt and foods high in salt
8. Choose low-fat and nonfat dairy products instead of high-fat dairy products (except for
young children)
While this also sounds reasonable by modern standards, with a few exceptions, the issuance
of the dietary goals was met with considerable debate and controversy, as industry groups and the
scientific community expressed doubt that the science available at the time supported the specificity
of the numbers provided in the dietary goals.
To support the credibility of the science used by the committee, the USDA and U.S. Department
of Health and Human Services (then called the Department of Health, Education, and Welfare)
selected scientists from the two departments and obtained additional expertise from the scientific
community throughout the country to address the public’s need for authoritative and consistent
guidance on diet and health.
In the 1980s, there were controversies over the RDA recommendations. In a celebrated case,
there was an argument over whether the RDA for vitamin C should be 45 or 60 mg/day, with the
hard scientists citing biochemical data, while public health-oriented nutritionists cited the need for
increased intake of fruits and vegetables as a way to reduce the risk of common forms of cancer and
other age-related chronic diseases (Levine et al. 1999).
When issued in 1989, the RDA had expanded from a coverage of 8 original nutrients to 27 nutri-
ents. The RDA generally reflected changes resulting from the emergence of new concepts in the
field of nutrition science. The RDAs have served as the basis for federal and state food and nutrition
programs and policies.
By the 1990s, a number of developments had occurred that dramatically altered the nutrition
science landscape and ultimately challenged the RDA. Prominent among these were the significant
gains made in scientific knowledge regarding epidemiological associations between diet, health,
and chronic disease, and the availability of advanced technologies that could measure the variations
in nutrition metabolism among individuals (van Ommen and Stierum 2002; Goodman et al. 2003).
Additionally, the use of fortified or enriched foods and the increased consumption of nutrients in
pure form, either singly or in combination with others, as dietary supplements outside of the context
of food, prompted examination of the potential effects of excess nutrient intake (Greenwald and
McDonald 2001; Honein et al. 2001).
2.2.3 Dietary Reference Intakes

The Food and Nutrition Board of the National Academy of Sciences Institute of Medicine began
in 1994 to work to develop a new, broader set of dietary reference values, known as the Dietary
Reference Intakes (DRIs) (Otten et al. 2006). The DRIs expanded on and replaced the RDAs with
four categories of values intended to help individuals optimize their health, prevent disease, and
avoid consuming too much of a nutrient.
The DRIs include five nutrient-based reference values that are used to assess and plan the diets of
healthy people. The reference values include the acceptable macronutrient range, estimated average
requirement (EAR), RDA, adequate intake (AI), and tolerable upper intake level (UL) (Figure 2.1
and Box 2.1).
1.0 EAR UL 1.0
Risk of adverse effects

RDA
Risk of inadequacy
0.5 0.5
0 0
Observed level of intake
FIGURE 2.1 The EAR is the intake at which the risk of inadequacy is 0.5 (50%) to an individual. The RDA
is the intake at which the risk of inadequacy is very small—only 0.02–0.03 (2–3%). The AI does not bear
a consistent relationship to the EAR or the RDA because it is set without the estimate of the requirement. At
intakes between the RDA and UL, the risks of inadequacy and excess are both close to 0. At intakes above the
UL, the risk of adverse effects may increase. (Reprinted from Institute of Medicine (U.S.), Panel on Dietary
Reference Intakes for Electrolytes and Water, DRI, Dietary Reference Intakes for Water, Potassium, Sodium,
Chloride, and Sulfate, National Academies Press, Washington, DC, 2005.)
BOX 2.1 Definition of the DRI Components
Acceptable macronutrient distribution ranges (AMDRs): Ranges of macronutrient

intakes that are associated with reduced risk of chronic disease, while providing rec-
ommended intakes of other essential nutrients.
Adequate intake (AI): The recommended average daily intake level based on observed
or experimentally determined approximations or estimates of nutrient intake by a
group (or groups) of apparently healthy people that are assumed to be adequate; used
when an RDA cannot be determined.
Estimated average requirement (EAR): The average daily nutrient intake level that is
estimated to meet the requirements of half of the healthy individuals in a particular
life stage and gender group.
Recommended dietary allowance (RDA): The average daily dietary nutrient intake
level that is sufficient to meet the nutrient requirements of nearly all (97–98%) healthy
individuals in a particular life stage and gender group.
Tolerable upper intake level (UL): The highest average daily nutrient intake level that is
likely to pose no risk of adverse health effects to almost all individuals in the general
population. As intake increases above the UL, the potential risk of adverse effects may
increase.
The DRI process included several principles that differed from the isolated nutrient approach of
the RDAs. The concepts of probability and risk were used in the determination of the DRIs and in
their application in assessment and nutritional planning. Greater emphasis was placed on the distri-
bution of nutrient requirements within a population, rather than on a single value, as was the case in
the RDAs. Where data existed, upper levels of intake were established regarding the risk of adverse
health effects. Compounds found naturally in foods that may not meet the traditional concept of a
nutrient, but have a potential risk or possible benefit to health, could be reviewed, and if sufficient
data existed, reference intakes could be established.
Among the most useful innovations introduced by the RDA was the development of ranges of
macronutrient intakes that are associated with reduced risk of chronic disease, which were called
acceptable macronutrient distribution ranges (AMDRs). This innovation solved one of the most vex-
ing problems in the area of popular high-protein diets by lifting the allowable protein intake above
0.8 g/kg of body weight. At the time, evidence was mounting that protein requirements should be
higher. The requirements for essential fats in the diet are so low that fatty acid deficiency disease
does not occur unless individuals have gastrointestinal disorders. Similarly, carbohydrates are not
essential nutrients, and refined carbohydrates can be reduced. As sweet and fat foods in excess are
a significant driver of the obesity epidemic and chronic disease, flexibility in designing healthy
dietary patterns was enabled by the advent of the AMDRs (Zello 2006).
2.2.4 The 2015–2020 Dietary Guidelines

A greater focus on the importance of healthy eating patterns as a whole, and how foods and bever-
ages act synergistically to affect health, has developed and is reflected in the 2015–2020 dietary
guidelines (U.S. Department of Health and Human Services and U.S. Department of Agriculture
2015).
The 2015–2020 dietary guidelines provided five overarching guidelines that encourage healthy
eating patterns. The guidelines also embody the idea that a healthy eating pattern is not a rigid
prescription, but rather an adaptable framework in which individuals can enjoy foods that meet
their personal, cultural, and traditional preferences and fit within their budget. Several examples of
healthy eating patterns that translate and integrate the recommendations in overall healthy ways to
eat are provided.
The overarching guidelines can easily be met while individualizing your patient’s nutrition pre-
scription. The guidelines are as follows:
1. Follow a healthy eating pattern across the life span. All food and beverage choices matter.
Choose a healthy eating pattern at an appropriate calorie level to help achieve and maintain
a healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease.
2. Focus on variety, nutrient density (high content of nutrients per calorie), and amount. To
meet nutrient needs within calorie limits, choose a variety of nutrient-dense foods across
and within all food groups in recommended amounts.
3. Limit calories from added sugars and saturated fats and reduce sodium intake.
Consume an eating pattern low in added sugars, saturated fats, and sodium. Cut back
on foods and beverages higher in these components to amounts that fit within healthy
eating patterns.
4. Shift to healthier food and beverage choices. Choose nutrient-dense foods and beverages
across and within all food groups in place of less healthy choices. Consider cultural and
personal preferences to make these shifts easier to accomplish and maintain.
5. Support healthy eating patterns for all. Everyone has a role in helping to create and support
healthy eating patterns in multiple settings nationwide, from home to school to work to
communities.
Key recommendations on healthy eating patterns include (1) a variety of vegetables from all the
subgroups, including dark green, red and orange, and legumes (beans and peas); (2) fruits, espe-
cially whole fruits; (3) grains, at least half of which are whole grains; (4) fat-free or low-fat dairy,
including milk, yogurt, cheese, and/or fortified soy beverages; and (5) a variety of protein foods,
including seafood, lean meats, poultry, eggs, legumes (beans and peas), nuts, seeds, and soy prod-
ucts, and healthy oils. It also limits saturated fats and trans fats, added sugars, and sodium.
Key recommendations that are quantitative are provided for several components of the diet that
should be limited. These components are of particular public health concern in the United States,
and the specified limits can help individuals achieve healthy eating patterns within calorie limits,
as follows: (1) consume less than 10% of calories per day from added sugars; (2) consume less than
10% of calories per day from saturated fats; (3) consume less than 2300 mg/day of sodium; (4) if
alcohol is consumed, it should be consumed in moderation—up to one drink per day for women and
up to two drinks per day for men—and only by adults of legal drinking age.
2.2.5 Dietary Patterns Recommended by the 2015–2020 U.S. Dietary Guidelines

To get away from individual nutrients such as fats, carbohydrates, and proteins, the dietary guide-
lines shifted to recommending dietary patterns. There are many different healthy eating patterns.
The healthy Mediterranean-style eating pattern and healthy vegetarian eating pattern, which were
developed by modifying the healthy U.S.-style eating pattern, are two examples of healthy eating
patterns individuals are provided in the guidelines. Similar to the healthy U.S.-style eating pattern,
these patterns were designed to consider the types and proportions of foods Americans typically
consume, but in nutrient-dense forms and appropriate amounts, which result in eating patterns that
are attainable and relevant in the U.S. population. Additionally, healthy eating patterns can be flex-
ible with respect to the intake of carbohydrates, protein, and fats within the context of the AMDR.
2.2.6 Physical Activity Guidelines

The Department of Health and Human Services issued the federal government’s first-ever physical
activity guidelines for Americans in 2008 to help Americans understand the types and amounts of
physical activity that offer important health benefits (Tucker et al. 2011). Physical activity is any
form of exercise or movement of the body that uses energy. Some of your daily life activities, includ-
ing doing active chores around the house, yard work, and walking the dog, are provided as exam-
ples of physical activity. The physical activity guidelines for Americans recommend 60 minutesof
physical aerobic activity daily for children ages 6–17 and 30 minutes daily for adults ages 18–64.
Only 21% of Americans follow these guidelines in recent surveys, again demonstrating that simply
issuing guidelines does not accomplish behavior change when it comes to exercise.
Dietary guidelines and physical activity guidelines by their nature are too generalized to be
directly used in writing the nutrition prescription for individual patients. The guidelines have recog-
nized the increased prevalence of obesity, but are still largely based on data developed considering
nutritional deficiency rather than optimum nutrition. In the next section, the commonality of over-
fatness even in individuals with normal body mass index (BMI) and waist circumference is a strik-
ing indicator of how common nutritional issues are in the general primary care practice community.
2.2.7 Daily Values and Label Reading

Since the DRIs report recommendations according to age, sex, and life stage, they contain too much
information to include on the Nutrition Facts label on packages of foods. To solve this problem, the
Food and Drug Administration (FDA) uses information from the DRIs to create one number that
represents the daily requirement for each nutrient.
This number, called the daily value (DV), is based on the amount of each nutrient needed for a
diet of 2000 calories/day. You will not find the DV on the Nutrition Facts label. Instead, it is used
to calculate the information you will find on the label: the percent DV. The percent DV tells you
what percentage of your daily requirement you will get from one serving of the product.
Since it is based on eating 2000 calories daily, your actual percentage will certainly vary
according to the calories in your diet, but it is still a good frame of reference and an easy way to
track your daily intake. It is also a helpful tool for identifying whether the food is a high or low
source of nutrients. A percent DV of 5% or less is considered low, while 20% or more indicates
a high source, according to the FDA. I find this percent DV to be misleading to many consumers
and teach my patients to read food labels as follows: proteins and carbohydrates each provide
about 4 calories/g. Fat provides 9 calories/g. It takes a little math, but multiplying fat grams by 9
and the protein and carbohydrate grams by 4 will provide your patients with a better assessment
of the percent fat in a food. The amounts of sugars are also listed on the food label. The only
other tricky part is determining what a serving size should be. Sometimes, the serving size is
not realistic in terms of what they will be eating (e.g., one-quarter package of corn chips). While
many people read the food labels mandated by the Nutrition Labeling and Education Act enacted
under the administration of President George H. W. Bush, many consumers are baffled by the
information they find there.
About half of all American adults have one or more preventable chronic diseases, many of which
are related to poor-quality eating patterns and physical inactivity. These include cardiovascular
disease, high blood pressure, type 2 diabetes, some cancers, and poor bone health. More than two-
thirds of adults and nearly one-third of children and youth are overweight or obese. These high rates
of overweight and obesity and chronic disease have persisted for more than two decades and come
not only with increased health risks, but also at a high cost to the economy.
2.3 BODY COMPOSITION AND PERSONALIZATION

OF THE NUTRITION PRESCRIPTION
In this section, the basis of a nutrition prescription individualized on the basis of lean body
mass and used to determine protein and calorie requirements is described. From that basis, it is
possible to build a personalized diet incorporating fruits, vegetables, whole grains, and healthy
fats. Colorful fruits and vegetables and spices provide antioxidant phytonutrients with little
impact on overall calorie intake. Many of the phytonutrients we have identified have estab-
lished cellular actions, but for others, there is much more to learn. For those who wish to begin
with the end in mind, Box 2.2 describes how to build a diet based on these principles, while
the following subsections provide the rationale. Variations in this diet are useful for weight
management in obese patients, but the general guidelines given in what follows will aid healthy
individuals in maintaining optimal body composition when combined with a regular exercise
program.
BOX 2.2 BUILDING A PERSONALIZED DIET BASED ON LEAN BODY MASS

Between what we know about nutrition and what our patients do about nutrition, there is an
implementation gap. When meeting with patients, a simple plan that a primary care doctor can
endorse and a dietitian or nurse can reinforce will change eating behaviors more readily than
generalized dietary guidelines, which by nature must be a compromise among several different
commodity-driven economically influenced arguments.
It is possible to build a balanced diet based on lean body mass determined using bioelectri-
cal impedance. First, determine the protein foods that will result in providing personalized
protein at 1 g/pound of lean body mass per day. This can be accomplished by prescribing 25 g
units of protein providing about 140 calories/portion in units of 4–8 providing between 100
and 200 g/day.
Food Item 1 Unit Calories Protein (g)

Breakfast
Egg whites 7 whites 115 25
Greek yogurt (0% fat) without fruit added 1 cup 130 23
Nonfat cottage cheese 1 cup 140 28
Vegetarian
Soy Canadian bacon 4 slices 80 21 (varies)
Soy protein powder 1 ounce 110 20–25
Soy cereal ½ cup 140 25 (varies)
Lunch and Dinner
Poultry breast 3 ounces, cooked weight 115–140 25
Ocean-caught fish 4 ounces, cooked weight 130–170 25–31
Shrimp, crab, lobster 4 ounces, cooked weight 120 22–24
Tuna 4 ounces, water pack 145 27
Scallops 4 ounces, cooked weight 135 25
Egg whites 7 whites 115 25
Nonfat cottage cheese 1 cup 140 28
Vegetarian
Soy protein powder 1 ounce 110 20–25
Soy hot dog 2 links 110 22 (varies)
Soy ground round ¾ cup 120 24
Morningstar Farms Better’n Burgers 2 patties 160 26
Tofu, firm ½ cup 180 20 (varies)
Boca Burgers (all varieties) 2 patties 180–220 26–28
Carbohydrates and fiber can come from seven servings per day of colorful fruits and vegeta-
bles, with a typical 100 g serving of vegetable providing about 50 calories and a 100 g serving
of fruit providing about 70 calories. Listed next are the calories and fiber content of fruits and
vegetables organized according to the color grouping used in my clinic.
Food Item Portion Calories Fiber

Red
Tomato juice 1 cup 40 1
Tomato sauce/puree 1 cup 100 5
Tomato soup, made with water 1 cup 85 0
Tomato vegetable juice 1 cup 45 2
Tomatoes, cooked 1 cup 70 3
Tomatoes, raw 1 large 40 2
Watermelon 1 cup of balls 50 1
(Continued)

Red/Purple
Beets, cooked 1 cup 75 3
Blackberries 1 cup 75 8
Blueberries 1 cup 110 5
Cranberries 1 cup raw 60 5
Cranberry sauce ¼ cup 100 1
Eggplant, cooked 2 cups 60 5
Peppers, red 1 large 45 3
Plums 3 small 100 3
Red apple 1 medium 100 4
Red cabbage, cooked 2 cups 60 6
Red pear 1 medium 100 4
Red wine 4-ounce glass 80 0
Strawberries 1½ cups, sliced 75 6
Orange
Acorn squash, baked 1 cup 85 6
Apricot 5 whole 85 4
Cantaloupe ½ medium 80 2
Carrots, cooked 1 cup 70 5
Carrots, raw 3 medium 75 6
Mango ½ large 80 3
Pumpkin, cooked 1 cup 50 3
Winter squash, baked 1 cup 70 7
Orange/Yellow
Nectarine 1 large 70 2
Orange 1 large 85 4
Papaya ½ large 75 3
Peach 1 large 70 3
Peach nectar ⅔ cup 90 1
Pineapple 1 cup, diced 75 2
Tangerine 2 medium 85 5
Yellow grapefruit 1 fruit 75 2
Yellow/Green
Avocado ¼ average fruit 80 2
Banana 1 average 90 2
Collard greens, cooked (ckd) 2 cups 100 10
Corn ½ cup kernels or 1 ear 75 2
Cucumber 1 average 40 2
Green beans, ckd 2 cups 85 8
Green peas ½ cup 70 4
Green peppers 1 large 45 3
Honeydew ¼ large melon 100 2
Kiwi 1 large 55 3
Mustard greens, ckd 2 cups 40 6
Romaine lettuce 4 cups 30 4
Spinach, cooked 2 cups 80 8
Spinach, raw 4 cups 30 4
Turnip greens, ckd 2 cups 60 10
Yellow peppers 1 large 50 2
Zucchini with skin, ckd 2 cups 60 5
(Continued)

Green
Broccoli, cooked 2 cups 85 9
Brussels sprouts 1 cup 60 4
Cabbage, cooked 2 cups 70 8
Cabbage, raw 2 cups 40 4
Cauliflower, ckd 2 cups 55 6
Chinese cabbage, ckd 2 cups 40 5
Kale, cooked 2 cups 70 5
Swiss chard 2 cups 70 7
White/Green
Artichoke 1 medium 60 6
Asparagus 18 spears 60 4
Celery 3 large stalks 30 3
Chives 2 tablespoons 2 0
Endive, raw ½ head 45 8
Garlic 1 clove 5 0
Leeks, cooked 1 medium 40 1
Mushrooms, cooked 1 cup 40 3
Onion 1 large 60 3
Whole grain and refined grain foods provide about 250 calories/100 g, so breads, cakes,
pastries, and cookies should be minimized in the diet. Two slices of whole grain sprouted bread
will have 140–200 calories while providing 4–8 g of protein. Instead of suggesting breads and
cereals as the base of the diet with six to eight servings per day, recommend having more fruits
and vegetables and fewer refined grains. This will both increase fiber intake and provide more
vitamins, minerals, and phytonutrients to the diet.
Grain/Starch Serving Size Calories Fiber (g) Protein (g)

Cooked beans 1 cup, cooked 230–280 10–14 14
Brown rice 1 cup, cooked 220 4 6
Lentils 1 cup, cooked 230 16 18
Potato, baked 1 medium 220 8 4
Sweet potato 1 small 100 2 2
Whole grain pasta 1 cup, cooked 2 6
Plain instant oatmeal 1 packet 100 3 4
Shredded Wheat, bite size ¾ cup 85 3 4
Fiber One cereal ¾ cup 90 21 4
All-Bran with extra fiber cereal ¾ cup 75 18 5
Kashi GOLEAN cereal ¾ cup 120 10 8
Kashi Good Friends cereal ¾ cup 90 8 3
Kellogg’s All-Bran cereal ¾ cup 120 15 6
Bran Chex cereal ¾ cup 120 5 4
Kellogg All-Bran Buds cereal ⅓ cup 85 12 2
Bread, Vogel 1 slice 100 3 5
Bread, Ezekiel sprouted wheat 1 slice 80 3 4
Then, you consider balancing the omega-6 and omega-3 fatty acids by reducing total fat,
which includes hidden trans fats and omega-6 fats, while consuming about 2 g of fish oils from
fish oil supplements or ocean-caught fish.
This is not a low-fat or high-fat diet. A practical reduction in hidden fats results in a diet
containing between 20% and 25% of total calories from fat. If a higher-fat diet is desired with
reduced carbohydrates, then omega-9 fats should be used from olive oil or avocados, since these
are neutral fats that do not upset the balance of omega-3 and omega-6.
This method is simple enough to enable personal choices of foods to obtain a diet that will
help maintain healthy body composition when combined with physical activity daily. It begins
from the assumption that most Americans are struggling to keep from storing excess body fat
due to a sedentary lifestyle and omnipresent high-fat, high-sugar foods.
The above foods can be used as building blocks incorporated into recipes using spices and
various cooking techniques, which are becoming increasingly popular. Recipes are outside the
scope of this book, but your partnering dietitians can develop recipes to provide to your patients
using widely available cookbooks and Internet recipe sites.
2.3.1 Rationale for a Balanced Diet Based on Supplemented Personalized Protein

Protein is the macronutrient that is most satiating and, in combination with exercise, can maintain or
build muscle mass. Increasing muscle mass has significant positive effects on metabolism and joint
health. Muscle cells take up glucose independent of insulin, reducing stress on the pancreas even
while glucose levels are normal in individuals with prediabetes or metabolic syndrome. Nutritional
assessment using bioelectrical impedance to estimate lean body mass is central to developing diets
to maintain optimal body composition, especially internal abdominal or visceral fat, which rapidly
accumulates when individuals are sedentary and in a positive calorie balance.
Dr. Jimmy Bell and colleagues at Hammersmith Hospital and Imperial College in London found
that 40% of apparently healthy individuals with a normal BMI and normal waist circumference had
excess intra-abdominal fat based on MRI studies (Thomas et al. 2012).
Dr. Bell originated the term TOFI (thin outside, fat inside), which is used to describe lean indi-
viduals with a disproportionate amount of fat stored within their abdomen. Figure 2.2 illustrates this
by showing two men, both aged 35 years, with a BMI of 25 kg/m2. Despite their similar size, the
TOFI man had 5.86 L of internal fat, while the healthy control had only 1.65 L.
To classify an individual as TOFI, it is essential to measure his or her internal fat content. The only
way that this is possible is by using MRI or computed tomography (CT) scanning. The parameters
of the MRI scanner are manipulated to show fat as bright (white) and lean tissue as dark. Indirect
methods, such as waist circumference, are not suitable, as individuals with an identical waist circum-
ference can have vastly different levels of internal fat. Figure 2.3 clearly shows that despite having an
identical waist circumference (in this example, all men had a waist of 84 cm), there is considerable
variation in the amount of visceral fat (volumes shown on the image in liters) present.
While the exact incidence of TOFI globally has not been established, the existence of this syn-
drome suggests a much wider distribution of excess body fat among those with reduced lean body
mass and increased body fat at normal body weight.
The amount of lean body mass is critical in estimating the resting energy expenditure, as each
pound of lean body mass burns about 14 (13.8 is the original number) calories/pound/day, while
each pound of fat burns only about 3 calories/pound/day (Cunningham 1980).
Using bioelectrical impedance analysis (BIA) is a practical and cost-effective way to assess body
composition in the office (Kyle et al. 2004). BIA depends on the fact that muscle is about 70% water
and conducts electricity, while fat is an insulator. The most commonly used machines are modified
scales with four contact points. By placing two contact points on the hands and two on the feet and
separating these by a wide distance, it is possible to pass an alternating microcurrent at 50 cycles/
second (50 Hz) through the body and assess impedance. The computer in the machine using propri-
etary algorithms then estimates both lean body mass and fat mass. The lean body mass measure-
ment is accurate, within 5–10%, while the body fat measurement is an estimate and does not specify
the location of the fat, as was done with MRI.
Similar age, gender, BMI and same % body fat

Different levels of internal fat = different disease risks
1.65 liters
5.86 liters
of internal
of internal
fat
fat
EL Thomas and JD Bell 2008
FIGURE 2.2 Coronal image of a TOFI and a normal control. Subjects defined as TOFI with a BMI of
<25 kg/m2 have increased levels of many of the risk factors associated with the metabolic syndrome. This
phenotype is a further refinement of “metabolically obese but normal weight” (MONW). (Reprinted from
Imaging fat—MRI images of subjects we have scanned, CC BY-SA 3.0, https://commons.wikimedia.org/w/index
.php?curid=20135561.)
While the dietary guidelines suggest that Americans get enough protein in their diet, the evidence
suggests that the pattern of intake at each meal leads to insufficient intake over the whole day (Schaafsma
2005). As shown in Figure 2.4, many individuals eat little protein at breakfast, a little more for lunch,
and a large amount at dinner, much of which is not utilized by the muscles for protein synthesis. A bal-
anced distribution of protein throughout the day provides support of muscle protein synthesis.
The amount of lean body mass can be used to prescribe an AI of lean protein to both control hun-
ger and maintain lean body mass. In the University of California, Los Angeles (UCLA) Risk Factor
Obesity Program, we utilize a nutrition prescription of 1 g/pound of lean body mass determined by
BIA. The variations in body composition can be significant and affect resting energy expenditure,
and this is does not correlate with BMI. It has been established that lean body mass (also called fat
free mass) is the strongest correlate of resting energy expenditure (Jew et al. 2009) (Figure 2.5).
While resting energy expenditure is not the same as total energy expenditure, it does accurately
describe the greatest personal differences in the ability to lose or gain weight among individuals.
A loss of 10 pounds of fat-free mass due to sedentary lifestyle and inadequate protein intake leads
to a reduction in resting energy expenditure of 140 calories/day. This can be significant for a small
woman who burns 1500 calories/day at age 25 but loses 20 pounds of lean body mass by age 40 and
Variation in visceral fat

content in men with the
same waist
circumference.
Visceral fat = 0.5 L Visceral fat = 1.1 L
Visceral fat = 1.2 L Visceral fat = 1.3 L Visceral fat = 1.7 L
Visceral fat = 1.8 L Visceral fat = 4.2 L Visceral fat = 4.3 L
FIGURE 2.3 Variation in visceral fat in men with the same waist circumference. (Reprinted from
Imaging fat—Images from cohort of volunteers, CC BY-SA 3.0, https://commons.wikimedia.org/w/index
.php?curid=20139540.)
Optimal protein distribution Skewed protein distribution
{Maximum protein synthesis}
Breakfast Lunch Dinner Breakfast Lunch Dinner
~30 g ~30 g ~30 g ~10 g ~20 g ~60 g

protein protein protein protein protein protein
(a) (b)
FIGURE 2.4 Protein distribution at meals. (a) Ingestion of 90 g of protein, distributed evenly at three meals.
(b) Ingestion of 90 g of protein unevenly distributed throughout the day. Stimulating muscle protein synthesis
to a maximal extent during the meals (a) is more likely to provide a greater 24-hour protein anabolic response
than the unequal protein distribution in B. (Reprinted from Paddon-Jones, D., and Rasmussen, B. B., Curr.
Opin. Clin. Nutr. Metab. Care, 12(1), 86–90, 2009.)
then burns only 1250 calories at rest. This results in the common clinical paradigm of a middle-aged
women stating that she is gaining weight while still eating the same number of calories.
The RDA for protein was determined using a method called nitrogen balance. In this method, the
average protein is considered to have 1 g of nitrogen/6.25 g of protein in the diet. This is an obvi-
ous approximation since there are 21 different amino acids, some having two nitrogen atoms, while
most have only one. Urinary urea excretion is the primary method of nitrogen exit from the body.
2500
2000
REE = 21.7 × FFM + 374
REE (kcal/day)
1500
1000
500
0
0 10 20 30 40 50 60 70 80 90
Fat-free mass (kg)
FIGURE 2.5 Resting energy expenditure (REE) and fat-free mass (FFM) are related in a curvilinear fash-
ion. However, for FFM between 40 and 80 kg, the REE-FFM relation is linear. (Reprinted from Wang, Z.
et al., Am. J. Physiol. Endocrinol. Metab., 279(3), E539–E545, 2000.)
While some exists as ammonia and some in cells in stool, urinary urea nitrogen is an acceptable
clinical method to test for the adequacy of protein intake.
In 1973, Dr. Vernon Young at the Massachusetts Institute of Technology (MIT) studied young
healthy men eating egg whites and found that they achieved positive nitrogen balance at an intake of
0.8 g/kg of body weight/day (Young et al. 1973). Young healthy men eating 0.8 g/kg of body weight
went into positive nitrogen balance (Figure 2.6). This was assumed to hold for all men, leading to a
recommendation of 56 g/day for men and 46 g/day for women as the RDA.
However, studies in 1989 found that in endurance athletes, more than 1.2 g/kg/day was needed to
achieve positive nitrogen balance (Figure 2.7). In weight lifters, a higher amount of more than 2 g/kg
of body weight was needed (Figure 2.8).
Taken together, these observations led us to conclude that the RDA was too low and too general.
The protein in the diet must be increased when lean body mass is increased. While the body tends to
conserve lean body mass during starvation, optimal lean body mass can only be achieved with resis-
tance exercise and surplus protein intake, as evidenced by elimination of excess urinary urea nitrogen.
It turns out that a reasonable recommendation to implement is 1 g/pound of lean body mass per
day. Lean body mass can be estimated with BIA, which is widely available. The math works out that
this level of protein intake represents 29% of resting energy expenditure. Therefore, as a percent of
40
Nitrogen balance (mg N/kg/day)
30
20
10
0
–10 0.2 0.4 0.6 0.8 1
–20
–30
–40
Egg protein intake (g/kg/day)
FIGURE 2.6 Studies in normal volunteers in 1973 demonstrated positive nitrogen balance when fed egg
white protein at a dose of 0.8 gm/kg/day. These data are still the basis of RDA values in many countries.
(Adapted from Young, V. R. et al., J. Nutr., 103(8), 1164–1174, 1973.)
80
60
N balance (mgkg–1∙day–1)
40
20
–20
–40
–60 RDA
–80
0.3 0.5 0.7 0.9 1.1 1.3 1.5
Protein intake (g∙kg–1∙day–1)
FIGURE 2.7 More than 1.2 g/kg/day is needed to achieve positive nitrogen balance. (Reprinted from
Meredith, C. N. et al., J. Appl. Physiol. (1985), 66(6), 2850–2856, 1989.)
Nitrogen balance (NBAL, mgN∙kg–1∙d–1)
100
75
50 S: NBAL = –16.8 + 24.3 (PROIN)
25
0
SA: NBAL = –71.6 + 50.9 (PROIN)
–25
–50
SA =
–75 S=
–100
0.0 0.5 1.0 1.5 2.0 2.5 3.0
Protein intake (PROIN, g∙kg–1∙d–1)
FIGURE 2.8 More than 2 g/kg of body weight/day is needed to achieve positive nitrogen balance in weight
lifters with a large lean body mass. (Reprinted from Tarnopolsky, M. A. et al., J. Appl. Physiol. (1985), 73(5),
1986–1995, 1992.)
Dietary reference intakes (DRIs)

Acceptable range of macronutrient intake for protein
RDA UL
Risk of Risk of adverse
inadequacy Acceptable affects
intake
Protein: 0.8 g/kg 2.5 g/kg

10% of kcal 35% of kcal
FIGURE 2.9 Acceptable range of protein intake within the DRI for protein. (Adapted from Fulgoni, V. L.,
3rd, Am. J. Clin. Nutr., 87(5), 1554S–1557S, 2008.)
total energy expenditure, this amounts to somewhere around 25% of the total, including exercise,
dietary thermogenesis, and fidgeting.
As shown in Figure 2.9, this recommended amount of protein intake per day is well within
the acceptable macronutrient range of 10–35% established by the Institute of Medicine of the
National Academy of Sciences.
2.3.2 Protein Quantity and Quality

There are 21 common amino acids, and while some amino acids can be made from other amino
acids in the liver through a chemical exchange called transamination, other amino acids are essen-
tial (Box 2.3) and must be obtained from the diet. Some amino acids are called conditionally essen-
tial because they must be consumed in the diet during growth to provide adequate growth rates,
but become nonessential in adults who are not growing. One such amino acid is histidine, which is
essential for growing rats but not adult rats. Much of the data on the essentiality of amino acids are
obtained from rats, where single amino acid elimination is a way of determining whether a given
amino acid is essential. For example, lysine and threonine cannot be made from other amino acids
by transamination and must be included in the diet.
BOX 2.3 AMINO ACIDS
Essential Amino Acids

Histidine Phenylalanine
Isoleucine Threonine
Leucine Tryptophan
Lysine Valine
Methionine
Nonessential Amino Acids
Alanine Glycine
Arginine Proline
Asparagine Serine
Aspartic acid Taurine
Cysteine Tyrosine
Glutamic acid Glutamine
Proteins containing all the essential amino acids and nonessential amino acids in proper amounts
are called complete, while proteins missing some essential amino acids are called incomplete. Two
incomplete proteins, such as those found in corn and beans or rice and beans, can be combined to pro-
duce a mixed protein with higher protein quality. The original biological value tables found in many
nutrition textbooks were assessed in animals and did not evaluate digestibility, leading to the impres-
sion that soy protein, the highest-quality protein in the plant world, had a biological value of 73 com-
pared with egg white, which has a value of 100. The protein digestibility-corrected amino acid score
(PDCAAS) has been adopted by the Food and Agriculture Organization (FAO) and World Health
Organization (WHO) as the preferred method for the measurement of the protein value in human
nutrition. The method is based on comparison of the concentration of the first limiting essential amino
acid in the test protein with the concentration of that amino acid in a reference scoring pattern. This
scoring pattern is derived from the essential amino acid requirements of the preschool-aged child. The
chemical score obtained in this way is corrected for true digestibility of the test protein. PDCAAS
values higher than 100% are not accepted as such but are truncated to 100%. Using this method, soy
protein, whey protein, and egg white all have a biological value of 100% (Schaafsma 2005).
2.3.3 Carbohydrates and Fibers

Carbohydrates contain carbon, hydrogen, and oxygen but no nitrogen, and are broken down into
sugars, such as glucose and fructose, or excreted from the body in undigested form. The term car-
bohydrate, while useful for classifying macronutrients, includes both the carbohydrates that have
been industrially processed to a refined form and the indigestible carbohydrates found in fruits,
vegetables, and whole grains. Refined carbohydrates are often free of vitamins, minerals, and phy-
tonutrients unless they are fortified. Moreover, fruits and vegetables, as noted in the above diet plan
have, much lower-calorie density, such that a 100 g serving of a vegetable provides only 50 calories
and fruit provides 70 calories, while a 100 g serving of a refined carbohydrate such as white rice
provides 250 calories.
Those carbohydrates excreted in undigested form or those partially or completely digested by
colonic bacteria are referred to as dietary fibers. Since they are not digested, dietary fibers do not
contribute directly to the nutritive value of foods in terms of calories, but they have many effects
on human physiology. Ancient humans ate a great deal of fiber, and this fiber resulted in numerous
large bulky stools that filled the colon and caused it to contract against a large-volume load. Modern
man eats a small amount of fiber, approximately 10–15 g/day, compared with 35 g/day in a healthy
plant-based diet and well over 50 g/day in ancient diets.
One consequence of eating a low-fiber diet is that the colonic muscles contract against a smaller
volume of stool and so exert higher pressures. It is generally believed that these higher pressures
account for the common occurrence of diverticulosis (outpouching of mucosa between strands of
muscle) in the colons of elderly individuals. Constipation is also very common in modern society,
since a low-fiber diet does not stimulate intestinal motility as well as a higher-fiber diet does.
This slowing of transit time—the time it takes foods to get through the gastrointestinal
tract—also permits greater reabsorption of substances normally excreted through the intes-
tines. For example, estrogen (the female hormone) is excreted in the bile from the liver into the
intestine. In the intestine, it is bound to fibers and excreted in the stool. Women with low-fiber
diets and constipation reabsorb this estrogen in the distal small intestine, called the ileum,
rather than excreting the estrogen. This is not a minor effect, and results in 20% higher blood
estrogen levels in women on a low-fiber diet than in those consuming a high-fiber diet (Rose et
al. 1991).
Total dietary fiber is classified as either soluble or insoluble dietary fiber. Insoluble dietary fibers,
such as cellulose (a structural carbohydrate making up plant cell walls), are not digested in the intes-
tine and pass out in the stool, where they can be found intact. Soluble carbohydrates, such as pectin,
guar, and starches, are digested by bacteria in the colon. Stool mass is determined by the mass of
fibers and the mass of bacteria in stool. A significant portion of stool mass is bacteria. Soluble fibers
contribute to stool mass by promoting the growth of the bacteria that digest the soluble fiber and
use it as fuel.
2.3.4 Simple Sugars and Complex Carbohydrates

Simple sugars include glucose, fructose, lactose, and sucrose. These are listed as sugars on food
labels, while the so-called “complex carbohydrates” are not included in this list, despite the simi-
larity discussed above. Lactose and sucrose are disaccharides made up of galactose or glucose and
glucose or fructose, respectively. The tastes of corn sugar, sucrose or table sugar, and fructose are
different. Fructose is the sweetest-tasting sugar and is the one found in fruits such as oranges. Corn
sugar tastes like pancake syrup and is the primary sweetener in colas in the United States. In some
countries, such as Mexico, sucrose is used to sweeten colas, and they taste distinctly different from
their U.S. counterparts.
The term complex carbohydrate usually means a long-chain carbohydrate made up of many
glucose or carbohydrate molecules linked together. According to the FDA, maltodextrin, or corn
sugar, made up of 15 glucose molecules linked together, is a complex carbohydrate. In fact, as soon
as corn sugar is dissolved in stomach acid, it breaks up, giving exactly the same glucose release into
the blood as table sugars.
From the standpoint of dental health, corn sugar can promote tooth decay (Ma et al. 2013). The
original patent on maltodextrin claimed that it would enable infants to get more calories with less
diarrhea, since each maltodextrin molecule had 15 times the calories of an equivalent caloric load
of glucose with much less osmolality (the physical chemical property of dissolved chemicals that
draws fluid into the colon). In fact, this does help, but many infants still have colicky diarrhea as the
infant expression of stress and food intolerance. Declaration of the different types of carbohydrates,
especially of maltodextrin or corn syrup, is insufficient in some products, and consequently, the
consumer is not alerted to their cariogenic potential when used in older children. Complex carbohy-
drates by the FDA definition help neither dental health nor the development of diabetes.
2.3.5 Glycemic Index, Glycemic Load, and Calories

Years ago, we simply talked about refined and complex carbohydrates. The refined were called bad,
because they caused a rapid rise in blood sugar, which could trigger snacking through effects on
brain chemistry. Then in 1981, Dr. David Jenkins of the University of Toronto developed the gly-
cemic index (GI) (Jenkins et al. 1981). To determine GI, compare how much the blood sugar rises
over a several-hour period with a fixed dose of pure corn sugar (or dextrose). In practice, a plot is
made of the values of blood sugar over a 2-hour period, and the dots are connected, creating a curve.
The area under the curve of blood sugars after the administration of a fixed portion of carbohydrate
(usually 50 g) of the test food is calculated and compared with the area under the curve following
the administration of the same number of grams of carbohydrate from glucose, which is given an
arbitrary score of 100. The higher the number, the greater the blood sugar response and the resulting
emotional impact on sugar craving. So, a low-GI food will cause a small rise, while a high-GI food
will trigger a dramatic spike in blood sugar. Table 2.1 lists common foods with their GI.
One problem with the GI is that it only detects carbohydrate quality, not quantity. A GI value tells
you only how rapidly a particular carbohydrate turns into sugar. It does not tell you how much of
that carbohydrate is in a usual serving of a particular food. You need to know both things to under-
stand a food’s effect on blood sugar. The best example of this is the carrot. The form of sugar in the
carrot has a high GI, but the total carbohydrate content of the carrot in a usual serving is low, so
it does not have much effect on blood sugar. This is where glycemic load (GL) comes in: it takes
into consideration a food’s GI, as well as the amount of carbohydrates per serving. A carrot has only
4 g of carbohydrate. To get 50 g, you would have to eat about a pound and a half of them. GL takes
the GI value and multiplies it by the actual number of carbohydrates in a typical serving. While this
number is useful for research studies, especially epidemiological studies, for the purpose of educat-
ing patients in primary care practice, it is enough to encourage the intake of healthy carbohydrates
from low-GI foods, such as fruits, vegetables, and whole grains, while advising reductions in foods
with refined carbohydrates, such as cookies, candy bars, cakes, and pastries. These foods typically
have hidden fats as well. Reducing the intake of sugar-sweetened drinks, such as colas, which have
a high GI, is also vital, as about one-third of all sugar in the diets of Americans come from this
one source. Substituting water and unsweetened teas when not exercising is an important piece of
advice. During prolonged exercise that is vigorous, sports drinks with added sugar are needed to
maintain muscle glycogen, but for most minimal exercise, simply drinking water to maintain hydra-
tion is adequate.
The studies of the effects and potential benefits of eating foods with a low GI require taking into
account GL. A food with a low GL is defined by consensus as one with a value of less than 16. GL
has been found to be an important variable in epidemiological studies of diet and the risk of chronic
disease. Populations eating a diet that has a high GL, such as the U.S. diet of processed grains and
few fruits and vegetables, have a higher risk of diabetes and heart disease than those in some Asian
TABLE 2.1
GIs of Food
Food GI
Cornflakes 92
Potatoes 85
Jelly beans 80
Cream of wheat 74
French bread 73
Watermelon 72
White bread 70
Life Savers 70
Rye bread 65
Mars bar 65
Rice, white 64
Pineapple 59
Banana 52
Whole wheat bread 51
Orange 48
All-Bran 42
Peach 42
Apple 40
Ice cream, full fat 38
Milk, skim 32
Yogurt, low fat, fruit 31
Lentils 29
Milk, full fat 27
Soybeans 18
Source: Heber, D., and S. Bowerman, The L.A. Shape

Diet: The 14-Day Total Weight Loss Plan, 1st
ed., Regan Books, New York, 2004.
countries where they eat lots of fruits and vegetables with few processed foods. This has been docu-
mented both in population studies, such as those conducted by the Harvard School of Public Health
(Bhupathiraju et al. 2014), and in weight loss studies in children conducted at Children’s Hospital
in Boston, where a low-GL diet was more effective in promoting weight loss than a high-GL diet
(Ebbeling et al. 2012).
Researchers at Harvard University also examined the relationship between diet and risk of
non-insulin-dependent diabetes mellitus (NIDDM) in a cohort of 42,759 men without NIDDM
or cardiovascular disease, who were 40–75 years of age in 1986 (Bhupathiraju et al. 2014). Diet
was assessed at baseline by a validated semiquantitative food frequency questionnaire. During
6 years of follow-up, 523 incident cases of NIDDM were documented. The dietary GL (an indica-
tor of carbohydrate’s ability to raise blood glucose levels multiplied by the number of grams of
carbohydrate per serving) was positively associated with risk of NIDDM after adjustment for age,
BMI, smoking, physical activity, family history of diabetes, alcohol consumption, cereal fiber,
and total energy intake.
The above findings support the hypothesis that diets with a high GL and a low cereal fiber con-
tent increase the risk of NIDDM in men, as recently reviewed by an international group of nutrition
experts (Augustin et al. 2015). Further, they suggest that grains should be consumed in a minimally
refined form to reduce the incidence of NIDDM. So once again, we are back to whole foods. Those
foods with more dietary fiber, such as natural fruits and vegetables, are less likely to lead to obesity
and diabetes than modern refined and processed carbohydrates with the fiber removed.
Poor gastrointestinal health is common in Americans, with up to 40% suffering from diarrhea
or constipation at any time. At the same time, diets that are high in refined grains are more calorie
dense, with refined grains having 20–30 times the calorie density (calories per bite) as fruits, veg-
etables, and whole grains.
The GI, GL, and total calories of foods are listed here (Foster-Powell et al. 2002). The GI of
foods is based on the GI—where glucose is set to equal 100. The other is the GL, which is the GI
divided by 100 multiplied by its available carbohydrate content (i.e., carbohydrates minus fiber) in
grams per serving (Tables 2.2 through 2.7).
TABLE 2.2
Low GI (<55) and Low GL (<16) Foods (Lowest Calorie, 110
Calories/Serving or Less)
GI GL Serving Size Calories
Most vegetables <20 <5 1 cup, cooked 40
Apple 40 6 1 average 75
Banana 52 12 1 average 90
Cherries 22 3 15 cherries 85
Grapefruit 25 5 1 average fruit 75
Kiwi 53 6 1 average fruit 45
Mango 51 14 1 small fruit 110
Orange 48 5 1 average fruit 65
Peach 42 7 1 average fruit 70
Plums 39 5 2 medium 70
Strawberries 40 1 1 cup 50
Tomato juice 38 4 1 cup 40
Source: Heber, D., and S. Bowerman, The L.A. Shape Diet: The 14-Day Total Weight Loss
Plan, 1st ed., Regan Books, New York, 2004.
TABLE 2.3
High GI (>55) but Low GL (<16) Foods (All Low Calorie, 110 or Less
per Serving)
Apricots 57 6 4 medium 70
Orange juice 57 15 1 cup 110
Papaya 60 9 1 cup of cubes 55
Pineapple 59 7 1 cup of cubes 75
Pumpkin 75 3 1 cup, mashed 85
Shredded wheat 75 15 1 cup of 110
mini-squares
Toasted oats 74 15 1 cup 110
Watermelon 72 7 1 cup of cubes 50
TABLE 2.4
Moderate Calorie, Low GI, Low GL (110–135 Calories/Serving or Less)
Apple juice 40 12 1 cup 135
Grapefruit juice 48 9 1 cup 115
Pear 33 10 1 medium 125
Peas 48 3 1 cup 135
Pineapple juice 46 15 1 cup 130
Whole grain bread 51 14 1 slice 80–120
Source: Heber, D., and S. Bowerman, The L.A. Shape Diet: The 14-Day Total Weight Loss Plan,
1st ed., Regan Books, New York, 2004.
TABLE 2.5
Higher Calorie, Low GI, Low GL (160–300 Calories/Serving)
Barley 25 11 1 cup, cooked 190
Black beans 20 8 1 cup, cooked 235
Brown rice 50 16 1 cup 215
Garbanzo beans 28 13 1 cup, cooked 285
Grapes 46 13 40 grapes 160
Kidney beans 23 10 1 cup, cooked 210
Lentils 29 7 1 cup, cooked 230
Soybeans 18 1 1 cup, cooked 300
Yam 37 13 1 cup, cooked 160
TABLE 2.6
Low GI and Low GL, but High Fat and High Calorie
Cashews 22 4 ½ cup 395
Premium ice cream 38 10 1 cup 360
Low-fat ice cream 37–50 13 1 cup 220
Peanuts 14 1 ½ cup 330
Potato chips 54 15 2 ounces 345
Whole milk 27 3 1 cup 150
Vanilla pudding 44 16 1 cup 250
Fruit yogurt 31 9 1 cup 200+
Soy yogurt 50 13 1 cup 200+
TABLE 2.7
High GI (>55) and High GL (>16) (Many Trigger Foods, Many Higher
Calorie)
Baked potato 85 34 1 small 220
Cola 63 33 16-ounce bottle 200
Corn 60 20 1 ear, 1 cup kernels 130
Corn chips 63 21 2 ounces 350
Cornflakes 92 24 1 cup 100
Cream of wheat 74 22 1 cup, cooked 130
Croissant 67 17 1 average 275
French fries 75 25 1 large order 515
Macaroni and cheese 64 46 1 cup 285
Oatmeal 75 17 1 cup, cooked 140
Pizza 60 20 1 large slice 300
Pretzels 83 33 1 ounce 115
Raisin Bran 61 29 1 cup 185
Raisins 66 42 ½ cup 250
Soda crackers 74 18 12 crackers 155
Waffles 76 18 1 average 150
White bread 73 20 2 small slices 160
White rice 64 23 1 cup, cooked 210
2.3.6 Fats and Oils

Fats and oils provide the most concentrated source of calories of any foodstuffs. Fats provide essen-
tial fatty acids (linoleic and linolenic acids), which are precursors for prostaglandins. They are
called essential because they must be consumed similar to vitamins. Animals can be demonstrated
to die within weeks on a fat-free diet, but humans with intact gastrointestinal tracts do not clini
cally demonstrate fat deficiency since only 5–10% of calories from essential fats are needed to
avoid fatty acid deficiency. Fats also require prolonged digestion and contribute to satiety, carry fat-
soluble vitamins, and concentrate the tastes of foods to make them more palatable. The key problem
for most people eating a Western diet is an excess of fat from processed foods, and these fats are rich
in pro-inflammatory omega-6 fatty acids.
Ninety-five percent or more of the fats you eat and store are triglycerides. These fats have a
3-carbon backbone and three fatty acids esterified at each of the three positions (Figure 2.10). When
all the fatty acids on a triglyceride are the same, they are called simple; otherwise, they are called
mixed triglycerides, which are more common. Excess calories, regardless of source, are stored as
triglycerides (Figure 2.11).
The principal dietary sources of fat are meats, dairy products, poultry, fish, nuts, and vegetable
oils and fats used in processed foods. Vegetables and fruits contain only small amounts of fat, so
that vegetable oils are only sources of fat due to the processing of vegetables. The most commonly
used oils and fats for salad oils, cooking oils, shortenings, and margarines in the United States
include soybean, corn, cottonseed, palm, peanut, olive, canola (low erucic acid rapeseed oil), saf-
flower, sunflower, coconut, palm kernel, tallow, and lard. These fats and oils contain varying com-
positions of fatty acids, which have particular physiological properties (Table 2.8).
Fatty acids in dietary fats
Lauric (C12:0)
H3C COOH
Saturated Myristic (C14:0) H3C COOH
Palmitic (C16:0) H3C COOH
H3C COOH
Stearic (C18:0)
H3C
Monounsaturated oleic (C18:1 n-9)
Unsaturated Linoleic (C18:2 n-6) H3C

COOH
Linolenic (C18:3 n-3) H3C COOH

H3C
Polyunsaturated Arachidonic (C20:4 n-6) COOH
H3C COOH
Eicosapentaenoic (C20:5 n-3)
H3C
Docosahexaenoic (C22:6 n-3) COOH
FIGURE 2.10 Chemical structure of the most common dietary fatty acids. These fatty acids are found in
triglycerides with a 3-carbon backbone, so that three fatty acids occur together. In the body, triglycerides are
digested and the fatty acids incorporated into body fat, where over a period of time the chemical composition
of the fat correlates with dietary fat structures to a certain extent. The cellular balance between the 20- and
22-carbon omega-6 (also called n-6) and omega-3 (also called n-3) polyunsaturated fatty acids can affect
immune function. Humans are very inefficient in converting the 18-carbon fatty acids to 20- and 22-carbon-
length n-3 fatty acids, so these must be consumed from the diet as ocean-caught fish or from fish oil supple-
ments. The n-3 and n-6 designations for polyunsaturated fats are based on the first double bond being three
or six carbons from one end. The monounsaturated fats, such as olive oil or avocado oil, have the first double
bond nine carbons from one end and are called n-9.
If a fat contains among the three fatty acids predominantly saturated, monounsaturated, or satu-
rated fats (Table 2.8), then we use the shorthand of calling these saturated, monounsaturated, or
saturated fats. Commonly eaten fats all have varying mixtures of the fatty acids shown in Table 2.8
in their triglyceride lipids, the primary dietary source of fatty acids (USDA 2003).
Table 2.9 lists the comparative ratios of omega-6 to omega-3 fatty acids in Paleolithic,
Mediterranean, US, UK, and northern European diets. The differences in omega-6 to omega-3
ratios are due to both increases in animal fat intake and the intake of vegetable oils rich in omega-6
fatty acids. Humans are inefficient at converting 18-carbon to 20- and 22-carbon fatty acids, espe-
cially in face of the high refined carbohydrate and fat intake of the modern diet. Fish are efficient at
this conversion and also obtain some fish oils from algae. Their contribution of omega-3 fatty acids
is discussed below.
BOX 2.4 WHICH IS BETTER: CHICKEN OR BEEF?

There are some surprising differences in the ratios of omega-6 to omega-3 between grass-fed
and corn-fed beef and chicken in the ratios of omega-6 to omega-3 fatty acids they contain.
Ratio of Omega-6 to Omega-3

Grass-fed beef 1.95
Grain-fed beef 6.38
Grain-fed chicken breast 185
n-6/n-3 fatty acids compete for metabolism
Vegetable oil, Green leafy

meat n-6 fatty acids n-3 fatty acids vegetable
Linoleic acid 18:2n-6 18:3n-3 α-linoleic acid

∆6-Desaturase (ALA)
γ-linoleic acid (GLA) 18:3n-6 18:4n-3
Elongase
Dimommo-γ- Seafood
Linoleic acid (DGLA) 20:3n-6 20:4n-3
Meat
∆5-Desaturase
Arachidonic acid 20:4n-6 20:5n-3 Eicosapentaenoic acid
Elongase (EPA)
Adrenic acid 22:4n-6 22:5n-3
22:5n-6 22:6n-3 Docosahexaenoic acid

(DHA)
Cell membrane phospholipids
Eicosanoids
Prostaglandins Thromboxanes Leukotrienes
FIGURE 2.11 Within the cell, the long-chain omega-6 and omega-3 fatty acids compete for the same
enzymes, leading to potentially different compositions of the cell membrane phospholipids. In turn, the
phospholipids used to synthesize eicosanoids are a group of signaling compounds, including prostaglandins,
thromboxanes, and leukotrienes, which affect cellular function in numerous ways. The balance of omega-6
and omega-3 promotes the synthesis of pro-inflammatory (2 and 4 series from omega-6) or anti-inflammatory
(3 series from omega-3) eicosanoids. In this sense, the fatty acids are signal molecules involved in inflamma-
tion, as well as serving as building blocks for stored triglycerides in fat cells.
These ratios can be misleading, because the total fat in chicken breast is far less than the
total fat in grain-fed beef or grass-fed beef. Therefore, chicken breast is still a better choice
overall than beef. The flesh of wild game is typically only 2–4% fat by weight compared with
domestic meats, which are 20–25% fat by weight, much of it in the form of saturated fat. Wild
meat has its gamey taste due to both omega-3 fatty acids and aromatic oils from the plant foods
eaten by these animals.
Note: You will not find this type of information in the dietary guidelines.
Another interesting comparison is that between farmed salmon and ocean-caught salmon. The
fat in farmed salmon contains less of the healthy omega-3 fatty acids than the fat in wild salmon.
Salmon fat is rich in omega-3 fatty acids, essential nutrients important to fetal brain development
and linked to reductions in the occurrence or symptoms of autoimmune disease, headaches, cramps,
arthritis, other inflammatory diseases, hardening of the arteries, Alzheimer’s disease, and heart
attacks. But USDA testing data show that the fat of farmed salmon contains an average of 35% fewer
omega-3 fatty acids (USDA 2003). Because farmed salmon contains 52% more total fat than wild
salmon, the total omega-3 fatty acid content of farmed and wild fish is similar. However, in the case
of farmed salmon, the fat is contaminated with polychlorinated biphenyls (PCBs) and more than
100 other pollutants and pesticides. Frequent farmed salmon eaters may exceed government health
limits for these pollutants.
TABLE 2.8
Fatty Acid Composition in Commonly Eaten Fats
Total Linoleic Acid (Omega-6) Linolenic Acid (Omega-3) Total
Saturated Polyunsaturated ) Polyunsaturated ) Monounsaturated
Dietary Fat (%) (18:2 n-6) (%) (18:3 n-3) (%) Fatty Acids (%)
Olive oil 14 9 1 74
Avocado oil 12 13 1 71
Corn oil 13 58 1 24
Soybean oil 14 51 7 23
Peanut oil 17 32 0 46
Safflower oil 6 75 0 14
Sunflower oil 10 66 0 20
Palm oil 49 9 0 37
Lard 39 10 1 45
Beef tallow 50 3 1 42
Butter fat 62 2 1 29
Coconut oil 87 2 0 6
Source: Heber, D., and S. Bowerman, The L.A. Shape Diet: The 14-Day Total Weight Loss Plan, 1st ed., Regan Books, New
York, 2004.
TABLE 2.9
Comparative Ratios of Omega-6 to Omega-3 Fats in Different
Diets
Population Ratio of Omega-6 to Omega-3
Paleolithic 0.79
Mediterranean (Greece prior to 1960) 1.0–2.0
Current United States 16.74
Current United Kingdom and northern Europe 15.0
Current Japan 4.0
Source: Adapted from Simopoulos, A. P., Biol. Res., 37(2), 263–277, 2004.
The simple solution for modern times is to select low-fat fish, white meat of poultry, and occa-
sionally very lean meat, preferably grass fed. The ratio of omega-6 to omega-3 for fish is not com-
parable to those shown in Box 2.4. Wild salmon has a ratio of 0.08, and farmed salmon has a ratio
of 0.29. Addition of just 3 ounces of ocean-caught fish (e.g., herring) or 3 g of fish oil capsules to a
low-fat diet will reduce the proportion of predicted omega-6 fatty acids in tissues from 80% to 40%.
This amazing impact of fish oils is a potent argument for including fish and fish oil supplements in
a healthy diet.
2.3.7 Dietary Pattern That Prevents Weight Gain

Since the major nutrition problem in the world of primary care is no longer malnutrition but over-
weight and obesity, the major preventive challenge is to find a dietary pattern that helps to main-
tain body weight and prevent the weight gain that occurs so commonly with aging in a sedentary
population.
2.0
1.5
Change in body weight (kg) Low-protein, high GI Control
1.0 HP-HGI
LP-LGI
0.5
0.0
High-protein, low GI
–0.5
0 2 4 6 10 14 18 22 26
Week
Source: Diogenes study
FIGURE 2.12 (See color insert.) Science backs protein: change in body weight during the DIOGENES
study. As the chart shows, the high-protein, low-GI diet produced the best weight loss results. HP, high pro-
tein; LP, low protein; HGI, high GI; LGI, low GI. (Reprinted from Larsen, T. M., N. Engl. J. Med., 363(22),
2102–2113, 2010.)
The Pan-European Weight Loss Study (DIOGENES) was conducted in eight European coun-
tries, and after an 8-week weight loss phase, those who lost weight on a very low-calorie diet were
randomized to one of five different diets for the next 6 months (Figure 2.12) (Aller et al. 2014). All
the combinations of high and low protein and high and low GI with constant fat intake were tested.
Only those subjects consuming the high-protein diet at 30% of calories combined with low-GI
fruits, vegetables, and grains maintained their weight over the next 6 months. Subjects eating all the
other possible diet combinations gained between 2 and 4 pounds over the next 6 months. In these
studies, the percent of fat calories was held constant. While every effort to reduce the intake of
high-fat foods with hidden fats is desirable, as discussed, efforts to reduce fat intake below 25% of
calories have not been successful in intervention trials. Nonetheless, there are societies where lower
amounts of fat are eaten. Given the many advantages that fat provides to food taste and the transport
of fat-soluble phytonutrients, substitution of healthy fats, such as olive oil, is a more practical alter-
native than restricting total fat intake below 25%.
This dietary pattern was not mentioned in the dietary guidelines but is within the AMDR and,
as indicated, can be individualized for weight maintenance or weight management, discussed in
Chapters 2 and 5. This is a dietary pattern that can provide simple instruction to your primary care
patients quickly, and your dietitians and nurses can participate in the instruction. It can even be
accomplished in small groups of patients.
2.4 OPTIMIZING VITAMIN, MINERAL, AND MICRONUTRIENT

INTAKE FROM FOODS AND SUPPLEMENTS
Vitamin and mineral deficiency diseases in the United States were relatively common prior to World
War II. Today, with the fortification of the food supply, classical vitamin deficiency diseases such as
scurvy and rickets are rare outside the setting of specific disease states, drug–nutrient interactions,
or extreme malnutrition due to poverty.
The 2007–2010 National Health and Nutrition Examination Survey (NHANES) study found
that the large majority of Americans, despite having a high prevalence of obesity, failed to get ade
quate levels of micronutrients through their diet. Vitamin D and E intakes were below the EAR in
94% and 88% of the population, respectively. In addition, 33–50% of Americans had inadequate
intakes of magnesium, calcium, and vitamins A and C. This was noted in the 2015 scientific report
of the 2015 Dietary Guidelines Scientific Advisory Committee, which also stated that vitamins A,
C, D, and E, as well as folate, calcium, magnesium, fiber, and potassium, were nutrients of concern.
While all these data are based on self-report, it is remarkable that 90% of adults consumed an inad-
equate amount of vitamin D.
Significant portions of the population with common chronic diseases also have inadequate
intakes of micronutrients. Obesity is associated with inadequate absorption of vitamins A, C, D,
and E, as well as calcium and magnesium.
Despite the uncommon occurrence of classical vitamin deficiencies sufficient to cause acute
disease in healthy individuals, a familiarity with the roles of the various common vitamins and
minerals, and some knowledge of their assessment in the clinical laboratory, will aid in the assess-
ment of the hospitalized or ambulatory patient with suspected nutritional deficiency. It will also be
helpful in identifying suboptimal intakes of vitamins relevant to the reduction of the risk for com-
mon chronic diseases.
2.4.1 Fat-Soluble Vitamins: A, D, E, and K

2.4.1.1 Vitamin A
Night blindness was well recognized in ancient Egypt, where it was treated with juice from cooked
liver or by including liver in the diet. The active agent, vitamin A, was discovered as a fat-soluble
growth factor necessary for the rat in 1914 and structurally analyzed in 1930 (Moore 1957). The
parent compound of the vitamin A family is all-trans-retinol. Its aldehyde and acid forms are retinal
and retinoic acid (RA).
The active form of vitamin A for vision is 11-cis-retinal, which is converted to trans-retinal
following the absorption of the energy of a light photon. Called photoisomerization, this light-
mediated change in conformation from the cis- to the trans- form results in the dissociation of the
protein rhodopsin, which results in nerve impulses through the optic nerve to regions in the visual
cortex where sight is formed from the integration of these impulses.
A second active function for vitamin A is cellular differentiation. RA is a morphogen derived
from retinol (vitamin A) that plays important roles in cell growth, differentiation, and organogen-
esis. The production of RA from retinol requires two consecutive enzymatic reactions catalyzed by
different sets of dehydrogenases. The retinol is first oxidized into retinal, which is then oxidized into
RA. The RA interacts with the retinoic acid receptor (RAR) and retinoic acid X receptor (RXR),
which then regulate the target gene expression within the nucleus of cells where they promote
differentiation. Vitamin A deficiency accounts for 500,000 cases of blindness in children in the
developing world. Vitamin A deficiency results in a thickening of the conjunctiva of the eye called
xerophthalmia. The latter is due to the second function of vitamin A in maintaining the epithelial
integrity of the cornea. In young children, Bitot’s spots, foamy white accumulations of sloughed
cells on the conjunctiva, can be useful in diagnosing vitamin A deficiency.
The recent discovery of four RA receptors (termed RAR-alpha through RAR-gamma) in the
nucleus of cells has begun to elucidate the molecular mechanisms by which vitamin A induces
differentiation of many types of cells (Anon 1987). A number of retinoids or synthetic vitamin A
analogs (the best known is 13-cis-RA, or Accutane) are used to treat acne and have been studied for
their differentiating activities in the prevention and treatment of premalignant lesions of the mouth,
trachea, and cervix (Petkovich et al. 1987). Given the importance of vitamin A, it is fortunate that
it can be formed from provitamin A carotenoids found in carrots, yellow squash, dark green leafy
TABLE 2.10
Blood Levels of Vitamin A and Laboratory Diagnosis
Deficient Marginal Satisfactory Excessive Toxic
<0.35 μmol/L 0.35–0.70 0.70–1.75 1.75–3.5 >3.5
Source: Adapted from Olson, J. A., Vitamin A: In Present Knowledge in Nutrition,

ILSI Press, Washington, DC, 1990.
vegetables, corn, tomatoes, papaya, and oranges. Preformed vitamin A is found as retinyl palmitate
in liver; various dairy products, including milk, cheese, butter, and ice cream; and fish, such as her-
ring, sardines, and tuna. In the United States, about 75% of vitamin A is obtained from preformed
dietary sources and 25% from provitamin A carotenoids (Olson 1987).
The term vitamin A applies to all compounds with biological activity similar to that of vitamin A.
The interconversion and pharmacology of these various vitamin A’s is controversial and still under
study. The international units (IU) apply only to animal experiments under standardized conditions.
In the IU system, 0.3 μg of retinol or 0.34 μg of retinyl acetate or 0.6 μg of beta-carotene corre-
sponds to 1 IU. Diet can provide numerous vitamin A-like substances. Requirements and intakes
are listed as retinal activity equivalents (RAE): 1 mg RAE = 1 mg of retinal, 1.15 mg of retinal
acetate, 6 mg of beta-carotene, and 3000 IU of vitamin A.
Low plasma concentrations of retinol (<0.35 μmol/L) are associated with clinical symptoms
of vitamin A deficiency (Control of vitamin A deficiency and xerophthalmia 1982). The RDA
for vitamin A is 5000 IU (800–1000 μg retinol equivalents [RE]) per day, and toxicity has been
reported at intakes of 25,000 IU/day. This makes vitamin A one of the most toxic vitamins
known. The plasma levels of vitamin A can be used to assess status as shown in Table 2.10
(Olson 1990).
2.4.1.2 Vitamin D
There are two forms of vitamin D: vitamin D3 and vitamin D2. Vitamin D3 (cholecalciferol) occurs
in some foods but is primarily produced in the skin on exposure to sunlight (Baggerly et al. 2015;
Holick 2016). Vitamin D2 (ergocalciferol) does not occur naturally but is manufactured by the ultra-
violet irradiation of ergosterol, which occurs in molds, yeasts, and plants. Vitamin D3 differs from
vitamin D2 in that D2 has a double bond between carbon 22 and carbon 23 and a methyl group on
carbon 24.
Only a few foods (cod liver oil, fatty fish, and egg yolks) contain substantial amounts of naturally
occurring vitamin D3. The amount of vitamin D typically obtained from food sources other than forti-
fied foods and skin synthesis often is insufficient. For this reason, food is supplemented with vitamin
D in most developed countries. In North America, food is supplemented with both vitamin D2 and
vitamin D3, with milk being the principal fortified dietary component. Since dairy products have been
fortified with vitamins A and D, dietary rickets has become rare in the United States. Vitamin D acts
to enhance calcium absorption from the intestine and has been shown to have differentiating effects
on a number of different cell types, including white blood cells and prostate cancer cells. The active
form of vitamin D is 1,25-dihydroxyvitamin D3 formed from 25-hydroxyvitamin D (25(OH)D) in the
kidneys. 25(OH)D is a large inactive pool formed and stored in the liver. The kidney also has an inac-
tivation enzyme (24-hydroxylase), which converts 25(OH)D to inactive 24,25-dihydroxyvitamin
D. When 1,25-dihydroxyvitamin D acts at the nucleus, it turns on the genes necessary to produce
the 24-hydroxylase enzyme. Whenever there is such a branch point in the body, there is additional
protection from toxicity, and it indicates a substance with important metabolic roles (e.g., apolipo-
protein B and thyroid hormones).
As people age, the skin becomes less effective in forming vitamin D and people are advised to
use sunscreens and avoid sun exposure to prevent skin cancer (Kockott et al. 2016). Vitamin D3 as a
supplement is preferable to D2 (found in plants) since D2 is more rapidly cleared and is less biologi-
cally active than D3. Taking a dose of 2000 IU/day is not toxic since it translates into an increase in
25(OH)D levels of only 24 ng/mL (Table 2.11). The Institute of Medicine has only recognized the
benefits of vitamin D for bone and has set the requirements accordingly.
However, toxicity is only noted at doses greater than 20,000 units/day, and many consumers
take 1000–5000 units daily to take advantage of emerging science on the actions of vitamin D
beyond its role in calcium absorption. Vitamin D is not just a vitamin, but a hormone that, like the
retinoids, travels to the nucleus to program the transcription of specific proteins. Research over the
last three decades has brought to light many additional functions of vitamin D and redefined what
is considered optimal vitamin D nutrition. It is now estimated that approximately 1 billion people
worldwide have blood concentrations of vitamin D that are considered suboptimal. Low vitamin D
serum concentrations are linked to several types of cancers, cardiovascular disease, diabetes, upper
respiratory tract infections, and all-cause mortality.
Immune effects of vitamin D have been recognized for more than a century, and are now appre-
ciated as having had a role in the use of sunlight in the therapy of tuberculosis in the preantibiotic
era. Topical application of vitamin D cutaneous tuberculosis resulted in disappearance of lesions. In
the last few years, the significance of these observations to normal human physiology has become
apparent (Hewison 2012). There are increasing data linking vitamin insufficiency with prevalent
immune disorders. Improved awareness of low circulating levels of precursor 25(OH)D in popula-
tions across the globe has prompted epidemiological investigations of health problems associated
with vitamin D insufficiency. Prominent among these are autoimmune diseases such as multiple
sclerosis, type 1 diabetes, and Crohn’s disease, but more recent studies indicate that infections
such as tuberculosis may also be linked to low 25(OH)D levels. Moreover, it is now clear that
cells from the immune system contain all the machinery needed to convert 25(OH)D to active
1,25-dihydroxyvitamin D, and for subsequent responses to 1,25-dihydroxyvitamin D. Mechanisms
such as this are important for promoting antimicrobial responses to pathogens in macrophages, and
for regulating the maturation of antigen-presenting dendritic cells. The latter may be a key pathway
by which vitamin D controls T-lymphocyte (T-cell) function. However, T-cells also exhibit direct
responses to 1,25-dihydroxyvitamin D, notably the development of suppressor regulatory T-cells.
Collectively, these observations suggest that vitamin D is a key factor linking innate and adap-
tive immunity, and both of these functions may be compromised under conditions of vitamin D
insufficiency.
These actions of vitamin D were excluded from the dietary guidelines or the Institute of Medicine
report. Yet many of your patients may be taking 1000–5000 units of vitamin D supplements with no
ill effects due to the natural deactivation of excess vitamin D.
TABLE 2.11
Serum 25-Hydroxyvitamin D Concentrations by Category
Category 25(OH)D Concentrations, ng/mL (nmol/L)
Deficiency <20 (<50)
Insufficiency 20–32 (50–80)
Sufficiency 32–100 (80–250)
Excess >100 (>250)
Intoxication >150 (>325)
Source: Adapted from Hossein-nezhad, A., and M. F. Holick, Mayo Clin.

Proc., 88(7), 720–755, 2013.
Vitamin D is not just a vitamin, but a hormone that, like the retinoids, travels to the nucleus to
program the transcription of specific proteins. Research over the last three decades has brought to
light many additional functions of vitamin D and redefined what is considered optimal vitamin D
nutrition. It is now estimated that approximately 1 billion people worldwide have blood concentra-
tions of vitamin D that are considered suboptimal. Low vitamin D serum concentrations are linked
to several types of cancers, cardiovascular disease, diabetes, upper respiratory tract infections, and
all-cause mortality.
Several observational studies and a few prospectively randomized controlled trials have dem-
onstrated that adequate levels of vitamin D can decrease the risk and improve survival rates for
several types of cancers, including breast, rectum, ovary, prostate, stomach, bladder, esophagus,
kidney, lung, pancreas, uterus, non-Hodgkin lymphoma, and multiple myeloma (John et al. 2007;
Davis and Milner 2011). Individuals with serum vitamin D concentrations of less than 20 ng/mL
are considered most at risk, whereas those who achieve levels of 32–100 ng/mL are considered
to have sufficient serum vitamin D concentrations, as in Table 2.11 (Hossein-nezhad and Holick
2013).
Vitamin D can be obtained from exposure to the sun, through dietary intake, and via supplemen-
tation. Obtaining a total of approximately 4000 IU/day of vitamin D3 from all sources has been
shown to achieve serum concentrations considered to be in the sufficient range. Most individuals
will require a dietary supplement of 2000 IU/day of vitamin D3 to achieve sufficient levels, as up to
20,000 IU/day is considered safe. The Endocrine Society has issued clinical guidelines recommend-
ing 1000 IU/day as a safe dose (Rosen et al. 2012). Vitamin D3 is available as an over-the-counter
product at most pharmacies and is relatively inexpensive, especially when compared with potential
and demonstrated benefits. Since vitamin D is fat soluble, it disperses into adipose tissue, and over-
fat individuals are known to have decreased levels compared with lean individuals and to require
higher doses to normalize blood levels of vitamin D.
2.4.1.3 Vitamin E
A group of fat-soluble substances, the tocopherols are referred to as vitamin E. One of these sub-
stances, alpha-D-tocopherol, is biologically active in rodents, where a deficiency can cause infertil-
ity. Tocopherols have antioxidant properties protecting tissues and substances from the effects of
oxygen. For example, these compounds can prevent oxidation of cholesterol, polyunsaturated fats,
and other membrane lipids and proteins. The antioxidant effects of vitamin E have been demon-
strated only at doses that cannot be derived from usual diets, but can only be achieved by using
supplement capsules.
In humans, severe vitamin E deficiency occurs as a result of genetic defects in the a-tocopherol
transfer protein (a-TTP), causing ataxia (Di Donato et al. 2010). The lack of functional a-TTP results
in the rapid depletion of plasma a-tocopherol (Traber et al. 1990; Morley et al. 2008), thereby dem-
onstrating that a-TTP is needed to maintain plasma a-tocopherol concentrations. Fat malabsorption
also leads to vitamin E deficiency, including patients with cholestatic liver disease or cystic fibrosis
(Traber and Manor 2012). In humans, when there is a vitamin E deficiency, in addition to spinocer-
ebellar ataxia, which gets worse over time, there is also muscle deterioration, including cardiomy-
opathy, ultimately resulting in death.
The use of vitamin E supplements has been associated with lower cardiovascular disease risk
in males, and has also been used effectively to retard oxygen-induced damage to the eye in infants
given 100% oxygen, known as retrolental fibroplasia. There is increased interest in using vitamin
E as an antioxidant for the prevention of cardiovascular disease and common forms of cancer. The
RDA for vitamin E is between 8 and 12 μg equivalents per day to prevent vitamin E deficiency
(infertility seen only in animals), but many individuals take 400–800 IU supplements without ill
effects.
A recent analysis of multiple studies found that above 330 IU/day was associated with a 5%
increase in overall mortality from cardiovascular disease. These results have been discounted by
many nutrition scientists and remain controversial. Studies have shown evidence of benefits of toco-
trienols, as well as tocopherols, but most supplements and multivitamins provide only synthetic
alpha-D-tocopherol.
2.4.1.4 Vitamin K
Vitamin K is a fat-soluble vitamin. The K is derived from the German word koagulation. Coagulation
refers to blood clotting, because vitamin K is essential for the functioning of several proteins involved
in blood clotting. Vitamin K acts on target proteins in the clotting cascade BY, adding a gamma-
carboxyl group to activate clotting proteins.
Half of vitamin K comes from the diet, and the other half is synthesized from precursors by
intestinal bacteria. Spinach, green leafy vegetables, cabbage, potatoes, cereals, and liver are good
sources (Booth 2012).
Since vitamin K is found in so many foods and is also formed by intestinal bacteria, deficiency
is rare. Individuals receiving prolonged antibiotic therapy destroying intestinal bacteria and indi-
viduals with fat malabsorption are at risk for vitamin K deficiency. The RDA for adults ranges from
45 to 80 μg/day. Because warfarin antagonizes the action of vitamin K, rich dietary sources of
vitamin K are restricted in patients on warfarin, also known as coumadin. For patients whose blood
tests, called the international normalized ratio (INR), vary greatly, it is an art to adjust the warfarin
dose, as dose adjustments often require 36 hours to manifest.
Vitamin K2 acts in bone as a cofactor for gamma-carboxylase, which converts the glutamic
acid in osteocalcin molecules to gamma-carboxyglutamic acid (Kidd 2010). It is also a transcrip-
tional regulator of bone-specific genes that act through steroid and xenobiotic receptors to favor the
expression of osteoblastic markers. Vitamin K deficiency has been shown to be a risk factor for hip
fractures in the elderly, and vitamin K2 supplementation increases serum levels of osteocalcin and
has a modest effect on bone mineral density.
A deficiency of this vitamin in newborn babies results in hemorrhagic disease, as well as postop-
erative bleeding and hematuria, while muscle hematomas and intercranial hemorrhages have been
reported. A shortage of this vitamin may manifest itself in nosebleeds or internal hemorrhaging.
There are two naturally occurring forms of vitamin K (Figure 2.13). Plants synthesize phyl-
loquinone, also known as vitamin K1. Bacteria synthesize a range of vitamin K forms, using
O O
O O
Menadione Phylloquinone
O
CH3
O
6
Menaquinone-7 (MK-7)
FIGURE 2.13 Forms of Vitamin K. Vitamin K1, or phylloquinone, is synthesized by plants and is the pre-
dominant form in the diet. Vitamin K2 includes a range of vitamin K forms collectively referred to as mena-
quinones. Most menaquinones are synthesized by human intestinal microbiota and found in fermented foods
and in animal products. Menaquinones differ in length from 1 to 14 repeats of 5-carbon units in the side chain
of the molecules. These forms of vitamin K are designated MK-n, where n stands for the number of 5-carbon
units (MK-2 to MK-14).
repeating 5-carbon units in the side chain of the molecule. These forms of vitamin K are desig-
nated menaquinone-n (MK-n), where n stands for the number of 5-carbon units. MK-n are collec-
tively referred to as vitamin K2. The synthetic compound known as menadione (vitamin K3) is a
provitamin that needs to be converted to MK-4 to be active. MK-4 is not produced in significant
amounts by bacteria, but appears to be synthesized by animals (including humans) from phylloqui-
none, which is found in plants (Nakagawa et al. 2010). MK-4 is found in a number of organs other
than the liver at higher concentrations than phylloquinone. This fact, along with the existence of
a unique pathway for its synthesis, suggests that there is some unique function of MK-4 that is yet
to be discovered.
2.4.2 Water-Soluble Vitamins
2.4.2.1 Vitamin B1 (Thiamin)
Thiamin deficiency disease, still seen today in alcoholics, is known as beriberi (McCullough et
al. 2000a). This disease, which damages the nervous and cardiovascular systems, is found in two
forms, wet beriberi with edema and congestive heart failure, and dry beriberi characterized by
muscle atrophy due to nerve damage. In alcoholics, Wernicke–Korsakoff syndrome, characterized
by mental confusion, memory disturbances, ataxia, opthalmoplegia, and nystagmus, can be fatal if
not treated with intravenous thiamin (Haas 1988).
The dietary vitamin is phosphorylated by transfer of a high-energy phosphate from ATP to
form thiamin pyrophosphate in the intestine. Its primary function is to act as a coenzyme for the
oxidative decarboxylation of alpha-keto acids to carboxylic acids (e.g., pyruvate to acetyl-CoA)
and the transketolase reaction of the pentose phosphate shunt. The latter pathway is important
for nucleic acid synthesis and the formation of NADPH for fatty acid synthesis and other reac-
tions. Decreased transketolase activity in red cells can be detected early in the course of thiamin
deficiency. The RDA of thiamin is 0.5 mg/1000 kcal, and this is four times the intake at which
deficiency signs are observed.
2.4.2.2 Vitamin B2 (Riboflavin)
Riboflavin is a yellow fluorescent compound found throughout the animal and plant kingdoms.
Humans and other mammals cannot synthesize these compounds, which function in numerous
enzyme complexes (including flavin mononucleotide and flavin adenine dinucleotide) involved in
electron transport oxidation–reduction reactions. It is the central component of the cofactors FAD
and FMN and, as such, is required for a variety of flavoproteoin enzyme reactions, including the
activation of other vitamins (Merrill et al. 1981).
Flavins are transported in the blood by albumin and immunoglobulins. Uncomplicated ribofla-
vin deficiency is uncommon, but dietary lack of the vitamin can lead to a deficit, not only in flavin
coenzyme functions, but also in the conversion of vitamin B6 to pyridoxal phosphate. The RDA for
riboflavin ranges between 1.2 and 1.8 mg/day for adults.
2.4.2.3 Vitamin B6 (Pyridoxine)
The active form of vitamin B6 is pyridoxal 5′-phosphate (PLP), and this coenzyme is involved in
more than 60 different enzymatic reactions in the body, including such common reactions as decar-
boxylation and aminotransferase reactions (Mooney et al. 2009).
Isolated deficiencies of vitamin B6 are rare, and it is most common to see deficiencies of multiple
B vitamins. The best measure of vitamin B6 status is plasma PLP, which can be measured by high-
performance liquid chromatography (HPLC). An intake of 2 mg/day is recommended as the RDA,
and doses greater than 1 mg must be given to change PLP levels. At intakes of greater than 25 mg,
PLP levels do not change further, with the excess vitamin B6 excreted in the urine as pyridoxal and
pyridoxic acid. Very large doses (e.g., 500 mg/day) can cause peripheral neuropathy by inducing
a conditioned deficiency of other B vitamins catabolized in a manner similar to that of the excess
vitamin B6 ingested.
2.4.2.4 Niacin
Vitamin B3, also known as niacin or nicotinic acid, can be synthesized by the body from tryp-
tophan. The nickname niacin came from linking several letters in the words nicotinic, acid, and
vitamin. When the properties of nicotinic acid, made by oxidation of nicotine, were first discovered,
it was decided that vitamin B3, or nicotinic acid, should be named in such a way as to dissociate it
from nicotine and not create the impression that either smoking provided this vitamin or wholesome
food contained a poison.
Once again, niacin refers to both nicotinic acid and nicotinamide, although sometimes it is used
just to indicate niacin. Nicotinamide is converted to the nicotinamide adenine dinucleotide cofac-
tors (NAD and NADH) essential for a number of enzymatic reactions and electron transport. Niacin
causes flushing and can reduce triglyceride levels in individuals with dyslipidemia at high doses of
500 mg three times a day, usually taken with aspirin to reduce the flushing reaction (Brown et al.
2001). Nicotinamide does not have these lipid-lowering effects.
The deficiency disease, pellagra, was observed to occur in populations consuming a maize-based
diet deficient in the amino acid tryptophan, which is the precursor for endogenous niacin forma-
tion. Large doses of nicotinic acid (1.5–3 g/day), but not nicotinamide, will lower cholesterol and
triglyceride levels and raise HDL levels in subgroups of hypercholesterolemic individuals. However,
long-acting forms of niacin in large doses have been associated with liver damage, facial flushing,
and worsening of hyperglycemia in diabetics. The RDA for niacin ranges between 13 and 20 mg/
day for adults.
2.4.2.5 Folic Acid
Folate is a micronutrient, once called vitamin M, which frequently is deficient in American diets
since it is derived from dark green, leafy vegetables. The root of the name folic comes from the
Latin word for leaf. Folic acid acts in cell maturation and differentiates epithelial tissues. In the lung
and the cervical epithelium, pro-differentiation effects have been demonstrated. Folic acid has also
been associated with the prevention of neural tube defects, such as spina bifida, through its effects
in epigenetic methylation in utero. It is included in all prenatal vitamins at an enhanced level.
Folate supplementation is restricted to 400 μg/tablet in over-the-counter vitamins given the fear
that someone with excessive folate and B12 deficiency (see Section 2.4.2.6) will develop subacute
combined spinal degeneration and paralysis (Drazkowski et al. 2002). Patients with pernicious
anemia are among those susceptible to subacute combined spinal degeneration from excess folate
intake, as are those who have had a gastric bypass operation or gastrectomy. Folate and folic acid
are not interchangeable terms. Folic acid is the oxidized form found in fortified foods and supple-
ments, while folate is the reduced form found naturally in foods as polyglutamates, which must be
cleaved and converted in a series of steps to 5-methyltetrahydrofolate, which plays a key role in
methyl donor reactions.
Food sources of folate include mushrooms and green vegetables. Raw foods have higher amounts
than cooked foods. Enrichment of white flour began in 1998 and is now the major source of folate
in the American diet. The bioavailability of dietary folate is about 50%.
One dietary folate equivalent (DFE) is equal to 1 μg of food folate, 0.6 μg of folic acid from a
supplement or fortified food consumed with a meal, or 0.5 μg of folic acid from a supplement taken
without food (empty stomach). Stated alternately, DFE = 1 μg of food folate + (1.7 × 1 μg of folic acid).
2.4.2.6 Vitamin B12
Vitamin B12, also called cyanocobalamin, is needed to make red blood cells and is necessary
for the synthesis of nerve sheaths, fatty acids, and DNA. Since this vitamin is stored in the liver,
nutritional deficiency usually takes years to develop. It is much more common to see metabolic
deficiencies. Most commonly, an anemia due to B12 deficiency results from an autoimmune disease
called pernicious anemia, in which the parietal cells in the stomach that make a binding protein
(intrinsic factor) necessary for B12 absorption are destroyed (Seetharam and Alpers 1982). The
healthy individuals most at risk of a dietary vitamin B12 deficiency are vegetarians, since there is
no B12 in any plant product. There is also a decreased capability for absorption of vitamin B12 in
the elderly due to decreased gastric acid secretion (Carmel 1997).
Vitamin B12 levels need to be measured in individuals at risk, since folate administered to an
individual with B12 deficiency will result in subacute combined degeneration of the spine and paral-
ysis. The RDA for adults is only 2–2.6 μg/day.
Vitamin B12 consists of a class of chemically related compounds, all of which have vitamin
activity. It contains the biochemically rare element cobalt sitting in the center of a planar tetrapyr-
role ring called a corrin ring. More recently, hydroxocobalamin, methylcobalamin, and adenosyl-
cobalamin can be found in more expensive pharmacological products and food supplements. Their
extra utility is currently controversial.
2.4.2.7 Choline
Choline is not considered a B vitamin since a portion of the choline requirement can be met via
endogenous de novo synthesis of phosphatidylcholine catalyzed by phosphatidylethanolamine
N-methyltransferase (PEMT) in the liver. A recommended dietary intake for choline of 550 mg/day
in humans was set in 1998, and although many foods contain choline, 90% of Americans do not get
enough in their diets (Zeisel 2011).
When deprived of dietary choline, most adult men and postmenopausal women develop signs of
organ dysfunction, such as fatty liver, liver or muscle cell damage, and reduced capacity to handle a
methionine load, resulting in elevated homocysteine levels in the blood.
Only some premenopausal women with a genetic polymorphism develop problems, because
estrogen induces expression of the PEMT gene and allows premenopausal women to make more of
their needed choline endogenously. The dietary requirement for choline can vary based on common
polymorphisms in genes of choline and folate metabolism, including the methylenetetrahydrofolate
reductase (MTHFR) gene. The CC polymorphism is the most common and protects individuals
from choline deficiency. The less common TT polymorphism in about 10% of individuals does not
protect individuals from choline deficiency.
Choline is critical during fetal development, when it alters DNA methylation and thereby influ-
ences neural precursor cell proliferation and apoptosis. This results in long-term alterations in brain
structure and function, specifically memory function. Along with folate and B12 deficiency, inad-
equate consumption of choline can lead to high homocysteine and all the risks associated with that,
including cardiovascular disease, neuropsychiatric illness (Alzheimer’s disease and schizophrenia),
and osteoporosis. Inadequate choline intake can also lead to fatty liver or nonalcoholic fatty liver
disease (NAFLD). The issues around homocysteine are an excellent example of the impact of nutri-
genetics, the differences among individuals impacting risk of age-related chronic diseases.
DNA methylation is dependent on a methyl donor. and S-adenosyl-L-methionine (SAM) is the
primary methyl group donor for most biological methylation reactions (Chiang et al. 1996). SAM is
generated by the methionine cycle, in which 5-methyltetrahydrofolate transfers single methyl groups
to homocysteine in a reaction catalyzed by methionine synthase to produce methionine. After donat-
ing the methyl group, 5-methyltetrahydrofolate is converted to tetrahydrofolate and then to 5,10-
methylenetetrahydrofolate by serine hydroxymethyltransferase. 5,10-Methylenetetrahydrofolate is a
key substrate that can be directed toward nucleotide biosynthesis or methionine regeneration. MTHFR
catalyzes the irreversible conversion of 5,10-methylenetetrahydrofolate to 5-methyltetrahydrofolate,
which can be used in the methionine cycle to generate SAM (Schwahn and Rozen 2001).
The MTHFR C677T polymorphism leads to the amino acid alanine being replaced by valine
(p.Ala222Val) and the production of a thermolabile variant of MTHFR with 30% less enzyme
activity (Sharp and Little 2004). The MTHFR C677T polymorphism has been suspected to induce
hypomethylation and then activate proto-oncogenes, which could explain the association between
this polymorphism and some types of cancer, including oral cancer (Sailasree et al. 2011).
2.4.2.8 Pantothenic Acid and Coenzyme A

Pantothenic acid is also called pantothenate or vitamin B5. Pantothenic acid is required to synthesize
coenzyme A (CoA), which is intrinsic to the synthesis of proteins, carbohydrates, and fats (Robishaw
and Neely 1985). The structure of pantothenic acid is made up of an amide linkage between pantoic
acid and alanine. Its name derives from a Greek root meaning “from everywhere,” since small quan-
tities of pantothenic acid are found in nearly every food, with high amounts in avocado, whole grains,
legumes, eggs, and meats. It commonly occurs in its alcohol form, pantothenol, and as calcium pan-
tothenate. Pantothenic acid is used as an ingredient in some hair and skin care products, since it is
reputed with no proof to prevent graying of the hair. It was discovered in 1933 by Dr. Roger Williams.
Within cells, pyruvate produced from the breakdown of glucose via the glycolytic pathway is
transported into mitochondria for the production of ATP via oxidative phosphorylation, as dis-
cussed earlier. When oxygen is available, pyruvate is converted into a 2-carbon acetyl group (acetyl-
CoA), which is then picked up by CoA. Acetyl-CoA can be used in a variety of ways by the cell, but
its major function is to deliver the acetyl group derived from pyruvate to the Krebs cycle of glucose
catabolism to produce ATP energy for the cell. In all living organisms, CoA is synthesized in a five-
step process that requires four molecules of ATP, from pantothenate and cysteine. The structure of
CoA was identified in the early 1950s at the Lister Institute in London, together with workers at the
Massachusetts General Hospital and Harvard Medical School (Theodoulou et al. 2014).
Since CoA contains a sulfhydryl group (SH), it can react with a carboxylic acid group to form
a thioester, which can be used to help transfer fatty acids with more than 10 carbons from the
cytoplasm to the mitochondria. A molecule of CoA carrying an acetyl group is also referred to
as acetyl-CoA. Examples of uses of CoA include fatty acyl-CoAs (proprionyl-CoA, butyryl-CoA,
myristoyl-CoA, crotonyl-CoA, acetoacetyl-CoA, benzoyl-CoA, and phenylacetyl-CoA), malonyl-
CoA, succinyl-CoA, and hydroxymethylglutaryl (HMG)-CoA. The last compound is involved in the
rate-limiting step in cholesterol biosynthesis, which is HMG-CoA reductase.
2.4.2.9 Biotin
Biotin, also known as vitamin B7, vitamin H, or coenzyme R, is a coenzyme for carboxylase
enzymes, involved in the synthesis of fatty acids, isoleucine, and valine, and in gluconeogenesis.
Biotin exists in food as protein-bound form or biocytin. Proteolysis by protease is required prior to
absorption. This process assists free biotin release from biocytin and protein-bound biotin. The bio-
tin present in corn is readily available; however, most grains have about a 20–40% bioavailability
of biotin. Biotin is found in a wide variety of foods, with high biotin content in peanuts, Swiss chard,
liver, Saskatoon berries, and leafy green vegetables.
Biotin deficiency can be caused by inborn metabolic errors affecting biotin-related enzymes. In
animals fed raw egg whites, biotin deficiency occurs due to a protein called avidin, which binds
biotin. Avidin is denatured with cooking, so cooked egg white does not affect biotin availabil-
ity. Patients with gastric bypass or gastrectomy can develop biotin deficiency in the absence of
supplementation since proteolysis is required in the stomach to release protein-bound biotin found
in foods. Symptoms include hair loss, dermatitis, and conjunctivitis (Mock and Said 2009). The
reason it is called vitamin H is from the German for hair and skin (hair and haut), since these are
characteristic of biotin deficiency. Neurological and psychological symptoms can occur with only
mild deficiencies. Dermatitis, conjunctivitis, and hair loss will generally occur only when deficiency
becomes more severe. Pregnant women tend to have a high risk of biotin deficiency. Nearly half
of pregnant women have abnormal increases of 3-hydroxyisovaleric acid, which reflects a reduced
status of biotin.
2.5 WRITING THE EXERCISE PRESCRIPTION AND EVALUATING FITNESS

A great deal of evidence indicates that regular physical activity is one of the most powerful influ-
ences on patient health that physicians and other health care professionals can have (Kraus et al.
2015). The lack of physical activity counseling in the primary care setting represents a lost oppor-
tunity to improve the health and well-being of patients with minimal cost. Among adults with pre-
diabetes, only 40% report receiving counseling on physical activity.
While time constraints, lack of tools, and skeptical attitudes are cited as reasons for the lack
of physical activity counseling, in the Activity and Counseling Trial clinicians in primary care
were taught to deliver a brief intervention over 3–4 minutes during routine office visits (Writing
Group for the Activity Counseling Trial Research Group 2001). At 2 years of follow-up, there were
improvements in cardiorespiratory fitness, as determined by measurement of maximum oxygen
consumption. Most clinicians reported that the counseling did not disrupt or increase the length of
the visit and that the counseling was an asset to their practice.
There are a number of practical steps that can be taken in order to incorporate physical activity
counseling into your primary care practice (Berra et al. 2015).
1. Make physical activity a vital sign at every visit.

2. Ask if the patient exercises regularly or engages in a physical activity.
a. If yes, ask what type, for how many minutes, and how often.
b. If no, ask if the patient is willing to start.
3. Associate physical activity with reduced risks of common diseases.
4. Write a prescription for agreed-upon daily physical activity, working up to at least 30 minutes
of walking or other moderate-intensity activity daily.
5. Encourage use of a pedometer or the free health app on some smartphones and advise
record keeping of daily activity.
6. Recognize success and encourage reluctant adopters.
Physicians and other health care professionals can help set priorities for patients with regard to
physical activity by personalizing the exercise prescription.
The first step in encouraging personalized exercise is to recommend walking 10,000 steps/day.
However, this is just a beginning for most patients. Thirty minutes per day of aerobic exercise at
one time or two bouts of exercise lasting 15 minutes each is the next level. For these sessions, it is
simple to calculate a personal target heart rate for aerobic activities, such as walking on a treadmill
or elliptical or riding an exercise bike. Simply subtract the patient’s age from 220 and multiply by
0.7. At this heart rate, fat burning is optimized.
The next level of exercise prescription may require the help of a knowledgeable physical therapist
with experience in biomechanics. An assessment of muscle strength through various muscle groups
will make it possible to design a personalized exercise regimen with specific endpoints in mind.
This type of program requires the highest level of commitment from your patients. For patients
who are working, it is important to consider ways to link the exercise in time and geography either
before or after work.
In order to adapt patients to exercising regularly, encourage a routine that includes special fitness
clothing, a low-calorie sports drink, and fitness music with a rapid beat, which tends to reduce feel-
ings of fatigue and add some fun to the workout.
The next level of fitness awareness requires the involvement of a physical therapist and trainer
knowledgeable in muscle biomechanics. The concept is to educate and rehabilitate muscles that
have atrophied due to disuse. When muscles atrophy, they do so in an asymmetrical way, putting
increased strain on joints.
An important example is the atrophy of the hamstring muscles due to a sedentary lifestyle. With
lack of use, the hamstring muscles foreshorten, and this puts a strain on the hip joints. Atrophy of
the gluteal muscles and poor abdominal tone put a strain on the lower back.
In the upper body, round shoulders are due to atrophy of the scapula muscles and maintenance of
poor posture. Exercising the upper back muscles, abdominal muscles, and gluteus posture muscles
can help correct poor posture.
The main message is to recommend exercises that have a goal and a measurable or visible result.
Reduced joint pain is a benefit, as is correction of poor posture. While walking and aerobic exercise
are good places to begin the exercise prescription, they are not the end of an exercise prescription.
2.6 LEVERAGING DIETETIC AND NURSING SUPPORT

It is critical to realize that you cannot do this yourself. You must build a team within your practice
and communicate sufficiently to align your messages. A system for communication can be estab-
lished if you are not already using the electronic health record. You will find that you and your
dietitians and nurses have complementary skills that can be combined to improve the nutrition and
fitness programs prescribed in your practice.
Since the education of many dietitians has centered around philosophies generated by the food
industry, it is important that the dietitians in your practice align with your philosophy. Take what
you like from this chapter and create your own messaging that is reinforced by your dietitians and
nurses.
2.7 ISSUES AROUND BOTANICAL DIETARY SUPPLEMENTS

Only very small clinical trials have been conducted with certain preparations of botanical
dietary supplements. The FDA has established good manufacturing practices and inspects man-
ufacturing sites to ensure compliance. Few companies have established the necessary, preclini-
cal, clinical, and postmarketing resources to responsibly monitor botanical dietary supplements.
Raw materials should be chemically characterized using chromatography or mass spectrometry
to fully identify the amounts of marker ingredients. This is an expensive effort and should be
followed by careful analysis of the finished products at the factory and during shipping. A full
discussion of the positive and negative aspects of botanical dietary supplements is outside the
scope of this book. Your primary role will be to screen out any supplements known to be toxic.
In addition, the FDA conducts postmarket surveillance for side effects, so you should use this
reporting system whenever you encounter a side effect that you attribute to a botanical dietary
supplement.
2.8 ENABLING PATIENT CHOICE IN NUTRITION

FOR DIETS AND SUPPLEMENTS
The most practical basic micronutrient supplementation program includes a daily multivitamin or
multimineral, calcium and magnesium, a vitamin D supplement, and a fish oil supplement. When
combined with dietary counseling, there is a good rationale for this simple approach.
A number of medical and government advisory groups have argued against the use of a daily
multivitamin supplement, but the overwhelming evidence is that this is only the first step in a
supplementation program. A Canadian study of men and women over 50 years of age found that
less than 5% of those who used a daily multivitamin or multimineral supplement had a deficiency
of vitamins A, C, B6, and B12, and folate (Shakur et al. 2012). Between one-third and one-half of
all Americans take multivitamin or multimineral supplements. By themselves, these supplements
do not make up for an unhealthy diet, but they have no adverse effects. As patients learn more about
nutrition, they will explore additional supplements with you and your dietitian, so it is important to
keep up on the latest trends in dietary supplements as they develop.
Here are just a few examples of supplements you may be asked about:
Coenzyme Q10 or ubiquinone: This is an antioxidant for which there is some evidence of
benefit in heart failure. Many heart patients will ask about this supplement. There are no
adverse effects associated with consuming this supplement.
SAMe: This is S-Adenosyl methionine, and there are some studies showing benefit for osteo-
arthritis and depression.
Glucosamine or chondroitin sulfate: Glucosamine has been shown to slow the loss of knee
cartilage in patients with osteoarthritis. There is less evidence for additional ingredients in
many supplements in this category. There are no adverse effects.
Phytosterols: Plants do not make cholesterol, but they synthesize phytosterols, which compete
with cholesterol for intestinal uptake. Their use is associated with about a 5% decrease in
cholesterol levels. There are no adverse effects.
Cranberry extracts for urinary tract prevention: There are specific compounds in cranberry,
called proanthocyanidins, with a unique structure that inhibits the adhesion of bacteria to
the bladder wall.
None of the above supplements have toxic effects. Rather than condemn all supplements, con-
sider allowing patients to consume those they think are helpful. Very few dietary supplements
have the scientific evidence from placebo-controlled trials that are typical of prescription drugs.
However, many patients with psychophysiological disorders benefit from taking supplements, even
when the rationale is weak and not scientifically based. There are multiple sources of information,
including the National Institutes of Health guide on dietary supplements, that can provide you with
key information on this topic. Unless there is a safety issue, it is best to enable, rather than criticize,
the use of botanical supplements as a rule.
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3 Nutrition and the
Immune System
3.1 INTRODUCTION
Unbalanced nutrition with too much sugar, salt, and fat; a sedentary lifestyle; and the effects of a
stressful obesogenic environment can compromise the host immune responses, increasing suscep-
tibility to a wide range of age-related chronic diseases. The new field of nutritional immunology or
immunonutrition primarily focuses on the role of diet and its nutritional contents in disease preven-
tion, while there is extensive scientific evidence for the effects of malnutrition on immune function,
going back more than 60 years. In fact, the system that classically fails in advanced protein–energy
malnutrition (PEM) is the immune system. Deficiencies of vitamins and minerals can also lead to
immune compromise, and some effects of classic vitamins, such as vitamin D, impact the immune
system, as well as bone mineral metabolism. One of the assessments used since the early 1970s
in clinical research on enteral and parenteral nutrition was delayed hypersensitivity to tuberculin,
mumps, and streptokinase and streptodornase (SKSD) antigens. More recently, the interactions of
obesity and immune function have been recognized.
3.2 THE FAT CELL AS AN ENDOCRINE AND IMMUNE CELL

The intricate interaction between immunity and fat metabolism has been recognized and investi-
gated extensively (Scrimshaw et al. 1968). Indeed, it has been demonstrated that adipose tissue is
not merely the site of energy storage, but can be considered an “immune-related” organ produc-
ing a series of molecules named “adipocytokines.” Nutritional depletion, specific deficiencies, and
kwashiorkor-like malnutrition suppress immune function, while accumulation of excess body fat as
a result of energy imbalance results in chronic low-grade inflammation.
The cloning of the obese gene (ob) and identification of its protein product, leptin, have provided
fundamental insight into the hypothalamic regulation of body weight. Circulating levels of this
adipocyte-derived hormone are proportional to fat mass but may be lowered rapidly by fasting
or increased by inflammatory mediators. The impaired T-cell immunity of mice, now known to
be defective in leptin (ob/ob) or its receptor (db/db), is related to the absence of functional leptin
signaling due to the absence of a functional leptin protein (ob/ob) or the leptin receptor protein (db/
db) (Faggioni et al. 2001). Impaired cell-mediated immunity and reduced levels of leptin are both
features of low body weight in humans. Indeed, malnutrition predisposes to death from infectious
diseases, and the impaired immune function resulting from PEM and HIV infection is well docu-
mented (Thea et al. 1996). On an evolutionary basis, the ability to fight off infection and the ability
to store fat in cells were both critical to survival. While the adaptation to starvation and associated
gradual weight loss do not impair immune function, rapid weight loss does (Scrimshaw et al. 1959).
Moreover, the close interrelationship of immune function and nutrition has been confirmed with
modern molecular nutrition tools.
The immune system during adapted starvation is a fail-safe system until it decompensates. On
the other hand, staying with the theme that humans are well adapted to starvation but poorly adapted
to overnutrition, there is chronic low-grade inflammation associated with overweight and obesity,
mediated by intra-abdominal fat-resident immune cells that cause a systemic inflammation. In order
to understand these two poles of the interaction of nutrition and immune function, it is necessary to
understand the difference between innate and adaptive immune mechanisms.
57
3.3 MALNUTRITION AND IMMUNE FUNCTION

Nutrient deficiencies can impair immune function, and nutrient supplementation can restore nor-
mal immune capacity (Bhaskaram 2002). The association of malnutrition and infection has been
recorded in ancient historical accounts. For example, an examination of church records in England
in the twelfth century shows an interesting association between consecutive years of famine and
epidemics of pestilence or communicable diseases. Recent epidemiologic studies in the Americas
and Asia have confirmed that infection, often added on malnutrition, is a major cause of morbidity
and is responsible for about two-thirds of all deaths among children under 5 years of age. In 1968,
Scrimshaw summarized the human and animal data on interactions, often synergistic but occasion-
ally antagonistic, between nutritional deficiencies and infectious illness (Scrimshaw et al. 1968).
Careful observations showed a correlation between nutritional status and morbidity and mortal-
ity largely due to infections (O’Neill et al. 2012). It was shown that the risk of death increased from
~0.1% in the well-nourished to as much as 18% in severely malnourished infants. The effect of mal-
nutrition on different infections is variable. For some organisms, for example, measles, tuberculosis,
and Pneumocystis carinii, there is little doubt that nutritional deficiencies enhance susceptibility
and worsen prognosis. For others, such as yellow fever and poliomyelitis, nutrition does not appear
to have a major influence on natural history and outcome.
PEM causes widespread atrophy of lymphoid tissues, especially in children. The thymus, spleen,
tonsils, and lymph nodes are all affected, with histological evidence of atrophy being greatest in
the T-lymphocyte areas of these tissues. Lymphocytes and eosinophils show lowered blood counts,
natural killer cells show reduced activity (Salimonu 1992), and cultured blood lymphocytes react
poorly to mitogens. Production of thymic hormones is reduced, as is a patient’s ability to fend
off and recover from infectious illnesses. These closely linked events can initiate a “downhill
spiral” or a “vicious cycle” that leads inexorably to death. PEM causes a marked repression of
cell-mediated immunity and the function of T-lymphocytes. Malnourished children show dermal
anergy, with loss of delayed dermal hypersensitivity (DDH) reactions, a decrease or reversal of
the T-helper/suppressor cell ratio, and loss of the ability of killer lymphocytes to recognize and
destroy foreign tissues. In contrast, B-lymphocyte numbers and functions generally appear to be
maintained. While existing antibody production is conserved or even increased during generalized
malnutrition, new primary antibody responses to T-cell-dependent antigens and antibody affinity
are impaired.
Research conducted in military personnel has shown immune dysregulation caused by stress that
is similar to the immune dysregulation noted in the elderly (e.g., anergy and decreased proliferative
response) (Castell et al. 2010).
3.4 IMMUNE FUNCTION IN OBESITY

As abdominal fat expands in response to positive energy balance, there is a need for new blood
vessel formation. However, these new vessels can often not keep up with the metabolic needs of
expanding abdominal fat, leading to the death of adipocytes. As these adipocytes die, they release
cellular debris, which results in the activation of macrophages, which release cytokines resulting
in insulin resistance in fat cells, as well as a systemic inflammation. The macrophages gather in
circular collections and engulf the fat released from dead adipose cells in both abdominal fat and
subcutaneous fat tissue (Le et al. 2011).
This systemic inflammation leads to an increase in innate immune function and defects in adap-
tive immunity. These defects have been identified in mice fed high-fat diets to induce obesity. Mice
fed a 70% fat diet develop obesity and specific defects in the ability of dendritic cells to present
antigens to the immune system, leading to defects in adaptive immunity (Smith et al. 2007).
There are a number of chronic diseases that are impacted by the enhanced innate immune func-
tion and inflammation. Since inflammation is a common mechanism across many different chronic
Nutrition and the Immune System 59
diseases of aging, obesity-associated changes in immune function are critical in mediating the
obesity-associated increased risks of heart disease, diabetes, common forms of cancer, asthma, and
connective tissue diseases.
3.5 IMMUNE FUNCTION AND VITAMIN AND MINERAL BALANCE

Vitamin A deficiency has long been known to be associated with increased susceptibility to viral
infections, such as mumps. While it has long been recognized that vitamin A and its metabolites
have immune regulatory roles, the mechanisms of action have not been known. Recently, there has
been significant progress in elucidating the functions of retinoic acid in the regulation of immune
cell development (Kim 2008). Retinoic acid (all-trans- and 9-cis-retinoic acid) is produced from
the cells of the intestine, such as dendritic cells, and provides an intestine-specific environmental
cue to differentiating immune cells. When T-cells and B-cells are activated in the intestine and
associated-lymphoid tissues, gut-homing receptors are induced on the cells in a retinoic acid and
antigen-dependent manner. Retinoic acid, produced by gut dendritic cells, is also an important sig-
nal that induces immunoglobulin A (IgA)-producing B-cells. The gut-homing T-cells and B-cells
play essential roles in protecting the digestive tract from pathogens. Retinoic acid is also required
for the production of mature phagocytes in bone marrow. On the other hand, retinoic acid induces
a subset of FoxP3+ regulatory T-cells, which is important for maintaining immune tolerance in the
gut. Therefore, retinoids provide both positive and negative regulatory signals to fine-control the
mucosal immune system.
Although the best-known actions of vitamin D involve its regulation of bone mineral homeosta
sis, vitamin D exerts its influence on many physiologic processes. One of these is the immune
system. Both the adaptive and innate immune systems are impacted by the active metabolite of
vitamin D, 1,25(OH)(2)D. These observations have been proposed as potential mechanisms medi-
ating the predisposition of individuals with vitamin D deficiency to infectious diseases, such as
tuberculosis, as well as to autoimmune diseases, such as type 1 diabetes mellitus and multiple
sclerosis (Bikle 2011).
Selenium (Se) is an essential trace element needed for the biosynthesis of a small number of
mammalian selenoproteins. Selenium intake and personal selenium status are implicated in wide-
spread human pathologies, including cancer, cardiovascular disease, and neurodegeneration (Papp
et al. 2007). Positive effects of selenium supplementation have been observed in a number of clinical
trials with patients suffering from sepsis, HIV infection, or autoimmune thyroid disease (Broome et
al. 2004). Most importantly, the lower the selenium status during critical illness, the more likely that
the patients will not survive (Manzanares et al. 2009). Supplementation with trace elements in some
individuals with nutritional deficiency to correct a selenium deficiency has been shown to enhance
antibody titers to influenza vaccination, and shows a trend toward fewer subjects with respiratory
tract infections. Another study reported better immune responsiveness and “fewer infection-related
illnesses” with a multivitamin supplement than with a placebo in apparently healthy, independent
living elderly (Chandra and Chandra 1986). Other researchers have supplemented the diets of
seniors with poor eating habits and found no immunological benefit or reduction in acute respira-
tory tract infections. The reason for the variability of results is likely related to the adaptation to
starvation, which can maintain immune function until late in the process as long as multivitamin
and mineral intake is normal. Some, but not all, clinical trials have proven effective in improving
the outcome of critically ill patients by selenium supplementation, but the best application regimen,
the most suitable selenium compound, and the mechanisms of action have not yet been established.
A randomized, double-blind, placebo-controlled trial was carried out to investigate the effects
of micronutrient supplementation on immunity and the incidence of common infections in type 2
diabetic outpatients (Liu et al. 2011). A total of 196 type 2 diabetic outpatients were randomized to
receive tablets of micronutrients (n = 97) or placebo (n = 99) for 6 months. Individualized dietary
energy intake and daily physical activity were recommended. Anthropometric measurements,
blood biochemical variables, and the incidence of common infections were measured at baseline
and at 6 months. Data on diet, exercise, and infection (upper respiratory tract infection, skin infec-
tion, urinary and genital tract infections, etc.) were recorded 1 month before the study and every
month during the study. Blood concentrations of total protein, iron (Fe), folic acid, and hemoglobin
increased, and unsaturated iron-binding capacity (UIBC) levels were decreased in the micronutri-
ent supplementation group compared with the placebo group at 6 months. Moreover, at 6 months,
compared with the placebo group, the blood concentrations of IgE, CD4+, CD4+/CD8+, white
blood cells, lymphocyte counts, and basophilic leukocytes increased and the CD8+ count decreased
in the supplementation group, and the levels of IgA, IgM, IgG, and complements C3 and C4 did
not differ. The incidence of upper respiratory infection, vaginitis, urinary tract infection, gingivitis,
and dental ulcer were lower, and body temperature and duration of fever greatly improved in the
supplementation group compared with the placebo group. These data suggest that supplementation
of micronutrients might increase immune function and reduce the incidence of common infections
in type 2 diabetic outpatients.
In addition, deficiencies of vitamins B6 and folate are associated with reduced immunocom-
petence (Chandra and Chandra 1986). Trace elements modulate immune responses through their
critical role in enzyme activity. Although dietary requirements of most of these elements are met
by a balanced diet, there are certain population groups and specific disease states that are likely to
be associated with deficiency of one or more of these essential elements. The role of trace elements
in the maintenance of immune function and their causal role in secondary immunodeficiency is
increasingly being recognized. There is growing research concerning the role of zinc, copper, sele-
nium, and other elements in immunity, and the mechanisms that underlie such roles. The problem
of interaction of trace elements and immunity is complex because of the frequently associated other
nutritional deficiencies, the presence of clinical or subclinical infections, which in themselves have
a significant effect on immunity, and finally, the altered metabolism due to the underlying disease
(Kim 2008).
3.6 INTERACTION OF OMEGA-3 FATTY ACIDS AND MACROPHAGE

As noted above, chronic activation of inflammatory pathways plays an important role in the patho-
genesis of insulin resistance, and the macrophage–adipocyte nexus provides a key mechanism
underlying many common chronic diseases associated with excess body fat (Schenk et al. 2008).
Migration of macrophages to adipose tissue (including intramuscular fat depots) and liver, with sub-
sequent activation of macrophage pro-inflammatory pathways and cytokine secretion, is the critical
link between overnutrition and inflammation.
Omega-3 fatty acids (n-3 FAs), docosahexaenoic acid (DHA) and eicosapentaenoic acid (EPA),
exert anti-inflammatory effects, but the mechanisms are poorly understood. Recently, it was dis-
covered that the G protein-coupled receptor 120 (GPR120) functions as an n-3 FA receptor or sen-
sor (Oh et al. 2010). Stimulation of GPR120 with n-3 FAs or a chemical agonist caused broad
anti-inflammatory effects in monocytes (RAW 264.7 cells) and in macrophages obtained from the
intraperitoneal fluid. All these effects were abrogated by GPR120 knockdown, demonstrating that
the GPR120 membrane protein functions as an n-3 FA receptor or sensor in pro-inflammatory
macrophages and mature adipocytes. Moreover, GPR120 is highly expressed in pro-inflammatory
macrophages and functions as an n-3 FA receptor, mediating the anti-inflammatory effects of
this class of FAs to inhibit both the TLR2/3/4 and the tumor necrosis factor α (TNF-α) response
pathways and cause systemic insulin sensitization. Therefore, the in vivo anti-inflammatory and
insulin-sensitizing effects of n-3 FAs are dependent on the expression of GPR120, as demonstrated
in studies of obese GPR120 knockout (KO) animals and wild-type (WT) littermates.
The worldwide diversity of dietary intakes of n-6 and n-3 FAs influences tissue composi-
tions of n-3 long-chain fatty acids (LCFAs) (EPA, docosapentaenoic acid, and DHA) and risks of
cardiovascular and mental illnesses (Hibbeln et al. 2006) via inflammatory mechanisms mediated
by eicosanoids synthesized from arachidonic acid and other n-6 LCFAs. By increasing n-3 FA
intake from fish and fish oil or algae oil supplements and decreasing n-6 FA consumption from veg-
etable oils and processed foods, it is possible to change tissue and plasma FA balance. More research
is needed to connect changes in the ratio of n-6 to n-3 fatty acids to changes in immune function
despite some supportive evidence on this relationship (Patterson et al. 2012). Polyunsaturated fatty
acids (PUFAs) are associated with increases in chronic inflammatory diseases such as nonalcoholic
fatty liver disease (NAFLD), cardiovascular disease, obesity, inflammatory bowel disease (IBD),
rheumatoid arthritis, and Alzheimer’s disease (AD). By increasing the ratio of n-6:n-3 PUFA in the
Western diet, reductions may be achieved in the incidence of these chronic inflammatory diseases.
3.7 CALORIC RESTRICTION WITHOUT MALNUTRITION

AND IMMUNE FUNCTION
It is well known and widely taught that marasmus, the condition of adapted starvation with signifi-
cant weight loss, occurs without compromising immune function. Calorie restriction (CR) without
malnutrition increases life span in simple model organisms and rodents (Fontana et al. 2010). CR
decreases inflammation, which is believed to protect against age-associated diseases (Meyer et al.
2006; Franceschi and Campisi 2014). Low-grade chronic inflammation has been identified as a
unifying mechanism in the pathogenesis of multiple age-associated chronic diseases and in aging
itself (Howcroft et al. 2013). Serum C-reactive protein (CRP) is formed in response to phospholipid
oxidation and is a systemic marker of inflammation. TNF-α is a pro-inflammatory cytokine. These
cytokines and others are associated with an increased risk of developing type 2 diabetes mellitus,
heart disease, and common forms of cancer (Hotamisligil et al. 1993; Matzinger 2002a,b; Serhan
2007; Lavie et al. 2009; Ingersoll et al. 2011; Taube et al. 2012; Koenig 2013). Increased adipose
tissue TNF-α expression (Kern et al. 1995) and serum TNF-α levels (Zahorska-Markiewicz et al.
2000; Bhaskaram 2002) are reduced by weight loss (Kern et al. 1995; Formoso et al. 2012). Some
studies in monkeys (Roecker et al. 1996) have shown suppression of immune responses with CR,
and studies in mice have shown increased susceptibility to infection in mice (Gardner 2005; Ritz
et al. 2008), while other studies in aging mice and monkeys show that CR can enhance immune
surveillance by T-cells (Messaoudi et al. 2006; Yang et al. 2009). CR in humans, when it includes a
restriction of protein and essential nutrients, impairs cell-mediated immune responses (Schaible and
Kaufmann 2007) and increases susceptibility to morbidity and mortality from infectious diseases.
A form of chronic CR in which protein and micronutrients are maintained has been studied
extensively in a multicenter, randomized clinical trial supported by the National Institute of Aging
of the National Institutes of Health (Ravussin et al. 2015). The effects of CR on inflammation and
cell-mediated immunity were determined in 218 healthy nonobese adults (20–50 years) who were
assigned 25% CR (n = 143) or an ad libitum (AL) diet (n = 75), and outcomes tested at baseline
and 12 and 24 months of CR. CR induced a 10.4% weight loss over the 2-year period. Relative to
AL group, CR reduced circulating inflammatory markers, including total WBC and lymphocyte
counts, intercellular adhesion molecule 1 (ICAM-1), and leptin. Serum CRP and TNF-α concen-
trations were about 40% and 50% lower in the CR group, respectively. CR had no effect on the
delayed-type hypersensitivity skin response or antibody response to vaccines, nor did it cause a
difference in clinically significant infections. In conclusion, long-term moderate CR without mal-
nutrition induces a significant and persistent inhibition of inflammation without impairing key in
vivo indicators of cell-mediated immunity. Given the established role of these pro-inflammatory
molecules in the pathogenesis of multiple chronic diseases, these CR-induced adaptations suggest
a shift toward a healthy phenotype. Clearly reducing body fat without malnutrition demonstrated
beneficial effects on immune function, and the observations apply to tackling both overweight and
obesity in the primary care setting.
3.8 GUT MICROBIOTA AND IMMUNE FUNCTION

While some 40–50 years ago there was interest in colonic bacteria that could produce compounds
from indigestible substances that could promote colon cancer, in the last decade, there has been an
explosion of interest in the metabolic and immune functions of the gut microbiota and their influ-
ence on metabolism and immune function. Anaerobic culture methods for gut bacteria have been
available in specialized labs for more than 40 years, but remain challenging for some bacterial
strains. The very recent introduction of technologies that can identify bacterial species based on
conserved sequences of 16s rRNA has enabled large-scale analysis of the genetic and metabolic
profile of gut microbiota. Some have suggested that the gut microbiota represents a forgotten organ
reflecting dietary intake, metabolizing indigestible substances into absorbed phytonutrients and
even providing new therapeutic interventions for challenging bacterial infections of the gut and
other organs. The gut microbiota is so complex in its interactions and constituents that it may be
helpful to make an analogy to the immune system, which is a collection of cells that work in unison
with the host that can promote health or initiate disease, depending on nutritional inputs. Moreover,
the gut-associated lymphoid tissue represents 70% of the immune system and plays a critical role
through interactions of dendritic cells with foreign bacterial antigens in alerting the immune system
to potential pathogens, while at the same time protecting those beneficial bacteria critical to an
effective barrier, protecting the single layer of epithelial cells lining the villi of the small intestine
and the colonic epithelium.
The National Institutes of Health-funded Human Microbiome Project investigated the micro-
biota of a variety of bodily niches, including the skin, as well as the oral, vaginal, and nasal cavities
(Segata et al. 2012). Currently, the majority of research is focused on the gut microbiota, since this
is where the greatest density and numbers of bacteria are found. In addition, most data have been
derived from fecal samples and, to a lesser extent, mucosal biopsies. While it is relatively easy to
obtain fresh fecal samples, the information obtained from them does not represent the complete
picture within the gut.
From a number of studies, we know that the small intestine, where most of the immune system
influences occur, contains a very different abundance and composition of bacteria, with greater
variation than the colon (Zoetendal et al. 2012). The colonic microbiota populations are largely
driven by the efficient degradation of complex indigestible carbohydrates and polyphenol phyto-
nutrients. The bacterial populations of the small intestine are shaped by the intestinal microbiota
capacity for the fast import and conversion of relatively small carbohydrates, and rapid adaptation
to overall nutrient availability. Therefore, fecal samples, while not an ideal proxy for the gastroin-
testinal (GI) tract, are more practical for research and provide a glimpse into the diversity of colonic
microbiota populations as they are influenced by nutrition.
Five phyla represent the majority of bacteria that comprise the gut microbiota. There are approxi-
mately 160 species in the large intestine of any individual (Rajilic-Stojanovic and de Vos 2014). The
ability to synthesize short-chain fatty acids (SCFAs) is found in all humans (Louis et al. 2010), but
the amounts vary due to changes in microbiota populations over time in the same individual and the
nutrient bacteria metabolizing.
Fermentation of indigestible carbohydrates is one of the central functions of the human gut
microbiota, driving the energy and carbon economy of the colon. Dominant and prevalent species
of gut bacteria, including SCFA producers, appear to play a critical role in initial degradation of
complex plant-derived polysaccharides (Flint et al. 2012), in conjunction with species that ferment
oligosaccharides (e.g., Bifidobacterium), to liberate SCFAs and gases, which are also used as car-
bon and energy sources by other more specialized bacteria, including reductive acetogens, sulfate-
reducing bacteria, and methanogens (which cause the blue flames when some foolish individuals
light a match as they produce gas from their anus) (Ze et al. 2013). Efficient conversion of complex
indigestible dietary carbohydrates into SCFAs serves microbial cross-feeding communities and the
host, with 10% of our daily energy requirements coming from colonic fermentation. Butyrate and
propionate can regulate intestinal physiology and immune function, while acetate acts as a sub-
strate for lipogenesis and gluconeogenesis (Macfarlane and Macfarlane 2011). Recently, key roles
for these metabolites have been identified in regulating immune function in the periphery; directing
appropriate immune response, oral tolerance, and resolution of inflammation; and regulating the
inflammatory output of adipose tissue (Arpaia et al. 2013). In the colon, the majority of this car-
bohydrate fermentation occurs in the proximal colon, at least for people following a Western-style
diet. As carbohydrates are broken down and the bolus of undigested material moves distally to the
transverse and descending colon, the gut microbiota switches to metabolism of proteins or amino
acids. Fermentation of amino acids, besides liberating beneficial SCFAs, produces a range of poten-
tially harmful compounds. Some of these may play a role in gut diseases, such as colon cancer or
IBD. Studies in animal models and in vitro show that compounds like ammonia, phenols, p-cresol,
certain amines, and hydrogen sulfide play important roles in the initiation or progression of a leaky
gut, inflammation, DNA damage, and cancer progression (Windey et al. 2012).
Dietary fiber and the intake of a plant-based diet appear to reduce these metabolites or absorb
them for excretion, supporting the importance of overall dietary balance when examining the func-
tion of the microbiota (Tang et al. 2013). Carbohydrate fermentation variation by gut microbiota
also provides a scientific basis for rational design of functional foods aimed at improving gut health
and for impacting microbiota activities linked to systemic host physiology through the gut–liver
axis, the gut–brain axis, and the gut–skin axis (Clarke et al. 2014).
Probiotics, prebiotics, and polyphenols have been shown to affect the gut microbiota and have led
to the development of supplements and functional foods intended to improve gut health or modulate
immune function (Tuohy and Del Rio 2014).
Probiotics are live microorganisms that when administered in sufficient amounts can confer
health benefit to their host (Khani et al. 2012). Lactobacilli and bifidobacteria are the two most
common types of probiotics. The global probiotic market is in the billions of U.S. dollars despite
few randomized clinical trials proving efficacy (Markets and Markets 2015). Probiotics have been
studied as alternative biotherapies for respiratory infection (Shida et al. 2017), IBD (Hahm et al.
2012), antibiotic-associated diarrhea (Wong et al. 2014), and ulcerative colitis (Goldin and Gorbach
2008). In spite of the booming in vitro and in vivo probiotic studies against metabolic diseases such
as diabetes mellitus and obesity, their application in primary care is not common (Carvalho and
Saad 2013; Gomes et al. 2014).
The dominant phyla in healthy adults ages 18–50 are Firmicutes, Bacteroidetes, Actinobacteria,
and Proteobacteria. As aging begins after about 65 years, there is a reduction in Firmicutes, espe-
cially the Bifidobacterium genus, and an increase in Proteobacteria, which contains several oppor-
tunistic pathogens (Duncan and Flint 2013). A cross-sectional study of the fecal microbiota of
different European populations showed that higher levels of bifidobacteria were seen in the 20- to
50-year-olds in Italy and Sweden in comparison with their over-60 counterparts. However, this
was comparable between age groups in France and Germany, but with those in Italy possessing
an average of 10- to 100-fold greater populations than other countries. Bacteroides species were
higher in the under-50s in Italy and the over-60s in Germany. This study demonstrated variations
in the age-related changes in the microbiota that probably relate to both location and dietary habits
(Mueller et al. 2006).
There are several methods of changing the human gut microbiota in order to counter digestive
diseases and other conditions. One is direct transplantation of healthy microbiota into a host who
suffers from a gut-related disorder, such as IBD (Eiseman et al. 1958), or Clostridium difficile-
associated diseases (Guo et al. 2012; Kelly et al. 2012). Fecal transplant is the method of using a
liquid suspension of a fecal sample from a healthy (disease-free) donor and transplanting it into an
individual through a nasogastric, nasoduodenal, or rectal catheter.
The consumption of probiotics and prebiotics is a more frequently used way of modulating
the gut microbiota. Prebiotics, discussed further below, are essentially substrates for the ben-
eficial commensal bacteria that already exist within the gut microbiota. They survive stomach
acid and the upper GI tract in order to be fermented by specific bacteria in the large gut (Gibson
and Roberfroid 1995). Probiotics are live microbial cultures of species known to elicit beneficial
effects, such as the effect on intestinal cell proliferation (Blottiere et al. 2003), production of vita-
mins and minerals (Hooper et al. 2002), and modulation of immune function by production of
anti-inflammatory cytokines (Dong et al. 2012). As mentioned, recent studies on changes in the gut
microbiota with age can vary by nationality (Mueller et al. 2006). Those that are more detrimental
to gut health are the reduction of bifidobacteria and the increase in pathogenic species. Probiotic
use is often limited to Lactobacillus and Bifidobacterium species, which have shown positive
effects when orally administered in studies with older volunteers (Ahmed et al. 2007; Lahtinen et
al. 2009; Moro-Garcia et al. 2013).
Since the vast majority of live bacteria entering the stomach from most probiotic supplements
and yogurts are destroyed or inactivated by stomach acid, spore-forming bacteria that can sur-
vive stomach acid to enter the intestine have been developed. Bacillus coagulans GBI-30, 6086
(GanedenBC30 [BC30]) is a spore-forming lactic acid-producing bacterium. Being spore form-
ers, they have the capacity to resist adverse conditions of stomach acid and bile in the GI tract
(Hyronimus et al. 2000; Maathuis et al. 2010). In vitro studies using continuous culture have inves-
tigated the ability of B. coagulans to affect pathogen survival in the human gut microbiota. This
strain could competitively exclude transient pathogens in vitro (Honda et al. 2011). Such bacteria are
also known to excrete antimicrobial peptides (Le Marrec et al. 2000; Bizani and Brandelli 2002).
Moreover, use of B. coagulans both in vitro and in vivo demonstrated an ability to reduce distension
in adults with postprandial intestinal gas-related symptoms (Kalman et al. 2009), and the probiotic
has also shown immunomodulatory effects (Jensen et al. 2010).
A prebiotic is defined as a “nondigestible food ingredient that beneficially affects the host by
selectively stimulating the growth and/or activity of one or a limited number of bacteria in the
colon and thus improves the host’s health.” A more refined definition for prebiotic is a selectively
fermented ingredient that allows specific changes, in both the composition and activity in the GI
microflora, that confer benefits. These definitions are attracting a great deal of interest in the field
of nutrition, both in scientific research and in food applications. It is necessary to establish clear
criteria for classifying a food ingredient as a prebiotic. Prebiotics require a science-based demon-
stration that the ingredient (1) resists gastric acidity, (2) is not hydrolyzed by GI tract enzymes, (3) is
not absorbed in the upper GI tract, (4) is fermented by intestinal microorganisms, and (5) induces
selective stimulation of growth and/or activity of intestinal bacteria, potentially associated with
health and well-being.
The daily dose of the prebiotic is not a determinant of the prebiotic effect, which is mainly influ-
enced by the number of bifidobacteria per gram in feces before supplementation of the diet with
the prebiotic begins. The ingested prebiotic stimulates the whole indigenous population of bifido-
bacteria to growth, and the larger that population, the larger is the number of new bacterial cells
appearing in feces. In connection with this, a new concept of “prebiotic index” is proposed and is
defined as the increase in the absolute number of bifidobacteria expressed divided by the daily dose
of prebiotic ingested.
Prebiotics of various types are found as natural components in milk; honey; fruits, such as banana;
vegetables, such as onion, Jerusalem artichoke, chicory, leek, garlic, and artichoke; and rye and bar-
ley. In most of these sources, concentrations of prebiotics range from 0.3% to 6% of fresh weight.
Asparagus, sugar beet, garlic, chicory, onion, Jerusalem artichoke, wheat, honey, banana, barley,
tomato, and rye are special sources of fructooligosaccharides (FOSs). Galactooligosaccharides
(GOSs) are found naturally in human and bovine milk. Seeds of legumes, lentils, peas, beans,
chickpeas, and mustard are rich in raffinose oligosaccharides. Xylooligosaccharide (XOS) is also an
emerging prebiotic that is found in bamboo shoots, fruits, vegetables, milk, and honey.
Prebiotics include oligosaccharides that, when fermented, mediate measurable changes within
the gut microbiota composition, usually an increase in the relative abundance of bacteria thought
of as beneficial, such as bifidobacteria or other SCFA producers. Prebiotic FOSs consist of fructose
units linked with glycosidic bonds with a terminal D-glucose unit, and GOSs are composed of
galactose units with a terminal D-glucose unit. Several studies have shown beneficial effects from
prebiotic supplementation in both in vitro and in vivo situations using samples from a younger
(18–50 years) cohort (Tuohy et al. 2001; Meyer et al. 2006; De Preter et al. 2010; Franceschi and
Campisi 2014).
Our group at University of California, Los Angeles (UCLA) conducted the first clinical study
evaluating the effects of daily treatment with 2 g of XOS derived enzymatically from corn cobs
on glucose tolerance and insulin resistance in prediabetic adults (Yang et al. 2015). Eight weeks of
XOS supplementation tended to increase insulin sensitivity by lowering the oral glucose tolerance
test (OGTT) 2-hour insulin response (p = 0.11), while no significant improvement of pre-diabetes
mellitus subjects’ metabolic situation was observed, using the parameters of body composition,
serum glucose, triglyceride, satiety hormones, and inflammation marker TNF-α. In a prior study
in healthy adults, we found that a dose of 2 g/day increased bifidobacteria with no effect on lacto
bacilli, and it did not cause any GI side effects (Finegold et al. 2014). XOS significantly modified gut
microbiota in both healthy and prediabetic subjects, and resulted in dramatic shifts of four bacterial
taxa associated with prediabetes. Future studies with a larger sample size are needed to study the
metabolic impact of XOS and understand the connection between XOS-mediated gut microbiota
changes and the pathogenesis of type 2 diabetes mellitus.
Polyphenols are a diverse class of plant secondary metabolites, often associated with the color,
taste, and defense mechanisms of fruit and vegetables. They have long been studied as the most
likely class of compounds present in whole plant foods capable of affecting physiological processes
that protect against chronic diet-associated diseases (Clifford 2004). The gut microbiota plays a
critical role in transforming dietary polyphenols into absorbable biologically active species, acting
on the estimated 95% of dietary polyphenols that reach the colon. Our group at UCLA investigated
the effect of pomegranate extract containing ellagitannins on the growth of major groups of intes-
tinal bacteria and on the formation of urolithins (Li et al. 2015). Urolithins are found in the urine
after ingestion of pomegranate and walnuts and are a metabolite of ellagic acid, which recirculates
after conjugation in the liver and has metabolic effects on mitochondria, with extension of life span
in Caenorhabditis elegans and enhanced muscle function in rodents (Ryu et al. 2016).
In our human study (Li et al. 2015), 20 healthy participants consumed 1000 mg of pomegran-
ate extract daily for 4 weeks. Based on urinary and fecal content of the pomegranate metabolite
urolithin A (UA), we observed three distinct groups: (1) individuals with no baseline UA presence
but induction of UA formation by pomegranate extract consumption (n = 9); (2) individuals with
baseline UA formation, which was enhanced by pomegranate extract consumption daily for 28 days
(n = 5); and (3) individuals with no baseline UA production, which was not inducible (n = 6). We
have demonstrated that pomegranate extract is a prebiotic in the sense that it changed bacterial
populations and is known to have beneficial health effects.
A Verrucomicrobia species (Akkermansia muciniphila) was 33- and 47-fold higher in stool sam-
ples of UA producers than in those of nonproducers at baseline and after 4 weeks, respectively.
This bacterium also occurs in the small intestine, where it breaks down mucin and stimulates more
mucin production from goblet cells to protect small intestinal epithelia. In UA producers, the genera
Butyrivibrio, Enterobacter, Escherichia, Lactobacillus, Prevotella, Serratia, and Veillonella were
increased and Collinsella decreased significantly at week 4 compared with baseline. Pomegranate
extract consumption may induce health benefits secondary to changes in the microbiota, which
amplify the production of urolithins.
3.9 PRACTICAL CONSIDERATIONS FOR MODULATING IMMUNE FUNCTION

The practical applications of the interaction of immune function and nutrition are fourfold. First, it
is important to achieve and maintain optimal intra-abdominal fat depots that do not trigger chronic
inflammation. The growing global epidemic of obesity and type 2 diabetes associated with the
adoption of Western diets and lifestyles has significant implications for immune function, but in the
opposite direction of that associated with malnutrition. Chronic inflammation is associated with
numerous age-related chronic diseases. Improved immune function in these individuals is achieved
through a balanced diet and a healthy active lifestyle.
It is clear that malnutrition, especially PEM associated with kwashiorkor-like findings in chil-
dren in the developed world or in hospitalized patients, can impair immune function. Therefore,
recognizing and treating malnutrition is a critical component of maintaining normal immune func-
tion in hospitalized patients, the elderly, and military personnel working under stressed conditions.
In addition to calorie and protein balance, micronutrients and the lipid balance of n-3 and n-6 are
critical. These needs can be met through a balanced diet, but in at-risk groups, including the elderly,
individuals consuming unbalanced diets, and military personnel under stress, it may be advisable
to include a multivitamin or multimineral dietary supplement to support healthy immune function.
For balancing n-3 and n-6 FAs in cells, it is important to both increase the intake of DHA and EPA
from fish or supplements and reduce the intake of n-6 FAs from foods containing vegetable oils.
Finally, studies of the microbiome, still in their infancy, are already demonstrating that gut bac-
teria can play an important role in modulating immune function, as well as in the efficiency of
absorption of nutrients, by adapting to key elements in the diet, including fiber and polyphenol phy-
tonutrients. Therefore, maintaining digestive health through treatment of irritable bowel syndrome
and encouragement of fiber intake at 25 g/day and a regular schedule of defecation may improve
immune function through the homeostatic effects of a healthy and stable microbiome.
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uptake and conversion of simple carbohydrates. ISME J 6 (7):1415–1426.
4 Nutrition and Gastrointestinal
Disorders
4.1 INTRODUCTION
The gastrointestinal tract is a complex system of organs that digest and absorb nutrients, micronu-
trients, xenobiotics, and metabolites of gut bacteria. Through the action of the liver and gallbladder,
the gastrointestinal tract also detoxifies and excretes toxic and potentially toxic substances from
the body. Food is converted into energy and other substances that are used by cells throughout the
entire body. Many diseases can affect the various organs of the gastrointestinal tract, and nutrition
can affect the course of these disorders.
Gastrointestinal disorders can result from deficiencies or excesses of specific nutrients in normal
individuals. In allergic or susceptible subjects, diseases such as food allergy, lactose intolerance,
gluten “sensitivity,” and gluten enteropathy may occur with intake of normal daily requirements.
Treatment of gastrointestinal disease may require dietary modifications, enteral supplements,
or exclusive enteral nutrition. If the gut is not functioning adequately, nutritional support via the
parenteral route may be required. In subjects with inflammatory bowel disease (IBD) and short gut
syndrome, replacement of specific nutrients may be required, particularly calcium, magnesium,
zinc, iron, folate, and vitamins B12, D, and A.
The process of digestion begins with the visualization of a food and the attributed hedonic value
of a food. This visualization can trigger central nervous system activation of gastrointestinal physi-
ology, including insulin secretion. Ninety percent of the nerves between the brain and gastrointesti-
nal tract carry messages from the gastrointestinal tract to the brain. The human brain is able to learn
and memorize sensory inputs, including those that accompany the consumption of food and drink.
From the taste of foods to their gastrointestinal sensations and social-cultural associations, nutrition
takes on many psychological attributes that in many patients overtake normal physiology, resulting
in strong cravings, addictions, and food intolerances.
True food allergies are much less common and are mediated through the immune system, which
is anatomically associated with the gastrointestinal tract. However, food allergies are also part of
the larger association of food with systemic reactions. Moreover, some patients mistake food intol-
erance for true food allergy, and the ability to distinguish these entities can be helpful in counseling
patients presenting with complex issues around food intake. In the extreme, food intolerance can
lead to established eating disorders and anorexia nervosa.
Irritable bowel syndrome (IBS) is a complex disorder that is extremely common in primary
care practice. This disorder affects a significant percentage of the general primary care patient
population. IBS is associated with an interaction of psychological stress-related effects on motility
and effects resulting from the ingestion of food. It is a clinical syndrome with a group of specific
symptoms. Food intake, particularly high-fat and low-fiber food, may play a role in triggering or
perpetuating symptoms in patients with IBS.
IBD involves chronic inflammation of all or part of the digestive tract. IBD primarily includes
ulcerative colitis and Crohn’s disease. While the precise mechanisms underlying the development
of IBD are not known, sufficient data suggest that it results from a complex interplay of genetic,
environmental, and immunologic factors. An inappropriate mucosal immune response to normal
intestinal constituents is a key feature, leading to an imbalance in local pro- and anti-inflammatory
cytokines. Diet and nutrition play important roles in the causation, primary treatment, and adjunc-
tive therapy of IBD.
71
This chapter reviews the interactions of nutrition and gastrointestinal disorders and the psycho-
logical, as well as physiological, aspects of the interactions between nutrition and the gastrointes-
tinal tract from the brain’s hedonic centers to the colonic flora digesting the substances we do not
digest.
4.2 FOOD ADDICTION OR SIMPLY CRAVING?

There are similarities between food craving and drug craving, whichs support the concept of a
physiological addiction to specific foods (Gearhardt et al. 2009). There are similarities in the neu-
roanatomy, neurochemistry, and learning of food cravings and food addictions. The brain mecha-
nisms for craving foods likely developed during evolution to promote seeking of nutrient-dense
foods such as sweet fruits with phytonutrients, vitamins, and minerals. Alcohol addiction and drug
addiction activate the same brain reward centers as junk foods.
Healthy, normal-weight individuals, by definition, do not suffer from food addiction; however,
some overweight and obese individuals meet criteria for addictive behavior established by the psy-
chiatric community, such as continuing a behavior in the face of known negative consequences.
While high-sweet and high-fat foods are not in themselves responsible for the obesity problem, the
marketing and availability of these foods in an obesogenic environment enables addiction in sus-
ceptible individuals. Some nonpalatable foods can also come to be desired and potentially eaten in
excess. In particular, pica, which is the consumption of mud or chalk by individuals, is an example
of addictive behavior not linked to what would be considered palatable food.
The evidence for food addiction as a psychophysiological entity is growing (Davis et al. 2011).
Clinical and evolutionary evidence has been combined with animal research and clinical research.
While classic drugs of abuse activate similar brain centers as some foods, a major difference is
the lack of withdrawal symptoms when the consumption of the addictive food is stopped. Food
addiction is fundamentally a behavioral disorder. There is evidence that some people lose control
over their food consumption, failing to reduce their intake and continuing to eat foods in the face
of known negative consequences. Other aspects of food addiction as an addiction similar to that of
drugs require more research, including evidence of tolerance to high-fat sweets and time spent in
buying, eating, and recovering from addictive food intake, including how overall nutrition and qual-
ity of life are affected by food addiction.
As the necessary research proceeds to prove the addictive nature of some overeating, a practical
approach in weight management programs in order to reduce both food cravings and addictions is
to provide education on trigger foods that may lead to addictive processes. This information can be
used to inform patients that for them, particular trigger foods cannot practically be included in their
weight management diet, as previously taught in the philosophy of balance, variety, and moderation.
These trigger foods may present special behavioral issues that make it impossible for susceptible
overweight and obese patients to restrict their intake.
The Yale Food Addiction Scale was the first tool developed to identify individuals with addic-
tive tendencies toward food. Using a sample of obese adults (aged 25–45 years), and a case-control
methodology, this instrument assesses three domains relevant to the characterization of conven-
tional substance dependence disorders: clinical comorbidities, psychological risk factors, and
abnormal motivation for the addictive substance (Rogers and Smit 2000). Among subjects surveyed
with this instrument, those who met the diagnostic criteria for food addiction had significantly
greater comorbidities demonstrated, including binge eating disorder, depression, and attention-deficit/
hyperactivity disorder, than their age- and weight-matched counterparts. Individuals with food
addiction were also more impulsive and displayed greater emotional reactivity than obese controls.
They also displayed greater food cravings and the tendency to “self-soothe” with food.
These findings identify some clinically relevant behavioral obesity phenotypes with different
susceptibility to environmental risk factors, and thereby could inform more personalized treatment
approaches for those who struggle with overeating and weight gain.
Nutrition and Gastrointestinal Disorders 73
The diagnosis of food addiction is based on psychological processes of ambivalence and attribu-
tion, operating together with normal mechanisms of appetite control, the hedonic effects of certain
foods, and socially and culturally determined perceptions of appropriate intakes and uses of those
foods (Rogers and Smit 2000). Ambivalence is the idea that some foods are “nice but naughty,” and
this has been used in the marketing of chocolate, particularly to women. There is a mixed mes-
sage here that chocolate is great tasting and has physiologically positive and rewarding effects, but
should be eaten with restraint. Attempts to restrict intake, however, cause the desire for chocolate
to become more salient, an experience that is then labeled as a craving. The example of chocolate is
not meant to minimize the potential effects of high-cocoa chocolate and flavonols, and the example
could easily have been savory snacks for men, or ice cream for both genders.
Behavioral strategies such as relapse prevention come directly from the addiction medicine lit-
erature and can be successfully employed once a food addiction has been identified.
4.3 EATING DISORDERS: FROM BULIMIA TO ANOREXIA NERVOSA

Anorexia nervosa and bulimia nervosa have their common origin in an obsession with body shape
and weight. While relationships, work, parenting, and sports performance form the core of a per-
son’s self-worth for most individuals, for patients with eating disorders, their self-worth stems from
their body shape and weight and their ability to control them. Eating disorders are commonly con-
sidered to include only anorexia nervosa and bulimia nervosa. However, there is a third eating
disorder called “atypical eating disorders” (Fairburn and Brownell 2002) or “eating disorders not
otherwise specified.” Atypical eating disorders are the most common diagnostic category, outnum-
bering patients with anorexia or bulimia, as documented in three well-executed case series (Millar
1998; Ricca et al. 2001). Atypical eating disorders primarily affect adolescents and young adult
women. A further eating disorder has also been proposed, termed binge eating disorder, and it
affects a significant percentage of overweight and obese patients, sometimes classified as “volume
eaters.”
Most atypical eating disorders resemble aspects of anorexia nervosa and bulimia nervosa (Ricca et al.
2001), and many are as severe and long lasting. Some are virtually identical to the two well-known dis-
orders, but do not meet their precise diagnostic criteria (Andersen et al. 2001). For example, such patients
may not meet the body weight criteria for anorexia nervosa, or they may still have intact reproductive
function. On the other hand, features such as extreme dieting, extreme exercising, and binge eating may
be present. Some patients may have a past history of anorexia nervosa or bulimia nervosa. Obsession with
shape and weight is usually present, but some patients primarily focus on controlling eating behavior.
Patients with anorexia and bulimia view their low body weight as an accomplishment rather than
a disease. They have little motivation to change their behavior. In bulimia nervosa, the struggle
to control shape and weight is interrupted by binge eating, so that patients describe themselves as
failed anorexics. Patients often identify negative physical and emotional states as feeling too fat.
They sometimes focus on a single fold of fat or a shape that promotes their misinterpretation of their
body size and shape.
Patients with anorexia nervosa who successfully lose weight well below what most would con-
sider healthy do this through a well-planned strategy of avoiding fattening foods and overconsum-
ing low-calorie, high-bulk foods, such as salads. They also typically exercise aerobically to achieve
an ever-thinner body. Self-induced vomiting to control body weight and the use of laxative and
diuretics are also methods used by some anorectic patients.
4.4 TREATMENT OF EATING DISORDERS

Eating disorders range from picky eating to anorexia and bulimia nervosa. There is a spectrum of
severity of disordered eating, ranging from picky eating in childhood and adolescent anorexia ner-
vosa to severe and sometimes fatal eating disorders in adulthood.
In most cases, picky eating in early childhood is a part of normal development. It is more com-
mon in preschool children and usually decreases in later childhood. However, picky eating may
persist into adulthood. The term refers to a range of conditions, including eating a limited variety
of food, and other specific features related to food and eating, such as eating very slowly or being
satiated soon after beginning to eat. Picky eating is often a major concern for parents of young chil-
dren (Cardona Cano et al. 2015). The most common approach to the management of picky eating is
to start with nutrition education. These programs are directed at the parents of children with picky
eating and are meant to increase nutrition knowledge while also improving feeding styles in order
to reduce negative interactions, including anxiety of parents and children around efforts to force
eating (Cardona Cano et al. 2015).
There are two types of anorexia nervosa—primary and secondary. The secondary form occurs
in the context of an underlying psychiatric condition and responds to treatment when the underlying
condition is resolved. Primary anorexia nervosa is far more complex and involves genetic predispo-
sition and the individual’s behavior in relation to the family, as well as the resulting psychodynamics.
Most clinical guidelines recommend family therapy for adolescent anorexia nervosa (National
Collaborating Centre for Mental Health 2004; American Psychiatric Association 2006; Hay et al.
2014; Blessitt et al. 2015), emphasizing the role of the family in the development of the illness and its
potential role as a mediator of successful treatment. While family therapy for adolescent anorexia
nervosa is now generally accepted as an effective treatment, there are clearly patients that do not
respond (Blessitt et al. 2015). Not just for family therapy, but more generally for anorexia nervosa,
there is still a strong need for more well-designed treatment studies (Hay et al. 2014). Compulsory
treatment is a last resort for anorexia nervosa, and is justified given its high mortality rate of 5%
per decade (Arcelus et al. 2011). In severe cases of anorexia nervosa, where the patient refuses life-
saving treatment, compulsory treatment needs to be considered (Elzakkers et al. 2014).
The treatment for bulimia nervosa and binge eating disorder in adults is based on individual
psychotherapy and cognitive behavioral therapy (CBT) (Fairburn et al. 2009; Kass et al. 2013;
Spielmans et al. 2013). In many countries where there are not enough therapists available to serve
the population, self-help manuals and interventions by the Internet have been shown to be effective
for cognitive behavioral treatment of eating disorders (Fairburn and Murphy 2015).
As with overweight and obesity, the majority of people with an eating disorder in the community
never enter the health care system (Hoek 2006). Therefore, the primary care practice as the first
entry point for individuals and families has a special role to play in the detection and treatment or
referral of patients with eating disorders.
4.5 FOOD INTOLERANCE AND FOOD ALLERGY

Food intolerance is a common nutritional problem that is encountered in primary care. Estimates
of the prevalence of this condition range from about 5% to 33% based on self-report (Bender and
Matthews 1981; Strobel 1993). Children have been studied more often than adults, as food intoler-
ance and even temporary allergies are more common (Young et al. 1994; Zeiger and Heller 1995;
Sampson 1996).
It is known that food allergy in adults is often associated with hay fever, and that the spectrum
of relevant food allergens is different from that in children (Hofer and Wuthrich 1985; Muhlemann
and Wuthrich 1991; Ring and Vieluf 1991; Jansen et al. 1994). Double-blind, placebo-controlled
food challenge results in much lower estimates of the incidence of food allergy than questionnaires
used in epidemiologic surveys. There are numerous alternative medicine practices based on invalid
testing of foods and their mood connections, often tested by adding drops of food extracts to the
tongue. It is important to distinguish food intolerance, which is a behavioral disorder often linked
with IBS, nausea, or other poorly defined symptoms, from a true food allergy, which activates an
immune reaction.
There is limited research on the connection between food allergies and the actual sensitization
by food challenge, as well as association with manifestations of atopy (Bjornsson et al. 1996; Chng
et al. 1999; Sicherer et al. 1999). When double-blind, placebo-controlled food challenge was used,
the prevalence of food allergies or intolerance was between 1.4% and 2.4% (Hofer and Wuthrich
1985; Jansen et al. 1994). These studies were carried out in relatively small numbers of subjects rang-
ing between 73 and 93. In one such study, a standard battery of eight allergens were tested, allowing
inferences only on these substances. Furthermore, some nonatopic reactions were included, such as
headache and behavioral and joint symptoms.
Food allergens in adults differ from those in childhood, where milk and egg account for the
majority of reactions. Reactions to nuts, fruit, milk, wine, and vegetables are most frequently
reported in adults. Peanut allergies are so common that the use of peanuts in producing foods is
often noted. The vast majority of reactions occur in the skin or mucosa (>70%). The given percent-
ages of reactions in population-based studies of different organ systems add to the data derived from
patient populations, and in which more severe reactions were seen (Ring and Vieluf 1991; Bjornsson
et al. 1996; Sicherer et al. 1999). In a nonatopic adult population from Singapore, 11.7% were found
to be sensitized to at least one of 18 food allergens in the skin prick test (SPT) (Chng et al. 1999).
Specific immunoglobulin E (IgE) antibodies to at least one of six food allergens were exhibited in
8% of a Swedish adult population (Bjornsson et al. 1996).
Researchers have found a strong association of sensitization to soy and celery or hazelnut, as well
as sensitization to celery or peanut and hazelnut. Clustering of food reactions suggests that there is
cross-reactivity between food and pollen allergens, causing food allergy in adults as a sequel to pol-
len sensitization. This is supported by the finding that more than 70% of subjects with food allergy
have a history of physician-diagnosed allergic rhinitis (Wuthrich et al. 1995). A strong and clini-
cally relevant association of food and pollen sensitization is known from several patient-based stud-
ies (Dreborg 1988). From patient populations, it was estimated that 65% of those with food allergy
exhibit other clinical manifestations of atopy (Muhlemann and Wuthrich 1991). Associations of
food allergy or sensitization with asthma and bronchial hyperresponsiveness were also reported in
a population-based study (Chng et al. 1999).
4.6 IRRITABLE BOWEL SYNDROME

IBS is characterized by chronically recurring abdominal pain or discomfort and altered bowel hab-
its. It is one of the most common syndromes seen by primary care providers, with a worldwide
prevalence between 10% and 15% (Drossman et al. 2002; Mayer 2008). IBS, while common, is a
diagnosis of exclusion, which in the absence of evidence of organic disease is defined by symptom-
based diagnostic criteria known as the “Rome criteria” (Longstreth et al. 2006).
In addition to the association of food intolerance with atopic reactions, IBS, including incipient
diarrhea, gas pain, or irregularity, is frequently reported in conjunction with specific food intake. Some
of these symptoms are physiologically based, including the well-known gas production from complex
sugars found in vegetables such as beans or broccoli. However, this syndrome is far more common than
even those related to specific foods and is based on behavioral factors in common with food intolerance.
Other functional gastrointestinal disorders, including functional dyspepsia, are frequently seen
in patients with IBS (Halder et al. 2007). In addition, fibromyalgia, chronic pelvic pain, and inter-
stitial cystitis (Whitehead et al. 2002; Wessely and White 2004) have been reported in association
with IBS. Coexisting psychological conditions are also common, primarily anxiety, somatization,
and symptom-related fears (e.g., “I am worried that I will have severe discomfort during the day if
I don’t empty my bowels completely in the morning”); these contribute to impairments in quality
of life (Spiegel et al. 2004) and excessive use of health care associated with IBS (Levy et al. 2001).
The use of fiber in treatment of IBS is well established. At least two recent meta-analyses with
published studies demonstrate that soluble fiber can improve symptoms of IBS, whereas there is
no evidence for recommending insoluble fiber for IBS. There were no severe adverse events seen
in any of the studies included in this meta-analysis. Minor side effects were reported, including
GI disturbances, which were a result of the action of soluble and insoluble fibers (Moayyedi et al.
2014; Nagarajan et al. 2015). The mechanism by which fiber helps alleviate the symptoms of IBS is
not established. Soluble fibers are digested and fermented in the distal small intestine and proximal
colon by endogenous bacteria to metabolites, including short-chain fatty acids (SCFAs). The pres-
ence of these carbohydrates may produce selective changes in the composition of the microbiota,
inducing different fermentation patterns. As such, carbohydrates such as inulin are regarded as
prebiotics, which may stimulate or alter the preferential growth of health-promoting species already
residing in the colon, including lactobacilli and bifidobacteria (Gibson et al. 1995; Roberfroid
2007). An increase in the production of SCFAs in stool can aid in the nourishment of the colonic
mucosa and improve mucus production. There is some emerging evidence that SCFAs can also
decrease inflammation at the cellular level, but further studies are needed to confirm this observa-
tion (Nagarajan et al. 2015).
FODMAPs is an acronym for “fermentable oligo-, di-, monosaccharides and polyols,” that is, low
in wheat, onions, beans, many kinds of fruit, and sorbitol. In recent years, studies supporting the
low-FODMAP diet for the management of IBS symptoms have been published, including several
randomized controlled trials, case-control studies, and other observational studies (Nanayakkara
et al. 2016). Dietary intervention studies have demonstrated that FODMAPs reduce symptoms in up
to 50% of patients with IBS (Gearry et al. 2009). In a study utilizing a placebo-controlled, crossover
rechallenge design (Shepherd et al. 2008), patients had fewer symptoms on the FODMAP-reduced
diet, and symptoms recurred in 70–80% of them when FODMAPs were reintroduced.
FODMAP restriction may reduce both osmotic load and gas production in the distal small bowel
and the proximal colon, providing symptomatic relief in patients with IBS. The long-term health
effects of a low-FODMAP diet are not known; however, stringent FODMAP restriction is not rec-
ommended, owing to risks of inadequate nutrient intake and potential adverse effects from altered
gut microbiota.
4.7 GLUTEN ENTEROPATHY AND GLUTEN SENSITIVITY

Gluten is the major protein component of wheat, rye, and barley (Kumar and Wijmenga 2011).
Gluten enteropathy, also called celiac disease, is an immune-mediated disease of the intestines that
is triggered by the ingestion of gluten in genetically susceptible individuals. Genetic predisposition
plays a key role in celiac disease. Gluten enteropathy is strongly associated with specific human
leukocyte antigen (HLA) class II genes located on chromosome 6p21. Approximately 95% of celiac
disease patients express HLA-DQ2, and the remaining patients are usually HLA-DQ8 positive.
However, the HLA-DQ2 allele is common and is carried by approximately 30% of Caucasian indi-
viduals. Thus, HLA-DQ2 or HLA-DQ8 is necessary for disease development but is not sufficient for
disease development; its estimated risk effect is only 36–53%. An additional 13 celiac disease risk
loci have been identified, but the genetic causes of celiac disease are still not established (Trynka
et al. 2011). Diagnosis is established by small intestinal biopsy.
The perception that gluten causes gastrointestinal symptoms and even central nervous system
symptoms in patients who do not have celiac disease, and are not allergic to wheat, is an increas-
ing clinical problem called gluten sensitivity (Verdu et al. 2009). There are now many more people
on a gluten-free diet following a self-diagnosis of gluten intolerance than there are patients with
celiac disease or gluten enteropathy confirmed by biopsy (Rubio-Tapia et al. 2012). This condition,
like IBS, is a clinical diagnosis without a biomarker or characteristic intestinal biopsy findings
(Ludvigsson et al. 2013).
The existence of the condition called gluten sensitivity remains controversial, and if it does exist,
its cause may not be gluten. Fermentable carbohydrates, including oligosaccharides, fructans, and
galactooligosaccharides (Sapone et al. 2012), have been termed FODMAPs, and they are capable of
triggering symptoms of IBS. Gluten-containing diets, which are low in FODMAPs, reduce symptoms
(Gibson et al. 2007; Biesiekierski et al. 2011; Shepherd et al. 2013; Molina-Infante et al. 2015), indicat-
ing that the benefits of a gluten-free diet in some patients diagnosed with gluten sensitivity may not be a
consequence of the elimination of gluten, but rather may be due to their reduced intake of FODMAPs.
4.8 INFLAMMATORY BOWEL DISEASES

IBDs are comprised of ulcerative colitis and Crohn’s disease. These are chronic and relapsing dis-
eases affecting both the gastrointestinal tract and the quality of life. IBD results from the interac-
tion of genetic susceptibility and environmental factors. Even though there is no cure for IBDs, a
combined pharmacological and nutritional therapy can induce remissions.
4.8.1 Malnutrition
Malnutrition and specific nutritional deficiencies are frequent among these patients. Malnutrition is
common in IBDs, and the underlying pathogenesis in these disorders is multifactorial. It is often a
combination of inadequate calorie intake and increased energy expenditure associated with disease
flares of inflammatory lesions (Hartman et al. 2009). In addition, both pharmacological and surgi-
cal treatment can impair digestion and absorption of nutrients because of drug–nutrient interactions
and reduced absorptive area of the intestine following surgical resections (O’Sullivan and O’Morain
2006). Reduced lean body mass and sarcopenia are common in patients with IBD, and these condi-
tions are associated with osteopenia and osteoporosis (Bryant et al. 2015).
Malabsorption is a major contributor to weight loss and malnutrition in adult Crohn’s disease
patients. Increased gastrointestinal nutrient losses are observed in patients after ileal resection or
with bile acid malabsorption (Vitek 2015). Bile acid malabsorption is common in patients, whether
the disease is localized in the ileum or not. It leads to malfunction of lipid digestion with steator-
rhea, impaired intestinal motility, and significant changes in intestinal microflora. Increased fat in
feces could also be a result of a deficit in pancreatic enzyme secretion. Gastric acid- and pancreatic
enzyme-impaired secretion have been found in 80% of Crohn’s disease patients.
4.8.2 Enteral and Parenteral Nutrition

Enteral feeding using formulas or liquids should always take precedence over parenteral feeding,
unless it has been completely contraindicated. Total parenteral nutrition may be used during the
acute inflammatory phase with obstruction, toxic megacolon, or active fistulas. It is also used in
the preoperative period and in patients with short bowel syndrome (SBS) due to previous extensive
bowel resections (Forbes et al. 2011; Mihai et al. 2013).
The idea of providing all nutrition through enteral supplements rather than foods is called exclu-
sive enteral nutrition, and it is used for active disease. It was first used in 1973 in adults with Crohn’s
disease resistant to other therapies (Voitk et al. 1973). Supplemental enteral nutrition may also be
used to maintain a disease remission or to achieve adequate weight gain and growth (O’Sullivan and
O’Morain 2006). Although research studies have confirmed its effectiveness in therapy, outcomes
of this approach, when implemented in patients, are highly variable. Exclusive enteral nutrition is
the initial therapy option in active Crohn’s disease. Parenteral nutrition is reserved to only being
considered as an alternative method of nutrition for those who cannot tolerate enteral nutrition or
during perioperative periods.
4.8.3 Breastfeeding
Breastfeeding has been associated with a lower risk of IBD. The mechanism by which breastfeeding
is protective is not known. Breastfeeding in the first months of life is crucial for the development
of gut microflora, as the complex carbohydrates in breast milk support the growth of a particular
Bifidobacterium species (Garrido et al. 2015). The gut microbiome stimulates innate and acquired
immunity, promotes the maturation of the mucosal immune system and the integrity of the mucosa,
and develops tolerance to food antigens (Scaldaferri et al. 2013; Ananthakrishnan 2015). Some
authors assign a special role in this process to lactoferrin (Frolkis et al. 2013). This peptide, which
is found in human milk but not in infant formula, has anti-inflammatory, antibacterial, and antiviral
properties (Brock 2002).
4.8.4 Specific Carbohydrate Diet

The specific carbohydrate diet (SCD) was introduced and initially described in the early 1920s to
treat celiac disease. In the years that followed, it became very popular due to several impressive
lay reports indicating the potential of SCD to treat IBDs. The underlying theory of the SCD is that
disaccharide and polysaccharide carbohydrates are poorly absorbed in the human intestinal tract,
resulting in bacterial and yeast overgrowth that might lead to inflammation and mucosal damage.
This diet restricts carbohydrate exposure to the monosaccharides glucose, fructose, and galactose.
Almonds, nuts, and coconut flours are recommended, while grain flours from wheat, rice, and corn
are excluded. Most dairy products are excluded, except for fermented yogurt, and the only sugar
allowed is honey. There has been no significant recent study examining the modification of carbo-
hydrate intake and its effects on the microbiome, which may be the likely mechanism of action for
both improvement and exacerbation of disease episode through an interaction of the microbiome
and the gut-associated immune system.
4.8.5 FODMAP Diet
Several trials have demonstrated the effect of a FODMAP-reduced diet in the treatment of IBS, as
described in Section 4.6. As a high percentage of patients with IBD experience IBS-like symptoms
(Appleyard et al. 2004; Soares 2014), a FODMAP-reduced diet might also be a therapeutic option
in IBD (Gibson and Shepherd 2005; Gearry et al. 2009). At least in one study, FODMAPs appear to
reduce some of the symptoms in Crohn’s disease (Donnellan et al. 2013). However, enthusiasm for
the FODMAP diet approach is reduced by the concern that such a structured dietary regimen will
have adverse effects secondary to reduced dietary diversity. It is particularly important to recognize
that this very same group of excluded nutrients plays a major role in modulating the composition of
gut microbiome. The majority of prebiotics are FODMAPSs (Rastall and Gibson 2015). Therefore,
it is important that patients following this diet do not restrict their fruit and vegetable intakes too
severely, in order to avoid vitamin and mineral deficiencies.
4.8.6 Western Diet and Obesity

The Western diet is characterized by higher intakes of red and processed meat, butter, high-fat
dairy products, eggs, refined grains, white potatoes, french fries in particular, and high-sugar drinks
(Hu 2002). The Western dietary pattern is associated with increased IBD risk (Ananthakrishnan 2015).
A German study of monozygotic and dizygotic twins correlated high consumption of processed
meat, including sausage, with an increased risk of Crohn’s disease, as well as ulcerative colitis
(Spehlmann et al. 2012). Similar associations have been noted in Japan, where increased intake
of dairy products and meat was associated with a rising incidence of ulcerative colitis (Ng 2014).
A potential mechanism is that allergy to proteins such as cow’s milk could increase the risk of
these diseases. Once study demonstrated that allergy to cow’s milk in infancy increased the risk of
Crohn’s disease and ulcerative colitis in later childhood (Virta et al. 2013).
Polyunsaturated fatty acids (PUFAs) may also play a role in the pathogenesis of IBDs. Increased
consumption of omega-6 fats from beef, pork, corn, sunflower oils, and polyunsaturated margarines
in place of omega-3 fats from fish has been associated with an increased incidence of IBD (Ueda et
al. 2008; Bernstein 2010). In addition, increased consumption of omega-6 fats has been associated
with a greater risk of developing ulcerative colitis in a dose-dependent manner (IBD in EPIC Study
Investigators et al. 2009). Recently, the European Prospective Investigation into Cancer (EPIC)
study, which included more than 350,000 participants with IBD, examined the association between
dietary pattern and IBD risks. While there was no overall association, they found that an imbal-
anced diet, with high consumption of sugar and soft drinks and low consumption of vegetables, was
associated with increased ulcerative colitis risk (Racine et al. 2016).
A significant proportion of patients with IBD are overweight (Kugathasan et al. 2007), which
is clearly associated with Western diets. A recent study showed that obesity prevalence in IBD
patients reflected the obesity index in the general population of the United States (Flores et al.
2015). Visceral fat localized around the intestine lumen is suspected to be pathogenic in IBDs (Fink
et al. 2012). Fat deposited around the small or large intestine is called “fat wrapping” (Weakley and
Turnbull 1971). In Crohn’s disease, fat surrounding more than 50% of the bowel circumference is
typical (Sheehan et al. 1992). It has been suggested that pro-inflammatory adipokines secreted by
this fatty tissue play a significant role in the pathophysiology of IBD (Ponemone et al. 2010).
4.8.7 Omega-3 Polyunsaturated Fatty Acids

Omega-3 PUFAs (from fish oils and some seed oils) are potent anti-inflammatory nutraceuticals,
capable of inhibiting the biosynthesis of important inflammation elicitors such as prostaglandin E2
(PGE2) and tumor necrosis factor α (TNF-α). In addition, omega-3 PUFAs also act as substrates for
the synthesis of the inflammation-resolving mediators resolvins, maresins, and protectins. A diet
rich in olive oil and fish, but also in vegetables, fruits, grains, and nuts, was inversely associated
with Crohn’s disease (D’Souza et al. 2008). The role of omega-3 PUFAs in the prevention and treat-
ment of inflammation in IBD in humans has been enthusiastically studied. However, these reports
show conflicting results. In some of them, omega-3 PUFAs had an important role in the course of
Crohn’s disease and ulcerative colitis, with reduced inflammation, improved clinical benefits, and
lower rates of relapse (Pearl et al. 2014; Calder 2015; Barbalho et al. 2016). This may be due to
differences in study design, amount and formulations of the fatty acids administered, dietary back-
ground, ratio of omega-6 to omega-3, or patient compliance (Belluzzi et al. 2000).
4.8.8 Vitamin D
Vitamin D deficiency is common among patients with IBD. The effects of low plasma 25-hydroxyvitamin
D (25(OH)D) on outcomes other than bone health are understudied in patients with IBD (Mouli and
Ananthakrishnan 2014). There is increasing support for the role of vitamin D in strengthening the
innate immune system by acting as an immunomodulator and reducing inflammation in experimen-
tal and human IBD (Reich et al. 2014). Moreover, supplementation with vitamin D and vitamin D
plasma levels correlated with quality of life in IBD patients during the winter and spring period in
some central European countries (Hlavaty et al. 2014).
4.9 SUMMARY
This chapter has integrated psychological, neurological, and physiological aspects of gastrointes-
tinal tract function to food intake. The immune system is largely located in proximity to the gas-
trointestinal tract, leading to interactions of the immune system with foods in the disorders of food
intolerance and food allergies. With further immune involvement with foods and some genetic com-
ponent, IBD may be triggered in the form of Crohn’s disease or ulcerative colitis. These inflamma-
tory conditions are associated with particular foods common in the Western diet, again emphasizing
the interaction of foods and the immune system in gastrointestinal tract disorders. FODMAPs and
fiber present a confusing and variable effect on both IBS and IBD, implicating possible differences
in response based on different gut microflora populations.
The management of these inflammatory conditions includes pharmacological, nutritional, and
surgical therapy. The main goal of the treatments is induction and maintenance of remission, cor-
rection of nutritional deficiencies, and prevention of complications (Hanauer 2006).
There is no single diet or meal plan for everyone with IBD, and dietary recommendations must
be individualized. Attention must be paid to avoiding foods that worsen or trigger disease symptoms
and meanwhile making healthy food choices, replacing nutritional deficiencies, and maintaining a
well-balanced nutrient-rich diet.
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5 Approach to the Overweight
and Obese Patient
The Elephant in the Room
5.1 INTRODUCTION
In Chapters 2 and 5, a diet and lifestyle program for the general population designed to maintain
healthy body composition on an individual basis is described. A key principle centered on dietary
protein at levels greater than those generally recognized as required by government agencies. The
physiology behind this idea centered on matching protein intake to the energetics and composition
of the body. Many of those so-called healthy individuals in industrialized countries, even at normal
body mass index (BMI) and waist circumference, are already overfat to some degree due to a seden-
tary lifestyle and unbalanced nutrition (Thomas et al. 2012). In this chapter, the overtly or obviously
obese patient based on BMI criteria presenting to primary care practices is the focus of discussion.
While overfatness is a hidden epidemic requiring increased vigilance toward prevention, the obvi-
ously obese require a coordinated program of care.
Often, obese patients have been left untreated in primary care, since they represented too great
a challenge for the typical practitioner with limited time. Instead of dealing with the underlying
obesity, palliative medications would be prescribed to deal with the cardiometabolic and endocrine
issues associated with obesity (Goodfellow et al. 2016). These metabolic consequences are due to
excess body fat and not excess body weight.
In fact, among the obviously obese there is a significant subpopulation of metabolically healthy
individuals (Lopez-Garcia et al. 2016) who will respond to diet and exercise with greater short-
term weight loss than the mildly overweight, because they tend to have greater resting metabolic
rates due to their increased lean body mass. These patients have less excess body fat than expected
based simply on their body weight. In childhood and adolescence, visibly obese children are often
ridiculed by their peers and suffer social and psychological trauma (Udo and Grilo 2016). However,
from a metabolic point of view, they may be as healthy as many lean patients except for the ortho-
pedic stress to their joints due to their excess weight. As they age, muscle atrophy and worsening
hips, knees, and back often lead to reduced physical activity and increased food intake, resulting in
rapid weight and fat gain, with resulting metabolic problems. Cardiopulmonary issues, including
those linked to sleep apnea and hypertension, are frequent comorbid conditions. The central role
that obesity plays in many organ system diseases in these patients is discussed in several of the later
chapters, but this chapter concentrates on the early recognition of these at-risk metabolically normal
obese individuals and the treatment of the already obese patient at risk for the metabolic syndrome
(MetS), diabetes, heart disease, and hypertension.
5.2 PATHOPHYSIOLOGY OF OBESITY
While the incidence of obesity in the United States has been increasing since the early decades of
the last century, dramatic accelerations worldwide have been described over the past four decades
(Zimmet et al. 2001; Caballero 2007), as significant changes in diet and lifestyle have led to what is
called an obesogenic environment. According to figures announced in 2015 by the World Obesity
85
Federation, it is suggested that 2.7 billion adults worldwide will be overweight by 2025 if current
trends continue (World Obesity Federation 2016). This is a 35% increase from 2.0 billion in 2014.
The current epidemic of obesity is caused primarily by an environment that promotes excess
food intake and discourages physical activity. This is a global epidemic, as Western ideals and
lifestyles are being adopted in urban and rural settings worldwide. Although humans have evolved
excellent physiological mechanisms to defend against starvation and infection associated with
calorie restriction, they have only weak physiological mechanisms to defend against body weight
gain when food is abundant and exercise is limited. The excessive consumption of energy-dense
foods rich in salt, fat, and sugar, in combination with sedentary lifestyles, urbanization, and
socioeconomic-dependent limited access to a healthy diet (Misra and Khurana 2008), under-
pins the global obesity epidemic.
Why is this so prevalent? To understand the commonality of obesity, it is important to under-
stand the genetic and epigenetic basis underlying the evolution of humankind. The adaptation to
starvation involves a switch to a fat-fuel economy after the glycogen stores in the liver and muscle
are exhausted, which usually occurs after just 3 days (Cahill 2006). Once carbohydrate stores are
exhausted, the primary way that the brain and red blood cells can get the glucose they need is to
break down body protein from cells and muscles. At first, about 75 g of body protein is broken down
per day, but over several weeks, this amount is reduced to about 20 g/day, as the brain begins to use
ketone bodies made from fatty acids for energy, reducing the amount of glucose needed by break-
ing down muscle and other body proteins. So, the primary goal of the adaptation to starvation is to
reduce the rate at which protein is broken down. With adequate hydration and vitamins, starving
individuals can survive about 6 months with no food intake. If the adaptation to starvation is inhib-
ited, then survival is only possible for about 60 days. If, in addition, there is active inflammation due
to tumor, trauma, or infection, survival may be only about 30 days.
These different durations of survival all have one thing in common. They occur when the pre-
illness body protein is reduced by 50% (Muller et al. 2015). At that point, there is impairment of
delayed cell hypersensitivity and immune function, so that death usually results from infection and
sepsis.
Since starvation and infection have been the greatest nutrition-related threats to human survival
over the last 100,000 years, it is reasonable that genetic evolution and epigenetic changes would seek
to maximize lean body mass as long as adequate protein was available in the environment.
There is great variability in BMI values, which have their origin in genetics and epigenetic
differences among individuals (Bouchard 2008; Fleisch et al. 2012; van Vliet-Ostaptchouk et al.
2012). While BMI is taken as a practical index of obesity, it clearly fails to account for variations
in lean body mass and fat mass among individuals from different ethnic groups and nutritional
environments.
A BMI cutoff of 30 kg/m2 is generally used to define medical obesity (WHO 2013). The BMI
threshold has been assessed by the risk for morbidity and mortality in populations of European
ancestry (de Gonzalez et al. 2010). Using a single standard cutoff value to define obesity has been
questioned, and ethnic-specific BMI cutoffs have been proposed (Evans et al. 2006; Romero-Corral
et al. 2008; Rahman and Berenson 2010). In Asian populations, increased disease risks occur at
normal BMI values of 20–25 kg/m2 (Yang et al. 2010).
A BMI paradox in the survival of patients with congestive heart failure where greater BMI predicts
better survival has been attributed to the increased lean body mass in some patients (Curtis et al. 2005).
It has long been known that increased BMI confers a survival benefit for obese individuals com-
pared with lean individuals based on their increased lean body mass and fat mass. The familial
aggregation of body size was first reported by Sir Francis Galton in 1894 (Galton 1894). Since then,
family history of obesity has become a well-established risk factor for childhood obesity. Studies
indicate that parental BMI or overweight or obesity status is associated with BMI or the risk of
overweight or obesity in children, and is an important predictor of obesity in adulthood (Danielzik
et al. 2002, 2004; Oliveira et al. 2007; Birbilis et al. 2013). The ethnic-dependent pattern of obesity
Approach to the Overweight and Obese Patient 87
prevalence further supports the heritability of obesity, which could be explained in part by specific
lifestyles or environmental exposures. In fact, most studies have demonstrated an important contri-
bution of both genes and environment (Muller et al. 2010).
Another important feature of lean body mass is that it is the strongest predictor of resting energy
expenditure, which in turn accounts for more than 75% of total calories burned per day, with the
remainder being related to exercise, dietary thermogenesis, brown fat cell metabolism, and a small
amount of measurable adaptive thermogenesis (Deriaz et al. 1992). Overnutrition increases energy
expenditure via putative effects on brown fat, and this effect, which has been controversial, is called
“luxuskonsumption” (Ravussin et al. 1985). Undernutrition decreases energy expenditure. With
very low-calorie diets, about a 10–15% decrease in energy expenditure has been ascribed to adap-
tive thermogenesis (Major et al. 2007).
5.2.1 Genetic and Environmental Interactions in Obesity

The completion of the human genome sequence, combined with high-throughput methodological
advances in the laboratory, has led to the identification of a large number of genes modulating both
BMI and the tendency to gain weight in an obesogenic environment.
Monogenic obesity syndromes are very rare and characterized by mental retardation, dysmorphic
features, and specific abnormalities in various organs, in addition to obesity (Waalen 2014). More
than 30 monogenic syndromes have been reported in the literature, of which many have not been
genetically elucidated (Garver et al. 2013). The most famous of these is the Prader–Willi syndrome,
first reported in 1956 by Andrea Prader. This syndrome has an incidence of 1 in 15,000–30,000
individuals (Cassidy and Driscoll 2009). Common characteristics include hypotonia, feeding dif-
ficulties, poor growth, and delayed development in the first year of life, followed by hyperphagia,
childhood obesity, short stature, and cognitive disability (Cassidy and Driscoll 2009).
Nonsyndromic monogenic obesity refers to a single gene disorder that leads to a highly pen-
etrant form of the disease. A frameshift homozygous mutation in the leptin (LEP) gene resulting in
truncated transcription of leptin was first discovered in 1997 in two severely obese cousins within a
highly consanguineous family of Pakistani origin (Montague et al. 1997). Other reports have con-
firmed this initial discovery in additional patients with no detectable leptin, in Pakistan, Turkey, and
Egypt (Gibson et al. 2004; Mazen et al. 2009). Two patients with severe early-onset obesity with a
homozygous LEP mutation exhibited detectable circulating leptin levels, indicating that the muta-
tion affects protein function rather than expression, leading to an inactive leptin protein (Wabitsch
et al. 2015). Clinical manifestations of patients with mutations in LEP or leptin receptor (LEPR)
include rapid weight gain within the first year of life, severe hyperphagia, and intolerant behavior
when presented with food restrictions (Farooqi et al. 2002). Onset of puberty is often delayed due to
hypogonadotrophic hypogonadism (Farooqi et al. 2007).
There was a great deal of excitement when the ob/ob mouse was found to have leptin deficiency
due to a mutation in the leptin gene. This led to the identification and synthesis of leptin, and its
administration led to resolution of obesity in mice with the genetic lesion, as well as in mice fed
a high-fat or high-sugar cafeteria diet. Clinical studies of leptin administration in humans only
resulted in reversal of obesity in individuals with the rare genetic defects described above, but not
in most individuals with typical obesity (Heymsfield et al. 1999). The reason for this is that obese
humans are resistant to leptin. Leptin has more to do with the adaptation to starvation than it does
with obesity.
During fasting, or when food intake is decreased, leptin levels decrease, leading to increased
food intake and decreased physical activity. Low leptin levels account in part for the ability of pris-
oners of war to regain weight rapidly as they undergo refeeding. Similarly, leptin levels are low in
obese individuals after weight reduction (Mantzoros et al. 2011). Obese individuals have a require-
ment for more calories due to their increased lean body mass compared with lean individuals. When
they eat to meet this energy requirement with the available foods in industrialized countries, they
Environment
Structural variation
Epigenetic variation
Single-nucleotide variation
Chromosome
Histone
Genetic and epigenetic DNA
Syndromic Monogenic Oligogenic Polygenic
Obesity
FIGURE 5.1 (See color insert.) Contribution of genetic, epigenetic, and environmental stimuli to obesity.
In monogenic and syndromic obesity, a single gene mutation could result in severe obesity, irrespective of
environmental stimuli. However, in cases of oligogenic and polygenic obesity, environmental factors can exac-
erbate the progression of obesity if the individuals have a genetic predisposition to weight gain. (Reprinted
from Pigeyre, M. et al., Clin. Sci., 130, 943–986, 2016.)
get additional calories from hidden fats and sugars, leading to weight gain. As discussed below, by
supplementing the diet with additional protein and cutting added sugars and hidden fats, this prob-
lem can be addressed in programs directed at the prevention and treatment of obesity.
As shown in Figure 5.1, polygenic obesity is the most common form and has a very significant
interaction with the environment, and the genetic underpinnings of this relationship are complex,
with multiple genetic and epigenetic influences, as well as single-nucleotide polymorphisms associ-
ated with this heterogeneous and common phenotype. The much rarer monogenic and oligogenic
forms have a greater genetic component. Research in this area continues in the hope of finding per-
sonalized approaches to obesity. However, as discussed below, the amount of genetic information in
the human genome is dwarfed by what is found in the gut microbiome, and there is increasing evi-
dence of the importance of microflora in the etiology of obesity, even in genetically identical twins.
5.2.2 Biological Signals Regulating Food Intake

Despite variations in the amounts and types of foods eaten each day, the body maintains a relatively
constant body weight. As already discussed, most of the physiology of obesity is directed at the
adaptation to starvation. However, the gastrointestinal (GI) tract has mechanisms to protect itself
from the overconsumption of foods in a meal. While a vast number of people eat even when they are
not hungry, there are well-defined signals from the gut to the brain that cause satiety. Satiety refers
to processes that end meals in order to limit meal size (Blundell and Halford 1994; Smith 1998).
After a meal, these signals can affect the time to the next meal, regulating the number of meals per
day, which is also entrained by learned habits (Strubbe and Woods 2004). A combination of neural
and endocrine signals originates in the gut in response to mechanical and chemical properties of
ingested food. While these signals end an ongoing meal, they do not delay the onset of the next meal
or food intake between meals, including snacks (Strubbe and Woods 2004).
By affecting intestinal motility and secretion of digestive enzymes, the satiety signals assist the
GI tract in carrying out its primary function of nutrient digestion and absorption. Some signals
directly affect GI motility and secretion and restrict the rate at which nutrients reach the gut (Gibbs
et al. 1973). Meals are stopped before gastric capacity is filled. The stomach has a large maximal
capacity, which is a major reason that the gastric bubble intervention of the 1990s failed.
The signals from the distention of the stomach and peptides released from gutendocrine cells
travel to the hindbrain via the vagus nerve and the bloodstream, respectively. Pathways relaying
short-acting satiation signals from the gut to the hindbrain also interact at several levels with long-
acting adiposity hormones involved in body weight regulation, such as leptin and insulin. Through
multifaceted mechanisms, adiposity hormones function as gain-setters to modulate the sensitivity
of vagal and hindbrain responses to GI satiation signals. Adiposity hormones thereby regulate short-
term food intake in order to achieve long-term energy balance (Figure 5.2) (Schwartz et al. 2000;
Morton et al. 2006).
Ghrelin is a peptide produced in the stomach and proximal small intestine. It gets its strange
name from its ability to release growth hormone, but its main function is to work exactly the oppo-
site of the satiety hormones (Cummings et al. 2005). It increases rather than decreases food intake
(Tschop et al. 2000). Ghrelin increases GI motility and decreases insulin secretion, resulting in
increased hunger between meals, and then it decreases after meals.
The ileal brake is a feedback phenomenon whereby ingested food activates distal-intestinal sig-
nals that inhibit proximal GI motility and gastric emptying (Pironi et al. 1993). It is mediated by
neural mechanisms and several peptides that are also implicated in satiation. These signals act to
put a behavior brake on eating to supplement the ileal brake’s actions and reduce the rate of nutrient
entry into the bloodstream (Strader and Woods 2005). Glucagon-like peptide 1 (GLP-1) is cleaved
from proglucagon, expressed in the gut, pancreas, and brain (Drucker 2006). Other proglucagon
products include glucagon (a counterregulatory hormone), GLP-2 (an intestinal growth factor), gli-
centin (a gastric acid inhibitor), and oxyntomodulin. The strongest evidence for satiety effects have
been found for GLP-1 and oxyntomodulin. Like GLP-1, oxyntomodulin is a proglucagon-derived
peptide secreted from distal-intestinal L-cells in proportion to ingested calories. PYY is produced
mainly by distal-intestinal L-cells, most of which coexpress GLP-1. It is secreted after meals in
proportion to caloric load, with a macronutrient potency of lipids being greater than that of carbo-
hydrates, which is greater than that of proteins (Degen et al. 2005).
This brief discussion was not meant to be comprehensive, but to indicate the complexity of the
regulation of food intake by endocrine glands, fat cells, and the GI tract, which has been called the
second brain due to its ongoing communication with the brain through the vagus nerve. There are
Hypothalamus
Brain stem
– – – – – – CCK
Vagus
nerve
Insulin OXM – GLP-1
+
Adiponectin Leptin PYY Ghrelin PP
Adiposity signals Gut hormones
FIGURE 5.2 Energy homeostasis is controlled by peripheral signals from adipose tissue, the pancreas, and
the GI tract. Peripheral signals from the gut include peptide YY (PYY), oxyntomodulin (OXM), ghrelin, pan-
creatic polypeptide (PP), GLP-1, and cholecystokinin (CCK). These gut-derived peptides and adiposity signals
influence central circuits in the hypothalamus and brain stem to produce a negative (−) or positive (+) effect
on energy balance. Thus, the drive to eat and energy expenditure are adjusted so that over time, body weight
remains stable. (Reprinted from Stanley, S. et al., Physiol. Rev., 85, 1131–1158, 2005.)
numerous ongoing discoveries of factors affecting food intake and energy expenditure not only in the
brain, but also in the gut, liver, and muscles. As is the nature of academics, each of these factors, like
leptin, is hailed as the cure for obesity. The main thing to understand from all this is that the regulation
of food intake is complex since it is vital to survival, especially survival from starvation (Figure 5.2).
Attempts to alter this system through drugs that target individual factors and surgery that
bypasses the digestive tract have been largely unsuccessful for two reasons. First, there are multiple
feedback systems that can block any effect of a drug on one system. A drug that is truly effective
on this system would also be toxic by inhibiting the adaptation to starvation. Second, the hedonic
inputs to food intake and food addiction overcome the effects of these attempted medical and surgi-
cal cures since people eat when they are not hungry. The available drugs and surgical approaches
will be discussed briefly, but they are often ineffective or toxic choices of last resort, rather than
the initial or preventive treatment of obesity, which should always be based on diet and lifestyle.
Psychology trumps physiology every time, and there are major behavioral inputs to food intake that
require a combined physical and behavioral treatment approach.
5.2.3 Protein Is the Most Satiating Macronutrient

A great deal of research has established that protein-enriched meal replacements are effective in
weight loss and weight maintenance largely through the effects of protein on satiety. In compari-
son with carbohydrate and fat, protein is the most satiating macronutrient, and when combined
with resistance exercise, it preserves lean body mass during weight loss (Leidy et al. 2007). In the
DIOGENES trial that spanned eight countries in Europe, a high-protein, low-glycemic-index diet
was the only one of five possible combinations of control and high- and low-protein or high- and
low-glycemic-index diets to maintain weight over 6 months following successful loss of weight over
8 weeks (McConnon et al. 2013). High-protein diets have also been shown to have positive effects
on mood and cognitive function (Spring et al. 1983; Jakobsen et al. 2011; Zeng et al. 2011). Both in
the short term and over the long term, protein is the most satiating macronutrient, even as snacks
between meals (Lieberman et al. 1986). While most snack foods are high in fat, salt, and sugar, a
study of high-protein soy snacks eaten between meals by adolescents improved appetite, satiety, and
diet quality while beneficially influencing aspects of mood and cognition. Therefore, prescribing the
right amount of protein from plant and animal sources is key to controlling hunger, and maintaining
lean body mass and resting energy expenditure during weight loss in obese patients.
Just as no drug is a cure-all (see the next section), protein has an important role to play, but must
be eaten within a daily diet plan with exercise and behavior change designed to have its maximum
effect not only on hunger control, but also on maintenance of lean body mass and resting energy
expenditure.
5.2.4 Drugs for Obesity

Lifestyle modifications such as diet and exercise intervention are essential for both prevention and
management of obesity, and pharmacotherapy may be considered if the interventions are ineffec-
tive for individuals with a BMI of ≥30 kg/m 2 or for those with a BMI of ≥27 kg/m 2 when comor-
bidities, such as hypertension or type 2 diabetes mellitus, are present (Clinical Guidelines 1998).
However, antiobesity drugs are a frequent adjunct, because these interventions have limited long-
term success (Kaukua et al. 2003; Li et al. 2005), and often weight is regained when treatment is
discontinued.
Phentermine is one of the centrally acting appetite-suppressant drugs of the β-phenethylamine
family, which was approved for short-term (up to 3 months) use in the treatment of obesity by the
U.S. Food and Drug Administration (FDA) in 1959 and remains available today. There are little
data from large randomized controlled trials (RCTs) relating to the long-term efficacy or safety of
phentermine, especially when used as monotherapy (Li et al. 2005).
As a substitute for phentermine, caffeine and green tea can help to increase mental energy and
mobilize fat, and represent an alternative since phentermine is only approved for short-term use in
the United States (Hursel and Westerterp-Plantenga 2013). In 2000, the European Medicines Agency
(EMA) recommended the market withdrawal of phentermine due to an unfavorable risk-to-benefit ratio.
In the 1990s, fenfluramine and dexfenfluramine were withdrawn from the market because of
heart valve damage (Connolly et al. 1997). The initial description including thickened valves was
previously associated with endomyocarditis of starvation and pulmonary hypertension. Subsequent
studies showed that the effects were largely reversed on discontinuation of the combination, which
is no longer available (Mast et al. 2001).
The first selective endocannabinoid CB1 receptor blocker, rimonabant, was developed due to the
idea that the reward circuits in the brain motivated eating in the absence of true hunger. By reduc-
ing the pleasure of eating, this drug was supposed to lead to weight loss. However, the drug was
never approved by the U.S. FDA due to an increased risk of psychiatric adverse events, including
depression, anxiety, and suicidal ideation (Christensen et al. 2007). Subsequently, rimonabant was
withdrawn from the European market in 2009.
Sibutramine, a selective noradrenaline and serotonin reuptake inhibitor, was widely used after
approval by the U.S. FDA in 1997. Sibutramine inhibited the decreases in blood pressure observed
with weight loss but did not increase blood pressure. Nonetheless, there was concern expressed for
cardiovascular risk associated with the use of this drug. Ultimately, sibutramine was withdrawn
from the market voluntarily by the manufacturer (James et al. 2010).
For completeness, here are the other commonly prescribed and approved drugs that are rarely used
by primary care physicians, and are largely restricted to bariatric or obesity medicine specialists.
Diethypropion is a sympathomimetic appetite suppressant available as a 25 mg immediate-
release form or a 75 mg sustained-release form. The 25 mg form is taken 30 minutes before meals
(Cercato et al. 2009). There is some concern about habituation to the use of this drug, which is con-
traindicated in individuals with cardiovascular disease (Cercato et al. 2009).
Combinations of drugs already approved for other indications have also been a source of new
pharmacological approaches to obesity. A combination of naltrexone and burproprion has been
approved and is based on the idea that addiction medicine is relevant to obesity. Both drugs have
been used individually for addictions, including smoking and drug addiction (Apovian et al. 2013).
Topiramate has been used alone and in combination with phentermine for the treatment of obesity
(Shin and Gadde 2013; Paravattil et al. 2016). This drug was first discovered to be an antiseizure
medication without the weight gain side effects of other commonly used antiseizure medications.
Subsequently, weight loss was demonstrated in clinical trials.
Lorcaserin was developed due to its similarity to fenfluramine in an attempt to develop a serotonin-
active agent without the side effects of fenfluramine (Apovian et al. 2016). The FDA approved two
combination drugs for weight loss consisting of combinations of drugs already approved for other
indications, including naltrexone combined with bupropion and topiramate with phentermine. In
addition, they approved lorcaserin, which was similar to fenfluramine but had extensive research
done demonstrating cardiovascular safety. In the end, the FDA approved these drugs given the
health impacts of obesity on diabetes, heart disease, and many other diseases realizing that there
were no approved drugs for this common condition increasingly becoming recognized by the public
other than orlistat, which blocks fat absorption (Azebu 2014).
5.2.5 Surgical Approaches to Obesity

Surgery is attractive to obese and overweight patients since they can turn over this difficult problem
to a surgeon. The appeal cannot be overestimated, as indicated by the popularity of many surgical
approaches, including the lap-band, gastric sleeve, and Roux-en-Y bypass. A full description of the
surgeries is outside the scope of this review. However, the unrealistic expectations of patients under-
going surgery for obesity have been well documented (Li and Heber 2014).
The amount of bariatric surgery being performed in the United States has changed dramatically
over the past two decades. Between 2009 and 2012, the number of inpatient bariatric operations
ranged from 81,005 to 114,780 cases annually (Nguyen et al. 2016). During this time period, the
annual rate of bariatric procedures was highest for 2012, at 47.3 procedures per 100,000 adults.
The bariatric surgery approach most commonly performed continues to be laparoscopic, ranging
from 93.1% to 97.1%. In 2012, there was a precipitous reduction in the number of gastric bypass and
gastric banding operations, which were replaced by an increase in the number of sleeve gastrectomy
operations. The in-hospital mortality rate remains low, ranging from 0.07% to 0.10% overall, but is
clearly higher in compromised patients. Therefore, surgery should be a last resort after other options
have been exhausted, including a medically supervised very low-calorie diet as part of a multidisci-
plinary approach, which can also result in rapid weight loss to resolve medical issues.
5.3 IMPACT OF EXCESS BODY FAT ON HEALTH

The reason that the chapter title includes the phrase “The Elephant in the Room” is that excess
fat in the abdomen, via its effects on metabolism and inflammation, is an important factor in the
etiology and progression of many of the most common diseases in the primary care office, and yet
it is rarely addressed in the process of prevention and treatment of the common chronic diseases
described next. The interaction of nutrition with some of these conditions is detailed further in
separate chapters, but the following subsections indicate the strength of the associations of these
common age-related chronic diseases to unbalanced nutrition and a sedentary lifestyle, which leads
to the accumulation of excess body fat.
5.3.1 Type 2 Diabetes Mellitus

Type 2 diabetes mellitus is the disease most closely associated with excess body fat. It is linked
to visceral obesity and inflammation and follows the epidemic of obesity so closely that the term
diabesity has been applied to this condition. Epidemiological studies using BMI have developed
convincing evidence of this association. The Nurses’ Health Study of 114,000 women followed
for 14 years demonstrated that the risk of developing type 2 diabetes was 93 times higher among
women who had a BMI of 35 or higher at the start of the study than among women with BMIs
lower than 22 (Colditz et al. 1995). This risk factor is well out of the range of all other obesity-
associated diseases, which typically are four to six times more common in obese than lean individu-
als. Weight gain during adulthood also increases diabetes risk, even among women with BMIs in
the healthy range, pointing to the known association of type 2 diabetes with abdominal visceral fat.
The Health Professionals Follow-Up Study found a similar association in men (Koh-Banerjee et al.
2004). Moderate weight loss can prevent or delay the start of diabetes in people who are at high risk
(Tuomilehto et al. 2001; Knowler et al. 2002; Li et al. 2008).
5.3.2 Hypertension and Renal Disease

Abdominal visceral obesity is a major cause of hypertension, accounting for 65–75% of the risk
for human primary or essential hypertension (Hall et al. 2015). Increased renal tubular sodium
reabsorption plays a significant role in initiating obesity-induced hypertension, but this condition is
mediated by several interrelated factors, including (1) physical compression of the kidneys due to
excessive fat in and around the kidneys, (2) activation of the renin–angiotensin–aldosterone system
by angiotensinogen secreted from adipocytes, and (3) increased sympathetic nervous system activ-
ity. Chronic obesity hypertension leads to renal injury. At this point, obesity-associated hypertension
becomes more difficult to control, often requiring multiple antihypertensive drugs and treatment of
other risk factors, including dyslipidemia, diabetes mellitus, and inflammation. The interaction of
nutrition and renal disease is complex and will be dealt with in detail in Chapter 12.
5.3.3 Cardiovascular Diseases: Coronary Artery Disease and Stroke

Cardiovascular disease is the leading cause of death in patients with type 2 diabetes mellitus and
obesity (Cho et al. 2002) and in those with chronic kidney disease (CKD) (Briasoulis and Bakris
2013), which is also associated with obesity. Diabetes and CKD are known independent risk fac-
tors for cardiovascular death, and patients with CKD are more likely to die from cardiovascular
causes than to progress to end-stage renal disease. Diabetes increases the risk of cardiovascular dis-
ease, including coronary artery disease (CAD), stroke, peripheral artery disease, and heart failure
(Boccara and Cohen 2004). The progression from diabetes to renal failure to heart disease–related
death is an all too common scenario among patients seen in primary care. While common diseases
occur frequently, in this case, these common diseases have a common etiology in excess abdominal
visceral fat.
Numerous studies have demonstrated a direct association between excess body weight and CAD.
While not perfect, since BMI is based on both lean body mass and fat mass, the correlations and
associations in these large studies send a clear message. The BMI-CAD Collaboration Investigators
conducted a meta-analysis of 21 long-term studies that followed more than 300,000 participants for
an average of 16 years. Study participants who were overweight had a 32% higher risk of developing
CAD than participants who were at a normal weight; those who were obese had an 81% higher risk
(Bogers et al. 2007). Although adjustment for blood pressure and cholesterol levels slightly lowered
the risk estimates, they remained highly significant for obesity. The investigators estimated that the
effect of excess weight on blood pressure and blood cholesterol accounts for only about half of the
obesity-related increased risk of coronary heart disease.
Since the vast majority of patients with type 2 diabetes are obese, these various disease conditions
are closely interrelated to diet and lifestyle. Ischemic (clot-caused) stroke and CAD share many of
the same disease processes and risk factors. A meta-analysis of 25 prospective cohort studies with
2.3 million participants demonstrated a direct, graded association between excess weight and stroke
risk. Overweight increased the risk of ischemic stroke by 22%, and obesity increased it by 64%.
There was no significant relationship between overweight or obesity and hemorrhagic (bleeding-
caused) stroke, however (Strazzullo et al. 2010). A repeat analysis that statistically accounted for
blood pressure, cholesterol, and diabetes weakened the associations, suggesting that these factors
mediate the effect of obesity on stroke.
In a meta-analysis of 26 observational studies that included 390,000 men and women, several
racial and ethnic groups, and samples from the United States and other countries, obesity was sig-
nificantly associated with death from cardiovascular disease. Women with BMIs of 30 or higher had
a 62% greater risk of dying early from heart disease, and also had a 53% higher risk of dying early
from any type of cardiovascular disease, than women who had BMIs in the normal range (18.5–
24.9). Men with BMIs of 30 or higher had similarly elevated risks (McGee and Diverse Populations
Collaboration 2005).
Modest diet and lifestyle changes leading to a weight loss of 5–10% of body weight have been
shown to lower blood pressure, LDL cholesterol, and triglycerides, and improve other cardiovascu-
lar risk factors (de las Fuentes et al. 2009; Dengo et al. 2010; Look AHEAD Research Group and
Wing 2010).
5.3.4 Obesity and Cancer

The association between obesity and cancer is not quite as clear as that for diabetes and cardiovas-
cular disease. This is due in part to the fact that cancer is not a single disease but a collection of
individual diseases.
Cancer incidence varies among populations, organs, and tissues, and sometimes it is not possible
to explain tumor occurrence by known potential determinants, such as environmental exposure,
pathogens, or inherited genes. It is impossible to predict exactly who will develop a cancer and who
will not. We know that several “risk factors” may increase the chance of getting cancer, and that
risk increases with age. However, even with that in mind, only a subset of cancers can be explained
based on diet and lifestyle.
In a paper published in the journal Science, Tomasetti and Vogelstein (2015) stated that most
cancers are “due to bad luck,” which refers to “random mutations arising in stem cells.” As the num-
ber of mutations in all cells increase over time, age is a clear risk factor for cancer, so that studies
looking at risk always look at age-adjusted cancer rates. Among patients, the idea that nothing can
be done to prevent cancer is prevalent, and many patients take this to mean that they can live an
unhealthy lifestyle with no impact on their risk of cancer.
In response to this hypothesis, researchers at the National Cancer Institute pointed out that there
are many known factors that can influence cancer incidence, which can be summarized as age;
sex; ethnic origin; geographic location; inheritance of susceptibility genes; overweight and obesity;
lifestyle; exposure to carcinogens, including chemical; and physical and infectious agents, such as
viruses or bacteria (Albini et al. 2015). Breast cancer risk is influenced by age at menarche, parity,
hormonal status, and lactation. Prostate cancers, which account for about one-third of all male can-
cers, have few stem cells involved and have a clear relationship to diet and lifestyle. Many influential
factors are still unknown, as are potential interactions among multiple factors.
A 2012 report from the Centers for Disease Control and Prevention highlighted the increased
cancer risk associated with excess weight (overweight or obesity) and lack of sufficient physi-
cal activity (<150 minutes of physical activity per week). Death rates from all cancers combined
decreased from 1999 to 2008, continuing a decline that began in the early 1990s, among both men
and women in most racial and ethnic groups. Death rates decreased from 1999 to 2008 for most
cancer sites, including the four most common cancers (lung, colorectal, breast, and prostate). The
incidence of prostate and colorectal cancers also decreased from 1999 to 2008. Lung cancer inci-
dence declined from 1999 to 2008 among men and from 2004 to 2008 among women. Breast cancer
incidence decreased from 1999 to 2004, but was stable from 2004 to 2008.
Incidence increased for several cancers, including pancreas, kidney, and adenocarcinoma of the
esophagus, which are all associated with excess weight. Although improvements are reported in the
U.S. cancer burden, excess weight and lack of sufficient physical activity contribute to the increased
incidence of many cancers, adversely affect quality of life for cancer survivors, and may worsen
prognosis for several cancers. The report highlighted the importance of efforts to promote healthy
weight and sufficient physical activity in reducing the cancer burden in the United States.
5.3.5 Obesity and Depression

Obesity and depression so frequently coexist, especially atypical depression, that the important
clinical decision is to determine whether depression is secondary to obesity or, alternatively, driv-
ing overeating and a sedentary lifestyle. An analysis of 17 cross-sectional studies found that people
who were obese were more likely to have depression than people with healthy weights (de Wit et al.
2010). The studies did not determine whether obesity increases the risk of depression or depression
increases the risk of obesity. A meta-analysis of 15 long-term studies that followed 58,000 partici-
pants for up to 28 years found that people who were obese at the start of the study had a 55% higher
risk of developing depression by the end of the follow-up period, and people who had depression
at the start of the study had a 58% higher risk of becoming obese (Luppino et al. 2010). Possible
mechanisms linking obesity and depression include inflammation, changes in the hypothalamic–
pituitary–adrenal axis, insulin resistance, and social or cultural factors.
5.3.6 Obesity and Infertility

Polycystic ovarian syndrome (PCOS) was classically characterized by obesity, hirsutism, and infer-
tility. It has been attributed to compensatory hyperinsulinemia due to insulin resistance. Elevated
insulin levels have been thought to promote hyperandrogenism. However, physiological insulin
infusion has no effect on androgen levels in PCOS (Gonzalez 2015). The cause of hyperandrogen-
ism and ovarian dysfunction in the 30–50% of women with PCOS who are of normal weight and
lack insulin resistance remains unexplained. Inflammation may also play a role in insulin resistance
when present in PCOS, and visceral fat may not have been detected in those studies of PCOS where
BMI is the sole measure of obesity utilized. Inflammation in PCOS is likely the result of excess
abdominal adiposity.
The association between obesity and female infertility is represented by a classic U-shaped curve.
In the Nurses’ Health Study, infertility was lowest in women with BMIs between 20 and 24, and
increased with lower and higher BMIs (Rich-Edwards et al. 2002). Eating disorders, malnutrition,
and excessive exercise can all lead to infertility. About 25% of ovulatory infertility in the United
States may be attributable to obesity. During pregnancy, obesity increases the risk of early and late
miscarriage, gestational diabetes, preeclampsia, and complications during labor and delivery (Huda
et al. 2010). It also slightly increases the chances of bearing a child with congenital anomalies
(Stothard et al. 2009). One small randomized trial suggests that modest weight loss improves fertil-
ity in obese women (Clark et al. 1995).
In normal-weight males, the incidence of low sperm count and poor sperm motility were each
increased with increasing BMI, by 5.3% and 4.5%, respectively. In obese men, these fertility param-
eters were increased by 15.6% and 13.3%, respectively (Hammoud et al. 2008). In contrast, a study
by Chavarro and colleagues (2010) found little effect of body weight on semen quality, except at the
highest BMIs (above 35), despite major differences in reproductive hormone levels with increasing
weight.
Erectile dysfunction may also be affected by obesity. Data from the Health Professionals
Follow-Up Study (Bacon et al. 2006), the National Health and Nutrition Examination Survey
(NHANES) (Saigal et al. 2006), and the Massachusetts Male Aging Study (Johannes et al. 2000)
indicate that the odds of developing erectile dysfunction increase with increasing BMI. Of note,
weight loss appears to be mildly helpful in maintaining erectile function (Wing et al. 2010).
Obese women are less likely than normal-weight women to report having had a sexual partner
in the preceding 12 months, but the prevalence of sexual dysfunction is similar in lean and obese
women (Bajos et al. 2010). Obese women have been found to have lower scores on the Female
Sexual Function Index and problems with arousal, orgasm, and satisfaction (Esposito et al. 2007).
5.3.7 Obesity and Pulmonary Diseases: Sleep Apnea and Asthma

Obesity very commonly leads to sleep apnea and impaired sleep quality, which can in turn per-
petuate overweight and obesity. Concomitant treatment of sleep apnea with continuous positive
airway pressure can both improve sleep quality and aid in weight reduction. Sleep questionnaire
responses and the presence of snoring can be used to screen for sleep apnea in the obese patient
(Raman et al. 2016).
Obesity impairs respiratory function via mechanical and metabolic pathways. Accumulation of
abdominal fat can limit the descent of the diaphragm and lung expansion. Visceral fat can also
reduce the flexibility of the chest wall, reduce respiratory muscle strength, and narrow airways in
the lungs (McClean et al. 2008). Cytokines generated by the low-grade inflammatory state that
accompanies obesity may also impede lung function.
In a meta-analysis of seven prospective studies that included 333,000 subjects, obesity was a
major contributor to obstructive sleep apnea, which is estimated to affect approximately one in five
adults. One in 15 adults has moderate or severe obstructive sleep apnea. This condition is associated
with daytime sleepiness, accidents, hypertension, cardiovascular disease, and premature mortality.
Between 50% and 75% of individuals with obstructive sleep apnea are obese (McClean et al. 2008).
Clinical trials suggest that modest weight loss can be helpful when treating sleep apnea (Tuomilehto
et al. 2009; Nerfeldt et al. 2010).
Asthma is now understood to be an inflammatory disease, with the bronchoconstriction that

occurs no longer being the only therapeutic target. Obesity most likely, through inflammation, is
linked to asthma pathophysiology (Beuther and Sutherland 2007).
5.3.8 Obesity in Aging and Brain Health

A recent systematic review and meta-analysis suggests a positive association between obesity in
midlife and later dementia, but the opposite in late life (Pedditizi et al. 2016). The influence of obesity
on dementia has been a subject of controversy for many years. A meta-analysis of studies suggest that
obesity and central obesity seem to play an independent role in the etiology of Alzheimer’s disease
and in some cases of vascular dementia, even when sociodemographic, lifestyle, and health-related
comorbid factors are controlled (Beydoun et al. 2008). Overall, there seems to be a U-shaped relation
between BMI status and dementia, with both obesity and underweight increasing the risk of demen-
tia. Whether weight reduction in midlife reduces risk is worthy of further study. A short-term healthy
lifestyle program combining mental and physical exercise, stress reduction, and healthy diet was
associated with significant effects on cognitive function and brain metabolism (Small et al. 2006).
5.3.9 Obesity and Musculoskeletal Disorders

Among the most common complaints of markedly obese patients are knee pain, back pain, and
ankle pain. Excess weight places significant mechanical and metabolic strains on bones, muscles,
and joints. Osteoarthritis of the knee and hip is positively associated with obesity, and obese patients
account for one-third of all joint replacement operations (Anandacoomarasamy et al. 2008). Obesity
also increases the risk of back pain, lower limb pain, and disability due to musculoskeletal conditions.
5.3.10 Obesity and Fatty Liver Disease

Nonalcoholic fatty liver disease is the most common liver disease worldwide, progressing from
simple steatosis to fibrosis and nonalcoholic steatohepatitis (NASH). As NASH advances, it leads in
some cases to cirrhosis and hepatocellular carcinoma (Katsiki et al. 2016). Inflammation, oxidative
stress, and insulin resistance are involved in the development and progression of these conditions.
Fatty liver has been associated with obesity, dyslipidemia, hyperglycemia, and hypertension.
5.3.11 Gallstones and Gout

A number of additional health outcomes have been linked to excess weight. These include the devel-
opment of gallstones in men (Tsai et al. 2004) and women (Stampfer et al. 1992), as well as gout
(Choi et al. 2005; Bhole et al. 2010).
5.3.12 Bottom Line on Obesity and Health

Obesity harms virtually every aspect of health, from contributing to chronic conditions, such as
diabetes and cardiovascular disease, to interfering with sexual function, breathing, mood, and social
interactions. Prevention of obesity—beginning at an early age and extending across the life span—
could vastly improve individual and public health, reduce suffering, and save billions of dollars each
year in health care costs.
5.4 DETERMINING THE OBESITY PHENOTYPE

This chapter deals with both overweight and obese patients who are obviously overweight or
obese. That weight is most likely a combination of excess fat and increased lean body mass in
most obese and obviously overweight patients. As we saw in Chapter 2, many individuals who
appear to be of normal weight have excess body fat. Attempts to divide up the obese, overweight,
normal weight with excess body fat, and overweight with excess lean body mass fall under the
general area of obesity phenotypes or body shape. The latter classifications have been expanded
by the clothing industry into a large number of fashion shapes, such as rectangles, triangles, pear
shape, and apple shape, for the purposes of design. That type of classification is not what will be
reviewed here. Rather, the impact of obesity phenotypes on obesity-associated diseases and the
need to customize and personalize approaches to treatment and prevention are the focus of the
balance of this chapter.
While BMI has generally been the most widely used tool to screen for obesity, about 10–25%
of those patients classified as obese (Bluher 2010) and a subgroup of clearly obese patients (Soverini
et al. 2010) are not affected by metabolic changes, such as those defining MetS, type 2 diabetes, or
hyperlipidemia (Brochu et al. 2001; Karelis et al. 2005; Stefan et al. 2008; Wildman et al. 2008).
These metabolically healthy obese patients are insulin sensitive and have increased lean body mass.
They typically have normal blood pressure, a favorable lipid profile, a lower proportion of visceral
fat, less liver fat, and a normal glucose metabolism despite having excess body fat (Reaven et al.
1996; Ruderman et al. 1998; Sims 2001; Karelis et al. 2004a,b; Aguilar-Salinas et al. 2008; Lynch
et al. 2009; Messier et al. 2010). At the other end of the spectrum, there are many normal-weight
individuals with metabolic changes characteristic of obesity (Conus et al. 2007). These patients are
called “metabolically obese, normal-weight individuals.” Thus, obesity consists of different sub-
types with different metabolic profiles (Figure 5.3).
The survey from Figure 5.3 included 205 individuals (80 men and 125 women) of normal weight
who had MetS and 94 obese individuals (27 men and 67 women) without MetS (Pajunen et al. 2011).
MetS was defined by three or more of the following five components: increased waist circumference
(≥94 cm in men and ≥80 cm in women), hypertriglyceridemia (≥1.7 mmol/L), HDL cholesterol level
of <1.0 mmol/L in men or <1.3 mmol/L in women, elevated blood pressure (systolic ≥130 mmHg
and/or diastolic ≥85 mmHg) or antihypertensive drug treatment or history of hypertension, and
elevated fasting plasma glucose of ≥5.6 mmol/L or drug treatment.
A metabolically healthy but obese phenotype was observed in 9.2% of obese men and in 16.4%
of obese women (Figure 5.3). Among all participants, the prevalence of healthy obesity was 2.0%
among men and 4.5% among women. Of the normal-weight individuals, 20.4% of men and 23.8% of
women had MetS. These data clearly demonstrate that it is important to determine the metabolic
phenotype in patients regardless of whether BMI categorization indicates normal weight, over-
weight, or obesity.
100 100
90.8
90 90 83.6
79.6 76.2
80 80
69.7
70 70
61.5
Percentages
Percentages
60 60
50 No metS
50
38.5 MetS
40 40
30.3
30 30
20.4 23.8 16.4
20 20
9.2
10 10
0 0
BMI<25 BMI 25–29.9 BMI>=30 BMI<25 BMI 25–29.9 BMI>=30
(a) (b)
FIGURE 5.3 Prevalence of persons with and without MetS within each BMI category among men (a) and
among women (b) (total 100% within the BMI class). (Reprinted from Pajunen, P. et al., BMC Public Health,
11, 754, 2011.)
Having tackled the metabolic aspects of obesity phenotypes based on weight or BMI, it is also
important to consider what the patient perceives. The body image is the perception of patients about
their weight, which refers to their ability to estimate the size and shape of the body. The difference
between a person’s perception of his or her body size and ideal body size is related to body satisfac-
tion (Dounchis et al. 2001). Body image dissatisfaction and distortion are common among obese
patients, so a reality check based on body composition measurements is warranted, along with a
discussion of an appropriate target weight.
Body weight and body image are often considered as one by patients, but they can be very dif-
ferent. Assessments of weight loss expectations by asking subjects to indicate their “dream” weight,
weight values that they would be “happy” with, body weights they would consider “acceptable,” and
those they would be “disappointed” with at the end of a weight loss intervention have been used to
study the impact of body image on the success of weight loss and weight maintenance (Foster et al.
1997). Having a realistic body image is a pretreatment variable significantly associated with suc-
cessful weight loss and weight maintenance (Traverso et al. 2000; Schwartz and Brownell 2004).
Unrealistic weight loss expectations can result in weight management failure and dropping out of
treatment regimens (Fowler et al. 1985; Bennett and Jones 1986; McLean et al. 2016).
Negative body image and quality of life are closely linked with obesity (Brown et al. 1990), and
compared with normal-weight individuals, obese patients are more dissatisfied and preoccupied
with physical appearance, and avoid more social situations because of their appearance concerns
(Ramirez and Rosen 2001). Overall, body image dissatisfaction has been described as the most
consistent psychosocial consequence of obesity (Sarwer et al. 2005).
5.5 ESTIMATING ENERGY EXPENDITURE AND PROTEIN REQUIREMENTS

One of the great advantages of bioelectrical impedance analysis is that the amount of lean mass is
measured directly with an accuracy of about 95%. It is sometimes called fat-free mass, and it is the
only directly measured body composition parameter, since lean mass is about 70% water, which
conducts electricity, while fat is an insulator that acts as an electrical capacitor. All the other esti-
mates, such as percent body fat, are derived from the total body weight and the lean body mass
through calculations. The algorithms for even lean body mass differ among different manufactur-
ers, and all these equations incorporate weight, height, age, and gender.
Nonetheless, the lean body mass serves as a means to provide personalized information to
patients, including estimates of resting energy expenditure, rate of weight loss on set number of
calories eaten each day, and a range of target weights based on body fat, which is approximate.
The resting energy expenditure is directly related to lean body mass, so that 1 pound of lean mass on
average burns 14 calories/day, or about 30 calories/kg. Since measurement of lean body mass assumes
that lean mass is about 70% water, fluid is erroneously included in the lean body mass when there is
edema. Therefore, in obese patients with significant edema, the lean body mass will be overestimated.
In all obese patients, it is a good policy to estimate the resting energy expenditure and protein
requirements on both the first and second visit. Usually, there is a diuresis that occurs secondary to
a decrease in insulin levels. Insulin, when elevated, acts to retain salt and water, and many obese
patients will lose between 5 and 10 pounds of weight in the first week of a calorie-restricted diet
due to salt and water diuresis, with each quart or liter of water weighing 2 pounds, or about 1 kg.
As water is measured as lean body mass, there can be an increase in percent body fat noted on a
bioelectrical impedance measure at the second visit, as water mass decreases more than fat mass.
It is important to explain what has occurred to the patient and reassure him or her that the second
measurement will be used going forward.
It is possible to predict the rate of weight loss once the lean body mass has been measured and the
resting energy expenditure calculated after the first week (Korth et al. 2007). For every 500 calories
below the resting energy expenditure recommended in the nutrition intervention, there will be a
weight loss of about 1 pound/week.
The resting energy expenditure can also be helpful in communicating to patients that you under-
stand their weight history. A female patient with a resting energy expenditure of 1200 calories/day
is someone who has dieted religiously with poor weight loss results, but may not have added in
daily exercise to boost her metabolism. On the other hand, a large man who burns 2500 calories/
day at rest and loves to eat red meat may be someone who has no trouble losing weight but has never
worked very hard at maintaining a healthy body weight over time. By simply cutting his steak in
half, he can lose 15 or 20 pounds, but inevitably, the weight is regained as his eating habits return
over time, to include high-fat, high-sugar foods. The concept that he can get away with eating more
calories due to a high resting metabolic rate contributes to the notion that he is not vulnerable to
gaining weight.
This collection of potential educational information for patients derived from a simple measure-
ment will also help establish your expertise in the eyes of your patients. The greater their confidence
in your guidance, the greater is the likelihood that they will be successful in a specific weight man-
agement intervention.
5.6 PROVIDING STRUCTURED DIET PROGRAMS THAT INCLUDE CHOICE

For many obese patients, a highly structured diet using meal replacements and portion-controlled
food is desirable. While for many individuals, including food is essential, as a single meal, the idea
that you are simply going to get someone to lose large amounts of excess body fat with minimal
changes to his or her diet and lifestyle is not realistic.
A highly structured program will lead to the most predictable rates of weight loss and provide
an opportunity for education on weight maintenance after weight loss. While some patients will
tolerate a diet of complete meal replacements classically used in very low-calorie diets, others want
at least one meal per day. The experience of more than 2000 patients with obesity, prediabetes, or
diabetes demonstrated comparable rates of weight loss using the diet program described below (Li
et al. 2014).
At the University of California, Los Angeles (UCLA) Risk Factor Obesity Clinic, we utilize two
different meal replacements. One of the formulas provides 100 calories with 15 g of protein, 10 g
of carbohydrate, and no fat, and the other provides 142 calories with 25 g of protein, about 10 g of
carbohydrate, and no fat. Using these formulas, the following typical examples apply:
• A woman, 62 inches tall, weighing 150 pounds, with 100 pounds of lean body mass. At a
resting energy expenditure of 1400 calories/day, she would be prescribed seven servings
of the 100-calorie supplement, delivering 700 calories and 105 g of protein. She would
be expected to lose about 1.5 pounds/week to a target weight she would help to choose of
between 120 and 130 pounds.
• The same woman returns 3 weeks later and complains that she can no longer live on shakes
alone. She wants to have one meal. Her plan would now shift to four meal replacements of
100 calories each and one meal of about 500 calories. This would reduce her rate of weight
loss to 1 pound/week. The meal should be structured to include a 25 g portion of protein,
such as 4 ounces of chicken, tofu, or fish; 2 cups of steamed vegetables; and a salad sea-
soned with lemon or rice vinegar. An alternative for some patients will be a frozen dinner
and salad.
• A man, 71 inches tall, weighing 240 pounds, with a lean body mass of 175 pounds, would
be prescribed 175 g of protein from seven 25 g protein shakes, each at about 140 calories,
for a total calorie intake of about 1000 calories/day. At a resting energy expenditure of
2450 calories/day, he will lose about 3 pounds/week to a target weight of 210–220 pounds.
• This man simply cannot stand having just liquids after 1 week. However, given his high
resting energy expenditure, you have the ability to provide him with a food meal that is
carefully constructed with a 50 g portion of protein (8 ounces of chicken breast, turkey,
or ocean-caught fish), providing 280 calories, in combination with steamed vegetables and
a salad with rice or wine vinegar, providing about 500 calories in total. This would elimi-
nate two of the protein shakes, or 280 calories, making the net increase in total calorie
intake about 220 calories, which will only reduce the rate of weight loss by ½ pound/week.
Of course, exercise daily will increase lean body mass in men and reduce fat mass in com-
parison with simply restricting calories.
Once the target weight range is reached, the diet can be liberalized so that there is only one
shake per day taken at breakfast. Patients who regain their weight can reenter the very low-calorie
or low-calorie diet intervention multiple times and still expect to lose weight at the same rate as they
did initially (Li et al. 2007). This information can be very helpful to patients fearing failure after
multiple weight loss attempts. I usually tell them to plan to reenter if they regain their weight, noting
that Mark Twain reportedly tried to stop smoking 10 times. Attendance at weekly group meetings
and regular physical activity, as discussed in the next section, will help with weight maintenance
and internalization of new diet and lifestyle habits. In terms of diets for weight maintenance in
the long term, the DIOGENES trial has shown a high-protein, low-glycemic-index diet to lead to
weight maintenance over 6 months after an 8-week weight loss on a very low-calorie diet, while
high-protein, high-glycemic-index and low-protein with either high- or low-glycemic-index foods
led to weight regain (Aller et al. 2014).
5.7 LEISURE TIME PHYSICAL ACTIVITY AND EXERCISE

Reductions in energy expenditure, secondary to sedentary lifestyles, have been identified as a key fac-
tor in the obesity epidemic (Peters et al. 2002; Wareham et al. 2005). Both leisure time physical activ-
ity and exercise that are associated with bodily movement result in increased energy expenditure and
account for the variation in daily energy expenditure among individuals with similar lean body mass.
Given the reduction in the requirement for physical activity at work and for activities of daily
living over the past several decades (Church et al. 2011; Archer et al. 2013), exercise during leisure
time has become an important component of total physical activity and total daily energy expendi-
ture (Westerterp 2003). While physical activity includes leisure time and work-related or transport-
related movement, exercise consists of planned and structured physical activities (Caspersen et al.
1985). A recent meta-analysis showed that exercise and sport have a stronger association with mor-
tality than do occupational or transport-related physical activity (Samitz et al. 2011).
Aerobic exercise has been associated with an increase in energy expenditure in young adults
(Westerterp 2008). However, differences in exercise type should be considered in terms of both
energy expenditure during exercise and the differential effect on energy expenditure after exercise.
Aerobic exercise has been shown to increase resting energy expenditure for up to 19 hours after
exercise (Hunter et al. 2006), while resistance exercise has been associated with an increase in func-
tional capacity, which could secondarily lead to an increase in total energy expenditure by enabling
an increase in total physical activity (Hunter et al. 2000; Levinger et al. 2007).
An example of how lifestyle can affect physical activity is an Australian study of time spent sit-
ting in a car commuting (Sugiyama et al. 2016). Among 2800 participants in this study, prolonged
time spent sitting in cars, in particular more than 1 hour/day, was associated with higher total and
central adiposity and a more adverse cardiometabolic risk profile.
Twin studies of 10 pairs of twins showed a 31% higher amount of intra-abdominal fat measure by
MRI in inactive twins over the prior 3 years compared with active twins (Rottensteiner et al. 2016).
The only major component of daily energy expenditure that can be voluntarily influenced is
physical activity through the replacement of sedentary activities by various kinds of muscle motor
activity, from standing rather than sitting to walking, running, swimming, or bicycling. Walking or
bicycling instead of driving a car for short trips would expend additional calories while traveling
the same distance.
Despite the physiological increase in energy expenditure that occurs and the role that physical
activity plays in addressing obesity from a behavioral viewpoint, it appears to produce only mod-
estly increased weight losses beyond those caused by dietary measures alone, and these effects are
variable among different individuals (Stefanick 1993). In numerous studies where increased physi-
cal activity is the only intervention, or in which it was added to dietary restriction, the component
of weight loss ascribable to exercise has been modest (Hunter et al. 2010).
Despite the observations of small effects on weight loss, observational studies have developed
evidence that physical activity can help prevent weight regain after an initial sizable weight loss
(Schoeller et al. 1997; Klem et al. 2000; Wing and Hill 2001; Weinsier et al. 2002; Nelson et al.
2007). These studies examined the effects of exercise in people who had lost between 30 and
50 pounds with maintained weight over several years. These studies used the technique of doubly
labeled water, which depends on the ratio of carbon-14 and oxygen-18 measured in urine samples,
together with a measure of the respiratory quotient (RQ), which is the ratio of the carbon dioxide
production to oxygen utilization (Schoeller et al. 1997). This method measures total energy expen-
diture encompassing both changes in dietary intake and exercise. Extrapolation from these carefully
conducted studies has led to the concept that 60–90 minutes of moderate-intensity physical activity
per day may be necessary for weight maintenance after weight loss.
When writing an exercise prescription for moderate-intensity physical activity, it is important to be
able to be somewhat specific, rather than simply saying “exercise more.” One method for estimating
energy expenditure during physical activity is the metabolic equivalent (MET) (Ainsworth et al. 2000a).
One MET represents the energy expended while sitting quietly. Walking at 3 mph on a flat, hard surface
will lead to the expenditure of about 3.3 METs. Jogging or running on a flat surface at a pace in which
a mile is completed in about 12 minutes (about 5 mph) will expend approximately 8 METs (Table 5.1).
For example, a person who walked at 3 mph for 30 minutes would accumulate 99 MET-minutes
of credited activity, which over 5 days/week would total 495 MET-minutes. If the patient jogged at
5 mph for 20 minutes, he or she would accumulate 160 MET-minutes (8 METs × 20 minutes = 160
MET-minutes). He or she could do this higher level of activity for only 20 minutes on 3 days and
derive the same benefit. The advantage of dosing exercise recommendations in this way is that it
provides flexibility to patients in both meeting their needs and assessing the effectiveness of their
overall activities. While the subject has been previously discussed in terms of general recommenda-
tions for a healthy population, the intensity of the recommendation for the maintenance of weight in
the obese population requires greater attention. When combining moderate- and vigorous-intensity
activity to meet the exercise recommendations for prevention of weight regain, the minimum goal
should be in the range of 450–750 MET-minutes/week. These values are based on the MET range
of 3–6 for moderate-intensity activity and 150 minutes/week (3 METs × 150 minutes = 450 MET-
minutes and 6 METs × 150 minutes = 750 MET-minutes).
Obese patients should start at the lower end of this range at the beginning of any prescribed activ-
ity program and slowly advance to the higher activity levels as they become more fit.
Personalized lifestyle change is vital in facilitating a physical activity prescription over the long
term (Kahn et al. 2002). To achieve long-term changes in behavior, medical, behavioral, social, and
environmental factors need to be comprehensively addressed (Sallis et al. 2002). Obese individu-
als often have increased lean mass, but maintaining or increasing lean mass can help to maintain
energy expenditure after weight loss and will also have functional benefits on the activities of daily
living. Resistance training at least twice per week provides a safe and effective method to improve
muscular strength and endurance (Pollock et al. 2000). It is recommended that 8–10 exercises be
performed on two or more nonconsecutive days each week using the major muscles. A resistance
(weight) should be used that results in substantial fatigue after 8–12 repetitions of each exercise.
Primary care professionals can broaden their advice to patients beyond the traditional prescrip-
tive program based on medical clearance and supervision by encouraging them to accumulate
moderate-intensity physical activity. Different activities should be identified that meet each person’s
interests, needs, schedule, and environment, and take into consideration family, work, and social
TABLE 5.1
MET Values for a Variety of Physical Activities That Are of Light, Moderate, or Vigorous
Intensity
Light, <3.0 METs Moderate, 3.0–6.0 METs Vigorous, >6.0 METs
Walking Walking Walking, jogging, and running
Walking slowly around home, store, or Walking 3.0 mph = 3.3a Walking at a very brisk pace
office = 2.0a Walking at a very brisk pace (4.5 mph) = 6.3a
(4 mph) = 5.0a Walking/hiking at moderate pace and
grade with no or light pack
(<10 pounds) = 7.0
Hiking at steep grades and pack
10–42 pounds = 7.5–9.0
Jogging at 5 mph = 8.0a
Jogging at 6 mph = 10.0a
Running at 7 mph = 11.5a
Household and occupation Cleaning—heavy: Washing windows Shoveling sand, coal, etc. = 7.0
Sitting—using computer work at desk, or car, cleaning garage = 3.0 Carrying heavy loads, such as
using light hand tools = 1.5 Sweeping floors or carpet, bricks = 7.5
Standing—performing light work such vacuuming, mopping = 3.0–3.5 Heavy farming, such as baling
as making bed, washing dishes, Carpentry—general = 3.6 hay = 8.0
ironing, preparing food, or working Carrying and stacking wood = 5.5 Shoveling, digging ditches = 8.5
as a store clerk = 2.0–2.5 Mowing lawn—pushing power
mower = 5.5
Leisure time and sports Badminton—recreational = 4.5 Basketball game = 8.0
Arts and crafts, playing cards = 1.5 Basketball—shooting around = 4.5 Bicycling—on flat: Moderate effort
Billards = 2.5 Bicycling—on flat: Light effort (12–14 mph) = 8.0; fast
Boating—power = 2.5 (10–12 mph) = 6.0 (14–16 mph) = 10
Croquet = 2.5 Dancing—ballroom slow = 3.0; Skiing cross-country—slow (2.5 mph) =
Darts = 2.5 ballroom fast = 4.5 7.0; fast (5.0–7.9 mph) = 9.0
Fishing—sitting = 2.5 Fishing from riverbank and Soccer—casual = 7.0; competitive =
Playing most musical instruments = walking = 4.0 10.0
2.0–2.5 Golf—walking and pulling Swimming—moderate/hard = 8–11b
clubs = 4.3 Tennis singles = 8.0
Sailing boat, wind surfing = 3.0 Volleyball—competitive at gym
Swimming leisurely = 6.0b or beach = 8.0
Table tennis = 4.0
Tennis doubles = 5.0
Volleyball—noncompetitive =
3.0–4.0
Source: Adapted from Ainsworth, B. E. et al., Med. Sci. Sports Exerc., 32(9), S498–S504, 2000b; Haskell, W. L. et al., Med.
Sci. Exec., 39(8), 1423–1434, 2007.
a On flat, hard surface.
b MET values can vary substantially from person to person during swimming as a result of different strokes and skin levels.
commitments. It is also helpful to have options for travel, such as portable exercise bands, and strate-
gies for exercising indoors when there is bad weather. Materials for patient education and counseling
are available from the National Institutes of Health (U.S. Department of Health and Human Services
2006), the American College of Sports Medicine (2003), and the American Heart Association (2016).
For primary care professionals, the challenge is to increase their professional credibility with
patients in the areas of nutrition and exercise by advising patients to undertake physical activity
programs that are designed to overcome barriers to long-term adherence, using effective behavioral
management and environmental change strategies, so that more patients can benefit from a healthy
active lifestyle.
5.8 BEHAVIORAL STRATEGIES THAT WORK

Government advisory groups in the United States have recommended that clinicians screen all
adults for obesity and offer intensive multicomponent behavioral interventions to affected individu-
als, either by providing such treatment themselves or by referring patients to appropriate interven-
tions (Moyer 2012). Reimbursement for these services has been authorized by the U.S. Centers for
Medicare and Medicaid Services. Specifically, reimbursement is contingent on the provision of
intensive behavioral counseling to obese seniors in primary care practice delivered by physicians,
nurse practitioners, or physician assistants from the practice (Jacques et al. 2011). It was recom-
mended that practitioners provide brief (15 minutes) weekly counseling sessions for the first month,
followed by every-other-week visits for an additional 5 months. Patients who lose more than 3 kg in
the first 6 months (in these 14 sessions) are eligible for six additional monthly visits.
The provision of behavioral weight loss counseling in primary care practices has been met with
limited success, in most cases producing mean weight losses of only 1–3 kg in 6–24 months. These
modest weight losses were most likely secondary to the infrequent treatment contacts, typically
at monthly to quarterly intervals, as well as to the brief duration of visits, usually lasting only
10–15 minutes. This low-intensity behavioral treatment may be all that can be practically delivered
in busy outpatient practices.
On the other hand, studies with greater intensity in academic medical centers have produced
weight losses of 7–10%. It is not fair to compare the results of underfunded pilot studies con-
ducted in primary care with findings in well-funded research settings that may not be generalizable
(Leblanc et al. 2011).
A more practical approach for primary care practices may be remotely delivered, high-intensity
behavioral weight loss counseling. It has been demonstrated that 12 weekly telephone sessions of
20 minutes each, followed by monthly calls, induced a mean loss of 6.1 kg at 6 months and 4.6 kg at
24 months. These losses were similar to those found with face-to-face interventions that combined
both group and individual visits.
A number of other trials, outside of primary care practices, using telephone-based counseling
alone, have found results comparable to those of on-site interventions (Logue et al. 2005; Donnelly
et al. 2007; Perri et al. 2008). Remotely delivered lifestyle counseling, whether provided by a pri-
mary care practice or by a call center with which it has contracted, would appear to be a very con-
venient option for patients. More importantly, it would support primary care practices so that they
could offer intensive behavioral counseling without overwhelming practice schedules.
5.8.1 Widely Accepted Behavioral Strategies

Clearly, behavioral interventions are very personal, and what is appropriate for one person may not
be for another. Nonetheless, there are some general principles that apply to behavior change that
may already be familiar to you. However, the key to successful behavioral intervention is following
a stages of change or transtheoretical model for behavior change, popularized by Prochaska and
DiClemente (Velicer et al. 1990) and widely accepted in the psychology and social services com-
munity not only for obesity but also for smoking cessation, drug addiction, and alcoholism.
The stages of change are as follows: (1) precontemplation (unaware of the problem), (2) con-
templation (aware of the problem and wants to change), (3) preparation (intends to take action),
(4) action (practices the desired behavior), and (5) maintenance (works to sustain behavior change).
For stage 1, it is important to point out issues around obesity and overweight in a health context. The
psychosocial morbidity of obesity makes patients extremely sensitive, and leading a careful conver-
sation to draw out the awareness of the patient is helpful and is called motivational interviewing in
the obesity literature. For stage 2, there is a common 10-point scale used to determine readiness
to change. For stage 3, it is important to establish a date to begin the new changed behaviors. For
stage 4, the actions have to be very simple. Sometimes, there is too much nutrition information
given, so that patients are confused as to what to do. I typically provide them with a “trigger foods
list” that contains the foods they should not eat and, together with a dietitian, develop a daily diet at
a personalized calorie level in the form of a daily menu of foods to eat.
As noted in Figure 5.4, relapse can occur at any one of the stages of change. Addiction theory,
which includes relapse prevention, plays a role in the maintenance of new behaviors that promote
weight maintenance. Relapse prevention incorporates a number of approaches, but is based on the
idea that behavior lapses are extremely common and have an antecedent cause and a consequence.
Charting lapses is the first step in prevention. The ABC theory of antecedents, behaviors, and con-
sequences can help patients identify the motivators of the lapse. A series of lapses is called a relapse,
and continued relapses lead to collapse.
Even when collapse occurs, patients should be encouraged to initiate the process again by get-
ting ready to change. As already reviewed, there is no reason that patients will not be able to change
again. It is helpful to indicate that one of the hardest things for patients to accomplish is behavior
changes, and that multiple attempts are not uncommon. Allaying fear of failure is an important part
of encouraging patients to undertake a new diet and lifestyle for weight management.
Cognitive behavioral therapy engages the thinking brain to control emotional urges around eat-
ing. This often requires blending nutritional and behavioral approaches. While there is some dietary
composition research reviewed in Chapter 2 with regard to the benefits of a high-protein and low-
glycemic-index diet in promoting weight maintenance after weight loss, there is clearly much more
at work in maintenance. Psychology trumps physiology as patients snack on high-fat, high-sugar
foods out of habit, in response to stress, or simply because of boredom. Teaching patients to get into
a daily rhythm of eating and exercise in which they recognize hunger and thirst normally is impor-
tant. Hunger is driven by gut hormones and nutrient signals and is heralded by stomach rumbles and
a sensation of emptiness. Stimulus control, stress reduction, and social support are important com-
ponents of an integrated behavioral approach. Stimulus control is simply planning appropriately for
future events. The simple example is that if you know that you are going to step on a cold floor in the
morning, put out slippers at the side of your bed the night before. In planning the diet, packing foods
for trips or deciding on healthy dinners in advance to avoid excessive restaurant eating or fast-food
eating at the last moment is an important strategy for weight maintenance.
Much snacking behavior is simply an attempt to avoid the natural feelings of hunger. Sometimes,
if the snack is healthy, such as nuts or a small protein snack in the afternoon, this can be helpful in
Pre-
Contemplation
contemplation
Relapse
can happen at any time
Maintenance Preparation
Action
FIGURE 5.4 Stages of change. (Adapted from Prochaska, J. O., and C. C. DiClemente, J. Consult. Clin.
Psychol., 51(3), 390–395, 1983 and described in detail in the text.)
maintaining a daily pattern of eating. On the other hand, night snacking, which occurs in about a
quarter of obese patients, is associated with excessive snack food consumption. The food industry
over the last 40 years has promoted snacking through the development of many snack foods listed
in the trigger food list:
1. Colas: A can of cola or soda has 150 calories; a big drink has more than 600! Have plain
water or mineral water with a slice of lemon or lime. Have fruit instead of fruit juices or
flavor water with juice to reduce calories, but recognize that some fruit juices can provide
phytonutrients (tomato, pomegranate, and orange juices), in addition to vitamins, minerals,
and water. Fruit juices are often only partially made with fruit juice. Some guava juices are
only 15% juice, but have high-fructose corn syrup added for sweetness so that they provide
150 calories in 8 ounces. Using 100% fruit juices is a way to avoid this issue.
2. Snack chips and movie popcorn: A small bag of potato chips or corn chips can have as
many as 400 calories. At a restaurant, a basket of corn chips can have as many as 550 calo-
ries. Movie popcorn with added oil can have 1200 calories in a large serving. Air-popped
popcorn will have much fewer calories.
3. Bread and pastries: There are more than 1200 calories in the typical loaf of bread. Choose
a high-fiber bread with about 80 calories/slice. Bread should be limited to one or two slices
per day. Ordering bread before a restaurant meal and then ordering a second serving is a
very common stress-related behavior.
4. Frozen yogurt, ice cream, cakes, and pastries: These desserts add lots of extra calories
as fat and sugar. Even the fat-free versions pack in many extra calories as sugar with too
little protein. Mixed fruits are an excellent dessert choice even when dressed with a small
amount of chocolate or cream.
5. Cheese and pizza: Hard cheese has up to 80% fat, and even nonfat cheese is 80 calories/
slice. American pizza is a popular trigger food composed largely of fat and refined carbo-
hydrates that is sold based on the taste provided by added oil, salt, and sugar with little pro-
tein. In Italy, thin-crust pizza made without the added oil of deep-dish pizza is a healthier
alternative. This type of pizza is also available in restaurants in the United States, but not
typically in large fast-food pizza franchises.
6. Red meat and fatty fish: One of the easiest ways to reduce excess calories is by limiting
consumption of red meat and fatty fish. Red meat includes veal, beef, pork, and lamb. One
14-ounce cut of prime rib has about 1500 calories and 50 g of fat. That is the total of fat and
calories many women require daily. A fast-food burger, milkshake, and fries have about
1300 calories and about 50% fat calories. Substituting skinless white meat of chicken or
white meat of turkey for red meat will reduce calories while maintaining protein intake. If
it will help those who enjoy savory tastes, suggest putting steak sauce on chicken to imitate
the taste of seasoned red meat. Dark poultry meat is higher in fat than white meat and can
have as much fat as some types of red meat. Dark poultry meat is included in many restau-
rant dishes to reduce tastes, and is preferred in many Asian recipes. However, white meat
of chicken or turkey or firm tofu is easily incorporated into many recipes without reducing
taste. Salmon, trout, and catfish that are farm fed are high in total fat. While the content of
omega-3 fatty acids is similar in farmed and ocean-caught salmon, the farmed variety have
twice as much omega-6, in addition to omega-3. Substituting halibut, cod, sole, canned
white tuna packed in water, orange roughy, red snapper, or Hawaiian fish will reduce calo-
rie and fat intake. Shrimp, scallops, lobster, and crab are also low in fat and have healthy
omega-3.
7. Mayonnaise, margarine, and butter: There is no daily margarine requirement. Even the
fat-free varieties (like ultra-fat-free margarine) are 100% fat. According to the law, these
can be labeled as fat-free because they have less than 0.5 g of fat/serving. Reducing
bread intake, which can be a trigger food, is important, but as a regular behavior, adding
margarine, mayonnaise, or butter to bread adds little additional taste and needless extra
calories.
8. Salad dressing: Chinese chicken salad, prepared in many restaurants with dressing, can
provide up to 1000 calories. Both creamy and oil-based salad dressings provide, on aver-
age, 150 calories and 10–20 g of fat/ounce. Dressings, including so-called low-fat varieties
add significant calories to salads, and their portion control is often problematic. Balsamic
vinegar, rice vinegar, lemon, and wine vinegar are good alternatives. Salads with dark
green lettuce, tomatoes, alfalfa sprouts, green pepper, and other vegetables will add taste
variety, so the taste of the salad is not dependent on salad dressing.
9. Rice, beans, and nuts: Rice and beans both provide about 250 calories/cup. Substituting
seasoned vegetables without butter for rice will reduce calories. Peanuts and some other
nuts can be a trigger food, depending on the context in which they are eaten. Having
2 ounces of pistachios, almonds, peanuts, or walnuts as a snack is a healthy choice as long
as there is a small portion package with listed calories. However, having large portions of
rice, beans, or nuts can add calories in significant amounts to the diet.
5.9 FOLLOW-UP AND SOCIAL SUPPORT

Follow-up of patients with frequent contact is one of the greatest challenges for primary care weight
management. Self-help and group support programs directed by educated lay health coaches are a
resource that can be employed to address this vexing issue. The increasing prevalence of obesity and
overweight has been mirrored by a parallel increase in the number of programs utilizing group sup-
port. Research evaluating these programs is limited compared with the large numbers of individuals
participating and the research available on weight management in clinical settings.
Weight Watchers was incorporated in 1963 to become a commercial weight loss program based
on groups of individuals coming together for self-help. As it developed, Weight Watchers incorpo-
rated a structured diet and exercise plan within a strong behavioral program designed by experts
in the field. Weight Watchers maintained a fee schedule affordable to lower- and middle-income
persons. Early in its history, Weight Watchers became a convenient database for researchers who
were no doubt attracted by its large membership (Misovich 1973; Stuart and Guire 1978; Hall et al.
1986; Andreen and Kohler 1992). Evaluative research of the program progressed from descriptive
reports of participant weight loss (Williams and Duncan 1976; Lowe et al. 2001) to a short-term
(4 weeks) study of weight loss by program participants compared with a self-help group (Lowe et
al. 1999), and finally to a randomized controlled study reporting results at 26 weeks and 2 years
(Heshka et al. 2000, 2003).
Take Off Pounds Sensibly (TOPS) was founded in 1948, providing peer group support to over-
weight people. It does not advocate any particular diet, leaving that decision to the participant and
his or her physician. TOPS has grown to include 10,300 chapters with more than 200,000 members.
Strictly speaking, TOPS is not a commercial program because it is a nonprofit organization whose
member fees ($20.00 per year in the United States) are used to pay organizational expenses and obe-
sity research (to date, $5.4 million has been spent to fund obesity research by well-known basic and
clinical scientists). The program consists of weekly meetings, which include a weigh-in, followed
by a group discussion during which members talk about their weight loss efforts and give each other
encouragement to continue.
In 1970, Stunkard published a descriptive study of the weight loss achieved by 485 members
enrolled in 22 chapters in West Philadelphia (Stunkard et al. 1970). This study had two interesting
findings: (1) 28% of TOPS participants lost more than 20 pounds, roughly equal to the weight loss
reported in the literature up to that time by medical programs, and (2) there was wide variation in
the average weight loss of individual chapters, suggesting that an unidentified program component
might be playing a part in the success or lack of success by individual chapters. However, this was
a cross-sectional study of active participants, saying little about the longer-term success of active
participants or of those who chose to drop out. Nevertheless, the data seemed to indicate that TOPS
was as successful as medically based programs. The variability in the success rate of individual
chapters was thought to possibly reflect important interchapter differences in program content and
presentation that, if identified, could provide insight on ways to improve the efficacy of weight loss
programs.
A follow-up study of the same chapters published 4 years later (Garb and Stunkard 1974) cast a
different light on the success of the TOPS program, and dampened hope that an analysis of inter-
chapter variability (noted in the first study) would lead to new insights on ways to structure more
effective weight loss programs. In this study, the authors found that the average weight loss of active
members was similar between the earlier and later studies (15 and 14.2 pounds), but that dropouts
were very high, 47% at 1 year and 70% at 2 years. Dropouts were also found to lose a lesser amount
of weight than those who remained with the program. Thus, the success of active participants did
not reflect the overall success of the program. The second survey showed less variability in weight
loss between chapters. Also, the rank order of chapters had changed from the first survey. Thus, it
appeared that the differences in weight loss between chapters were not due to programmatic dif-
ferences, but rather to differences in the characteristics of their participants. Although these two
studies do not substantiate the weight loss efficacy of the TOPS program for most of its enrollees, it
should be said that TOPS is one of the least expensive programs available to people seeking support
in losing weight.
Herbalife International was founded in 1980 and distributed weight management products,
including meal replacements, through direct sales methods. Beginning in 2001, Dr. Enrique Varella,
a college professor and independent businessman with Herbalife International, originated the idea
of a nutrition club to enable groups of up to about 20 individuals to afford to consume a daily meal
replacement shake in a group setting, even if they could not afford to buy the usual product contain-
ing about 30 servings of the product. As this model evolved, it became clear that many subjects who
experienced positive results wanted to start their own clubs. The club directors would train them in
the preparation of shakes and proper social interactions in the clubs, and the number of clubs grew
progressively. A unique feature of the club is that individuals do not pay for product directly. Rather,
they join the club for a daily affordable fee comparable to what would have been spent on a high-fat
breakfast. A nutrition education program is currently being pilot tested in Mexico that involves sim-
plified education on general public health and nutrition. The number of clubs is currently approxi-
mately 100,000 worldwide. Herbalife members from other countries have come to Mexico to learn
how to establish this type of club. The clubs grow organically, with high rates of retention in the long
term addressing one of the key deficits of earlier versions of group weight loss programs.
These group programs are community resources for referral of weight management patients in
primary care. Alternatively, these groups could be started under the auspices of the primary care
practice in unused space in the office on nights and weekends. This approach combines the social
support provided by these group programs with medical supervision.
Individual-focused education strategies have been limited in effecting behavior change and
improving health outcomes (Bouchard 2008). Despite numerous preventive efforts regarding dietary
behavior and chronic diseases, obesity and associated chronic conditions continue to increase in
prevalence. Identifying unhealthy behaviors and developing educational strategies to change fail to
include contextual and environmental influences (Bouchard 2008; Misra and Khurana 2008; Fleisch
et al. 2012; van Vliet-Ostaptchouk et al. 2012; Muller et al. 2015; World Obesity Federation 2016).
Yet, few studies have investigated individuals’ perceptions of the relationship between their environ-
ment and diet and physical activity behaviors (Bouchard 2008). A number of groups have recognized
the impact of cultural context and socioeconomic factors in obesity. Figure 5.5 summarizes one such
effort attempting to clarify the relationship between the environment and lifestyle behaviors.
The framework shown in Figure 5.5 organizes the various factors working on the individual
obese or overweight patient, including multiple levels where social support has influences on eating
behavior and physical activity.
Framework: determinants
of physical activity and
eating behavior
Distal
leverage points
Proximal
leverage
Lifest points
yle Behavioral
settings
Enablers
of choice
Social
Cultural
Psychobiologic
core
tyle
Lifes
FIGURE 5.5 Determinants of physical activity and eating behavior. (Reprinted from Booth, S. L. et al.,
Nutr. Rev., 59 (3 Pt. 2), S21–S39, 2001.)
We have extensively discussed the psychobiological core of the individual. The factors in this
core include the genetically programmed metabolism and behaviors related to eating and physi-
cal activity. Early conditioned behaviors and experiences can lead to identifiable behavioral and
metabolic phenotypes expressed within a given environment. The psychobiologic core also includes
current health conditions.
The cultural core includes personal values and beliefs that are influenced by cultural factors and
immediate social and cultural settings.
The societal core includes how society views the individual and how the individual views soci-
ety. In other words, how society views the individual also influences how the individual views
himself or herself.
Enablers of choice are the most proximal factors affecting food choices and physical activity and
are seen as barriers to change.
Current lifestyle is a mixture of the present physical activity and eating behaviors, as well as the
aspirational behaviors. Therefore, these are also the factors that are the focus of lifestyle change.
Behavior settings comprise the physical and social settings in which physical activity and eating
behaviors take place and where choices are made within a situational context.
Proximal leverage points include controllers of the structure and features of the microenviron-
ment that affect the physical activity and eating behavior choices.
Distal leverage points include the behavior settings and environments influenced by additional
direct or indirect factors, for example, snack foods that consumers purchase or are exposed to,
along with the laws, policies, economics, and politics affecting their sale. The distal leverage points
also include media effects on attitudes, beliefs, and knowledge about eating behaviors and physical
activity.
This is one of many such models, but it displays the complexity of individual behavior and
many of the reasons our medical prevention and treatment models are not as successful as we
would like in many patients. The primary care practice is only one of many influences, but the
hope is that providing social support and follow-up will help many patients change their lifestyle
behaviors.
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6 Evolution of Type 2
Diabetes Mellitus
6.1 INTRODUCTION
While the majority of obese and insulin-resistant individuals do not develop type 2 diabetes mellitus
(T2DM), it is estimated that 20% or more of obese individuals will develop type 2 diabetes (T2DM)
in their lifetime. This chapter provides the background science on how those who develop T2DM
or “diabesity” differ from the majority of obese individuals. Diabetes and prediabetes affect half of
the population of the state of California (Babey et al. 2016) and about half the population in China
(Xu et al. 2013). These statistics are likely to be repeated elsewhere in the world and represent both
an economic and a global health disaster in the making. The ability of diet and lifestyle, in combi-
nation with the long-established, off-patent, and safe drug metformin, to reduce the rate of progres-
sion of T2DM with benefits on cardiovascular mortality will be the emphasis of the intervention
approach recommended here. The issues previously reviewed in Chapter 2 on dietary recommenda-
tions and in Chapter 5 on obesity treatment will not be repeated here, but those considerations fully
apply to the individuals with obesity who are at risk of T2DM.
Insulin resistance is very common and may have benefits for the adaptation to starvation.
However, individuals predisposed to T2DM have additional factors that mediate the risk to develop
T2DM, including reduced pancreatic β-cell mass at birth or in childhood, which when faced with
the ongoing demand for insulin related to hyperglycemia results in the death of β-cells and ulti-
mately leads to T2DM. Predispositions to oxidant stress and inflammation also likely play a role at
a cellular and systemic level (Marseglia et al. 2015).
Analytical methodologies such as genetic profiling and genome-wide scans have largely failed to
establish a genetic cause for most T2DM, while risk factors are clearly recognized. Age, family his-
tory of diabetes, gestational diabetes, obesity, physical inactivity, hypertension, and hyperlipidemia
are all risk factors for the development of T2DM. While the genetic findings are still inconclusive,
there is an appreciation for the role of insulin-associated polypeptide (IAPP), inflammation, obesity,
oxidant stress, and toxicity from glucose and lipids in promoting the demise of β-cells and the devel-
opment of diabetes. In this chapter, the genetic, social, economic, and nutritional factors increasing
risk are reviewed, with the hope that this knowledge will lead to earlier screening and intervention
with nutrition and increased physical activity to help prevent progression to diabetes.
6.2 SOCIAL AND ECONOMIC DETERMINANTS OF RISK

Social and economic factors driving the diabetes epidemic globally are also contributing to an
increase in the prevalence of T2DM. Existing data support the concept that the global increase in dia-
betes prevalence is due to macroeconomic and lifestyle factors associated with the observation that
for the first time in human history, there are more overweight than underweight people in the world.
The global nutrition transition has resulted in a greater number of overweight than underweight
individuals in most lower- and middle-income countries around the world, especially in urban
areas (Mendez et al. 2005; Alexandratos 2006; Popkin 2006; Monteiro et al. 2007; Kearney 2010;
Subramanyam et al. 2010). Changes in global per capita food intake in many countries and an
increased proportion of food intake derived from energy-dense and fatty foods have contributed to the
epidemic of obesity (Bell et al. 2002; Alexandratos 2006; Popkin 2006; Kearney 2010; Ng and Popkin
2012; Wang et al. 2012; Marseglia et al. 2015). Means of transportation (Misra and Khurana 2008),
119
types of employment, and selected leisure activities have all become more sedentary, contributing
to an imbalance of energy intake and expenditure (Bell et al. 2002; Zhai et al. 2007; Ng and Popkin
2012). Macroeconomic factors, including economic development, urbanization, foreign investment,
and trade liberalization, have contributed to shifting patterns of diet, physical activity, and stress and
poor sleep patterns (Popkin 2006; Misra and Khurana 2008). Economic development and increases
in per capita income are associated with increased consumption of energy-dense foods (Zhai et al.
2007). Moreover, economic development is associated with a faster rate of growth in the prevalence of
overweight among lower-income groups in many countries where obesity was rare just 20 years ago
(Jones-Smith et al. 2011, 2012). Urbanization increases access to processed diets, limits opportunities
for physical activity, and exposes people to pervasive food advertising and subliminal marketing mes-
sages. These social and economic factors in combination promote a sedentary lifestyle associated with
reduced energy expenditure and increased calorie intake, which work in opposition to the universal
human adaptation to food scarcity and mandatory physical activity, rather than excess food supplies
and labor-saving devices, including automobiles, kitchen appliances, and air conditioning (Misra and
Khurana 2008). The globalization of the world’s economies through foreign investment in developing
countries, in combination with free trade agreements (Hawkes 2005), has reshaped the global market
for food, particularly in developing lower- and middle-income countries, by competing with and often
displacing traditional agricultural practices while facilitating the processing, distribution, and market-
ing of lower-cost, energy-dense food (Popkin et al. 2012; Stuckler et al. 2012).
6.3 MINORITY HEALTH DISPARITIES AND RISK

FACTORS IN THE UNITED STATES
African Americans have been demonstrated to have a 1.9-fold higher incidence of T2DM than Caucasians
(Cowie et al. 2009), and this difference is found in all age groups (Cowie et al. 2006). The higher preva-
lence of T2DM in U.S. African Americans compared with Caucasians may be due to a higher frequency
of risk factors or a higher inherent susceptibility to T2DM, or it may be that the risk factors have a
greater pathophysiological effect. Although most risk factors are more common in African Americans,
this higher frequency does not completely explain the racial disparity in the prevalence of T2DM. After
adjustment for all risk factors by logistic regression, an elevated risk of diabetes in African Americans is
particularly evident at higher obesity levels. The risk for developing diabetes was 70% higher in African
Americans at 150 percent of desirable weight in comparison to Caucasians with the same degree of
overweight (95% confidence interval 1.1–2.8). The risk of diabetes associated with obesity is greater
in African-American women than men. The odds of developing diabetes in this group were sevenfold
higher at a percentage of desirable weight of 150 versus Caucasians with the same degree of overweight.
The possibility of racial differences in metabolic adaptation to obesity highlights the importance
of preventing this condition among African Americans, particularly women.
Hispanic Americans, who represent the largest minority population in the United States, are also
at increased risk for obesity and diabetes (Yracheta et al. 2015). Both genetic and environmental
factors might account for their increased risk for these conditions. Excessive intake of sugary bever-
ages has been highlighted as an important contributory cause in this population. Studies focusing
on decreasing the intake of sugary beverages among Hispanic Americans could potentially reduce
renal and cardiovascular complications in this population.
T2DM is an increasing concern among Asian Americans, the fastest-growing ethnic group in the
United States. The U.S. Centers for Disease Control has determined that the age-adjusted prevalence
of T2DM for Asian Americans is 9%, placing them at moderate risk. However, different levels of
risk emerge when Asian American ethnic groups are examined separately. Filipino, Pacific Islander,
Japanese, and South Asian groups are consistently described as having the highest prevalence of
diabetes (Nguyen et al. 2015b). For many years, health services for Asian American populations
have been affected by the myth that Asian Americans are self-sufficient and well educated, and have
lower burdens of disease (Chen and Hawks 1995; Tendulkar et al. 2012). This myth of a so-called
Evolution of Type 2 Diabetes Mellitus 121
model minority was perpetuated by the lack of reliable data that often lumped Asian Americans into
one large category, when in fact they represent a varied and heterogeneous group.
6.4 ADAPTATION TO STARVATION SETS THE STAGE FOR T2DM

When deprived of food, a metabolic adaptation is triggered by a series of hormonal adaptations,
including a decrease in insulin that results in the utilization of fat, rather than glucose, for energy.
Since protein breakdown is required for the synthesis of glucose after the first 3 days of starvation,
after which glycogen stores of only 1200 calories are depleted and the red cells and brain continue
to require glucose, the adaptation to starvation has been key to human survival in times of famine
and food shortages throughout history. Multiple observations have shown that when body cell mass
is reduced to 50% of preillness levels, life ends regardless of whether the cause was starvation,
trauma, tumor, or surgical complications. A second threat to the survival of ancient man was death
from infection. This latter threat is key to understanding the benefits of activating the immune sys-
tem during starvation, as well as understanding that a negative skin tuberculin test in malnourished
patients is a sign of a nutritionally compromised immune system and the breakdown of this part of
the adaptation to starvation. Women have both gynoid and visceral fat, while men have only visceral
fat. The visceral fat is the store of fat most rapidly mobilized during starvation, but it is also a lim-
ited store of fat, with excess fat being deposited ectopically primarily in the liver.
The common occurrence of insulin resistance when energy stores are overloaded in the overweight
and obese patient has stimulated the notion that relative insulin resistance as insulin levels drop during
starvation may have some survival benefit, accounting for its commonality. Energy storage, mainly
as glycogen in liver and triglycerides in adipose tissue, is regulated by the anabolic actions of insulin.
On the other hand, mobilization of stored energy during infection, trauma, or stress is served by the
temporary inhibition of insulin action in target tissues by pro-inflammatory cytokines and stress hor-
mones. Theoretically, individuals with greater insulin resistance would have even more efficient mobi-
lization of fat stores during starvation, extending survival (Tsatsoulis et al. 2013; Babey et al. 2016).
In the current obesogenic environments of much of the industrialized and developing world, high
energy intake, low physical activity, and chronic stress favor the storage of surplus fat in adipose tissue
depots that far exceeds their storage capacity and results in the export of triglycerides into the circula-
tion from the liver. Lipid overload in visceral fat initiates an inflammatory response and adipocyte
dysfunction with resultant low-grade systemic inflammation and lipid overflow to peripheral tissues.
In turn, inflammatory cytokines and lipid metabolites, accumulated in liver and muscle cells, activate
the mechanism of insulin resistance, as would occur in the case of infection or stress. The same factors,
together with the ensuing insulin resistance, put a burden on pancreatic β-cell insulin synthesis and
secretion, leading to cellular death (Costes et al. 2013; Xu et al. 2013). In individuals beginning life with
reduced pancreatic β-cell mass, the ongoing demand for insulin ultimately leads to T2DM, while oxi-
dation of lipids and inflammation lead to cardiovascular disease (Lee et al. 2012; Marseglia et al. 2015).
The physiology of starvation and its undoing by excess calorie intake and sedentary lifestyles
provide a framework for the notion that insulin resistance evolved as a physiological adaptive mech-
anism in human survival, and that the same mechanism is inappropriately activated on a chronic
basis in the current environment, leading to the manifestations of the metabolic syndrome. While
this syndrome is extremely common, it is not universal, and there are healthy obese individuals and
unhealthy thin-appearing individuals with excess visceral fat who do not develop T2DM. The cur-
rent science on the factors promoting pancreatic burnout is rapidly providing a coherent picture on
why some people develop T2DM while others do not.
6.5 PANCREATIC β-CELL EXHAUSTION AND THE DEVELOPMENT OF T2DM

T2DM is characterized by a reduction of β-cell mass with aging and accumulation of islet amyloid
derived from IAPP in the pancreatic islets (Kloppel et al. 1985). Islet amyloid deposition can occur
in up to 80% of patients with diabetes mellitus and is thought to be a key factor in triggering β-cell
destruction when misfolding of the protein occurs (Clark and Nilsson 2004). IAPP is a 37-amino-
acid peptide synthesized and secreted with insulin from pancreatic β-cells. It functions as a short-
loop feedback to insulin secretion and regulating glucose levels. It inhibits the effects of insulin, as
well as arginine-stimulated glucagon release by α-cells (Young et al. 1995; Nguyen et al. 2015a).
In addition, IAPP has been demonstrated to have other physiological functions, such as sleep and
appetite regulation via the gut–brain axis, and it functions as a growth factor to maintain β-cell
mass (Wookey et al. 2006). The incidence of T2DM is considered to increase with age because of
the reduced proliferative capacity and increased apoptosis rate of β-cells, which can also lead to
higher rates of IAPP aggregation (Gunasekaran and Gannon 2011).
Human IAPP (h-IAPP) is only identified histologically at autopsy or in surgical specimens, but
pancreatic β-cell apoptosis and the induction of diabetes have been confirmed in h-IAPP transgenic
rat and mouse models, supporting the idea that amyloids are associated with the induction and pro-
gression of diabetes (Butler et al. 2004). Indeed, an h-IAPP transgenic model formed toxic IAPP
oligomers that eventually generated endoplasmic reticulum stress-induced apoptosis and charac-
teristics of T2DM, including hyperglycemia, impaired insulin secretion, insulin resistance, and
hyperglucagonemia (Matveyenko and Butler 2006a; Huang et al. 2007).
IAPP aggregates have been shown to induce inflammation in islets of Langerhans. IAPP aggre-
gates were observed in macrophages present in pancreatic tissues of biopsy samples from T2DM
patients, as well as in diabetic monkeys, cats, and transgenic h-IAPP mice (de Koning et al. 1998).
These macrophages could not efficiently remove the IAPP aggregates, but internalization of IAPP
aggregates led to secretion of multiple inflammatory cytokines, including interleukin 1β (IL-1β) in
cell culture studies (Gitter et al. 2000; Yates et al. 2000; Westwell-Roper et al. 2011, 2014). A three-
fold increased risk of developing diabetes has been demonstrated in individuals with elevated levels
of both IL-1β and IL-6, but not IL-6 alone (Spranger et al. 2003), suggesting that an inherited brisk
inflammatory response contributes to the pathogenesis of diabetes. Within immune cells from the
bone marrow, phagocytized h-IAPP oligomers activate the NLRP3 inflammasome, leading to IL-1β
secretion (Masters et al. 2010). Moreover, a recent study indicated that h-IAPP oligomers induce
a pro-inflammatory response in islet resident macrophages, including IL-1β secretions, leading to
islet dysfunction in the transgenic h-IAPP mouse model (Westwell-Roper et al. 2015).
The presence of misfolded IAPP aggregates deposited in the pancreatic islets of patients with
T2DM and the loss of β-cells is well established. The key question is whether these aggregates
are simply bystanders that accumulate as a result of the tissue damage during the disease, or they
actually play a key role in the pathogenesis of T2DM. Amyloid deposits occur as a consequence
of folding and failure to clear intracellular proteins with the propensity to form amyloid deposits.
These proteins may form a variety of oligomers, the most toxic of which are those that form rela-
tively early and interact with cellular membranes (McLaurin and Chakrabartty 1996; Janson et al.
1999). In contrast, if misfolded IAPP oligomers organize into amyloid fibrils, these are generally
less toxic but also relatively inert, and as such, they tend to accumulate in the extracellular space,
where they may play a role as a physical barrier and contribute to cellular dysfunction (Clark et al.
1987; Hayden et al. 2007). The diabetes field has mostly ignored the potential importance of IAPP
aggregates in diabetes. Evidence in favor of a direct toxic effect of islet amyloid (Lorenzo et al.
1994) was outnumbered by studies that did not identify such toxicity (Janson et al. 1999; Butler et
al. 2003b). However, toxic amyloid forms were not considered in these studies. This contrasts with
the situation in neurodegenerative conditions such as Alzheimer’s disease and Parkinson’s disease,
where elevated protein aggregates are an accepted component of disease progression, if not the
causative factor. In the brain, as in the pancreas, inflammation triggered by misfolded proteins and
tau tangles also appears to be part of the pathogenesis of neurodegenerative diseases.
The formation of intracellular IAPP oligomers and extracellular amyloid fibrils in humans
implies that the mechanisms to prevent accumulation of misfolded proteins are overloaded. There
is a threshold of IAPP expression that, if exceeded, leads to formation of IAPP oligomers, leading
to the adverse consequences described (Couce et al. 1996; Janson et al. 1996; Soeller et al. 1998;
Matveyenko and Butler 2006b; Huang et al. 2010). This threshold may be exceeded due to an exces-
sive influx of IAPP at a level that exceeds the capacity of a healthy pancreatic β-cell to fold, process,
and dispose of the proteins or because the threshold is decreased by other pathological factors.
h-IAPP transgenic rodent models and transgenic β-cells imply that both of these mechanisms may
be involved (Couce et al. 1996; Janson et al. 1996; Soeller et al. 1998; Matveyenko and Butler 2006b;
Huang et al. 2010). h-IAPP transgenic mice and rats develop diabetes in a transgene dose–response
manner (Janson et al. 1996), or if h-IAPP expression is increased by drug- or obesity-induced insu-
lin resistance (Soeller et al. 1998).
The most common risk factor for T2DM is obesity. With increasing obesity, insulin resistance
increases, requiring increased expression of insulin and IAPP (Mulder et al. 1995). The stress
placed on the pancreatic β-cells in an individual is dependent on overall insulin demand, but also
the number of β-cells that can meet this demand. The number of β-cells in humans increases during
early childhood through the mechanism of β-cell replication, and then remains relatively constant
through adult life once the capacity for β-cell replication declines after early childhood (Butler et
al. 2003a; Meier et al. 2008; Rahier et al. 2008). An underappreciated but potentially important
characteristic of β-cell mass expansion during the postnatal period is the wide range of β-cell mass
that then accrues (Figure 6.1). A wide variation in the mass of pancreatic β-cell has been observed
in adult humans, monkeys, pigs, and rodents (Kjems et al. 2001; Butler et al. 2003a; Matveyenko
and Butler 2006a; Ritzel et al. 2006; Meier et al. 2008; Saisho et al. 2010). This variation is probably
due to nutritional programing in utero (Matveyenko et al. 2010) and to genetic variations related to
the adaptation to starvation (Morris et al. 2012). These adaptations through genetics and epigenetics
are meant for an environment of food scarcity and end up leading to obesity and diabetes when con-
fronted with excessive food intake or hormonal changes that promote insulin resistance.
A proposed model for the interaction of obesity-induced insulin resistance with a wide range of
β-cell mass after postnatal expansion is shown in Figure 6.1. The demand for protein synthesis per
2500
Insulin and IAPP synthesis/β-cell
p < 0.001
β-cell number (millions)
2000 A T2DM
Threshold
healthy
1500
B
1000 C
500 C B
A
0
20 30 40
3
14
18
21
.8
5.
4–
–
–1
3–
14
18
5.
2
8
0.
1.
Age groups BMI

(a) (b)
FIGURE 6.1 (a) β-Cell mass growth varies widely in childhood. The postnatal expansion of β-cell number
plays a major role in establishing β-cell mass in adult humans and is highly variable between individuals. Total
number of β-cells in 46 children aged 2 weeks to 21 years. Data are represented as individual data points.
Individuals with high (A, star), intermediate (B, diamond), and low (C, circle) β-cell numbers are shown for
consideration of β-cell workload in response to obesity in panel B. (b) The interaction of postnatal β-cell mass
and body mass index (BMI) on insulin and IAPP synthetic demand is shown schematically. The risk of T2DM
in individuals with high, intermediate, and low β-cell mass formed after postnatal growth incorporating the
influence of obesity is shown as increasing BMI. The protein synthetic burden per β-cell increases more steeply
in those with a low (individual C) than a high (individual A) number of β-cells. The burden placed on β-cells by
obesity is thus higher in individual C, as is the risk to overcome the threshold for protein folding and disposal,
ultimately leading to β-cell failure in T2DM. (Adapted from Costes, S. et al., Diabetes 62 (2), 327–335, 2013.)
β-cell of insulin and IAPP increases much more steeply in those with a low number of β-cells than
in those with a high number.
6.6 GENETICS OF T2DM LINKED TO MULTIPLE RISK FACTORS

The genetics of the most common form of T2DM is complex. To date, variants in at least 65 genetic
loci have been implicated in the susceptibility to T2DM, which together explain approximately
10–11% of cases (Morris et al. 2012). Many genetic studies, including single gene studies and
genome-wide association studies (GWASs), aim to identify risk alleles for T2DM. Each of the vari-
ants identified by GWASs is associated with only a small increase in diabetes risk; in one analysis,
even if an individual carried risk alleles at all 10 identified loci, the incremental disease risk (over
noncarriers) was rather small, with risk rising only from 5% to 20% (Scott et al. 2007).
Studies of the genetics of diabetes have also supported the notion of mitochondrial oxidative
dysfunction in the observed metabolic inflexibility, reduced lipid oxidation, and increased accumu-
lation of intramyocellular lipid characteristic of insulin resistance (Kelley et al. 2002; Sreekumar
et al. 2002; Mootha et al. 2003; Patti et al. 2003). It has not been determined whether these defects
are critical in disease pathogenesis, or simply secondary to obesity, lipid accumulation (Crunkhorn
et al. 2007), and the metabolic environment of the at-risk individual (Sreekumar et al. 2002).
Additional studies in both muscle and adipose tissue from human subjects will be required to deter-
mine whether defects in mitochondrial gene expression are also a feature of isolated insulin resis-
tance early in the course of progression to diabetes.
There is a significant amount of hereditary risk that cannot be simply explained by individual risk
genes. In general, GWASs support the evidence that environmentally triggered insulin resistance
interacts with genetically programmed β-cell dysfunction to precipitate diabetes. There is still a need
for developing systems biology approaches to integrate comprehensive genetic information and pro-
vide new insight on gene–nutrient and gene–gene interaction in the risk for the development of T2DM.
Genetic risk profiling for T2DM does not currently have proven clinical utility (Kuehn 2010;
Mihaescu et al. 2011). Genetic counseling in cases of confirmed T2DM is simply focused on family
history-based recurrence risk. The American Diabetes Association recommends that before age 45,
a fasting or random glucose, oral glucose tolerance test, or glycosylated hemoglobin be performed
in individuals who are overweight and have one or more additional risk factors, one of which is a
first-degree relative with diabetes (Table 6.1) (Mihaescu et al. 2011).
Maturity-onset diabetes of the young (MODY) is the most common type of inherited diabetes,
resulting from one of several single gene defects in β-cell function. It is inherited in an autosomal
dominant manner. In the classic criteria, patients typically present with diabetes at a young age
(<25 years), are not necessarily obese, continue to make insulin, and do not have type 1 diabetes-
related autoantibodies. They also have other family members with diabetes (Froguel and Velho
1999; Ehtisham et al. 2004).
MODY can often be mistaken for both type 1 diabetes and T2DM due to overlapping features.
Thirteen different genes have been implicated in causing MODY (Ledermann 1995; Schober et
al. 2009; Molven and Njolstad 2011; Bonnefond et al. 2012). Most commonly, MODY results from
TABLE 6.1
Nonmodifiable and Modifiable Risk Factors for T2DM
Nonmodifiable Risk Factors Modifiable Risk Factors
History of gestational diabetes Physical inactivity
Race/ethnicity High body fat or body weight
Age over 45 years High blood pressure
Family history of diabetes High cholesterol
mutations in transcription factor genes, involved in the insulin secretion/β-cell development path-
ways (Frayling et al. 1997; Shields et al. 2010). Mutations in the GCK gene, encoding the enzyme
glucokinase, are implicated in 32% of MODY cases (Froguel et al. 1993; Byrne et al. 1994;
Matschinsky et al. 1998; Shields et al. 2008). About 10% of MODY cases are due to mutations in
HNF4A (MODY1), encoding the transcription factor HNF4a. Some MODY families remain geneti-
cally unexplained (MODY-X), but with advancements in DNA sequencing techniques, more genes
will likely be identified (Bonnefond et al. 2012). Patients with transcription factor MODY sub-
types develop progressive hyperglycemia, typically in adolescence or early adulthood (Bellanne-
Chantelot et al. 2011). They are at risk for diabetes-related complications if not treated, and so
require appropriate monitoring, including regular eye and foot exams and screening of the urine for
microalbuminuria (Velho et al. 1996).
6.6.1 Gestational Diabetes Mellitus

Gestational diabetes mellitus (GDM) is hyperglycemia first diagnosed during pregnancy, a time
of insulin resistance induced by placental hormones (Kuhl 1991; Janson et al. 1999). Women diag-
nosed with GDM are at a significantly increased risk for developing T2DM later in life (McLaurin
and Chakrabartty 1996; Lobner et al. 2006). For some women, a diagnosis of GDM may be the first
recognition of preexisting T2DM, which can be asymptomatic. Maternal hyperglycemia in the third
trimester, as seen with true GDM, is associated with adverse maternal, fetal, and neonatal outcomes,
including macrosomia and perinatal distress, and preexisting maternal hyperglycemia increases the
risk for certain congenital malformations. Therefore, diagnosis and effective treatment are essential
(Clark et al. 1987; Hapo Study Cooperative Research Group et al. 2008). Treatment of GDM can
include lifestyle therapy with diet and exercise, or pharmacological therapy with antidiabetic pills
or insulin, depending on the degree of hyperglycemia (Hayden et al. 2007; Blumer et al. 2013). In
addition, screening for diabetes is recommended 6–12 weeks postpartum given the increased risk.
GDM is often viewed not as a specific disease, but as a manifestation of underlying glucose intol-
erance brought out by the insulin sensitivity-challenging conditions of pregnancy, and this is borne
out by association of T2DM variants with GDM (Lorenzo et al. 1994; Watanabe 2011). Family
history of both GDM and T2DM can be used as a guide to estimate risk of GDM. After 10 years,
women participating in the National Institutes of Health (NIH) Diabetes Prevention Program with
a history of GDM and hyperglycemia assigned to placebo had a 48% higher risk of developing
diabetes than women without a history of GDM with hyperglycemia. In women with a history of
GDM, intensive lifestyle intervention and metformin reduced progression to diabetes compared
with placebo by 35% and 40%, respectively. Among women without a history of GDM, intensive
lifestyle intervention reduced the progression to diabetes by 30%, but metformin did not reduce the
progression to diabetes (Butler et al. 2003b; Aroda et al. 2015). These observations suggest that
women with a history of GDM have a different status than women without in terms of insulin action
and developing T2DM.
6.6.2 Gene–Environment Interaction and Risk for T2DM

Risk factors for the development of T2DM include (1) family history of diabetes, implying heri-
table genetic polymorphisms (Barroso et al. 1999; Horikawa et al. 2000; Fajans et al. 2001;
O’Rahilly et al. 2005; Florez et al. 2006; Grant et al. 2006; Owen and McCarthy 2007), and
(2) both pre- and postnatal environmental factors, including suboptimal intrauterine environment
resulting in epigenetic changes (Barker et al. 1993; Dabelea et al. 2000), low birth weight (Barker
et al. 1993; Rich-Edwards et al. 1999), obesity (Despres 1993; Lazar 2005), inactivity (Manson
et al. 1991), gestational diabetes (Buchanan and Xiang 2005), and advancing age (Lonnroth and
Smith 1986) (Figure 6.2). Each of these risk factors can lead to skeletal muscle, adipose, and
hepatic insulin resistance, and β-cell dysfunction. Ultimately, insulin resistance accompanied by
Adverse
intrauterine
environment
Family history Other
risk factors
Epigenetic Aging Insulin
altered Genetic shared resistance
development environment
Type 2
Altered gene and protein expression diabetes
Cellular Mitochondrial Beta-cell

nutrient dysfunction dysfunction
and energy ER stress
excess Oxidative stress
Inflammation
Obesity “Glucolipotoxicity”
(hyperglycemia, hyperlipidemia)
Dietary excess Inactivity
FIGURE 6.2 Multiple risk factors are involved in the pathogenesis of T2DM, including classic genetic risk
(family history); prominent contribution from multiple environmental risk factors, such as a suboptimal intra-
uterine environment, which can impact the development of key tissues in metabolic homoeostasis; and post-
natal factors, including obesity, inactivity, and aging. Together, these factors can lead to progression of insulin
resistance and β-cell dysfunction, both of which are required for the ultimate development of T2DM. The
pathophysiology of diabetes is further complicated by the influence of hyperglycemia and hyperlipidemia on
the β-cell, creating a vicious cycle leading to β-cell decompensation in susceptible individuals. (Adapted from
Jin, W., and Patti, M. E., Clin. Sci. (Lond.), 116(2), 99–111, 2009.)
inadequate insulin secretory responses results in postprandial and fasting hyperglycemia. In turn,
diabetes-related hyperglycemia and associated metabolic abnormalities can further alter signal
transduction and gene expression (glucolipotoxicity), thus contributing to a vicious cycle (Wang
et al. 1998; Patti et al. 1999).
6.6.3 Prediabetes
Prediabetes reflects failing pancreatic compensation to an underlying state of insulin resistance,
most commonly caused by excess body weight or obesity. Current criteria for the diagnosis of
prediabetes include impaired glucose tolerance, impaired fasting glucose, or metabolic syndrome.
Any one of these factors is associated with a fivefold increase in the risk for T2DM (Garber et al.
2008).
The primary goal of prediabetes management is weight loss through a combination of increased
physical activity and the creation of a caloric deficit while maintaining balanced nutrition. Loss of
visceral fat reduces insulin resistance and can effectively prevent progression to diabetes, as well as
improve lipids and blood pressure. However, weight loss may not directly address the pathogenesis
of declining β-cell function.
Antihyperglycemic medications, such as metformin and acarbose, reduce the risk of future dia-
betes in prediabetic patients by 25–30%. Both medications are relatively well tolerated and safe, and
they confer a cardiovascular risk benefit (Chiasson et al. 1994; U.S. Food and Drug Administration
2016). In clinical trials, thiazolidinediones prevented future development of diabetes in 60–75%
of subjects with prediabetes, but this class of drugs has been associated with a number of adverse
outcomes (Knowler et al. 2005; Dream Trial Investigators et al. 2006). Glucagon-like peptide 1
receptor agonists may be equally effective, but the cost and discomfort of daily injections has to date
limited the application of this approach (Astrup et al. 2009).
6.7 CONCLUSION
The “thrifty gene hypothesis” suggests that human evolution has selected for genes promoting effi-
cient food collection and nutrient storage in order to promote survival during periods of famine. In
the present era of food excess, these genes would be disadvantageous because they may contribute
to energy storage, impaired energy expenditure, and an increased risk for the development of T2DM
(Speakman 2007).
T2DM in the United States and around the world has reached epidemic proportions. From 1980
to 2014, the number of Americans with diagnosed diabetes has increased fourfold, from 5.5 million
to 22.0 million (U.S. Department of Health and Human Services 2016). The global prevalence of
diabetes among adults over 18 years of age has risen from 4.7% in 1980 to 8.5% in 2014, and the
incidence of diabetes is projected to continue to rise exponentially, reaching 642 million by 2040
(da Rocha Fernandes et al. 2016). Diabetes also exacts enormous personal tolls, including long-term
complications of cardiovascular disease, retinopathy, neuropathy, and nephropathy.
Intimately linked with the rise in the prevalence of diabetes is the global epidemic of obesity
in both highly developed industrialized countries and lower- and middle-income countries. It is
estimated that in 2014, more than 1.9 billion adults, 18 years and older, were overweight. Of these,
more than 600 million were obese (World Health Organization 2016). Despite the expenditure of
billions of dollars on diets and health clubs, the rates of obesity continue to increase (Ogden et al.
2006). In 2004, 17.1% of children aged 2–19 years old in the United States were overweight, and
32.2% of adults over 20 years of age were obese (American Diabetes Association 2016). These find-
ings are particularly alarming, as obesity is a major risk factor for insulin resistance and T2DM.
In 2012, 86 million Americans age 20 and older had prediabetes (fasting blood glucose between
100 and 125 mg/dL). This is an increase from 79 million in 2010 (American Diabetes Association
2016). Many more individuals have insulin resistance and an unappreciated risk for T2DM. An
important public health goal should be to identify individuals at high risk for the development of
diabetes in order to implement prevention and early intervention strategies, including exercise,
modest weight loss, and some medication, as needed (Tuomilehto et al. 2001; Knowler et al. 2002).
Primary care providers can be on the front line of this effort if they familiarize themselves with
the factors increasing the risks for developing T2DM and appropriate screening and intervention.
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7 Managing Diabetes
without Weight Gain
7.1 INTRODUCTION
This chapter is about managing patients with diagnosed diabetes mellitus while also e ncouraging
a nutrition program that not only controls blood sugar but also is consistent with addressing over-
weight and obesity-related comorbidities, including age-related chronic diseases. Nutrition is central
to the prevention and treatment of diabetes mellitus, but the confusing array of medications and the
focus on glucose control have blinded the primary care practitioner to the benefits of weight man
agement interventions for type 2 diabetes (T2DM), which are wrongly thought to be a futile exercise.
The approaches to type 1 (T1DM) and type 2 (T2DM) diabetes mellitus are different. T1DM
results from an autoimmune destruction of insulin-secreting cells in the pancreas and requires insu-
lin replacement and matching of the diet to the insulin provided (Hahr and Molitch 2008). On the
other hand, T2DM is closely associated with excess adiposity and requires primary attention to
weight management in prevention and treatment until the late stages of T2DM, when insulin stores
are depleted (Wycherley et al. 2010).
Given the prevalence of T2DM, weight reduction and weight management in T2DM are discussed
first, followed by sections on the various foods that can have a role in controlling blood sugar in
patients with either T1DM or T2DM. Controlling blood sugar is an important component of treat-
ment, but not the sole aspect of improving the quality of life of diabetes patients. Overall lifestyle
change can help control risk factors for cardiovascular disease, which is heightened by the inflam-
mation, oxidative stress, and lipid abnormalities that frequently accompany T2DM. As with other
common chronic diseases, those risk factors present before diagnosis and reviewed in Chapter 5 are
likely to be present at the time that these patients are diagnosed with diabetes.
7.2 DIAGNOSIS OF T2DM
The diagnosis and management of diabetes has advanced and evolved over time in response to
advances in laboratory diagnosis. The management of diabetes has changed dramatically during the
past several thousand years. The option preferred by the physicians consulting with the pharaoh of
Egypt 3500 years ago was a mixture of “water from the bird pond,” elderberry, fibers from the asit
plant, milk, beer, cucumber flower, and green dates (Sanders 2002).
Diabetes mellitus in Latin translates to “sweet urine.” Historically, there were two disorders
that caused the production of excessive amounts of urine: diabetes mellitus and diabetes insipidus.
Diabetes insipidus is due to inappropriate production of antidiuretic hormone (ADH), and the urine
is not sweet. You might wonder how these physicians knew that the urine was sweet in one condi-
tion and not in the other in the absence of clinical laboratory measurements. The unpleasant fact is
that they tasted the urine.
Until 1921, there was little you could do but watch a patient with T1DM and a total lack of insulin
die from starvation. At that time, Banting and Best transformed T1DM from a malignant disease
into a chronic disorder. Only 2 years passed between the initial experiments in dogs that led to the
discovery of a pancreatic factor that could cure T1DM and its widespread human application and the
awarding of the Nobel Prize in 1923. Insulin-related research was the impetus for three other Nobel
Prize awards for the determination of the chemical structure of insulin by Frederick Sanger in 1958,
the determination of the three-dimensional structures of insulin by Dorothy Hodgkin in 1964, and
135
the development of the radioimmunoassay by Solomon Berson and Rosalyn Yalow in 1959–1960,
which transformed the fields of endocrinology and metabolism and led to a Nobel Prize for Yalow
in 1977, as Berson tragically died before receiving the award (Kahn and Roth 2004). Their key dis-
covery using this method was that patients with T1DM had little or no insulin prior to treatment but
developed anti-insulin antibodies. These anti-insulin antibodies were then mixed with radioactive
insulin that had been chemically labeled with an iodine isotope. As a result of this famous experi-
ment, it was found that that T2DM patients had not only detectable but also sometimes high levels of
insulin in the face of high blood sugars.
Today, we have sophisticated diagnostic criteria for the diabetes mellitus diagnosis from the
American Diabetes Association (ADA), including any of the following (ADA 2010):
1. A hemoglobin A1c (HbA1c) level of 6.5% or higher. The test should be performed in a lab-
oratory using a method that is certified by the National Glycohemoglobin Standardization
Program (NGSP) and standardized or traceable to the Diabetes Control and Complications
Trial (DCCT) reference assay.
2. A fasting plasma glucose (FPG) level of 126 mg/dL (7 mmol/L) or higher. Fasting is
defined as no caloric intake for at least 8 hours.
3. A 2-hour plasma glucose level of 200 mg/dL (11.1 mmol/L) or higher during a 75 g oral
glucose tolerance test (OGTT).
4. A random plasma glucose of 200 mg/dL (11.1 mmol/L) or higher in a patient with classic
symptoms of hyperglycemia (i.e., polyuria, polydipsia, polyphagia, and weight loss) or
hyperglycemic crisis.
As you will notice, all the above methods utilize glucose for practical reasons while under-
standing that both T1DM and T2DM, the latter being far more common, have different etiologies,
which are discussed in detail in Chapter 5. In fact, there was much confusion about the distinctions
between the two diagnoses in the 1970s and 1980s. Nonetheless, the focus on glucose control has
stimulated most of the drug development targeted at the treatment of diabetes.
In 1947, Jean Vague was the first to suggest that the regional distribution of body fat was a more
important correlate of the complications of obesity than excess fatness (Vague 1996a,b). In the
1980s, Björntorp and Kissebah simultaneously reported convincing metabolic and epidemiological
data that confirmed that the proportion of abdominal fat was a key correlate of metabolic abnor-
malities leading to both diabetes and atherosclerosis (Kissebah et al. 1982; Lapidus et al. 1984;
Larsson et al. 1984; Ohlson et al. 1985).
As a result of this focus on glucose control, most primary care providers and endocrinologists have
been focused for decades on the use of insulin to lower blood sugar. Various insulin preparations that
were short acting or long acting were used in both T1DM and T2DM. A large number of drugs were also
developed based on their ability to lower glucose levels. As discussed in the next section, metformin
is the most widely used drug globally for the treatment of diabetes, but there are also a large array
of diabetes drugs that both mystify and occupy primary care practitioners in a quest to control blood
sugar while having to accept noncompliance with dietary and weight management interventions that
could prove useful until the very late stages of diabetes, when insulin deficiency is the primary issue.
7.3 PHARMACOLOGICAL TREATMENT OF DIABETES: A BRIEF HISTORY

French lilac, or goat’s rue (Galega officinalis), was used as a folk remedy for diabetes in south-
ern and eastern Europe during medieval times (White and Campbell 2008). In the early twentieth
century, the glucose-lowering compound in this plant, guanidine, was isolated and synthesized
(Frank et al. 1926). It was named Synthalin in Germany and used to treat diabetes during the 1920s
(Galloway 1988). These early drugs were toxic to the liver, and their use ended with the discovery of
insulin. However, in the 1960s and 1970s, drugs modified to reduce toxicity included the biguanide
Managing Diabetes without Weight Gain 137
drugs phenformin in the United States, metformin in France, and buformin in Germany (Alberti
et al. 1997). Phenformin and buformin were associated with lactic acidosis, especially in elderly
individuals with reduced renal function. Metformin, first introduced in 1959, was approved in the
United States in the 1990s. Metformin is the most widely used glucose-lowering drug in the world
(White and Campbell 2008).
Some drug companies promoted the idea that insulin was no longer the central pillar in diabetes
treatment, and that there was now an oral “cure” for diabetes. Manufacturers of one of the drugs
being promoted used the acronym DBI-TD for “Don’t Buy Insulin Today” as a marketing slogan.
Another class of drugs lowering blood sugar are the sulfonylureas. In the 1950s, the first sulfon-
lyurea, tolbutamide, was marketed in Germany (Quianzon and Cheikh 2012). This was followed by
the introduction of the other first-generation agents, including chlorpropamide, acetohexamide, and
tolazamide. Glipizide and glyburide were more potent and were introduced in 1984. These agents
had been in use in Europe for several years before this. Glimepiride, which is sometimes referred
to as a third-generation agent, was released in 1995 (Quianzon and Cheikh 2012). The major side
effects of the sulfonylureas are hypoglycemia and weight gain.
Thiazolidinediones, which are also known simply as “glitazones,” were initially introduced to
the U.S. market in 1996. These agents are peroxisome proliferator-activated receptor γ activators
whose mechanisms of action are enhancement of skeletal muscle insulin sensitivity and reduction in
hepatic glucose production (Inzucchi et al. 2012). These agents do not increase the risk of hypogly-
cemia and have a more durable effect than metformin or sulfonylureas, but the two currently avail-
able agents, pioglitazone and rosiglitazone, can cause fluid retention and must be used with caution
in patients with heart failure (Inzucchi et al. 2012).
The meglitinides, also called “glinides,” have a mechanism of action similar to that of the sul-
fonylureas but are structurally unrelated to sulfonylureas. These drugs lower blood glucose levels
by stimulating insulin release from the pancreas. As with the sulfonylureas, glinide-induced insulin
stimulation is dependent on functioning pancreatic β-cells (White and Campbell 2008). However,
the effect of these drugs is glucose dependent and diminishes at low glucose concentrations. The
glinides have a more rapid onset and a shorter duration of action than the second-generation sulfo-
nylureas, so that multiple daily dosing is required. Repaglinide (approved in 1997) and nateglinide
(approved in 2000) are the two drugs in this class (Quianzon and Cheikh 2012).
Glucagon-like peptide 1 (GLP-1) and its analogs reduce glucose levels via a glucose-linked
enhancement of insulin secretion; this was first observed when it was noted that oral glucose stimu-
lated insulin secretion to a greater extent than intravenous insulin due to gastrointestinal hormones
called incretins. The short half-life of 1–2 minutes of native GLP-1 due to rapid degradation by the
enzyme dipeptidyl peptidase 4 (DPP-4) led to the search for GLP-1 analogs and DPP-4 inhibitors.
Exendin-4 was isolated from the salivary gland venom of the Gila monster reptile (Heloderma
suspectum). Xenatide, a synthetically produced form of exendin-4, was the first GLP-1, in 2005.
A second GLP-1 receptor agonist, liraglutide, was approved in 2010, which is modified to be long
acting. In 2012, a long-acting form of exenatide that could be administered weekly was approved.
Weight loss is one advantage of treatment with incretin-based agents. However, these compounds
can cause significant gastrointestinal side effects, particularly early in therapy, and concerns about
associations between GLP-1 receptor agonists and pancreatitis are ongoing. They are also expen
sive and injectable. The first DPP-4 inhibitor, called sitagliptin, could be taken orally and acted by
prolonging the circulating half-life of GLP-1. It was approved in 2006 and followed by the release
of saxagliptin and linagliptin. Alogliptin was approved by the Food and Drug Administration
(FDA) in 2013. Vildagliptin has been approved for use in Europe but is not available in the United
States. DPP-4 inhibitors are weight neutral and do not tend to cause hypoglycemia (White 2014).
However, pancreatitis has been reported in patients treated with DPP-4 inhibitors (Quianzon and
Cheikh 2012).
The endogenous neuroendocrine hormone amylin was discovered in 1987. Amylin is cosecreted
with insulin by the β-cells in equimolar amounts. Patients with T2DM have reduced amounts of
amylin, whereas patients with T1DM have essentially no amylin. The only amylin analog currently
on the market is pramlintide, approved by the FDA in 2005 (Quianzon and Cheikh 2012). It delays
gastric emptying, reducing postprandial glucose and glucagon and causing some weight loss. The
primary side effect is nausea.
The sodium glucose cotransporter 2 (SGLT-2) inhibitors antagonize a high-capacity, low-affinity
glucose transporter found primarily in the kidney (White 2010). This transporter is responsible for
~90% of glucose reabsorption in the kidney. When this transporter is antagonized, excess glucose
in the renal tubules is not reabsorbed, and glucose is excreted in the urine. This results in a net
loss of glucose and a reduction in hyperglycemia. In addition to reducing hyperglycemia, SGLT-2
inhibitors have also been associated with slight reductions in weight and body mass index (BMI).
However, an increase in urinary or genital infections is common and is especially troublesome in
female patients (Monami et al. 2014).
7.4 DIABETES AND OBESITY

It had been noted for decades that those adults with T2DM were also often overweight or obese and
had poor eating habits, but that finding did not impact treatment until the obesity epidemic was
recognized in the 1990s. There are now 11 different categories of medications directed at the man-
agement of hyperglycemia in patients with diabetes, which is the major focus of medical approaches
to diabetes treatment. Additionally, the potential dosing and various combinations of these agents
are staggering and can be bewildering to primary care providers trying to design optimum therapy
regimens for a given patient.
Obesity is more than a risk factor for the development of T2DM; it is a necessary component of
the pathophysiology of the disease until the very late stages, when insulin is virtually absent and
type 2 has virtually become a variant of T1DM with a different origin. The most profound and alarm
ing impact of the epidemic of obesity is the development of T2DM in large numbers of overweight
and obese children and teenagers. Some pediatric endocrinologists report that up to one-third of
their patients have T2DM, which was rare up until about 20 years ago.
The focus on controlling blood sugar with insulin and diet has dominated the medical and dietetic
approaches to T2DM, combined with attention to the deadly complications of diabetes, including
nephropathy leading to renal failure, retinopathy leading to blindness, vascular disease leading
to amputations, hypertension leading to strokes and contributing to renal failure, hyperlipidemias
leading to cardiovascular disease, painful neuropathies, and increased susceptibility to common
infections of the skin and urine when blood sugar is >180 mg/dL. The combination of hyperlip-
idemia, hypertension, and elevated blood sugar affects many of these comorbid conditions. The
combination is more than a statistical coincidence; it is the definition of metabolic syndrome when
combined with an increased waist circumference, a marker of visceral fat. There is some attention
to dietary counseling in modern diabetes practice, but it is largely related to blood sugar control.
The busy diabetes specialist or primary care doctor dealing with this increasingly common disease
has little or no time for counseling on weight management given all the activity described above. In
this chapter, we review the consequences of the glucose-centric approach to diabetes, and provide
practical suggestions for the nutritional management of T2DM patients in order to avoid weight
gain, a common problem that has significant metabolic consequences and increases morbidity and
mortality from this very common disease.
7.5 NUTRITION AND DIABETES MANAGEMENT

Nutrition is central to the treatment of diabetes mellitus, but the approaches to T1DM and T2DM
are different. T1DM, due to the destruction of insulin-secreting cells in the pancreas, requires insu-
lin replacement and matching of the diet to the insulin provided (Hahr and Molitch 2008). On the
other hand, T2DM is closely associated with excess adiposity and requires primary attention to
weight management in treatment until the late stages of T2DM, when insulin stores are depleted
(Wycherley et al. 2010). Given the prevalence of T2DM, weight reduction and weight management in
T2DM are discussed first, followed by sections on the various foods that can have a role in controlling
blood sugar in patients with either T1DM or T2DM. Controlling blood sugar is an important compo
nent of treatment, but not the sole aspect of improving the quality of life of diabetes patients. Overall
lifestyle change can help control risk factors for cardiovascular disease, which is heightened by the
inflammation, oxidative stress, and lipid abnormalities that frequently accompany poor control of
blood glucose.
7.5.1 Weight Management and Weight Reduction in T2DM

The vast majority of patients with T2DM have excess body fat, and about 36% are medically obese
(Cowie et al. 1994). Since obesity is more common in underserved minority populations, so is T2DM
(Cowie et al. 1994). T2DM results primarily from insulin resistance and increased body fat, both
of which result from a gene–environment interaction (Olefsky et al. 1982; Campbell and Gerich
1990). While hyperglycemia is the hallmark of T2DM, the increased risk of cardiovascular mortality
is associated with hyperlipidemia and hypertension, which occur more commonly in patients with
T2DM than in the general population (Albu et al. 1995). The Action to Control Cardiovascular Risk
in Diabetes (ACCORD) trial also recently showed a significant reduction in the rate of nonfatal
cardiovascular events in a follow-up of its study population (Gerstein et al. 2014), but that benefit
was offset by an increase in mortality in the original trial (Gerstein et al. 2008). In contrast, no
reduction in the rate of cardiovascular events or in mortality was found in a follow-up of the Action
in Diabetes and Vascular Disease (ADVANCE) trial (Zoungas et al. 2014). The Veterans Affairs
Diabetes Trial showed that intensive glucose lowering, compared with standard therapy, did not sig-
nificantly reduce the rate of major cardiovascular events among 1791 military veterans (Duckworth
et al. 2009). The extended 10-year follow-up of the study participants showed that subjects who had
been randomly assigned to the intensive glucose control for 5.6 years had 8.6 fewer major cardio-
vascular events per 1000 person-years than those assigned to standard therapy, but no improvement
was seen in the rate of overall survival (Hayward et al. 2015).
Because weight reduction can decrease insulin resistance and the demands on the pancreatic
β-cell to secrete insulin, weight loss is an integral and necessary component of treatment for obese
individuals with T2DM. Weight loss in T2DM patients is associated with decreased insulin resistance,
improved measures of glycemia, reduced serum lipids, and reduced blood pressure (Hughes et al.
1984; Henry et al. 1986; Amatruda et al. 1988).
The Diabetes Prevention Program (DPP) demonstrated long-term benefit in people with glu-
cose intolerance from structured, intensive lifestyle programs (Wing et al. 1998; DPP 1999). In the
DPP, participants randomly assigned to an intensive lifestyle intervention that included a low-fat
diet, increased physical activity, educational sessions, and frequent follow-up were able to lose 7%
of body weight in the first year and sustain a 5% weight loss over an average follow-up period of
3 years. DPP participants received training in diet, exercise, and behavior modification from case
managers who met with them for at least 16 sessions in the first 24 weeks and monthly thereafter.
With intensive lifestyle intervention, the risk of developing diabetes was reduced by 58% relative to
standard care. The DPP study subjects in the intensive lifestyle group succeeded in reaching their
target goal of a 7% mean weight loss by 6 months and were able to maintain that level of mean
weight loss for the first 12 months (Wing et al. 1998). Subsequently, they underwent a slow weight
regain, and they had a mean weight loss of 4% at the time of study termination. The placebo group
maintained their weight throughout the duration of the study, with neither weight gain nor weight
loss, whereas the metformin treatment group initially lost a mean of approximately 2.5% of their
body weight within the first year and then regained weight during the subsequent 2 years.
The primary outcome of the DPP was the effect of the intervention strategies on the development
of diabetes. Subjects with an elevated fasting plasma glucose level demonstrated an exceptionally
high rate of progression to confirmed diabetes mellitus. Those study participants in the placebo
group reflected the natural history of progression to diabetes and demonstrated an 11% per year
incidence. This rate was reduced by 31% (to 7.8% per year) by treatment with metformin and by
58% (to 4.8% per year) by intensive lifestyle intervention. Therefore, this study demonstrated that
intensive lifestyle change or metformin could delay the onset of diabetes in patients with impaired
glucose tolerance and elevated fasting blood sugar. A 58% reduction in the onset of new cases of
diabetes were found in a Finnish population studied in the same way (Tuomilehto et al. 2001).
The National Institutes of Health (NIH) Look Action for Health in Diabetes (AHEAD) trial,
examining the impact of weight loss on cardiovascular mortality in patients with T2DM, demon-
strated significant weight loss in 1 year using a combination of dietary counseling, modest exer
cise recommendations, and meal replacements. There were three predictors of successful weight
loss: (1) use of meal replacements, (2) physical activity, and (3) recording dietary intake (Wadden
et al. 2009). At diagnosis, patients are often advised to accept having a lifelong disease so that
they can cope with T2DM (Delahanty et al. 2007). Sequential addition of therapies is required,
and within 10 years of diagnosis, 50% of individuals are on insulin therapy (Turner et al. 1999).
Therapeutic weight loss in T2DM patients has been very difficult to achieve (Milne et al. 1994;
Redmon et al. 2005), and patients with T2DM have less success with maintaining their weight
loss (Pi-Sunyer 2005). Many of the medications traditionally employed to control blood glucose
in diabetics, including insulin, thiazolidinediones, and sulfonylureas (Fonseca 2003; Heller 2004;
Del Prato and Pulizzi 2006), can result in increased body fat over time. Among the above inter
ventions, insulin is the one associated with the greatest amount of weight gain when used as mono-
therapy. Two of the largest studies to demonstrate this include the DCCT (1993) and UK Prospective
Diabetes Study (UKPDS) Group (1998b). Insulin sensitizers such as thiazolidinediones and insu
lin secretagogues such as sulfonylureas also produce weight gain as monotherapy, but not to the
same extent as that found with insulin (Del Prato and Pulizzi 2006; Mori et al. 1999; Patel et al.
1999).
The effort to drive HbA1c down to prevent complications can reduce the effectiveness of
weight management interventions. There is most likely no one specific reason why weight gain
is an associated side effect of these hypoglycemic medications. Current proposed mechanisms
include (1) reduction of glycosuria, resulting in retention of calories; (2) anabolic effects of insulin;
(3) increased appetite; (4) decreased leptin production; and (5) fluid retention (Pi-Sunyer 2005). Of
these, increased appetite and reduction of glycosuria appear to have the greatest effect on weight gain.
In practice, physicians focus on the control of hyperglycemia while giving inadequate or no
attention to weight management through changes in diet and lifestyle because of their belief that
this is an exercise in futility (Pi-Sunyer 2005). In a retrospective analysis, we examined the efficacy
of diet, exercise, and lifestyle intervention programs in producing weight loss in obese patients with
prediabetes or diabetes in comparison with normoglycemic obese patients enrolled in the same
outpatient program and found that prediabetes and diabetes patients all lost weight as effectively
with a very low-calorie diet (VLCD) or LCD over 12 months (Li et al. 2014). Therefore, there is
no metabolic reason that patients with T2DM given a personalized protein-rich, calorie-controlled
diet that creates a caloric deficit cannot lose weight. The reason for lack of weight loss is inevitably
failure to adhere to the recommended diet and exercise.
7.5.2 Typical Modern Management of T2DM

Today, a patient with T2DM can expect to be prescribed two to three glucose-lowering agents, two
drugs to control blood pressure, a statin, a low-dose aspirin, urine test strips, and lancets for testing
blood glucose on a portable device. If neuropathy is present, they may also receive a prescription
for gabapentin or amitriptyline to alleviate their pain. Reviewing the standard laboratory mea-
sures, including fasting blood sugars, HbA1c, fasting lipids, blood pressures, and urinary microal-
bumin, makes for a busy office and lots of opportunity to miss the impact of overweight and obesity,
especially sarcopenic obesity, which is not evident to the naked eye. That is why a team approach
beyond the physician in a cramped exam room is needed to address this disease. An integrated
approach, as described in Chapter 1, is most effective and simulates the conditions of our LCD and
VLCD clinic at the University of California, Los Angeles (UCLA) (Li et al. 2014).
There is confusion on what to prescribe other than metformin for most patients with T2DM and
insulin for all patients with T1DM. Two recent studies attempted to address these dilemmas. However,
drugs other than metformin may not contribute to a reduction in overall mortality and morbidity.
A study of a very large cohort in Belgium including more than 100,000 patients with T2DM who had
been prescribed metformin, a sulfonylurea, or insulin, either alone or in combination, was con-
ducted from 2003 to 2007 (Claesen et al. 2016). In Belgium, a single-payer system supports a large
database, including data on diabetes medications and outcome, including mortality. Twelve control
subjects were matched to each patient, including age and diagnoses of hypertension and heart dis-
ease. Patients on metformin monotherapy had longevity similar to that of controls, while those on
insulin and/or sulfonylureas did not do as well. Both patients with diabetes and controls benefited
from the use of statins. There were no data reported in this study on diet or obesity. So, careful glu-
cose management by adding more insulin and sulfonylureas was associated with greater mortality.
Could the missing link here be ignorance of nutrition and physical activity effects? To what degree
does the focus on drugs and glucose fail the patient?
7.5.3 Use of Metformin in T2DM

Metformin is clearly the most beneficial and widely used drug in T2DM. It is troubling that a recent
study reports some disagreement among experienced prescribers on how to use this drug (Goldberg
et al. 2015). Questionnaires were sent to prescribers with 5–15 years of experience asking them how
they would navigate some of the most common issues that arise in the use of metformin, including
lack of efficacy, reduced renal function, alcoholism, and gastrointestinal side effects. There was
divided opinion on whether to increase metformin doses, add another agent, or discontinue the
metformin entirely, pointing out the lack of consensus on a standard treatment regimen and the
confused state of diabetes pharmacotherapy.
Metformin is the only medication for T2DM that has demonstrated reproducible benefits on car-
diovascular morbidity and mortality (UK Prospective Diabetes Study [UKPDS] Group 1998a). Thus,
metformin is considered first-line treatment for T2DM according to the ADA’s clinical practice
guidelines (ADA 2015). In the UKPDS, cardiovascular morbidity and mortality benefits were dem-
onstrated in patients with uncontrolled diabetes who were treated daily with metformin at doses
of 1700–2550 mg (UK Prospective Diabetes Study [UKPDS] Group 1998a). At these doses, metformin
reduced the risk of any diabetes-related end point, myocardial infarction, and all-cause mortality by
32%, 39%, and 36%, respectively (UK Prospective Diabetes Study (UKPDS) Group 1998a). Despite
these findings, manufacturer guidelines suggest that the minimum effective dose of metformin is
1500 mg/day (Bristol Myers Squibb 2009). While the optimal dose has not been established in
clinical trials, the trial on which much of the evidence for cardiovascular benefit is based, the
UK Prospective Diabetes Study (UKPDS 1998a,b), used a median dose of 2550 mg metformin.
Establishing how the dose-effect relationship may vary at different doses and what the maximum
effective dose may be is an area for future work. Despite the clear benefits on glycemic control,
morbidity, and mortality, metformin prescribing remains suboptimal (Calabrese et al. 2002; Desai
et al. 2012). It is estimated that metformin treatment is not initiated in nearly 50% of patients with
T2DM (Berkowitz et al. 2014).
Reasons for this suboptimal prescribing are not clearly defined in the literature, but they may be
attributable to fear of precipitating lactic acidosis in patients with known risk factors. Potential risk
factors for lactic acidosis include chronic kidney disease, hepatic dysfunction, heart failure, chronic
obstructive pulmonary disease (COPD), alcohol abuse, and a history of lactic acidosis. Although
there is little information on the exact risk of lactic acidosis with metformin, data suggest that the
association is negligible; one study demonstrated an incidence of 4.3 per 100,000 patient-years
(Salpeter et al. 2010). Furthermore, previous studies demonstrated no increased risk of lactic aci-
dosis with metformin use in the settings of heart failure and renal dysfunction (Eurich et al. 2013;
Norwood et al. 2013; Richy et al. 2014). Despite these data, the manufacturer recommends discon-
tinuing metformin when serum creatinine exceeds 1.5 mg/dL for men and 1.4 mg/dL for women
(Bristol Myers Squibb 2009), likely because of medicolegal concerns over the risk of lactic acidosis.
This fear of increased lactic acidosis risk with metformin may stem from a preexisting medication,
phenformin, which was associated with fatal cases of lactic acidosis in patients and has since been
removed from the market (Lipska et al. 2011). However, there is no information that clearly supports
similar concerns over the use of metformin. While the majority of clinicians would stop metformin
because of impaired renal function, it is unclear whether the reason is due to a perceived risk of
lactic acidosis or something else, perhaps a fear of legal liability, the contraindication in the manu-
facturer’s package insert, or unfamiliarity with the actual consequences of metformin use.
There are several major guidelines outside the United States that indicate that the glomerular fil-
tration rate (GFR) is a better measure of kidney function than serum creatinine and should be used
to assess metformin use in patients with diabetes (Chadban et al. 2010). Although creatinine clear-
ance (using the Cockcroft–Gault equation) is typically preferred for renal drug dose adjustments,
metformin dose adjustments have not been evaluated in the same fashion as most other medications;
thus, GFR, which is a more accurate indicator of renal function, is preferred when dosing metformin
(Lipska et al. 2011; Trinkley et al. 2014; ADA 2015).
Current prescribing practices for metformin are not optimal. In patients with uncontrolled dia
betes and an HgbA1c of 8.3%, most providers (84%) chose to titrate metformin from 500 to 2000 mg
daily, whereas 11% chose 1500 mg of metformin daily as an appropriate regimen. Interestingly, in
a similar patient with an HgbA1c of 7.3%, 75% of providers would increase metformin from 1500 to
2000 mg daily, whereas 18% of providers would choose to add a sulfonylurea. Of providers, 50%
followed the metformin manufacturer’s recommendations to discontinue metformin use when the
serum creatinine is >1.5 mg/dL. The other 50% of providers accepted the GFR as a better indicator
of when to discontinue metformin use, but there seems to be no consensus among providers on what
the GFR cutoff should be. In patients taking 1750 mg of metformin daily with either hepatic dys-
function or heart failure, there was great variation in provider prescribing attitudes and no notable
trends. For patients with COPD, however, 90% of providers did not alter the patient’s metformin
therapy. In patients with alcoholism, 59% of providers would not alter metformin dosing, but many
providers would alter the dose recommended based on varying degrees of alcohol use. For patients
with current or a history of lactic acidosis, provider attitudes were inconsistent. Much more needs
to be done so that more patients with diabetes can benefit from metformin’s unique cardiovascular
morbidity and mortality effects.
The findings of survey studies strongly suggest that there is no consensus around the dosing and
use of metformin based on glycemic control or comorbidities. This confusion drives prescribers to
other classes of drugs when targets for glucose control are not achieved and minimize consideration
of diet and lifestyle in favor of the easy answer of writing another prescription. Optimizing the use
of metformin, in combination with diet and exercise, is an effort that would pay great dividends in
the management of T2DM.
7.5.4 Meal Replacements as a Tool for Planning Weight Management Diets

Partial meal replacement diets using protein-enriched shakes as meal substitutes are a viable strat-
egy for weight reduction in patients with T2DM, resulting in beneficial changes in measures of glyce-
mic control and a reduction of medications (Li et al. 2005). Structured meal replacements provide
a defined amount of energy (usually 200–300 calories), often as a prepackaged meal, snack bar, or
formula product. Most of the energy is derived from protein and carbohydrates. Vitamins, miner-
als, and fiber may also be included. Use of meal replacements once or twice daily to replace a usual
meal can result in significant weight loss (Ditschuneit et al. 1999; Metz et al. 2000; Quinn Rothacker
2000; Ashley et al. 2001; Rothacker et al. 2001). Presumably, the meal replacement causes a reduc-
tion in energy intake by eliminating the choice of type and amount of food. Weight loss can be as
much as 11% of starting weight at 2 years, but meal replacement therapy must be continued if weight
loss is to be maintained; attrition may occur in about 33% of patients (Ditschuneit et al. 1999).
Studies including a meta-analysis of weight loss interventions in adults with T2DM showed
that multidisciplinary interventions, including VLCDs, held promise for achieving weight loss
(Amatruda et al. 1988; Henry and Gumbiner 1991; Wing et al. 1991; Capstick et al. 1997; Norris
et al. 2005). A prospective, longitudinal study comprised three phases: a VLCD for 8 weeks, a
stepped return to isocaloric intake of normal food over 2 weeks, and a structured, individualized
weight maintenance program over 6 months achieved continuing remission of diabetes for at least
6 months in the 40% patients who responded to a VLCD by achieving an FPG of <7 mmol/L
(Steven et al. 2016).
Abnormalities of protein metabolism are assumed to be less affected by insulin deficiency and
insulin resistance than abnormalities of glucose metabolism (Henry 1994). However, moderate
hyperglycemia may contribute to increased turnover of protein in T2DM subjects. During moderate
hyperglycemia, obese subjects with T2DM, compared with nondiabetic obese subjects, demonstrate
an increase in whole body nitrogen flux and a higher rate of protein synthesis and breakdown
(Gougeon et al. 1997, 1998). A high-quality protein (95 g of protein/day), very low-energy diet
capable of maintaining nitrogen balance in obese subjects without diabetes did not prevent negative
nitrogen balance in diabetic subjects, despite weight loss and improved glycemic control (Gougeon
et al. 1997). This increased protein turnover was restored to normal only with oral glucose-lowering
agents or exogenous insulin sufficient to achieve euglycemia and with increased protein intake
(Gougeon et al. 1998, 2000). These study results suggest that people with T2DM have an increased
need for protein during moderate hyperglycemia and an altered adaptive mechanism for protein
sparing during weight loss. Thus, with energy restriction, the protein requirements of people
with diabetes are likely to be greater than the recommended dietary allowance (RDA) of 0.8 g of
protein/kg of body weight, and increased amounts of protein may aid in weight management efforts
through effects on satiety and maintenance of lean body mass (Flechtner-Mors et al. 2010). As
detailed in Chapter 2, the use of protein-enriched meal replacements is safe and effective in patients
with T2DM (Li et al. 2010).
In the remaining meals, as already discussed in Chapter 5, reducing dietary fat and hidden sug-
ars restricts calorie intake, especially from processed foods. Spontaneous food consumption and
total energy intake are increased when the diet is high in fat and decreased when the diet is low in
fat (Lissner et al. 1987; Kendall et al. 1991). So, a minimal amount of olive and avocado oil should
be used and high-glycemic-index (GI) foods avoided. There is no conflict between low-fat and
reduced-GI foods. In the popular literature, there has been confusion over the idea that every low-
fat diet is high in refined carbohydrates, while every high-protein diet is also high fat. It is possible,
using meal replacements, to achieve a level of protein intake of 1 g/pound of lean body mass, which
equates to 25–30% of total calories per day, in combination with good carbohydrates from fruits
and vegetables, with limited amounts of whole grains. Fats should be used sparingly as needed, and
overall processed food intake and restaurant eating should be minimized.
7.5.5 Physical Activity, Including Resistance Exercise, to Increase Muscle Mass

Exercise improves insulin sensitivity and lowers blood glucose in patients with diabetes. Exercise by
itself has only a modest effect on weight loss, but it is the most efficient intervention for long-term
weight maintenance and prevention of weight regain (Pavlou et al. 1989; Maggio and Pi-Sunyer
1997; Bouchard et al. 1993).
Aerobic exercise improves glucose control (Ronnemaa et al. 1986; Mourier et al. 1997; Boule
et al. 2001) and insulin sensitivity (Ruderman et al. 1979; Dengel et al. 1996; Mourier et al. 1997).
It also reduces visceral adiposity (Mourier et al. 1997) and improves lipid profiles (Segal et al. 1991),
arterial stiffness (Yokoyama et al. 2004), and endothelial function (Stewart 2002).
The ADA recommends that individuals with T2DM perform at least 150 minutes of moderate-
intensity aerobic exercise and/or at least 90 minutes of vigorous aerobic exercise per week (Sigal
et al. 2004). However only 28% of individuals with T2DM achieve these recommendations (Plotnikoff
et al. 2006). Individuals with severe obesity, arthritis, physical disabilities, and/or diabetes com-
plications may have difficulty walking for 30 minutes. Alternate forms of personalized physical
activity recommendations that produce similar metabolic improvements are therefore vital to be
integrated into the management of T2DM.
Resistance training has been used as a method to prevent and treat chronic diseases (Ghilarducci
et al. 1989; Hare et al. 1999; Pu et al. 2001; Kongsgaard et al. 2004; Haykowsky et al. 2005). Its
safety and efficacy have been demonstrated in the elderly (Singh et al. 1997, 1999) and obese (Cuff
et al. 2003) individuals. Resistance training can increase muscle strength (Hunter et al. 2004;
Ouellette et al. 2004), lean muscle mass (Ryan et al. 2001), and bone mineral density (Nelson et al.
1994; Hurley and Roth 2000), which could therefore enhance functional status and glycemic control
and assist in the prevention of sarcopenia and osteoporosis. Resistance training was also demon-
strated to improve insulin sensitivity (Miller et al. 1984; Eriksson et al. 1998; Poehlman et al. 2000),
daily energy expenditure (Hunter et al. 2000; Ades et al. 2005), and quality of life (Kell et al. 2001).
However, unlike aerobic exercise, resistance training is dependent on equipment and knowledge
of exercise technique, and often requires some initial instruction. Therefore, research is needed to
come up with practical, sustainable, safe, and cost-efficient ways to implement resistance training
for individuals with T2DM.
7.5.6 Low-GI Foods, Fiber, and Resistant Starches in T1DM and T2DM

Low-GI foods include most fruits and vegetables, whole grains, and protein-rich and fat-rich foods.
The acute effects of high-GI foods, such as rice, potatoes, and refined grain pasta, are established.
However, the clinical utility of low-GI diets without any instructions on weight management is
controversial (Pi-Sunyer 2002). Thomas and Elliott assessed randomized controlled trials (RCTs)
with interventions greater than 4 weeks comparing a low-GI diet with a higher-GI diet for T1DM
or T2DM (Thomas and Elliott 2010). Twelve RCTs with 612 participants were identified. There
was a significantly greater decrease in glycated hemoglobin (HbA1c) with the low-GI diet than
with the control diet, indicating improved glycemic control. Glycosylated albumin levels decreased
significantly with the low-GI diet, but not with the high-GI diet, in the one study that reported this
outcome. Therefore, lowering the GI of the diet in combination with other changes may contribute
to improved glycemic control in diabetes.
In the Canadian Trial of Carbohydrates in Diabetes (CCD), a 1-year controlled trial of low-GI
dietary carbohydrate in subjects with T2DM managed by diet alone with optimal glycemic control,
the levels of HbA1c were not changed by altering the GI or the amount of dietary carbohydrate.
Differences observed in the ratio of total cholesterol to high-density lipoprotein (HDL) cholesterol
among diets had disappeared by 6 months. However, because of sustained reductions in postpran-
dial glucose, a low-GI diet may be preferred for the dietary management of T2DM.
There is a positive effect of large amounts of fiber (>30 g/day) on glycemia in suboptimally con-
trolled T1DM subjects, probably by changing intestinal transit times and the delivery of glucose into
the bloodstream after meals (Vaaler et al. 1980; Chenon et al. 1984; Riccardi et al. 1984). In subjects
being treated with two or more injections of insulin per day and HbA1c levels of 7–10% consum-
ing either a high-fiber (50 g/day), low-GI diet or a low-fiber (15 g/day), high-GI diet for 24 weeks,
the high-fiber diet significantly reduced the mean daily blood glucose concentration (p < 0.05), the
number of hypoglycemic events (p < 0.01), and in the subgroup of patients compliant to the diet,
HbA1c (p < 0.05). However, the diet had no beneficial effects on cholesterol, HDL cholesterol, or
triglyceride concentrations (Giacco et al. 2000).
In T2DM, weight management has the greatest benefit. Since low-GI foods are also often high
in fiber, the replacement of foods with a high-GI and/or low-fiber content for foods with a low-GI
and/or high-fiber amount seems to be a practical alternative for the dietary management of patients
with diabetes. However, this assumption needs to be confirmed in long-term clinical trials that fac-
tor in the effects of weight management.
Resistant starches, including nondigestible oligosaccharides and the starch amylose, are not
digested and therefore not absorbed as glucose in the small intestine. They are almost completely fer-
mented in the colon and produce about 2 kcal/g of energy (Carbohydrates in Human Nutrition 1998).
It is estimated that resistant starch and unabsorbed starch represent <10 g/day of the total starch
ingested in the average Western diet (Wursch 1989). Legumes are the major food source of resistant
starch in the diet, containing 2–3 g of resistant starch per 100 g of cooked legumes. Uncooked corn-
starch contains about 6 g of resistant starch per 100 g of dry weight (Englyst et al. 1996).
It has been suggested that ingestion of resistant starch produces a smaller increase in postpran-
dial glucose than digestible starch, and correspondingly lower insulin levels. As a result, it has been
proposed that food containing naturally occurring resistant starch, such as cornstarch, or food mod-
ified to contain more resistant starch with high-amylose cornstarch may modify postprandial gly-
cemic response, prevent hypoglycemia, and reduce hyperglycemia. These effects may also explain
differences in the GIs of some food (Brennan 2005).
There have been several one-meal (Raben et al. 1994; Granfeldt et al. 1995; Hoebler et al. 1999)
and two-meal (Heijnen et al. 1995; Achour et al. 1997; Liljeberg et al. 1999) studies in nondiabetic
subjects, comparing subjects’ physical response to food high in resistant starch and their response to
food with an equivalent amount of digestible starch. All studies found some reduction in postprandial
glucose and insulin responses to the first meal, but observed mixed results after the second meal.
Long-term studies have not consistently confirmed these results (Behall and Howe 1995; Luo
et al. 1996; Noakes et al. 1996; Jenkins et al. 1998; Axelsen et al. 1999). Published studies involving
people with diabetes have focused on uncooked cornstarch and its potential to prevent nighttime
hypoglycemia (Axelsen et al. 1997, 2000; Alles et al. 1999). In uncontrolled studies, evening corn-
starch in specific dosages or dosages based on grams per kilogram of body weight resulted in less
hypoglycemia around 2:00 a.m. in all groups (Kaufman et al. 1995; Axelsen et al. 1999). It has not
been established that bedtime cornstarch snacks are more effective in preventing nocturnal hypo-
glycemia than other types of carbohydrates.
7.5.7 Monounsaturated Fats
Diets high in monounsaturated fat (MUFA) (Parillo et al. 1992; Rasmussen et al. 1993; Campbell
et al. 1994; Walker et al. 1996) result in improvements in glucose tolerance and lipids compared with
diets high in saturated fat. An important caveat is that adding fat to the diet adds calories, so added
olive or avocado oil should be used to enhance taste by spraying them on fruits, vegetables, and
whole grains, rather than liberally spooning these fats into recipes. A meta-analysis has found that
high-MUFA diets reduce fasting glucose in patients with T2DM (Schwingshackl and Strasser 2012).
Diets enriched with MUFA may also reduce insulin resistance (Parillo et al. 1992). There is, how-
ever, concern that when high-MUFA diets are eaten ad libitum outside of a controlled setting, they
may result in increased energy intake and weight gain (Yu-Poth et al. 1999). A recent meta-analysis
of nine randomized controlled intervention trials with a total of 1547 participants and a running
time of at least 6 months compared high- and low-MUFA diets among adults with abnormal glucose
metabolism (T2DM, impaired glucose tolerance, and insulin resistance), being overweight or obese. It
was found that high-MUFA diets appear to be effective in reducing HbA1c, and therefore should be
recommended in the dietary regimes of T2DM (Schwingshackl et al. 2011). More studies comparing
diets high in MUFA with diets high in carbohydrate with ad libitum energy intake are needed to
evaluate the efficacy of these diets and determine the effects of MUFA in reducing cardiovascular
risk in diabetes.
7.5.8 Omega-3 Fatty Acids

The relationship between omega-3 polyunsaturated fatty acids (n-3 PUFAs) from seafood sources
(eicosapentaenoic acid [EPA] and docosahexaenoic acid [DHA]) or plant sources (α-linolenic acid
[ALA]) and risk of T2DM remains unclear. A meta-analysis that searched multiple literature data-
bases through June 2011 did not support either major harms or benefits from fish and seafood or
EPA and DHA on the development of diabetes mellitus, and suggested that ALA may be associated
with a modestly lower risk (Wu et al. 2012).
A multicenter, randomized, double-blind, placebo-controlled study evaluated the possible wors-
ening of glycemic control after a moderate daily intake of n-3 fatty acid ethyl esters in patients
with hypertriglyceridemia with and without glucose intolerance or diabetes (Sirtori et al. 1997).
Plasma triacylglycerol concentrations decreased significantly, up to 21.53% at 6 months compared
with baseline (decreased 15% compared with placebo), with a tendency toward a progressive reduc-
tion with time. There was no evidence for a different response in patients with either non-insulin-
dependent diabetes mellitus (NIDDM) or impaired glucose tolerance. Among NIDDM patients, the
triacylglycerol reduction was greater in those with HDL cholesterol of ≤0.91 mmol/L. There was no
alteration in the major GIs—fasting glucose, HbA1c, insulinemia, and oral glucose tolerance—in
patients with impaired glucose tolerance or NIDDM after treatment with n-3 ethyl esters.
In a pooled analysis with 23 RCTs and 1075 participants, n-3 PUFA supplementation in T2DM low
ered triglycerides and very low-density lipoprotein (VLDL) cholesterol, but it may raise LDL cho-
lesterol (although results were nonsignificant in subgroups) and has no statistically significant effect
on glycemic control or fasting insulin (Hartweg et al. 2008). Nonetheless, eating ocean-caught fish
three times per week as a substitute for meats will reduce calories and provide some cardiovascular,
eye, and brain benefits.
7.5.9 Spices and Glucose Control

Spices such as cinnamon (Ròu Guì, Cinnamomum cassia), red chili, cloves, black pepper, and gin-
ger also exhibit effects in insulin resistance, and the most active of them is cinnamon (Hlebowicz
et al. 2007; Aggarwal 2010). Cinnamon is commonly used as a spice across the world, and it is not
toxic at culinary levels, where it has been shown to be beneficial. Several studies have been con-
ducted to confirm the effect of cinnamon on decreasing the blood glucose of diabetic patients (Khan
et al. 2003; Lu et al. 2012; Allen et al. 2013).
7.5.10 Micronutrients
Selected micronutrients may affect glucose and insulin metabolism, but the data are minimal and
somewhat inconsistent for most trace minerals with this reputation, such as vanadium. On the
other hand, the positive effects of chromium on glucose metabolism have been recognized since
the observation that brewer’s yeast improved glycemic control in the 1920s. In 1957, chromium was
identified to be the active component of the glucose tolerance factor from brewer’s yeast (Mertz
1998; Chowdhury et al. 2003). Two recent studies did not show an improvement in either glycemia
or lipid parameters (Kleefstra et al. 2006; Ali et al. 2011). Western populations, which showed a
negative result with chromium supplementation, were chromium sufficient, in contrast to Asian
populations, such as the Chinese and Asian Indians, who tend to be chromium deficient. These
differences, as well as ethnic variations, may account for the disparate results in different studies
from various geographical and ethnic regions. Cefalu and coworkers conducted a comprehensive
evaluation of chromium supplementation on metabolic parameters in a cohort of T2DM subjects
representing a wide phenotype range to evaluate changes in “responders” and “nonresponders”
(Cefalu et al. 2010). After preintervention testing to assess glycemia, insulin sensitivity (assessed
by euglycemic clamps), chromium status, and body composition, subjects were randomized in
a double-blind fashion to placebo or 1000 μg of chromium. There was not a consistent effect of
chromium supplementation to improve insulin action across all phenotypes, but response to chro-
mium was more likely in insulin-resistant individuals who had more elevated fasting glucose and
A1c levels.
7.6 CONCLUSION
The nutritional approach to the adjunctive treatment of T1DM and T2DM patients is very different
despite the common observation of increased glucose in both groups.
The type 1 patient must have insulin and may benefit from the effects of foods that minimize glu-
cose excursions after meals, such as low-GI and high-fiber foods and foods rich in resistant starch.
However, if a type 1 patient is also obese, they would benefit from weight management, which
would also decrease the amount and complexity of their insulin regimen.
For type 2 patients, where obesity is almost universal, the primary goal is weight management.
Metformin is the first-line therapy for this condition. When the additional drugs described in this
chapter are added, it is important to question the adherence of the patient to dietary and exer-
cise recommendations. Clearly, weight loss is possible in simply obese, prediabetic, and diabetic
patients. To the degree that physicians and other caregivers communicate that weight management
is futile or that pharmacology is preferable with agents beyond metformin, we do a disservice to
diabetes patients. Recognizing that physicians alone cannot intervene effectively, we recommend
that an integrated primary care program be utilized. Our experience in 2000 patients with obesity,
prediabetes, or diabetes demonstrated clearly that significant weight loss can be achieved. Similarly,
the Look AHEAD trial achieved weight losses using meal replacements, physical activity, and food
logs. The treatment of T2DM can be revolutionized with the incorporation of these ideas into primary
care practice.
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8 Fatty Liver Disease
8.1 INTRODUCTION
Nonalcoholic fatty liver disease (NAFLD) is the most common cause of liver disease and the third
most common reason for liver transplantation. Other common liver diseases, including alcoholic
liver disease and viral hepatitis, often occur in obese patients who also have NAFLD.
Among patients over 50 years of age with diabetes or obesity, two-thirds are estimated to have
nonalcoholic steatohepatitis (NASH) with advanced fibrosis (Rinella 2015). The ability to identify
the NASH subtype within those with nonalcoholic fatty liver requires liver biopsy. Weight man
agement, diet, exercise, and lifestyle modification are the foundation of treatment for patients with
nonalcoholic steatosis. The association between NASH and cardiovascular disease is likely related
to the overlap with metabolic syndrome. The incidence of NAFLD-related hepatocellular carci-
noma (HCC) is increasing.
This common nutrition-related disorder occurs in between 75 million and 100 million individu-
als in the United States alone, and it has clear influences on systemic diseases, including cardiovas-
cular disease, when associated with metabolic syndrome (Rinella 2015). Current estimates suggest
that NAFLD and its progressive subtype NASH affect 30% and 5%, respectively, of the current
U.S. population. Fatty liver is found in 10–15% of normal-weight individuals and 70% of obese
subjects (Vernon et al. 2011).
The most common causes of death in patients with NASH are cardiovascular disease and malig-
nancy, and it is the most rapidly increasing indication for liver transplantation. Liver failure is often
associated with malnutrition and a clinical presentation that is common with jaundice, ascites, and
esophageal varices. Many of these patients require nutritional support, but there is no evidence that
it affects outcomes significantly at this late stage of disease.
It is important that primary care physicians and other health care providers be aware of the
commonality and the long-term health effects of NAFLD in association with obesity and diabetes.
Identification of patients with NASH at an early stage may help improve patient outcome through
lifestyle change.
8.2 PATHOPHYSIOLOGY OF NAFLD
The presence of liver fat deposition or steatosis is necessary but not sufficient for NASH to develop.
Fat accumulation of at least 5% of liver weight in the absence of significant alcohol intake is the
standard for diagnosing NAFLD (Vernon et al. 2011). The prevalence of NAFLD is approximately
20–30% in developed societies, but reaches up to 70–90% among subjects with obesity or dia
betes (Targher et al. 2010). The evidence that NAFLD is an independent risk factor for cardiovascu-
lar diseases (Bhatia et al. 2012; Lonardo et al. 2015b; Hazlehurst et al. 2016), as well as for type 2
diabetes mellitus (Kotronen et al. 2007; Anstee et al. 2013; Yki-Jarvinen 2014), is solid. Moreover,
the presence of both NAFLD and diabetes increases the likelihood of the development of complica-
tions of diabetes and more severe adverse outcomes of NAFLD.
The mechanisms leading one patient to develop NASH and another to only have steatosis with-
out inflammation are not known. It is known that abdominal visceral fat is a limited depot for fat
storage, and that fat is stored in the liver as well. In animal models, fat moves into the liver once
155
apoptosis of abdominal fat cells occurs. Visceral adipose tissue secretes adipokines under these
circumstances, which have been proposed to affect lipid and glucose metabolism, leading to hepatic
fat deposition and establishing inflammatory microenvironments in the liver that trigger cellular
injury. Oxidative stress, lipotoxic fatty acids, and apoptotic pathways contribute to liver damage. As
part of the injury response, fibrosis develops and can lead to cirrhosis. Inflammation can also lead
to the development of hepatocellular cancer in some patients (Figure 8.1).
Precursors and modifiers

Dietary fat
Genetic predisposition
Gut microbiome
Increased visceral
adipose tissue
Proinflammatory Insulin resistance Increased FFA

mediators
Liver
Altered glucose Altered lipid
metabolism metabolism
Hepatic steatosis
Lipotoxicity
Portal Intestinal
Inflammation
endotoxin dysbiosis
Steatohepatitis
Hepatocyte injury
(ballooning)
Endoplasmic Mitochondrial dysfunction

reticulum stress
Oxidative stress
Hepatocyte death
Necrosis
Necroptosis
Apoptosis
Proinflammatory Activation of hepatic

signaling stellate cells
Collagen deposition
Fibrosis
Cirrhosis
Hepatocellular
cancer
FIGURE 8.1 Mechanisms involved in the pathophysiology of fatty liver disease. FFA: Free fatty acids.
(Reprinted from Rinella, M. E., JAMA, 313(22), 2263–2273, 2015.)
Fatty Liver Disease 157
8.3 NAFLD AND METABOLIC SYNDROME

The overlap between NAFLD and metabolic syndrome is significant due to the common risk fac-
tors and pathophysiological mechanisms involved in both conditions (Kotronen et al. 2007; Stefan
et al. 2008; Fabbrini et al. 2010; Anstee et al. 2013; Machado and Cortez-Pinto 2014; Yki-Jarvinen
2014; Lonardo et al. 2015a). There are also population studies demonstrating the association of
metabolic syndrome and NAFLD (Ballestri et al. 2016). Insulin resistance, low adiponectin levels,
subclinical inflammation, endothelial dysfunction, and a prothrombotic state with impaired fibri-
nolysis are all linked to NAFLD and cardiovascular diseases, and the more aggressive forms of
NAFLD confer greater cardiovascular risk (Targher et al. 2010; Bhatia et al. 2012; Anstee et al.
2013; Liu and Lu 2014).
It has been proposed that in those who have NAFLD without concomitant metabolic syndrome,
the condition may originate from genetic susceptibility, while in those who have both NAFLD and
metabolic syndrome, the conditions are due to a Western lifestyle and its consequences, obesity and
insulin resistance. In the absence of metabolic syndrome, NAFLD does not increase the risk for
developing type 2 diabetes mellitus in comparison with healthy subjects. The perception that there
are different phenotypes of NAFLD and that the major division between the phenotypes is whether
the NAFLD is combined with insulin resistance is founded on numerous studies, including genetic
studies, some on a polymorphism of the PNPLA3 gene that is associated with NAFLD without
metabolic syndrome (Speliotes et al. 2010; Shen et al. 2014; Lonardo et al. 2015a; Park et al. 2015;
Petaja and Yki-Jarvinen 2016).
8.4 NAFLD AND CIRRHOSIS

Cryptogenic cirrhosis is unexplained by any other etiologies, including chronic viral hepatitis, alco-
hol abuse, toxin exposure, autoimmune disease, congenital disorders, vascular outflow obstruction,
or biliary tract disease. NAFLD is the most common cause of cryptogenic cirrhosis. A cause–effect
relationship between NAFLD and cryptogenic cirrhosis was first suggested (Caldwell et al. 1999)
when patients with cryptogenic cirrhosis typically presented one decade older with a high preva-
lence of obesity and diabetes, and similar in all other respects to patients with NASH. The relation-
ship between NASH and cryptogenic cirrhosis was also supported by a subsequent case-controlled
study (Poonawala et al. 2000). In one series, 27 of 37 (73%) patients presenting with cryptogenic
cirrhosis were overweight, and among the overweight group, 88% had diabetes, 56% had hypertri-
glyceridemia, and 90% had a family history of obesity or diabetes (Ratziu et al. 2002). The observed
rates were significantly increased in this overweight group compared with the lean patients with
cryptogenic cirrhosis and obese or lean patients with hepatitis C cirrhosis. The latter findings lend
additional credence to the concept that NAFLD is a common antecedent condition in many patients
with cryptogenic cirrhosis.
8.5 NAFLD AND HEPATOCELLULAR CANCER

In 2008, primary liver cancer was estimated to be the fourth most often diagnosed cancer in males
and the seventh in females (Jemal et al. 2011); moreover, it represented the second and fifth causes of
cancer deaths in males and females, respectively. The estimate in 2012 was even more alarming, as
liver cancer represented the overall second cause of cancer death in the world (IARC 2012). These
statistics reflect the poor prognosis of liver cancer worldwide.
The prevalent histological subtype of primary liver malignancies is HCC, which accounts for
70–85% of cases (El-Serag 2011). The major risk factor for HCC is cirrhosis, and the underlying
etiologies are viral infections (Tsukuma et al. 1993; Velazquez et al. 2003), alcohol, and metabolic
factors. While the epidemiological data concerning HCC in viral hepatitis and alcoholic hepatitis
are consistent, there is a lack of strong epidemiological data concerning the incidence and preva-
lence of HCC in NAFLD.
A few longitudinal outcome studies explored the prevalence of HCC in NAFL and NASH,
reporting a prevalence varying from 0% to 3% on a follow-up period between 5.6 and 21 years
(White et al. 2012). The percentage was increased if the incidence of HCC in NAFLD cirrhosis was
considered, with a cumulative HCC incidence ranging between 2.4%, with a median follow-up of
7.2 years, and 12.8%, with a 3.2-year median follow-up (White et al. 2012).
Obesity is associated with an increased relative risk of dying of cancer. It has been associated
with colorectal, breast, endometrial, and kidney cancer and esophageal adenocarcinoma (Calle and
Kaaks 2004). This association has also been established for HCC in a population perspective study
in the United States. More than 900,000 people were enrolled and stratified according to their body
mass index (BMI).
When matched with normal-weight individuals, the relative risk of dying from HCC was about
4.5-fold greater in patients with obesity (Calle et al. 2003). Another study, from Korea, which fol-
lowed 700,000 men for almost 10 years, confirmed the same strong association between HCC and
obesity (Oh et al. 2005). A higher relative risk for HCC in obese patients has also been described
in a Swedish population study of 362,552 subjects (Samanic et al. 2006). An article collecting data
from Norway, Austria, and Sweden found a 1.5-fold increased risk for HCC in obese subjects when
adjusted to the alcohol consumption in order to avoid confounding factors (Borena et al. 2012). In
a European prospective cohort study, general and abdominal obesity correlated with the risk of
HCC, and this was confirmed in a subanalysis that excluded hepatitis C virus (HCV)- and hepatitis
B virus (HBV)-positive subjects (Schlesinger et al. 2013). Also, in an Italian study the correlation
of obesity and HCC was confirmed; the correlation increased if the patients also had metabolic
syndrome (Turati et al. 2013).
In between about 7% and 50% of HCC in different series, the underlying etiology of liver disease
could not be determined (Marrero et al. 2002; Bosch et al. 2005; Bugianesi 2007). In 641 cases of
HCC, 44 patients, or 6.9%, were categorized as having cryptogenic cirrhosis. The prevalence of
diabetes and obesity was significantly higher in these subjects if compared with patients with viral
and alcoholic etiologies for their cirrhosis.
Obesity and diabetes are also two recognized risk factors of NASH, and the authors suggest
that NASH might represent the missing link between cryptogenic cirrhosis and HCC (Bugianesi
et al. 2002). The pathological features typical of NASH may not be present in the late stages of
liver disease (Powell et al. 1990; Caldwell et al. 1999; Poonawala et al. 2000), and in decom-
pensated cirrhosis, the typical clinical characteristics of NAFLD may be missing. In another
study, cryptogenic cirrhosis accounted for up to 29% of the cases of HCC. Half of these patients
expressed histological or clinical features of NAFLD, and at least 13% had histologically con-
firmed NAFLD (Marrero et al. 2002). These data suggest that the role of NAFLD in HCC might
be underestimated by the current epidemiological data, and that NAFLD could account for part
of the cryptogenic-related HCC. Based on these studies, the incidence of HCC can be expected
to grow globally, along with the increasing incidence of obesity and diabetes (Calle and Kaaks
2004). This observation is further supported by the fact that up to 70% of patients with type 2
diabetes and up to 90% of obese patients might have some degree of fatty liver disease (Siegel and
Zhu 2009; Michelotti et al. 2013).
The emergence of HCC in chronic liver disease occurs slowly over decades, with a transition
through dysplasia, precancer, and carcinoma (Thorgeirsson and Grisham 2002). There are many
known tumorigenic mechanisms that may contribute to genomic instability, including telomere
erosion, chromosome segregation defects, and alterations in the DNA damage repair pathways
(Farazi and DePinho 2006). When NAFLD is present, mechanisms related to obesity and diabetes
are also involved in the development of HCC (Karagozian et al. 2014; Margini and Dufour 2016)
(Figure 8.2).
Obesity
Chronic low grade

Peripheral inflammation response
insulin resistance Leptin
Adiponectin
Alteration of
Insulin
HCC gut microbiota
IGF
LPS
Iron
absorption
Hepatic
insulin resistance
Increased lipid storage Genetic polymorphism

and lipotoxicity PNLPA3
FIGURE 8.2 (See color insert.) The development of HCC in NAFLD is most likely multifactorial and
involves obesity-mediated mechanisms, including low-grade chronic inflammatory response, increased lipid
storage and lipotoxicity, alteration of gut microbiota with increased levels of lipopolysaccharide (LPS), and
insulin resistance with hyperinsulinemia and increased insulin-like growth factor (IGF) levels. Genetic poly-
morphisms might also contribute to the development of HCC in NASH. Increased iron absorption in NASH
has also been reported recently; although the mechanisms are at present still being investigated, a contribution
of iron in the development of HCC has been suggested. All these mechanisms are, at least partially, indepen-
dent from fibrosis, and this might explain the epidemiology of HCC in NASH, where noncirrhotic HCC is
more than a sporadic event. (Reprinted from Margini, C., and Dufour, J. F., Liver Int., 36(3), 317–324, 2016.)
8.6 FATTY LIVER INTERACTIONS WITH ALCOHOLIC AND VIRAL HEPATITIS

Fatty liver interacts with both alcohol and hepatitis C in increasing the risk of cirrhosis. The most
common causes of liver injury include acute and chronic viral infections (hepatitis A, B, and C),
alcohol damage, fatty liver, cirrhosis, and cancer. Much less common are drug-induced liver injuries
due to direct toxicity or less well-defined immunoallergic reactions.
Alcohol abuse remains one of the most common causes of both acute and chronic liver disease
in the United States and must be excluded in diagnosing NAFLD (Sofair et al. 2010). Up to 50% of
cases of end-stage liver disease are related primarily to alcohol, but alcoholic liver disease and fatty
liver due to obesity and diabetes can coexist and interact to promote the more rapid development of
liver failure (Orholm et al. 1985).
The association of obesity (i.e., BMI ≥30.0 kg/m2 or waist circumference ≥102 cm in men and
≥88 cm in women) and specific patterns of alcohol use (i.e., nondrinkers, nonexcessive drinkers,
and excessive drinkers) as a predictor of elevations in serum alanine aminotransferase (ALT) and
aspartate aminotransferase (AST) was studied in 8373 adults aged ≥20 years who participated in
the 2005–2008 National Health and Nutrition Examination Survey (Kochanek et al. 2011). The
survey revealed that 34.7% of adult men and 38.6% of adult women in the United States had both
obesity and any alcohol use, including 16.4% of men and 9.8% of women who had both obesity
and excessive drinking, between 2005 and 2008. When compared with male nondrinkers without
obesity after multivariate adjustment, male excessive drinkers with obesity were three times more
likely to have elevated ALT and 2.4 times more likely to have elevated AST. Similarly, when com-
pared with female nondrinkers without obesity, female excessive drinkers with obesity were 2.4
times more likely to have elevated serum ALT and 3.4 times more likely to have elevated serum
AST. The co-occurrence of obesity and excessive drinking may place adults at an increased risk
for potential liver injury (Kochanek et al. 2011). Since obese individuals commonly have fatty liver,
these observations support an interaction between alcohol abuse and obesity in promoting liver
damage.
8.7 DIAGNOSTIC DILEMMAS
There are no diagnostic tests that can predict who will develop advanced NAFLD characterized
by bridging fibrosis or cirrhosis. A BMI of more than 27, age older than 50 years, an ALT level
twice or more than the reference range, and a triglyceride level of 1.7 mmol/L or higher (≥151 mg/
dL) have been independently associated with advanced disease (Ratziu et al. 2002). Studies sug-
gest that there are some clinical factors that can be used to identify high-risk patients for whom
accurate diagnosis and staging may be most important.
In addition, there are no noninvasive tests to diagnose or stage NAFLD. Liver biopsy remains the
most sensitive diagnostic test but cannot distinguish NAFLD from other causes of fatty liver dis-
ease, such as alcohol abuse. Elevated serum aminotransferase levels suggest a diagnosis of NAFLD.
However, these tests are both nonspecific and insensitive biomarkers of NAFLD-associated liver
damage. The degree of liver enzyme elevation does not correlate with the level of histologic cellular
damage. Liver function tests cannot reliably distinguish steatosis from steatohepatitis or cirrhosis.
Serum aminotransferase levels may be normal or only slightly elevated even though liver disease
is advanced.
Imaging studies, such as abdominal ultrasound, computed tomography (CT), or MRI, are useful
in demonstrating hepatic steatosis when fat accumulation is moderate to severe. However, these tests
cannot separate steatosis from NASH. Portal hypertension as evidenced by splenomegaly, ascites,
and varices indicates the presence of cirrhosis, which can occur without much liver fat being present
at the time of diagnosis. Thus, imaging tests for fat are most useful for detecting earlier stages of the
disease, when hepatic steatosis predominates.
Therefore, the diagnosis of NAFLD remains one of exclusion after other causes of chronic liver
disease have been excluded. Operationally, therefore, NAFLD percolates to the top of the list of
potential diagnoses in individuals whose liver disease remains cryptogenic after the standard, non-
invasive clinical and laboratory evaluation for liver disease has been completed. Diagnostic confi-
dence is increased considerably when overweight, obesity, and type 2 diabetes mellitus are present
as well. In one study of asymptomatic patients who were referred for diagnosis of mild, cryptogenic
liver enzyme elevations, histological proof of steatosis or steatohepatitis was found in approximately
70% of individuals (Skelly et al. 2001).
A presumptive diagnosis can be made when the following are present: (1) elevated serum liver
enzyme levels (AST, ALT, or γ-glutamyltransferase), (2) imaging studies with evidence of fat, (3) min-
imal or no alcohol intake, and (4) negative test results for viral hepatitis, autoimmune disease (primary
biliary cirrhosis), and congenital liver diseases such as Wilson’s disease.
8.8 CLINICAL PRESENTATION OF SIGNIFICANT LIVER DAMAGE

Once advanced liver disease results in a significant breakdown of hepatic reserve for repair and
regeneration, jaundice occurs secondary to increased levels of bilirubin in the blood and in tis-
sues. The increased bilirubin results from the breakup of the hemoglobin of dead red blood cells.
Normally, the liver removes bilirubin from the blood and excretes it through the bile. Diseases that
interfere with liver function will lead to derangement of these processes. However, the liver has a
great capacity to regenerate and has a large reserve capacity. In most cases, the liver only produces
symptoms after extensive damage.
The classic symptoms of liver damage include the following:
1. Pale stools, when stercobilin, a brown pigment, is absent from the stool. Stercobilin is derived
from bilirubin metabolites produced in the liver.
2. Dark urine, when bilirubin mixes with urine.
3. Jaundice, which is a yellowing of the skin and whites of the eyes due to bilirubin deposits,
and pruritus, which is a common presenting complaint with liver failure, even in patients
without jaundice. Often, this pruritus cannot be relieved by drugs.
4. Swelling of the abdomen, ankles, and feet, because the liver fails to make albumin, leading
to osmotic flow of fluids into extracellular space and peritoneal fluid.
5. Fatigue, as a result of malnutrition associated with nausea and anorexia.
6. Bruising and easy bleeding, from reduced liver synthesis of clotting proteins.
Liver diseases can be diagnosed by physical examination, imaging, and liver-associated labora-
tory tests. The term liver function tests is commonly used for AST, ALT, bilirubin, alkaline phos-
phatase, and lactate dehydrogenase (LDH) measurements. These tests are not measures of liver
function, but rather reflect biochemical functions of the liver or the release of liver enzymes into
the bloodstream due to damage to liver cells. These liver-associated tests can be used in the overall
evaluation of liver function, but sometimes can be normal even in the face of liver cirrhosis or liver
failure. When infections are suspected, serologic studies can be informative, and when trace miner-
als are suspected, chemical testing can be informative.
8.9 NUTRITIONAL APPROACHES TO LIVER DISEASE

There are currently no approved proven treatments for NAFLD. Some options under study are
(1) lifestyle modifications to induce weight loss through caloric restriction and physical activity;
(2) insulin-sensitizing agents, including biguanide (metformin) and thiazolidinediones (rosigli-
tazone and pioglitazone); (3) antioxidants, including but not limited to vitamin E, betaine, and
N-acetylcysteine; (4) ursodeoxycholic acid; and (5) lipid-lowering agents.
Lifestyle modifications, including smoking cessation and weight loss, if applicable, are crucial
to improving the outcome of those suffering from NAFLD complicated by obesity, alcoholic liver
disease, and viral hepatitis. Smoking is an independent risk factor for the advancement of hepatic
fibrosis, which can lead to more rapid progression of liver disease, and may be linked to the devel-
opment of HCC (Armstrong 1992; Corrao et al. 1994). Obesity, which can also cause fatty liver,
NASH, and cirrhosis, may be an independent risk factor for the progression of alcoholic liver dis-
ease (Naveau et al. 1997).
8.9.1 Fructose and Fatty Liver

Fructose is an isomer of glucose (Stanhope and Havel 2010) but is metabolized very differently
from glucose. Recent decades have witnessed an enormous rise in fructose consumption. Studies on
ancient diets have shown that at the dawn of agriculture 8500 years ago, the intake of fructose per
capita was around 2 kg/year from fruits and vegetables. The industrialization of sugar production
from plantations in the seventeenth century converted a rare spice from the Orient into an expen-
sive staple item used in baked goods and candies. Significant increases in consumption occurred
following the abolition of sugar taxes in the 1870s. By 1950, annual consumption had increased to
45 kg/person/year, and by 1997, nearly 20 years after the introduction of high-fructose corn syrup
into the food supply, consumption had risen to 69 kg/year (Lim et al. 2010; Lustig 2010). Fructose
is used in a wide variety of food products due to its sweeter taste and its lack of inhibition of satiety
compared with other sugars (Lustig 2010). From a metabolic standpoint, fructose is absorbed by the
small intestine and is transported across the epithelial barrier into cells and the bloodstream by the
fructose-specific GLUT5 transporter (Tappy et al. 2010). Entry of fructose into cells is not insulin
dependent and does not promote insulin secretion, unlike glucose. Absorbed fructose is transported
in plasma via the hepatic portal vein to the liver, where fructose is predominantly metabolized via
its phosphorylation; only a small amount of fructose is metabolized by hexokinase in muscle and
adipose tissue (Lim et al. 2010; Lustig 2010).
Starting in the 1960s, a number of animal and human studies have reported associations between
excessive fructose consumption and adverse metabolic effects, which may have important hepatic
consequences (including the development of NAFLD). The potential role of fructose in the patho-
genesis of NAFLD has recently gained increased attention (Lim et al. 2010; Lustig 2010; Nseir et
al. 2010; Stanhope and Havel 2010; Tappy et al. 2010; Alisi et al. 2011; Anania 2011; Castro et al.
2011; Nomura and Yamanouchi 2012). Fructose can lead to NAFLD by promoting an increase in
fasting and postprandial triglycerides, which can in turn result in liver fat deposition (Teff et al.
2004; Ackerman et al. 2005; D’Angelo et al. 2005; Lê and Tappy 2006; Koo et al. 2008; Zhu et al.
2008; Gallagher et al. 2010, 2011; Moore 2010; Sanyal et al. 2010; Huang et al. 2011; McCullough
2011). In addition, hypertriglyceridemia secondary to excess fructose consumption under conditions
of positive calorie balance has been shown to promote insulin resistance (Gallagher et al. 2010;
Huang et al. 2011). Chronic fructose consumption causes hyperinsulinemia due to insulin resistance
(Gallagher et al. 2010).
Continuous fructose ingestion may impose a metabolic burden on the liver through the induction
of fructokinase and fatty acid synthase. In the liver, fructose is metabolized to fructose-1-phosphate
by fructokinase, which consumes ATP (Lim et al. 2010; Lustig 2010). As a consequence, a massive
incorporation of fructose into liver metabolism can lead to high levels of metabolic stress via ATP
depletion. In an experimental study in the rat (Koo et al. 2008), it was shown that fructose-induced
fructokinase hyperexpression in the liver can be reduced (by 0.6-fold) by the hydroxymethyl-
glutaryl-coenzyme A reductase inhibitor atorvastatin. Of note, clinical studies have shown that
atorvastatin can improve liver injury in NAFLD patients with hyperlipidemia (Teff et al. 2004; Lê
and Tappy 2006). Fatty acid synthase catalyzes the last step in the fatty acid biosynthetic pathway
and is a key determinant of the maximal capacity of the liver to synthesize fatty acids by de novo
lipogenesis (D’Angelo et al. 2005). In a clinical study, increased fructose consumption in patients
with NAFLD was associated with hyperexpression of hepatic mRNA for fatty acid synthase, sug-
gesting that this molecular derangement could play a crucial role in fructose-induced fatty liver
infiltration (Ackerman et al. 2005).
8.9.2 Vitamin E, Fish Oils, Phytonutrients, and Overall Nutrition for Liver Disease
In fatty liver disease, some evidence exists supporting the use of vitamin E. Vitamin E was studied
in 167 adult patients with NASH and without diabetes who received either vitamin E at a dose of
800 IU daily (84 subjects) or placebo (83 subjects) for 96 weeks (Sanyal et al. 2010). The primary
outcome was an improvement in histologic features of NASH, as assessed with the use of a com-
posite of standardized scores for steatosis, lobular inflammation, hepatocellular ballooning, and
fibrosis. There was an improvement in histologic features in 43% of those who received vitamin E
compared with 19% of those receiving placebo. Additional studies are necessary to confirm these
findings.
Omega-3 fatty acids are approved in the United States to treat hypertriglyceridemia. They are
also available over the counter as dietary supplements. There has been significant interest in explor-
ing the effects of omega-3 fatty acids in animal models of fatty liver, as well as in humans with
NAFLD. Many of the human trials have been in small numbers of individuals treated for varying
times. In one study of 144 NAFLD patients with dyslipidemia given either 2 g of omega-3 fatty acids
from seal oils or placebo for 24 weeks, omega-3 fatty acid supplementation was associated with
significant improvement in serum aminotransferases, serum triglycerides, and hepatic steatosis at
24 weeks (Zhu et al. 2008). There is an ongoing phase 3, multicenter, randomized controlled trial
of eicosapentaenoic acid (EPA) in patients with biopsy-proven NASH in the United States, and its
results are expected to shed further light on the role of omega-3 fatty acids in the management of
NAFLD (ClinicalTrials.gov identifier: NCT01154985).
Coffee consumption has been associated with benefits in liver disease for unclear reasons, with
some proposing that aromatic extracts isolated from coffee beans may be beneficial (Huber et al.
2002). Coffee oils, called diterpenes, have been evaluated. The diterpenes kahweol and cafestol
have been shown to have beneficial effects on glutathione metabolism (Scharf et al. 2001). However,
the idea of diterprene effects on liver health may be mitigated by the fact that most of these fats are
trapped by the filter paper used to make traditional American coffee by the drip method. They sur-
vive in coffee made by the French press method. Nonetheless, it is also possible that caffeine itself
may have antioxidant activity providing a beneficial effect (Lee 2000).
Lecithin, a mixture of phospholipids from plant sources, may have a role to play in liver dis-
ease, but to date, the human studies have not demonstrated clear benefits. Lecithin has been dem-
onstrated to prevent alcoholic liver cirrhosis in baboons (Lieber et al. 1994) and appears to have
anti-inflammatory, antiapoptotic, and antifibrotic effects (Cao et al. 2002; Okiyama et al. 2009).
However, a Veterans Affairs Cooperative Study evaluating lecithin in humans with early alcoholic
liver disease (Lieber et al. 2003b) failed to show definitive benefits. It has been proposed that the
results were compromised by patients decreasing their alcohol use markedly during the trial.
Milk thistle (Silybum marianum) is a popular dietary supplement for patients wishing to main-
tain liver health. The active ingredient on which studies have been performed is silymarin, and
supplements recommended should be standardized for silymarin content. In animal models, hepato-
protective effects of milk thistle in several forms of liver injury (toxic hepatitis, fatty liver, cirrhosis,
ischemic injury, radiation toxicity, and viral hepatitis) have been shown. Mechanisms including
anti-inflammatory, antioxidative, antifibrotic, and immunomodulating effects are thought to explain
the benefit of silymarin in liver disease (Lieber et al. 2003a). A randomized, double-blind control
evaluating placebo versus silymarin in alcohol- and non-alcohol-induced cirrhosis showed a 39%
versus 58% 4-year survival, respectively (Ferenci et al. 1989). However, similar trials have failed
to show outcome benefit (Parés et al. 1998; Lucena et al. 2002). Meta-analyses have failed to dem-
onstrate a benefit for silymarin, but as is often the case in meta-analyses, the trials analyzed had
numerous flaws, making any interpretation difficult (Rambaldi and Gluud 2006).
In hepatitis and cirrhosis, abnormal hepatic gene expression of methyl donor metabolism, specif-
ically in methionine and glutathione metabolism, occurs and often contributes to decreased hepatic
S-adenosylmethionine (SAM), cysteine, and glutathione levels (Lee et al. 2004). Rodent and pri-
mate studies demonstrate that SAM depletion occurs in the early stages of fatty liver infiltration,
and decreased SAM concentration, liver injury, and mitochondrial damage can be reversed with
SAM supplementation (Lieber 2002). SAM appears to attenuate oxidative stress and hepatic stel-
late cell activation in an ethanol-LPS-induced fibrotic rat model (Karaa et al. 2008). Clinical trial
evidence is lacking.
Betaine (trimethylglycine) is a key nutrient for humans that is similar in function to choline and
can be obtained from a variety of foods and nutritional supplements (Purohit et al. 2007). In the liver,
betaine can transfer one methyl group to homocysteine to form methionine. This process removes
toxic metabolites (homocysteine and S-adenosylhomocysteine), restores SAM levels, reverses ste-
atosis, prevents apoptosis, and reduces both damaged protein accumulation and oxidative stress
(Kharbanda et al. 2007; Kharbanda 2009). Betaine also appears to attenuate alcoholic steatosis by
restoring phosphatidylcholine generation via the phosphatidylethanolamine methyltransferase path-
way (Kharbanda et al. 2007). Studies suggest that betaine offers hepatic protection against ethanol-
induced oxidative stress by decreasing sulfur-containing amino acid breakdown as well (Kim et al.
2008). Betaine supplementation is promising, but there are further clinical studies needed.
8.9.3 Management of Protein Malnutrition in Advanced Liver Disease

It has long been established that patients with liver disease can be malnourished, with the degree of
malnutrition correlating with disease severity (Prijatmoko et al. 1993; Halsted 2004). In addition,
complications of liver disease (e.g., infections, encephalopathy, ascites, and variceal bleeding) have
been shown to be strongly associated with protein–calorie malnutrition (PCM) (Nielsen et al. 1993;
Prijatmoko et al. 1993). Micronutrient deficiencies of folate, vitamin B6, vitamin A, and thiamin
are among the most commonly encountered. Mineral and element (e.g., selenium, zinc, copper, and
magnesium) levels are often altered in alcoholic liver disease and, in some instances, are thought
to be involved in its pathogenesis (Halsted 2004). In particular, zinc is decreased in patients with
liver disease. In animal models, zinc supplementation has been shown to improve, attenuate, and/or
prevent alcoholic liver disease through a variety of mechanisms (Kang and Zhou 2005).
Patients with liver disease can have varying nutritional status, from morbid obesity to profound
underweight and malnutrition. Given the high-caloric content of alcohol (7.1 kilocalories/g), patients
with both alcoholic liver disease and fatty liver due to obesity can expect to have more rapid pro-
gression of underlying liver damage, such as that associated with alcoholic liver disease (Nielsen
et al. 1993; Raynard et al. 2002). Given similar mechanisms of pathogenesis, including oxidative
stress and inflammation, patients with the metabolic syndrome or insulin resistance and concomi-
tant alcoholic liver disease or viral liver disease would be expected to have more severe disease with
a quicker progression to fibrosis (Griffith and Schenker 2006).
At the other end of the nutritional spectrum, several mechanisms are hypothesized to contribute
to advanced liver disease-associated malnutrition. Decreased caloric intake (secondary to anorexia
and reduced intake of nonalcohol calories), decreased intestinal absorption and digestion of nutri-
ents (secondary to altered gut integrity, pancreatic insufficiency, decreased bile excretion, and a
decrease in intestinal enzymes), and decreased processing and storage of nutrients (secondary to
decreased functional liver mass, abnormal oxidation of fat, and preferential metabolism of alcohol)
are all thought to be involved in the malnutrition associated with alcoholic liver disease (Griffith
and Schenker 2006). Increased catabolism of skeletal muscle and visceral proteins leading to a
hypermetabolic state in alcoholic hepatitis is also a key component in the development of PCM in
alcoholic liver disease (John et al. 1989).
With so many mechanisms at play, the diagnosis and treatment of malnutrition in patients with
liver disease is sometimes difficult. The laboratory tests most commonly used to assess nutritional
status (e.g., anthropometry and serum albumin concentration) are often affected by concomitant
liver disease. In order to obtain valid data on the prevalence and degree of malnutrition among
alcoholics with alcoholic liver disease, reliable and sensitive methods to assess nutritional status
are required. Easily applicable techniques include anthropometric measurements, such as BMI, tri-
ceps skinfold thickness, and midarm muscle area. Other approaches include bioelectric impedance
analysis for assessing body composition, and the determination of resting energy expenditure by
indirect calorimetry. Each technique has limitations and may give erroneous results in patients with
alcohol-related cirrhosis. For metabolic studies, direct measurements are needed. In a recent study,
different methods for the assessment of body composition in patients with liver cirrhosis were com-
pared (Prijatmoko et al. 1993). All applied techniques, including bioelectric impedance analysis,
total body nitrogen content, dual x-ray absorptiometry, and four-site skin-fold measurements, could
detect advanced protein malnutrition, but differed significantly in patients with high volumes of
extracellular fluid, such as ascites and peripheral edema. Although these mistakes may be avoided
with more precise approaches, such as in vivo neutron activation analysis and isotope dilution tech-
niques (Nielsen et al. 1993), application of these methods is time-consuming and restricted to the
research setting. Patients with severe forms of liver disease should simply be considered malnour-
ished and treated as such.
Nutritional support for these patients depends on the severity of liver disease, concomitant fac-
tors leading to malnutrition (e.g., anorexia and pancreatic insufficiency), and the presence of obesity.
Obese patients with less severe liver injury should be referred to a dietician and advised concerning
dietary restriction and regular exercise. In outpatient therapy for patients with liver disease, nutri-
tional support in patients with cirrhosis improves nutritional status and cell-mediated immunity,
as well as decreases infectious complications and consequent hospitalizations (Hirsch et al. 1993,
1999). Another study of patients with cirrhosis demonstrated that a late-evening nutritional supple-
ment over a 12-month period improved body protein stores (Plank et al. 2008). While more study is
warranted, our general practice is to encourage bedtime nutritional supplements in outpatients with
severe liver disease or cirrhosis.
The Veterans Administration Cooperative Studies Program (Mendenhall et al. 1984, 1985,
1986, 1993, 1995; Prijatmoko et al. 1993) included more than 600 patients hospitalized with alco-
holic liver cirrhosis. PCM was present in nearly all patients. The degree of malnutrition correlated
with the development of serious complications, such as encephalopathy, ascites, and hepatorenal
syndrome. Moreover, nutritional support improved nutritional and metabolic parameters, severity
of liver injury, and most importantly, mortality in patients with moderate malnutrition and alco-
holic liver disease. A major multicenter study demonstrated that enteral nutrition, when compared
with corticosteroids, has similar short-term mortality rates, improved 1-year mortality rates, and
reduced infectious complications (Cabré et al. 2000). An additional study demonstrated the benefit
of tube-fed nutrition (improved clinical status, bilirubin, and markers of liver function based on
drug clearance) compared with a regular diet (Kearns et al. 1992). Parenteral nutrition for patients
with liver disease is rarely indicated but appears to improve liver function and nitrogen balance.
However, it fails to convey a survival benefit over standard therapy (Simon and Galambos 1988;
Cabré et al. 2000).
The American College of Gastroenterology (ACG) and the American Association for the Study
of Liver Diseases (AASLD) guidelines recommend 1.2–1.5 g/kg of protein and 35–40 kilocalories/
kg of body weight/day in patients with advanced liver disease (McCullough and O’Connor 1998).
The available clinical trials vary considerably regarding the composition of the nutritional support
utilized (Griffith and Schenker 2006). In patients with advanced cirrhosis, supplementation with
oral branched-chain amino acids (BCAA) was compared to lactalbumin or maltodextrin. BCAA
supplementation by comparison to lactalbumin or maltodextrin led to improved perceived health
status, improved biomarkers, and reduced hospital stays (Marchesini et al. 2003). Another study
demonstrated that long-term BCAA supplementation is associated with decreased frequency of
hepatic failure and overall complication frequency (Charlton 2006). Other studies have not been as
clear in establishing a benefit (Calvey et al. 1985).
While some studies have failed to demonstrate a clear survival benefit for all patients with severe
liver disease receiving enteral nutrition (Cabré et al. 2000; Griffith and Schenker 2006), the imple-
mentation of aggressive nutritional support in these patients is generally performed since at a mini-
mum, nutritional support will improve metabolic status.
8.10 CONCLUSION
The majority of patients with NAFLD are overweight and obese, lead relatively sedentary lifestyles,
and have underlying insulin resistance. Treatment aimed at improving body weight and activity
should be the basis of approaches to combating this disease. Evidence suggests that diets low in pro-
cessed carbohydrates and saturated fats with a goal to achieve a 500–1000 calorie/day deficit improve
insulin sensitivity, reduce serum aminotransferases, and decrease hepatic steatosis. Improvements
are seen with as little as a 5% reduction in body weight. Weight loss through total caloric restriction
results in improved parameters of insulin sensitivity and regression of hepatic steatosis (Petersen et
al. 2005). Data regarding the utility of specific dietary regimens may be debated, but it appears that
diets consisting of a reduction in processed carbohydrates and saturated fats to effect a caloric deficit
of 500–1000 calories/day may be beneficial and can be recommended in overweight or obese patients
with NAFLD (Paredes et al. 2012). Histopathologic parameters of steatohepatitis also appear to
improve with weight loss. Antioxidant supplementation, specifically with vitamin E, may be consid-
ered as adjunctive therapy. Larger confirmatory studies are needed to ensure they are safe and ben-
eficial in patients with NASH. For patients failing to achieve weight loss goals, future approaches are
likely to consist of combination therapy targeting insulin resistance, oxidative stress, and fibrogenesis.
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9 Lipid Disorders
and Management
9.1 INTRODUCTION
This chapter examines and discusses the issues around lipid disorders and primary care man-
agement, integrating nutrition and lifestyle intervention, which is not the traditional educational
paradigm. Education on lipid metabolism in primary care has traditionally centered on the phar-
macological treatment of elevated blood cholesterol levels in order to prevent atherosclerosis and
cardiovascular (CV) events and mortality (Berliner et al. 1995; Levine et al. 1995).
In the 1980s, statins were being strongly credited as a singular way to prevent heart disease.
When cholesterol-lowering drugs were first marketed, it was already evident that the etiology
of atherosclerosis was a complex of factors at the cellular level involving oxidation, inflammation,
and genetics (Berliner et al. 1995). Beyond simply cholesterol, the differing dietary responsive-
ness of lipid levels among individuals with different lipid disorders is stressed in this chapter,
along with the role of nutrition in these processes. While official guidelines always mentioned that
dietary intervention should be the first step in treating lipid disorders, this was always followed
by the statement that if diet failed, as was frequently expected, one should use pharmacological
treatment.
The most common dyslipidemias have elevations of both triglycerides and cholesterol and respond
to weight reduction and the inclusion of nutrients that lower blood cholesterol levels. Patients with
isolated hypercholesterolemia (Fredrickson type IIa) have minimal responses to dietary changes.
However, these unrepresentative patients with isolated hypercholesterolemia were studied in some
of the most widely read publications, incidentally supported by the drug industry. To balance the
emphasis in primary care education, the effects of dietary changes on lipids need to be emphasized,
along with the importance of a healthy diet and lifestyle for overall health. Therefore, this chapter
concentrates on nutritional effects in more common lipid disorders, with a brief review of current
drug therapies and clinical guidelines on pharmacotherapy in lipid management.
Familial hypercholesterolemia (FH) of the most common type, which includes both elevated
triglycerides and cholesterol, demonstrated greater effects of statin in lowering cholesterol levels
when statins were used together with low-fat diets than when they were used with high-fat diets
under metabolic ward conditions (Cobb et al. 1991).
The observations on the interactions of diet and lipid-lowering therapy have not made it into
the consciousness of many primary care practitioners. As a result, some patients believe that they
can eat whatever they want as long as they are taking cholesterol-lowering drugs, without fear of
developing heart disease.
While there has been a somewhat consistent but evolving message on cholesterol-lowering phar-
macotherapy and heart disease, which is reviewed later in this chapter, changes over the past few
decades in dietary advice to the public have been filled with controversies, such as the one on the
effects of saturated fats and dietary cholesterol on blood lipid levels and the general cacophony of
controversies on the importance of nutrition altogether in lipid management. These controversies
have led many primary care health care providers to simply give lip service to nutrition while rely-
ing on drug therapy to manage lipid disorders. Starting from basic physiology and metabolism and
describing the most common lipid disorders, this chapter redirects your attention to the important
role of nutrition.
173
9.2 LIPOPROTEINS AND LIPID METABOLISM

Lipoproteins consist of both lipids and protein, as the term implies. Since lipids are not soluble
in the aqueous phase of the circulation, lipoproteins, with a polar surface and lipophilic core,
enable the movement of lipids around the circulation for delivery to cells for synthesis of vari-
ous hormones and other lipid metabolites. In addition, lipoproteins have proteins embedded in
their outer core that signal the identity of the particular lipoprotein to enzymes that mediate their
metabolism.
Lipoproteins are classified based on their behavior in sucrose gradient centrifugation so that they
are characterized as high density if they deposit lower in the gradient (e.g., high-density lipoproteins
[HDLs]) or low density (e.g., low-density lipoproteins [LDLs] and very low-density lipoproteins
[VLDLs]), which float at higher levels. In addition, LDLs exist in small, dense and large, fluffy
fractions with different atherogenic potentials.
This chapter is a discussion of lipid disorders and management. While disorders of choles-
terol metabolism and transport are important, the numerous implications of maintaining lipid
levels beyond just cholesterol in a healthy range are also important. For example, triglycerides
and HDL cholesterol (HDL-C) can serve as important biomarkers of metabolic syndrome, insu-
lin resistance, and prediabetes, among other disorders. Small, dense LDLs are associated with
visceral obesity and hypertriglyceridemia. Moreover, it is important to understand the important
role of nutrition and how recommendations such at the step I and step II diets by the American
Heart Association (AHA) have evolved over the last decade to incorporate modern nutritional
concepts.
9.3 DISORDERS OF CHOLESTEROL METABOLISM AND TRANSPORT

Cholesterol is carried into vessel walls by several types of lipoproteins to different extents, includ-
ing VLDL (Knopp et al. 1994), remnant lipoprotein (Coresh and Kwiterovich 1996), LDL, and the
small, dense form of LDL found in association with abdominal obesity (Coresh and Kwiterovich
1996). Conversely, cholesterol is carried away from the arterial wall by HDL (Fielding and Fielding
1995; Oram and Yokoyama 1996).
In healthy persons, these lipoproteins function to distribute and recycle cholesterol, triglyc-
erides, and other lipid-soluble substances, including phytonutrients (Knopp 1989). Cholesterol
is absorbed from the intestine and transported to the liver by chylomicron remnants, which are
Lipid from FHTG

diet FCHL
Chylomicrons
VLDL
Lipoprotein
lipase FHTG
Remnants Peripheral
Remnants RRD
cell
Cholesterol
LRP LDL LDL-R
LDL-R
FH Cholesterol
Hepatic CETP
Bile acids lipase
cholesterol HDL
Hypoalphalipoproteinemia
FIGURE 9.1 (See color insert.) Pathways of lipid transport. (Reprinted from Knopp, R. H., N. Engl. J. Med.,
341(7), 498–511, 1999.)
Lipid Disorders and Management 175
taken up by the LDL receptor-related protein (LRP). Hepatic cholesterol enters the circulation as
VLDL and is metabolized to remnant lipoproteins after lipoprotein lipase removes triglyceride.
The remnant lipoproteins are removed by LDL receptors (LDL-Rs) or further metabolized to
LDL and then removed by these receptors. Cholesterol is transported from peripheral cells to the
liver by HDL. Cholesterol is recycled to LDL and VLDL by the cholesterol-ester transport protein
(CETP) or is taken up in the liver by hepatic lipase. Cholesterol is then excreted in bile.
The points in the processes of cholesterol transport in Figure 9.1 can be affected by five primary
lipoprotein disorders, including (1) familial hypertriglyceridemia (FHTG), (2) familial combined
hyperlipidemia (FCHL), (3) remnant removal disease (RRD) (also known as familial dysbetalipo-
proteinemia), (4) FH, and (5) hypoalphalipoproteinemia.
9.4 DIFFERENTIATING COMMON AND RARE LIPID DISORDERS

9.4.1 Familial Hypertriglyceridemia and Secondary Hypertriglyceridemia
Hypertriglyceridemia is one of the most commonly encountered lipid abnormalities. Elevations of fasting
triglycerides above 150 mg/dL are found in a significant percentage of populations diagnosed with the
metabolic syndrome and are extremely common. On the other hand, only 1.7% of a sample of 5680 sub-
jects participating in the National Health and Nutrition Examination Survey from 2001 and 2006 had
severe hypertriglyceridemia, defined as levels between 500 and 2000 mg/dL. These individuals were
more likely to be men (75.3%), non-Hispanic whites (70.1%), and ages 40–59 years (58.5%). More than
14% of those with severe hypertriglyceridemia reported having diabetes mellitus, and 31.3% reported
having hypertension. Only 14% of the subjects reported using statins, and 4.0% reported using fibrates.
The factors significantly associated with having severe hypertriglyceridemia included HDL of <40 mg/
dL, non-HDL of 160–189 mg/dL, diabetes mellitus, and chronic renal disease (Christian et al. 2011).
Evidence of fasting hypertriglyceridemia should prompt an investigation for secondary causes,
such as high-fat diet, uncontrolled carbohydrate intake, excessive alcohol intake, certain medica-
tions, and medical conditions, such as type 2 diabetes mellitus and hypothyroidism. Patients should
also be evaluated for other components of the metabolic syndrome, including abdominal obesity,
fasting hyperglycemia, reduced HDL levels, and hypertension.
Hypertriglyceridemias are classified as primary FHTG when there are no secondary causes
found. The two most common familial dyslipidemias are Fredrickson type IIb (FCHL) and type
IV (FHTG). Together, these two dyslipidemias account for 85% of familial dyslipidemias. Primary
hypertriglyceridemia is the result of various genetic defects leading to disordered triglyceride
metabolism. It is important to treat severe hypertriglyceridemia in order to prevent pancreatitis
by reducing triglyceride levels to <500 mg/dL. Severe hypertriglyceridemia accounts for 1–4% of
cases of acute pancreatitis. Although a few patients can develop pancreatitis with triglyceride lev-
els of >500 mg/dL, the risk for pancreatitis does not become clinically significant until levels are
>1000 mg/dL (Athyros et al. 2002; DiMagno and Chari 2002).
Lifestyle changes are the first line of treatment for most patients with hypertriglyceridemia.
These changes include a weight management plan incorporating a low-saturated-fat, carbohydrate-
controlled diet, combined with alcohol reduction, smoking cessation, and regular aerobic and resis-
tance exercise. High doses of omega-3 fatty acids on the order of 2–4 g/day from fish and fish oil
supplements will lower triglyceride levels significantly. When patients do not reach their goals by
lifestyle and nutritional interventions, then drug therapy should be started. In cases of isolated
hypertriglyceridemia, fibrates are indicated. In patients with low HDL levels and hypertriglyceride-
mia, extended-release niacin can be considered.
While cholesterol has been the focus of preventive cardiology for decades, there is an increased
interest in triglycerides for two reasons. First, hypertriglyceridemia is the most common lipid disor-
der, as it is associated with dyslipidemias and insulin resistance, both of which are components of
the metabolic syndrome. Second, despite aggressive statin therapy, residual risk remains a problem
for patients with this disorder, especially those with mixed hyperlipidemia (Christian et al. 2011).
They have increased triglyceride-rich lipoproteins and small, dense LDL particles that easily pen-
etrate the endothelium of coronary arteries and arterioles throughout the body.
Although triglyceride is not directly found in atheromas, high triglyceride levels are found in
excess atherogenic remnants, such as VLDL and small, dense LDL. Insulin resistance can con-
tribute to hypertriglyceridemia by increasing free fatty acid delivery to the liver, which can either
increase lipoprotein production or promote hepatic lipogenesis. Triglycerides are the most sensitive
index of the metabolic syndrome (Li et al. 2013).
Despite triglyceride levels being cardiovascular disease (CVD) risk predictors based on epi-
demiologic studies, clinical studies have thus far not examined the direct effects of triglyceride
lowering. A triglyceride-to-HDL ratio of >3.5 is a good predictor of insulin resistance and can
thus be used as a target for treatment with diet and lifestyle or drug therapy. A triglyceride
level of <150 mg/dL is considered an achievable target; if the level is below 150 mg/dL, fur-
ther reductions can raise HDL. In addition to dietary changes and drugs, increased exercise by
increasing the insulin sensitivity and fatty acid oxidation capacity of muscle can further reduce
triglyceride levels.
Combination therapy aimed at lowering triglyceride levels can be used, along with aggressive
statin therapy in individuals at high risk of CVD (Davidson 2007). Potential combinations include
niacin and fibrates. The addition of omega-3 fatty acid supplements to simvastatin (40 mg) further
lowers non-HDL-C, triglycerides, and VLDL (Harris 2007). Omega-3 fatty acids work as well
as fenofibric acid and do not have some of the potentially negative effects of fenofibrate, such as
increased creatinine and homocysteine levels. Omega-3 fatty acids reduce triglyceride levels by
inhibiting hepatic lipogenesis and increasing hepatic fatty acid oxidation, while also increasing
peroxisome proliferator-activated receptor (PPAR) α.
Tissue triglyceride stores are a balance among uptake, oxidation, and storage. Although the
release of stored triglyceride from adipocytes was thought to depend on the actions of hormone-
sensitive lipase (HSL), creation of HSL knockout mice failed to show this and led to the discovery
Glycogen Triglycerides Phospholipids
Lipolysis
Synthesis Breakdown Synthesis Synthesis
Glucose Fatty acids
Gluconeogenesis Glycolysis Synthesis β-oxidation
Pyruvate Acetyl-CoA
Acetyl-CoA
TCA
cycle
Generation of NADH/FADH2
Electron transport chain
ATP synthesis
FIGURE 9.2 Mobilization of stored triglycerides is initiated by lipolytic enzymes. Liberated fatty acids are
then activated to their respective acetyl-CoA metabolites. Breakdown of fatty acyl-CoA to acetyl-CoA occurs
in peroxisomes or mitochondria via β-oxidation enzymes. TCA, tricarboxylic acid.
of a new enzyme, adipose triglyceride lipase (ATGL). Genetic deletion of ATGL in mice leads to
a marked increase in triglyceride storage in tissues (Zechner 2007). Intricate metabolic networks
tightly coordinate the flow of sugars and triglycerides through synthesis, storage, and breakdown
pathways (Figure 9.2).
9.4.2 Hypercholesterolemia and Familial Hypercholesterolemia

FH is due to genetic mutations in either the LDLR gene that encodes the LRP, which normally
removes LDL from the circulation, or apolipoprotein B (apoB), which is the part of LDL that binds
with the receptor. Mutations in other genes are rare. People who have one abnormal copy of the
LDLR gene may develop CVD prematurely at the age of 30–40. Having two abnormal copies may
cause severe CVD in childhood. Heterozygous FH is a common genetic disorder, inherited in an
autosomal dominant pattern, occurring in 1 in 500 people in most countries. Homozygous FH is
much rarer, occurring in 1 in 1 million births (Rader et al. 2003).
Heterozygous FH is normally treated with statins that lower cholesterol levels. New cases are
generally offered genetic counseling. Homozygous FH often does not respond to medical therapy
and may require other treatments, including LDL apheresis (removal of LDL in a method similar to
dialysis) and occasionally liver transplantation (Rader et al. 2003).
Hypercholesterolemia is typically due to a combination of environmental and genetic factors
(Rader et al. 2003). Environmental factors include obesity, diet, and stress. A number of secondary
causes of hypercholesterolemia include diabetes mellitus type 2, obesity, alcohol, monoclonal gam-
mopathy, dialysis, nephrotic syndrome, hypothyroidism, Cushing’s syndrome, anorexia nervosa,
and medications (thiazide diuretics, ciclosporin, glucocorticoids, β-blockers, and retinoic acid)
(Bhatnagar et al. 2008).
9.5 HYPERTRIGLYCERIDEMIA AND THE UNRECOGNIZED

IMPACT OF VISCERAL FAT
As already discussed, a large body of evidence supports the reduction of LDL cholesterol (LDL-C)
as the primary objective of dyslipidemia management, and the administration of statins is consid-
ered the most effective regimen for achieving this. Consequently, statins have become the treatment
of choice in the majority of patients, including those with type 2 diabetes mellitus, with the over-
whelming majority of these patients having concomitant excess internal body fat or obvious obesity
(Graham et al. 2007).
The Cholesterol Treatment Trialists’ (CTT) meta-analysis of 27 large statin trials, with
almost 175,000 participants with five categories of CVD risk, demonstrated that statin treat-
ment is beneficial in all categories (Mihaylova et al. 2012). However, it is also clear that many
patients remain at high risk despite reaching recommended LDL-C targets using statins. The
“residual risk” identified with these observations is due to hypertriglyceridemia and reduced
levels of HDL-C (Fruchart et al. 2008). It is likely that HDL-C is an integrated biomarker of
several metabolic processes, including insulin resistance and inflammation. HDL-C has mul-
tiple targets, and both the amount of HDL-C and functions of HDL lipoprotein are associated
with CVD risk in a complex fashion (Voight et al. 2012). Hypertriglyceridemia is also associ-
ated with an increased CVD risk, but the association is weakened by adjustment for other risk
factors, including HDL-C, so that some studies find no association with CVD risk (Emerging
Risk Factors Collaboration et al. 2009). The poor understanding among physicians and patients
of the importance of hypertriglyceridemia in association with low HDL-C as a risk factor is one
of the reasons for inadequate treatment of residual CVD risk (Reiner et al. 2010a,b). Another
major reason is that this lipid pattern is associated with the metabolic syndrome, obesity, and
type 2 diabetes, all these requiring a combined diet and lifestyle change program, as well as
pharmacotherapy.
Fibrates are the most efficient drugs for treating hypertriglyceridemia, in addition to diet and
lifestyle (Rubins et al. 1999; Bezafibrate Infarction Prevention Study 2000; Keech et al. 2005).
Gemfibrozil monotherapy has been shown to decrease rates of CVD events in subjects with elevated
non-HDL-C or low HDL-C (Rubins et al. 1999; Fruchart et al. 2008), including men with type 2
diabetes (Rubins et al. 2002; Voight et al. 2012). However, gemfibrozil is not recommended for addi-
tion to a statin (Oram and Yokoyama 1996; Zechner 2007; European Association for Cardiovascular
Prevention & Rehabilitation et al. 2011; Perk et al. 2012) because of its association with an elevated
risk of myopathy and/or rhabdomyolysis. The randomized Action to Control Cardiovascular Risk
in Diabetes (ACCORD) lipid study investigated whether fenofibrate reduced the risk of CVD when
added to simvastatin in patients with type 2 diabetes mellitus (ACCORD Study Group et al. 2010).
The primary outcome, the annual rate of first occurrence of nonfatal MI, nonfatal stroke, or CVD
mortality, was not significantly different between treatments. Heterogeneity in the patient popula-
tion was thought to contribute to the lack of a statistically significant result, while subgroup analysis
suggested a benefit in patients who at baseline had elevated triglycerides and low HDL-C. Data from
ACCORD were included in a meta-analysis of five trials, which was published as a letter (Sacks
et al. 2010). These data suggest that fibrates reduced the risk of CVD events by 35% in subjects with
low HDL-C and high triglycerides, but not in those without this dyslipidemia.
9.6 CONTROL OF LDL CHOLESTEROL FOR PREVENTION

OF ATHEROSCLEROTIC CARDIOVASCULAR DISEASES
In 1985, the National Heart, Lung, and Blood Institute of the National Institutes of Health created
the National Cholesterol Education Program (NCEP) in order to educate the medical profession
and the general public on the need to identify and treat high blood cholesterol in reducing coronary
heart disease (CHD) risk (Warnick et al. 2002). Most experts agree that there is clear evidence of
benefit, but the natural history of atherosclerosis goes beyond cholesterol in millions of individuals.
Therefore, the clinical guidelines have evolved under the guidance of the Adult Treatment Panel
(ATP), a panel of experts from major medical and health professional associations, voluntary health
organizations, community programs, and governmental agencies. The ATP was formed to develop
guidelines for the detection, evaluation, and treatment of high blood cholesterol in adults.
The ATP guidelines remain the most accepted reference guideline for clinical management
of high blood cholesterol. With continual clinical advances in the science of cholesterol manage-
ment, these guidelines have been updated several times. The first ATP guideline (ATP-I) published
in 1988, outlined a strategy for the primary prevention of CHD in individuals with high LDL-C
(>160 mg/dL) or borderline-high LDL-C (130–159 mg/dL) and more than two risk factors (Report
of the National Cholesterol Education Program 1988; Expert Panel on Detection, Evaluation, and
Treatment of High Blood Cholesterol in Adults 2001). In 1993, ATP-II, the second ATP guideline,
supported the approach of ATP-I and added a new feature of intensive management of LDL-C
in patients with established CHD (secondary prevention) and fixed a new, lower LDL-C goal of
<100 mg/dL in CHD patients (Anon 1993; Ansell et al. 1999). In 2001, the third ATP guideline,
ATP-III (Report of the National Cholesterol Education Program 1988; Expert Panel on Detection,
Evaluation, and Treatment of High Blood Cholesterol in Adults 2001; National Cholesterol Education
Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults
2002), updated the recommendations for clinical management of high blood cholesterol and related
abnormalities. The key features of ATP-III included consideration of LDL-C of <100 mg/dL as an
optimal level and the introduction of the Framingham risk score (10-year CHD risk) to calculate
treatment intensity. It also, for the first time, introduced a diet and lifestyle program called “thera-
peutic lifestyle modification,” or TLC. Also for the first time, secondary targets in ATP-III included
non-HDL-C in patients with a triglyceride value of ≥200 mg/dL and metabolic syndrome.
Since ATP-III, five major clinical trials involving statins have been completed. In 2004, a further
updated ATP-III based on the results of these five clinical trials was published (Grundy et al. 2004;
Stone et al. 2005). These trials addressed important issues that were not included in ATP-III. For
patients at extremely high risk, a new LDL-C goal of <70 mg/dL was added.
This gradual evolution of NCEP guidelines in the form of ATP guidelines (ATP-I through ATP-
III) has had a significant impact on cholesterol management (Conti 2002). The 2013 American
College of Cardiology/American Heart Association (ACC/AHA) Guideline on the Treatment of
Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the ACC/
AHA Task Force on Practice Guidelines in November 2013 (Warnick et al. 2002). The final docu-
ment now serves as the most current U.S. guidelines for management of blood cholesterol for CVD
risk reduction (Gibbons et al. 2013).
For primary prevention, the recommended risk assessment tool in the ACC/AHA guidelines is
the new CV risk calculator based on the pooled cohort equations, as described in the 2013 ACC/
AHA Guideline on the Assessment of Cardiovascular Risk (Goff et al. 2014). The equations are
derived from large, diverse, community-based cohorts that are generally representative of the U.S.
population of whites and African Americans (Dawber et al. 1963; Kannel et al. 1979; Friedman
et al. 1988; Atherosclerosis Risk in Communities 1989; Fried et al. 1991). The calculator provides
race- and sex-specific estimates of the 10-year risk of first hard atherosclerotic cardiovascular dis-
ease (ASCVD) event (nonfatal myocardial infarction, CHD death, and fatal or nonfatal stroke) and
should be used in non-Hispanic African Americans and non-Hispanic whites between 40 and 79
years of age.
Lifetime or 30-year risk is also provided for individuals age 20–59 years who are not at high
short-term risk. Recommended optional variables and/or screening tests that may be considered
to refine risk assessment include family history of premature ASCVD; high-sensitivity C-reactive
protein (hsCRP) of >2 mg/L; coronary artery calcium score of >300 Agatston units, or >75th per-
centile for age, sex, and ethnicity; and ankle brachial index. Based on expert opinion, the presence
of any of these screening abnormalities supports revising the patient’s risk assessment to a higher
level of risk.
In addition to a new risk calculator for CVD risk assessment, the ACC/AHA guidelines also
recommend a novel strategy for the management of LDL-related risk. Guidelines from multiple
organizations have previously focused on the fasting lipid panel as the initial evaluation of lipid-
related CVD risk. Within each category of ASCVD risk, targets of treatment are then specified in
these recommendations.
Upon systematic review of the evidence, authors of the new ACC/AHA guidelines determined
that current clinical trial data did not support this approach. Also, the data are inadequate to indicate
specific lipoprotein goals of therapy. Therefore, the panel made no recommendation for or against
specific targets (LDL-C or non-HDL-C) for primary or secondary ASCVD prevention. Instead,
these experts identified four groups of patients in which there is the most extensive evidence of the
benefit of statin therapy for the prevention of ASCVD:
1. Individuals with clinical ASCVD

2. Individuals with primary elevations of LDL-C of >190 mg/dL
3. Individuals 40–75 years of age with diabetes and LDL-C of 70–189 mg/dL
4. Individuals without clinical ASCVD or diabetes who are 40–75 years of age with LDL-C
of 70–189 mg/dL and an estimated 10-year ASCVD risk of >7.5% by the pooled risk
equations
For each risk group, the guidelines recommend an intensity of statin therapy, either moderate
or high intensity. Low-intensity statins are recommended only in patients who have experienced or
are at risk for adverse effects of treatment. The guidelines do not support dose titration to achieve
optimal levels of LDL-C, non-HDL-C, or apoB, as recommended in previous guidelines. Also, in
a significant departure from previous guidelines, the 2013 ACC/AHA guidelines recommend mea-
surement of on-therapy LDL-C only as an assessment of adherence and response to therapy.
Application of the new risk assessment tool in the National Health and Nutrition Examination
Surveys of 2005 and 2010 resulted in a substantial increase in adults eligible for statin therapy (12.8
million), particularly in older adults (Pencina et al. 2014). In a European cohort, investigators deter-
mined that application of the new CV risk calculator would recommend that all men and 65% of
women older than age 55 years would be candidates for treatment with a statin (Kavousi et al. 2014).
In the study populations of the Multi-Ethnic Study of Atherosclerosis, the Women’s Health Study,
the Physicians’ Health Study, and the Women’s Health Initiative Observational Study, authors com-
pared the observed and predicted event rates by the CV risk calculator, finding that the new algo-
rithm overestimated observed risks by approximately 75–150% (Ridker and Cook 2013). However,
in the Reasons for Geographic and Racial Differences in Stroke study, the observed and predicted
5-year ASCVD risks were similar when patients with diabetes, LDL-C of <40 or >189 mg/dL, and
current statin therapy were excluded, and in Medicare participants (Muntner et al. 2014). Certainly,
validation of the CV risk calculator in other data sets will address these concerns and determine its
applicability in persons at varying levels of ASCVD risk and in more ethnically diverse populations.
Finally, the risk calculator also provides 30-year or lifetime risk for patients who are age 20–59
years, but the guidelines provide limited specific information on treatment recommendations for
individuals with high lifetime risk.
It is no surprise that a revolutionary change from decades of emphasis on LDL-C goals of ther-
apy in dyslipidemia would generate considerable controversy and confusion among health care
providers, the media, and patients. It is important to note that although there are significant changes
in the new 2013 ACC/AHA guidelines, there are recommendations that are consistent with those
of the NCEP ATP-III, ATP-III update panels, and other organizations. LDL remains the lipopro-
tein of interest, as recommended in the previous guidelines of the ATP-III and current recom-
mendations of the International Atherosclerosis Society (IAS), American Association of Clinical
Endocrinologists (AACE), Kidney Disease: Improving Global Outcomes (KDIGO), and others not
reviewed here. Very high-risk patients with manifest ASCVD or FH and/or LDL-C of >190 mg/dL
continue to be candidates for high-intensity statin therapy. Also, in patients with FH, combination
therapy with high-intensity statins and cholesterol absorption inhibitors, bile acid sequestrants, LDL
apheresis, or newer therapies is considered for additional reduction of LDL-C levels, even in the
absence of a specific LDL-C target. As in previous guidelines, the new ACC/AHA recommenda-
tions consider diabetic patients as a high-risk group; however, the intensity of therapy is now based
on the 10-year estimate of risk of a hard ASCVD event by the pooled risk equations.
Overall, adherence to all doses of statin therapy in at-risk patients is poor in both primary pre-
vention and high-risk populations (Anon 1997; Jackevicius et al. 2008; Kumbhani et al. 2013). As
the new ACC/AHA guidelines recommend initiation of only high- and moderate-intensity statins
in high-risk patients, there is concern for even further reductions in compliance with prescribed
statin or appropriate statin intensity. Although a newly validated risk assessment algorithm is rec-
ommended by the ACC/AHA in primary prevention patients and diabetics without ASCVD, the
intensity of statin therapy is still closely related to the intensity of risk, as recommended by other
guidelines.
In summary, all these guidelines now recognize the heterogeneity of the populations with ele-
vated cholesterol and are working around the edges of what is clearly a multifactorial disease in
which statins are not the total solution. Personalized nutrition therapy, in conjunction with pharma-
cotherapy as needed, with an emphasis on compliance, should do much to rationalize the overuse of
statins, as recommended in the most recent guidelines.
9.7 IMPACT OF NUTRITION ON LIPID DISORDERS

Diet has an effect on blood cholesterol, but the size of this effect varies substantially between indi-
viduals. Reductions in the dietary intake of cholesterol lead to increased production of the choles-
terol principally by the liver. As the cholesterol pool is reduced through binding and excretion, the
rate of cholesterol synthesis increases in the liver so that net reductions in blood levels of cholesterol
are modest (Howell et al. 1997). As recognized in the latest U.S. dietary guidelines, eating high-
cholesterol foods is not prohibited in cholesterol-lowering diets, including shellfish, which were on
the avoidance list of the American Heart Association for decades. Foods rich in saturated fats and
calories are also rich in omega-6 fatty acids, so lean meats should be recommended for occasional
intake, while ocean-caught fish, plant proteins, and low-fat poultry, such as chicken breast and tur-
key breast meats, are consistent with a nutritional plan intended to help manage lipid levels.
A number of dietary interventions have been developed with an emphasis on lipid management.
Meta-analyses and randomized controlled trials published in English and including data on the
effect on blood lipid levels were reviewed to establish an evidence-based recommendation on these
diets (Huang et al. 2011). Randomized controlled trials were included if they were at least 4 weeks
in duration and had a minimum of 50 participants. A total of 22 different dietary interventions and
136 studies published between January 1990 and December 2009 were reviewed that met specific
inclusion criteria. In this broad-based approach, the Pritikin, Ornish, Mediterranean, and portfolio
diets, discussed below, were found to have beneficial effects on lipids.
Special dietary patterns beyond the low-fat diets of Nathan Pritikin (Barnard et al. 1982; Pritikin
1984) and Dean Ornish (Ornish et al. 1990) have been recommended to reduce cholesterol levels
and prevent heart disease. In fact, both the Ornish and Pritikin diets were approved by Medicare to
be included in cardiac rehabilitation programs (Anon 2010). The original composition of these very
low-fat diets included only about 15% of calories from fat and 15% of calories from low-fat protein
from plant and animal sources. As a result, the balance of calories often came from refined carbo-
hydrates, which at calorie balance led to increased triglycerides in about half of patients treated.
The Atkins high-fat diet, originally a weight loss diet as a result of severely restricted refined
carbohydrates, has been shown to help control triglycerides, especially in patients with diabetes or
prediabetes (Dr. Atkins’ 1973). However, the initial benefits on weight loss and lipids by comparison
with a low-fat diet seen over 6 months disappear at 1 year. Compliance with the recommended high-
fat proteins is especially difficult for women, and men tend to introduce carbohydrates after a few
months on this strict diet (Foster et al. 2003). The Mediterranean diet emphasized using omega-9 fat
from olives and avocados, together with a diet based on Italian and Greek cuisine (de Lorgeril 2013),
with no particular emphasis on calorie restriction. The portfolio, developed by Dr. David Jenkins in
Canada, emphasized monounsaturated fats from nuts and seeds (Ramprasath et al. 2014).
In addition to the above dietary patterns, a number of individual foods and nutrient have been
used for lipid management. Soy protein substituted for animal protein led to a reduction in cho-
lesterol levels and an approved health claim in the United States for soy protein when used with a
low-fat diet (Anderson and Bush 2011). Soluble fibers, such as guar and pectin, have been shown
to lower cholesterol modestly (Gunness and Gidley 2010). Plants do not synthesize cholesterol, but
they do make phytosterols, which are structurally similar to cholesterol (Malina et al. 2015). As a
result, phytosterols are able compete for uptake in the ileum with cholesterol, resulting in a modest
drop in cholesterol levels (Malina et al. 2015). β-Glucan, found in oatmeal and whole grain foods,
can also lower cholesterol (Ho et al. 2016). While omega-3 fatty acid supplementation primarily
lowers triglyceride levels, it also finds its way into general recommendations for lipid management.
Chinese red yeast rice is derived from a yeast called Monascus purpureus, which was fermented
on white rice in traditional Chinese medicine. The yeast synthesizes a family of polyketide anti-
biotics called monacolins. One of these, monacolin K, is structurally identical to lovastatin, sold
as Mevacor by Merck and approved by the Food and Drug Administration (FDA) in 1987 for the
control of cholesterol The Dietary Supplement Health and Education Act (DSHEA) was approved in
1994 and had within it a paragraph stating that any substance previously approved as a drug could
not be considered a dietary supplement. It was originally marketed in the United States following
a clinical study at the University of California, Los Angeles (UCLA) showing that 6 mg of mona-
colin K within a 1200 mg capsule containing rice and yeast led to a 20% reduction in cholesterol
levels over 12 weeks, comparable to the effects of 20 mg of lovastatin (Heber et al. 1999). It was
proposed that the other monacolins and bioactive substances in the red yeast rice contributed to the
cholesterol-lowering activity. The clearance by the liver of Chinese red yeast rice is greater than the
clearance of lovastatin, likely due to the multiple compounds activating liver clearance mechanisms
(Heber et al. 1999). In any case, the FDA sued the manufacturer and based on the DSHEA law,
Chinese red yeast rice was declared an unapproved drug from China. It is legal in most other coun-
tries, and in 2010, it was the subject of a positive opinion by the European Food Safety Authority.
Suffice it to say that used in the way that drugs are used without regard to diet, none of the above
supplements will provide adequate lipid control. The basis of all efforts to control lipids must be to
exercise regularly and eat a diet low in fat, high in fiber, and using low-fat plant and animal protein.
Beyond those guidelines, patients should be given discretion to choose supplements that are safely
manufactured and shown to be effective in clinical studies.
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10 Nutrition and Coronary
Artery Disease
10.1 INTRODUCTION
Over the past 30 years, the cellular and molecular basis of coronary artery disease (CAD) has been
demonstrated to be linked to inflammation promoted by unbalanced nutrition, hypertension, dia-
betes, stress, sedentary lifestyle, obesity, and poor-quality diets. The reduction of the progression
of atherosclerosis through modulation of inflammatory, immune, and vascular factors reinforces
a nutritional approach to secondary prevention in individuals with diagnosed CAD. For patients
who have yet to develop disease of the coronary arteries, the concept of heart disease is theoreti-
cal and focused on a reduction in cholesterol and other lipid levels for some preventive benefit, as
discussed in Chapter 9. The emphasis of that chapter was to move patients away from a sole focus
on cholesterol by discussing lipid disorders and metabolism broadly, while stressing the importance
of triglycerides, dyslipidemia, and the metabolic syndrome as the most common lipid disorders.
In this chapter, the emphasis is on patients who have suffered a cardiac event and have diagnosed
CAD. These patients are likely to be concerned with secondary prevention and, much like a cancer
survivor, are likely to be interested in detailed discussions of how to prevent a recurrence of their
cardiovascular event and death. According to the World Health Organization, cardiovascular dis-
ease is the leading cause of mortality worldwide, leading to an estimated 18 million deaths each
year (Murray et al. 2012). CAD is considered the main cardiovascular disorder, causing 46% of the
cardiovascular mortality in men and 38% in women (Wong 2014). It is estimated that about 80%
of all mortality from cardiovascular disorders could be prevented with the elimination of obesity,
sedentary lifestyles, and poor-quality diets (World Health Organization 2011).
It has been demonstrated repeatedly that adherence to a higher-quality diet is associated with
decreased mortality risk (Jankovic et al. 2014). In common with the state of primary care education
on other age-related chronic diseases reviewed in this book, nutrition and lifestyle changes are not
the focus of primary care education in the treatment of CAD and secondary prevention. In addition
to the treatment of CAD with drugs, primary care education focuses on the availability of modern
interventional cardiology procedures, such as stenting, percutaneous aortic valve replacement, and
cardiac surgery. While these advances in procedures have a central role in cardiology practice, the
primary care practice can contribute to better patient outcomes by adding an emphasis on dietary
and lifestyle factors that can delay, reduce, or reverse the progression of CAD to an unstable plaque
that bursts and causes a cardiac event that may be fatal.
CAD shares many features of the age-related chronic diseases reviewed in other chapters and
involves a critical role for elevated blood lipids, but also involves multiple cellular and molecular
events, providing an opportunity for diet and lifestyle changes to reduce the progression of athero-
sclerosis in patients with diagnosed CAD until the very late stages of the disease.
Inflammation has a significant role at all stages of atherosclerosis, including initiation, progres-
sion, and plaque formation. Secondary prevention is possible even after a cardiac event occurs or
when atherosclerosis is advanced based on imaging evidence, such as coronary arterial calcifica-
tion by computed tomography (CT) scan, or evidence of cardiac muscle dysfunction by electro-
cardiogram (EKG) stress treadmill or cardiac angiograms. The progression of atherosclerosis is
not an inevitable forward process. Not only does elevated cholesterol from the circulation settle
in the space below the endothelium of the coronary arteries as oxidized cholesterol, but there is
also reverse cholesterol transport mediated by high-density lipoprotein (HDL) cholesterol particles.
187
In addition, there are other healing processes, such as angiogenesis and nitric oxide (NO) produc-
tion, that can be augmented through nutrition and exercise.
Therefore, the role of inflammation and oxidative stress in atherosclerosis, which has been estab-
lished over the past 30 years, will be the central emphasis of this chapter, with dietary recommenda-
tions that augment those already provided with regard to the control of lipid metabolism and lipid
disorders in Chapter 9.
10.2 CORONARY ARTERY DISEASE, UNSTABLE PLAQUES,

AND MYOCARDIAL INFARCTION
The heart is the only organ that provides its own blood supply via branches from the major coronary
arteries, including the main coronary artery, the left anterior descending artery, the right coronary
artery, and the circumflex artery. From each of these major arteries, there are smaller branches
providing oxygen and nutrients to a region of the heart muscle. Most regions of the heart muscle are
supplied by two coronary arteries. In the regions between zones of coronary artery blood supply,
there are areas of the heart muscle that are particularly vulnerable to hypoxic injury.
The coronary arteries supply blood flow to the heart, and when functioning normally, they ensure
adequate oxygenation of the myocardium at all levels of cardiac activity. Constriction and dilation
of the coronary arteries, governed primarily by local regulatory mechanisms, regulate the amount
of blood flow to the myocardium in a manner that matches the amount of oxygen delivered to the
myocardium with the myocardial demand for oxygen.
Gradual hypoxia stimulates angiogenesis in the heart, providing additional oxygen as needed in
areas where blood flow may be diminished due to CAD. Angiogenesis during cardiac rehabilitation
from a myocardial infarction can play a major role in protecting the heart. However, a sudden block-
age of a large or medium-sized coronary artery can trigger hypoxic injury of large amounts of heart
muscle, leading to sudden death or congestive heart failure. Such sudden blockages result from the
formation of blood clots when an unstable atherosclerotic plaque bursts suddenly. The transition of
atherosclerotic plaques with necrotic cores, calcified regions, accumulated modified lipids, inflamed
smooth muscle cells, endothelial cells, leukocytes, and foam cells from stable lesions to unstable
plaques that rupture or erode suddenly is responsible for the sudden blockage of a coronary artery
(Figure 10.1), leading to a myocardial infarction (Murray et al. 2012).
Intracoronary imaging studies have revealed that unstable plaques that are vulnerable to rupture
have a number of typical features, including increased plaque volume, a necrotic core, increased
lipid and inflammatory cell content, thin fibrous caps, and neovascularization and hemorrhage
within the plaque (Virmani et al. 2002). Many unstable plaques often coexist in the coronary arter-
ies of individuals with CAD. Clinical trials have demonstrated the benefits of primary and sec-
ondary prevention therapies targeted against CAD risk, and progress has been made in reducing
some risk factors, such as dyslipidemia (Cholesterol Treatment Trialists Collaboration et al. 2010)
and hypertension (blood pressure) (Turnbull and Blood Pressure Lowering Treatment Trialists
Collaboration 2003), while both diabetes and obesity are increasingly common, so that the preva-
lence of plaque rupture or erosion leading to initial or recurrent myocardial infarctions remains
high (Libby 2005).
(a) (b) (c)
FIGURE 10.1 Schematic representation of (a) normal coronary artery with normal blood flow, (b) partially
blocked coronary artery with stable plaque, and (c) acutely ruptured unstable plaque leading to blockage and
myocardial infarction.
Nutrition and Coronary Artery Disease 189
The realization that unstable plaques are the cause of heart attacks, rather than some uniform and
gradual accumulation of cholesterol that completely blocks a coronary artery, led to a major shift in
preventive cardiology, from the idea of simply lowering cholesterol levels to stabilizing or reversing
the process of atherosclerosis so that unstable plaques would be stabilized and some stable plaques
reduced in size.
10.2.1 Cellular Basis of Atherosclerosis and Inflammation

Atherosclerosis is the most common pathological process that leads to CAD, a disease of large- and
medium-sized arteries of the heart. Atherosclerosis has been called hardening of the arteries due to
calcification in the walls of the vessels, first noted by Rudolf Virchow in the early twentieth century,
as he noticed a loud click as he passed a scalpel through a coronary artery vessel during an autopsy.
For much of the nineteenth and early twentieth centuries, it was believed that atherosclerosis was
simply a lipid storage disorder that gradually narrowed blood flow through the coronary arteries,
ultimately blocking them. Low-density lipoprotein (LDL) cholesterol that enters the endothelial
space and is oxidized remains the most important risk factor for atherosclerosis, and has been the
focus of most pharmacological research on CAD. However, immune and inflammatory mechanisms
of atherosclerosis have come to be understood as important mechanisms for the development of CAD
over the past 30 years (Ross 1999; Hansson and Libby 2006; Mayerl et al. 2006; Methe and Weis
2007; Weber et al. 2008). Inflammation plays a vital role in all stages of the disease, from plaque
initiation and lesion progression up to ultimate complications, such as plaque rupture, intraplaque
hemorrhage, and thromboembolism (Ross 1999). The many components of atherosclerotic plaques
demonstrate that the vascular, metabolic, and immune systems are involved in this process.
The term arteriosclerosis was first introduced in 1829 (Mayerl et al. 2006). Within a few years,
the associated cellular immune alterations within the arteries were described by two different
schools of pathology, resulting in two theories of atherosclerosis. Rudolf Virchow postulated an
initial role for aortic cellular conglomerates, emphasizing that cellular actions were critical to the
progression of atherosclerosis. In contrast, Carl von Rokitansky suggested that initial injury of the
vessel wall owing to mechanical injury and toxins led to endothelial dysfunction and further inflam-
mation (Methe and Weis 2007). As with many competing theories in medicine, both ideas came to
be accepted as part of the pathogenesis of atherosclerosis.
In the 1970s, the response-to-injury model was described (Ross 1999). However, a large num-
ber of recent papers have emphasized that the chronic inflammatory response also has an immune
component (Hansson and Libby 2006). Arterial samples from Rokitansky’s collection of ves-
sels obtained at autopsy were analyzed and showed T-cell accumulation present in early lesions,
suggesting that lymphocytes play an essential role in atherosclerosis. The detailed mechanisms
whereby endothelial cell function, lipid metabolism, and lipid retention become unbalanced and
disturbed within the plaque have not been determined, but it appears that atherosclerosis entails
immune responses locally mediated through complex cellular interactions within the endothe-
lium, and that, in addition, injury to the wall of the blood vessel may trigger an innate immune
response.
There are multiple factors involved in the formation and progression of established atheroscle-
rotic plaques. Most of the research on atherosclerotic plaque formation, progression, and instability
has been conducted on tissues obtained at autopsy and surgery or from studies on experimental ani-
mals, since it is difficult to acquire atherosclerotic tissue from living patients (Ludewig et al. 2000;
Libby et al. 2002). The presence of active inflammation with resident T-lymphocytes or macro-
phages within plaque is one of the criteria that make these arterial wall lesions vulnerable to rupture
(Gerrity et al. 1979). White blood cells within atherosclerotic lesions were first found in the early
1980s (Gerrity et al. 1979), including neutrophils, macrophages, and lymphocytes (van der Wal and
Becker 1999; Galkina and Ley 2007a). Blood monocytes enter different tissues and differentiate
into tissue-resident macrophages or dendritic cells.
Atherosclerotic plaques are formed in very specific regions of the aortic tree in mice, where
flow is disturbed. On the other hand, very little inflammation or atherosclerosis is found in portions
of the aorta in mice where there is smooth laminar flow (Jongstra-Bilen et al. 2006). Activated by
disturbed flow, endothelial cells increase their expression of adhesion molecules and chemokines,
which accelerate leukocyte recruitment to the vessel wall. Rolling and firm adhesion of monocytes
to aortic endothelium was documented in an ex vivo model of the carotid artery and in vivo (Galkina
and Ley 2007b) as the first step in monocyte entry into the subendothelial space.
Macrophages within plaques can assume different phenotypes (Byrne and Kalayoglu 1999;
Stoneman et al. 2007). M1 macrophages are characterized by high local production of NO and reac-
tive oxygen intermediates. The production of NO in this context is a pro-inflammatory event medi-
ated by the inducible nitric oxide synthase (NOS) in macrophages, similar to events documented
in tumor tissue. This reaction should not be confused with the production of NO from nitrite in
cardiac muscle under conditions of hypoxia, which is a beneficial event discussed later in this chap-
ter. M1 macrophages typically participate in the resistance against intracellular parasites and tumor
development (Mantovani et al. 2009). M2 macrophages are mainly functional in tissue remodel-
ing, angiogenesis, and tumor progression. M2 macrophages are also involved in the regulation of
immune function and allergic reactions (Mantovani et al. 2004; Adamson and Leitinger 2011).
There is further complexity of macrophage phenotype beyond simply M1 and M2. According to the
stimulus they receive, alternative M2 macrophages can be classified into at least four distinct phe-
notypes (Adamson and Leitinger 2011). Human atherosclerotic lesions have highly heterogeneous
macrophage phenotypes. Many factors in the microenvironment can modulate the macrophage
phenotype, including various cytokines and bioactive lipids, such as cholesterol crystals, oxidized
lipoproteins, fatty acids, and immune complexes (Adamson and Leitinger 2011).
Dendritic cells of the immune system get their name from their similarity to neurons in having
thin branches extending out from the cell body to gather information for transmission to B-cells
and T-cells in the immune system. These cells leave the atherosclerotic lesions within a few days
of entering the subendothelial space and migrate back to lymph nodes and the spleen through the
lymphatic vessels. The number of dendritic cells is significantly elevated in atherosclerosis-prone
arteries, demonstrating the involvement of the immune system in atherosclerosis (Stoneman et al.
2007). Atherosclerosis is a dynamic process, and the inflammation that accompanies atherosclerosis
progresses through different stages.
During regression of plaques, monocytes leave the plaque, but during progression, they remain
in the plaque. The inflammation mediated by lymphocytes is tightly controlled by regulatory
T-lymphocytes, which are critical in maintaining immunological tolerance (Sakaguchi et al.
2006). Atherosclerosis has some aspects of an autoimmune disease, as significant evidence shows
a response to self-antigens such as HSP-60 and oxidized LDL during atherosclerosis. Many auto-
immune diseases, such as systemic lupus erythematosus and diabetes, accelerate atherosclerosis
development, probably through the defective clearance of apoptotic cells.
Platelets also play a major role in plaque thrombus formation upon injury and form the acute clot
that leads to a myocardial infarction when an unstable plaque ruptures. They also secrete inflamma-
tory mediators that modulate the recruitment of white blood cells into inflamed tissues (Lundberg
and Govoni 2004; von Hundelshausen and Weber 2007).
There is a large body of evidence supporting the notion that obesity, diabetes, and atheroscle-
rosis are connected via their effects on immune function and inflammation (Katagiri et al. 2007).
Visceral adipocytes secrete cytokines, resulting in modulation of inflammation, including adipo-
nectin, leptin, resistin, visfatin, tumor necrosis factor α (TNF-α), interleukin 6 (IL-6), IL-1, and
CCL2 (Tilg and Moschen 2006). Serum levels of adiponectin are markedly decreased in obesity,
insulin resistance, type 2 diabetes, and atherosclerosis (Arita et al. 1999). Basic science studies in
animals demonstrate that adiponectin counteracts both atherosclerosis progression and thrombosis
by reducing lipid accumulation in macrophage-derived foam cells (Tian et al. 2009) and suppress-
ing the production of chemokines, including CXCL10, CXCL11, and CXCL9, leading to reduced
T-cell homing into atherosclerosis-prone aortic regions (Okamoto et al. 2008). Adiponectin can also
reduce the inflammatory phenotype of endothelial cells and smooth muscle cells (Tilg and Moschen
2006) and reduce platelet aggregation (Kato et al. 2006).
On the other hand, leptin, which is increased in the circulation of individuals with visceral obe-
sity, promotes inflammation and atherosclerosis. Leptin increases the secretion of the chemokine,
CCL2, and initiates proliferation and oxidative stress in endothelial cells. Leptin also promotes
migration and proliferation of smooth muscle cells (Yang and Barouch 2007) and promotes throm-
bosis by increasing platelet aggregation (Maruyama et al. 2000). The discovery of adipokines has
spawned the concept of an association between atherosclerosis and inflammation mediated systemi-
cally by distant visceral fat and locally by fat associated with the pericardium, which is a visceral
fat depot increased in obesity.
10.2.2 Endothelial Dysfunction and Nitric Oxide in CAD

NO is an important protective mediator that helps to control blood flow in the heart by modulating
the amount of dilation of very small blood vessels in the myocardium. This function is mediated
by the endothelial cell lining of these blood vessels, which produces NO as a gas that is short-
lived but functions to relax smooth muscle in myocardial arterioles, increasing vessel diameter and
blood flow. Abnormalities in NO generation play an important role in the pathophysiology of CAD
(Kugiyama et al. 1996). NO is synthesized from L-arginine by the action of NOS. There are at least
three isoenzymes of NOS: inducible NOS, neuronal NOS, and endothelial NOS (eNOS) (Nathan
and Xie 1994). The inducible NOS, as already mentioned, is found in macrophages and is part of an
inflammatory response that should not be confused with the vascular roles described here.
NOS enzymes produce NO by catalyzing a five-electron oxidation of the guanidine nitrogen of
arginine that requires the binding of five cofactors: flavin adenine dinucleotide, flavin mononucleo-
tide, heme iron, tetrahydrobiopterin, and calcium–calmodulin (Bredt and Snyder 1990). If any of
these cofactors is deficient or limiting, NO production from NOS is restricted and NOS produces
superoxide instead, which is a pro-oxidant. This mechanism has been termed “NOS uncoupling”
(Landmesser et al. 2003). Therefore, both adequate oxygen and sufficient substrate supply are nec-
essary for proper NOS function, and in the absence of these factors, NOS becomes harmful.
NO is involved in a wide variety of regulatory mechanisms of the cardiovascular system, beyond
endothelium-dependent vasodilatation. NO also inhibits smooth muscle cell proliferation, platelet
adhesion and aggregation, and monocyte adhesion. Cardiovascular disease risk factors, including
hypercholesterolemia, hypertension, diabetes mellitus, and cigarette smoking, lead to a reduction in
the ability of the endothelium to produce NO (Galle et al. 1991; Makimattila et al. 1996; Busse and
Fleming 1999). Endothelial dysfunction is the term used to refer to a decrease of endothelial NO
formation due to insufficient oxygen and cofactor supply or inactivation by reactive oxygen species.
In a healthy heart, the vascular endothelium plays an important role in maintaining homeostasis,
and it functions to promote vasodilation, inhibit luminal and vascular wall coagulation, and prevent
the proliferation of smooth muscle and foam cells. However, these functions may be perturbed,
particularly when the bioavailability of NO is low, leading to a state favoring vasoconstriction,
thrombosis, vascular smooth muscle cell proliferation, and the generation of atherosclerotic plaque
(Cooke and Dzau 1997).
Endothelial dysfunction is a key element facilitating the development of atherosclerosis. Lack of
NO also promotes aggregation and invasion of inflammatory cells in the vessel wall and promotes
the calcification of arteries. There is a vicious cycle in which progressive deprivation of blood sup-
ply with hypoxia of tissues and organs leads to less NO production. Despite the growth of new
vessels as the result of angiogenesis, the resulting blood vessels often do a poor job of providing
adequate oxygen to damaged areas of cardiac muscle, and there is reduction in cardiac output,
which in extreme cases leads to heart failure. A damaged heart is also more susceptible to sudden
and sometimes fatal ventricular arrhythmias.
10.2.3 Coronary Artery Calcification

Coronary artery calcification (CAC) is an easily detected biomarker of atherosclerosis, often occur-
ring as calcified atheroma or spotty calcification within a lipid core. Its measurement by rapid CT
scan of the chest is commonly used clinically to avoid an invasive angiogram or as a marker for
atherosclerosis in studies (Rumberger et al. 1995). Cardiovascular risk factors and the presence
and extent of CAC are predictive of coronary event risk (National Cholesterol Education Program
Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults 2002;
Zeb and Budoff 2015), and are used as a decision point in whether to begin statin therapy in men
over 65 years of age. There is currently no specific treatment for arterial calcification, with both
statins and vasodilators having little effect (Henein and Owen 2010).
Arterial calcification represents segmental bone formation, which is known to be progressive
even after controlling risk factors. Calcification of the coronary arteries results from some bio-
chemical or other pathological effect associated with CAD risk factors, and it cannot be reduced
through optimum control of risk factors (McCullough and Chinnaiyan 2009; Henein and Owen
2011; Zhao et al. 2016). Nonetheless, dyslipidemia, smoking, obesity, and family history of CAD
have been shown to be predictive of CAC presence and progression in large population studies,
such as the Multi-Ethnic Study of Atherosclerosis and Heinz Nixdorf Recall (Kronmal et al. 2007;
Schmermund et al. 2007).
10.3 TYPE 2 DIABETES AND CAD

Type 2 diabetes mellitus is associated with a markedly increased incidence of cardiovascular dis-
eases, accounting for ~70% of diabetic mortality (Grundy et al. 2005; Tziomalos et al. 2010). In
the background of cardiovascular complications, disorders of microcirculation and endothelial
dysfunction associated with type 2 diabetes precede atherosclerosis and critically alter the func-
tions of the healthy endothelium and its production of factors that regulate vascular tone, smooth
muscle cell proliferation, and vessel wall inflammation (Berwick et al. 2012). Advanced glycation
end products (AGEs) produced in type 2 diabetes affect nearly every type of cell and molecule in
the body and are thought to be one factor in aging and some age-related chronic diseases (Glenn
and Stitt 2009; Semba et al. 2009a,b). In diabetes-associated CAD, modification of proteins by
reducing sugars leads to the formation of AGEs in vivo, and there is evidence that dietary AGEs
(called dAGEs) can be absorbed into the circulation and add to the burden of AGEs promoting
disease (Uribarri et al. 2010).
These nonenzymatic glycation reactions continue progressively during aging and substantially
accelerate with type 2 diabetes and atherosclerosis, providing a rationale for the effects of sustained
hyperglycemia on chronic disease progression (Basta et al. 2004). Alterations in glucose and lipid
metabolism likely lead to the production of excess aldehydes and formation of AGEs, although the
exact mechanisms have not been established. AGEs act directly or via receptors and participate in
the cross-linking proteins of extracellular matrix (Basta et al. 2004).
The receptor for AGE (RAGE) is a member of the immunoglobulin superfamily and is expressed
by endothelial cells, smooth muscle cells, monocytes, and lymphocytes with enhanced expression
in atherosclerotic lesions. The AGE-RAGE interaction leads to oxidative stress, increased endo-
thelial dysfunction, increased production of inflammatory cytokines and tissue factors, elevated
expression of adhesion molecules, and accelerated development and progression of atherosclerosis
(Basta et al. 2004).
10.4 EFFECTS OF STATIN DRUGS IN CAD BEYOND LIPID LOWERING

Statins are produced naturally by 39 species of fungi and yeast as polyketides which act as antibiot-
ics against bacteria attacking these species. Through a serendipitous investigation of Aspergillus
species of fungi, Japanese researchers discovered monacolins in the 1970s. The drug isolated from
these fungi is mevinolin, which is converted to the active drug mevalonic acid in the body. This
compound inhibits 3-hydroxy-3-methylglutaryl coenzyme A reductase and increases the hepatic
expression of the LDL receptor, which decreases LDL levels in the circulation (Le et al. 2013;
Hennessy et al. 2015). In addition to these cholesterol-lowering effects, which have led to a multi-
billion-dollar global bonanza for the pharmaceutical industry, statins also provide protection against
cardiovascular diseases by other effects, such as antioxidation, anti-inflammation, and increased
bioavailability of NO (Kureishi et al. 2000; Wolfrum et al. 2003; Thanassoulis et al. 2014). Since
the lipid-lowering effects are the most widely known and publicized effects of statins, these other
effects are called pleiotropic effects of statins.
At the cellular and molecular level, statins can increase eNOS activity and NO production in
endothelial cells through a kinase-dependent pathway and protein–protein interactions (Sun et al.
2006; Su et al. 2014). Despite the many heralded advances of statins in preventing cardiac events,
statin treatment is not uniformly effective in improving endothelial cell function and inflammation
in patients with CAD (Kureishi et al. 2000; Walsh and Pignone 2004; Artom et al. 2014; Drapala et
al. 2014; Goldstein and Brown 2015).
It is a well-founded community standard to prescribe statins for all patients leaving the hospi-
tal after a coronary event, which is a good idea given the effects reviewed above beyond simply
lowering LDL cholesterol. However, given that other cardiovascular disease risk factors related to
lifestyle, such as smoking, obesity, diabetes, and sedentary lifestyle, are commonly present, these
should also be addressed through diet and exercise prescriptions, which are the focus of this text.
10.5 DIETARY RECOMMENDATIONS FOR PATIENTS

WITH CORONARY ARTERY DISEASE
Patients with CAD who have suffered angina or a cardiac event are motivated to obtain any advice
that can prevent another cardiac event or improve their quality of life. The fear of death that per-
vades the interaction with patients who have CAD is similar to that encountered with cancer survi-
vors and may push individuals to consider invasive procedures for cure while also minimizing their
confidence in the role of nutrition and exercise.
Given the multifactorial etiology of the progression of atherosclerosis, diet and lifestyle intervention
has an advantage over drugs in targeting multiple pathways simultaneously. While dietary and lifestyle
changes are not as potent as drug therapy, they have the advantage of an improved quality of life.
10.6 WEIGHT MANAGEMENT THROUGH NUTRITION

AND EXERCISE TO REDUCE VISCERAL FAT
Chief among the various recommendations is to achieve and maintain optimum personal body com-
position, especially as it concerns visceral adiposity. Obesity was only identified as an independent
risk factor in the 1990s, and evidence for the impact of excess visceral fat on atherosclerosis progres-
sion has already been reviewed above. Excess visceral adiposity promotes diabetes, hypertension,
and dyslipidemia and has other effects that could affect progression of atherosclerosis (Figure 10.2).
These dietary recommendations are adjunctive in that patients with established CAD are typi-
cally treated with statins to lower cholesterol and drugs for hypertension and diabetes as needed.
Statin treatment is a standard of care after discharge from the hospital with a coronary event.
10.6.1 Dietary Pattern and CAD

The idea that nutrition was important for established CAD only became accepted in the late 1950s
due to the efforts of Nathan Pritikin, a successful inventor who was not a doctor.
194
TNF-α
IL-6
Leptin
Adipokines
Resistin
Cytokines Adiponectin
Microvasculature
Adipose tissue
Endothelial
cell Relaxation
Arterioles
• Oxidative stress O2
NADPH O–
2 NO
oxidase
• Impaired vasomotor
function (EDV) NO synthase
• Enhanced thrombosis
L-arginine Smooth
(b) muscle
Capillary
Platelet
Capillaries
• Reduced perfusion PMN
• Leukocyte plugging
• Angiogenesis
RBC
Macrophage Adipocyte
(c) Blood flow
Mitochondrial
Venules T-cell
ER
• Oxidative stress Adipokines ROS ROS
• Leukocyte adhesion RANTES
PMN Insulin
• Platelet recruitment Insulin NFκB resistance
• Vascular permeability resistance TNF-α
CAMs IL-6
Adipokines
(a)
Endothelial
cell Platelet
(d)
FIGURE 10.2 (See color insert.) Interaction of excess visceral fat with cellular and molecular mechanisms promoting the progression of atherosclerosis. EDV, end-
diastolic volume; NADPH, nicotinamide adenine dinucleotide phosphate; PMN, polymorphonuclear; RBC, red blood cell; ROS, reactive oxygen species; NFκB, nuclear
factor κB; CAMs, cell adhesion molecules. (Reprinted from Vachharajani, V., and Granger, D. N., IUBMB Life, 61(4), 424–430, 2009.)
After being diagnosed with heart disease in 1957, he was told he needed open-heart surgery.
Based on studies indicating that people in primitive cultures with primarily vegetarian lifestyles
had little history of heart disease, he developed a low-fat diet high in unrefined carbohydrates,
including vegetables, fruits, beans, and whole grains, along with a modest aerobic exercise regime.
The Pritikin diet has been called one of the “gold standards of American dieting success.” He
established the Pritikin Longevity Center in 1976 and served as its director. In the early 1980s, he
began to suffer severe pain and complications related to hairy cell leukemia. He committed suicide
on February 21, 1985, in Albany, New York, registered in a hospital under an assumed name so that
no one would think his diet played a role in the leukemia that killed him. While many people lost
weight and improved their endurance on the Pritikin diet, it was not a weight loss diet.
His major competitor was Dr. Robert Atkins, whose primary focus was a high-fat, high-protein
diet for weight management, which contrasted with the low-fat diet of Pritikin. During the early
years of his medical practice, stress and poor eating habits led Atkins to gain a considerable amount
of weight. In 1963, at a weight of 224 pounds, he decided to go on a restrictive diet based on
the research of Dr. Alfred W. Pennington, who recommended removing all starch and sugar from
meals. He advocated for the complete elimination of sugar from the diet and a marked increase in
both fat and protein. Atkins found immediate and lasting success on the plan, and began advertising
its effects to his patients. Atkins suffered cardiac arrest in April 2002, leading many of his critics to
point to this episode as proof of the inherent dangers in the consumption of high levels of saturated
fat associated with the Atkins diet. A medical report issued by the New York medical examiner’s
office a year after his death showed that Atkins had a history of heart attack, congestive heart fail-
ure, and hypertension. It also noted that he weighed 258 pounds at his death.
There has continued to be a debate on whether restricting carbohydrates and lowering triglycer-
ides or reducing fats without concern over whether carbohydrates were refined or unrefined would
reduce cardiac deaths. For men, the Atkins diet promised that they could lose weight while still
eating red meat and other high-fat foods, and so would not have to give up on tasty treats, as was
required with the Pritikin diet.
Dr. Dean Ornish embraced many of Nathan Pritikin’s ideas, with a strong focus on heart disease.
Ornish is known for his lifestyle-driven approach to the control of CAD. He promotes lifestyle
changes, including whole foods, plant-based diet, smoking cessation, moderate exercise, and stress
management techniques, including yoga and meditation. His program has a strong element of psy-
chosocial support. He has acknowledged Swami Satchidananda for helping him develop his holistic
perspective on prevention.
Medicare reviewed six studies of the Pritikin program and nine on the Ornish version appear-
ing in peer-reviewed publications. Most of these were conducted or sponsored by the Ornish and
Pritikin programs. For example, eight of the nine Ornish studies include Ornish as the lead or
senior author. Nevertheless, Medicare accepted the reported data as valid and adequate to demon-
strate the effectiveness of the programs under the agency’s statutory and regulatory requirements.
The agency’s review of published data on the Ornish and Pritikin intensive cardiac rehabilitation
programs found that they effectively slowed or reversed progression of coronary heart disease and
reduced the need for coronary artery bypass graft surgeries and percutaneous interventions. These
programs are considered medically appropriate alternatives to standard intensive cardiac rehabilita-
tion for persons who meet medical necessity criteria for intensive cardiac rehabilitation. However,
they are considered experimental and investigational as a treatment for diabetes, hyperlipidemia,
prostate cancer, metabolic syndrome, and all other indications.
Elements of the Pritikin and Ornish approach include (1) smoking cessation; (2) a vegetarian diet
with less than 10% of calories from fat and minimal amounts of saturated fat; (3) group support
and psychological counseling to identify sources of stress and develop tools that help manage stress
more effectively; (4) moderate exercise, usually a treadmill and walking program; and (5) reliance
on the daily use of stress management techniques, including various stretching, breathing, medi-
tation, yoga, and relaxation exercises. The greatest advantage of this program over usual cardiac
rehabilitation programs is the emotional reassurance provided to patients frightened about the pos-
sibility of a sudden heart attack and death.
Using the Ornish program, the Lifestyle Heart Trial found that 82% of patients diagnosed with
heart disease who followed this plant-based diet program had some level of regression of athero-
sclerosis, and 91% had a reduction in the frequency of angina episodes, whereas 53% of the control
group, fed the American Heart Association diet, had progression of atherosclerosis (Ornish et al.
1998). In addition, the study showed a reduction in LDL (37.2%) that is similar to results achieved
with lipid-lowering medications. Similarly, other researchers showed that compared with a control
group, the plant-based diet group had a 73% decrease in coronary events and a 70% decrease in all-
cause mortality (de Lorgeril et al. 1999). In 1998, a collaborative analysis using original data from
five prospective studies was reviewed and showed that, compared with nonvegetarians, vegetarians
had a 24% reduction in ischemic heart disease death rates (Key et al. 1998).
There are several varieties of vegetarian diets. The so-called semivegetarians eat chicken and
fish but not red meat. The strict vegetarians eat eggs and milk, as well as fruits and vegetables, and
vegans eat no meat, fish, eggs, or dairy. The moderate position in this spectrum is the plant-based
diet, which is followed by many who are semivegetarian or vegetarian.
A plant-based diet is increasingly becoming recognized as a healthier alternative to a diet domi-
nated by meat fat and refined carbohydrates. A plant-based diet has significant health benefits,
and studies have shown that a plant-based diet can be an effective treatment for obesity (Berkow and
Barnard 2006; Rosell et al. 2006; Tonstad et al. 2009; Farmer et al. 2011), diabetes (Snowdon and
Phillips 1985; Campbell 2004; Barnard et al. 2006; Rosell et al. 2006; Vang et al. 2008), hyperten-
sion (de Lorgeril et al. 1999), hyperlipidemia (Appleby et al. 1995), and heart disease (Ornish et al.
1998; Esselstyn 2001).
While the Pritikin and Ornish programs were clearly directed at CAD, many other diets that
promote wellness have documented some benefits for heart disease. The basic message here is that
eating a healthy diet according to general criteria set forth by the U.S. Department of Agriculture
(USDA) is beneficial for heart health. The Healthy Eating Index 2010 (HEI-2010), the Alternative
Healthy Eating Index 2010 (AHEI-2010), the Alternate Mediterranean Diet Score (aMED), and the
Dietary Approaches to Stop Hypertension (DASH) have all been associated with a lower risk of all-
cause mortality, cardiovascular disease, cancer, cognitive impairment, Alzheimer’s disease, type 2
diabetes, and obesity in both adults and children (Boggs et al. 2013; Singh et al. 2014; Harmon et al.
2015; Perry et al. 2015; Jacobs et al. 2016).
The components and scoring of these healthy dietary patterns vary somewhat, but overall, they
emphasize a diet containing a variety of fruits and vegetables, along with whole grains, lean protein
(including legumes, nuts, and fish), and a higher ratio of unsaturated fats to saturated fat. In addi-
tion, most recommend limiting red and processed meat, sugar-sweetened beverages (SSBs) and
fruit juice, trans fats, added sugars, sodium, and refined carbohydrates (Harmon et al. 2015). The
AHEI-2010 and aMED favor the consumption of limited quantities of alcohol (Harmon et al. 2015).
10.6.2 Nitrate-Rich Foods Defend Endothelial Health under Hypoxic Conditions

Among the benefits of a plant-based diet are an increased intake of nitrates, especially from dark
green leafy vegetables. While nitrate levels were controlled in agriculture by the USDA with the
idea that they promoted formation of carcinogenic nitrosamines in the stomach of humans, this
has turned out to be a phenomenon restricted to rodents (Katan 2009). Nitrates ingested in vege-
tables such as spinach are converted to nitrite by anaerobic bacteria in the mouth (Lundberg et al.
1994, 2004; Duncan et al. 1995; Lundberg and Govoni 2004). This is a reaction humans do not
carry out, but one that has been proven to be critical through experiments in which mouthwash
was administered to kill the anaerobic bacteria with the result that NO was not formed (Lundberg
et al. 2004). The nitrite then is converted to nitrous acid in the stomach, and NO diffuses into
the bloodstream acutely. It is then converted to nitrite again and stored in the muscle, including
Muscle nitrite
reductase activity
Tissue
oxygen concentration
DeoxyHb
DeoxyMb
NO Nitrite in muscle
Plasma NO
Dietary nitrate
FIGURE 10.3 Nonenzymatic NO formation occurs through one electron reduction of nitrite to NO by fer-
rous heme proteins like deoxyhemoglobin in the blood or deoxymyoglobin in the heart. This occurs under
conditions of low oxygen, shown in the two triangles in the figure. The nitrite reductase activity of these pro-
teins increases as oxygen tension in the tissues decreases with hypoxia.
cardiac muscle. NO can also stimulate angiogenesis beneficial to heart tissue that has been dam-
aged (Kumar et al. 2008).
NO can be obtained from nitrites stored in muscle under conditions of low oxygen (Figure 10.3).
In recent years, it could be demonstrated that NO can be formed independently of its enzymatic
synthesis in the endothelium by reduction of inorganic nitrite under hypoxic conditions. This nitrite
stored in muscle awaits hypoxia and comes to the rescue when low-oxygen conditions occur in
skeletal or myocardial muscle.
A diet rich in vegetables, such as the Mediterranean or the traditional Japanese diets, contains
more nitrate than the recommended acceptable daily intake recommended by the World Health
Organization (Katan 2009). Even a portion of spinach consumed in one serving of salad can exceed
the acceptable daily intake for nitrate (Lundberg and Govoni 2004). However, scientific evidence
supports the conclusion of the European Food Safety Authority that benefits of vegetable and fruit
consumption outweigh any perceived risk of developing cancer from the consumption of nitrate and
nitrite in these foods. Observational epidemiologic and human clinical studies support the hypoth-
esis that nitrates and nitrites of plant origin play essential physiologic roles in supporting cardiovas-
cular health.
10.6.3 Refined Carbohydrates and Sugar versus Fruits

and Vegetables in Low-Glycemic-Index Diets
Carbohydrates are arguably the most misunderstood of the macronutrients, as they exist in a vast
array of foods, ranging from fiber-rich fruits, vegetables, low-fat dairy, and whole grains (all of
which are generally underconsumed) to sugar-sweetened beverages (SSBs), processed foods with
added sugar, refined “white” carbohydrates, and baked goods (which are generally overconsumed)
(U.S. Department of Health and Human Services 2015).
The view on carbohydrates has shifted somewhat in the past decade due to research showing
that refined starch and sugar may actually increase cardiometabolic risk, while increased intakes of
carbohydrate-containing vegetables and fruits decreased cardiometabolic risk (Malik et al. 2010;
Burger et al. 2012; Ley et al. 2014; Yang et al. 2014).
Sugar intake has increased dramatically over the past century. More than 70% of U.S. adults
consume at least 10% of their total daily calories from added sugar, and 10% consume 25% or more
of their calories from sugar according to recent data (Yang et al. 2014). Approximately 75% of all
foods and beverages contain some form of added sugar (Bray and Popkin 2014), and the association
of added versus total sugar is far more robust in terms of both diet quality and disease risk (Louie
and Tapsell 2015). Added sugar intake exceeding 10% not only displaces healthy nutrients, leading
to micronutrient dilution (Moshtaghian et al. 2016), but also has been associated with an increased
risk of overweight and obesity (Wang et al. 2013), metabolic syndrome, type 2 diabetes (Malik et al.
2010; Ley et al. 2014), and cardiovascular mortality (Yang et al. 2014).
SSBs, including soft drinks, sports drinks, sweetened milk, water, teas, and juices, are major
sources of added sugar, but added sugar can be found in unexpected products, including salad dress-
ing, bread, sauces, and baked beans, in addition to foods generally perceived as healthful, including
yogurt and whole grain cereals (Chun et al. 2010). A number of prospective cohort studies have
investigated the associations between consumption of SSBs and the risk of CAD.
A meta-analysis of six studies suggested that a higher consumption of SSB was associated with
a higher risk of CAD (Xi et al. 2015). The PREDIMED (PREvención con DIeta MEDiterránea)
study prospectively examined 1868 participants and found that consumption of >5 servings/week of
all types of beverages, including artificially sweetened beverages, was associated with an increased
risk of metabolic syndrome in elderly individuals at high risk of CAD (Ferreira-Pêgo et al. 2016).
Cohort studies have consistently shown a dose–response relationship between SSB consumption,
weight gain, and diabetes, and a recent meta-analysis showed a 55% higher risk of being overweight
or obese in adulthood with high versus low intake (Hu 2013).
The 2015–2020 Dietary Guidelines for Americans (DGAs) recommend limiting added sugar
to less than 10% of total calories (U.S. Department of Health and Human Services 2015), and the
American Heart Association has even more stringent criteria, limiting added sugar to 6 teaspoons
daily for women (24 g) and 9 teaspoons daily for men (36 g) (Johnson et al. 2009). The Food
and Drug Administration (FDA) recently finalized new labeling changes that included listing
“added sugar” in both grams and percent daily value to the label, which will make it much easier
to choose a more healthful dietary pattern that includes packaged foods (U.S. Food and Drug
Administration 2016).
Many foods that do not contain sugar, such as white potatoes and rice, have a high glycemic
index (GI) and increase blood sugar rapidly after they are consumed. The clinical application of
the GI to the prevention and treatment of heart disease is controversial. No evidence exists for
the implementation of low-GI diets for a reduction in coronary heart disease mortality, events, or
morbidity.
10.6.4 Phytonutrients, Potential Role in Stabilizing Atherosclerotic Plaques

Atherosclerotic lesions become unstable and prone to rupture due to the formation of reactive oxy-
gen species that are produced by the inflammatory milieu in the atherosclerotic plaque. The carot-
enoids are a group of red, orange, or yellow pigmented polyisoprenoid hydrocarbons synthesized
by prokaryotes and higher plants. Lycopene, lutein, and other carotenoids have antioxidant activity
that attenuates the inflammatory atherosclerotic process and delays vascular aging. This ability
improves endothelial function due to the increase in bioavailability of NO. Carotenoid consumption
also improves the metabolic profile, decreasing the incidence of diabetes, lowering LDL levels, and
improving blood pressure control. The beneficial metabolic effect is translated to improvement in
atherosclerosis, which is characterized by a decrease in carotid intima-media thickness (IMT). The
favorable antiatherosclerotic effect of carotenoids was also demonstrated in cross-sectional popula-
tion studies showing a positive correlation between low carotenoid levels and adverse cardiovascu-
lar outcome.
In particular, the impact of the oxygenated carotenoid lutein, a pigment found in dark green
leafy vegetables, egg yolks, and other foods, has been studied in the Los Angeles Atherosclerosis
Study. Progression of IMT of the common carotid arteries over 18 months was determined ultra-
sonographically and was related to plasma lutein among a randomly sampled cohort of 480 utility
employees age 40–60 years (Figure 10.4).
0.04
IMT progression (mm/18 mo)

p-trend = 0.0007
0.03 (sexes combined)
0.02
0.01
0.00
0.1 0.2 0.3 0.4 0.5
Plasma lutein (quintile median, µmoles/L)
FIGURE 10.4 Inverse relation between change in carotid IMT and quintiles of plasma lutein. Graph
depicts IMT means within lutein quintiles (median) for women (n = 5214) and men (n = 5248) adjusted
for cardiovascular risk factors. Ranges of plasma lutein concentrations (mmol/L) for consecutive quintiles
were 0.070–0.182, 0.184–0.240, 0.244–0.296, 0.297–0.360, and 0.367–0.805 for women and 0.019–0.180,
0.184–0.230, 0.231–0.279, 0.280–0.347, and 0.350–0.790 for men. Error bars indicate the standard error of
the mean (SEM). Serum lutein was measured by high-performance liquid chromatography (HPLC) at the
University of California, Los Angeles (UCLA) Center for Human Nutrition. (Reprinted from Dwyer, J. H.
et al., Circulation, 103(24), 2922–2927, 2001.)
In vitro, lutein was highly effective in a dose-dependent manner in reducing the attraction of
monocytes in the coculture model of lipoprotein oxidation in the artery wall. A dramatic inhibitory
effect of lutein on chemotaxis was observed with pretreatment of cultured cells. The impact of lutein
supplementation on atherosclerotic lesion formation was assessed in vivo by assigning apoE null
mice to chow or chow plus lutein (0.2% by weight) and LDL receptor null mice to Western diet or
Western diet plus lutein. IMT progression declined with increasing quintile of plasma lutein. Lutein
supplementation reduced lesion size by 44% in apoE null mice (p < 0.009) and 43% in LDL receptor
null mice (p < 0.02) by comparison with mice fed the control diets.
According to the latest dietary guidelines report, less than 20% of Americans meet the daily
recommendations for vegetable intake, and just over 20% meet the recommended intake for fruit,
while most Americans exceed the recommendations for added sugar, saturated fat, and sodium
(U.S. Department of Health and Human Services 2015). A significant percentage of Americans
do not consume daily recommended micronutrient intakes from food alone (Fulgoni et al. 2011),
despite consuming adequate or, in many cases, excess calories. We are in the midst of an obesity
epidemic, with more than one-third of adults and 17% of youth in the United States classified as
obese, and yet much of our population is inadequately nourished from a nutrient, not calorie, per-
spective (Ogden et al. 2014).
Dietary fiber is defined by the Institute of Medicine (IOM) as nondigestible carbohydrates and
lignins that are intrinsic and intact in plants (Dahl and Stewart 2015). The recommended daily
intake for fiber is 14 g/1000 kilocalories/day, or 25 g for women and 38 g for men. The health ben-
efits of dietary fiber continue to be an area of great interest and represent a tremendous opportunity
for improving diet quality, particularly with the emerging research on the essential role of the gut
microbiome in improving health and preventing disease (Zhernakova et al. 2016).
There are established benefits of dietary fiber in reducing the risk of CAD (Threapleton et al.
2013). A recent prospective study that included 367,442 participants followed over 14 years found an
inverse association between whole grain and cereal fiber intake and all-cause mortality, including
death from cancer, cardiovascular disease, diabetes, respiratory disease, and infections (Huang et
al. 2015). A pooled analysis with 23 randomized controlled trials (RCTs) for CAD risk factors sug-
gested reductions in total cholesterol and LDL cholesterol, and reductions in diastolic blood pres-
sure with increased fiber intake.
Whole grains as dietary fiber have been associated with a lower risk for CAD since 1977 (Trowell
1972). Fruits and vegetables are a great source of fibers with added nutritional benefits. A prospective
study done in the Netherlands found a 34% decreased risk of CAD in those with high fruit and veg-
etable intake compared with those with lower intake. The association was especially strong with deep-
orange-colored fruits and vegetables (Oude Griep et al. 2011). A meta-analysis of prospective cohort
studies found a significantly reduced risk of type 2 diabetes with higher intake of fruit and green leafy
vegetables (Li et al. 2014). Berries, rich in the bioactive phytonutrient polyphenols, have been associated
with better cardiovascular outcomes (Pribis and Shukitt-Hale 2014). The most prudent dietary patterns
should include much greater amounts of a variety of fiber-rich foods than we are currently consuming.
10.7 CONCLUSION
The primary role of cholesterol and oxidized lipids in promoting atherosclerosis is well established.
However, the advent of new science on the cellular and molecular basis of atherosclerosis has opened
new avenues of investigation into multiple aspects of diet and lifestyle that can impact cardiac events
and CAD-associated mortality.
While controversial areas continue to exist in nutrition science, there are far more areas of agree-
ment among nutrition experts. The benefits of consuming a healthy diet rich in minimally pro-
cessed fruits, vegetables, whole grains, lean protein, and healthful fats, along with reducing sugar
and limiting or eliminating processed red meat, are convincing. Debate will undoubtedly continue
surrounding specific recommendations within individual food and nutrient groups, but focusing
on an overall healthful dietary pattern gives the individual a great deal of flexibility in developing
a healthful, enjoyable and sustainable approach to eating. For the CAD patient, it is important to
provide social and emotional support, as well as exercise therapy.
Whether intensive cardiac rehabilitation as practiced by Ornish is superior to more individual-
ized approaches has not been established.
Offering each patient an overview of what is known about atherosclerosis and emphasizing that
it can be slowed or reversed with diet and lifestyle should increase adherence to healthy dietary
patterns as adjuncts to medical treatment, including statins and antihypertensive drugs, as needed.
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11 Hypertension and Obesity
11.1 INTRODUCTION
In order to understand the common condition of obesity-associated hypertension, it is helpful to
understand the regulation of body sodium and body water as an adaptation to ancient environments
requiring exertion with the potential of limited or absent water and salt. On a natural plant-based
diet, potassium would be plentiful and sodium would need to be conserved. Freshwater fish have
a similar problem living in a sodium-poor environment. In addition, long days on the savannahs
of Africa looking for food would create a need to maintain extracellular fluid volume in the face
of water lost through sweat or the gastrointestinal tract. Just as modern humankind has flooded an
obesogenic environment with sugar and fat, mostly hidden in processed foods, salt has also been
introduced for its various benefits in food processing, including masking of off-tastes of meats and
paradoxically enhancing the taste of some sweet and fat foods, such as salty chocolate bars. The
key objectives for health in ancient environments would be to maintain adequate pressure and blood
flow to nourish the organs and excrete toxins through the kidney in the face of water losses through
sweat, diarrhea, or inadequate sources of water.
In discussing many of the issues around obesity, the concept that humankind is well adapted to
starvation and poorly adapted to obesity resulting from changes in lifestyle and diet over the last
few hundred years has been a key point of reference. The same notion applies to dehydration. If you
stop all food intake and starve, within the first day, one of your major discomforts, in addition to
hunger, will be thirst. A dinner at a restaurant with salty foods often leads to thirst a few hours later.
While the body adapts to hunger through shifts in macronutrient metabolism, the drive to consume
water and sodium continues unabated. The systems that are disordered in obesity and hypertension
are the same ones that permitted survival under adverse conditions of salt or water restriction in
ancient times.
Hypertension is extremely common, affecting one in three adult Americans and contributing
to nearly half of all cardiovascular deaths in the United States (Egan et al. 2010). Obesity is by
far the most common cause of essential hypertension. Although the diagnosis of hypertension
is made at a sustained blood pressure (BP) level of 140/90 mmHg, the risk of cardiovascular
death with elevated BP is actually a continuum of risk that doubles for every 20/10 mmHg rise
in BP above 115/75 mmHg (Chobanian et al. 2003)—hence the creation of the new category of
“prehypertension” in the hypertension classification scheme for BP (120–139/80–89 mmHg) to
promote the adoption of lifestyle changes that have been shown to lower BP prior to the onset of
hypertension.
As we have already discussed extensively in previous chapters, two-thirds of the U.S. population
is either overweight or obese, and globally, for the first time in human history, there are more over-
weight than underweight individuals around the world. This chapter examines the overlap between
these two common conditions, including the adaptive mechanisms underlying the influence of obe-
sity on BP, and the role of nutrition and weight management in addressing this common and prevent-
able condition that causes so much morbidity and mortality. Finally, we examine the controversies
around sodium restriction as a primary means of nutritional prevention of hypertension, as well
as the evidence for effective means of using potassium-rich, nitrate-rich vegetables; arginine-rich
proteins; and antioxidant spices as strategies to enable the use of salt as a spice to retain the taste of
foods while maintaining BP in the normal range.
207
11.2 EPIDEMIOLOGY OF OBESITY AND HYPERTENSION

BP varies in different populations and among individuals in the same population for a wide vari-
ety of reasons (Blackburn and Prineas 1982). Populations eating a vegetarian diet typically have
lower BP than nonvegetarians, and plant-based dietary patterns in which whole grains, fruits, and
vegetables are eaten regularly have been associated with lower BPs (Ascherio et al. 1996). As we
discuss the mechanisms underlying BP elevation in association with obesity, the reasons for better
BP maintenance as the result of eating a plant-based diet will become clear. BP typically increases
with age, but the changes can be lessened by a high intake of fruits and vegetables in both men and
women (Ascherio et al. 1992; Bazzano et al. 2002). The intake of as little as three or more servings
of fruits and vegetables a day has been associated with a 42% lower stroke mortality and a 27%
lower cardiovascular disease mortality in one cohort over 19 years after adjustment for established
cardiovascular disease risk factors (Appel et al. 1997).
As a consequence of being overweight or obese, individuals have a higher prevalence of hyper-
tension and of associated metabolic disorders. Studies in diverse populations throughout the world
have shown that the relationship between body mass index (BMI) and systolic and diastolic BP is
nearly linear (Jones et al. 1994; Hall 2003). Risk estimates from the Framingham Heart Study, for
example, suggest that 78% of primary or essential hypertension in men and 65% in women can be
ascribed to excess weight gain (Garrison et al. 1987). Clinical studies indicate that maintenance
of a BMI of <25 kg/m2 is effective in the primary prevention of hypertension, and that weight loss
reduces BP in most hypertensive subjects (Jones et al. 1999; Stevens et al. 2001).
The distribution of fat is another important consideration. Most population studies that have
investigated the relationship between obesity and BP have measured BMI rather than visceral or
retroperitoneal fat, which appear to be better predictors of increased BP than subcutaneous fat
(Tchernof and Després 2013). Although the importance of obesity, especially when associated with
increased visceral or retroperitoneal fat, is well established as a cause of hypertension, the patho-
physiological mechanisms involved, which are reviewed in the next sections, are complex and inter-
acting. Therefore, in thinking about hypertension and obesity, it is important not to look for the
single factor promoting this disorder and the drug that can reverse it. This goes against the grain of
primary care education. Despite the availability of very sophisticated and targeted drugs, hyperten-
sion remains poorly addressed from a public health standpoint.
11.3 DIET IN OBESITY AND HYPERTENSION

The undesirable dietary changes in the United States contributing to both obesity and hypertension
during the past 50 years include fructose, fat, and sodium. The introduction of high-fructose corn
syrup (HFCS) and its dramatic increase in consumption compared with other carbohydrates after
1990 has been implicated in the observed increases in obesity, renal disease, and diabetes mellitus
over the last few decades (Bray et al. 2004; Johnson et al. 2013; Khitan and Kim 2013). Fructose is
found in sucrose, a disaccharide of fructose and glucose, as well as sugar cane, beets, and HFCS.
In excess, all these sugars increase the circulating levels of triglycerides, insulin, glucose, and
LDL cholesterol (Hallfrisch 1990). It is not that HFCS is a toxin, but rather that its widespread
use in colas, cakes, pastries, and even pizza and ketchup has increased overall sugar and fructose
consumption in the setting of an obesogenic environment. As fructose is phosphorylated initially
without regard to energy status, the process continues unabated even in the face of excess calories
from fructose. The need for phosphate to continue this process results in the stripping of phosphate
consecutively from ATP, then ADP, then AMP and IMP leading to the formation of excess blood
levels of uric acid with can cause gout or deposit in the kidney leading to kidney failure (Hallfrisch
1990) (Figure 11.1). Emerging evidence supports a role for uric acid in the development of hyperten-
sion, renal failure, and heart disease by decreasing nitric oxide (NO) (Nguyen et al. 2009; Johnson
et al. 2013).
Hypertension and Obesity 209
Fructokinase
FRUCTOSE FRUCTOSE 1-P
ATP a se ADP
late kin
Adeny
AMP
AMP deaminase Pi
Inosine
monophosphate
(IMP)
5’ nucleotidase ATP
Inosine
Nucleoside
phosphorylase
Hypoxanthine Xanthine URIC ACID
Xanthine Xanthine
oxidase oxidase
FIGURE 11.1 Fructose metabolism when excess in the liver leads to formation of uric acid, which is impli-
cated in the metabolic syndrome. (Reprinted from Pillinger, M. H., and Keenan, R. T., Bull. NYU Hosp. Jt.
Dis., 66(3), 231–239, 2008.)
Another undesirable change in the Western diet has been an increase in the intake of omega-6
fatty acid-rich fats and oils, many hidden in processed food products (see Chapter 2 for a more
detailed discussion). The excess of omega-6 from processed foods in the Western diet relative to a
lack of intake of omega-3-rich fats from ocean-caught fish, seafood, and fish oil supplements has
created an imbalance in the immune system favoring chronic low-grade inflammation. Omega-3
and omega-6 fatty acids must be obtained from the diet, and humans evolved on plant-based diets
that contained fairly equal amounts of omega-6 and omega-3 fatty acids. However, in the past
50 years, the U.S. diet has become overloaded with omega-6 fatty acids, with a ratio of omega-6 to
omega-3 of greater than 15 to 1. This increase in omega-6 intake reflected in blood and tissue con-
tent resulted from increased consumption of plant-derived oils such as corn oil, which have had the
omega-3 removed to extend shelf life, as well as red meat from grain-fed animals, which are rich
in omega-6 but not omega-3 fatty acids (Simopoulos 2002). Clinical studies demonstrate that fish
oil supplements can lower BP in patients with hypertension (Appel et al. 1993; Morris et al. 1993).
The Dietary Approaches to Stop Hypertension (DASH) diet (Appel et al. 1997), which is rich
in nutrients from fruits, vegetables, and dairy, with modest levels of sodium and omega-3 and
omega-6 fatty acids, has emerged as a balanced dietary strategy for the management of hyperten-
sion. Approaches such as the DASH diet include green leafy (e.g., cabbages, spinach, and lettuces)
and root (carrots and beets) vegetables that are rich in inorganic nitrate (Hord et al. 2009). Beetroot
juice, which also contains high levels of inorganic nitrate, can also lower BP (Coles and Clifton
2012; Siervo et al. 2013). The nitrate content of these foods is likely to contribute to increased NO
bioavailability, which has multiple beneficial pleiotropic effects in the vasculature, such as vasodila-
tion (Moncada et al. 1991).
However, the DASH study also revealed another interesting finding. Subjects consuming the
DASH diet with a similar sodium intake had even lower BPs than the low-sodium diet alone. This
raised the question of how the DASH diet differed from the control diet, accounting for this added
antihypertensive effect. The DASH diet contained more protein than the control diet (17.9% vs.
13.8%). To date, the majority of studies conducted on hypertensive patients to determine whether
dietary protein intake has an effect on BP have suggested that a moderate increase in protein
intake will indeed lower BP. For instance, a study conducted using the 10,020 participants from
the International Study of Electrolyte Excretion and Blood Pressure (INTERSALT) investigated
the relationship of BP and dietary protein. The study demonstrated an inverse relationship between
BP and dietary protein intake (Stamler et al. 1996b). Similar results were found during other
population-based studies, such as the Multiple Risk Factor Intervention Trial (MRFIT) (Stamler et
al. 1996a), OmniHeart randomized trial (Bramlage et al. 2004), and Caerphilly Heart Study (Yach
et al. 2006). Typically, human studies use data from 24-hour dietary recall, food frequency ques-
tionnaires, and common methods of BP measurement to determine whether an inverse relationship
between protein intake and BP exists. However, human studies that used data from biochemical
methods such as urinary markers of protein intake have also confirmed the existence of an inverse
relationship between BP and protein intake (Krotkiewski et al. 1983).
One component of protein that may explain its antihypertensive properties is arginine. Soy
protein, a protein rich in arginine, is effective in lowering BP (He et al. 2005). Dietary L-arginine
can improve serum nitrate and nitrite levels, an index of NO bioavailability, in obese subjects
(Mirmiran et al. 2016). The relationship between L-arginine and serum nitrate and nitrite levels
is greater in obese normotensives than in obese hypertensives (Sledzinski et al. 2010). Therefore,
it has been proposed that L-arginine-dependent NO formation is compromised in obese hyper-
tensive subjects when compared with obese nonhypertensive subjects. Plasma nitrate and nitrite
levels are lower in obese hypertensive subjects than in obese subjects without hypertension
(Rajapakse et al. 2014).
Weight reduction in obese patients not only results in the expected decrease in BP but also
was demonstrated to be associated with increased plasma nitrate and nitrite levels and reduced
plasma L-arginine levels (Sledzinski et al. 2010). These findings are consistent with the concept
that weight reduction improves L-arginine-dependent NO formation while also leading to normal-
ization of BP.
L-Arginine is the main substrate for NO formation, and extracellular L-arginine concentration
can affect NO bioavailability (Chin-Dusting et al. 2007; Rajapakse et al. 2014). Within the endothe-
lial cell, L-arginine concentrations far exceed the amount needed for endothelial NO synthase, sug-
gesting that transport of arginine into the cell is critical to the generation of NO (Chin-Dusting et al.
2007). In normal rats, the reduced expression or deletion of the gene for the L-arginine transporter
protein, found in endothelial cells and in the kidney, results in the development of hypertension
in otherwise normal rats (Kakoki et al. 2002). In experimentally induced obesity with hyperten-
sion animals, expression of the renal transporter for L-arginine is reduced (Rajapakse et al. 2014).
Increasing endothelial-specific L-arginine transport, including that within the kidney, abolished
obesity-induced hypertension in mice (Rajapakse et al. 2014). In addition, it has been demonstrated
that arginase expression and activity are greater in obese hypertensive rats than in lean controls
(Johnson et al. 2015). Arginase inhibition normalized BP in these rats, suggesting that augmented
arginase activity and subsequent reductions in L-arginine levels can contribute to obesity-induced
hypertension (Johnson et al. 2015). Augmented arginase activity has also been documented in mor-
bidly obese humans (El Assar et al. 2016).
Increased dietary L-arginine can improve NO bioavailability in obese normotensive subjects,
and this association is weakened in obese hypertensives (Mirmiran et al. 2016). Therefore, the asso-
ciation between the L-arginine-NO pathway and obesity-related hypertension holds true beyond
the experimental setting. Further studies are required to determine the mechanisms underlying
augmented arginase activity, impaired L-arginine transport, and reduced NO bioavailability in the
setting of obesity.
These experimental and human observations raise an important question as to whether
reductions in NO bioavailability are central to the development of obesity-associated hyperten-
sion (Giam et al. 2016). Support for this notion comes from findings that indicate that reduced
NO levels can induce and maintain hypertension via multiple mechanisms (Rajapakse et al.
2014). Further experimental and, in particular, clinical studies are required to assess whether
interventional strategies aimed at augmenting L-arginine transport and/or NO bioavailability
can halt or reverse obesity-related hypertension in man and nitrite levels (Kakoki et al. 2002),
and as expected, weight reduction also leads to reduced arterial pressure (Sledzinski et al.
2010).
11.4 MECHANISMS MEDIATING OBESITY-RELATED HYPERTENSION

This adaptation to dehydration starts in the hypothalamus with the secretion from hypothalamic
nerve cells of arginine vasopression (AVP), also known as antidiuretic hormone (ADH). Secretion
results from the shrinkage of specific nerve cells in the hypothalamus as the result of dehydration or
other losses of perfusion. Dehydration leads to changes in membrane structure and physical effects
on microtubules and ion channels. These changes are highly sensitive to osmolality dependent on
sodium concentration related to hydration status (Figure 11.2). The end product of this interaction is
the extracellular fluid volume that perfuses the kidney. This system works perfectly in healthy indi-
viduals when they lose fluid volume due to strenuous exercise, water deprivation, or increased water
intake. Given that ancient man was dependent on running to find food or escape predators, being
able to survive while losing fluid volume through sweating was a critical body function. Today,
long-distance runners continue to be fascinated by the issue of water balance and hotly debate the
best hydration for athletic performance.
The global epidemic of obesity and the concomitant increase in hypertension have led to numer-
ous investigations over the past few decades into the role of obesity in the pathogenesis of hyper-
tension. Overweight and obesity, especially when associated with increased visceral adiposity,
increase the risk of hypertension, accounting for 65–75% of the risk for human primary or essential
hypertension. Increased renal sodium retention impairs pressure-induced sodium excretion in renal
tubules, playing a key role in the development of obesity-associated hypertension.
The mechanisms underlying abnormal kidney function and increased BP during the develop-
ment of obesity-associated hypertension include activation of the renin–angiotensin–aldosterone
system (RAAS), increased sympathetic nervous system (SNS) activity, and physical compression
of the kidneys by fat in and around the kidneys. Other than physical compression of the kidneys
by fat and secondary changes in fatty kidney promoting chronic kidney disease and renal failure,
Plasma
osmolality
ADH release ADH release
Water Plasma
reabsorption osmolality
FIGURE 11.2 Plasma osmolality is tightly regulated between 275 and 295 mOsm/L by release of ADH,
which prompts water reabsorption by the kidney. Similarly, a decrease in osmolality triggers a decrease in
ADH secretion and greater water excretion by the kidneys.
the activation of the RAAS and the associated hormonal and SNS changes can be understood as a
maladaptation of the normal mechanisms maintaining fluid and sodium homeostasis.
In order to understand the impact of obesity on hypertension at the level of the kidneys, it is
useful to review some basic physiology principles. In 1989, Arthur C. Guyton was recognized for
stating the hypothesis that sustained hypertension can occur only when the relationship between
arterial pressure and sodium excretion in the urine is abnormal. If a normal relationship between BP
and renal sodium excretion exists, then increased pressure results in increased sodium excretion and
lowering of BP (Laragh 1989). In fact, the amount of sodium excreted in the urine reflects sodium
intake and has been used in epidemiological studies to assess the impact of salt intake on BP and
disease outcomes.
The hormone aldosterone, by increasing renal tubular sodium reabsorption, causes hyperten-
sion when present in excess due to endocrine disorders even in patients with normal renal function.
Obesity is associated with increased blood flow, vasodilatation, cardiac output, and hypertension.
Although cardiac index (cardiac output divided by body weight) does not increase, cardiac output
and glomerular filtration are increased. Renal sodium reabsorption also increases, leading to hyper-
tension (Hall 2000; Frohlich 2002; Hall et al. 2002).
The RAAS is a hormone system that acts to regulate the plasma sodium concentration and arte-
rial BP, among other functions. The RAAS is activated whenever blood flow through the kidneys
is reduced, and when there are sodium losses in conditions such as diarrhea, vomiting, or excessive
sweating. These losses reduce extracellular fluid volume, and this in turn reduces arterial BP, which
triggers the RAAS through several different mechanisms.
Whenever plasma sodium concentration is reduced or renal blood flow is reduced, juxtaglomeru-
lar cells in the kidneys convert prorenin into the enzyme renin, which is then secreted directly into the
circulation. Plasma renin then removes a decapeptide from angiotensinogen, forming angiotensin I.
Angiotensin I is then converted to angiotensin II, by the enzyme angiotensin-converting enzyme
(ACE) found in the lung capillaries, which removes two amino acids from angiotensin I. Angiotensin
II is a potent vasoactive peptide that constricts arterioles to increase arterial BP. Angiotensin II also
stimulates the secretion of aldosterone from the adrenal gland. Aldosterone increases the reabsorp-
tion of sodium ions from the tubular fluid into the blood, while at the same time causing potassium
excretion into the urine. When the RAAS is overactive, BP is increased (Figure 11.3).
Angiotensinogen
Renin
Angiotensin I
Converting
enzyme
Angiotensin II
Stimulation of
aldosterone
secretion
Vasoconstrictor
Aldosterone
Increased water and

sodium retention
Increased
blood pressure
FIGURE 11.3 The RAAS maintains BP in the face of varying sodium and vascular volume challenges.
The RAAS also functions as a hormonal system that is able to act directly in many tissues in an
autocrine and paracrine way (Paul et al. 2006). White adipose tissue (WAT) plays a central role in
the pathophysiology of the metabolic syndrome not only through the secretion of angiotensinogen,
but also because it accounts for the increased oxidative stress and the low-grade inflammatory state
observed in obesity, which in turn favors insulin resistance (Paul et al. 2006).
RAAS blockade improves glucose homeostasis and prevents diabetes in patients suffering from
the metabolic syndrome (Dream Trial Investigators et al. 2006; Andraws and Brown 2007; Navigator
Study Group et al. 2010). Modulation of RAAS components leads to changes in body WAT content
and function (Engeli et al. 2003; Giacchetti et al. 2005; Jandeleit-Dahm et al. 2005; Henriksen 2007;
Luther and Brown 2011; Putnam et al. 2012; Underwood and Adler 2013). For example, RAAS in
the WAT of lean subjects regulates adipogenesis, triglyceride storage, or release in a homeostatic
fashion, while in obesity, RAAS increases oxidative stress and inflammation in WAT.
RAAS components are not only present in WAT but also produced in the skeletal muscle, the
liver, and the pancreatic islets, where they modulate insulin production from β-cells. In these key
tissues for blood glucose control, RAAS governs a dual axis with opposing effects on glucose
homeostasis. The angiotensin II receptor type 1 (AT1R) and aldosterone favor hyperglycemia and
generate an increased diabetes risk. On the flip side, the angiotensin II receptor type 2 (AT2R) tends
to lower blood glucose and protect against the risk of developing diabetes.
Adipocytes in obese patients, especially those located in the visceral fat, contribute to vascular
and systemic insulin resistance and stimulation of the SNS and RAAS (Kurukulasuriya et al. 2011;
Sowers 2013). Structural and functional changes in the kidney, including activation of intrarenal
angiotensin II, are also important in the development of obesity-associated hypertension (Sharma
2004). Arterial hypertension in obesity is mediated, in part, by increased intravascular volume, car-
diac output (Messerli et al. 1981), and proximal tubule sodium absorption in the kidney (Strazzullo
et al. 2001). However, cross talk between components of the intravascular RAAS, specifically
angiotensin II and aldosterone, can also regulate vasoconstriction independently of renal control
(McCurley et al. 2012; Bender et al. 2013).
Accumulating evidence suggests that endothelial dysfunction also contributes to vascular stiff-
ness, which is in turn strongly associated with insulin resistance (Sandoo et al. 2010; Aroor et al.
2013). Impaired vascular reactivity to insulin before the onset of hypertension is seen in spontane-
ously hypertensive rats (Li et al. 2010), suggesting that insulin resistance is an early event in hyper-
tension development.
Endothelial dysfunction and arterial stiffness are thought to be the earliest manifestations of
vascular dysfunction in obesity and precede the development of prehypertension and hypertension
(Liao et al. 1999; Femia et al. 2007; Cavalcante et al. 2011; Aroor et al. 2013). Increased arterial
stiffness is seen in patients who are normotensive but have obesity and who are predisposed to
develop hypertension; moreover, incident hypertension is more robustly predicted in patients who
are in the highest quartile of arterial stiffness (Liao et al. 1999; Femia et al. 2007; Cavalcante et al.
2011; Aroor et al. 2013).
Effects on sodium and pressure natriuresis can be caused by an increase in adipose tissue mass
and extracellular matrix accumulation, which compress the renal medulla. Renal vascular remodel-
ing, characterized by inflammation, endothelial dysfunction, and vascular smooth muscle prolifera-
tion, is found in individuals with hypertension and ultimately contributes to progression to renal
failure (Montecucco et al. 2011). Tubulointerstitial inflammation owing to a systemic immune and
inflammatory response, elevated uric acid levels, tubulointestinal infiltration of immune cells, cir-
culating pro-inflammatory immune cells and enhanced inflammation, oxidative stress, and fibrosis
collectively contribute to renal damage (Kurukulasuriya et al. 2011; Harrison et al. 2012; Johnson
et al. 2013; Khitan and Kim 2013).
In obesity, other systems interact with the normal control mechanisms. For example, activation
of the RAAS is likely due, in part, to renal compression, as well as SNS activation. Obesity also
causes mineralocorticoid receptor activation independent of aldosterone or angiotensin II.
SNS activation in obesity appears to require leptin and activation of the brain melanocortin sys-
tem. With prolonged obesity and development of target organ injury, especially renal injury, obesity-
associated hypertension often requires multiple antihypertensive drugs and treatment of other risk
factors, including dyslipidemia, insulin resistance and diabetes, and inflammation. Obesity is a risk
factor for so-called treatment-resistant hypertension, as these associated factors related to obesity
and the metabolic syndrome are often not remedied in the setting of drug therapy for hypertension.
Other factors generally considered responsible for obesity-related alterations in the relation-
ship between pressure and sodium excretion include enhanced sympathetic tone, activation of the
RAAS, hyperinsulinemia, structural changes in the kidney, and visceral fat-associated adipokines.
11.5 NUTRITION APPROACHES TO OBESITY-ASSOCIATED

HYPERTENSION AND THE METABOLIC SYNDROME
The morbidity and mortality of hypertension stem in part from the tendency of elevated BP to occur,
together with other cardiovascular disease risk factors and a cluster of metabolic disorders known as
metabolic syndrome. Since the risk of cardiovascular death at any given level of BP depends on the
number of concurrent cardiovascular disease risk factors, a comprehensive clinical and laboratory car-
diovascular risk assessment is needed to establish the cardiovascular disease burden and determine the
scope of lifestyle changes and/or need for pharmaceutical intervention in patients with hypertension.
Many of the cardiovascular disease risk factors are behavioral and modifiable by lifestyle
changes. Although the potential therapeutic impact of established lifestyle changes on BP varies
across the spectrum, they have all been shown to lower BP and/or mitigate the risk of cardiovascular
death in a dose- and time-dependent fashion.
11.5.1 Sodium Restriction in Therapy of Hypertension and Obesity

There is no disagreement that weight management is an essential component of treating obesity-
associated hypertension based on the well-documented effects of weight reduction on BP (The
Trials of Hypertension Prevention Collaborative Research Group 1997). Salt restriction as a recom-
mendation to the general public has encountered significant controversy. Based on the discussions
in this chapter, it should be clear that there is a difference in sodium regulation in obese and lean
individuals. In the obese patient, insulin acts to retain sodium and water, which could increase BP.
In the first week of a hypocaloric diet, a sodium chloride and water diuresis leads to weight loss and
a decrease in BP. So if weight management is successful, sodium restriction becomes a secondary
consideration. Sodium reduction will have some minor effects on BP, especially when vascular
dysfunction is present.
The key recommendation to obese patients for sodium reduction should be to replace high-salt,
high-fat, and high-sugar processed snack foods with fruits and vegetables. This has the dual effect
of decreasing calorie intake and increasing both water and potassium intakes, which counteracts
effects of dietary sodium. Salt used as a spice, together with other spices, can reduce excessive
amounts of salt found in some snack foods, such as potato chips and processed meats. However,
salt-free foods often sacrifice taste, leading to noncompliance. Spices can help maintain taste in the
face of reduced salt, which properly used should be a spice to enhance taste and not an adulterant
to cover up off-tastes or enhance the habituation of high sugar consumption. While the sodium
consumed is generally excreted in normal individuals, in obese patients resistant to weight manage-
ment, there is an argument that sodium increases BP and should be reduced.
Here are some tips that you can transmit to obese patients with hypertension:
1. Check nutrition labels on prepared and packaged foods, because up to 75% of the sodium
consumed is hidden in processed foods. Watch for the words soda and sodium and the
symbol Na on labels, which means sodium compounds are present.
2. Cook fresh, skinless poultry that is not enhanced with sodium solution, instead of fried or
processed chicken.
3. Choose lower-sodium varieties of soups and enhance tastes with herbs and spices, such as
cilantro, garlic, or chili powders.
4. Make sandwiches with lower-sodium meats and low-fat, low-sodium cheeses.
5. Eat more fruits and vegetables in preference to starchy salted side dishes. Fruits and veg-
etables have little sodium and lots of potassium, which can counter the effects of sodium.
During weight maintenance, the general guidelines for healthy individuals pertain. While no one
argues with the kind of commonsense advice about healthy diets given above, there is a significant
disagreement among scientists with regard to the 2300 mg/day and even stricter 1500 mg/day rec-
ommendations of government advisory groups.
Public health guidelines for the general public have recommended that adults consume less salt,
but the relationship of salt intake to hypertension remains controversial (Institute of Medicine 2004,
2006, 2013). The need to define more precisely the efficacy of reduction in salt intake for the general
population has been particularly controversial given conflicting Institute of Medicine (IOM) reports
(Institute of Medicine 2004, 2006, 2013). One report defined a recommended upper sodium intake
amount of 2300 mg/day or 100 mmol/day (Institute of Medicine 2004). However, the most recent
IOM report concluded that “science was insufficient and inadequate to establish whether reducing
sodium intake below 2300 mg/day either decreases or increases cardiovascular disease risk in the
general population” (Institute of Medicine 2013). Furthermore, the 2300 mg/day recommendation
is in conflict with the IOM’s own rules on how to define adequate intake for a nutrient, which is “the
approximate intake found in apparently healthy populations” (Institute of Medicine 2006). This is
much higher than 2300 mg/day (McCarron et al. 2013).
When typical sodium intakes around the world based on urinary sodium excretion are esti-
mated, the recommended levels are much lower than the usual levels of intake globally, which
are in the range of 3000–5000 mg/day of sodium. Opponents of the government efforts to reduce
sodium have stated, “If a ‘normal’ range of sodium intake exists that is consistent with the optimal
function of established peripheral and central nervous system (CNS) mechanisms, that fact should
be the sole basis of national nutrition guidelines for dietary sodium intake. To attempt to use pub-
lic policy to abrogate human physiology would be futile and possibly harmful to human health”
(McCarron et al. 2009).
The justification for the 2300 mg/day recommendation is based on the controversial associa-
tion between sodium intake and BP (Graudal et al. 1998; Sacks et al. 2001; He and MacGregor
2002; Graudal et al. 2011) and on modeling studies (Bibbins-Domingo et al. 2010; Mozaffarian
et al. 2014). These use selected cross-sectional sodium intake data and BP data to create a sodium
dose–BP response relation and successively apply this dose–response relation to BP mortality
data. Disregarding side effects, these models predict millions of lives saved through salt restriction
(Bibbins-Domingo et al. 2010; Mozaffarian et al. 2014). However, these artificial data are in con-
trast to the outcome of real data from population studies, which indicate that both low and exces-
sive sodium intake are associated with increased mortality, thus demonstrating a J-shape relation
between sodium intake and outcome (Graudal et al. 2014).
Based on measures of urinary sodium excretion, which are the research standard, opponents of
the guidelines to reduce salt intake see 2300 mg/day or 100 mmol/day as being below a physiologi-
cal minimum of 117 mmol/day, where sodium appetite is increased, and doubt that such a reduction
could be practically achieved.
11.5.2 Pharmacological Adjunctive Treatment May Be Necessary

Lifestyle modifications that include dietary changes, weight reduction, and exercise are the cor-
nerstones in the prevention and treatment of obesity-associated prehypertension and hypertension.
However, adherence to this approach often meets with failure in clinical practice; therefore, drug
therapy should not be delayed when hypertension is diagnosed.
This chapter, however, has approached the prevention and treatment of hypertension in obesity
from a nutritional rather than the typical drug treatment vantage point. Changing diet and lifestyle
can lead to a reduced need for medication, but careful follow-up is required to properly integrate
nutrition and lifestyle changes with pharmacological treatment. A detailed discussion of the various
pharmacological approaches to hypertension and the weaning of patients off of antihypertensive
drugs as they lose weight is outside the scope of this chapter.
A practical issue in writing about pharmacological treatment is the variety of different drugs
targeting sodium and fluid balance, the SNS, and different parts of the RAAS. Theoretically, the
ideal pharmacological antihypertensive regimen should target the underlying mechanisms involved
in this syndrome in obese patients, including sympathetic activation, increased renal tubular sodium
reabsorption, and overexpression of the RAAS by the adipocyte. Few prospective trials have been
conducted in the search for the ideal antihypertensive regimen in patients with obesity and hyper-
tension. It is safe to say that the optimal antihypertensive drug therapy in these patients has not been
defined and an individualized tailored approach should be taken based on efficacy and side effects.
Although caution exists regarding the use of thiazide diuretics due to potential metabolic derange-
ments, there is insufficient data to show worsened cardiovascular or renal outcomes in patients treated
with these drugs. In regard to β-blockers, the risk of accelerating conversion to diabetes and worsen-
ing of inflammatory mediators described in patients treated with traditional β-blockers appears much
less pronounced or absent when using the vasodilating β-blockers. RAAS inhibition with an ACE or
an angiotensin receptor blocker (ARB) and treatment with calcium channel blockers appear safe and
well tolerated in obesity-related hypertension and in patients with metabolic syndrome.
Future prospective pharmacological studies in this population are needed.
11.6 SUMMARY AND OVERALL TREATMENT RECOMMENDATIONS

Hypertension, like obesity, remains a very common and significant risk factor for cardiovascular
and renal diseases, including stroke, coronary heart disease, heart failure, and kidney failure, and
obesity-associated hypertension is the most common form of essential hypertension. According to
recent National Health and Nutrition Examination Survey (NHANES) surveys (1999–2000), 27%
of adult Americans have hypertension (systolic BP of ≥140 mmHg, diastolic of BP ≥90 mmHg, or
use of antihypertensive medication), and another 31% have prehypertension (systolic BP of 120–
139 mmHg or diastolic BP of 80–89 mmHg, not on medication) (Wang and Wang 2004).
Prehypertensive individuals have a high probability of developing hypertension and carry an excess
risk of cardiovascular disease compared with those with a normal BP (systolic BP of <120 mmHg
and diastolic BP of <80 mmHg) (Vasan et al. 2001). It has been estimated that among adults over
50 years of age, the lifetime risk of developing hypertension approaches 90% (Vasan et al. 2002).
Notably, no evidence of a BP threshold exists. The risk of cardiovascular disease increases pro-
gressively throughout a range of increased BP, including for those in the prehypertensive range
(Lewington et al. 2002). It has been estimated that almost a third of BP-related deaths from coro-
nary heart disease occur in individuals with BP in the nonhypertensive range (Stamler et al. 1993).
Nutrition and lifestyle factors have a predominant role in BP regulation. In nonhypertensive indi-
viduals, including those with prehypertension, dietary changes that lower BP have the potential to
prevent hypertension and, more broadly, reduce BP and thereby lower the risk of BP-related clinical
complications. Indeed, even an apparently small reduction in BP, if applied to an entire population,
could have an enormous beneficial impact. For instance, it has been estimated that a 3 mmHg reduc-
tion in systolic BP could lead to an 8% reduction in stroke mortality and a 5% reduction in mortality
from coronary heart disease (Stamler 1991).
In uncomplicated stage I hypertension (systolic BP of 140–159 mmHg or diastolic BP of
90–99 mmHg), dietary changes can serve as initial treatment before the start of drug therapy.
Among hypertensive individuals who are already on drug therapy, dietary changes, particularly a
reduced salt intake, can further lower BP and facilitate medication step-down. In general, the extent
of BP reduction from dietary therapies is greater in hypertensive than in nonhypertensive individuals.
Numerous clinical trials have documented that weight loss lowers BP before attainment of a
desirable body weight. In a meta-analysis that combined results from 25 clinical trials, mean sys-
tolic and diastolic BP reductions from an average weight loss of 5.1 kg were 4.4 and 3.6 mmHg,
respectively (Stamler 1991). Within-trial dose–response analyses (Stevens et al. 1993; Neter et al.
2003) and prospective observational studies (Stevens et al. 2001) document that greater weight loss
leads to greater BP reduction. Additional trials have documented that modest weight loss, with or
without sodium reduction, can prevent hypertension by about 20% among overweight, prehyperten-
sive individuals (Huang et al. 1998) and can facilitate medication step-down and drug withdrawal
(Langford et al. 1985). Lifestyle intervention trials have uniformly achieved short-term weight loss,
primarily through a reduction in total caloric intake, with maintenance achieved through a sus-
tained habit of daily physical activity. After all is said and done, this is the central principle of nutri-
tion therapy for obesity and hypertension.
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epidemics of obesity and diabetes. Nat Med 12 (1):62–66.
12 Nutrition, Chronic Kidney
Disease, and Kidney Failure
12.1 INTRODUCTION
Obesity is associated with an increase in the risk of a number of age-related chronic diseases,
including chronic kidney disease (CKD), which often progresses to renal failure (Bray et al. 1998;
Anon 2000; U.S. Department of Health and Human Services 2001). In the United States, obesity
is now the second leading cause of preventable disease and death, surpassed only by smoking.
These two common conditions are clearly connected by more than coincidence, as both the asso-
ciation and the pathogenic mechanisms involved are well established (Kambham et al. 2001; Fox
et al. 2004). The concurrent rise in CKD with the dramatic rise in obesity has led to an increased
prevalence of renal failure, doubling in the past decade (Hsu et al. 2006). The prevalence of CKD
has held steady since the early 2000s, a reversal of the previous increasing trend from the 1990s,
according to a report from the Centers for Disease Control and Prevention Chronic Kidney Disease
Surveillance Team (Murphy et al. 2016).
The number of people with end-stage renal disease (ESRD) has been increasing over the past
four decades, but recent studies have suggested a declining incidence of the disease. The crude
prevalence of stage 3 and 4 CKD increased from 4.8% in 1988–1994 to 6.9% in 2003–2004, but
remained stable thereafter, with a prevalence of 6.9% in 2011–2012 (Murphy et al. 2016). Non-
Hispanic whites showed a prevalence trend similar to the overall trend, but the crude prevalence
among non-Hispanic blacks increased progressively across the study period, from 3.7% in 1988–
1994 to 4.9% in 2003–2004 to 6.2% by 2011–2012. The prevalence of CKD among individuals
with diabetes was 19.1% in 2011–2012 (Murphy et al. 2016), pointing to the major role of diabetes
in CKD, as discussed further in the next section. Awareness of kidney disease remains very low
among the public, as CKD is an asymptomatic condition until the very end stage.
The definition of ESRD in the medical literature is chronic irreversible renal failure. Renal fail-
ure is also called CKD stage 6. Early diagnosis of renal dysfunction and prevention or delay of
progression through treatment of comorbid conditions, including primarily hypertension, but also
obesity, glucose intolerance, and type 2 diabetes mellitus, through diet, lifestyle, and adjunctive
pharmacotherapy, are obviously preferable to treating diagnosed renal failure.
Once renal failure has been diagnosed, renal replacement therapy is needed, as either dialysis or
transplant. Unfortunately, most individuals with CKD at earlier stages have no symptoms, which is
why active screening for this condition through monitoring of estimated glomerular filtration rate
(eGFR) in all at-risk patients and for microalbuminuria in some at-risk patients is so critical.
A retrospective survival analysis in 311 ESRD patients treated at a hospital in the Netherlands
between 2004 and 2014 at ages over 70 demonstrated how little survival benefit, on average, is
provided by renal dialysis. In the study, patients chose either conservative medical management
using pharmacotherapy or dialysis (Verberne et al. 2016). A total of 107 patients chose conservative
management and 204 chose dialysis. Comorbidity scores were similar for both groups. The median
survival from the time they chose either course of action was only 3.1 years for patients treated with
dialysis and 1.5 years for those who chose conservative management. This was statistically signifi-
cant (p < 0.001), but neither group had very good survival on dialysis. Among patients 80 and older,
median survival was 2.1 years for the dialysis group and 1.4 years for the conservative management
group, a statistically nonsignificant difference (p = 0.08). These data and others demonstrate that
223
dialysis is not a cure for renal failure. These median survival times emphasize the need for early
detection and efforts in the prevention of progression of CKD to ESRD.
Because they generally are older and frequently have comorbidities, patients with type 2 diabetes
mellitus and ESRD seldom are selected for renal transplantation. Thus, information on transplanta-
tion results from controlled studies in this high-risk category of patients is scarce. Patient survival
after kidney transplant has been improving for all age ranges in comparison with dialysis therapy.
The main causes of mortality after transplant are cardiovascular and cerebrovascular events, infec-
tions, and cancer. Therefore, renal transplantation is not the ultimate answer to reducing the mor-
bidity and mortality of CKD, underlining again the importance of early detection and treatment of
CKD.
If nutrition and weight management could prevent obesity-associated kidney disease and its pro-
gression to renal failure, many hundreds of thousands of lives would be saved and health care
costs for dialysis and transplantation would be saved (Zandi-Nejad and Brenner 2005; Hallan et
al. 2006b). Modifiable risk factors for kidney disease are closely associated with obesity, includ-
ing hypertension and type 2 diabetes mellitus (Erdmann 2006; Hallan et al. 2006b; Kramer 2006;
Keller 2006; Ram et al. 2006; Ritz 2006; Srivastava 2006).
The incidence of kidney disease outcomes varies in conjunction with the variation in obesity
rates across different regions of the world, with the highest incidence in North America and the
lowest incidences in Asia (Parkin 1998; Calle et al. 2003; Chalmers et al. 2006; Hallan et al. 2006a;
Iseki 2006; Wang et al. 2006). Studying risk factors for kidney disease is difficult due to the low
incidence and long latency period of many forms of kidney disease, but many studies suggest that
obesity is a risk factor for CKD and renal failure (Perneger et al. 1995).
12.2 OBESITY, FATTY KIDNEY, AND CHRONIC KIDNEY DISEASE

Excess visceral fat is a major driving force for almost all the disorders associated with the metabolic
syndrome, including CKD, through systemic effects on blood pressure (BP), lipids, and cytokines
(Hall et al. 2004; Tchernof and Despres 2013). CKD rates have increased in parallel to increases
in overweight and obesity (Hall et al. 2002, 2004). In the United States, more than 10% of people
over 20 years of age, or about 200,000 individuals, are estimated to have some degree of CKD, and
the prevalence of CKD in those over age 60 is approximately 25% (Centers for Disease Control
and Prevention 2014). In 2009, almost 900,000 people in the United States were being treated for
renal failure, with an estimated cost of nearly $40 billion (U.S. Department of Health and Human
Services 2013). CKD is associated with increased morbidity and mortality, so that after adjusting
for age, sex, race, comorbidity, and prior hospitalizations, CKD patients experience a 59% higher
mortality rate than patients without CKD (National Institutes of Health 2012).
Overweight and obesity account for 65–75% of the risk for essential hypertension (Garrison et
al. 1987). Type 2 diabetes, which accounts for more than 90% of diabetes, is uniformly accom-
panied by increased visceral adiposity. Hypertension and diabetes, along with other disorders
associated with the metabolic syndrome, may interact synergistically to increase the risk of CKD
and progression to renal failure. However, there is also evidence that obesity may damage the
kidney and increase the risk for CKD independent of diabetes and hypertension (Hall et al. 2004;
Ejerblad et al. 2006).
Abdominal visceral obesity is associated with CKD independently of overall adiposity or
increased body mass index (BMI), although there is generally a good association between BMI
and visceral obesity. In a study of almost 6500 nondiabetic participants, increasing BMI and
waist circumference were associated with reduced eGFR and increased CKD (Burton et al. 2012).
Abdominal obesity, defined as a waist circumference of >102 cm in men or >88 cm in women, was
associated with a higher risk of renal insufficiency (odds ratio = 1.40), even after adjustment for
other components of the metabolic syndrome, such as dyslipidemia, hyperglycemia, hypertension,
and BMI, in patients with essential hypertension (Gomez et al. 2006).
Nutrition, Chronic Kidney Disease, and Kidney Failure 225
Ectopic fat accumulation in and around the kidney may also have adverse consequences on renal
function and has been called “fatty kidney.” Renal sinus fat is associated with stage 2 hyperten-
sion and the number of antihypertensive medications required to control BP (Morales et al. 2003).
Furthermore, in the Framingham Heart Study, individuals with fatty kidneys (high perinephric fat
levels) had a higher risk for hypertension (odds ratio = 2.12), which persisted after adjustment for
BMI and visceral fat (Navaneethan et al. 2009). Fatty kidney was also associated with increased
risk for CKD (odds ratio = 2.30), even after adjustment for BMI and visceral adiposity.
Obesity can affect the kidneys directly through so-called obesity-related glomerulopathy. It is
characterized histologically by enlargement of glomeruli, which can be accompanied by focal and
segmental glomerulosclerosis observed in association with hypertrophied glomeruli (D’Agati et al.
2011). There are also lipid deposits in mesangial and tubular cells, along with changes similar to
those seen in type 2 diabetes, including focal mesangial sclerosis. Focal thickening of glomerular
and tubular basement membranes, a feature of diabetic nephropathy, is also seen in obese patients
without diabetes.
Glomerular hyperfiltration accompanies obesity and has been implicated as one of the most
important pathogenic mechanisms in producing the characteristic changes in fatty kidney (Chagnac
et al. 2008). There is a linear correlation between different markers of obesity, including BMI,
waist circumference, and waist-to-hip ratio, and GFR (Bosma et al. 2004). Increased glomerular
blood flow in obesity results in glomerular hypertension, glomerular enlargement, and stretching of
microvessels in the kidney.
Epidemiological studies provide insight into why some obese patients develop CKD, while oth-
ers, with equal or greater degree of obesity, do not. Once again, it is not simply body weight or
BMI, but the presence of each of the components of metabolic syndrome, including hypertension,
hypertriglyceridemia, low HDL cholesterol, and elevated fasting serum glucose levels, that is sig-
nificantly associated with the risk of developing CKD. The risk for developing CKD was higher in
metabolically unhealthy nonobese subjects than in metabolically healthy obese ones (Hashimoto et
al. 2015). These observations point the way toward effective prevention and secondary prevention
strategies to reduce the rate of progression of CKD.
Fatty kidney typically presents with proteinuria in an obese patient with otherwise normal uri-
nalysis. In about 70% of cases, proteinuria is below the nephrotic range of >3.5 g/day, while the
remaining 30% have frank proteinuria without other signs of nephrotic syndrome, such as hypoal-
buminemia, edema, and hyperlipidemia (Kambham et al. 2001; Praga et al. 2001). Another impor-
tant consequence of this presentation is that obese people who develop proteinuria can go unnoticed
for years, owing to the absence of clinical manifestations, and be detected at a stage when the renal
function is already severely impaired. Besides proteinuria, hypertension and dyslipidemia are found
in a majority of obese patients with fatty kidney characterized by large glomeruli secondary to
increased blood flow, with secondary changes in the kidney including focal glomerular sclerosis.
Both observational studies and prospective randomized trials have shown that weight loss is
associated with a significant reduction in proteinuria (Morales et al. 2003; Navaneethan et al. 2009)
and is the preferred treatment. Blockade of the renin–angiotensin–aldosterone system (RAAS) with
ACE inhibitors or angiotensin receptor blockers in observational studies has demonstrated signifi-
cant reductions in proteinuria studies (Praga et al. 2001). Aldosterone antagonists can also reduce
proteinuria in obese patients. In the REIN study, comparing an ACE inhibitor, ramipril, versus
placebo in patients with chronic proteinuric nephropathies, obese patients were more sensitive to
the effects of ramipril in protecting the kidney and reducing proteinuria than nonobese patients
(Mallamaci et al. 2011).
12.3 RENAL INSUFFICIENCY AND CHRONIC KIDNEY DISEASE

Chronic renal insufficiency is the ninth leading cause of death in the United States, according to the
Centers for Disease Control and Prevention (2012). In this disease, the kidneys are damaged and
cannot filter blood effectively. This damage can cause wastes to build up in the body and lead to
other health problems, including cardiovascular disease (CVD), anemia, and bone disease. People
with early CKD tend not to feel any symptoms. The only ways to detect CKD are through a blood
test to estimate kidney function, and a urine test to assess kidney damage. If left untreated, chronic
renal insufficiency leads to renal failure.
The most common cause of chronic renal insufficiency is diabetes (Vallon and Thomson 2012).
After 10–20 years of diabetes mellitus, approximately 20% of patients with either type 1 or type
2 diabetes mellitus develop diabetic nephropathy, making diabetes mellitus the leading cause of
ESRD. Both genetic and environmental factors determine which patients eventually develop dia-
betic nephropathy, and there remains a need for research to better understand the pathophysiology
and molecular pathways that lead from the onset of hyperglycemia to renal failure. Changes in the
vasculature and the glomerulus, including those to mesangial cells, the filtration barrier, and podo-
cytes, play important roles in the pathophysiology of the diabetic kidney.
High BP is the second most common cause of chronic renal insufficiency and is often associ-
ated with metabolic syndrome and obesity. However, the exact mechanism of the development of
hypertension in obesity remains to be established (Hall et al. 1992). Patients with nondiabetic and
diabetic CKD should have a target BP goal of <130/80 mmHg (National Kidney Foundation 2002;
Chobanian et al. 2003; American Diabetes Association 2012). Ultimately, the rationale for lower-
ing BP in all patients with CKD is to reduce both renal and cardiovascular morbidity and mortal-
ity. Maintaining BP control and minimizing proteinuria in patients with CKD and hypertension is
essential for the prevention of the progression of kidney disease and the development or worsening
of CVD (National Kidney Foundation 2002; Chobanian et al. 2003; American Diabetes Association
2012).
Recent literature suggests that BP targets in diabetic and nondiabetic CKD may need to be
individualized based on the presence of proteinuria. Some trials have failed to show a reduction in
cardiovascular or renal outcomes in diabetic and nondiabetic patients with CKD when a BP target of
<130/80 mmHg is achieved compared with lowering BP to <140/90 mmHg (ACCORD Study Group
et al. 2011; Upadhyay et al. 2011).
However, patients who have proteinuria are less likely to experience a decline in renal function,
kidney failure, or death when the lower BP target is achieved (Brenner et al. 2001; Upadhyay et al.
2011). It is likely that future guidelines may include a lower BP goal, <130/80 mmHg, for patients
with proteinuria, but maintain a goal of <140/90 mmHg for patients without proteinuria.
Polycystic kidney disease is the most common inherited kidney disease (Nishiura et al. 2009). It
causes cyst formation in the kidneys. If the cysts are numerous and large enough, they may prevent
the kidneys from carrying out their normal functions.
Kidney stones can also lead to chronic renal insufficiency. When kidney stones become too
numerous and too big, they can interfere with normal kidney functions, causing chronic renal insuf-
ficiency (Nishiura et al. 2009). Having one kidney stone puts a patient at a 50% increased risk of
having another within 5–7 years. Treatment of kidney stones is essential to preventing chronic renal
insufficiency.
Urinary infections, if long lasting, can lead to chronic renal insufficiency (Heikkila et al. 2011).
Urinary infections mostly affect the bladder but can also spread to the kidneys. If the glomeruli in
the kidneys become infected, they can no longer eliminate excess fluid and waste at the rate that is
necessary to keep the body healthy. Urinary infections, if treated successfully, can prevent chronic
renal insufficiency. Once renal function declines so that metabolic derangements, including elec-
trolyte balance and uremia, become prominent, protein restriction is used to increase the interval
between dialysis sessions (Aparicio et al. 2012).
Cardiovascular disease is the leading cause of morbidity and mortality among people with CKD.
CKD has increased over the past decade to become a worldwide public health problem. The defini-
tion of a biomarker is a characteristic objectively measured and evaluated as an indicator of normal
biologic processes, pathogenic processes, or pharmacologic response to a therapeutic intervention.

Thus, biomarkers of kidney function would include serum creatinine and, more recently, eGFR.
These biomarkers and microalbuminuria, a potential biomarker, predict cardiovascular events
and mortality. Recent analyses of cross-sectional data indicate that eGFR is a much stronger
predictor of cardiovascular events than microalbuminuria. While microalbuminuria indicates
endothelial dysfunction and is associated with increased risk for cardiovascular events, its level
is related more to the level of BP and glycemic control than directly to the pathophysiology of ath-
erosclerosis. Hence, microalbuminuria could be viewed as a biomarker but not a risk factor for car-
diovascular since risk factors must be an integral part of the disease pathophysiology. Conversely,
while microalbuminuria is not of prognostic value to predict CKD outcomes, increases over time
into the albuminuria range, >200 mg/day, clearly indicate the presence of kidney disease and are
associated with a more rapid decline in kidney function. Thus, concomitant evaluation of both
biomarkers eGFR and albuminuria is recommended to assess kidney function and cardiovascular
risk thoroughly.
Since the risk of cardiovascular death at any given level of BP depends on the number of con-
current cardiovascular disease risk factors, a comprehensive clinical and laboratory cardiovascular
risk assessment is needed to establish the cardiovascular disease burden and determine the scope
of lifestyle changes and/or need for pharmaceutical intervention in patients with hypertension and
renal insufficiency. Many of the cardiovascular disease risk factors are behavioral and modifiable
by lifestyle changes. Although the potential therapeutic impact of established lifestyle changes on
BP varies among individuals based on their adherence, lifestyle changes, when implemented, have
all been shown to lower BP and/or mitigate the risk of cardiovascular death in a dose- and time-
dependent fashion.
Damage to the glomeruli leads to an increase in protein filtration, resulting in abnormally
increased amounts of protein in the urine (microalbuminuria or proteinuria) (Yoshioka et al.
1987; Keane and Eknoyan 1999). Microalbuminuria is the presentation of small amounts of
albumin in the urine and is often the first sign of CKD. Proteinuria (protein-to-creatinine ratio
≥200 mg/g) develops as CKD progresses, and is associated with a poor prognosis for both kidney
disease and CVD (Sarnak et al. 2003; Rashidi et al. 2008; Chronic Kidney Disease Prognosis
Consortium et al. 2010).
The estimated GFR, which helps clinicians determine how well the kidneys are filtering waste, is
used in the staging of CKD. The National Kidney Foundation defines CKD as either kidney damage,
identified by markers in the urine or blood or by imaging, with or without changes in the GFR, or
a GFR of <60 mL/minute/1.73 m2 for a minimum of 3 months (National Kidney Foundation 2002).
Table 12.1 depicts the staging criteria as determined by the Kidney Disease Outcomes Quality
Initiative (K/DOQI) guidelines.
TABLE 12.1
Staging of Chronic Kidney Disease
Stage Description GFRa (mL/minute/1.73 m2)
1 Kidney damage with normal or increased GFR ≥90
2 Kidney damage with mildly decreased GFR 60–90
3 Moderately decreased GFR 30–59
4 Severely decreased GFR 15–29
5 Kidney failure <15 or on dialysis
a The GFRs are from Collins, A. J. et al., Am. J. Kidney Dis., 59(1 Suppl. 1), A7.e1–e420, 2012.
12.4 NUTRITION AND PREVENTION OF CHRONIC KIDNEY DISEASE

Nutrition plays its most prominent role in the prevention of renal disease through the treatment of
hypertension and diabetes. CKD has become more common over the last 20 years in association
with increases in the prevalence of metabolic syndrome, hypertension, diabetes, and obesity. It was
reported to affect more than 13% of the U.S. population in 2004 (Coresh et al. 2007). In 2010, it
was reported by the Centers for Disease Control and Prevention that more than 35% of people aged
20 years or older with diabetes have CKD, and that more than 20% of people aged 20 years or older
with hypertension have CKD (Collins et al. 2012). The rise in incidence of CKD has been attributed
to an aging populace and increases in hypertension, diabetes, and obesity within the U.S. popula-
tion, conditions affected by diet. CKD is associated with electrolyte imbalances, mineral and bone
disorders, anemia, dyslipidemia, and hypertension. Furthermore, a reduced GFR and albuminuria
are independently associated with an increase in cardiovascular and all-cause mortality (Rashidi et
al. 2008; Chronic Kidney Disease Prognosis Consortium et al. 2010).
From another viewpoint, hypertension has been reported to occur in 85–95% of patients with
CKD (stages 3–5) (Rao et al. 2008). The relationship between hypertension and CKD is cyclic in
nature. Uncontrolled hypertension is a risk factor for developing CKD, and hypertension is associated
with a more rapid progression of CKD, and is the second leading cause of ESRD in the United States
(Botdorf et al. 2011; Segura and Ruilope 2011). Meanwhile, progressive renal disease can exacer-
bate uncontrolled hypertension due to volume expansion and increased systemic vascular resistance.
Multiple guidelines discuss the importance of lowering BP to slow the progression of renal disease
and reduce cardiovascular morbidity and mortality (National Kidney Foundation 2002; Chobanian et
al. 2003; American Diabetes Association 2012). However, in order to achieve and maintain adequate
BP control, most patients with CKD require combinations of antihypertensive agents; often up to
three or four medication classes may need to be employed (Bakris et al. 2000).
12.5 NUTRITION IN CHRONIC KIDNEY DISEASE

AND END-STAGE RENAL DISEASE
Patients with CKD, and particularly those with advanced or stage 5 CKD, have protein wasting
with sarcopenia, resulting in fatigue and weakness. Moreover, due to aggravation of metabolic and
hormonal parameters, protein wasting in these individuals is associated with increased morbid-
ity and mortality (Kalantar-Zadeh et al. 2005; Menon et al. 2005; Muntner et al. 2005; Weiner et
al. 2008). It has not been established whether protein depletion itself or secondary comorbidities,
including cardiovascular risk factors such as elevated triglycerides, and inflammatory cytokines
that often accompany renal failure, may be the cause of protein depletion (Kopple 1997; Kopple
et al. 1999; Kalantar-Zadeh and Kopple 2001). Protein restriction is established as a standard
component of the nutritional management of patients with advanced renal disease, since high-
protein diets lead to the accumulation of potentially toxic metabolites of protein metabolism, as
well as potassium, fat, and pro-inflammatory fatty acids. Thus, the balancing of protein intake is a
complex undertaking, particularly as anorexia and other comorbid conditions often influence what
patients can or will eat.
Numerous clinical studies of the effects of low-protein intake on the progression of CKD were
carried out in the 1970s and 1980s. Subsequently, the National Institutes of Health supported the
largest and most comprehensive multicenter trial of protein in renal disease ever conducted—the
Modification of Diet in Renal Disease (MDRD) Study. This randomized prospective controlled trial
was undertaken to test the effects of low-protein and low-phosphorus diets and strict BP control on
the progression of renal disease (Klahr et al. 1994). The MDRD Study investigated the effects of
three levels of dietary protein and phosphorus intakes and two BP goals on the progression of CKD.
Eight hundred forty adults with various renal diseases, except for insulin-dependent diabetes mel-
litus, were studied.
MDRD Study A included 585 patients who had a GFR, measured by 125I-iothalamate clear-
ances, of 25–55 mL/minute/1.73 m2. These persons were randomly assigned to 1.3 g of protein/kg
of standard body weight/day and 16–20 mg of phosphorus/kg/day, or to 0.58 g of protein/kg/day
and 5–10 mg of phosphorus/kg/day. They were also assigned to either a mean arterial BP goal of
107 mmHg (113 mmHg for those of 61 years of age or older) or 92 mmHg (98 mmHg for those of
61 years of age or older).
In MDRD Study B, 255 patients with a baseline GFR of 13–24 mL/minute/1.73 m2 were ran-
domly assigned to a 0.28 g of protein/kg/day and 4–9 mg of phosphorus/kg/day diet supplemented
with 0.28 g/kg/day of keto acids and amino acids, or to 0.58 g of protein/kg/day with 5–10 mg of
phosphorus/kg/day. They were also randomly assigned to either the above modest or strict BP con-
trol groups.
Progression of renal failure was measured periodically for an average of 2.2 years. There were no
differences between the groups in the decline in GFR in Study A. In Study B, there was a borderline
significantly greater rate of decline in GFR with the 0.58 g of protein/kg/day diet than with the very
low-protein keto acid and amino acid diet (p = 0.07).
In the 12-year follow-up analysis of Study A, during the first 6 years after the initiation of dietary
protein prescription, there was a significantly lower adjusted hazard ratio of reaching ESRD or a
combination of ESRD and mortality in those assigned to the 0.58 g of protein/kg/day diet compared
with those assigned to the 1.3 g of protein/kg/day diet (Levey et al. 2006).
In a long-term follow-up of the MDRD Study, assignment to a very low-protein diet did not delay
progression to kidney failure, but appeared to increase the risk of death (Menon et al. 2009). It is
important to appreciate that after an average of 2.2 years of follow-up, the patients were discharged
to be followed up with their various primary care physicians, and therefore probably had little or no
aggressive dietary therapy, and essentially no clinical follow-up data were available except for the
times of onset of their dialysis therapy and mortality.
A large multicenter study proved that providing essential amino acids rather than a mixture of
essential and nonessential amino acids during protein restriction does not affect the progression of
renal disease (Menon et al. 2009). The principal goal of protein-restricted regimens is to decrease
the accumulation of nitrogen waste products, hydrogen ions, phosphates, and inorganic ions while
maintaining an adequate nutritional status to avoid secondary problems, such as metabolic acidosis,
bone disease, and insulin resistance, as well as proteinuria and deterioration of renal function.
Probably the major safety issue concerning low-protein diets is the risk of protein–energy wast-
ing. This concern is especially important when individuals are prescribed as little as 0.6 g of
protein/kg/day. This concern is based on two related issues. The fact that the low-protein diet of
0.6 g/kg/day is close to the dietary requirement for clinically stable individuals who are normal or
have CKD indicates that some people may be at increased risk for protein malnutrition. In contrast,
rather extensive research indicates that such diets provide adequate daily protein for almost all
clinically stable CKD patients (Eyre and Attman 2008).
The other issue is that with such restriction in protein intake, it often becomes more difficult to
meet the average daily energy needs of the patient. This is particularly true because in order to pro-
vide adequate quantities of essential amino acids with these protein-restricted diets, a large propor-
tion of the protein must be of high biological value, that is, animal protein. In contrast, it is often the
foods higher in lower-quality protein that provide the most calories (e.g., bread, rolls, pasta, biscuits,
and cakes). This is the case because high-calorie butter, jam, cream cheese, sauces, and so forth, can
be readily added to these latter foods.
A solution to this dilemma is to frequently monitor the protein–energy status of the patient.
If evidence for protein malnutrition emerges, the protein intake may be increased up to 0.80 g
of protein/kg/day. Evidence for energy malnutrition may be treated with dietary counseling, by
increasing the protein intake as above, as this will increase the availability of low-quality proteins
that can be ingested with a consequent increase in energy intake, or with oral or parenteral high-
energy supplements.
An analysis of 14 studies with a total of 666 subjects with CKD (GFR <20 mL/minute) who were
prescribed a dietary protein intake from 0.3 g/kg/day (supplemented with keto acids and amino
acids) to 0.5 g/kg/day of protein for more than 12 months found that in all but two studies, low-
protein diets were not associated with deterioration in body composition (Fouque et al. 2000). Other
recent studies have reported similar findings (Chauveau et al. 2003).
There is no clear evidence base on which to recommend a dietary protein intake for patients with
stage 1 or 2 CKD. Published trials to a large extent have examined the effect of protein intake on the
progression of renal failure in individuals with stages 3–5 CKD. Since the published data so far have
not been definitive, consent should be obtained from the patient after a discussion of the evidence and
the side effects of a low-protein diet, including possible loss of lean body mass. Then a diet providing
0.60–0.75 g of protein/kg/day can be prescribed. To ensure an adequate intake of essential amino
acids, this diet should provide at least 50% of the protein as high biological value. This amount of
protein intake normally will maintain a neutral or positive nitrogen balance (Kopple 1999).
For stages 4 and 5 CKD, the potential advantages of a low-protein and low-phosphorous diet at
this degree of renal insufficiency are more compelling. The rationale for a low-protein diet at this
stage is that toxic products of nitrogen metabolism begin to accumulate in significant amounts at
these levels of renal insufficiency. A low-protein diet generates less nitrogenous and other com-
pounds, including guanidines, organic acids, and minerals, which have been considered potentially
toxic to the patient. Hence, a low-protein diet may reduce the risk of uremic symptoms.
Patients can suffer from anorexia and nausea. As a result, they may eat too little protein rather
than too much. These patients are at increased risk for malnutrition. Encouragement and specific
training to follow the prescribed diet may increase the likelihood that they do not ingest less than
the recommended intake or other nutrients. To maintain a neutral or positive nitrogen balance,
patients should be prescribed 0.60 g of protein/kg/day. For individuals who are unable to maintain
adequate dietary energy intake with such a diet or will not accept this diet, an intake of up to 0.75 or
0.80 g of protein/kg/day may be recommended. This latter protein intake is easier for most people to
adhere to and, as indicated above, frequently enables people to more readily ingest a higher dietary
energy intake.
Nephrotic syndrome is a nonspecific disorder in which the kidneys are damaged, causing them
to leak large amounts of protein. The prescribed protein intake in nephrotic patients is not increased
unless their proteinuria exceeds 5.0 g/day. Above 5.0 g of proteinuria/day, the prescribed diet is
increased by 1 g/day of high-biological-value protein for each additional gram per day of protein-
uria. Proteinuria is monitored periodically; if urinary protein excretion changes the diet, protein
intake can be modified accordingly. This approach is based on the adverse consequences observed
in CKD patients who are protein wasted (Rambod et al. 2009).
Clinical practice guidelines for nutrition in CKD from the National Kidney Foundation recom-
mend a protein intake of 1.2–1.3 g of protein/kg/day for clinically stable chronic peritoneal dialy-
sis (CPD) patients (Clinical Practice Guidelines 2000). Dietary protein requirements in patients
undergoing automated peritoneal dialysis appear to be similar. Patients undergoing hemodialysis
lose protein in the dialysate. Nitrogen balance studies suggest that to maintain normal total body
protein and protein balance, some maintenance hemodialysis patients require more than 1.0 g of
protein/kg/day. Clinical practice guidelines (2000) on nutrition in CKD patients recommend 1.2 g
of protein/kg of body weight/day for clinically stable patients; half of the dietary protein should be
of high biological value.
During maintenance hemodialysis, monitoring nitrogen balance requires a consideration of total
nitrogen appearance (TNA), which is defined as the sum of dialysate, urine, fecal nitrogen losses, and
(in dialysis patients) the postdialysis increment in body urea nitrogen content (Westra et al. 2007).
As nitrogen is rather expensive to measure, and there are few commercial laboratories that mea-
sure nitrogen, urea is usually measured instead. Urea is the major nitrogenous product of protein
and amino acid degradation, and unlike nitrogen, it can be both precisely and inexpensively mea-
sured. TNA usually can be estimated accurately by measuring urea nitrogen appearance (UNA).
UNA is the amount of urea nitrogen that appears or accumulates in body fluids and all outputs (most
commonly, urine and dialysate).
Clinically stable people who are at zero nitrogen balance should theoretically have a total nitro-
gen output that is equal to nitrogen intake minus about 0.5 g of nitrogen/day from such unmea-
sured losses as sweat, blood drawing, growth of nails, and replacement of exfoliated skin. Nitrogen
output therefore should closely correlate with nitrogen intake in these individuals and can be used
to estimate dietary nitrogen output, and therefore dietary protein needs to maintain balance. In
stable CKD patients, both TNA and UNA are in balance with dietary nitrogen and protein intake
(Cook et al. 2007).
For the purpose of estimation, dietary proteins are assumed to have 6.25 g of nitrogen/g of
protein. UNA is calculated as follows: UNA (g/day) = UUN + DUN + Change in Body UN (all in
units of g/day), where Body UN is body urea nitrogen and DUN is the dialysate urea nitrogen. The
change in body urea nitrogen (g/day) is different than blood urea nitrogen (BUN) and is calculated
by subtracting the final BUN after dialysis from the initial BUN. Since BUN goes down during
dialysis, this is expressed as BUN(final) minus BUN initial as a positive number. This difference
is then multiplied by the body water volume estimated as 0.6 times body weight. You have now
accounted for the change in BUN during dialysis from the point of view of BUN, but you also
must correct for the change in body water that occurs as the result of dialysis. This is calculated
by multiplying 0.6 times the difference between the final body weight and the initial body weight,
and then multiplying this result by the final BUN in grams per liter. The final body weight will be
greater than the initial body weight or body water, and by multiplying by the final BUN, you have
accounted for this change during dialysis.
Mathematically, the formulas can be summarized as follows:
UNA = UUN + DUN + ∆ Body UN
(
∆ Body UN =  BUN(final) − BUN(initial)  × 0.6 BW )

(
+  BW(final) − BW(initial)  × BUN(final) )
The calculation is made to reflect the time between dialysis intervals and then normalized to
24 hours. Body weight (BW) times 0.6 to estimate body water is valid for average body com-
position. In edematous or lean patients, the estimated proportion of body weight that is water is
increased, and in the obese or the very young, it is decreased.
Although there are not yet any systematically collected data on which to recommend protein
requirements in maintenance hemodialysis patients receiving more frequent dialysis treatments,
this dietary intake is estimated to provide adequate protein nutrition.
Alterations in dietary protein intake have an important role in the prevention and management
of CKD. Using soy protein instead of animal protein reduces the development of kidney disease in
animals (Eknoyan and Agodoa 2002). Reducing protein intake preserves kidney function in persons
with early diabetic kidney disease. These observations lead to the potential for substitution of soy
protein for animal protein, to result in less hyperfiltration and glomerular hypertension, with result-
ing protection from diabetic nephropathy. Specific components of soy protein may lead to benefits
for specific peptides, amino acids, and isoflavones. Substituting soy protein for animal protein usu-
ally decreases hyperfiltration in diabetic subjects and may reduce urine albumin excretion. Limited
data are available on the effects of soy peptides, isoflavones, and other soy components on renal
function in diabetes. Further studies are required to discern the specific benefits of soy protein and
its components on renal function in diabetic subjects (Eknoyan and Agodoa 2002).
Studies clearly indicate that people prescribed special diets are much more likely to adhere to them
if they are periodically monitored, educated, and encouraged to follow their dietary prescription. In
order to maximize compliance, physicians and dietitians should schedule frequent, often monthly,
visits with patients who have CKD stage 5 and often stage 4. Less frequent visits may be convened
with patients who have stable and less severe renal insufficiency, as long as evidence indicates that
they are adequately compliant.
12.6 SUMMARY
CKD is a global public health problem (Eknoyan and Agodoa 2002; Levey et al. 2007; Crowe et al.
2008), affecting 10–16% of the adult population on several continents (Chadban et al. 2003; Hallan
et al. 2006a; Coresh et al. 2007; Wen et al. 2008) and increasing the risk of adverse outcomes
(Chronic Kidney Disease Prognosis Consortium et al. 2010; Astor et al. 2011; Gansevoort et al.
2011; Levey et al. 2011; van der Velde et al. 2011). The definition and staging of CKD is based on
the level of GFR and the presence of kidney damage, usually ascertained as albuminuria (Eknoyan
and Agodoa 2002; Levey et al. 2011; Tonelli et al. 2011).
In international population cohorts, the crude prevalence of reduced eGFR (<60 mL/ minute/1.73 m2) in
Asians, whites, and blacks was 5.1%, 15.8%, and 9.4%, respectively. The prevalence of elevated albumin-
uria (≥30 mg/g by albumin-to-creatinine ratio [ACR] or ≥1+ by urine dipstick) in these three racial groups
was 2.8%, 9.7%, and 16.8%, respectively. The difference in prevalence of reduced eGFR and elevated
albuminuria across racial groups was attenuated after age standardization, particularly for reduced eGFR.
The GFR thresholds for the definition and staging of CKD were first proposed in 2002, using
data derived predominantly from a general U.S. population (Eknoyan and Agodoa 2002). In the last
decade, these eGFR thresholds have been incorporated into clinical guidelines in other countries
(Crowe et al. 2008; Levin et al. 2008; Japanese Society of Nephrology 2009). The recognition of
albuminuria as an independent risk factor for adverse outcomes has now led to the incorporation of
albuminuria categories into CKD staging, and this analysis has utilized the new recommendations
for categories of albuminuria and eGFR (Kidney Disease 2013). The relationship of eGFR and
albuminuria to overall CKD and CVD outcomes, irrespective of race, gives additional credence to
their use in clinical detection of early CKD.
Aggressive screening of patients presenting with low eGFR and nutritional interventions
designed to reduce BP, including the Dietary Approaches to Stop Hypertension (DASH) diet and
increased fruit and vegetable intake, together with reasonable control of sodium intake in obese and
hypertensive patients, should be standard practice in primary care. The emphasis in primary care
education on hypertension treatment has traditionally been the use of various drugs, with only lip
service paid to lifestyle and nutrition. This has been due to the recognized difficulties in dietary
and lifestyle change, but prevention carried out by a multidisciplinary primary care team, including
dietitians, using integrated methods of nutrition, lifestyle change, and appropriate individualized
pharmacotherapy, should help reduce the morbidity and mortality of CKD.
Primary care providers need to be very attentive to the risks of progressive kidney disease and
should screen patients, particularly those at increased risk—patients with hypertension, patients
with diabetes mellitus, and patients with a family history of kidney disease—with blood tests for
serum creatinine and urine testing to look for albuminuria, with a spot urine for calculation of an
ACR. This is of particular importance among populations where there is an increased risk of CKD.
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13 Nutrition and Heart Failure
13.1 INTRODUCTION
With increased aging of the world’s population and increases in the comorbid diseases associated
with cardiovascular disease, including metabolic syndrome, type 2 diabetes, and hypertension, the
number of people globally affected by heart failure (HF) has increased over the last few decades
both in the United States and around the world. Patients with HF can benefit from nutrition and
lifestyle intervention, but the major emphasis for treating HF has been pharmacotherapy, as well
as fluid and sodium restriction. Despite advances in drug treatment and mechanical assist devices,
HF continues to be characterized by high morbidity and mortality comparable to common forms of
advanced cancer (Curtis et al. 2008).
The economic impact associated with the very frequent hospitalization of patients with HF to
treat acute HF decompensation has a significant public health impact (Writing Group Members
et al. 2010). HF affects about 6 million individuals in the United States and 23 million worldwide.
The direct costs of HF in the United States were $32 billion in 2013, and the cost is projected to
increase threefold by 2030 (Heidenreich et al. 2013). The lifetime cost of HF per individual was
estimated in 2011 to be $110,000/year, with more 75% of the cost consumed by “in-hospital care”
(Dunlay et al. 2011). HF is a very serious disease with a 5-year mortality rate of approximately 50%,
comparable to the mortality of some forms of advanced cancer (Askoxylakis et al. 2010). Among
Medicare patients, 30-day, all-cause, risk-standardized readmission rates after hospital discharge
are 20–25% (Ni and Xu 2015).
As noted, the prevalence of HF has markedly increased (Roger 2013), and it has been proposed
that the increased number of aged individuals may be one of the reasons behind the increased
prevalence of HF (Poole et al. 2012). Hospitalization due to acute decompensation of HF accounting
for about 80% of HF-related hospital admissions can be caused by a number of factors, most com-
monly including nonadherence to medication, increased sodium intake, and uncontrolled hyper-
tension. In addition, acute coronary syndrome, myocardial ischemia, arrhythmias, exacerbation of
chronic pulmonary disease, alcohol intoxication, excess thyroid hormone, pregnancy, postoperative
fluid overload, and administration of steroids or nonsteroidal anti-inflammatory drugs can all cause
decompensation of a failing heart (Poole et al. 2012).
13.2 ETIOLOGY AND CLINICAL CLASSIFICATION OF HEART FAILURE

HF is caused by structural and functional defects in cardiac muscle, resulting in impairment of the
ventricular filling or ventricular ejection fraction, the ratio of blood in the ventricle that is ejected
during systole. The most common cause for HF is reduced left ventricular function due to prior
myocardial function leaving behind nonfunctional heart muscle. However, disorders of the pericar-
dium, endocardium, heart valves, or great vessels alone or in combination can also cause HF.
The heart is the only organ that provides its own blood supply, and it does so in proportion to
oxygen demand for cardiac output in healthy hearts. Microvascular dysfunction and subsequent
decrease in oxygen and nutrient delivery to the myocardium can be an important component of
maintaining cardiac function in a failing heart. Therapeutic strategies to improve muscle microvas-
cular nutritive and oxygen delivery functions via exercise training and anti-inflammatory and anti-
oxidant agents have been proposed to be essential to provide better exercise tolerance and quality of
life for patients with HF (Ohtani et al. 2012).
237
Low-output failure is the most common form of HF. Large myocardial infarctions and acute
pulmonary emboli typically cause low-output failure. High-output HF is an uncommon condition in
which a very rapid heart rate does not allow adequate time for optimal filling of the cardiac cham-
bers, resulting in reduced effective organ perfusion and edema. High-output HF can be caused by
severe anemia, large intracardiac flow shunts, hyperthyroidism, and vitamin B1 deficiency.
Clinically, there are two important subtypes of HF based on the function of the ventricles. HF
with preserved ejection fraction is differentiated from HF with reduced ejection fraction. In patients
with preserved ejection fraction of greater than 50%, the volume of the left ventricle is typically
normal, but the left-ventricle wall is thick with reduced wall motion (Dassanayaka and Jones 2015).
In HF with reduced ejection fraction, the left ventricle is typically enlarged and floppy. The size of
heart muscle cells is smaller in HF with reduced ejection fraction than in HF with preserved ejection
fraction (Dassanayaka and Jones 2015). These clinical subtypes are important because they influ-
ence the likelihood of treatment responses. Patients who have HF with reduced ejection fraction
typically respond to pharmacotherapy, while patients who have HF with preserved ejection fraction
respond to nitrates but not to the forms of pharmacotherapy meant to counteract activation of the
renin–angiotensin axis. Patients with preserved ejection fraction also have a worse prognosis than
patients with reduced ejection fraction (Glean et al. 2015; Zamani et al. 2015).
HF is also classified according to the functional capacity of patients. The New York Heart
Association (NYHA) functional classification defines four functional classes as
• Class I: HF that does not cause limitations to physical activity. Ordinary physical activity
does not cause symptoms.
• Class II: HF that causes slight limitations to physical activity. The patients are comfortable
at rest, but ordinary physical activity results in HF symptoms.
• Class III: HF that causes marked limitations of physical activity. The patients are comfort-
able at rest, but less than ordinary activity causes symptoms of HF.
• Class IV: HF patients are unable to carry on any physical activity without HF symptoms
or have symptoms when at rest.
The American College of Cardiology/American Heart Association (ACC/AHA) staging system

is defined by four stages:
• Stage A: High risk of HF, but no structural heart disease or symptoms of HF

• Stage B: Structural heart disease, but no symptoms of HF
• Stage C: Structural heart disease and symptoms of HF
• Stage D: Refractory HF requiring specialized interventions
HF is a clinical diagnosis and can present with symptoms of shortness of breath, orthopnea, par-
oxysmal nocturnal dyspnea, fatigue, edema, distended abdomen, rales on auscultation, and pleural
effusion (Watson et al. 2000; Yancy et al. 2013). Early stages of HF are more difficult to diagnose
due to a lack of specific signs, as compensatory physiological mechanisms are activated.
13.3 DIAGNOSIS AND MEDICAL TREATMENT OF HEART FAILURE

13.3.1 Heart Failure with Preserved Ejection Fraction
Patients with HF are also classified based on ejection fraction in terms of either preserved or reduced
ejection fraction. Systolic HF refers to HF with reduced ejection fraction, while diastolic HF refers
to HF with preserved ejection fraction. Approximately 50% of the patients with HF have preserved
ejection fraction, and they have higher morbidity and mortality rates than patients with reduced
ejection fraction. HF with preserved ejection fraction is an emerging epidemic because of the rising
Nutrition and Heart Failure 239
prevalence in patients over the age of 65 and the lack of effective treatment for impaired myocardial
energy availability (Oktay et al. 2013).
It has been proposed that increased production of radical oxygen species within the myocar-
dium in response to activation of the renin–angiotensin–aldosterone system (RAAS) and sympa-
thetic nervous system (SNS) leads to impairment of the mitochondrial bioenergetics with decreased
adenosine triphosphate production (Munzel et al. 2015). Both of these factors are now believed to
be major mechanisms for the development of HF with preserved ejection fraction (van Heerebeek
et al. 2012b; Paulus and Tschope 2013; Andersen and Borlaug 2014). Research on mitochondrial
bioenergetics in the myocardium and supplementation of antioxidants is being explored for this
subtype of HF.
The principal symptoms of HF with preserved ejection fraction include exertional shortness of
breath and fatigue (van Heerebeek et al. 2012a). The majority of patients are older women with a
history of hypertension. In addition, these patients have many comorbidities, such as obesity, diabe-
tes mellitus, dyslipidemia, and coronary artery disease (Owan et al. 2006; Lee et al. 2009). There
are no pharmaceutical agents that have altered the clinical course of HF with preserved ejection
fraction.
Studies have indicated that moderate walking exercise for these patients is associated with
improved symptoms of fatigue and shortness of breath, and with weight loss and improved quality
of life. However, exercise may not change the patient’s systolic or diastolic function (Kitzman et al.
2013; Fleg et al. 2015; Pandey et al. 2015). Adjunctive therapy, such as omega-3 polyunsaturated
fatty acids (PUFAs) (Macchia et al. 2005; Tavazzi et al. 2008), coenzyme Q10 (CoQ10) (Mortensen
et al. 2014), and D-ribose (Bayram et al. 2015) supplementation, has been found useful for reduc-
ing the symptoms of HF with preserved ejection fraction, but more research is needed because the
recommended management has not been effective in reversing the poor prognosis for these patients.
13.3.2 Pharmacotherapy of Heart Failure with Reduced Ejection Fraction

About half of all patients with HF have reduced ejection fraction, and the pharmacotherapy of this
type of HF is based on using drugs that modify the RAAS and SNS responses to the reduction in
cardiac output (Figure 13.1). The ACC and AHA jointly published updated clinical guidelines for
Myocardial Reduced cardiac

injury output
Activation of Activation of
sympathetic renin−
nervous system angiotensin axis
Increased heart Vasoconstriction and

rate and increased workload (angio II)
myocardial increased sodium retention
toxicity increased preload (aldo)
Heart failure with reduced ejection fraction
FIGURE 13.1 Pathophysiology of HF with reduced ejection fraction. Low blood pressure triggers carotid
baroreceptors, which activate the SNS, leading to tachycardia and increased myocardial oxygen needs.
Increases in epinephrine and norepinephrine lead to increased afterload via peripheral vasoconstriction.
Reduced renal blood flow leads to activation of the renal–angiotensin axis, resulting in sodium and water
retention. Angiotensin II (Angio II) also leads to vasoconstriction and increased afterload. Aldo, aldosterone.
the treatment of HF in May 2016, updating their 2013 guidelines (Yancy et al. 2016). These guide-
lines focus primarily on pharmacotherapy and follow a form that attempts to provide digestible
blocks of information in response to specific issues, as suggested by the Institute of Medicine and
formulated by the ACC/AHA (Greenfield and Steinberg 2011; Institute of Medicine 2011; Jacobs
et al. 2013; Anderson et al. 2014; Arnett et al. 2014; Jacobs et al. 2014). However, beyond sodium
and fluid restriction, dietary recommendations are general and encourage eating a “healthy diet.”
The SNS and RAAS are activated as a physiological means to retain sodium and water, elevate
heart rate, and increase peripheral vasoconstriction. Increased epinephrine and norepinephrine lev-
els act to increase heart rate, contractility, and afterload via peripheral vasoconstriction. In the short
term, this will work to increase cardiac output and relieve HF symptoms; however, chronically this
has deleterious effects and causes further left ventricular systolic decline. β-Blockers are used to
reduce SNS activation and angiotensin-converting enzyme (ACE). The activation of the RAAS has
been demonstrated to contribute to negative remodeling of the heart, resulting in even worse overall
cardiac function.
B-type natriuretic peptide and A-type natriuretic peptide have beneficial effects on blood flow
during HF and represent another physiological mechanism activated to reverse changes secondary
to low cardiac output. These peptides are released in the atrium as the elevated cardiac pressures
stretch atrial myocytes. They act to vasodilate and cause sodium excretion, resulting in natriuresis.
Natriuretic peptide levels may be used to monitor diuretic therapy during hospitalizations for
acute fluid overload and pulmonary edema (Berger et al. 2010; Januzzi 2012; Sanders-van Wijk
et al. 2013). Diuretic therapy is only of secondary value, due to potential worsening of the underly-
ing physiology, which is triggered by reduced blood pressure and so may worsen the underlying
evolution of HF. On the other hand, fluid overload with edema secondary to HF remains the over-
whelming reason for hospital admission, and diuretics remain the mainstay for treating volume
overload. Detecting marked elevation or increased natriuretic peptide concentrations can facilitate
more effective and prompt use of diuretics, leading to reduced hospital stays for congestion. Another
benefit of monitoring with natriuretic peptides may be a reduction in needed doses of diuretics,
lessening the risk of hypotension.
13.3.3 Sodium Restriction in Low-Output Heart Failure

Dietary sodium restriction is commonly recommended for patients with HF to prevent fluid reten-
tion, exacerbation of symptoms, and hospitalization for acute decompensated HF. However, evi-
dence for effectiveness of this widely used approach is mostly observational. All current guidelines
emphasize sodium and fluid intake restriction, but there is disagreement on whether strict sodium
restriction is beneficial.
Results from several studies have raised concern that restricting dietary sodium to <2 g/day may
not be beneficial in HF and may actually be harmful. High circulating levels of aldosterone lead to
retention of sodium and water. On the surface, salt restriction appears to make physiological sense,
given that interstitial edema is due to the water that follows salt into interstitial spaces. Clinical
evidence suggests that for subjects who are not sodium deprived, high sodium intake may actually
expand intravascular volume via fluid shift from the interstitial space without increasing total body
water. Moreover, in the setting of HF pharmacotherapy with drugs that block the RAAS as well as
diuretics, there is little direct evidence that sodium restriction can improve HF symptoms. In fact,
increasing doses of diuretics can compromise renal perfusion, further stimulating the RAAS and
increasing edema. In addition, stimulation of vasopressin secretion from the hypothalamus due to
reduced perfusion can cause retention of free water and hyponatremia.
Controlled trials supporting the notion of less severe sodium restriction were carried out in
which patients were randomized to either a 1.8 or 2.8 g sodium diet. Patients were also placed on a
1–2 L fluid restriction and high doses of diuretics. The earliest of these studies included a sample
of 107 patients with severe HF followed for 7–36 months after discharge for the treatment of HF
exacerbation. Survival in the 2.8 g sodium diet group was significantly better than in the 1.8 g
sodium group (55% vs. 13%) (Licata et al. 2003). Similar results were reported in a larger study of
232 patients with less severe HF (NYHA class II) enrolled 30 days postdischarge from hospitaliza-
tion for exacerbation of HF (Paterna et al. 2008). Over the 180-day study period, patients in the 1.8 g
sodium intake group had a higher readmission rate. At 12 months, patients on the 1.8 g sodium diet
had higher rates of combined end points of hospital admissions and death than patients on a 2.8 g
diet (Parrinello et al. 2009). Additional clinical trials are underway to address the long-term effects
of dietary sodium restriction on clinical outcomes in patients with HF (Butler et al. 2015; Colin-
Ramirez et al. 2015).
13.3.4 Heart Failure Treatment: Medical Therapy

Educating patients in regards to the importance of medication compliance is crucial to prevent epi-
sodes of HF decompensation leading to hospitalization. There are many available pharmacothera-
pies for patients with low-output congestive HF. It is important to understand which therapies are
the most important and reduce mortality versus those that are for symptom relief only.
13.3.4.1 ACE Inhibitors and Angiotensin Receptor Blockers

ACE inhibitors act primarily through blockade of the ACE, which converts angiotensin I to angio-
tensin II. Angiotensin II causes vasoconstriction, increasing afterload and systemic blood pressure.
Angiotensin also contributes to the production of aldosterone, which leads to sodium and water retention.
Reducing the activity of the RAAS is crucial in HF, during which it is overactive and contributes
to negative remodeling. ACE inhibitors can reduce the symptoms of HF and have been shown in
multiple clinical trials to have a mortality benefit in systolic HF patients with reduced ejection frac-
tion. Commonly used ACE inhibitors include lisinopril, captopril, Ramipril, and enalapril.
Angiotensin receptor blockers (ARBs) act by blocking the angiotensin receptor. Very similar
effects on the RAAS are achieved when using ARBs compared with ACE inhibitors. ARBs are
primarily used when a systolic HF patient is not able to tolerate an ACE inhibitor, frequently due to
the side effect of coughing sometimes associated with ACE inhibitors.
ACE inhibitors reduce morbidity and mortality in HF with reduced ejection fraction. Randomized
controlled trials (RCTs) clearly establish the benefits of ACE inhibition in patients with mild, moderate,
or severe symptoms of HF and in patients with or without coronary artery disease (The CONSENSUS
Trial Study Group 1987; The SOLVD Investigators 1991; Pfeffer et al. 1992; The Acute Infarction
Ramipril Efficacy (AIRE) Study Investigators 1993; Kober et al. 1995; Packer et al. 1999).
ACE inhibitors can produce angioedema and should be given with caution to patients with low
systemic blood pressures, renal insufficiency, or elevated serum potassium. ACE inhibitors also
inhibit kininase and increase levels of bradykinin, which can induce cough, but also may contribute
to their beneficial effect through vasodilation.
ARBs were developed with the rationale that angiotensin II production continues in the presence
of ACE inhibition, driven through alternative enzyme pathways. ARBs do not inhibit kininase and
are associated with a much lower incidence of cough and angioedema than ACE inhibitors, but like
ACE inhibitors, ARBs should be given with caution to patients with low systemic blood pressure, renal
insufficiency, or elevated serum potassium. Long-term therapy with ARBs produces hemodynamic,
neurohormonal, and clinical effects consistent with those expected after interference with the renin–
angiotensin system and have been shown in RCTs to reduce morbidity and mortality, especially in ACE
inhibitor-intolerant patients (Cohn et al. 2001; Pfeffer et al. 2003a,b; Konstam et al. 2009).
13.3.4.2 β-Blockers
β-Blockers antagonize β-1 and β-2 receptors, which are the usual targets of the SNS, including
epinephrine and norepinephrine. The overactive SNS has deleterious effects on long-term cardiac
function, as described earlier.
β-Blockers improve outcomes in HF by lowering blood pressure, reducing left ventricular

hypertrophy and diastolic dysfunction, slowing the heart rate, and reducing myocardial oxygen
demand (Brophy et al. 2001; Klingbeil et al. 2003; Bergstrom et al. 2004; Lund et al. 2014). Three
β-blockers are approved in the United States by the Food and Drug Administration (FDA) for the
treatment of systolic congestive HF: metoprolol succinate, carvedilol, and bisoprolol. β-Blockers are
contraindicated specifically in systolic HF when pulmonary edema is present, which can include
signs of cardiogenic shock, severe bradycardia, hypotension, or wheezing related to asthma.
13.3.4.3 Aldosterone Antagonists
Aldosterone antagonists (spironolactone and eplerenone), also known as “potassium-sparing diuret-
ics,” block the action of aldosterone, inhibiting the reuptake of sodium and water. Normally, when
sodium is reabsorbed, it is exchanged with potassium, which is then excreted. Since aldosterone
inhibition decreases sodium reabsorption, it also decreases potassium excretion, resulting in higher
serum potassium levels.
Spironolactone is indicated in systolic HF with recent or current NYHA functional class IV
symptoms, preserved renal function, and a normal potassium concentration. Spironolactone was
investigated in the Randomized Aldactone Evaluation Study (RALES) trial, and a mortality benefit
was shown in NYHA functional class III and IV patients (Vardeny et al. 2014). However, significant
hyperkalemia did contribute to sudden cardiac death.
13.3.4.4 Digoxin
Digoxin blocks the sodium-potassium ATPase pump. The mechanism by which this decreases atrio-
ventricular conduction is not clear; however, it is perhaps due to increased vagal tone. Intracellular
calcium within the cardiac myocytes is increased by digoxin, resulting in increased inotropy (con-
tractility), and thus digoxin is frequently used when atrial fibrillation and left ventricular systolic
dysfunction coexist.
While digoxin therapy is indicated for the treatment of symptomatic systolic congestive HF, the
Digitalis Intervention Group (DIG) trial showed no mortality benefit; however, there was improve-
ment in symptoms and fewer hospitalizations for HF (Abdul-Rahim et al. 2016). Digoxin toxicity is
a concern, and the dose must be adjusted in the setting of renal failure.
13.3.4.5 Diuretics
The loop diuretics furosemide, bumetanide, and torsemide are utilized to help maintain euvolemia
in HF patients. These drugs are for symptom relief only and have never been shown to have a mor-
tality benefit. The dose frequently needs adjusting based on the patient’s lifestyle, including fluid
and salt intake.
13.3.4.6 ADH Antagonists
Tolvaptan is a vasopressin receptor antagonist. Vasopressin (aka antidiuretic hormone [ADH]) helps
to regulate water retention by absorbing water in the collecting ducts of the nephron. Blocking this
receptor will allow water to be excreted more readily. Many HF patients present with some degree
of hyponatremia from water retention.
Tolvaptan has been shown in more than one clinical trial to raise sodium levels; however, mortal-
ity and rehospitalization were not improved (Felker et al. 2017). While tolvaptan is FDA approved
for the treatment of euvolemic hyponatremia and hypervolemic hyponatremia, it has no place in the
treatment of HF.
13.3.4.7 Nesiritide
Nesiritide is a recombinant form of B-type natriuretic peptide and is used for the treatment of acute
decompensated HF. Nesiritide has potent vasodilatory properties and reduces pulmonary capillary
wedge pressure effectively. This results in improvement of dyspnea.
One large trial (ASCEND-HF) randomized 7141 patients to nesiritide versus placebo. While
nesiritide did improve the symptom of dyspnea better than placebo, there was no reduction in
30-day rehospitalization and no mortality benefit. Hypotension was significant in the nesiritide
group.
Nesiritide is not recommended for routine use during decompensated HF. If patients with normal
blood pressures are not responding well to typical management with loop diuretics, then nesiritide
can be considered.
13.3.4.8 Hydralazine and Nitrates

Hydralazine is a direct arterial vasodilator that decreases afterload. Isosorbide mononitrate is a
long-acting oral nitrate that decreases preload. The combination of these two drugs has an effect
similar to that of an ACE inhibitor or ARB without reducing renal function or causing hyperka-
lemia. The combination of hydralazine and nitrates, however, does not have the neurohormonal
blockade benefit of ACE inhibitors or ARBs, which is thought to play an important role. Despite
this, a clear mortality benefit has been present with this combination when ACE inhibitors or ARBs
are contraindicated, especially in the African American population (Sliwa et al. 2016).
13.3.5 Heart Failure Treatment: Mechanical, Revascularization, and Heart Transplant

The treatment of HF with therapies other than medications, such as the use of devices, is consid-
ered mechanical therapy. This includes biventricular pacing, implantable cardioverter defibrillators
(ICDs), and left ventricular assist devices (LVADs). Revascularization with stenting and coronary
bypass surgery are also implemented in some cases. Heart transplant is a last resort in treating HF.
A discussion of these options is outside the scope of this chapter, which includes medical therapies,
and sodium and fluid restriction simply to increase understanding of the physiology and potential
impact of altering the responses to low-output HF.
13.4 BMI PARADOX IN HEART FAILURE

Despite evidence demonstrating the adverse effects of excess weight, the relationship between body
mass index (BMI) and mortality in HF patients remains controversial. Because obesity and diabetes
mellitus increase the risk of HF, it is attractive to hypothesize that weight loss would be beneficial to
patients with HF and obesity, with or without diabetes mellitus. Paradoxically, several large cohort
studies have shown that overweight and obese HF patients seem to have better survival than their
healthy-weight counterparts (Horwich et al. 2001; Curtis et al. 2005; Lavie et al. 2005), which is
inconsistent with our understanding of the negative effects associated with obesity and contradicts
current recommendations to promote weight loss in the HF population.
There are a number of limitations in these studies that must be addressed before definitive con-
clusions can be drawn about the association between increased body fat and survival:
1. Many samples were composed primarily of men; thus, women have been underrepresented.
2. Many studies have been retrospective.
3. Few of the previous studies examined the impact of percent body fat on outcomes, while
BMI may not be the right clinical indicator to assess excess body fat, especially in the pres-
ence of sarcopenia obesity.
4. None of the studies examined the effects of nutritional intake and nutritional status on
outcomes.
5. None of the studies examined possible mechanisms that may be responsible for the posi-
tive effects of increased body fat on survival, so it is not possible to determine whether this
relationship is causal.
6. None of the studies examined the effect of voluntary weight loss on outcomes.
7. Some of the findings reflect outcomes related to involuntary weight reduction that involves
loss of lean tissue, muscle, and bone (cardiac cachexia), which is an independent predictor
of increased mortality in advanced stages of HF (Kalantar-Zadeh et al. 2005).
8. None of the studies controlled for age, medication regimen, NYHA class, HF severity, or
ejection fraction; thus, there are limited data to support the argument that weight loss may
be detrimental to patients with HF, obesity, and diabetes mellitus.
Prospective studies that address limitations of past studies are needed before recommendations to
change practice can be made.
Recently, in this advanced HF cohort, an unadjusted obesity survival paradox disappeared after
adjustment for confounders. Overweight and obese males had higher adjusted mortality than normal-
weight males, whereas a BMI in the overweight range was associated with a significant survival benefit
in females (Vest et al. 2015). Another study involving 2527 subjects with diabetes conducted over 10
years demonstrated no benefit from the obesity paradox in congestive heart failure (Zamora et al. 2016).
13.5 MACRONUTRIENTS
13.5.1 Protein in Sarcopenia and Cardiac Cachexia
While the loss of body weight is a defining component of cachexia, sarcopenia is not necessarily
associated with changes in body weight, because declining muscle mass can be masked by propor-
tional increases in adipose tissue. Alternatively, high BMI may be associated with increased muscle
mass, as already discussed in the previous section with regard to the BMI paradox. The failure to
use body composition methods rather than simply body weight may hinder the clinical detection of
sarcopenia and requires the use of imaging techniques for muscle mass, including dual-energy x-ray
absorptiometry, computed tomography, or magnetic resonance imaging.
Clinically, it is virtually impossible to distinguish between sarcopenia and cachexia-related mus-
cle wasting in advanced stages of HF. Yet, it should be noted that muscle mass is lost earlier than
adipose tissue during the progression of HF. Older patients with HF may develop sarcopenia before
becoming cachectic (von Haehling 2015). Although sarcopenia is primarily an age-dependent phe-
nomenon, its course is accelerated by HF (Buford et al. 2010). Indeed, sarcopenia affects approxi-
mately 20% of older adults with HF, which exceeds the prevalence observed in individuals of the
same age without HF (Fulster et al. 2013). Older patients with HF and sarcopenia show a lower
exercise capacity than those with preserved muscle mass and function (Fulster et al. 2013). This
finding suggests that the recognition of sarcopenia in the context of HF and the implementation of
nutritional strategies to increase muscle mass, along with exercise, may help ameliorate functional
capacity, before the wasting disorder enters its later stages.
HF treatment guidelines provide no recommendations regarding the intake of protein. It has
recently been suggested that the amount and composition of dietary macronutrients may affect the
symptoms and outcomes in HF patients (Chess and Stanley 2008). Specifically, it has been suggested
that a high-protein diet might be beneficial in the advanced stages of HF. Current HF treatment guide-
lines provide no recommendations regarding the intake of protein, fat, and carbohydrate (Lindenfeld
et al. 2010). An adequate energy–protein intake, when combined with amino acid supplementation,
was shown to improve nutritional and metabolic status in most cardiac cachexia patients (Aquilani
et al. 2008). A 12-week high-protein diet tested at the University of California, Los Angeles (UCLA)
resulted in moderate weight loss and reduced adiposity in overweight and obese patients with HF and
was associated with improvements in functional status, lipid profiles, glycemic control, and quality of
life (Evangelista et al. 2009). It has been proposed that increasing protein and/or total energy intake
in cachexic HF patients may prevent or reverse cachexia, but this remains to be definitively estab-
lished (Rozentryt et al. 2010). High-protein intake might improve protein synthesis and cell function,
and prevent deterioration in mitochondrial and left ventricular function.
13.5.2 Balancing Omega-3 and Omega-6 Fats in the Diet

Linoleic acid is a major constituent of diets in industrialized nations and increasingly in the develop-
ing world as processed foods are distributed globally. In the North American diet, this single fatty
acid, at an intake of 16 g/day, accounts for approximately 7% of daily caloric intake and 20% of total
dietary fatty acid intake (Blasbalg et al. 2011). This intake is more than threefold higher than the
historic norm of 2%, owing mainly to the increased consumption of seed oils containing 20–54% of
total fatty acids as linoleic acids (Blasbalg et al. 2011).
The mammalian liver can convert linoleic acid to longer-chain omega-6 PUFAs, particularly
arachidonic acid, through elongation and desaturation reactions. Linoleic acid competes with
α-linolenic acid for the same elongation and desaturation enzymes capable of converting α-linolenic
acids to longer-chain omega-3 PUFAs, including eicosapentaenoic acid (EPA) and docosahexaenoic
acid (DHA) (Bazinet et al. 2003; Domenichiello et al. 2014), which are associated with potential
health benefits (Yurko-Mauro et al. 2010; Carter et al. 2013; Dalli et al. 2013). Linoleic acid and
arachidonic acid are both n-6 fatty acids that are metabolized to pro-inflammatory bioactive oxida-
tion products (Ramsden et al. 2012) and eicosanoids (Toborek et al. 1999). Increased levels of both
fatty acids in the blood have been associated with conditions including nonalcoholic steatohepa-
titis, Alzheimer’s disease, and asthma (Yoshida et al. 2009; Feldstein et al. 2010; Mabalirajan et
al. 2013) in which inflammation plays a major pathogenic role. On the other hand, omega-3 EPA,
docosapentaenoic acid (DPA), and DHA can be converted into anti-inflammatory and pro-resolving
lipid mediators (Tjonahen et al. 2006; Bazan 2013; Dalli et al. 2013; Orr et al. 2013). This has been
characterized as an imbalance of omega-6 and omega-3 fatty acids, which need to be balanced by
both reducing omega-6 fat intake from processed foods and increasing omega-3 fat intake from
ocean-caught fish and fish oil or algal oil supplements.
Data from the Atherosclerosis Risk in Communities (ARIC) study and the Physicians’ Health
Study have shown an inverse relationship between omega-3 PUFA intake and incident HF
(Yamagishi et al. 2008; Wilk et al. 2012). Supplementation with omega-3 PUFAs has been of poten-
tial interest as a therapy for HF. Trials in primary and secondary prevention of coronary heart dis-
ease showed that omega-3 fatty acid supplementation results in a relative risk reduction of 10–20%
in fatal and nonfatal cardiovascular events (Tavazzi et al. 2004). The Cardiovascular Health Study
showed an inverse association in the intake of baked or broiled fish and incidence of congestive HF
(Mozaffarian et al. 2005).
Further evidence on the benefit of omega-3 PUFA in HF was shown by the Gruppo Italiano
per lo Studio della Sopravvivenza nell’Infarto Miocardico Heart Failure (GISSI-HF) investigators.
Almost 7000 patients with NYHA class II through IV chronic HF were randomized to receive
1 g/day of omega-3 PUFAs or matching placebo (Tavazzi et al. 2008). Death from any cause was
reduced from 29% with placebo to 27% in those treated with omega-3 fatty acids. The coprimary
outcome of death or admission to hospital for a cardiovascular event was also reduced. In a follow-
up study, 3-month treatment with omega-3 PUFA markedly enriched circulating EPA and DHA,
independently of fish intake, and lowered pentraxin-3. Low EPA levels are inversely related to total
mortality in patients with chronic HF (Masson et al. 2013).
Omega-3 PUFA supplementation may represent a novel therapeutic approach in late-stage HF
characterized by cardiac cachexia (Mehra et al. 2006; Wang et al. 2006).
Further studies are needed to determine not only the optimal dose of omega-3 PUFA protection in
different stages of HF, but also the underlying mechanism of action responsible for these benefits. It is
clear that supplementation with omega-3 PUFA provides significant overall benefit with minimal risk
(Fonarow 2008). Recent reviews have discussed the basic pathophysiological mechanisms and treat-
ment effects in clinical trials (Endo and Arita 2016; Glück and Alter 2016). Integration of omega-3
into the microenvironment of cardiomyocyte ion channels led to allosteric changes and increased
the electrical stability. Moreover, omega-3 also prevents the conversion of arachidonic acid into pro-
inflammatory eicosanoids by serving as an alternative substrate for cyclooxygenase or lipoxygenase,
resulting in the production of less potent products. In addition, a number of enzymatically oxygenated
metabolites derived from omega-3 PUFAs were recently identified as anti-inflammatory mediators.
These omega-3 metabolites may contribute to the beneficial effects against cardiovascular diseases
that are attributed to omega-3. A better understanding of these interacting endogenous mechanisms
appears to be required for interpreting the findings of recent experimental and clinical studies.
13.6 MICRONUTRIENTS
HF is now recognized as a systemic illness in which hormonal and neural activation results in the
release of inflammatory cytokines, which cause oxidative stress in tissues and organs, including
the heart. The role of micronutrients and minerals beyond sodium has been recognized in patients
with HF. The vast majority of patients with HF follow a diet deficient in calcium, magnesium, and
potassium (Lemon et al. 2010).
Micronutrient deficiencies, including calcium, magnesium, selenium, zinc, and vitamin D, may
play a more important role than previously thought. Elevated levels of aldosterone and chronic use
of diuretics increase urinary excretion of calcium and magnesium, leading to secondary hyperpara-
thyroidism. Hyperparathyroidism depletes calcium from the bone and drives calcium into cells,
increasing oxidative stress. Other micronutrients, including selenium, zinc, thiamine, and CoQ10,
also appear to be reduced in patients with HF.
A combination of micronutrient supplements was administered to 30 elderly patients with stable
systolic dysfunction and ejection fractions less than 35% due to ischemic heart disease, and the
effects on left ventricular function and quality of life were determined (Witte et al. 2005). Patients
were randomized to receive a combination of calcium; magnesium; zinc; copper; selenium; vita-
mins A, B6, B12, C, D, and E; thiamine; riboflavin; folate; and CoQ10 or placebo for 9 months.
At the end of the study, the supplemented group had an increase of 5% in left ventricular ejection
fraction (p < 0.05) and improved quality of life scores, while patients receiving placebo exhibited
no changes. The sample size was small and included only elderly patients with HF due to ischemic
heart disease and micronutrients at varying doses between 1/3 and 200 times the recommended
dietary allowance (RDA). The study suggests the need for more research on which micronutrients
are most important and whether these observations are extended to other types of HF and at which
stages benefits are observed. In the balance of this chapter, the evidence available on selected micro-
nutrients in HF is reviewed.
13.6.1 Coenzyme Q10 Supplementation

Mechanistically, the hallmarks of the failing heart include abnormal energy metabolism, increased
production of reactive oxygen species (ROS), and defects in excitation–contraction coupling. HF is
a highly dynamic pathological process, and observed alterations in cardiac metabolism and function
depend on the disease progression (Akhmedov et al. 2015).
In the early stages, cardiac remodeling characterized by normal or slightly increased fatty acid
oxidation plays a compensatory, cardioprotective role. However, upon progression of HF, fatty acid
oxidation and mitochondrial oxidative activity are decreased, resulting in a significant drop in car-
diac ATP levels. In HF, as a compensatory response to decreased oxidative metabolism, glucose
uptake and glycolysis are upregulated, but this upregulation is not sufficient to compensate for a
drop in ATP production.
Elevated mitochondrial ROS generation and ROS-mediated damage, when they overwhelm the
cellular antioxidant defense system, induce heart injury and contribute to the progression of HF
(Akhmedov et al. 2015). Mitochondrial uncoupling proteins (UCPs), which promote proton leak
across the inner mitochondrial membrane, have emerged as essential regulators of mitochondrial
membrane potential, respiratory activity, and ROS generation. Although the physiological role of
UCP2 and UCP3, expressed in the heart, has not been clearly established, increasing evidence
suggests that these proteins, by promoting mild uncoupling, could reduce mitochondrial ROS gen-
eration and cardiomyocyte apoptosis and thereby ameliorate myocardial function. Further investi-
gation on the alterations in cardiac UCP activity and regulation will advance our understanding of
their physiological roles in the healthy and diseased heart, and also may facilitate the development
of novel and more efficient therapies.
CoQ10 (also called ubiquinone) is an antioxidant, the main function of which is the production
of ATP through the electron transport chain. CoQ10 has been shown in all tissues and organs in the
body, with highest concentrations in the heart. It has been postulated to improve functional status
in congestive HF. Observational studies have reported that the plasma CoQ10 concentration was an
independent predictor of mortality in patients with HF (Molyneux et al. 2008). Several RCTs have
examined the effects of CoQ10 on congestive heart failure with inconclusive results. A meta-analysis
in 2013 including 13 RCTs showed that supplementation with CoQ10 resulted in a net change of
3.67% in the EF and a significant decrease of the NYHA functional class (Fotino et al. 2013).
The effects of CoQ10 on morbidity and mortality in chronic HF were further studied in a 2-year
prospective trial in patients with moderate to severe HF. A total of 420 patients were randomly
assigned to either 100 mg of CoQ10 three times daily or placebo, in addition to standard therapy.
Patients in the supplement group had improved symptoms and reduced major adverse cardiovascu-
lar events (Mortensen et al. 2014).
13.6.2 Thiamine
Thiamine, otherwise known as vitamin B1, serves as a key cofactor in carbohydrate metabolism.
It is not synthesized in humans, and little thiamine is stored endogenously. As such, continual
ingestion is required to prevent thiamine deficiency. Severe thiamine deficiency can result in severe
vasodilatation and high-output HF, known as wet beriberi. This form of thiamine deficiency clearly
warrants thiamine supplementation; however, wet beriberi is increasingly uncommon (Sole and
Jeejeebhoy 2000). The benefit of thiamine supplementation in less severe forms of thiamine defi-
ciency is still unclear. Thiamine deficiency in HF has typically been attributed to the use of loop
diuretics, which promote the excretion of thiamine and other water-soluble B vitamins (Brady et
al. 1995; Zenuk et al. 2002). However, poor dietary intake is likely a contributing factor in many
patients (Brady et al. 1995). A series of studies have shown thiamine deficiency to be fairly common
in the HF population, with prevalence ranging from 13% to 33% (Kwok et al. 1992; Hanninen et al.
2006). The prevalence may be even higher in hospitalized and elderly patients with HF (Kwok et
al. 1992; Pfitzenmeyer et al. 1994). A number of small studies have shown improved markers of LV
function after thiamine supplementation (Seligmann et al. 1991; Shimon et al. 1995). Other studies
have shown mixed results from thiamine supplementation in HF (Pfitzenmeyer et al. 1994). Larger
studies are necessary to examine the benefit of thiamine supplementation in HF, but it appears
reasonable to supplement thiamine in chronic HF patients, especially those taking high-dose loop
diuretics.
13.7 CONCLUSION
Despite significant progress in cardiovascular medicine, myocardial ischemia and infarction, pro-
gressing eventually to the final end-point of HF, remain the leading cause of morbidity and mortal-
ity in the United States. HF is a complex syndrome that results from any structural or functional
impairment in ventricular filling or blood ejection. Ultimately, the heart’s inability to supply the
body’s tissues with enough blood may lead to death.
There is no doubt that diet and exercise can have profound effects on age-related chronic dis-
eases, including HF. Randomized trials have demonstrated the dramatic impact of combinations
of diet and exercise on cardiovascular disease and diabetes. To extend these recommendations to
HF, more evidence is needed on the effects of various components of diet, fluid restriction, and
nutritional supplements. The high rates of hospital admissions, readmissions, and mortality asso-
ciated with HF make such clinical research feasible. Considering the persistently high morbidity
and costs associated with HF, it is time for primary care practices and researchers to optimize
pharmacotherapy adherence and define the role of protein, lipid, antioxidant, and micronutrient
supplementation in patients with stable and advancing HF. In the absence of well-developed clini-
cal guidelines on nutrition, commonsense supplementation and nutritional support may benefit
patients with HF.
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14 Pulmonary Function,
Asthma, and Obesity
14.1 INTRODUCTION
Obesity significantly interferes with pulmonary function by decreasing lung volumes, particularly
the expiratory reserve volume (ERV) and functional residual capacity (FRC). Strength and resis-
tance may be reduced as the result of muscle weakness, especially in those with sarcopenic obesity
associated with aging. These mechanical limitations lead to inspiratory overload, which increases
respiratory effort, oxygen consumption, and respiratory energy expenditure. Body fat distribution
significantly influences the function of the respiratory system, likely via the direct mechanical
effect of fat accumulation in the chest and abdominal regions, as well as the systemic cytokines
released by visceral fat. Asthma and obstructive sleep apnea (OSA) are obesity-associated diseases
that involve interactions among environmental, genetic, and behavioral factors.
Approximately 60% of obese individuals have metabolic syndrome (Beltran-Sanchez et al.
2013). In this context, an association between metabolic syndrome and pulmonary disease has been
investigated in recent years (Samson and Garber 2014; Baffi et al. 2016). Metabolic syndrome has
been identified as an independent risk factor for worsening respiratory symptoms, impairment of
lung function, asthma, and pulmonary hypertension. Several possible mechanisms have been pro-
posed to explain these associations, including exposure to high insulin levels during fetal matu-
ration (which induces alterations in airway smooth muscle), the effects of abdominal adiposity,
deregulation of adipokine metabolism, and inflammation induced by ectopic fat in the lungs
(Lee et al. 2014). Inflammation also impacts asthma in children and adults, and the roles of oxi-
dative stress and elevated adipokines are still being evaluated relative to other causative factors,
such as allergies and air pollution.
Therefore, obesity and metabolic syndrome both combine to impair lung function in the over-
weight and obese patient. A strong correlation exists between lung function and body fat distribu-
tion, with greater impairment when fat accumulates in the chest and abdomen. In combination with
reflux esophagitis and anatomic changes with obesity, OSA leads to sleep disturbances, which cre-
ate a vicious circle of increased calorie intake and poor sleep. The concomitant use of continuous
positive airway pressure (CPAP) devices, together with a diet and lifestyle plan to reduce excess
body fat and build lean body mass, including diaphragmatic strength through respiratory therapy,
promises to reduce the morbidity associated with obesity and reduced pulmonary function.
14.2 PULMONARY FUNCTION IN OBESITY

Normal pulmonary function depends on the operation of the structures that compose the respira-
tory system. In obese individuals, structural changes of the thoracic–abdominal region lead to lim-
ited diaphragm mobility and rib movement, both essential for appropriate ventilatory mechanics.
Additionally, the adipose tissue is an endocrine and paracrine organ that produces a large number of
cytokines and bioactive mediators, thus generating in obese individuals a pro-inflammatory state
that is associated with allergic reactions, bronchial responsiveness, and increased risk of asthma.
In order to maintain pulmonary homeostasis, the structures of the respiratory and cardiovascu-
lar systems need to work in equilibrium; that is, the lungs should be ventilated and the gases should
diffuse through the alveolar–capillary barrier in a balanced fashion. It is practical in primary care
practice to evaluate lung function by determining lung volumes. The most accurate techniques
255
for determining lung volumes are spirometry and plethysmography. In normal breathing, the dia-
phragm contracts, pushing the abdominal content downward and forward, and at the same time,
contraction of the external intercostal muscles tractions the ribs upward and forward. In obese
individuals, this mechanism is hindered, since the excess adiposity that covers the thorax and the
abdomen encumbers the breathing muscles. Any interference in the chest bellows or in chest mobil-
ity, generating a decrease in lung volume, can be considered a restrictive illness. In the obese,
excess fat in the abdominal cavity and chest limits the two primary inspiratory movements:
diaphragm contraction propelling the abdominal content downward and forward, and increased
chest diameter by means of rib movement.
Evaluation of static lung volumes in overweight and obese patients reveals a reduction in the ERV,
FRC, and total lung capacity (TLC). Reductions in FRC and ERV are detectable even at a modest
increase in weight. This results from a shift in the balance of inflationary and deflationary pressures
on the lung due to the mass load of adipose tissue around the rib cage and abdomen (Salome et al.
2010). Elevated intra-abdominal pressure can be transmitted to the chest. This dramatically reduces
the FRC and ERV and requires patients to breathe in a less efficient part of their pressure–volume
curve, which in turn increases the work of breathing (Steier et al. 2014). Marked reductions in ERV
may lead to abnormalities in ventilation distribution, with closure of airways in the dependent zones
of the lung and inequalities in the ventilation–perfusion ratio (Salome et al. 2010).
Spirometry measurements of lung function in morbidly obese subjects reveal a proportional
reduction in forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1), sug-
gesting the occurrence of restrictive lung disease (Carpio et al. 2014; Melo et al. 2014). The FEV1/
FVC ratio is generally well preserved or elevated even in morbidly obese individuals, indicating
that FEV1 and FVC are affected at the same rate (Wells et al. 1995; Thyagarajan et al. 2008). A
reduction in expiratory flows in an obese individual is unlikely to indicate bronchial obstruction
unless the flow measurements have been normalized for the reduction in FVC (Salome et al. 2010).
In the supine position, the weight of the abdomen in obese individuals causes the diaphragm to
ascend into the chest, resulting in the closure of small airways at the base of the lung, and thereby
generating an intrinsic positive end-expiratory pressure that results in increased ventilatory work
and consequent respiratory muscle impairment (Chlif et al. 2009; Arena and Cahalin 2014).
Most obese individuals present an arterial partial pressure of oxygen (PaO2) within the normal
range. However, among morbidly obese subjects, the alveolar–arterial oxygen gradient (P(A-a)O2)
is slightly widened because of the presence of areas of atelectasis and maldistribution of ventila-
tion (Rivas et al. 2015), which can cause a major ventilation–perfusion imbalance. In these indi-
viduals, the lower parts of the lungs are relatively poorly ventilated and perfused, possibly due to
the closure of small airways, whereas the upper regions of the lungs exhibit enhanced ventilation
(Brazzale et al. 2015).
14.3 ASTHMA AND OBESITY

Obesity is also associated with a higher incidence, prevalence, and severity of asthma. Asthma in
obese patients is characterized by poor treatment response and greater morbidity (Torchio et al.
2009; Boulet et al. 2012; Dixon et al. 2015; Lu et al. 2015; Pakhale et al. 2015; Ulrik 2016). The
incidence of asthma is almost one and a half times higher in obese individuals than in nonobese
individuals, and a three-unit increase in body mass index (BMI) is associated with a 35% increase
in the risk of asthma (Hjellvik et al. 2010; Brumpton et al. 2013). Decreases in FRC and tidal vol-
ume, in addition to sedentary lifestyle and limited ability to perform physical activities, may worsen
asthma symptoms among obese patients (Hjellvik et al. 2010; Yawn et al. 2015; Ulrik 2016). In a
cohort study of more than 25,000 children and adults with asthma, a higher BMI was associated
with worsened asthma control and an increased risk of asthma exacerbations (Schatz et al. 2015).
Obesity and metabolic syndrome are associated with a state of chronic systemic inflammation that
is driven predominantly by the action of substances released by adipose tissue. Chronic inflammation
Pulmonary Function, Asthma, and Obesity 257
is caused by activation of the innate immune system, which promotes a pro-inflammatory state
and oxidative stress and a consequent systemic acute-phase response Increased levels of leptin,
tumor necrosis factor α (TNF-α), transforming growth factor β (TGF-β), C-reactive protein (CRP),
and eotaxin may interact with asthma-associated inflammation from atopic reactions to exacerbate
cytokine effects on the contractility of the bronchial airway smooth muscles (Torchio et al. 2009;
de Lima Azambuja et al. 2015).
Different obesity-associated asthma phenotypes are now recognized (Bates 2016). An early-
onset allergic form that is complicated by obesity and a late-onset nonallergic form that occurs only
in the setting of obesity have been identified. Late-onset obese asthmatics have more compliant
airways, while early-onset obese asthmatics demonstrate inflammatory thickening of the airways.
These two phenotypes are characterized by different pathological findings, but more research is
needed on the interactions of allergens, dietary pattern, and asthma in obesity.
14.4 OBSTRUCTIVE SLEEP APNEA AND HYPOVENTILATION SYNDROME

Obesity is associated with both hypoventilation and OSA. Obesity is the most common known risk
factor for the development of OSA (Duarte and Magalhaes-da-Silveira 2015). The prevalence of
OSA associated with high rates of morbidity and mortality increases with age; the peak incidence
occurs at approximately age 55, and the condition is more prevalent in males than in females by a
ratio of 2:1 (Pinto et al. 2016).
OSA is a systemic disease that causes an increase in TNF-α, IL-6, insulin resistance, and glucose
intolerance; these inflammatory cytokines have also been implicated in the immunological mecha-
nisms of obesity (Aurora and Punjabi 2013). Central obesity and increased neck circumference are
predisposing factors for OSA (Blomster et al. 2015; Ren et al. 2015). The resulting reduction or
interruption of airflow, which occurs despite inspiratory effort, causes poor alveolar ventilation
and oxyhemoglobin desaturation and, in cases of prolonged events, a progressive increase in the
arterial partial pressure of carbon dioxide (Pierce and Brown 2015). There is a strong association
between OSA and metabolic syndrome as a whole or with its individual components (Baffi et al. 2016).
The prevalence of metabolic syndrome in patients with OSA is 60%, which is significantly higher
than in the general population (Gil et al. 2013). This association is partially explained by the fact
that patients with OSA are more likely to have high visceral adiposity, as well as abnormal glucose
metabolism (Baffi et al. 2016; Bozkurt et al. 2016). There is ample evidence suggesting that OSA
may exacerbate or induce the majority of the components of metabolic syndrome.
Some of these effects can be improved with the use of CPAP. However, the modest and incon-
sistent benefits obtained with this technique suggest that factors other than intermittent hypoxia
or the apnea–hypopnea index may play an important role (Baffi et al. 2016). Some obese indi-
viduals develop obesity hypoventilation syndrome (OHS), which is defined by the triad of obe-
sity. Hypoventilation during the day and sleep-disordered breathing represent hypoventilation that
occurs in the absence of a neuromuscular, mechanical, or metabolic cause (Chau et al. 2012).
The prevalence of OHS is estimated to be 8.5% in patients with OSA and 19–31% in obese sub
jects (BaHammam 2015; Shetty and Parthasarathy 2015). OHS is more prevalent in women than
in men, and postmenopausal women with OSA have a higher prevalence of OHS. This has been
attributed to hormonal influences, particularly to the role of progesterone as a respiratory stimulant
prior to menopause (Jehan et al. 2015; BaHammam et al. 2016). Compared with eucapnic obese
patients, patients with OHS have severe upper airway obstruction, restrictive pulmonary dam-
age, a decreased central respiratory drive, an increased incidence of pulmonary hypertension, and
increased mortality (Chau et al. 2012).
Among the possible mechanisms involved in the pathogenesis of OHS, some studies have
reported damage to respiratory mechanics caused by obesity, leptin resistance leading to central
hypoventilation, respiratory sleep disorders, and impaired compensatory responses to acute hyper-
capnia (Chau et al. 2012; Pierce and Brown 2015; Shetty and Parthasarathy 2015). With respect to
pulmonary function, patients with OHS present a reduction in chest wall compliance compared with
patients with eucapnic obesity, as well as increased pulmonary resistance that is likely secondary to
the reduction in FRC (Chau et al. 2012).
14.5 EFFECTS OF POOR-QUALITY SLEEP IN OBESITY

Poor-quality sleep is characterized by a decrease in sleep duration and disruptions in sleep patterns
and increased wake after sleep onset (Ohayon et al. 2004). A good night’s sleep is dependent on
a sufficient amount of deep sleep and a sleep efficiency, that is, total sleep time divided by time
in bed, of greater than 85% (Akerstedt et al. 1994). In both obese and nonobese individuals, the
quality of sleep declines with age, with a major reduction in the duration of slow-wave sleep and
increased sleep fragmentation (Van Cauter et al. 2000).
Adequate sleep quality and quantity are important for the normal functioning of daily meta-
bolic and hormonal processes, and appetite regulation (Van Cauter et al. 2008). These factors may
contribute to energy dysregulation that leads to weight gain and obesity. Several epidemiological
studies have demonstrated an association between sleep duration and obesity (Marshall et al. 2008;
Nielsen et al. 2011).
While many obese individuals presenting with daytime sleepiness or somnolence will be diag-
nosed with OSA, a significant proportion of such patients will continue to have somnolence after
weight loss. Clinical studies demonstrate that obesity without sleep apnea is also associated with
a higher prevalence of somnolence, and that bariatric surgery can markedly improve somnolence
before resolution of OSA. Patients with OSA and excessive daytime sleepiness who undergo bar-
iatric surgery experience a dramatic improvement in subjective sleepiness (Dixon et al. 2005;
Fritscher et al. 2007; Holty et al. 2011). In a study of severely obese patients with OSA who under-
went gastric bypass, the Epworth sleepiness score for the group fell from 14 (severe sleepiness)
preoperatively to 5 (normal) at 1 month after surgery, a time when weight loss was expected to be
just 10–12 pounds (Varela et al. 2007).
Short-term sleep restriction in young healthy adults also promotes insulin resistance, impaired
glucose tolerance, and obesity (Spiegel et al. 1999, 2005). Insufficient sleep, in combination with
physical inactivity, has been shown to impede weight loss in overweight individuals matched for
caloric intake (Nedeltcheva et al. 2010).
Regular consumption of high-fat foods and excessive calories predicts excessive daytime sleepi-
ness and poor quality of nocturnal sleep (Craig and Richardson 1989; Wells et al. 1995, 1998;
Harnish et al. 1998). Food-induced sleepiness may be due to the acute hormonal and neuroen-
docrine effects of a high-fat meal. High-fat content and excessive nutrients ingested on a regular
basis could then cause regularly occurring symptoms of excessive sleepiness. For years, people
attributed the sleepiness after a very large Thanksgiving meal to the tryptophan in the turkey
typically served at this meal. The sleepiness is induced by both tryptophan and the effects of a
high-glycemic-index meal, which increases tryptophan availability (Herrera et al. 2011).
While the mechanisms explaining sleepiness beyond obstructive apnea are not fully established,
a number of hormonal studies have been carried out in lean and obese individuals. The most con-
vincing of these studies demonstrate that sleep deprivation affects leptin and ghrelin levels and
appetite. In two studies where leptin levels were measured at multiple time points throughout the
day and food intake was controlled, several days of sleep deprivation or restriction to four hours per
night in young healthy men resulted in increased appetite and decreased leptin levels, with flatten-
ing of circadian peaks in leptin (Mullington et al. 2003; Spiegel et al. 2004). In fact, shortening the
sleep time by just 90 minutes per night for 2 weeks is sufficient to markedly increase appetite and
caloric intake (Nedeltcheva et al. 2009). Interestingly, ghrelin increases in parallel with increased
appetite (Schmid et al. 2008). Elevated ghrelin levels may predict food intake during sleep restric-
tion, suggesting a potential mechanism by which sleep loss may lead to increased food intake and
the development of weight gain.
14.6 PRIMARY CARE SLEEP HYGIENE RECOMMENDATIONS

Sleep problems are prevalent among patients seen in primary care practice beyond those with OSA,
or clinical sleep disorders related to obesity. In these patients, sleep problems may promote overeat-
ing and lead to the development of overweight and obesity. Sleep problems of this type refer gener-
ally to any combination of acute or chronic problems with prolonged sleep onset latency, excessive
wake after sleep onset, short total sleep time, low sleep efficiency, or poor-sleep quality based on
subjective and/or objective assessments.
More than half (56%) of Americans suffer from sleep problems, compared with 31% of western
Europeans and 29% of Japanese (Leger et al. 2008). Although the majority of these individuals
report functional impairment as a result of their sleep problems, most (61–79%) do not meet clinical
diagnostic criteria for insomnia based on self-reported symptoms (Leger et al. 2008).
Sleep problems are of growing concern, because poor sleep is associated with impairments in
motivation, emotion, and cognitive functioning, as well as increased risk for serious medical con-
ditions, including diabetes, cardiovascular disease, cancer, and all-cause mortality, even when the
symptoms are below the threshold for clinical sleep disorders (Banks and Dinges 2007; Walker
2009; Zaharna and Guilleminault 2010).
Despite the potential widespread benefit for sleep promotion, established behavioral treatments
such as cognitive behavioral therapy for insomnia are largely limited to practices directed by sleep
medicine professionals rather than primary care teams. Patients with intermittent or less severe
sleep impairments or those for whom specialized sleep treatments are unavailable or inaccessible
are more likely to seek assistance from primary care providers or self-help materials to manage
their sleep problems, and as a result will likely be exposed to sleep hygiene recommendations that
are widely used in medical settings (Zarcone 2000; Stepanski and Wyatt 2003) and are easily acces-
sible on the Internet.
It may be useful to establish a practical set of evidence-based behavioral recommendations
regarding caffeine use, nicotine, exercise, and stress for patients in primary care reporting sleep
problems but who do not have evidence from sleep studies of sleep apnea.
Current sleep hygiene recommendations on caffeine intake for such patients vary widely, rang-
ing from complete abstinence to avoiding caffeine only in the afternoon or evening (Stepanski and
Wyatt 2003). Few studies have actually tested the impact of morning caffeine consumption on sub-
sequent nighttime sleep, but 400 mg of caffeine consumed in the late afternoon and evening within
the half-life of caffeine has been demonstrated to impair sleep onset and quality. It was found that
even doses ingested up to 6 hours before bedtime were associated with disturbances in both sub-
jectively and objectively assessed sleep (Drake et al. 2013). The participants in these studies were
often not regular consumers of caffeine, and therefore may differ in their response to caffeine from
the general population of caffeine users (Roehrs and Roth 2008). Nonetheless, it is reasonable to
conclude that consuming large quantities of caffeine near bedtime is likely to disrupt sleep, but less
is known about the clinical significance of low to moderate amounts of caffeine.
Nicotine promotes arousal and wakefulness, primarily through stimulation of cholinergic neu-
rons in the basal forebrain (Boutrel and Koob 2004). Sleep hygiene recommendations suggest
avoidance of nicotine use to promote better sleep. Nicotine, whether from cigarette smoking or
administration via pill or patch, is associated with impaired sleep (Jaehne et al. 2009). Whereas
caffeine tolerance results in a lesser impact on sleep disturbance, data suggest that even after years
of smoking, smokers experience significantly worse sleep than nonsmokers (Jaehne et al. 2009).
In the early stages of smoking cessation, sleep complaints are very common. This is likely due to
nicotine withdrawal, which results in heightened arousal and cravings. Symptoms of withdrawal
peak a few days after cessation and last for 3–4 weeks (Hughes 2007).
Regular exercise is a common sleep hygiene recommendation, with the caveat that exercise
should be avoided close to bedtime (Stepanski and Wyatt 2003). Exercise may improve sleep
through its effects on body temperature, arousal, and/or adenosine levels (Youngstedt 2005).
In general, recommending regular exercise as part of a healthy active lifestyle will also contribute
to improved sleep.
Although stress is not traditionally a core component of sleep hygiene, several recommenda-
tions have emerged over the years encouraging individuals to reduce worry or engage in relaxing
activities, particularly right before bedtime (Stepanski and Wyatt 2003). Stress typified by an event
or events that lead to acute or chronic physiological stresses, including increased heart rate and
blood pressure, and psychological anxiety responses can precipitate cognitive arousal and physi-
ological arousal, which can cause problems with sleep initiation and maintenance. Techniques
known to reduce stress and arousal, such as relaxation and mindfulness-based stress reduc-
tion, have been examined in relation to sleep and have provided some preliminary support for
stress management as an effective recommendation to promote sleep (Dijk and Czeisler 1995;
Lichstein et al. 2001; Dijk and Lockley 2002).
Sleep hygiene recommendations often encourage regular bedtimes and wake times in order to
maximize the synchrony between physiological sleep drive, circadian rhythms, and the nocturnal
sleep episode. Homeostatic sleep drive and the circadian hormonal systems work together to pro-
mote stable patterns of sleep and wakefulness (Dijk and Czeisler 1995). Sleep duration and con-
tinuity are worsened with changes in sleep patterns associated with jet lag or rotating shift work
(Dijk and Lockley 2002).
None of the above recommendations are backed by strong science, but are meant to provide some
guidance for primary care practices dealing with sleep problems both as an initial presentation and
as residual complaints in patients with obesity treated for either OSA or daytime sleepiness.
14.7 SUMMARY
Obesity is associated with abnormal pulmonary function based on the physical effects of excess
body fat on respiratory muscle function, inflammation from adipokines, and the superimposi-
tion of allergies common in the general population, such as cat allergy, which affects one in three
individuals.
OSA can be documented with sleep studies. A simple screening questionnaire can be used to
detect those suitable for study. Beyond that, recommendations for weight management need to also
include recommendations on sleep hygiene, as the evidence strongly suggests that sleep problems
promote obesity and overweight.
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15 Frailty, Nutrition,
and the Elderly
15.1 INTRODUCTION
The term frailty describes elderly patients who have multiple chronic diseases, limited activities
of daily living, and increased risk of disability and loss of independence. Frailty is a geriatric syn-
drome that compromises the ability to maintain organismal functioning and is associated with an
increased risk for multiple adverse health-related outcomes, including falls, fractures, disability,
institutionalization, and death. The components of frailty consist of weight loss, fatigue, slow gait
speed, weakness, and low activity levels. According to this model, those individuals with one or two
of these conditions would be considered “prefrail,” just as we have classifications for prediabetes,
prehypertension, and early stages of renal failure. The idea inherent in defining a state of prefrailty
is to promote efforts to prevent the progression of this condition to frailty, which is defined as three
or more of the above conditions of weight loss, fatigue, slow gait speed, weakness, and low activity
levels (Fried et al. 2001). Once frailty develops, there are steps toward rehabilitation using physical
therapy and nutrition, which will be discussed.
Loss of skeletal muscle mass is central to the development of frailty in older people. Sarcopenia
is common with advancing age, and the rate of progression of sarcopenia is responsive to nutritional
status, particularly dietary protein. Along with sarcopenia, increased fat mass and decreased bone
mass combine with environmental factors to increase the risk of frailty.
Healthy older people consuming the current U.S. recommended dietary allowance (RDA) for
protein are at risk of losing skeletal muscle at an accelerated rate and developing frailty. Therefore,
increased dietary protein will preserve or increase muscle mass and function when combined with
strength training. Just to be clear, as discussed in Chapter 2, we recommend a higher protein intake
than the U.S. RDA for everyone, but it is critical in the elderly. Periods of extreme inactivity. such
as prolonged bed rest during hospitalization. promote sarcopenia. Changes in taste and the ability
to digest foods, as well as behavioral issues around eating and the quality of institutional foods, are
additional factors promoting sarcopenia.
Another common feature of aging is an increase in body fatness, as the elderly often select sweet
low-protein and high-fat snack foods to the exclusion of balanced meals. Body fat is an independent
predictor of disability and poor functional status; however, caloric restriction intended to produce
weight loss can result in substantial loss of muscle mass. Bone density is often decreased in com-
bination with sarcopenia due to reduced physical activity and inadequate gravitational or exercise-
induced stress across weight-bearing bones.
Sarcopenic obesity is the combination of excess body fat and decreased muscle mass. This clini-
cal presentation presents a challenge, since resting metabolic rates are directly related to lean body
mass. Therefore, usual caloric restriction for weight loss will be less effective and can be harmful in
the absence of adequate attention to protein intake and muscle rehabilitation. Strategies for weight
loss for older people should include exercise to help preserve lean mass and a shift in macronutrient
intake toward a lower-fat and higher-protein and higher-carbohydrate intake to maintain nutritional
status.
265
15.2 NATURE OF AGING
Biological aging varies in its rate of progression among individuals based on genetic and nutri-
tional factors. Biologic aging is different than chronological aging, which is your age or the simple
passing of time. Nonetheless, none of us are getting out of this alive, and aging inevitably leads to
progressive deterioration in both the structure and function of various molecular, cellular, and tis-
sue components. Research efforts and clinical interventions can influence the rate of progression of
age-related changes, and some gerontologists view aging as a chronic disease process that can be
influenced by a combination of pharmacological, nutritional, and lifestyle factors, so that we can
achieve a theoretical maximum of 120 years or so of life. In fact, advances in medicine, sanitation,
and nutrition have advanced the life span from 50 years at the beginning of the twentieth century to
about 85 years currently, and it is predicted that individuals born today may live to over 100 years.
Researchers are studying centenarians, who are a small but rapidly growing group of elders. The
other effort that is important, beyond extending life span, is the extension of health span, and that
critically depends on preventing age-related chronic diseases and the physical disability related to
the development of frailty.
A number of basic theories have been proposed to explain aging mechanisms, including the
shortening and/or loss of telomeres, the accumulation of damaged DNA in cells, and dysfunc-
tion of important cellular organelles, such as the endoplasmic reticulum (ER) and mitochondria.
Mitochondria in muscle are not the little circular organelles inside cells as depicted in high school
biology texts, but are long structures that can increase or decrease in size and modulate their activity
in oxidative phosphorylation as needed to provide energy to the muscle fibers. Part of the age-related
loss of muscle function involves a degradation of mitochondria and the muscle fibers adjacent to
them.
Age-associated accumulation of senescent cells in various tissues and organs causes functional
disruption of tissue structure, partly through the appearance and accumulation of senescent-associated
secretory proteins (Coppe et al. 2008; Rodier and Campisi 2011). Organismal aging proceeds with a
gradual decline in cell proliferation of the somatic cells. The macroscopic outcome is evidenced by
the appearance of dysfunctional and “worn out” tissues that degrade continuously, finally resulting
in structural instability and death of the organism.
Our bodies are composed of a combination of somatic and progenitor cells that have a range of
capacities for cell division, and pluripotent stem cells with a high capacity for division. In addition
to stem cells, there are immortal germ cells in the spermatogenic tubules of the male testis and at
the base of the small intestinal epithelial crypts that divide rapidly. The latter two cell types have
telomerase, which restores the ends of DNA lost with each cell division. The emergence of a cancer
cell with telomerase occurs through neoplastic transformation and acquisition of cellular immortal-
ity, but at the expense of having corrupted genetic and epigenetic states that confer potentially lethal
behavior. On the other hand, emergence of an aged cell occurs through the induction of cellular
senescence.
Cellular senescence differs from loss of proliferation or quiescent states by the occurrence of
altered gene expression and metabolic activity, as well as accumulated insults that lead to irrevers-
ible arrest. Senescent cells are resistant to apoptosis (Moiseeva et al. 2006). Another property of
senescent cells is a secretory phenotype. Senescent cells convert into pro-inflammatory counter-
parts and promote pathology, including sarcopenia.
The immune system of older people declines in reliability and efficiency with age, resulting in
greater susceptibility to pathology as a consequence of inflammation, for example, cardiovascular
disease, Alzheimer’s disease, autoreactivity, and vaccine failure, as well as an increased vulnerabil-
ity to infectious disease (Pawelec 1999; Targonski et al. 2007; Weiskopf et al. 2009). These changes
are further compounded by reduced responsiveness and impaired communication between all cells
of the immune system. The overall change to the immune system with age is termed immunosenes-
cence and has a multifactorial etiology, a consequence of the complexity of the immune system, as
Frailty, Nutrition, and the Elderly 267
well as of multiple genetic and environmental influences (Weiskopf et al. 2009). Immunosenescence
of the innate immune system is primarily characterized by reduced cellular superoxide production
and capability for phagocytosis. Involution of the thymus and reduced responsiveness to a new
antigen load, owing to a reduced naïve–memory cell ratio and expansion of mature cell clones,
characterize immunosenescence of the acquired immune system.
The term inflammaging was developed to describe an upregulation of the inflammatory response
that occurs with age, resulting in a low-grade chronic systemic pro-inflammatory state that plays a
role in progressing aging (Franceschi et al. 2000; Vasto et al. 2007). In this sense, aging resembles
age-related chronic diseases, and while aging cannot be reversed (you cannot stop time), the rav-
ages of aging can be reduced through healthy diet and lifestyle. Inflammaging is characterized by
raised levels of inflammatory cytokines, including interleukin 1 (IL-1), IL-6, and tumor necrosis
factor α (TNF-α). These cytokines have been shown to rise with age (De Martinis et al. 2006) and
be involved in the pathogenesis of most age-related chronic diseases (De Martinis et al. 2006).
C-reactive protein (CRP), also known as high-sensitivity CRP (hsCRP), is an acute-phase protein
produced by the liver in response to inflammation. It is also a useful marker of inflammation asso-
ciated with aging and chronic diseases when the highly sensitive assay for it is used. hsCRP in the
upper quartile of the normal range is used clinically as a predictor of the risk for cardiovascular and
other age-related chronic diseases (Buckley et al. 2009; Ansar and Ghosh 2013). In practice, it is
elevated well above the normal range by mild upper respiratory viral infections and other common
infections, limiting its usefulness in screening and follow-up.
The physiological response to inflammation is an increase in circulating cortisol levels (Giunta
2008). Cortisol is a part of most stress responses, but it is also immunosuppressive. Cortisol secre-
tion from the adrenal gland is stimulated by the hypothalamic corticotrophin-releasing hormone
and pituitary adrenocorticotropic hormone (ACTH), which together are called the hypothalamic–
pituitary–adrenal (HPA) axis (Phillips et al. 2010). Neuronal cells within the HPA axis contain
multiple cytokine receptors, particularly for IL-1, IL-6, and TNF (Turnbull and Rivier 1999), and
it has been demonstrated in human beings in vivo that injection of IL-6 or TNF induces a marked
change in HPA axis activity (Straub et al. 2000).
While the anti-inflammaging response attempts to counter the inflammaging process, it may
also have negative implications via catabolic effects of cortisol on several tissue types, such as
liver (gluconeogenesis), muscle (protein catabolism), and bone (resorption) (Giunta 2008), which
promote the development of frailty.
15.3 EPIDEMIOLOGY OF FRAILTY
Muscle mass and strength decline with aging, due to a combination of α-motor neuron loss and
inherent reductions in the number and size of muscle fibers (Evans and Campbell 1993; Evans 1995;
Rosenberg 1997). Consequently, strength decreases with age, and muscle weakness can compro-
mise well-being and activities of daily living. Sarcopenia is estimated to affect up to 30% of adults
over the age of 70 years (Rosenberg 1997; Baumgartner et al. 1998; Morley 2001). Health care costs
attributed to sarcopenia amount to tens of billions of dollars per year (Morley et al. 2005).
There are many causes of sarcopenia, including disuse atrophy, endocrine disorders such as
Cushing’s disease or glucocorticoid overuse, chronic disease conditions, inflammation, insulin
resistance, and nutritional deficiencies. While advanced malnutrition or cachexia may be a com-
ponent of sarcopenia, these conditions are not the same. Sarcopenia can occur at normal or even
increased body weights.
The diagnosis of sarcopenia should be considered in all older patients who present with observed
declines in physical function, strength, or overall health. Sarcopenia should specifically be con-
sidered in patients who are bedridden, cannot independently rise from a chair, or have a mea-
sured gait speed of less than 3 feet/second. Patients who meet these criteria should further undergo
body composition assessment using bioelectrical impedance and dual-energy x-ray absorptiometry
(DEXA), with sarcopenia being defined using currently validated definitions.
A diagnosis of sarcopenia is consistent with a reduced gait speed and an objectively measured
low muscle mass. Sarcopenia is a highly prevalent condition in older persons that leads to disability,
hospitalization, and death.
Sarcopenia is correlated with functional decline and disability (Baumgartner et al. 1998; Melton
et al. 2000; Janssen et al. 2002; Lauretani et al. 2003; Delmonico et al. 2007). Findings are often
stronger in men than in women, depending on the indexing method used. Sarcopenia has also been
associated with increased mortality (Metter et al. 2002), although (Newman et al. 2006) weakness
has been demonstrated to be a more powerful predictor of mortality in elderly people than muscle
mass. In the longitudinal Rancho Bernardo study, sarcopenia was shown to be predictive of falls
(Castillo et al. 2003).
The term sarcopenic obesity was first used by our group at the University of California, Los
Angeles (UCLA) in 1996 (Heber et al. 1996) and describes persons with reduced body mass out of
proportion to their adipose mass. Sarcopenic obesity is associated with disability, gait problems,
and falls to a greater extent than persons with sarcopenia without increased body fat (Baumgartner
et al. 2004). In longitudinal studies over 8 years, sarcopenic obesity was a better predictor of physi-
cal disabilities, abnormalities in gait or balance, and falls in the prior year than either sarcopenia
or obesity alone.
These observations were confirmed in the Framingham and National Health and Nutrition
Examination Survey (NHANES) studies, demonstrating that elderly people with high body fat and
low muscle mass had the highest rate of disabilities (Davison et al. 2002). These data point to the
fact that the development of disability and impaired mobility in older people has multiple etiologies,
not just loss of muscle.
Muscle mass is an important, but not the only, predictor of muscle strength or physical function.
Fat has several adverse effects on muscle function. Higher body fatness and older age have been
associated with greater intramuscular lipid and reduced muscle quality, defined as reduced strength
or cross-sectional area (Kelley et al. 1999; Goodpaster et al. 2006). It is also possible that higher
body fatness decreases the capacity to generate power (force × speed), and muscle power is more
closely related to functional capacity than muscle strength (Bassey et al. 1992). Several indices of
sarcopenia that account for muscle and fat mass have been examined in relationship to function.
These studies illustrate the complexity in defining sarcopenia in relationship to fat mass (Newman
et al. 2003). When fat mass is considered, the role of lean mass per se is apparently small.
In addition to muscle loss and fat gain, there is a loss of bone mineral density with aging and an
increase in fracture risk. Epidemiological studies have now clearly established that in both women
and men, bone loss begins as early as the early part of the third decade—immediately after peak
bone mass and long before any change in sex steroid production (Looker et al. 1998). Supporting
these epidemiological data, volumetric bone mineral density analysis at the tibia and spine, in a
large age- and sex-stratified population sample using quantitative computed tomography, demon-
strated substantial trabecular bone loss in both sexes even when sex steroids were sufficient (Riggs
et al. 2008). In women, the loss of trabecular bone in the spine accelerates substantially after meno-
pause, as does the rate of fractures at the wrist, spine, and hip (Khosla and Riggs 2005), attesting to
the adverse role of estrogen deficiency on skeletal homeostasis and its contribution to the accelera-
tion of the age-associated bone loss. Cortical bone loss begins to decline after the age of 50 in both
sexes, albeit at a faster rate in women than men.
Osteoporosis, determined as decreased bone mass per unit volume of anatomical bone, is only
one of the factors responsible for the compromised bone strength that predisposes to an increased
risk of fracture in the frailty syndrome. Aging contributes to fracture risk independent of bone mass
(Hui et al. 1988). At the same bone mineral density, a 20-year increase in age is accompanied by a
fourfold increase in fracture risk. Increased propensity to falls due to age-related decline in neuro-
muscular function is without doubt a factor for the age-related increase in fracture risk. However,
there are also age-related changes in the bone itself, which contribute to the increase in fracture risk
at the same mineral density due to an increase in age-related changes in the bone (Hui et al. 1988).
For example, type I collagen is structurally complex and can deteriorate as it ages, with changes
such as loss of cross-linking between the component chains (Bailey and Knott 1999). Collagen
can also be damaged by accumulation of advanced glycation end products (Vashishth et al. 2001),
another general feature of the aging process. Such changes could account for the age-related decline
in cortical bone tensile strength (Wall et al. 1979). Defective collagen cannot be repaired, so the
bone containing it must be replaced by remodeling.
15.4 SARCOPENIA
Aging is associated with a reduction in myofibrillar (Welle et al. 1993; Balagopal et al. 1997; Proctor
et al. 1998) and mitochondrial (Rooyackers et al. 1996) protein synthetic rates and partially attrib-
uted to a reduction in growth factors such as insulin-like growth factor 1 (IGF-1) (Proctor et al.
1998). An acute bout of resistance exercise increases the muscle protein fractional synthetic rate
and the absolute magnitude to a degree similar to that seen for young adults (Yarasheski et al. 1993;
Hasten et al. 2000). Muscle cells hypertrophy when stretched in an eccentric movement. They then
attract and merge with satellite cells, resulting in a thickened and stronger muscle fiber. This process
is targeted to the muscle fibers activated in the movement that induced the stretch and attraction of
satellite cells (Figure 15.1). There appears to be less activation of satellite cells in older adults in
response to a single bout of resistance exercise (Dreyer et al. 2006). Therefore, nutrition and train-
ing exercises that enhance satellite cell recruitment (Olsen et al. 2006; Mackey et al. 2007) may be
particularly effective in treating the sarcopenia of aging.
There is also a decrease in mitochondrial enzyme activity and mitochondrial transcriptome
pattern and an increase in oxidative stress associated with aging (Evans and Campbell 1993;
Hypertrophy
De-training
Satellite cell Re-training

fusion
First training
Atrophy
Untrained Previously trained
FIGURE 15.1 (See color insert.) Model for the connection between muscle size and number of myonuclei.
In this model, myonuclei are permanent. Previously untrained muscles acquire newly formed nuclei by fusion
of satellite cells preceding the hypertrophy. Subsequent detraining leads to atrophy but no loss of myonuclei.
The elevated number of nuclei in muscle fibers that had experienced a hypertrophic episode would provide a
mechanism for muscle memory, explaining the long-lasting effects of training and the ease with which previ-
ously trained individuals are more easily retrained. (Reprinted from Egner, I. M. et al., Development, 143(16),
2898–2906, 2016.)
Evans 1995; Baumgartner et al. 1998; Parise et al. 2005a,b; Melov et al. 2007). These two processes
may be linked in that oxidative stress per se can lead to DNA, lipid, and protein damage that can
disrupt the structure and replicative capacity of mitochondria.
Disuse atrophy results in an increase in reactive oxygen species (ROS) production in skeletal
muscle. There is also a decreased expression of mitochondrial proteins and decreased mitochondrial
oxidative phosphorylation for ATP production. Increased ROS production alters redox signaling in
muscle fibers that can increase proteolysis and decrease protein synthesis. To further compound
these effects, disuse muscle atrophy is associated with an overall decrease in skeletal antioxidant
capacity due to a decreased antioxidant scavenging ability.
Endurance exercise increases oxidative stress in skeletal muscle. The short-term increase in ROS
production with exercise has been demonstrated to be a powerful signaling molecule in activating
signaling pathways. The transient oxidative stress that occurs with exercise is likely required for
skeletal muscle adaptation to occur.
The key difference between exercise-induced oxidative stress and oxidative stress associated
with disuse atrophy is the duration of the exposure. Oxidative stress following exercise is transient
in nature, while disuse atrophy results in chronic exposure to elevated ROS.
A reduction in the metabolic capacity of mitochondria to carry out oxidative phosphorylation to
form ATP (Evans and Campbell 1993; Evans 1995; Parise et al. 2005a,b) and decreases in muscle
blood flow during exercise (Morley 2001) contribute to the observed reduction of VO2max that
occurs with aging. Although VO2max does decline with aging, there is no question that older trained
athletes can have VO2max values equivalent to those of sedentary young individuals and definitely
higher than those of sedentary older adults, despite an inevitable loss of aerobic capacity with aging
(Coggan et al. 1990; Rogers et al. 1990; Morley et al. 2005; Delmonico et al. 2007).
15.5 MUSCLE PROTEIN SYNTHESIS

The mixed muscle fractional protein synthetic rate is similar in younger and older adults in the fast-
ing state, which is also called the postabsorptive state in the scientific literature (Paddon-Jones et al.
2004, 2006; Katsanos et al. 2005, 2006). While a few studies have found lower rates of fractional
synthetic rate in older adults (Yarasheski et al. 1993; Hasten et al. 2000), a reduction in mitochon-
drial and myofibrillar protein synthetic rates has been consistently observed (Welle et al. 1993;
Yarasheski et al. 1993; Balagopal et al. 1997; Hasten et al. 2000).
The data show that it is not the difference in the fasting state but the response to feeding that dif-
ferentiates younger from older adults (Paddon-Jones et al. 2004, 2006; Katsanos et al. 2005, 2006;
Symons et al. 2007). There is higher amino acid retention in younger than in older muscle at lower
levels of protein intake (Symons et al. 2007). However, with adequate amounts of essential amino
acids, this blunting of amino acid accumulation in older adults is not observed (Symons et al. 2007).
It appears, in fact, that the leucine component of the essential amino acids is the most important
in restoring the absorptive protein synthetic rate in older adults to that seen in younger individuals
(Katsanos et al. 2006). Leucine is both a nutrient amino acid and a signal to increase protein syn-
thesis via specific intracellular signals known as the mTOR pathway. Of practical interest, however,
is the finding that a single serving of 4 ounces of lean beef results in a similar stimulation of muscle
protein synthetic rate in both older and younger adults (Symons et al. 2007).
In response to short-term weight training, there is a similar increase in myosin heavy chain and
mixed muscle protein synthetic rates of about 150% in both older and younger adults (Hasten et al.
2000). The consumption of carbohydrate plus protein plus leucine after 30 minutes of activities of
daily living exercises leads to a significant increase in muscle fractional protein synthetic rate and a
net positive balance, compared with a carbohydrate feeding alone, in both younger and older adults
(Koopman et al. 2006). Greater myofibrillar proteolysis in skeletal muscle in older than in younger
adults has been observed (Trappe et al. 2004). Consequently, strategies to reduce proteolysis and
increase synthesis could be important countermeasures to sarcopenia. Overall, older adults retain
the ability to stimulate muscle and myofibrillar protein synthesis following a bout of resistance
exercise, and this effect is enhanced with carbohydrate and protein nutrition to a greater extent than
carbohydrate alone. Furthermore, older adult muscle appears to be less responsive to acute feeding
if protein intake is quite low; however, with adequate amounts of high-quality protein, the diet-
induced stimulation appears to be similar to that seen in younger adults.
15.6 PROTEIN REQUIREMENTS
There is generally accepted science that the elderly require more protein to attain a positive nitrogen
balance, and that clinical recommendations of 1.0–1.2 g/kg of body weight are generally accepted
and recognized as being well above the RDA of 0.8 g/kg of body weight. We will not repeat here
the argument that body weight independent of body composition is not an appropriate way to rec-
ommend protein intake, but this is discussed in detail in Chapter 2 and is an important principle in
understanding research done on protein requirements in the elderly and attempts to prevent or delay
the development of sarcopenia.
Protein requirements in resistance-trained older adults have been extensively investigated
(Campbell et al. 1999a,b; Haub et al. 2002; Campbell 2007; Campbell and Leidy 2007). When
dietary protein intake was between 1.03 and 1.17 g/kg/day, resistance training induced gains in
muscle mass and strength to a similar extent in the groups consuming a beef-containing diet and
those on the lacto-ovo vegetarian regimen (Haub et al. 2002). At the molecular level, it has been
clearly shown that when older adults consume suboptimal levels of protein (0.5 g/kg/day), rather
than an adequate amount (1.2 g/kg/day), there are alterations in mRNA transcript abundance,
which is directionally supportive of adverse metabolic, functional, and structural components
that would favor sarcopenia (Thalacker-Mercer et al. 2007). Taken together, these data suggest
that older adults completing resistance-type exercise should ensure that their dietary protein
intake is more than 0.8 g/kg/day (more appropriately between 1.0 and 1.2 g/kg/day), and that
their sources of protein include those with high biological value (e.g., egg whites, milk, beef,
and fish).
Studies have found that skeletal muscle with strength training has a net positive protein balance
only with feeding, particularly with amino acids (Biolo et al. 1995a,b, 1997). Net protein balance
is also more positive following resistance exercise in postmenopausal women receiving protein and
carbohydrate than placebo (Holm et al. 2005). From a practical perspective, the provision of a sup-
plement containing 10 g of protein, 7 g of carbohydrate, and 3 g of fat immediately after exercise,
compared with 2 hours after exercise, resulted in greater muscle mass and strength gains in older
adults following a 12-week resistance exercise training program three times per week (Esmarck et
al. 2001). Such findings highlight the importance of the early provision of proteins with essential
amino acids, including leucine and some carbohydrate, to promote an insulin response following
exercise. This regimen takes advantage of the intracellular milieu of muscle cells at the time when
the greatest increase in net protein retention can occur.
15.7 SMELL AND TASTE CHANGES WITH AGING

Loss of smell and taste with aging has been linked to inadequate nutritional intake, reduced social
pleasure, and decreased psychological well-being. It may even be life threatening, impairing the
detection of smoke in a fire or the ability to identify spoiled food.
The sense of smell is mediated through stimulation of the olfactory receptor cells by volatile
chemicals. To stimulate the olfactory receptors, airborne molecules must pass through the nasal
cavity with relatively turbulent air currents and contact the receptors. Odorants can also be per-
ceived by entering the nose posteriorly through the nasopharynx to reach the olfactory receptor via
retronasal olfaction. Each olfactory receptor cell is a primary sensory bipolar neuron. The average
nasal cavity contains more than 100 million such neurons. There are more than 900 genes encoding
these receptors. The olfactory neurons are unique because they are generated throughout life by the
underlying basal cells. New receptor cells are generated approximately every 30–60 days.
Sense of smell decreases with age, and it has been shown that the number of fibers in the olfac-
tory bulb decreases throughout one’s lifetime. In one study (Bhatnagar et al. 1987), the average loss
in human mitral cells was 520 cells/year, with a reduction in bulb volume of 0.19 mm3 (Bhatnagar
et al. 1987). These olfactory bulb losses may be secondary to sensory cell loss in the olfactory mucosa
and/or general decline in the regenerative process from stem cells in the subventricular zone.
Various neuropsychiatric disorders (e.g., depression, schizophrenia, and seasonal affective disor-
der) have been linked to hyposmia. It has been shown that patients with acute major depressive dis-
order have reduced olfactory sensitivity and reduced olfactory bulb volumes (Negoias et al. 2010).
Schizophrenia patients have also been shown to have decreased olfactory bulb volume and impaired
odor detection abilities (Nguyen et al. 2011).
The toxicity of systemic and inhaled aminoglycosides, formaldehyde, and other drugs can con-
tribute to olfactory dysfunction. Many other medications and compounds may alter smell sensitivity,
including alcohol, nicotine, organic solvents, and direct application of zinc salts (Tuccori et al. 2011).
Much of what is perceived as a taste defect is truly a primary defect in detecting smells. The
components that comprise the sensation of flavor include the food’s smell, taste, texture, and tem-
perature. Each of these sensory modalities is stimulated independently to produce a distinct flavor
when food enters the mouth.
Ongoing research has identified odor and taste receptors in surprising places, including skeletal
muscle, brain, respiratory tract, and gastrointestinal tract. Taste receptors are present from the stom-
ach to the colon and function in nutrient sensing (Depoortere 2014).
Oral cavity and mucosal disorders, including oral infections, inflammation, and radiation-
induced mucositis, can impair taste sensation. The site of injury with radiotherapy is probably the
microvilli of the taste buds rather than the taste buds themselves, which are resistant to radiation
damage.
Aging causes taste loss due to changes in taste cell membranes involving altered function of ion
channels and receptors rather than taste bud loss (Boesveldt et al. 2011; Wylie and Nebauer 2011).
Nutritional deficiencies, which can be associated with aging, are also involved in taste aberrations.
For example, decreased zinc, copper, and nickel levels are associated with taste alterations. These
and other nutritional deficiencies may be caused by changes in eating behaviors, anorexia, malab-
sorption, and/or increased urinary losses.
Smell and taste disorders traditionally have been overlooked in most aspects of medical practice
because these specialized senses often are not considered critical to life. However, they affect enjoy-
ment of food, and they impair detection of the potentially dangerous smells of smoke or spoiled
food.
Anxiety and depression, as well as anorexia and nutritional deficiencies, may result from taste
and smell disorders. Many causes of smell and taste disorders exist, and the modalities of treatment
begin with treating the specific deficit, if possible.
15.8 PREVENTION AND TREATMENT OF FRAILTY

Nutritional support of the elderly with prefrailty and frailty is established practice, but is not com-
prehensive enough to make a difference for the frail elderly. Like the can of nutritional formula
that sits on the bed table without being consumed, nutrition support alone does not consider all
elements of the frailty state in the elderly. Nutrition intervention for frailty refers not only to nutri-
tional improvement but also to associated efforts to strengthen or rehabilitate the elderly with func-
tional disability through exercise and physical therapy (Wakabayashi 2010; Minnella et al. 2016).
Nutrition intervention of the prevention and treatment of frailty is similar to sports nutrition in
including nutrition, exercise, and behavioral components. The key aims are to assess the following:
(1) the presence and cause of malnutrition, (2) the presence and cause of sarcopenia, (3) the presence
and cause of dysphagia, (4) the adequacy of nutrition care management with prediction of future
nutritional status, and (5) whether functional improvement, such as resistance training and endur-
ance training, can be conducted (Minnella et al. 2016).
Following a stroke, hip fracture, major surgery, or any number of medical conditions requiring
extended stays in bed, there is an associated deconditioning that leads to muscle loss, fat gain, and
decreases in bone mineralization, which are hallmarks of unhealthy aging via poor nutrition and
inactivity. The prevalence of malnutrition in those settings, such as hospitals and nursing homes
where patients are sent for rehabilitation, is high. In elderly patients hospitalized for rehabilita-
tion, the prevalence of compromised nutrition status is between 49% and 67% (Strakowski et al.
2002). In Australia, up to 51.5% of patients admitted to rehabilitation hospitals were classified as
malnourished and at nutritional risk (Charlton et al. 2010). One study found that the prevalence of
malnutrition in elderly people was highest in rehabilitation settings at 50.5%, in comparison with a
prevalence of 38.7% in acute care hospitals (Kaiser et al. 2010). A study using the Mini Nutritional
Assessment—Short Form (MNA-SF) revealed a 40.8% prevalence of malnutrition in rehabilitation
settings (Kaiser et al. 2011).
A systematic review found that malnutrition in older adults admitted to rehabilitation units
negatively affected functional recovery and quality of life following discharge to the community
(Marshall et al. 2014). Furthermore, rehabilitation outcome has been shown to be poor in malnour-
ished patients with stroke (Davis et al. 2004), hip fracture (Anker et al. 2006), hospital-associated
deconditioning (Wakabayashi and Sashika 2011, 2014), and a variety of other diseases.
It is not surprising that sarcopenia is a frequent occurrence in the hospital and rehabilitation
center settings. Sarcopenia affects between 10% and 30% of community-dwelling elderly (Fielding
et al. 2011). In a study of patients who were 60 years and older in an ambulatory rehabilitation
facility, it was found that about 40% of individuals had sarcopenia (Yaxley et al. 2012). It has been
demonstrated that 46.5% patients admitted to a subacute geriatric care unit who underwent a reha-
bilitation intervention met the diagnostic criteria for sarcopenia (Sanchez-Rodriguez et al. 2014).
Sarcopenia can be classified into primary age-related sarcopenia and sarcopenia secondary to
reduced activity, comorbid diseases, and nutrition-related sarcopenia (Cruz-Jentoft et al. 2010).
Assessment of the multifactorial causes of primary and secondary sarcopenia is critical in deter-
mining therapeutic strategies for sarcopenia.
Age-related sarcopenia can be treated with resistance training, protein and amino acid supple-
mentation, smoking cessation, and some pharmacological approaches, including androgens and ana-
bolic agents (Wakabayashi and Sakuma 2013, 2014). Pharmaceutical therapy with androgens and
anabolic drugs is adjunctive in the therapy of sarcopenia (Sakuma and Yamaguchi 2012; Sakuma et
al. 2015), but nutrition and exercise are the foundation of treatment. Exercise, protein supplementa-
tion, and avoiding bed rest are important for preventing and treating activity-related sarcopenia.
Treatment of disease-related sarcopenia also includes therapies for advanced organ failure, inflam-
mation, malignancy, and endocrine disorders, in addition to appropriate nutrition supplementation
to increase muscle mass. In the United States, the six most common conditions receiving inpatient
rehabilitation are stroke, lower extremity fracture, lower extremity joint replacement, debility, neu-
rologic disorders, and brain dysfunction (Ottenbacher et al. 2014).
Difficulty swallowing or dysphagia can be due to sarcopenia of generalized skeletal muscles and
swallowing muscles (Kuroda and Kuroda 2012; Wakabayashi 2014). Age-related loss of the tongue
and geniohyoid muscle mass has been demonstrated in the elderly and is termed sarcopenic dyspha-
gia (Tamura et al. 2012; Feng et al. 2013). Sarcopenic dysphagia is an important public health issue,
because it is common in the elderly and can lead to aspiration pneumonia, which is more common
with the global aging of society (Wakabayashi 2014).
Hip fractures are associated with a greater degree of disability, more health care costs, and
higher mortality than all other osteoporotic fractures combined (Ensrud 2013). In 2005, hip frac-
tures in the United States accounted for only 14% of total fractures but 72% of total fracture-related
health care costs (Ensrud 2013). Global trends are for an increased number of hip fractures in many
countries. The number of hip fractures worldwide is expected to rise from 1.6 million documented
in 2000 to an estimated 6.3 million in 2050 (Ensrud 2013). Hip fracture is the most common condi-
tion requiring geriatric musculoskeletal rehabilitation. Malnutrition has been demonstrated in hip
fracture patients using a variety of methods. In a typical study, 11.6% of hip fracture patients were
malnourished, 44.2% were at risk of malnutrition, and 44.2% were well nourished (Koren-Hakim
et al. 2012). The presence of malnutrition predicted gait status and mortality 6 months after hip
fracture (Gumieiro et al. 2013). Serum albumin level and weight loss, as documented by body
mass index (BMI), significantly influenced mortality after hip fracture (Miyanishi et al. 2010).
Malnutrition and being at risk for malnutrition are common in patients with hip fracture, and mal-
nutrition clearly affects outcome.
Stroke is the most common cause of disability in the West and in East Asian countries. More than
60% of patients remain disabled after a stroke. About 50% of patients suffer from hemiparesis, and
30% remain unable to walk without assistance (Kelly-Hayes et al. 2003). Rehabilitation, including
nutrition and physical therapy, plays a critical role in functional recovery after stroke (Scherbakov
and Doehner 2011; Scherbakov et al. 2013).
Both malnutrition and obesity are nutritional problems in stroke, and both impair recovery of
function. Malnutrition and dysphagia respectively occur in up to 53% of patients after a stroke
(Foley et al. 2009). Stroke-induced sarcopenia is difficult to assess. In a review of loss of skel-
etal muscle mass after stroke (English et al. 2010), lean tissue mass was significantly less in the
paralyzed than the unaffected lower limb and upper limb, as might be expected based on denerva-
tion atrophy. Thigh muscle area was significantly less in stroke patients 6 months after the event.
The pathogenic mechanisms of muscle wasting in stroke-related sarcopenia include disuse atrophy,
spasticity, inflammation, denervation, reinnervation, impaired feeding, and intestinal absorption
(Scherbakov et al. 2013). More research is needed to diagnose and treat stroke-induced sarcopenia.
15.9 SUMMARY
The prevention of prefrailty and frailty in the elderly is possible by increasing protein intake as
recommended in Chapter 2 of this book in proportion to lean body mass, while also advising
patients in targeted resistance exercises to balance muscle function through the major muscle
groups controlling posture and walking. As walking speed and falls both correlate with morbid-
ity and mortality, targeting these two functions in an aggressive preventive manner will help to
reduce health care costs. The primary care practice can serve as the central triage for the various
specialties that need to be engaged in the process of prevention and treatment of frailty in the
middle-aged and elderly.
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16 Nutrition in
Neurodegenerative Disorders
and Cognitive Impairment
16.1 INTRODUCTION
Cognitive impairment and dementia are increasing globally, as the population of the world ages at
a rapid rate. This aging of the world’s population has been attributed to advances in nutrition and
sanitation, as well as a declining birth rate in developed nations. Aging is the primary risk factor for
Alzheimer’s disease (AD), which is the most common form of dementia (Ballard et al. 2011). Aging
is the only risk factor that is consistently identified after age 80. In that age group, more women than
men have dementia, but this may be due to the longer life span in women. The high prevalence of
inherited dementias among individuals under age 65, previously called presenile dementia, has led
to the identification of causative genes and subsequent molecular pathology of direct relevance to
the more common sporadic disease seen in older patients.
In this chapter, the differences among the major dementia diseases, including (1) AD, (2) vas-
cular disease, (3) dementia with Lewy bodies, (4) frontotemporal lobar degeneration (FTLD), and
(5) chronic traumatic encephalopathy (CTE), are briefly reviewed, and other causes of dementia
are mentioned. Although patients who present with the mild but consistent cognitive decline that
accompanies aging, such as forgetting first names or losing objects like mobile phones, should not
be categorized as having dementia, it is increasingly important to make a specific early diagnosis
of the cause of cognitive impairment when appropriate, particularly with the possibility of disease-
modifying treatments becoming available in the future.
Over the past 40 years, a great deal of information on the connections between nutrition and brain
health has been developed. This has led to an explosion of research on various dietary supplements,
drugs, and the effects of reducing visceral fat through diet and exercise as approaches to prevention
of AD. Most of this research has been done in individuals with mild cognitive impairment (MCI) or
age-related memory deficits and in numerous animal and cellular models in the laboratory.
Although the impact of nutrition on normal brain development in utero and during childhood is
well established, having driven public health recommendations for adequate folate intake during
pregnancy, as well as adequate nutrition during pediatric care, more recently, attention has focused
on brain health and nutrition throughout the life span, including adult medicine and geriatrics, as
the impact of global aging and associated age-related chronic diseases, such as type 2 diabetes mel-
litus, has been recognized. Approaches that result in the reduction of visceral fat lead to decreased
inflammation. A healthy lifestyle also has an impact on other aspects of brain health, helping to
maintain normal mood, mental focus, motivation, and attention. This chapter highlights some of
the scientific evidence indicating a relationship between nutrition and brain health, and summarizes
some nutritional recommendations for maintaining cognitive health and mood stability in adults as
they age.
16.2 EPIDEMIOLOGY
Increasing age is the strongest risk factor for dementia, and the only risk factor consistently identi-
fied after age 80. While prevalence is consistently higher among women, incidence is not; thus,
281
the higher prevalence is largely thought to be a function of longer life spans in women. Lower
educational levels have been found to be associated with higher prevalence. Within the United
States, prevalence has been reported as elevated in African American and Latino populations; some
authors have attributed these findings to lower education and higher cardiovascular morbidity in
those populations. An estimated 35.6 million people worldwide were living with dementia in 2010,
and this number is expected to increase to 115.4 million people by 2050 (Prince et al. 2013).
Several modifiable risk factors contribute to the possibility of developing AD. Diabetes, physical
inactivity, and obesity are among the risk factors that share pathologic features, including dyslipid-
emia and insulin resistance. In addition, the strongest genetic risk factor for sporadic AD is the pres-
ence of the E4 isoform of the lipoprotein carrier apolipoprotein E (apoE). This isoform alters lipid
physiology in the brain and periphery (Liu et al. 2013). As a result, several diet- and metabolism-
based treatments to reduce dyslipidemia and visceral fat are being examined in AD patients.
AD is the most common type of dementia among Western countries, corresponding to about
60% of cases (Kalaria et al. 2008; Horton 2012), while vascular dementia (VaD) is the second, with
about 20% of all cases. Due to the overlaps in symptomatology, pathophysiology, and risk factors,
AD and VaD are not easily distinguished. In fact, VaD refers to a group of clinical syndromes,
which include dementia, resulting from ischemic, hemorrhagic, anoxic, or hypoxic brain damage.
Ischemic VaD may be due to macrovascular or microvascular cerebral disease or a combination of
both types of lesions. The cause of hemorrhagic VaD may be hypertension, leading to cerebral amy-
loid angiopathy, the source of intralobar hemorrhages, or multiple petechial hemorrhages.
In AD, causes and progression are not well understood. The disease is associated with tangles
and plaques in the brain, loss of connections, inflammation, and eventual death of brain cells, so
it is classified as a neurodegenerative disorder. All these brain changes lead to memory loss and
alterations in thinking and other brain functions. The disease usually progresses slowly and gradu-
ally gets worse as more brain cells die. The distribution of dementia around the world seems to
vary according to cultural and socioeconomic differences among nations. Interestingly, the overall
prevalence of dementia in general and AD in particular appears to be higher in developed countries
than in developing ones (Rizzi et al. 2014).
Nonetheless, in a global survey performed in 2001, 60.1% of all people with dementia were living in
developing countries. This is not inconsistent with the higher prevalence in developed countries since
the population in developing countries is so much greater. Aging of the world’s population is proceed-
ing rapidly, especially in China, India, and Latin America, where dementia is rapidly becoming the
major public health problem. Although epidemiological information about the prevalence of dementia
and its subtypes remains scarce (Ferri et al. 2005; Liu et al. 2013), the Delphi Consensus Study found
that the prevalence of dementia was high in the Americas and low in less developed regions of the
world, such as Africa and the Middle East. The prevalence of dementia in Latin America will be
similar to that encountered in North America by 2040 (Ferri et al. 2005). Among developed countries,
Japan has the lowest prevalence of both dementia in general and AD in particular.
Modifiable risk factors that contribute to the risk of developing AD include diabetes, physical
inactivity, and obesity (Lee 2011). Pathologic features shared among these risk factors include dys-
lipidemia and insulin resistance. In addition, the strongest genetic risk factor for sporadic AD is the
presence of the E4 isoform of the lipoprotein carrier apoE. This isoform alters lipid physiology in
the brain and periphery (Braak and Braak 1991; Liu et al. 2013). As a result, treatments that include
dietary interventions to balance nutrition and a healthy active lifestyle in order to reduce insulin
resistance and dyslipidemia are being examined in AD patients. These studies are examining the
interactions among apoE, lipids, inflammation, amyloid β (Aβ) peptides, glucose, central nervous
system (CNS) insulin, and peripheral insulin and seem increasingly important.
Cardiovascular risk factors, including hypertension, diabetes, obesity, and dyslipidemia, contrib-
ute to the high prevalence of mixed dementias, including both AD and VaD in developed countries.
On the other hand, developing societies where hypertension is the major problem seem to have a
proportionally higher prevalence of VaDs.
Nutrition in Neurodegenerative Disorders and Cognitive Impairment 283
16.3 DIAGNOSIS OF DEMENTIA
Dementia includes symptoms of memory loss, changes in mood and behavior, and problems with
communication, reasoning, and the ability to carry out daily activities. A diagnosis of dementia
requires substantial impairment to be present in one or more cognitive domains. The impairment
must be sufficient to interfere with independence in everyday activities. The diagnosis of mild neuro
cognitive disorder or MCI is made when there is modest impairment in one or more cognitive
domains. The individual is still independent in everyday activities, albeit with greater effort. The
impairment must represent a decline from a previously higher level and should be documented both
by history and by objective assessment. Further, the cognitive deficits must not occur exclusively in
the context of a delirium or be better explained by another mental disorder.
A full discussion of the differential diagnosis of dementias and MCI is beyond the scope of
this chapter. However, primary care providers working with specialized memory clinics can diag-
nose the syndromes of dementia and MCI. The diagnosis is based on history, examination, and
objective assessments, using standard criteria established by the American Psychiatric Association
Diagnostic and Statistical Manual of Mental Disorders (DSM-5) (Table 16.1) (American
Psychiatric Association 2013).
Dementia is associated with diseases causing structural and chemical changes in the brain.
Dementia can lead to depression, psychosis, aggression, and wandering. There are many diseases
that result in dementia. The most common types of dementia include (1) AD; (2) VaD; (3) mixed
dementia, commonly AD and VaD together; (4) dementia with Lewy bodies; (5) frontotemporal
dementia, also known as Pick’s disease; and (6) CTE.
Alzheimer’s dementia presents with difficulty remembering recent conversations, names, or
events. This is often an early clinical symptom. Apathy and depression are also often early symp-
toms. Later symptoms include impaired communication, poor judgment, disorientation, confu-
sion, behavior changes, and difficulty speaking, swallowing, and walking. Revised criteria and
guidelines for diagnosing Alzheimer’s were published in 2011 and affirmed in 2013 (American
Psychiatric Association 2013), recommending that Alzheimer’s be considered a slowly progressive
brain disease that begins well before symptoms emerge. Abnormalities are deposits of the protein
fragment β-amyloid, also known as plaques. Whether these are the key causative factor remains in
question, since there are documented cases of amyloid deposits detected by Pittsburgh compound
TABLE 16.1
Functional Limitations Associated with Impairment in Different Cognitive Domains
Cognitive Domain Examples of Changes in Everyday Activities
Complex attention Normal tasks take longer, especially when there are competing stimuli; easily distracted;
tasks need to be simplified; difficulty retaining the information needed over several minutes
to do mental arithmetic or dial a phone number
Executive functioning Difficulty with multistage tasks, planning, organizing, multitasking, following directions,
keeping up with shifting conversations
Learning and memory Difficulty recalling recent events; repeating self; misplacing objects; losing track of actions
already performed; increasing reliance on lists, reminders
Language Word-finding difficulty; use of general phrase or wrong words; grammatical errors; difficulty
with comprehension of others’ language or written material
Perceptual motor/ Getting lost in familiar places; more use of notes and maps; difficulty using familiar tools and
visuospatial function appliances
Social cognition Disinhibition or apathy; loss of empathy; inappropriate behavior; loss of judgment
Source: Adapted from American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 5th ed.,
American Psychiatric Association, Arlington, VA, 2013.
B (PiB)–positron emission tomography (PET) imaging in individuals with normal cognition (Snitz
et al. 2015). There are also twisted strands of the protein tau, also called tau tangles, as well as
evidence of nerve cell damage and death in the brain. These latter changes would be consistent
with inflammation being the primary driver of AD, and this is consistent with what is known about
the risk factors, including those that could be impacted by nutrition. A recent study suggested that
greater amounts of amyloid at baseline in a prospective study were associated with more rapid pro-
gression of AD (Petersen et al. 2016). However, the jury is still out on whether amyloid is the key
pathogenic factor or a bystander to an inflammatory process.
VaD presents with changes in cognition, suddenly following strokes that block major brain
blood vessels (O’Brien and Thomas 2015). Problems in cognition and reasoning may begin as mild
changes that worsen gradually as a result of multiple minor strokes or other conditions that affect
smaller blood vessels, leading to cumulative damage. At earlier stages, the term vascular cognitive
impairment (VCI) is used rather than VaD to indicate that changes can range from mild to severe.
VaD is the second most common cause of dementia, after AD, accounting for 20–30% of cases,
and it may be underdiagnosed.
Mixed dementia presents with dementia findings, including both vascular brain changes and
changes linked to other types of dementia, including AD and dementia with Lewy bodies (Claus
et al. 2015). Several studies have found that vascular changes and other brain abnormalities may
interact in ways that increase the likelihood of a mixed dementia diagnosis.
Dementia with Lewy bodies often presents with memory loss and thinking problems common
in Alzheimer’s, but those diagnosed with it are more likely than people with Alzheimer’s to have
initial or early symptoms, such as sleep disturbances, well-formed visual hallucinations, and slow-
ness, gait imbalance, or other parkinsonian movement features (Morra and Donovick 2014). Lewy
bodies are abnormal aggregations (or clumps) of the protein α-synuclein. When they develop in a
part of the brain called the cortex, dementia can result. α-Synuclein also aggregates in the brains of
people with Parkinson’s disease, but the aggregates may appear in a pattern that is different from
dementia with Lewy bodies.
The brain changes of dementia with Lewy bodies alone can cause dementia, or they can be pres-
ent at the same time as the brain changes of AD and/or VaD, with each abnormality contributing to
the development of dementia. When these pathologies occur together, it is another form of mixed
dementia.
Frontotemporal dementia (Galimberti et al. 2015) is characterized by nerve cell damage and loss
of function in the frontal and temporal brain regions, which variably cause deterioration in behavior
and personality, language disturbances, or alterations in muscle or motor functions. There are a
number of different diseases that cause frontotemporal degenerations. The two most prominent are
(1) a group of brain disorders involving the protein tau and (2) a group of brain disorders involv-
ing the protein called TDP43. The reason these localize to the frontal and temporal regions is not
known. This condition is also called Pick’s disease after Arnold Pick, a physician who in 1892 first
described a patient with distinct symptoms affecting language.
CTE is a brain condition associated with repeated blows to the head (Galimberti et al. 2015). This
form of dementia came into public consciousness with the suicide deaths of several National Football
League players in the United States. They shot themselves in parts of their bodies such as the chest
and abdomen purposely far from their heads in order to enable a study of their brain tissue post-
mortem. Potential signs of CTE are problems with thinking and memory, personality changes, and
behavioral changes, including aggression and depression. People may not experience potential signs
of CTE until years or decades after brain injuries occur. A definitive diagnosis of CTE can only be
made after death, when an autopsy can reveal whether the known brain changes of CTE are present.
Other diseases can also lead to secondary dementia. These rarer causes include alcohol-related
brain damage such as Wernicke–Korsakoff syndrome, due to irreversible damage from thiamin defi-
ciency (Ilomaki et al. 2015), HIV (Brew and Chan 2014), and Creutzfeldt–Jakob disease (Sobreira
et al. 2013), a slow prion disease first discovered in cannibals. Bovine spongioform encephalopathy
(Wells and Wilesmith 1995) is another prion disease that is contracted by eating meat from cows
that were fed nerve parts or brains from other animals.
Working with neurologists who specialize in dementias and memory disorders, it is possible to
diagnose the etiological subtypes of dementia syndromes using standard criteria for each of them.
Brain imaging and biomarkers are used in the differential diagnoses among the different disorders.
Treatments for the most part are still symptomatic. Therefore, the role of nutrition and lifestyle is
best employed as early as possible for the prevention or slowing of progression. Many nutritional
approaches in use currently are based on a combination of evidence from epidemiological stud-
ies, animal and cellular studies, and a very limited number of clinical intervention studies of short
duration.
16.4 AGE-RELATED CHANGES IN THE BRAIN

A well-functioning brain has intact neurons and synapses that communicate messages to control
basic bodily functions like breathing, heart rate, sensation, and movement, as well as such mental
experiences as mood, thinking, reasoning, attention, and visual-spatial skills. Age-related altera-
tions in the striatum are accompanied by spatial disorientation, as well as declines in motor function
that lead to diminished muscle strength and loss of balance and coordination.
As the brain ages, it atrophies, its synaptic connections become less effective, and cells do not
communicate as well as during youth.
A gradual deposition of abnormal protein deposits, including amyloid plaques and tau tangles,
accumulate in brain regions controlling cognition, and these accumulations correlate with cognitive
decline (Wansink and Linder 2003). PET scanning can measure the extent of brain plaques and tan-
gles when a specific indicator is used (FDDNP) (Merrill et al. 2012). In a study of middle-aged and
older nondemented adults with a median age of 64 years, increases in frontal, posterior cingulate,
and global FDDNP binding at follow-up correlated with progression of memory decline (r = −0.32
to −0.37, p = 0.03–0.01) after 2 years. Moreover, it was found that higher baseline FDDNP bind-
ing was associated with future decline in most cognitive domains, including language, attention,
executive, and visuospatial abilities (r = −0.31 to −0.56, p = 0.05–0.002). These regional plaque and
tangle binding patterns are consistent with known neuropathological patterns of plaque and tangle
brain accumulation, spreading from the medial temporal to other neocortical regions as cognitive
decline progresses. These abnormal protein deposits have also been found to correlate with late-life
major depression and symptoms of anxiety and depression in nondemented volunteers (Quinn et al.
2010; Danthiir et al. 2011).
In addition to plaque and tangle accumulation, numerous neurotransmitter systems decline with
aging, particularly cholinergic cells in the basal forebrain that project to brain regions controlling
cognitive skills (e.g., frontal, parietal, and medial temporal) (Holmes et al. 2005). Neurons in the
hippocampus (a brain region critical to forming new memories) show decline (Kepe et al. 2006),
and age-associated general and regional brain atrophy accelerates when people develop MCI and
dementia (Burggren et al. 2011). Loss of such neurotransmitters as dopamine and muscarine leads
to decreased sensitivity to stimulation.
Age-related decline in brain health is accompanied by decline in cognitive skills. Although ear-
lier studies suggested that cognitive decline did not begin until age 60, recent research indicates
that such decline can be observed as early as age 45 years. Singh-Manoux and coworkers (2012)
observed 5198 men and 2192 women who ranged in age from 45 and 70. Their cognitive abili-
ties were assessed three times over a 10-year period. The investigators found that cognitive scores
declined in all areas except vocabulary. They reported a 3.6% decline in mental reasoning in those
aged 45–49 years and a 9.6% decline in men and 7.4% in women in the age range 65–70 years.
These and other investigators point to the public health implications of such findings for prevent-
ing dementia: since these gradual declines in brain health and cognitive abilities precede the onset
of dementia symptoms by decades, it might be possible to develop prevention treatments that delay
the onset of those symptoms. Moreover, targeting individuals with risk factors for heart disease—
obesity, hypertension, or high cholesterol—could protect them not only from future cardiac disease
but also from cognitive decline and dementia.
16.5 INFLAMMATION, OXIDATIVE STRESS, AND THE BRAIN

As the brain ages, inflammation and oxidation appear to contribute to neurodegeneration, just as they
do in heart disease, diabetes, cancer, and aging of other body organs (Akiyama et al. 2000; Romano
et al. 2010). In fact, the amyloid plaques that accumulate in the brains of AD patients show evidence
of inflammation, including cytokines (protein molecules that attack foreign material) and activated
microglia (cells that clean out cellular waste, ridding the brain of damaged neurons, plaques, and
infectious agents). A growing body of evidence also suggests that Parkinson’s disease is associated
with oxidative damage via iron accumulation in the substantia nigra, where neurons are destroyed.
Many scientists theorize that chronic inflammation in the brain destroys neurons, and several investi-
gations have suggested that certain medicines, foods, and healthy behaviors can reduce inflammation.
Age-related oxidative stress also damages neurons. Omega-3 fats from nuts and fish and antioxidant
fruits and vegetables may diminish age-related inflammatory and oxidative neuronal damage.
Nourishing our brains through a healthy diet appears to protect us from cognitive decline. A
recent study (Gu et al. 2010) of more than 2000 people age 65 and older showed that research sub-
jects who ate a greater amount of nuts, fish, tomatoes, poultry, vegetables, and fruits, and a lesser
amount of high-fat dairy products, red meat, and butter, had a lower risk for AD. These kinds of
findings point to proper nutrition as a way to bolster brain health as we age.
A diet rich in anti-inflammatory omega-3 fatty acids from ocean-caught fish and seafood is asso-
ciated with a lower risk for developing AD (Cole et al. 2009). The most abundant omega-3 fatty acid
in the brain, docosahexaenoic acid (DHA), protects brain neurons against the toxic events associ-
ated with amyloid plaques and tau tangles. The prevalence of dementia among Nigerians, who eat a
diet low in animal fat, is low compared with that of African Americans, who eat a diet with a higher
intake of omega-6 fatty acids (Ogunniyi et al. 2000).
16.6 HEALTHY LIFESTYLE AND THE BRAIN

Considerable scientific evidence points to lifestyle as key to protecting brain health as people age
(Small et al. 2000; Kosashvili et al. 2010; Lee et al. 2010; Rolland et al. 2010; Sofi et al. 2010; Merrill
and Small 2011). Nutrition, mental and physical exercise, stress reduction, and social engagement
can improve cognitive performance and possibly delay the onset of dementia. Dr. Gary Small and
colleagues at the University of California, Los Angeles (UCLA) (Miller et al. 2012) found that a
6-week healthy lifestyle program, including healthy nutrition, physical conditioning, memory train-
ing, and stress management, improved both encoding and recalling of new verbal information, as
well as self-perception of memory ability in older adults residing in continuing care retirement com-
munities. In another study, the same group found that a 2-week healthy lifestyle program combin-
ing mental and physical exercise, stress reduction, and healthy diet was associated with significant
effects on cognitive function and brain metabolism (Small et al. 2006). The reduced resting activity
in the left dorsolateral prefrontal cortex observed following the 2-week program may reflect greater
cognitive efficiency of a brain region involved in working memory. Such evidence suggests that
the impact of nutrition on brain health could be augmented when combined with several healthy
lifestyle behaviors.
16.6.1 Exercise and Brain Health

Exercise training can influence brain morphology at older ages. Hippocampal and medial temporal
lobe volumes are larger in highly fit adults, and physical activity training increases hippocampal
perfusion. A 52-week randomized controlled trial with 120 older adults (aged 55–80 years) showed
that aerobic exercise training increased the size of the anterior hippocampus, leading to improve-
ments in spatial memory (Erickson et al. 2011). Exercise training increased hippocampal volume by
2%, effectively reversing age-related losses in volume by 1–2 years. Hippocampal volume declined
in the control group. Caudate nucleus and thalamus volumes were unaffected by the intervention.
These findings indicate that aerobic exercise training is effective at reversing hippocampal volume
loss in older adults, which is accompanied by improved memory function.
Brain-derived neurotrophic factor (BDNF) plays an important role in neuronal survival and
growth, serves as a neurotransmitter modulator, and participates in neuronal plasticity, which
is essential for learning and memory. It is widely expressed in the CNS, gut, and other tissues.
Decreased levels of BDNF are associated with neurodegenerative diseases with neuronal loss, such
as Parkinson’s disease, AD, multiple sclerosis, and Huntington’s disease.
Studies investigating the effects of physical activity and acute exercise and/or training on the
plasma concentrations of BDNF in humans (Gold et al. 2003; Knaepen et al. 2010) demonstrated
that exercise increased BDNF release (Goekint et al. 2008, 2010a,b, 2011; Goekint 2011). After
training for 8 weeks, baseline BDNF levels are lower, possibly due to a receptor adaptation, while
detraining will abolish the exercise-induced effects (Goekint et al. 2010a). Little is known about the
effect of resistance exercise on hippocampus-dependent memory, although this type of exercise is
increasingly recommended to improve muscle strength and bone density and to prevent age-related
disabilities. It was shown that resistance training does not significantly increase peripheral BDNF
levels (Goekint et al. 2008); however, it seems that resistance exercise increases cognitive perfor-
mance, especially in the elderly population (Cassilhas et al. 2007).
16.6.2 Omega-3 Fatty Acids and Fish Oils

Although many Americans seem to prefer animal fat in their diet, at least one study suggested that
substituting other healthier fats can promote satiety and may help with weight.
Theoretically fish oil supplements rich in DHA should have similar effects to seafood in reduc-
ing inflammation in the brain. A meta-analysis of randomized controlled trials of fish oil supple-
ments alone without lifestyle changes failed to demonstrate a benefit in the treatment of dementias
(Burckhardt et al. 2016). This is not surprising, as supplementation in the absence of reducing
omega-6 fatty acids is less effective in altering tissue levels of omega-3 fatty acids.
It may be that patients with an apoE-4 isoform would be more responsive to changes in dietary fat
from omega-6 to omega-3. An interesting 26-week study of cognitively intact subjects age 65 years
or older demonstrated that those subjects with the apoE-4 genetic risk for AD demonstrated bet-
ter attention span from ingesting either a low daily dose (226 mg of eicosapentaenoic acid [EPA],
176 mg of DHA) or a high daily dose (1093 mg EPA, 847 mg DHA) of fish oil than a placebo group
(van de Rest et al. 2008).
Better cognitive health in older adults has been associated with omega-3 polyunsaturated fatty
acids (PUFAs). The omega-3 long-chain PUFAs EPA and DHA are necessary for normal brain
development and function (Danthiir et al. 2011). Epidemiological studies have demonstrated a clear
connection between cognitive performance and omega-3 fatty acids, but clinical trials of DHA
supplementation have not been successful in slowing the rate of cognitive and functional decline in
patients with mild to moderate Alzheimer disease compared with placebo (Quinn et al. 2010). Even
though a treatment may not show benefit in patients with dementia, it still may be effective in people
with milder forms of cognitive impairment. To this end, an 18-month randomized, double-blind,
controlled trial of omega-3 fatty acids in cognitively healthy older adults is currently in progress
(Danthiir et al. 2011).
Omega-3 fatty acids also may offer a benefit in alleviating symptoms of depression. An 8-week
controlled trial of 1050 mg of EPA and 150 mg of DHA daily found improvement in mood in
patients with a major depressive episode without comorbid anxiety (Lesperance et al. 2011). EPA
appears to be the key omega-3 fatty acid component that is associated with efficacy in major
depressive disorders.
16.6.3 Antioxidant-Rich Foods
Antioxidant-rich foods protect neurons from oxidative free radicals that damage DNA. Polyphenols
are potent antioxidants that can be found in strawberries, blackberries, blueberries, and other color-
ful berries, as well as grapes, pears, plums, cherries, broccoli, cabbage, celery, onions, and parsley.
Several large-scale studies indicate a link between dietary antioxidant intake and better brain
health, including the Rotterdam Study, which demonstrated an association between higher dietary
intake of the antioxidant vitamin E and a lower risk for developing AD (Devore et al. 2010). Another
large-scale European study in people age 65 and older showed an association between daily consump-
tion of fruits and vegetables and a lower risk for all forms of dementia (Barberger-Gateau et al. 2007).
Although memory impairment is associated with low antioxidant blood levels, short-term mem-
ory has been found to improve in laboratory animals fed antioxidant-rich berry extracts (Goyarzu
et al. 2004). Other research suggests that when study subjects drink fruit or vegetable juice at least
three times a week, they have a lower probability of developing AD than those who drink these
juices less than once a week (Dai et al. 2006).
Pomegranate juice is rich in antioxidant polyphenols, and recent studies suggest its brain health
benefits. Our group at UCLA performed a preliminary, placebo-controlled, randomized trial of pome-
granate juice in older subjects with age-associated memory complaints using memory testing and
functional brain activation (fMRI) as outcome measures (Bookheimer et al. 2013). Thirty-two sub-
jects were enrolled and 28 completed the study. Subjects were randomly assigned to drink 8 ounces of
either pomegranate juice or a flavor-matched placebo drink for 4 weeks. Subjects received memory
testing, fMRI scans during cognitive tasks, and blood draws for peripheral biomarkers before and
after the intervention. Investigators and subjects were all blind to group membership. After 4 weeks,
only the pomegranate group showed a significant improvement in the Buschke selective remind-
ing test of verbal memory and a significant increase in plasma antioxidant capacity and urolithin
A– glucuronide, a metabolite of pomegranate ellagitannins formed by the colonic microflora.
Furthermore, compared with the placebo group, the pomegranate group had increased fMRI activity
during verbal and visual memory tasks. While preliminary, these results suggest a role for pomegran-
ate juice in augmenting memory function through task-related increases in functional brain activity.
Research suggests that cocoa flavanols improve memory and learning, possibly as a result of their
anti-inflammatory and neuroprotective effects (Lamport et al. 2015). These effects may be mediated
by increased cerebral blood flow, with subsequent stimulation of neuronal function cerebral blood
flow was measured before and after consumption of a 330 mL drink containing low (23 mg) or high
(494 mg) amounts of cocoa flavanols. The drinks were matched for caffeine, theobromine, taste,
calories, and appearance. The study was conducted in 8 males and 10 females between the ages of
50 and 65 using a randomized, counterbalanced, crossover, double-blind design and measured the
study subjects’ abilities to retain information over several minutes for doing mental arithmetic or
dialing a phone number. Significant increases in regional perfusion across the brain were observed
following consumption of the high-flavanol drink relative to the low-flavanol drink, particularly in
the anterior cingulate cortex and the central opercular cortex of the parietal lobe. Other randomized
placebo-controlled trials indicate that daily consumption of flavanol-rich cocoa drinks over 8 weeks
is associated with improved cognitive function in healthy older adults (Mastroiacovo et al. 2015)
and in older adults with MCI (Desideri et al. 2012).
Green tea contains a family of antioxidant phytochemicals known as catechins, including epigal-
locatechin gallate (EGCG). These antioxidant substances have both antiamyloid and anti-inflammatory
properties and are bioavailable (Kim et al. 2010).
Used for centuries as a treatment for inflammatory diseases, curcumin (diferuloylmethane) is
a yellow pigment in the spice turmeric. Considerable research has demonstrated that curcumin
mediates its anti-inflammatory effects through the downregulation of inflammatory transcription

factors, enzymes, and cytokines (Aggarwal and Sung 2009). A study including more than 1000
volunteers aged 60–93 years (Ringman et al. 2005) showed that volunteers who ate curried foods
more frequently had higher scores on the Mini-Mental State Examination. Although evidence sug-
gests that the antiamyloid and anti-inflammatory effects of curcumin might protect brain health and
improve cognitive functioning, a previous study in patients with Alzheimer’s dementia did not show
cognitive benefits (Eskelinen and Kivipelto 2010).
It is still possible that the potential anti-inflammatory and antiamyloid effects of curcumin may
only be observed in people at risk for dementia. The mechanism of action for curcumin is not
clear, and evidence thus far has not confirmed that it is brain protective when taken as a supple-
ment, since the oils used to cook curried dishes may be necessary for it to benefit neuronal health.
Moreover, it may not be necessary for curcumin to penetrate the blood–brain barrier for it to exert
anti-inflammatory effects, which may be triggered by interactions with immune cells in the gas-
trointestinal tract.
Our research team at UCLA recently initiated a study of curcumin versus placebo in nonde-
mented older adults. Both neuropsychological tests and PET scans of amyloid plaques and tau
tangles will be used as outcome measures. Curcumin is one of many spices and herbs that are anti-
oxidant and have potential to promote brain health. Others are cinnamon, oregano, vanilla, parsley,
ginger, basil, pepper, and chili.
16.6.4 Coffee, Caffeine, and the Brain

Several epidemiological studies have demonstrated an association between drinking coffee and
better brain health. For example, a large-scale Swedish investigation showed that drinking up to
three cups of coffee a day was associated with a 65% lower risk for AD (Chen et al. 2010). Coffee
consumption is also associated with a lower rate of developing Parkinson’s disease and diabetes,
both of which increase the risk for dementia (Ng et al. 2006).
Coffee and other caffeinated beverages also have short-term effects on the mental state. Positive
effects include an increase in alertness and attention, as well as an elevated mood. Drinking coffee
can improve learning and recall; however, excessive caffeine consumption may result in irritability,
anxiety, and insomnia. Some people cannot tolerate the acidity of coffee, so they prefer to get caffeine
by drinking tea. Chocolate is another source of caffeine: 6 ounces of brewed coffee contains 100 mg
of caffeine, compared with 40 mg from a similar amount of tea, and 10 mg from a chocolate bar.
16.6.5 Alcohol and the Brain

Clearly, alcoholism, with its distortion of nutrient and B vitamin intake, is both a major health
problem worldwide and a cause of dementia. However, alcohol use in moderation is associated with
a lower risk for dementia. A recent study demonstrated that light drinkers had almost a 30% lower
risk for developing dementia than did people who either abstain from alcohol or drink in excess
(Anstey et al. 2009). Because this study was not a double-blind, placebo-controlled trial, it does
not definitely prove a cause-and-effect relationship. It is possible that drinking in moderation is
also associated with some other factor that protects brain health and lowers risk for dementia. For
example, moderate drinkers may deal with other aspects of their lives in moderation, which could
reflect a personality style associated with lower stress levels.
Precisely what defines light or moderate alcohol use varies among studies, but many experts
agree that one glass of wine or spirits for women and two glasses for men per day is a reasonable
definition. The male–female differences likely reflect the body weight and size differences between
men and women. Red wine compounds, including resveratrol, have been touted for their brain
health effects (Liu et al. 2015). While there are many studies in vitro and in animals, resveratrol has
poor bioavailability. A growing body of evidence indicates that resveratrol plays an important role
in reducing organ damage following ischemia- and hemorrhage-induced reperfusion injury. Such
a protective phenomenon is reported to be implicated in decreasing the formation and reaction of
reactive oxygen species and pro-inflammatory cytokines, as well as the mediation of a variety of
intracellular signaling pathways, including the nitric oxide synthase, nicotinamide adenine dinu-
cleotide phosphate oxidase, deacetylase sirtuin 1, mitogen-activated protein kinase, peroxisome
proliferator-activated receptor λ coactivator 1 α, hemeoxygenase-1, and estrogen receptor-related
pathways. If bioavailability issues can be solved, this polyphenol may have some potential benefit
for brain health in the future.
16.6.6 Dietary Supplements and the Brain

An antioxidant vitamin and mineral supplementation regimen was studied in a double-blind, placebo-
controlled, randomized trial. A total of 4447 French participants aged 45–60 years were randomized
to receive a combination of vitamin C (120 mg), β-carotene (6 mg), vitamin E (30 mg), selenium
(100 μg), and zinc (20 mg), or a placebo. Subjects receiving the active antioxidant supplementation
had better episodic memory scores. Verbal memory also improved by antioxidant supplementation
only in subjects who were nonsmokers or who had low serum vitamin C concentrations at baseline
(Kesse-Guyot et al. 2011).
Epidemiological studies have connected dietary vitamin D to brain health and better cognitive
abilities. These investigations have led to randomized clinical trials demonstrating cognitive ben-
efits, but these effects may be limited to older adults. For example, a 6-week controlled trial of daily
vitamin D (5000 IU of cholecalciferol) or placebo included 128 young adult participants (mean age
22 years) and showed no cognitive benefits (Dean et al. 2011).
A cross-sectional study of nutrient status and psychometric and imaging indices of brain health
was performed in 104 dementia-free older adults, with an average age of 87 years (Bowman et
al. 2012). The investigators reported two nutrient biomarker patterns to be associated with better
cognitive performance and MRI measures: one high in plasma vitamins B (B1, B2, B6, folate, and
B12), C, D, and E, and the other high in plasma marine omega-3 fatty acids. A third pattern that
was high in hydrogenated fats was associated with less favorable cognitive function and less total
brain volume.
16.7 DIABETES, VISCERAL FAT, INFLAMMATION, AND ALZHEIMER’S DISEASE

Diabetes mellitus type 2, or “diabesity,” is the most common metabolic disorder worldwide, and
its prevalence is increasing dramatically. It is estimated that 387 million people live with diabe-
tes, of which nearly 50% are unaware they have the disease, mostly due to the fact that diabetes
can remain asymptomatic or be misdiagnosed for several years. The underlying determinants of
diabetes are the same all over the world. Economic development is associated with increasingly
“obesogenic environments,” characterized by increasing access to energy-rich diets and decreased
physical activity.
Diabetes causes micro- and macrovascular diseases (American Diabetes Association 2013). In
addition, increasing evidence has also demonstrated that type 2 diabetes results in complications in
the CNS, with many brain structures being sensitive to changes in glucose and insulin. Diabetes-
associated cognitive decline (also known as diabetic encephalopathy) results from a complex inter-
play between direct and indirect metabolic consequences of long-term hyperglycemia, insulin
deficiency, and additional components, such as genetic and environmental factors (Stranahan 2015).
Diabetes-associated cognitive decline has been linked to learning and memory deficits, which in
turn increase the risk for dementia, AD, and affective disorders (Biessels et al. 1994; Yates et al.
2012). In this context, recent studies have shown that elevated body mass index, obesity, and insulin
resistance are correlated with increased risk of dementia and cognitive impairment (Raji et al. 2010;
Grillo et al. 2011). The mechanisms by which cognitive abilities are impaired in diabetes have not
been clearly identified. Nevertheless, it has been shown that altered neurogenesis, electrophysiologi-
cal deficits, and oxidative stress injury, inflammation, and apoptosis can induce structural changes
and be involved in brain dysfunction during the course of diabetes (Wrighten et al. 2009; Stranahan
2015).
16.8 PRIMARY CARE PHYSICIAN AND CASE MANAGER

COLLABORATION IN DEMENTIA PATIENTS
People with dementia need help with challenging changes in behavior, memory, physical disability,
and mood (van der Roest et al. 2007). All the nutritional knowledge in this chapter is useless if there
is no way to deliver the physical and nutritional care needed to the patient.
The main source of help is family caregivers, who often suffer from the burdens of caregiving
and from depression and health problems themselves (Dupuis et al. 2004). Therefore, the entire
family or key caregivers become your patients as well in cases of dementia, and they may require
psychological support.
It has been shown that early intervention makes the greatest difference in management of
symptoms. The World Health Organization states that it would be challenging to intervene with-
out effective involvement of primary care (World Health Organization and Alzheimer’s Disease
International 2012). Dementia case management interventions are becoming a central component
of primary health care organizations in North America and Europe (Morales-Asencio et al. 2008;
Bergman 2009; Bamford et al. 2014; Iliffe et al. 2014).
According to the Case Management Society of America, case management is “a collabora-
tive process of assessment, planning, facilitation, care coordination, evaluation, and advocacy for
options and services to meet an individual’s and family’s comprehensive health needs through com-
munication and available resources” (Case Management Society of America 2016).
Case managers are health care professionals who provide follow-up, coordinate individual care,
and interact with other health care providers. They also work in collaboration with family physi-
cians, primary care teams, and dementia specialists (Laurant et al. 2004; Callahan et al. 2006;
Stevenson and Herschell 2006; Vickrey et al. 2006; Jedenius et al. 2008, 2011; Schoenmakers et
al. 2010; Jansen et al. 2011; Fortinsky et al. 2014). It is clear that dietitians knowledgeable in nutri-
tion support, as well as neurological limitations to nutritional intake, will be critical in this effort,
bringing their knowledge to bear in terms of the nutrition and supplements that patients and family
members obtain so that no harm is done as every effort is made to implement ideas drawn from
cutting-edge research on nutrition and brain health.
16.9 SUMMARY
The proportion of people with dementia is growing dramatically. According to the U.S. Alzheimer’s
Association, by 2030, 50% of Americans aged 65 years and older will be diagnosed with demen-
tia (Alzheimer’s Association 2014). In Canada in 2011, 747,000 Canadians lived with cognitive
impairment (Alzheimer Society of Canada 2015). Today, the combined costs are $33 billion per
year (Alzheimer’s Association 2014), and they are projected to increase to $872 billion by 2038
(Dudgeon 2010; Prince et al. 2015). Worldwide, dementia is the main contributor to disability-
adjusted life years (11.2%), representing a greater burden than cerebral vascular accident (9.5%),
heart disease (5.0%), or cancer (2.4%) (Mathers and Leonardi 2000).
The interaction between nutrition and brain health is complex. Several gastrointestinal hormones
or peptides, such as leptin and glucagon-like peptide 1 (GLP-1), have an influence on emotions and
cognitive processes (Li et al. 2002; Komori et al. 2006). Leptin is synthesized in adipose tissue and
sends signals to the brain to reduce appetite (receptors in the hypothalamus, cortex, and hippocam-
pus). Leptin also elevates brain BDNF, a protein that stimulates brain cell growth and synaptic con-
nections, leading to a more efficient, sensitive, and adaptive brain. Both leptin and BDNF facilitate
synaptic plasticity in the hippocampus. Genetically obese rodents with dysfunctional leptin recep-
tors show impaired spatial learning (Li et al. 2002; Komori et al. 2006).
Pro-inflammatory cytokines present in the adipose tissue of central obesity trigger excess inflam-
mation throughout the body, and a low-calorie diet can alter the expression of inflammatory genes
in this adipose tissue. A healthy brain diet includes many foods that fight inflammation, including
fruits, vegetables, fish, whole grains, legumes, spices, and herbs. Flavonoids, present in cocoa, cit-
rus fruits, and green leafy vegetables, also have anti-inflammatory effects and have been found to
benefit cognition in older subjects and laboratory animals (Gomez-Pinilla 2008).
A diet that emphasizes antioxidant fruits and vegetables; proteins from fish, poultry, or lean beef;
and complex carbohydrates and whole grains, as well as avoids processed foods and high-glycemic-
index carbohydrates, maintains ideal body weight, and includes omega-3 fatty acids, is likely to
support brain health and lower the risk for age-related cognitive decline and mood disturbances
throughout life. Scientists are continuing to tease out the specific components of brain healthy nutri-
tion in order to develop more evidence-based recommendations for consumers.
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17 Gene–Nutrient Interaction
17.1 INTRODUCTION
The interaction of nutrition with the human genome and the microbiome has attracted a great deal
of attention in the last decade. The sequencing of the human genome was followed by the discovery
that our bodies are covered with trillions of bacteria, and their genome outnumbers our own. Our
understanding of the functioning of the genome has advanced far beyond the idea of a basic code for
amino acids to an understanding of gene–gene, gene–nutrient, microRNA (miRNA), and epigenetic
regulation of gene expression, with many of these processes influenced by nutrition. It is clear that
gene sequencing is useful for the diagnosis of genetic diseases, but it is not ready for application
in providing point-of-service personalization in diets to reduce age-related chronic diseases, as
imagined by some commercial promoters who offered analysis of common genetic polymorphisms
based on a sputum sample, followed by dietary recommendations. However, it is clear that what we
already know about gene–nutrient interaction underscores the importance of an integrated approach
to diet and lifestyle change in primary care practice.
Gene–nutrient interactions serve to moderate the certainty with which we provide some nutri-
tional recommendations. We cannot assume that one size fits all for all nutrients, but genetics does
not invalidate most commonsense nutrition recommendations. It is more likely from what we know
that everyone benefits from balanced nutrition and a healthy active lifestyle, but some may benefit
even more based on a genetic predisposition to inflammation and age-related chronic diseases.
Most age-related chronic diseases are still about 70% dependent on diet and lifestyle and only
30% on genetics. Identical twin studies examining the correlations among twins of common dis-
eases tend to overestimate the impact of genetics on obesity and chronic diseases. However, identi-
cal twin studies have been used effectively to show the impact of microbiome changes on the risk
of obesity. In these studies, identical twins who were different in that one twin was obese and
other was lean were studied. Stool microflora from the obese twin and the normal twin were trans-
planted into germ-free mice, and on the same diet, the mouse with the microflora from the lean twin
remained lean, while the mouse with the microflora from the obese twin gained weight.
Another important demonstration of the impact of nutrients on gene expression is the epigenetics,
which occurs in utero. A yellow mouse called the agouti mouse has a heterozygous agouti gene
mutation. This mutation confers a yellow coat color to the mice, obesity, and an increased risk of
cancer. If a pregnant yellow agouti heterozygote mother is treated with methyl donor vitamins,
including folic acid, then she gives birth to normal brown mice with no obesity or increased risk of
cancer. The folic acid and other methyl donors prevent the expression of the agouti gene by methyla-
tion of CpG islands in the promoter region of the gene in utero. There are many other examples of
epigenetic influences on gene expression based on in utero effects, and this phenomenon has been
called nutrition programming.
While genetic diagnosis of rare inherited metabolic diseases is taught in medical schools, the
emphasis is largely on those genes that can be targeted by drugs or used to diagnose an intolerance
for certain nutrients, such as the amino acid phenylalanine in phenylketonuria (PKU). The search
for small-molecule drugs that can treat cancers and other metabolic diseases, such as cystic fibrosis,
has added to the general impression in medical school and primary care education that nutrition is
less important than pharmacology.
In fact, nature’s first pharmacy was the plant world, and prehuman mammals evolved with a
plant-based diet for millions of years. The consumption of land-based mammals that were grass
fed and ocean-caught fish and other seafood maintained the links to the plant world, since all
297
these animals concentrated substances from their plant-based environment. Modern agriculture
and animal husbandry is a relatively recent phenomenon in our human evolutionary history and
has resulted in a number of gene–nutrient imbalances expressed through an increased risk of age-
related chronic diseases. When first introducing the topic of gene–nutrient interaction in 1996 at the
University of California, Los Angeles (UCLA) Center for Human Nutrition, with the dedication of
the Dennis A. Tito Gene-Nutrient Interaction Laboratory, a great deal of skepticism was expressed
by oncologists at UCLA about what exactly was meant by the term. This prejudice remains active,
but the emphasis in this chapter and ongoing research on plant-based supplements and phytonutrient
extracts aim to modify gene expression by restoring the balance of genes and nutrients through a
diet rich in colorful phytonutrient-rich fruits, vegetables, and spices.
17.2 HUMAN NUTRITION AND GENE–NUTRIENT INTERACTION

The understanding of human nutrition has evolved throughout history in parallel to the development
of key sciences, including chemistry, biochemistry, physiology, and most recently, genetics, with the
sequencing of the human genome in the first decade of the twenty-first century.
During the “naturalistic era” (400 BC–1750 AD), Hippocrates (Karagiannis 2014) hypothesized
that the body had “innate heat” and coined his famous phrase “Let food be your medicine and medi-
cine be your food.” During the next 500 years, little happened in the development of either scientific
knowledge or nutrition science. However, the level of knowledge that could be gleaned from careful
clinical observation of the effects of foods on physiological function was remarkable, as typified in
the writings of Maimonides in the eleventh century AD. This medieval rabbi, physician, and phi-
losopher was ahead of his time in applying Aristotelian understanding to the common ailments that
could be modified by eating prescribed foods and carrying out simple hygienic practices that were
not routine for many centuries after his death (Gesundheit 2011).
The late 1700s ushered in the “chemical-analytical era” (1750–1900), highlighted by Lavoisier’s
calorimetry studies (Severinghaus 2016). He discovered how food is metabolized by oxidation to car-
bon dioxide, water, and heat. He also invented the calorimeter, crucial to further understanding of heat
energy. In the nineteenth century, Liebig (Usselman 2003) recognized that carbohydrates, proteins,
and fats are oxidized by the body and calculated energy values for each. While chemists were examin-
ing the composition of foods and metabolism, physicians were studying the mechanisms and process
of digestion, the means by which food is converted to useful intermediates that ultimately yield energy.
The “biological era” (1900–present) was founded on advances in chemistry, biochemistry, and
understanding of metabolic pathways. In the early twentieth century, considerable research had
been done on energy exchange and on the nature of foodstuffs. Once an understanding of macronu-
trients and better tools were developed, nutrition scientists turned their attention to the understand-
ing of micronutrients, discovering the essential fatty acids and vitamins (McCollum 1967; Spector
and Kim 2015).
The “cellular era” of the late twentieth century, beginning after the Second World War, focused
on understanding functions of essential nutrients and the roles of micronutrients (vitamins and min-
erals) as cofactors for enzymes and hormones, and their subsequent roles in metabolic pathways.
The roles of carbohydrates and fats in diseases such as diabetes and atherosclerosis were discovered,
and underlying mechanisms were uncovered (Kritchevsky 1998).
Today, we are still in the era of cellular nutrition, but the “molecular and cellular” era is developing in
the twenty-first century. It has been spurred on by the sequencing of the human genome, but it is not yet
ready for application. Here is a glimpse of the future of nutritional science and personalized medicine.
17.3 NUTRIGENETICS
Observations of health and disease in the twentieth century raised some new questions. Why can
some individuals consume high-fat diets and yet show no evidence of atherosclerotic disease?
Gene–Nutrient Interaction 299
Individual genetic differences in response to dietary components have been evident for years: lac-
tose intolerance, alcohol dehydrogenase deficiency, and individual and population differences in
blood lipid profiles and health outcomes after consumption of high-fat diets.
Genetic differences certainly were suspected, but elucidating and proving cellular, molecular,
and ultimately genetic-level mechanisms in both healthy and unhealthy individuals proved to be
a challenge. With the continuing developments in tools that enable molecular-level exploration of
cause–effect phenomena, scientists have begun to develop hypotheses and conduct experiments
to lay the foundation for a deeper level of understanding of gene–nutrient interactions. Today, an
emerging field of nutritional research focuses on identifying and understanding molecular-level
interaction between nutrients and other dietary bioactives with the human genome during transcrip-
tion, translation, and expression, the processes during which proteins encoded by the genome are
produced and expressed. The field of nutrition is likely to be the greatest beneficiary of the emerg-
ing trends in research on chronic diseases of aging, including cancer, heart disease, and mental
dysfunction.
Nutrigenetics examines the individuality of response to nutrients based on genetics, while nutrig-
enomics examines the impact of nutrition on gene expression and disease risk. These definitions are
often interchanged or confused even by scientists in the field, so you will see both terms.
The goal of nutrigenetics is to elucidate the effect of genetic variation on the interaction between
diet and disease. Nutrigenetics has been used for decades in certain rare monogenic diseases such as
PKU. In this disease, individuals must avoid phenylalanine-containing foods, or they risk develop-
ment of serious mental dysfunction. More than 950 phenylalanine hydroxylase (PAH) gene variants
have been identified in people with PKU. These vary in their consequences for the residual level of
PAH activity, from having little or no effect to abolishing PAH activity completely (Blau 2016). A
warning on diet soft drinks that use aspartame is specific to PKU. Advances in genotyping technol-
ogy and the availability of locus-specific and genotype databases have greatly expanded the under-
standing of the correlations between individual gene variants, residual PAH enzymatic activity, and
the clinical PKU phenotype.
Nutrigenetics in the general population has been proposed to have the potential to provide a basis
for personalized dietary recommendations based on the individual’s genetic makeup in order to
prevent common multifactorial disorders decades before their clinical manifestation. A number of
metabolic differences in metabolic pathways occur among individuals. Some of these affect the risk
of certain cancers, such as lung and colon cancer.
One example of very common variants in nutrient metabolism that affect chronic disease risk
is related to the metabolism of glucosinolates from cruciferous vegetables such as broccoli. The
chemoprotective effect of cruciferous vegetables is due to their high glucosinolate content and
the capacity of glucosinolate metabolites, such as isothiocyanates (ITCs) and indoles, to modu-
late biotransformation enzyme systems (e.g., cytochrome P450 and conjugating enzymes). Data
from molecular epidemiologic studies suggest that genetic and associated functional variations in
biotransformation enzymes, particularly glutathione S-transferase (GST) M1 and GSTT1, which
metabolize ITCs, alter cancer risk in response to cruciferous vegetable exposure. Moreover, genetic
polymorphisms in receptors and transcription factors that interact with these compounds may fur-
ther contribute to variation in response to cruciferous vegetable intake.
Biotransformation enzymes, also referred to as xenobiotic- or drug-metabolizing enzymes, play
a major role in regulating the toxic, mutagenic, and neoplastic effects of chemical carcinogens, as
well as metabolizing other xenobiotics (e.g., phytochemicals and therapeutic drugs) and endog-
enous compounds (e.g., steroid hormones). Phytochemicals in plant foods modulate biotransforma-
tion enzyme activities, one mechanism by which fruits and vegetables, and cruciferous vegetables
in particular, may contribute to reduced cancer risk.
There are two main groups of biotransformation enzymes. Phase I enzymes (cytochrome P450
and flavin-dependent monooxygenases) convert hydrophobic compounds to reactive electrophiles
by oxidation, hydroxylation, and reduction reactions to prepare them for reaction with water-soluble
moieties. Phase II enzymes (e.g., GST, UDP-glucuronosyltransferases [UGTs], sulfotransferases,

and N-acetyltransferases) primarily catalyze conjugation reactions. Genetic polymorphisms in these
enzyme systems can influence cancer susceptibility when coupled with the relevant carcinogen
exposures. The understanding of how genetic differences in components of the biotransformation
pathways alter response to chemopreventive foods such as cruciferous vegetables has only been
discovered in the last few decades.
Null genotypes for GSTM1 and GSTT1 occur commonly and result in the absence of the respec-
tive enzymes. Both of these enzymes are involved in the metabolism of environmental carcinogens
and reactive oxygen species. Thus, until recently, the primary hypothesis has been that individuals
with the GST null genotypes are at higher risk for cancer because of reduced capacity to dispose of
activated carcinogens. Numerous epidemiologic studies have focused on interactions between these
polymorphisms and carcinogen exposure. Now, researchers are also studying relationships between
GST polymorphisms and exposure to preventive agents (i.e., ITCs), with the hypothesis being that
because ITCs are metabolized by GST, polymorphisms associated with reduced GST activity will
result in longer circulating half-lives of ITCs and potentially greater chemoprotective effects of
cruciferous vegetables (Lampe et al. 2000).
A null genotype has a modest effect on increasing the risk of cancer, but the individual with a
null genotype has a greater opportunity to reduce the risk by eating cruciferous vegetables, which
induce protective GST enzyme activity more briskly than is found in the wild-type GST individual.
Therefore, a null mutation increases the risk of cancer modestly but provides that individual with
an increased opportunity to benefit from nutrients beyond that of individuals who do not have the
null mutation.
17.4 NUTRIGENOMICS: EFFECTS OF NUTRIENTS ON GENE EXPRESSION

Nutrigenomics explores the effects of nutrients on the genome, proteome (all of an organism’s
proteins), and metabolome (all the metabolites of a cell or organism). Nutrients previously
thought to be simply sources of calories, such as lipids, can modulate gene expression—as can
many phytochemicals derived from fruits, vegetables, and spices that were simply thought to be
antioxidants.
Although epigenetic aberrations frequently occur in aging and cancer and form a core com-
ponent of these conditions, perhaps the most useful aspect of epigenetic processes is that they
are readily reversible. Unlike genetic effects that also play a role in cancer and aging, epigenetic
aberrations can be relatively easily corrected. One of the most widespread approaches to the epi-
genetic alterations in cancer and aging is dietary control. This can be achieved not only through
the quality of the diet, but also through the quantity of calories that are consumed. Many phyto-
chemicals, such as sulforaphane (SFN) from cruciferous vegetables and green tea, have anticancer
epigenetic effects and are also efficacious for preventing or treating the epigenetic aberrations of
age-associated diseases besides cancer. Likewise, the quantity of calories that are consumed has
proven to be advantageous in preventing cancer and extending the life span through control of
epigenetic mediators.
17.5 EPIGENETICS AND DIET

Epigenetic processes involve changes that are heritable but are not encoded with the DNA sequence
itself. There are numerous types of epigenetic mechanisms, but the three most important in humans
include changes in DNA methylation, histone modifications, and noncoding RNAs.
DNA methylation is the most studied of the epigenetic processes and is based on the addition
of a methyl group enzymatically from S-adenosylmethionine (SAM) to the 5-positon of cytosine,
primarily occurring in CpG dinucleotides. This is carried out by three major methyltransferases
(DNMT1, DNMT3A, and DNMT3B). In general, the more methylated a gene regulatory region
becomes, the less transcription will occur from the promoter, although there are notable excep-
tions to this dogma, as occurs with the gene that encodes human telomerase reverse transcriptase
(hTERT), the key regulatory gene of telomerase (Poole et al. 2001; Daniel et al. 2012).
Epigenetic changes can also occur through modification of the histone proteins coating the chro-
mosomes. Modification of the histones opens up the chromatin to allow transcription or, alter-
natively, to protect the DNA from inappropriate transcription. Although histone acetylation and
methylation are the most studied of these modifications, others also occur, such as histone phos-
phorylation, ubiquitination, biotinylation, sumoylation, and ADP-ribosylation.
The number of enzymes that carry out histone modifications is large relative to those that medi-
ate DNA methylation, and the two that often attract interest, especially with regard to cancer and
aging, are the histone acetyltransferases (HATs) and the histone deactylases (HDACs) (Kouzarides
2007). In general, the more acetylated the histone amino tails become, the more likely it is that
the gene promoter region that contains those histones will have increased transcriptional activity
(Clayton et al. 2006).
Noncoding RNA, the third major type of epigenetic control in mammalian systems, is also impor-
tant in gene expression. For example, miRNA consists of single-stranded noncoding RNAs that are
usually about 21–23 nucleotides in length. These sequences suppress gene expression by altering the
stability of gene transcripts and also by targeting the transcripts for degradation, although miRNA
may also lead to an increase in gene transcription (Mathers et al. 2010). Many miRNAs have now
been identified and can regulate a large number of varied genes that affect metabolism and onco-
gene expression (Esquela-Kerscher and Slack 2006).
Epigenetic alterations can also provide a format for long-term dietary programming of the genome,
suggesting that nutritional supplementation may affect gene regulation in humans, and that well-
adapted diets applied in utero and after birth may exert a fundamental and long-lasting positive
impact. Some evidence shows that chronic diseases in adulthood are due to persistent influences
from early-life nutrition.
Intrauterine growth restriction (IUGR) is a perinatal condition affecting fetal growth, with under
the 10th percentile of the weight curve expected for gestational age, and it is more common among
mothers with nutritional imbalances or malnutrition. This condition has been associated with higher
cardiovascular and metabolic risk and postnatal obesity. There are also major changes in placental
function, and particularly in a key molecule in this regulation, nitric oxide. The synthesis of nitric
oxide has numerous control mechanisms and competition with arginase for their common substrate,
the amino acid L-arginine. This competition is reflected in various vascular diseases, and particu-
larly in the endothelium of the umbilical vessels of babies with IUGR. Along with this, there is
regulation at the epigenetic level, where methylation in specific regions of some gene promoters,
such as the nitric oxide synthase, regulates their expression (Casanello et al. 2016). The concept
that a pregnant mother suffering nutritional insults has mechanisms in place for in utero epigenetic
changes, preparing the newborn infant for an environment of nutritional deficiency, is being vali-
dated in numerous studies in both animals and humans.
Whereas many of the earlier studies had assumed that single-nucleotide polymorphisms (SNPs)
were the main source of human genetic variability, an increasing body of evidence now suggests
the importance of additional layers of variability, including copy number polymorphisms and epi-
genetic regulation, such as DNA methylation. Epigenetics is just beginning to reveal its possible
implications in nutrition.
As diet is the most prominent lifelong environmental impact on human health and as, with pro-
longing life span and changing lifestyle in developed countries, chronic diseases become more prev-
alent, nutrigenomics and nutrigenetics are key scientific platforms to promote health and prevent
disease through nutrition that better meets the requirements and constraints of consumer groups
with specific health conditions and particular lifestyles, and in certain stages of life.
17.6 GENE–NUTRIENT INTERACTIONS IN CANCER AND AGING

Since aging is the primary risk factor for the development of cancer, it is worthwhile to examine
the epigenetics of the regulation of cellular proliferation and cell death, as well as the epigenetics
of aging, as common gene–nutrient interactions affect both processes. Nutrition can influence gene
expression through epigenetics in cancer and aging. Over half of the gene defects that occur in
cancer are due to epigenetic alterations rather than genetic mutations, and aging is associated with
changes in methylation, as described below (Issa 1999). These acquired changes in gene expression
can be influenced by changes in dietary intake, including both total calories and phytonutrients that
have epigenetic effects.
General DNA hypomethylation has been described in cells, in addition to gene-specific hyper-
methylation, often leading the uncovering of gene expression leading to uncontrolled cell growth
and neoplasia (Baylin et al. 1998). It is thought that these changes in DNA methylation play an early
role in cancer genesis and lead to aberrations in cellular proliferation, as well as immortalization of
previously normal cells.
Population studies demonstrate an association between green tea consumption and the inhibi-
tion of numerous cancers (Kim et al. 2010; Chen et al. 2011; Shanmugam et al. 2011). Among the
antioxidants in green tea called catechins, the most widely studied is (−)-epigallocatechin-3-gallate
(EGCG). Although EGCG has many effects on cells, it can inhibit DNA methyltransferase activity
by directly interacting with the enzyme (Fang et al. 2003).
Another key dietary component that has epigenetic effects is SFN of cruciferous vegetables such
as broccoli, cauliflower, brussels sprouts, cabbage, and kale. We have already discussed the role of
glucosinolates in inducing metabolic enzymes in the liver and other tissues with detoxifying activi-
ties. In addition, SFN can inhibit DNMT (Meeran et al. 2010b), and can also inhibit HDAC activity
(Myzak et al. 2007; Dashwood and Ho 2008; Schwab et al. 2008; Nian et al. 2009).
Curcumin (turmeric), resveratrol (grapes and red wine), and genistein (soybeans), as well as
many other phytonutrients, have also been demonstrated to have epigenetic effects, suggesting that
a general phenomenon of phytonutrients may be regulation of gene expression (Meeran et al. 2010a).
Changes in DNA methylation during aging likely contribute to a number of changes in the regu-
lation of epigenetically controlled genes such as hTERT, which affects telomerase and can contrib-
ute to the aging process (Liu et al. 2003). Aging is associated with general hypomethylation of the
genome, as well as regional or gene-specific hypermethylation (Issa 1999; Liu et al. 2003), which
may be due to changes in the expression of the DNMTs (Lopatina et al. 2002; Casillas et al. 2003).
Histone modifications are also involved in the aging process. Sirtuin 1 (SIRT1) is a class II
NAD+-dependent HDAC that has been demonstrated to increase the life span of a diverse range of
animal models (Cohen et al. 2004; Kanfi et al. 2008). The SIRT1 enzyme appears to be an impor-
tant nutrient sensor linked to metabolic rate. The redox potential, simplified as the NAD/NADH
ratio, may be important in regulating SIRT1 activity, which is a key indicator for oxygen consump-
tion and the respiratory chain. Although many other epigenetic changes occur during the aging
process, the regulation of DNA methylation and histone modifications, as well as epigenetic control
of hTERT and the role of SIRT1 in modulating aging biological processes, appear to be central to
the nutrient modulation of the aging process.
Caloric restriction with constant protein intake in rodents has been shown to increase life span,
and in multiple species, caloric restriction extends life span through multiple mechanisms, includ-
ing epigenetic mechanisms (Weindruch et al. 1986; Sinclair 2005). In his original experiments at
UCLA, working in the laboratory of Roy Walford, Richard Weindruch restricted calories at a set
level below those of ad libitum-fed animals but kept protein constant (Weindruch et al. 1986).
Protein restriction affects the lean body mass of rodents, including their tail, which is made of col-
lagen. Therefore, Weindruch and coworkers wanted to control for differences in organ size in exam-
ining longevity. It turned out that the protein provided was a constant 30% of total energy intake
(personal communication), which is very close to the 29% of resting energy expenditure in humans
resulting from 1 g of protein/pound of lean body mass used in our obesity treatment regimens. The
restriction of total calories by 25–60% relative to normally fed controls while providing essential
nutrients and protein can lead to a 50% increase in life span (Holloszy and Fontana 2007; Colman
et al. 2009; Cruzen and Colman 2009; Li and Tollefsbol 2011).
The life extension effects of sirtuins were originally discovered in yeast (Guarente and Picard
2005), and activation of SIRT1 is often observed in various tissues of animals subjected to caloric
restriction, while inactivation of SIRT1 may lead to ablation of the life span-extending effects of
caloric restriction. It is therefore apparent that epigenetic processes are not only central to the aging
process, but also involved with key mediators of aging, such as DNA methylation and SIRT1.
17.7 GENOME-WIDE SCANNING AND DISEASE RISK

By scanning the genomes of thousands of people and comparing the sick with the healthy, markers
for DNA sequences are being discovered that are believed to increase the risk of type 2 diabetes,
cancer, heart disease, inflammatory bowel disease, and other common chronic diseases of aging.
Genome-wide association studies derive their power from the Human Genome Project, which identi-
fied the complete genome of a few individuals. More recently, a haplotype map project has begun to
catalog human genetic variation by grouping together those genetic variations that are associated in
function across different ethnic groups. The research has been made possible by the much reduced
cost of gene scanning and by efficient gene chip technologies, available only in the past few years.
In the past, geneticists focused only on single genes with marked effects on disease risk. They
would examine a large family where a number of individuals have been afflicted with some rare dis-
ease. Typical examples include cystic fibrosis, Huntington’s disease, and inherited forms of cancer.
By tracking a small number of genetic markers that were linked to a rare disease in such families,
researchers successfully isolated rare genes that caused disease.
For example, the gene variants BRCA1 and BRCA2 have been shown to increase breast cancer
risk significantly. The lifetime risk of cancer associated with these rare variants is about 85–90%,
leading women to elect to have a prophylactic mastectomy if they are found to have these genes.
Other gene discoveries often led to insights into the pathway causing the disease, but had the draw-
back that only a small percent of common diseases, such as breast cancer, could be attributed to
these rare gene defects. At most, inherited forms of colon, prostate, and breast cancer account for
10–15% of all cases. Family studies such as these lacked the power to pick up genetic variants that
have a modest effect or that may interact with environmental exposures.
An alternative to traditional linkage studies is to search for “candidate genes” known to play a
role in some biologic process, such as insulin production. Looking for associations between muta-
tions in these candidates and common diseases has been going on for the past several decades.
Hundreds of studies have reported such associations. But few have been reproduced more than once
or twice.
Rather than work with a few thousand genomic markers, genome-wide association studies use
gene chips that can scan an individual’s DNA sample for anywhere from 100,000 to 500,000 or
more single-base changes. Known as SNPs, these changes are selected to reflect patterns of com-
mon genetic diversity. Such high SNP density makes it much easier to detect potentially significant
DNA changes. The studies can be done on tens of thousands of individuals as well, since the cost
of using such chips has dropped in the past few years. By compiling the SNPs from every DNA
sample in a database, and comparing the SNPs in heart attack patients with those in healthy people,
it is possible to discern even subtle genetic signals that contribute to heart disease risk. However,
the SNPs identified in these studies may not directly be involved in the cause of the disease, but are
simply located in or near the problematic DNA.
With the exception of macular degeneration in Table 17.1, where the gene variant raises disease
risk about two to three times in those with one copy, most of the genes found so far increase disease
TABLE 17.1
Selected Genome-Wide Scan Results
Disease Publication Date Sample Size Gene or Variant Approximate Risk
Macular degeneration 2005 1,700 1 new gene 400–600%
Inflammatory bowel 2006 4,500 1 new gene 120%
disease
Prostate cancer 2007 17,500 2 variants in the 123%
same region (1 new)
Obesity 2007 38,700 1 new gene 67%
Type 2 diabetes 2007 32,500 9 variants (3 new) 80%
Heart disease 2007 41,600 1 new variant 25–40%
Source: Couzin, J., and Kaiser, J., Science, 316, 820–822, 2007.
risk to a much lesser extent. Although a 50% increase may sound substantial, in absolute terms, it
is modest. For example, assume that a 65-year-old man’s prostate cancer risk is 3%. If he carries
two copies of the most potent prostate cancer gene found to date, this makes him 1.23 times more
likely to develop prostate cancer. In other words, his overall risk increases from 3% to about 3.7%.
17.8 THE MICROBIOME AND THE METAGENOME

Interest in the role of the microbiome in human health has burgeoned over the past decade, with
the advent of new technologies for interrogating complex microbial communities. The large-scale
dynamics of the microbiome can be described by many of the tools and observations used in the
study of population ecology. Deciphering the metagenome and its aggregate genetic information
can also be used to understand the functional properties of the microbial community. Both the
microbiome and metagenome probably have important functions in health and disease; their explo-
ration is a frontier in human genetics. However, at this point in the development of the research on
the interactions of the microbiome, the immune system, and the expression of genes involved in
chronic disease, there is too little information outside of gastrointestinal disorders to be of practical
use in clinical applications.
17.9 CASE STUDY OF CLINICAL APPLICATION IN PRIMARY

CARE OF GENE–NUTRIENT INTERACTIONS
There is no better example of the application and misapplication of medical genetics than familial
hypercholesterolemia (FH), already discussed extensively in Chapter 9.
The FH phenotype can be divided into heterozygous and homozygous FH, with a prevalence of
1 in 300–500 and 1 in 1 million, respectively (Hopkins et al. 2011). The clinical syndrome of het-
erozygous FH is characterized by elevated plasma LDL cholesterol concentrations and premature
coronary heart disease at ages 30–60. There is also a family history of heart disease and elevated
cholesterol levels, along with tendon xanthomas. This presentation of FH is usually due to a single
LDL receptor gene mutation; the very rare form of homozygous FH is caused by at least two LDLR
mutations and presents with much higher cholesterol levels and much earlier presentation of heart
disease, often in the twenties. LDL receptor mutations account for greater than 90% of the variants
of the FH phenotype.
LDL particle size has also been associated with increased heart disease risk. Increased levels
or percentage of small, dense LDL cholesterol has been correlated with increased future coronary
heart disease events in the ARIC study (Hoogeveen et al. 2014). It is proposed that these smaller
LDL particles contribute to the pathogenesis of atherosclerosis due to a higher LDL particle num-
ber, or because smaller LDL circulating particles can penetrate the endothelium more easily. The
finding of small, dense LDL has been related to increased markers of inflammation and the meta-
bolic syndrome, and the development of adverse lipid profiles (Siri-Tarino et al. 2009).
Polygenic hypercholesterolemia is characterized by the FH phenotype, but none of the classic
mutations that lead to heterozygous or homozygous FH. In a population study in the United Kingdom,
it was demonstrated that 40% of those with the FH phenotype had no mutations in the described genes
for LDL receptors, apolipoprotein B, or the enzyme PCSK9, which in the upregulated form degrades
LDL receptors, increasing plasma cholesterol (Taylor et al. 2010; Santos and Maranhao 2014).
Given these findings, some have proposed the concept that less potent but more common gene
variants across multiple genes may be playing a role in these cases (Teslovich et al. 2010). Based on
genome-wide association studies that utilize high-throughput genotyping techniques, many SNPs
have been found to have significant associations with elevated LDL cholesterol. It is thought that an
individual may carry multiple variants that work together to produce an FH-like phenotype. Some
investigators have proposed utilizing a polygenic or genotype score, which tallies SNPs from mul-
tiple LDL cholesterol-raising alleles, to use in risk assessment. In some studies, higher genotype
scores have been associated with increased heart disease events (Kathiresan et al. 2008; Talmud
et al. 2013; Santos and Maranhao 2014). Clearly, more research is needed to validate such genotype
scores, especially when considered in the context of the classic risk factors for heart disease, includ-
ing diabetes, hypertension, and visceral obesity.
Therefore, the genetics of hypercholesterolemia can be divided into two main groups. First is a
classic clear pattern of Mendelian inheritance, which requires pharmacological intervention or liver
transplantation for the homozygous condition. Second, and more commonly, there can be a presen-
tation where an inheritance pattern is not easily found. In these patients, there may be a collection
of gene variants that, together with traditional dietary and lifestyle factors, exert a compound effect
similar to that of the classic gene mutations of FH. If index cases are found and are highly sugges-
tive of FH on the basis of clinical criteria, genetic testing is not necessary to confirm a primary
mutation, but it may still be done, and cascade screening of relatives is recommended. Some studies
have shown the cost-effectiveness of the screening of relatives utilizing this approach (Marks et al.
2002; Ademi et al. 2014).
There is still controversy regarding universal screening of children for FH, with some believing
that early identification can lead to early treatment and, as a result, reduction in total “cholesterol
years.” However, the long-term effects of statin therapy and the thresholds for initiation of treatment
in young children are currently being debated. Groups such as the American Heart Association do not
endorse universal screening, but they do state that cholesterol testing should be considered in children
of parents with premature coronary heart disease and/or a history of elevated total cholesterol levels.
FH is an underdiagnosed condition worldwide, despite the fact that there are effective ways to treat
it and prevent long-term damage. The National Lipid Association guidelines stressed the need, in the
primary care setting, to identify FH on the basis of clinical criteria and cholesterol levels. These
guidelines noted that a negative genetic test does not exclude FH, because up to 20% of patients will
not be found to have a known mutation. Also, remember that the incidence of FH is 1 in 300–500
individuals, while the most common reason for elevated cholesterol levels is hypertriglyceridemia
as part of the metabolic syndrome, occurring in about half of middle-aged populations. The lipids
within very low-density lipoprotein particles, which carry triglycerides, are 20% cholesterol. Finally,
beyond the effects of lifestyle change on cholesterol levels, normalization of excess body fat results
can reverse the atherogenic lipid particle profile consisting of small, dense LDL particles.
17.10 SUMMARY
Personalized medicine based on gene–nutrient interaction is not ready for prime time. It is a futur-
istic concept promoted through the growing knowledge of genomics. Realistically, achieving this
vision will require a personalized behavioral approach, as well as changes in foods that are eaten
and exercises designed to maintain lean body mass. In the future, genomic information, including
proteomics and genome-wide scanning, may be used to understand the basis of individual differ-
ences in response to dietary patterns, as well as the interaction of the human genome, the proteome,
and the microbiome. The resulting nutrigenomic data have the potential to provide a sound basis for
the development of safe and effective diet therapies for individuals or subgroups of the population.
Another aspect of the future understanding of gene–nutrient interactions will be refined models
of disease mechanisms based on understanding the genome. This understanding may provide new
lines of research and possibly new diet and lifestyle interventions. The elaboration of physical and
genetic linkage maps, combined with techniques to catalog massive databases of genetic informa-
tion, may uncover new genes and gene interactions that, together with diet and lifestyle, may influ-
ence disease progression or even prevent common chronic diseases of aging and slow the aging
process itself to maximize life span.
Who will do this? Public health officials will most likely continue to issue one-size-fits-all solu-
tions and will necessarily need to run these through the funnel of special interests, which distort
nutritional advice given to the public. The drug industry, while recognizing that nutrition may play
a role, will minimize the role of diet and lifestyle and use only general government guidelines in
patients given drugs to ameliorate conditions driven by diet and lifestyle, such as hypertension,
hyperlipidemia, and diabetes. Food processors marketing mainstream products will wait a long
time for the products to be created and the demand to be established. In the future, it will be primary
care physicians and allied health care professionals, such as fitness instructors, dietitians, and psy-
chologists armed with high-tech tools, who will catalyze lifestyle changes in those at risk of chronic
diseases associated with aging, as well as the aging process itself.
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18 Nutrition and the Risk of
Common Forms of Cancer
18.1 INTRODUCTION
While cancer is not the leading cause of death with aging, it is the most feared, with the possible
exception of dementia, which is a living death (Witte and Allen 2000). The public yearns for a cure
for cancer. However, cancer is not a single disease, and many different solutions to its many differ-
ent forms are needed. Cancer sometimes seems like a random killer of innocent people, but there
are established risk factors, such as smoking, diet, and lifestyle.
Smoking tobacco, which is now an accepted risk factor for lung cancer, was not recognized as
such even as recently as 70 or 80 years ago. In the 1940s and 1950s (Gardner and Brandt 2006),
doctors appeared in advertisements for cigarettes and even endorsed specific brands. In 1964, the
surgeon general’s warning on cigarettes and lung cancer emerged based on a combination of popu-
lation studies demonstrating an association and the work of basic scientists defining the pathways
of tobacco carcinogenesis, including animal studies where rodents smoked cigarettes (U.S. Public
Health Service 1964). Nonetheless, cigarette smoke was still rising over the slide projectors at major
scientific meetings, such as those held in Atlantic City by the Federation of Societies of Experimental
Biology in the 1970s. These scientific meetings included the most prominent medical experts in
the nation, including many who were aware of the cancer connection to tobacco. Nonetheless, an
equilibrium existed between the large tobacco companies aided by lobbies and their own select
scientists and the larger scientific community that advanced basic research to describe the mecha-
nisms of tobacco carcinogenesis at a cellular level. Extensive public health advertising, beginning
in California and combined with tobacco taxes, ultimately reduced smoking in California and in
many parts of the country, as these practices were applied nationally (Hu et al. 1995). The annual
U.S. per capita cigarette consumption among adults ≥18 years of age rose from virtually zero in the
early 1900s to more than 4000 during the 1960s, before declining to nearly 1700 in 2006, a level not
seen since 1935 (National Center for Chronic Disease Prevention and Health Promotion 2014). In
concert with this, there has been a significant decrease in the prevalence of squamous and small-cell
carcinoma since the 1990s, although less rapidly among females than males. Adenocarcinoma rates
decreased among males only through 2005, after which they then rose during 2006–2010 among
every racial, ethnic, and gender group (Lewis et al. 2014). Laws in many cities prohibit smoking in
restaurants and places of business. In airports, smokers are confined to glass-enclosed ventilated
rooms. Public health can work to decrease cancer risk at least for smoking. Despite this background,
tobacco products continue to be promoted globally. However, a final rule issued by the U.S. Food
and Drug Administration (FDA) in 2016 has made tobacco products subject to the Federal Food,
Drug, and Cosmetic Act, as amended by the Family Smoking Prevention and Tobacco Control Act,
so that there are finally restrictions on the sale and distribution of tobacco products and required
warning statements for tobacco products (Food and Drug Administration 2016).
The challenge for relating nutrition to cancer risk is much greater than for tobacco, which
has taken more than 80 years from scientific discovery to implementation of a rule by the FDA.
Nutrition-related cancer risks are more complex and require more carefully designed research. It
is easy do studies demonstrating a lack of effect of a single nutrient, such as fat, but it is difficult
to carry out comprehensive studies of dietary patterns. While you can encourage the public to stop
smoking, it is not possible to tell them to stop eating.
309
The idea that somehow diet and lifestyle could impact the collection of deadly diseases com-
prising cancer has for decades seemed unlikely to the oncology and general medical communi-
ties, which continue to this day to emphasize screening for prevention and early treatment as a
sort of prevention. In common with the diabetes and cardiology communities, only minimal atten-
tion is given to primary prevention through lifestyle change. Until the 1980s, the only government
guidelines on nutrition for cancer patients emphasized restoring lost body weight in patients with
advanced cancer and weight loss by recommending high-calorie foods and intravenous nutrition.
The idea of encouraging some cancer patients to lose weight was not even considered.
It was the rediscovery of the impact of obesity on cancer, which had first been identified in the
1930s, that spurned a renewal of research efforts on nutrition in animal models of breast cancer
and other obesity-associated cancers (Kritchevsky 1997). The prevalent view that high-fat diets
were the sole cause of obesity led to several large trials in breast cancer patients, including the
Women’s Health Initiative (Prentice et al. 2006) and the Women’s Intervention Nutrition Study
(Chlebowski et al. 1992), which concentrated on lowering dietary fat without addressing the other
causes of obesity, including refined carbohydrates, hidden sugar, and sedentary lifestyles. When
these studies were proposed, there was controversy on the use of federal funds for such “soft sci-
ence” coming from the biochemical nutrition community (Palmer 1986). When these expensive
clinical trials failed to show a benefit, a general cooling of interest in nutrition and cancer followed
at the National Institutes of Health and the National Cancer Institute. It was only the efforts of the
public through prominent donors and nonprofit foundations such as the Prostate Cancer Foundation
that kept dietary risk factors in the public eye (Lohse et al. 2016).
Primary care practices are conscious of the relation of obesity to type 2 diabetes, hypertension,
pulmonary diseases, and heart disease. However, there is still a lack of understanding among many
of the impact of obesity, poor-quality diets, and sedentary lifestyle on the risk of common forms
of cancer. In this chapter, we review those risk factors and their impact on cancer, emphasizing not
only weight management but also the role of phytonutrients from colorful fruits and vegetables and
spices, which are also part of the solution to the obesity epidemic.
18.2 NUTRITION AND PHYSICAL ACTIVITY AS RISK FACTORS

Nutrition and physical activity are the most modifiable risk factors for the prevention of common
forms of cancer other than smoking cessation (Lohse et al. 2016). Around the world, an estimated
11 million people are diagnosed each year with cancer, and nearly 7 million people are recorded as
dying from cancer. Projections for 2030 predict that these figures will double. Cancer is increasing
at rates faster than the increase in global population, in part due to the aging of the world’s popula-
tion (DeSantis et al. 2014).
As a result of the export of Western dietary habits and urbanization, obesity and cancer are
becoming more common in high-income but also in middle-income and low-income countries. The
global epidemic of obesity and the nutritional changes and sedentary lifestyles that cause obesity
are associated with dietary patterns that have characteristics likely to promote the development of
common forms of cancer, such as breast cancer and prostate cancer. The World Health Organization
noted some years ago that for the first time in human history, there are more overweight than under-
weight individuals in the world (Vandevijvere et al. 2015). As treatments for these cancers improved
and screening caught prostate and breast cancers at an earlier curable stage, a growing population
of cancer survivors developed. For those individuals where obesity was a risk factor for the develop-
ment of their cancer, they often ultimately die not of the cancer, but of complications of diabetes and
heart disease (Demark-Wahnefried et al. 2015).
Human diets have moved away from plant-based origins that dominated our food supply for
tens of thousands of years to a diet based on processed foods with greater amounts of sugar, fat,
and calories than ever consumed in human history, but also with a lack of antioxidant phytonutri-
ents, vitamins, and minerals that may help to prevent common forms of cancer. Processed snack
Nutrition and the Risk of Common Forms of Cancer 311
foods and soft drinks became ever present in American diets over the last 50 years through the
efforts of the media and advertisers encouraging people to eat when they are not hungry. It is clear
that some methods of food production, processing, preservation, and preparation influence the
development of some cancers. The consumption of colorful antioxidant-rich fruits and vegetables,
and spices is associated with a reduced incidence of cancer, and only recently have these habits
received more attention from segments of the public. Nonetheless, 80% of Americans fail to eat
the five to nine servings of fruits and vegetables recommended by the National Cancer Institute
(Sangita et al. 2013).
Evidence has also been developed that physical activity and resulting changes in body compo-
sition can impact the risk of a number of cancers, suggesting that bioenergetics is another factor
determining cancer risk and tumor development (Hoffman 2016). As far back as the 1970s, evidence
began to develop that obesity and excess body fat through effects of hormones could increase the
risk of common forms of cancer, most notably breast, prostate, and colon cancer (Lipsett 1975).
Since obesity measured by body mass index (BMI) is a surrogate for increased body fat, the
impact of diet and lifestyle on body composition and fat distribution were linked to increased risks
of cancer. In this regard, visceral fat emerged as the key element in mediating the increased risks
associated with obesity through its association with the secretion of inflammatory cytokines called
adipokines (Moran Pascual et al. 2016). Common forms of cancer are age-related chronic diseases
that share some pathogenic mechanisms, including oxidant stress and inflammation with heart dis-
ease and diabetes. This realization was a departure from the view that cancer was strictly a disease
of the genome that could only be affected by pharmacological intervention. The realization that
nutrition affects gene expression through epigenetics and immune function through the microbiome
has breathed new energy into nutrition and cancer research.
The evidence that diet and lifestyle are risk factors for common forms of cancer has developed
over decades from a combination of observational studies in populations, extensive studies in exper-
imental model systems including animals, and a limited number of human intervention studies. Due
to the interactive effects of multiple components of the Western diet pattern, studies of nutrition and
cancer prevention are more complex than studies examining smoking and cancer. From 1991 until
2006, our group at the University of California, Los Angeles (UCLA) was fortunate to be one of
only two National Cancer Institute-funded clinical nutrition research units in the nation charged to
promote interdisciplinary research, education, training, and public awareness of the relationships
of nutrition to cancer development. This center grant fostered research on nutrition and common
forms of cancer through government and private foundation funding that led to some of the earliest
published research on nutrition intervention in prostate cancer (Li et al. 2008). The evolution of our
understanding of the impact of obesity and phytonutrients was developed through many other stud-
ies in our laboratories and others, including some of the first studies of the effects of pomegranate
juice polyphenols in prostate cancer in both animal models and humans (Pantuck et al. 2015).
18.3 RISK FACTORS VERSUS STATISTICAL BAD LUCK AND CANCER RISK

Many patients, medical oncologists, and primary care providers simply view cancer as “bad luck,”
which supposes that nutrition and physical activity have little relationship to cancer risk. If this were
true, then eating as much of anything that tastes good, regardless of fat, sugar, or salt content, and
remaining sedentary would be justified in terms of cancer risk reduction.
A controversial paper by two esteemed scientists in a high-impact, widely read, and credible sci-
entific journal demonstrated a statistical correlation between the number of stem cell divisions in an
organ and the lifetime cancer risk in that organ. They argued that diet and lifestyle played a lesser
role in cancer than mutations to DNA in dividing stem cells (Tomasetti and Vogelstein 2015). Stem
cells are renewing cells, and their number differs in different tissues. The idea that random muta-
tions in the DNA of dividing stem cells is the cause of the majority of age-related cancers has been
interpreted to indicate that environmental and hereditary factors combined explain only one-third
of cancers and deserve less emphasis (Witte and Allen 2000). However, this argument is method-
ologically flawed and has been widely criticized on technical bases too esoteric to repeat here. In
summary, these counterarguments point out that the pool of dividing stem cells is the substrate
on which risk factors act, and so risk factors deserve attention. Risk factors and proliferation rates
are not independent, but interact to increase cancer risk (Coleman et al. 2010; Gotay et al. 2015;
O’Callaghan 2015; Potter and Prentice 2015; Song and Giovannucci 2015; Weinberg and Zaykin
2015; Wild et al. 2015).
The cancers illustrated to represent lifetime risk as the result of mutations in dividing stems cell
are all susceptible to risk factors common in the United States, including obesity, physical inactivity,
tobacco, alcohol, diet, and infectious agents. There is little evidence that a cancer would exceed a
substantial rate, greater than a 1% lifetime risk, in the absence of an important risk factor. In organs
with low stem cell divisions, the lifetime cancer risk will typically be very low. The major types and
most abundant cancers arise from tissues that have relatively high stem cell division rates and a high
prevalence of strong relevant risk factors. The exception to this rule is prostate cancer, which has a
small stem cell population that divides slowly.
There are many known risk factors (Table 18.1) that can influence cancer incidence, including
age, gender, overweight and obesity, ethnic origin, geographic location, susceptibility genes modi-
fied by diet and lifestyle, and exposure to carcinogens, including chemical, physical, and infectious
viruses or bacteria. For breast cancer, age at menarche, parity, hormonal status, and lactation are
important risk factors likely mediated through effects of reproductive hormones, but also signifi-
cantly modified by nutrition and obesity.
At autopsy, approximately 40% of women between 40 and 49 years of age have occult breast
cancers (Nielsen et al. 1987), yet breast cancer is diagnosed in only 2% of women of this age.
Similarly, prostate cancer has been found in 24% of men age 60–70 years (Sanchez-Chapado et
al. 2003) yet is diagnosed in only 8% of these men. By age 90, it is estimated that 80–90% of
men will have pathologically detectable but clinically undetectable prostate cancer. At surgery for
prostatectomy, 98% of prostate glands have evidence of inflammation pathologically, as well as the
frequent occurrence of a precancerous pathology called proliferative inflammatory neoplasia (PIN).
In women with breast cancer, the precancerous form is called ductal carcinoma in situ (DCIS). It
is also estimated that microscopic thyroid cancers are present in 98% of individuals by the age of
70 years (Harach et al. 1985; Black and Welch 1993), yet these cancers become clinically significant
in less than 0.5% of these individuals. Pathologists have renamed some indolent thyroid cancers
as hyperproliferative conditions rather than cancer. These clinically indolent, microscopic foci of
cancers are likely due to the inability of the tumor itself to trigger angiogenesis, tumor-promoting
inflammation, and suppression of immune surveillance (Albini et al. 2012) within the tumor micro-
environment (Albini and Sporn 2007; Hanahan and Weinberg 2011). It is often difficult to identify
TABLE 18.1
Risk Factors
Unmodifiable Risk Factors Modifiable Risk Factors Treatable Risk Factors
Age Tobacco Chronic inflammation
Genetics Overweight and obesity Viral infections
Hereditary and mutations Diet quality Bacterial infections
Gender Physical activity Diabetes
Ethnicity Exposure to carcinogens Irradiation
Family history Alcohol Hormonal status
Geographic location Lactation
Source: Adapted from Albini, A. et al., J. Natl. Cancer Inst., 107(10), 2015.
patients with precancerous lesions in adequate numbers to perform nutrition intervention studies,
and often such patients have surgery or other forms of therapy to rid themselves of such lesions and
would not participate in nutrition trials in any case. Given these difficulties, much information on
nutritional risk factors comes from epidemiology and basic research rather than clinical trials.
Tumorigenesis describes the process that occurs in the period between the original mutation of
DNA and when a tumor is formed (Figure 18.1). A mutation of nuclear DNA that is acquired or
inherited is the transformation of a normal cell into a precancerous cell. From there to the develop-
ment of a clinically detectable tumor from these transformed cells requires growth promotion to
a detectable size and the development of a blood supply to feed the tumor through the process of
angiogenesis, which is stimulated by inflammation.
However, the tumor microenvironment is also an integral, essential part of tumorigenesis (Figure
18.2). In fact, the microenvironment often mediates and amplifies the influence of nutritional and
Genetic alterations; clinical

Increase in cell growth and manifestation;
decrease in apoptosis loss of growth control
Initiation Promotion Progression
FIGURE 18.1 (See color insert.) Tumorigenesis is a multistep process initiated with mutation of genes that
control cell cycle, cell differentiation, apoptosis, and DNA repair. Once the cancer stem cells are established,
the tumor mass grows as angiogenesis provides the critical blood supply to the tumor. Once the tumor mass is
clinically detected, the phase of progression leading to metastasis begins. The typical tumor develops over a
window of 10–15 years, providing an opportunity for prevention prior to the formation of a clinically detect-
able tumor. Overexpression of oncogenes and failure of expression of tumor suppressor genes in tumor cells
have been implicated in this process.
The reductionist view A heterotypic cell biology

Cancer cells Cancer cells Fibroblasts
Immune cells
Endothelial cells
FIGURE 18.2 (See color insert.) Much research is done on isolated cancer cells in culture, but the tumor
microenvironment is complex and may mediate effects of bioactive substances not found in pure cell culture.
Nutrition may impact tumor growth by inhibiting angiogenesis or altering immune function. (Reprinted from
Hanahan, D., and Weinberg, R. A., Cell, 100(1), 57–70, 2000.)
environmental risk factors. Therefore, it is necessary to consider not just the biology of the cancer
cell but also the influence of the surrounding tumor microenvironment. The stromal, inflammatory,
and endothelial cells have crucial roles in the developing tumor and might account for different
tumor risk even in the presence of the same amount of dividing stem cells (Baker 2015). Chronic
inflammation is linked to carcinogenesis (de Visser et al. 2006; Noonan et al. 2008). Immune, endo-
thelial, and stromal cells in the microenvironment that normally maintain homeostasis can act to
promote transformed cell survival and replication. The microenvironment can be a primary factor
in determining whether stem cells after a transformation event will continue to grow and become
a cancer or remain as a microhyperplasia or even be cleared by the immune system. Epigenetics,
which defines changes due to methylation or histone acetylation affecting gene expression while
the DNA base sequence remains constant, can be modified by nutritional factors. Epigenetics also
appears to play a key role in permitting a mutated cell to become a tumor or remain in an indolent
state (Burgio and Migliore 2015). Therefore, bad luck may be prevented by protecting the tumor
microenvironment, curbing inflammation, or stimulating antitumor adaptive immune responses, as
can be seen from the recent success of immune blockade anticancer drugs (Pardoll 2012).
The health impact of cancers is related to mortality rather than incidence, and the cancer survi-
vor population is increasing as the result of improved screening, prevention, and treatment. Certain
common tumors, such as basal cell carcinoma, have very high survival rates. Among 300,000 men
diagnosed with prostate cancer, only 10% will die of the disease, while most will die of heart
disease and other age-related chronic diseases. So, a key insight is that the risk factors promoting
cancer need to be addressed even after diagnosis and treatment, as they may affect survival and,
in some instances, tumor cell behavior and clinical recurrence. Proving the latter in clinical trials
is a challenge that will require significant amounts of clinical research. Pancreatic carcinomas are
diagnosed very late in their course and are often rapidly fatal, but there are some common risk fac-
tors for pancreatic cancer that have been identified that could be applied earlier as better surrogate
biomarkers for prostate cancer are identified. Only 10–15% of cancers are due to inherited suscepti-
bility genes by most estimates, suggesting that diet and environment influence clinical cancer, even
though it is difficult to demonstrate that influence.
It is important to determine whether a cancer is present, but it is even more important to deter-
mine whether and when it will become clinically meaningful to the patient. Some individuals
leading a healthy lifestyle will still be diagnosed with cancer because of bad luck, but on the aver-
age, they will be diagnosed less frequently with common cancers than those leading an unhealthy
lifestyle or those exposed to known carcinogens. Therefore, efforts to address modifiable risk
factors, including those involving diet and physical activity, are worth addressing in primary care
practice.
18.3.1 Obesity and Cancer

Among the risk factors for cancer, overweight and obesity are prominently listed. Obesity is asso-
ciated with increased risks of common forms of cancer, including postmenopausal breast cancer,
advanced prostate cancer, colorectal cancer, endometrial cancer, kidney cancer, liver cancer, gall-
bladder cancer, and esophageal cancer. National Cancer Institute Surveillance, Epidemiology, and
End Results (SEER) data estimated that in 2007 in the United States, about 34,000 new cases of
cancer in men (4%) and 50,500 in women (7%) were due to obesity. The percentage of cases attrib-
uted to obesity varied widely for different cancer types, but was as high as 40% for some cancers,
particularly endometrial cancer and esophageal adenocarcinoma. By 2030, assuming continuation
of existing trends in obesity, there will be about 500,000 additional cases of cancer in the United
States attributable to obesity. This analysis also found that if every adult reduced their BMI by 1%,
which would be equivalent to a weight loss of roughly 1 kg, or 2.2 pounds, for an adult of average
weight, this would prevent the increase in the number of cancer cases due to obesity and actually
result in a reduction in cancer incidence of about 100,000 new cases per year. While these statistical
estimates are only approximate and lifestyle changes should clearly result in more than a 1 kg
weight loss, this calculation indicates the importance of weight management in cancer control.
The BMI associations with common forms of cancer may only be the tip of the iceberg for two
reasons (IARC Working Group on the Evaluation of Carcinogenic Risks to Humans 2010). First,
there are major ethnic differences in the correlation of BMI and visceral fat, especially among
Asians and South Asians. In the normal BMI range of 20–25 kg/m2, men and women in Asia have
been found to have an increased risk of type 2 diabetes, which is related to increased visceral fat.
Using MRI, studies in London found that 45% of women and 60% of men had excess visceral fat at
normal BMI and normal waist circumference. Obesity in association with Western diets also has a
number of other characteristics beyond simply excess energy. These include excess fat, sugar, and
salt intake in processed foods, together with inadequate fiber intake and intakes of fruits and veg-
etables of only two to three servings per day, resulting in suboptimal consumption of antioxidant
phytonutrients.
It is the multiple mechanisms integrated within a poor-quality diet and a sedentary lifestyle that
combine to make obesity the nutritional risk factor most strongly associated with an increased risk
of cancer, excluding nutritional toxins such as aflatoxin from moldy nuts and grains. Studies of indi-
vidual nutrients, such as fat and sugar, studied in isolation have been disappointing. Human fat cells
contain the enzyme aromatase, which converts adrenal androgens into estrogens. For postmeno-
pausal women, the fat is the primary source of estrogen, and numerous studies have established
that obese women have increased production of estrogen and increased blood levels of estrogens.
Uterine cancer and breast cancer are known to be estrogen responsive, so increased estrogen from
excess body fat is considered a risk factor for postmenopausal breast cancer. Excess body fat is also
associated with increased levels of insulin and insulin-like growth factor 1 (IGF-1) due to insulin
resistance. IGF-1 in experimental models increases the growth of a number of different cancers,
including breast and prostate cancer. Fat cells also produce pro-inflammatory cytokines called adi-
pokines that can stimulate tumor cell growth. Excess abdominal visceral fat causes a chronic low-
level inflammation, which has been associated with increased cancer risk as well.
18.3.2 Alcohol
According to the National Institute on Alcohol Abuse and Alcoholism, an alcoholic drink in the
United States contains 14 g of pure alcohol or ethanol. Generally, this amount of pure alcohol is
found in 12 ounces of beer, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof
liquor. The federal government’s dietary guidelines define moderate alcohol drinking as up to one
drink per day for women and up to two drinks per day for men. Heavy alcohol drinking is defined as
having more than three drinks on any day or more than seven drinks per week for women, and more
than four drinks on any day or more than 14 drinks per week for men. Alcohol is not calorie-free
and contributes to obesity. A typical beer is 220 calories, and a light beer has about 110 calories/
12 ounces. Wine has about 90 calories/5 ounce serving, and this is about the same number of calories
as 1.5 ounces of hard liquor. In addition to the calories associated with alcohol, drinking excessive
amounts of alcohol can lower the ability to control overall calorie intake at a meal.
Based on extensive research, there is a scientific consensus for a connection between alcohol
consumption and several types of cancer (IARC Working Group on the Evaluation of Carcinogenic
Risks to Humans 2010, 2012). The National Toxicology Program of the U.S. Department of Health
and Human Services lists consumption of alcoholic beverages as a known human carcinogen. The
research evidence indicates that both the amount of alcohol consumed and the number of years
of regular alcohol consumption contribute to the risk of developing an alcohol-associated cancer.
Based on data from 2009, an estimated 3.5% of all cancer deaths in the United States (about 19,500
deaths) were alcohol related (Nelson et al. 2013).
Clear patterns have emerged between alcohol consumption and a number of common forms of
cancer. People who consume 50 g or more of alcohol per day, which is about 3½ or more drinks
per day, have a two to three times greater risk of developing cancer of the head and neck, including
the mouth, pharynx, and larynx, than nondrinkers (Baan et al. 2007). Moreover, the risks of these
cancers are substantially higher among persons who consume this amount of alcohol and also use
tobacco (Hashibe et al. 2009). Alcohol consumption is a major risk factor for esophageal squamous
cell carcinoma (IARC Working Group on the Evaluation of Carcinogenic Risks to Humans 2012).
In addition, people who inherit a deficiency in an enzyme that metabolizes alcohol have been found
to have substantially increased risks of alcohol-related esophageal squamous cell carcinoma.
There are a number of other forms of cancer where alcohol consumption increases risk. Alcohol
consumption is an independent risk factor for, and a primary cause of, liver cancer (Grewal and
Viswanathen 2012). Population studies have demonstrated the association between alcohol con-
sumption and the risk of breast cancer in women. These studies have consistently found increased
risks of breast cancer associated with increasing alcohol intake. A meta-analysis of numerous stud-
ies, including 58,000 women with breast cancer, estimated that women who drank more than 45 g
of alcohol/day, or about three drinks, had a 50% greater risk of developing breast cancer than
nondrinkers (Hamajima et al. 2002). The Million Women Study in the United Kingdom, including
more than 28,000 women with breast cancer, estimated that for every 10 g of alcohol consumed per
day, there was a 12% increase in the risk of breast cancer (Allen et al. 2009). Alcohol consumption
is associated with a modestly increased risk of colorectal cancer (Fedirko et al. 2011).
18.4 PHYTONUTRIENTS FROM FRUITS, VEGETABLES, AND SPICES

Phytonutrients are sometimes called phytochemicals, because some scientists focus on the potential
toxicity of these compounds. In the amounts found in fruits, vegetables, and culinary spices, there
are no toxic effects demonstrated. These compounds are aggressively metabolized by the same
enzymes in the liver that detoxify drugs, and increased amounts in a reasonable range induce more
enzyme activity for the metabolism and excretion of phytonutrients. These compounds are naturally
found in fruits, vegetables, grains, and other plant products and are often responsible for distinct
plant characteristics, such as color pigmentation and smell.
Basic studies have revealed that these compounds are able to affect cell proliferation and cell
cycle regulation, and usually participate in multiple signaling pathways, which are often disrupted
in tumor initiation, proliferation, and propagation (Surh 2003; Murakami 2009; Lee et al. 2011;
Priyadarsini and Nagini 2012; Howes and Simmonds 2014). Although prior observations have
resulted in many successful preclinical studies, only a limited number of clinical trials have been
carried out (Surh 2003). Many of the investigators have attributed an inability to detect preventive
effects to the variable bioavailability and distribution of compounds, and that the appreciable risk
reduction may take several years to detect in large population studies. As global cancer incidence
continues to rise, understanding the impact of these dietary modifications may fuel simple and inex-
pensive ways to improve health worldwide.
Clearly, eating more fruits and vegetables is an aspect of effective lifestyle modification for
weight management while also providing phytonutrients and increasing the antioxidant and anti-
inflammatory properties of the diet by comparison with diets not containing fruits, vegetables, and
spices. One effective tool for educating patients on ways to enhance their intake of a variety of phy-
tonutrients is to point out that the colors of fruits and vegetables represent families of phytonutrients
(Heber and Bowerman 2001).
18.5 ANTIOXIDANT SUPPLEMENTS
Oxidative stress reflects an imbalance between the production of reactive oxygen species (ROS) and
an adequate antioxidant defense. Due to the unchecked dramatic cell proliferation of cancer cells,
higher amounts of ROS are produced with increased proliferation and a low level of intracellular
oxidants have been shown to stimulate cancer cell proliferation (Palozza et al. 2010; Lee et al. 2011;
Ono et al. 2015; Tong et al. 2015). Numerous endogenous antioxidants are produced in the body
to help neutralize ROS, and external sources of antioxidants from fruits, vegetables, and spices
may also contribute to antioxidant defense, especially with aging, as endogenous oxidant stress is
increased (Chlebowski et al. 1992; Tokarz and Blasiak 2014).
Since dietary interventions are more difficult and expensive, the first attempts to demonstrate
the effects of antioxidant phytonutrients were carried out with dietary supplements. Lycopene;
β-carotene; vitamins A, C, and E; selenium; and other purified micronutrients outside their nor-
mal food matrix have been broadly studied in humans for preventing common forms of cancer.
Preclinical studies have shown that antioxidants are capable of preventing cellular damage induced
by free ROS, suggesting that cancer development may be slowed in the setting of increased levels of
dietary exogenous or endogenous antioxidant supplements (Glasauer and Chandel 2014; Key et al.
2015). However, these studies and the clinical trials on which they are based could not duplicate the
food matrix and dietary patterns where these phytonutrients are found. Therefore, it is not surpris-
ing that many did not demonstrate preventive effects. The early so-called negative results of these
studies have been used to minimize the impact of nutrition in cancer prevention, but there is much
to be learned on how to conduct such studies in the future.
One of the most infamous early trials was the Carotene and Retinol Efficacy Trial (CARET),
which examined the effects of daily supplementation with β-carotene and retinol on the incidence of
lung cancer in smokers, and showed that both β-carotene (15 mg) and retinol (25,000 IU) daily sup-
plementation was associated with increased lung cancer and increased overall mortality (Albanes
et al. 1996; Ilic et al. 2011). Prior to the study, it was known that smoking affected the metabolism
of β-carotene, and the dose selection was partly based on the ability of the chromatographs at that
time to detect β-carotene. Furthermore, β-carotene in early population studies was often taken as
the biomarker of overall antioxidant intake, which is clearly a flawed concept. The adverse effects
in the CARET persisted up to 6 years after supplementation ended, as reported in an updated study,
with the caveat that the higher risk of lung cancer and all-cause mortality was no longer statistically
significant (Etminan et al. 2004; Goodman et al. 2004).
The Linxian trial showed that a combination of 15 mg of β-carotene, 30 mg of α-tocopherol, and
50 μg of selenium daily for 5 years initially showed a lower mortality risk from gastric cancer but
not esophageal cancer. The study also concluded that polyphenols did not affect the risk of develop-
ing either gastric or esophageal cancer (Blot et al. 1993; Abdull Razis and Noor 2013). A new report
10 years later analyzing those who took this antioxidant supplementation compared with placebo
failed to show a persistent reduced risk of mortality (Qiao et al. 2009; H. Wang et al. 2012).
Trials that have failed to show clinical significance of antioxidant therapy in cancer prevention
have been performed in a variety of other models. β-Carotene and/or α-tocopherol has failed to
show an effect on the incidence of lung cancer and other cancers, including urothelial, pancreatic,
colorectal, and digestive tract cancers (The Alpha-Tocopherol, Beta Carotene Cancer Prevention
Study Group 1994; Rautalahti et al. 1999; Virtamo et al. 2000; Wright et al. 2007; Mukherjee et al.
2008; Link et al. 2010; Mansuy 2011; X. Wang et al. 2012). Expanding this to other supplements
has also yielded mixed results. Clinical studies of α-tocopherol (400 IU) and/or vitamin C (500 mg)
in combination versus placebo did not reduce the incidence of prostate cancer or other cancers,
including lymphoma, leukemia, melanoma, lung, bladder, pancreas, or colorectal cancers, in male
U.S. physicians older than 50 years of age for a median of 7.6 years of follow-up (Gaziano et al.
2009; Wang et al. 2014). The authors also concluded after the trial that after a mean of 10.3 years of
follow-up, α-tocopherol and vitamin C supplementation had no immediate or long-term detectable
effects on the risk of total or site-specific cancers (Wang et al. 2014).
Differences in chemical composition of naturally occurring antioxidants in food compared
with those purified into supplements may contribute to the failure to see positive impacts of anti-
oxidant supplementation. Vitamin E is naturally found in eight different forms, called α-, β-, λ-,
and δ-tocopherols and -tocotrienols, in nature but are usually studied in supplements only as
α-tocopherol (Vance et al. 2013). In addition, studies in individuals without clinical cancer must be
carried out over very long periods of time to show an effect and suffer from the same problem as
antiaging studies in this regard.
18.5.1 Folic Acid
Preclinical studies have suggested that folate may have anticancer properties because of its role
in DNA repair and its role in modulating S-adenosylmethionine, a universal methyl donor group
for DNA methylation reactions. Therefore, several large-scale cross-sectional studies have shown
that dietary folate intake may be associated with a lower risk of several cancers, including lung,
breast, pancreatic, esophagus, stomach, and colorectal cancer (Lamprecht and Lipkin 2003; Tio
et al. 2014). Results from large prospective studies have shown that there is a near 25% risk reduction
in the risk of colorectal cancer in those with high folate intake compared with low intake. Recently,
a meta-analysis of 16 prospective and 26 case-control studies demonstrated that women with higher
daily dietary folate intake had a significant reduction in breast cancer risk compared with those with
lower folate intake. Interestingly, despite this effect, there was no significant association between
circulating folate levels and breast cancer risk (Chen et al. 2014).
18.5.2 Lycopene
Lycopene is a naturally occurring carotenoid found in many fruits and vegetables, with particularly
high concentration in tomatoes and tomato-based products (Shi and Le Maguer 2000; Kaefer and
Milner 2011). Lycopene localizes to the prostate gland and in preclinical studies lowers intracellular
generation of ROS by augmenting proteins involved in antioxidant reactions, including superoxide
dismutase-1 (SOD-1) and glutathione S-transferase Ω-1. Lycopene may also reduce oxidative stress
by downregulating expression of ROS-generating proteins (Palozza et al. 2010; Rubio et al. 2013).
Furthermore, lycopene has been shown to inhibit cell proliferation, induce apoptosis, and in prostate
cancer models, attenuate the metastatic capacity of cancer cells (Palozza et al. 2010; Gupta et al.
2013; Rubio et al. 2013; Ono et al. 2015).
Consistent with the above experimental data, epidemiological and observational studies have
linked increased consumption of lycopene-rich food with lower prostate cancer risks (Ilic et al.
2011; Butt et al. 2013; Chen et al. 2013; Fridlender et al. 2015; Key et al. 2015; Tyagi et al. 2015).
In a meta-analysis of 21 observational studies, both moderate and high lycopene-rich diets were
associated with lower prostate cancer incidence, 6% and 11%, respectively. Although the trend was
not statistically significant, it highlighted that single interventional randomized trials are required
to assess the true clinical effect (Etminan et al. 2004; Shehzad et al. 2010). A recent meta-analysis
of eight randomized clinical trials showed a minor, insignificant decrease in the incidence of
benign prostatic hyperplasia and prostate cancer patients compared with controls (Chen et al. 2013;
Fridlender et al. 2015).
18.5.3 Glucosinolates from Cruciferous Vegetables

Glucosinolates are a group of sulfur-containing glycosides that occur in some 450 species of plants,
but are primarily consumed from cruciferous vegetables such as broccoli, cabbage, brussels sprouts,
and cauliflower. Many epidemiological and basic research studies have revealed that the consump-
tion of cruciferous vegetables has substantial potential for the prevention of common forms of can-
cer (Abdull Razis and Noor 2013).
Glucosinolates and their derivatives, which include isothiocyanates, phenylethyl isothiocya-
nate, di-indolyl methane, and indole-3-carbinol, may modulate many relevant processes, such as
the induction of metabolic enzymes in the liver; inhibition of inflammatory processes; modula-
tion of cancer signaling pathways, including cellular proliferation; angiogenesis; the epithelial–
mesenchymal transition; cancer stem cell self-renewal; and suppression of diverse oncogenic
signaling pathways, including nuclear factor κB (NF-κB), hormone receptor, and the signal trans-
ducer and activator of transcription (Mukherjee et al. 2008; H. Wang et al. 2012; X. Wang et al.
2012). Glucosinolate derivatives have the potential to modulate epigenetic alterations, such as DNA
methylation, histone modifications, noncoding microRNAs (miRNAs), regulation of polycomb
group proteins, and epigenetic cofactor modifiers, all of which may contribute to carcinogenesis
(Link et al. 2010; H. Wang et al. 2012).
Dietary glucosinolates are hydrolyzed by a plant enzyme called myrosinase when the vegetable
is crushed, releasing the volatile metabolites, such as isothiocyanate. These compounds travel to
the liver and induce phase 2 detoxifying enzymes, including glutathione S-transferases and UDP
glucuronosyl transferases (UGTs). These enzymes in the liver catalyze conjugation reactions to
inactivate or detoxify exogenous carcinogens and endogenous compounds, including sex steroid
hormones related to cancer development (Mansuy 2011; Navarro et al. 2011; Boddupalli et al. 2012).
Indole glucosinolate hydrolysis products, such as di-indolyl methane and indole-3-carbinol, also
induce both phase 1 drug metabolic and phase 2 detoxifying enzymes by direct interaction with
aryl-hydrocarbon receptor (AhR) or increasing the binding affinity of AhR to xenobiotic response
elements (XREs) in target genes (Navarro et al. 2011).
Although there has been extensive research on dietary phytochemicals contributing to the overall
understanding of glucosinolate derivatives in terms of their chemical and biological functions and
beneficial effects in human health, clinical studies of human participants on the biological effects of
dietary glucosinolate are lacking and limited to determining the effects of raw cruciferous vegeta-
bles or their extracts under some biological parameters (Singh and Singh 2012; Fujioka et al. 2014).
In a pilot study supported by the UCLA National Cancer Institute-funded clinical nutrition
research unit in 1997, a case-control study was conducted of mainly asymptomatic subjects aged
50–74 years who underwent a screening sigmoidoscopy at either of two Southern California Kaiser
Permanente medical centers during 1991–1993 (Lin et al. 1998). A total of 459 individuals had
a first-time diagnosis of histologically confirmed adenomas detected by flexible sigmoidoscopy.
Another 507 patients seen at the same clinics had no polyps detected. Subjects had a 45-minute in-
person interview for information on various risk factors and basic demographic data and completed
a 126-item food frequency questionnaire. Blood samples were used for glutathione S-transferase
M1 (GSTM1) genotyping. In any normal population, approximately 50% of individuals have the
null mutation, meaning that the GSTM1 enzyme is not functional.
Subjects with the highest quartile of broccoli intake (an average of 3.7 servings per week) had an
odds ratio of 0.47 (95% confidence interval 0.30–0.73) for colorectal adenomas, compared with sub-
jects who reportedly never ate broccoli. When stratified by GSTM1 genotype, a protective effect of
broccoli was observed only among subjects with the GSTM1 null genotype (p for trend, 0.001; p for
interaction, 0.01). The observed broccoli–GSTM1 interaction is compatible with the isothiocyanate
mechanism described above. If a patient has a GSTM1 null mutation, meaning that the enzyme is
inactive, they actually obtain a greater preventive benefit by eating broccoli than individuals with a
functional enzyme. As the result of the absence of GSTM1 function, other glutathione S-transferases
are upregulated to a greater extent, providing a greater preventive benefit of consuming glucosino-
lates. This mechanism was demonstrated in a metabolic ward study where cruciferous vegetables
specifically upregulated a glutathione S-transferase in red blood cells (Lampe et al. 2000).
One clinical pearl is that many broccoli extracts are simply dried broccoli and have minimal
levels of glucosinolate, and they cannot be cleaved to active metabolites due to the absence of
myrosinase. Ongoing development of supplements with both glucosinolates and myrosinase is under
evaluation currently.
18.5.4 Green Tea Polyphenols

The tea plant (Camellia sinensis) is cultivated in more than 30 countries. Green, black, and oolong
teas are the most common varieties, all of which are derived from the leaves of the tea plant, but
differ according to their manufacturing processes (Mukhtar and Ahmad 2000; Katiyar et al. 2007).
Studies have shown that green tea possesses significant beneficial effects due to an abundance of
monomeric catechins or epicatechins, which include (−)-epicatechin (EC), (−)-epicatechin-3-gallate
(ECG), (−)-epigallocatechin (EGC), and (−)-epigallocatechin-3-gallate (EGCG) (Katiyar et al.
2007). Of these, EGCG is the major and most active ingredient of green tea polyphenols (GTPs) and
is shown to have potent anticancer activities in both in vitro and in vivo models (Meeran and Katiyar
2008; Nandakumar et al. 2011). In particular, EGCG has been shown to inhibit cellular prolifera-
tion and to induce apoptosis in many cancer cell types through multiple mechanisms (Ahmad et al.
2000; Baliga et al. 2005; Meeran et al. 2006). Several elegant studies have addressed the modes of
actions of various tea polyphenols, including EGCG, in cancers. Recent studies have suggested that
the anticancer activity of EGCG is mediated, at least in part, through its epigenetic effects on DNA
methylation and histone acetylation (Fang et al. 2003; Meeran et al. 2011; Nandakumar et al. 2011).
EGCG is involved in direct inhibition of DNA methylating enzymes by forming hydrogen bonds to
the active sites of the enzyme inhibiting substrate binding (Fang et al. 2003). Our group at UCLA
has demonstrated that green tea but not black tea inhibited markers of oxidation and localized to
the prostate gland when administered prior to prostatectomy (Henning et al. 2015). In preliminary
studies, our group has also shown that the combination of quercetin and green tea extract leads to
greater bioavailability of EGCG, as measured by plasma levels (P. Wang et al. 2012).
In a comprehensive study of many green teas, our group has found variations in the contents of
catechins. In general, catechins are safe at doses consumed in green tea beverages (Henning et al.
2003). There have been rare reports in Europe of hepatotoxicity with highly concentrated extracts
of green tea, where EGCG was concentrated far beyond the usual profile of catechins (Pillukat et al.
2014). In our research on prostate cancer patients prior to prostatectomy, we have used standardized
brewed green tea (Henning et al. 2015).
If you are planning to use or recommend a green tea supplement, it is wise to use a standard-
ized water- or alcohol-extracted green tea from a trusted supplement manufacturer or to drink tea
with known amounts of catechins. As with many dietary supplements, there is no standardization
required, as with drug preparations, which makes research on green tea in humans difficult.
18.6 SPICES
Spices have been consumed throughout the world as condiments for thousands of years because of
their flavor, taste, and color. Spices were also used as food preservatives and as medicinal plants
in folk medicine for the treatment of inflammation in various diseases. Some antioxidants from
spices, such as curcumin (turmeric), eugenol (clove), and capsaicin (red pepper), have been shown in
experimental model systems to control cellular oxidative stress due to their antioxidant properties
and their capacity to block the production of ROS and interfere with signal transduction pathways
(Kaefer and Milner 2011; Rubio et al. 2013). In addition, inflammatory mechanisms could be modu-
lated by spice compounds such as curcumin (Gupta et al. 2013; Tyagi et al. 2015). Both epidemio-
logical and experimental studies have demonstrated that certain spices could lower risks of some
forms of cancer (Butt et al. 2013; Fridlender et al. 2015). Among spices, curcumin is one that has
both basic and clinical research and will be reviewed below.
Curcumin, or turmeric (bis-α,β-unsaturated β-diketone), is a polyphenol derived from the roots
of the perennial Curcuma longa plant, and is a gold-colored spice widely used in Indian cooking,
textile dyes, and traditional Ayurvedic medicine (Shehzad et al. 2010). In recent decades, in vitro
models have shown that curcumin inhibits the growth of a variety of cell lines by inducing cell cycle
arrest and apoptosis, most importantly through pleiotropic modulation on several distinct cancer
targets, including NF-κB, cyclooxygenase-2 (COX-2), tumor necrosis factor α (TNF-α), STAT-3,
and cyclin D1 (Bar-Sela et al. 2010; Shehzad et al. 2010; Hasima and Aggarwal 2014; Bortel et al.
2015). Building on preclinical work, several phase 1 clinical trials have confirmed both the safety
and pharmacokinetics of curcumin in patients with doses escalated up to 8 g/day, and these trials
have shown measurable biological effects in patients with a variety of malignancies, including pan-
creatic cancer, multiple myeloma, and advanced colorectal cancer, refractory to standard chemo-
therapy (Sharma et al. 2001; Dhillon et al. 2008; Epelbaum et al. 2010; Yang et al. 2013).
Curcumin is preferentially distributed into the colonic mucosa compared with other tissues, lead-
ing many initial clinical studies to focus on identifying whether this compound may play a role in
colorectal cancer models (Bar-Sela et al. 2010). This hypothesis was tested in patients with famil-
ial adenomatous polyposis (FAP), an inherited condition that leads to unregulated development of
innumerable precancerous adenomatous growths throughout the colon, with eventual development
of colorectal cancer at a young age. In one study, patients were given a combination of curcumin
and quercetin (400/20 mg), a common flavonoid compound found in several supplements and foods.
Compared with baseline colonoscopies performed prior to initiation of treatment, all five patients
tested were found to have a decreased number of polyps and reduced polyp size after 6 months of
treatment without other laboratory abnormalities and minimal adverse effects (Cruz-Correa et al.
2006). Although this study was limited and used a combination of both curcumin and quercetin, it
raised awareness for future research testing the therapeutic potential of curcumin in precancerous
models (Cruz-Correa et al. 2006).
18.7 MICROBIOTA METABOLISM OF PHYTONUTRIENTS

AND IMMUNE FUNCTION
Polyphenols are metabolized by the gut microbiota into substances such as urolithin from pome-
granate juice and phenolic acid from green tea catechins. These smaller metabolites of phytonutri-
ents have anticancer properties in vitro and are an emerging area of research.
Pomegranate juice prepared by squeezing whole pomegranates contains a family of several
high-molecular-weight hydrolyzable tannins, including punicalagin and punicalin, called ella-
gitannins, which have potential as nontoxic chemopreventive dietary agents for prostate cancer
based on animal studies and some human observational studies in prostate cancer patients (Heber
2008). However, ellagitannins are not absorbed intact in the human gastrointestinal tract, but
are hydrolyzed, generating different metabolites, including ellagic acid, which appears in the
circulation between 30 minutes and 5 hours after consumption of pomegranate juice (Seeram
et al. 2008). Through the action of human colonic microflora, ellagic acid is then partially con-
verted into metabolites, including urolithin A. Both ellagic acid and urolithin A are absorbed,
transported in the blood, conjugated in the liver, and excreted in glucuronidated form in the
urine between 12 and 56 hours after pomegranate juice consumption (Cerda et al. 2005; Mertens-
Talcott et al. 2006).
In vitro and mouse studies have demonstrated that pomegranate ellagitannins inhibit tumor
angiogenesis (Sartippour et al. 2008), delay the transition from androgen-dependent to androgen-
independent phenotype, and induce apoptosis through a NF-κB-dependent mechanism in vitro and
in tumor tissue excised from castrated severe combined immunodeficiency mice with Los Angeles
prostate cancer–human prostate cancer xenografts (Rettig et al. 2008). Previous in vitro studies
have shown that pomegranate metabolites, ellagic acid and urolithin A, inhibit prostate cancer cell
proliferation (Seeram et al. 2007; Malik et al. 2011) and affect multiple signaling pathways in sev-
eral cell types (Li et al. 2005; Edderkaoui et al. 2008; Gonzalez-Sarrias et al. 2009). For instance,
urolithin A decreased both activity and expression of tumor-specific cytochrome P450, CYP1B1, in
a human prostate cancer cell line (Kasimsetty et al. 2009), while ellagic acid induced apoptosis via
a caspase-dependent pathway (Malik et al. 2011) and cell cycle arrest involving cyclin-dependent
kinase inhibitory protein p21 (Narayanan et al. 1999). Furthermore, ellagic acid showed a selective
antiproliferative activity for cancer cell lines without affecting the viability of human nonneoplastic
cells (Losso et al. 2004; Rocha et al. 2012).
The point of this detailed mechanistic discussion and proof of concept is simply to indicate
that the gut microflora may play an active role in converting phytonutrients into smaller molecules
that contribute to their cancer preventive effects. While this complicates research on phytonutrient
effects, it also demonstrates the lasting effects of a single glass of pomegranate juice, since these
conjugated metabolites persist for up to 48 hours after a single glass of juice (Seeram et al. 2006).
Moreover, in a study in human volunteers published in 2015, our group demonstrated that admin-
istration of pomegranate juice altered gut microbial populations and increased those producing
urolithin A in individuals who were urolithin producers (Li et al. 2015). Based on urinary measure-
ment of urolithin A, about 70% of normal subjects are producers and 30% are nonproducers. Some
nonproducers can be induced to produce urolithin A through repeated administration of pomegran-
ate juice daily for 28 days. Ongoing research is examining aspects of this phenomenon, but pome-
granate polyphenols in common with green tea and cranberry juice appear to have polyphenols that
change gut microbiota.
It is unlikely that the concept that metabolites are formed by microflora that have cancer preven-
tive potential is unique to pomegranate, since we also found that consumption of green tea and black
tea led to a rise in plasma and urine levels of phenolic acids as the result of microflora metabolism.
These phenolic acids demonstrated antiproliferative effects on colon cancer cells (Henning et al.
2013). Emerging evidence from our lab indicates that green tea can also modify the microbiome.
While prebiotics are typically fibers, there is now some consideration of classifying polyphenols as
prebiotics as well.
18.8 SUMMARY
There is clearly a great deal of evidence on the impact of nutrition on the risk of common forms of
cancer. The major factors are obesity, alcohol, and the lack of phytonutrients from fruits, vegetables,
spices, and green tea. The modulation of immune function and inflammation by these dietary fac-
tors is mediated by the gut microflora, which metabolize phytonutrients and form recirculating
substances such as phenolic acids and urolithins, which in turn are beginning to demonstrate some
anticancer effects.
However, the complexity of nutritional patterns and the chemistry and biology of fruits and
vegetables suggests that there is no single fruit, vegetable, or tea that would be a sole recommended
cancer preventive food. Instead, a global dietary approach to achieve and maintain body compo-
sition through adequate protein and physical activity, five to nine servings of colorful fruits and
vegetables, and the use of spices would be a reasonable recommendation for any patient concerned
about reducing the risk of common forms of cancer. Dietary supplements should be taken with due
consideration to all the factors already discussed in earlier chapters. Patients with fear of cancer are
often targeted by charlatans, and the primary care practice can serve as a reasoned source for useful
information on dietary supplements using the information provided in this text.
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19 Nutrition and the
Cancer Patient
19.1 INTRODUCTION
Cancer screening and early detection of cancer are well established in primary care practice, and
the follow-up care of cancer survivors is increasingly being triaged to primary care practices from
oncology practices, as they are overburdened with the treatment of more cancer patients.
Primary care physicians and their multidisciplinary teams will be called on increasingly in the
future to provide care to cancer patients while they are undergoing chronic treatment under the care
of oncology specialists and during follow-up care. The increasing population of cancer survivors
with concerns about the prevention of cancer recurrence with obesity and comorbid conditions will
require lifestyle recommendations to reduce the risk of cancer recurrence.
Malnutrition in advanced cancer patients continues to be a vexing problem that contributes to mor-
bidity and mortality. Nutrition support interventions have traditionally been used for patients with
malnutrition secondary to cancer or cancer treatments. More recently, nutritional interventions includ-
ing diet and lifestyle changes and dietary supplements have been studied and utilized in the primary
and secondary prevention of common forms of cancer (Heber et al. 2006) and as part of the cancer
treatment modality. As the number of cancer survivors who have successfully completed therapy
increases, together with a growing population of patients with ongoing preventive pharmacology based
on small-molecule cancer therapy (Hoelder et al. 2012), the need for nutrition counseling to decrease
risk of cancer recurrence or for general health is becoming more recognized (Blanchard et al. 2008).
During the emotional stress of dealing with a diagnosis, patients can derive increased quality of life
and a sense of control over their lives as the result of receiving supportive advice on diet and lifestyle.
The evidence base for nutrition intervention in cancer patients is drawn from a combination
of extensive epidemiological inference from association studies of the relationship of nutrition
and physical activity to cancer and extensive animal studies demonstrating cellular and molecular
mechanisms of the interaction. There are very limited nutrition intervention studies in humans.
The general advice given for cancer prevention may also be beneficial to reduce risks of other
common age-related chronic diseases, such as diabetes and heart disease. In the absence of proven
benefits of nutrition intervention in this population, the interventions should be based on generally
accepted macronutrient ranges according to the Institute of Medicine guidelines and be based on
clinical trials that show a lack of adverse events when the nutrition interventions have been utilized.
As is repeatedly emphasized here, the cancer patient is a vulnerable individual and easily subject
to nutritional claims for curing cancer from unqualified and sometimes dangerous practitioners.
Patient’s families also read about the promise of nutrition for cancer in the popular press and must
be educated as to its realistic and potential benefits, as well as limitations and potential harms, for
each patient’s situation.
19.2 PRIMARY CARE ONCOLOGY

The number of cancer patients presenting to primary care physicians is expected to increase, driven
by the epidemic of obesity and the increased aging of the U.S. and world populations. The number
of oncologists in practice over the coming decades will be inadequate to meet the demands for care
by cancer patients. As cancer is converted in many cases to a chronic disease, and as the popula-
tion of cancer survivors grows globally due to earlier detection and better treatments, primary care
329
physicians and their multidisciplinary teams will be called on to deliver supportive care to can-
cer patients and to deliver healthy recommendations for secondary prevention to cancer survivors
(Erikson et al. 2007; Warren et al. 2008).
A recent study estimated a 48% increase in the demand for oncology services, accompanied by
a shortage of oncologists in the future (Warren et al. 2008). The greater involvement of primary
care physicians in cancer care has been proposed as one means of addressing this shortfall (Warren
et al. 2008), despite projections of a looming primary care physician shortage (Bodenheimer 2006).
While age is the primary risk factor for common forms of cancer, incidence rates, as already
reviewed in Chapter 17, are influenced by diet and lifestyle. We are in the midst of a global epidemic
of obesity and diabetes, which increases the risks of common forms of cancer, including prostate,
breast, colon, uterine, gallbladder, liver, and pancreatic cancers. As the result of advances in screen-
ing, prevention, and treatment, there is a growing population of cancer survivors. This chapter
written some 30 years ago would have concentrated solely on malnutrition in cancer. While nutri-
tion support is still a vital need of patients with diagnosed cancer, it is also increasingly appreciated
that cancer patients who have survived often contract common age-related chronic diseases. Some
of the hormonal and inflammatory pathways that are important in diabetes and heart disease may
also play a role in reducing tumor recurrence in survivors, but can also increase quality of life and
reduce comorbid conditions.
Cancer care generally requires referral to medical oncologists, surgeons, and radiation oncolo-
gists for treatment. However, primary care practices are often the initial point of contact for patients
in obtaining screening or evaluating symptoms. In addition, the primary care practice serves as
the central contact point for cancer patients by making referrals, coordinating care with various
specialists and support services, and managing both symptoms of cancer and its treatment, as well
as preexisting medical conditions, such as diabetes, heart disease, or hypertension. Moreover, for
cancer survivors, the primary care practice can be a central support service for lifestyle changes
involving diet, exercise, and rational dietary supplementation.
Another important task for primary care practices is counseling cancer patients about treatment
options and monitoring treatment progress and side effects (Williams 1994). Studies document
the role that primary care physicians and practices can play in follow-up care for cancer survivors
(Worster et al. 1995, 1996; Grunfeld et al. 2006; Keating et al. 2007; Snyder et al. 2008). The critical
role of primary care practices in cancer screening and early detection is well established, and their
role in the follow-up care of cancer survivors is emerging currently (Institute of Medicine 2006).
Two general medical care roles are often assumed by primary care rather than by cancer specialists:
(1) managing comorbid conditions and (2) evaluating and treating depression. Comorbid condi-
tions and depression are common in cancer patients and survivors (Ko and Chaudhry 2002; Mao
et al. 2007; Reich 2008). The management provided is important, as cancer patients with comorbid
conditions such as diabetes experience worse outcomes (Ko and Chaudhry 2002; Smith et al. 2008;
Lloyd-Williams et al. 2009). Oncologists often fail to identify depression in cancer patients experi-
encing moderate to severe depressive symptoms, and this is an area where primary care practices
can provide important support for cancer patients and survivors (Passik et al. 1998).
The growth of the cancer patient and survivor populations in the United States, along with the
anticipated shortages of oncologists, heightens the need for better information about participation of
primary care physicians and their multidisciplinary teams in cancer care. Therefore, a greater knowl-
edge of the nature of cancer and its treatment is an important background for primary care providers.
Many of the nutritional principles of primary cancer prevention also apply to secondary prevention,
such as increased intakes of fruits and vegetables and the achievement of optimal body composition.
19.3 CHANGING FACE OF CANCER

Due to advances in screening, early detection, and better treatment options, there has been an
increase in overall 5-year survival rates among cancer patients. A total of 1,685,210 new cancer
Nutrition and the Cancer Patient 331
cases and 595,690 cancer deaths were projected to occur in the United States in 2016 (Siegel et al.
2016). Overall cancer incidence trends are stable in women, but declining by 3.1% per year in men
from 2009 to 2012, much of which is because of recent rapid declines in prostate cancer diagnoses.
The cancer death rate has dropped by 23% since 1991, translating to more than 1.7 million deaths
averted through 2012. Despite this progress, death rates are increasing for cancers of the liver, pan-
creas, and uterine corpus, and cancer is now the leading cause of death in 21 states, primarily due
to exceptionally large reductions in death from heart disease. Prostate, lung, and colorectal cancers
account for 44% of all cases in men, with prostate cancer alone accounting for one in five new cases
in the United States. For women, the three most commonly diagnosed cancers are breast, lung, and
colorectal cancers, representing one-half of all cases. Breast cancer alone accounts for 29% of all
new cancer diagnoses in American women.
19.4 CANCER SURVIVORS IN PRIMARY CARE

Patients presenting in primary care practice with a past medical history of cancer diagnosis and
treatment are becoming much more common. As a result, more emphasis is being placed on recom-
mendations to enhance overall health in this unique clinical population (Williams 1994). A recent
report from the Institute of Medicine of the U.S. National Academy of Sciences specifically calls
for lifestyle recommendations as part of implementing survivorship care planning in order to opti-
mize health and quality of life after cancer treatment (Worster et al. 1995). Recommendations for
cancer survivors are divided into three broad areas of weight management, physical activity, and
diet quality.
The evidence supporting a weight management recommendation for cancer survivors is well
established. A significant number of survivors of cancers where obesity and overweight are risk fac-
tors are overweight or obese when they are diagnosed with cancer and during follow-up. Survivors
likely to be overweight or obese include postmenopausal breast cancer patients, as well as patients
with cancers of the colon, endometrium, gastric cardia, kidney, pancreas, ovary, and gallbladder
(Worster et al. 1996; Grunfeld et al. 2006; Keating et al. 2007). There is an increasing body of
evidence suggesting that obesity may be contributing to recurrence and cancer-related mortality
(Snyder et al. 2008).
Obesity and poor outcomes in cancer patients are most strongly linked in breast cancer, where
numerous observational studies have evaluated the relation between body weight status at the
time of cancer diagnosis and the risk of cancer recurrence and mortality. A recent meta-analysis
of 82 studies that included 213,075 women with breast cancer demonstrated that for each 5 kg/
m2 increment in body mass index (BMI), there was a 14–29% increased risk of disease-specific
mortality and an 8–17% increased risk of total mortality (Chan et al. 2014). Results of a similar
magnitude were observed in a meta-analysis in prostate cancer; that analysis of 18,203 patients
demonstrated that each 5 kg/m 2 increase in BMI was associated with a 21% increased risk of
biochemical recurrence and a 20% higher risk of prostate cancer-specific mortality (Cao and Ma
2011). For colorectal cancer, a recent meta-analysis of 51,303 patients across 29 studies demon-
strated slightly increased overall survival among obese individuals versus normal-weight indi-
viduals (Wu et al. 2014).
It should be noted that for breast cancer, the associations between body weight status and mor-
tality are not linear, but instead indicate that the greatest risk is among women who are under-
weight (BMI <18.5 kg/m2) or obese (BMI >29.9 kg/m2) compared with those who are normal weight
or overweight with a BMI between these extremes. For colorectal cancer, the lowest-risk patients
appear to be those who are overweight, with higher risk observed among underweight and normal-
weight patients (BMI <25 kg/m2), as well as those who are obese (BMI ≥30 kg/m2) (Cao and Ma
2011; Wu et al. 2014). Although meta-analyses have not been reported for other cancers, systematic
reviews suggest that obesity is directly associated with recurrence and overall survival, although the
data are less consistent (Parekh et al. 2012; Arem and Irwin 2013).
Obesity also can contribute to morbidity from cancer treatment and is a risk factor for poor wound
healing, postoperative infections, and lymphedema, as well as for the development of comorbid
illness (e.g., cardiovascular disease, cerebrovascular disease, and diabetes) and functional decline
(Parekh et al. 2012; Arem and Irwin 2013). In addition, obesity places individuals at greater risk for
developing second primary malignancies (Ligibel et al. 2014).
The associations between BMI and long-term outcomes and prognoses are weak in comparison
with visceral obesity in cancer patients (Worster et al. 1995, 1996; Ko and Chaudhry 2002; Institute
of Medicine 2006; Lee et al. 2008; Moon et al. 2008; Cecchini et al. 2011; Clark et al. 2013). In
the nononcological setting, the waist circumference (WC) and waist-to-hip ratio (WHR) have been
found to be better discriminators of diabetes and cardiovascular risks than BMI (Zimmet et al.
2005; Mao et al. 2007; Lee et al. 2008; Reich 2008). In the oncological setting, WC and WHR have
been found to be associated with increased risk of endometrial, esophageal, colorectal, and breast
cancers (Passik et al. 1998; Smith et al. 2008; Lloyd-Williams et al. 2009; Aune et al. 2015; Harding
et al. 2015; Steffen et al. 2015). There is a suggestion that WC and WHR are associated with poor
outcomes in colorectal cancer (Chan et al. 2014; Fedirko et al. 2014).
The combination of sarcopenia and obesity is classified as sarcopenic obesity (Heber et al. 1996).
Several factors could increase the risk of sarcopenic obesity. Age-related body composition changes
with progressive decline in muscle mass and/or strength are a significant risk factor. Hormonal
changes, sedentary lifestyle, and malnutrition may also occur in the elderly, contributing to sarco-
penic obesity. In addition, adipose tissue secretes pro-inflammatory cytokines and adipokines,
promoting insulin resistance, and these pro-inflammatory markers can contribute toward low mus-
cle mass and obesity (Roubenoff 2004; Schrager et al. 2007).
Studies have supported the clinical observation that the weight gain that breast cancer patients
experience after treatment is different from the weight losses observed in other cancers, such as
pancreatic cancer or lung cancer, since it occurs either in the absence of gains in lean tissue or in
the presence of lean tissue losses (Cheney et al. 1997; Demark-Wahnefried et al. 1997; Aslani et al.
1998, 1999; Kutynec et al. 1999; Peterson et al. 2001).
It is clear that a combination of diet and exercise is necessary to correct sarcopenic obesity in
cancer survivors. Preliminary data show some reversal of sarcopenia in premenopausal women
undergoing adjuvant chemotherapy (Demark-Wahnefried et al. 2002). In a 12-week diet and exer-
cise program in healthy but obese postmenopausal women, a diet and exercise regimen including
resistance exercise led to improvements in body composition and exercise performance, including
fat mass loss (14% average drop), improved VO2max (+36% increase), and strength improvement
(+26%) (Carpenter et al. 2012). Breast ductal fluid markers also declined from baseline, with estra-
diol showing a 24% reduction and interleukin 6 (IL-6) a 20% reduction. Reductions from baseline
in hormones and cytokines were observed, including leptin (36% decline), estrone sulfate (10%
decline), estradiol (25% decline), and IL-6 (33% decline) (Carpenter et al. 2012).
Based on this background, the American Cancer Society’s practical recommendations for cancer
survivors’ weight management, physical activity, and diet quality (Demark-Wahnefried et al. 2015)
are as follows:
1. Achieve and maintain a healthy weight. If overweight or obese, limit consumption of high-
calorie foods and beverages and increase physical activity to promote weight loss.
2. Engage in regular physical activity.
3. Avoid inactivity and return to normal daily activities as soon as possible after diagnosis.
4. Aim to exercise at least 150 minutes/week, and include strength training exercises at least
2 days/week.
5. Achieve a dietary pattern that is high in vegetables, fruits, and whole grains.
In addition, limit consumption of processed meat and red meat and eat at least 2.5 cups of veg-
etables and fruits daily. Choose whole grains instead of refined grain products, and if you drink
alcoholic beverages, limit consumption to no more than one drink daily for women or two drinks
daily for men. This advice is reasonable and can be individualized to meet the needs of patients with
comorbid conditions.
19.5 MALNUTRITION AND CANCER

Weight loss in cancer patients is due to depletion of both adipose tissue and skeletal muscle mass,
while the nonmuscle protein compartment is relatively preserved, thus distinguishing cachexia from
simple starvation (Fearon 1992). The loss of both adipose tissue and skeletal muscle mass can be
extensive. Studies of the body composition of lung cancer patients showed that they lost 32% of
their preillness stable weight, compared with a group of controls matched for age, sex, height, and
preillness stable weight. Although the overall weight loss was 32%, the cachectic patients had lost
85% of their total body fat and 75% of their skeletal muscle, and there was also a significant decrease
in mineral content, suggesting erosion of bone. This marked loss of skeletal muscle explains why
patients with cachexia have a reduced mobility, and thus quality of life, together with a shorter life
span, since loss of respiratory muscle function will lead to death from hypostatic pneumonia.
Death occurs with a 25–30% total body weight loss (Wigmore et al. 1997). A similar situation
is found in patients with acquired immunodeficiency syndrome (AIDS), where death is imminent
when they have lost 34% of their ideal body weight (Kotler et al. 1990). Respiratory failure has
been found to be responsible for the death of 48% of cancer patients (Houten and Reilley 1980).
At the time of diagnosis, 80% of patients with upper gastrointestinal (GI) cancers and 60% of
patients with lung cancer have significant weight loss (Bruera 1997; McMahon et al. 1998), defined
as at least a 10% loss of body weight in the prior 6 months (Rivadeneira et al. 1998). In addition,
malnutrition is a common complication of patients undergoing chemotherapy, radiation, or surgery
for cancer.
This common problem in cancer patients has been recognized as a significant contributor to
morbidity and mortality in cancer. Malnutrition is associated with a decreased quality of life in
cancer patients, and significant weight loss is a biomarker of poor prognosis in cancer patients
(McMahon et al. 1998). Nutrition intervention can help cancer patients maintain body weight and
nutrition stores, offering relief from symptoms and improving their quality of life (American Cancer
Society 2015). Poor nutrition practices, which can lead to undernutrition, can contribute to the inci-
dence and severity of treatment side effects and increase the risk of infection and mortality in cancer
patients (Vigano et al. 1994).
While weight loss is traditionally associated with cancer in the minds of professionals and the
public, weight gain can occur as the result of chemotherapy treatment for early-stage cancers, pos-
sibly resulting from decreases in lean body mass and resting metabolism (Harvie et al. 2004). This
is especially common in postmenopausal women with breast cancer who develop sarcopenic obesity
after treatment. Sarcopenic obesity has been shown to be a risk factor for breast cancer progression
(Prado et al. 2009). Obesity has also been associated with increased mortality in prostate cancer
(Hsing et al. 2007). The nutrition of cancer patients should be assessed throughout the continuum
of care to reflect changing objectives of nutrition intervention.
19.5.1 Protein–Energy Malnutrition
Protein–energy malnutrition (PEM) is the most common secondary diagnosis in individuals diag-
nosed with cancer. PEM leads to progressive wasting, weakness, and debilitation, as protein synthe-
sis is reduced and lean body mass is lost, often leading to death (McMahon et al. 1998). PEM results
most commonly from inadequate intake of macronutrients needed to meet energy requirements. In
addition to reduced food intake, there are a number of associated abnormalities that can combine to
worsen malnutrition, including reduced absorption of macronutrients secondary to changes in the
GI tract. Cancer-induced metabolic abnormalities secondary to inflammation affect the metabolism
of the major nutrients, including glucose and protein. Such abnormalities may include glucose
intolerance and insulin resistance, increased lipolysis, and increased whole body protein turnover
(Heber et al. 1986).
Increased turnover of liver and muscle proteins and gluconeogenesis from amino acids of muscle
origin are thought to contribute to rapid muscle wasting seen in cancer-associated malnutrition (Mutlu
and Mobarhan 2000; Nitenberg and Raynard 2000). Whole body protein breakdown is increased
in lung cancer patients and has been shown to correlate with the degree of malnutrition, such that
more malnourished patients have greater elevations of their whole body protein breakdown rates,
expressed per kilogram of body weight. Muscle catabolism, measured by 3-methylhistidineexcre-
tion, was increased in lung cancer patients compared with that of healthy controls. Methylhistidine
excretion rates did not correlate with weight loss, percentage of ideal body weight, or age in the lung
cancer patients studied. Glucose production rates were markedly increased in lung cancer patients
compared with healthy controls, and changes in glucose production rates in the cancer patients
studied did not correlate with weight loss, percent of ideal body weight, or age.
Anorexia, the loss of appetite or desire to eat, is typically present in 15–25% of all cancer patients
at diagnosis and may also occur as a side effect of treatments. Anorexia is an almost universal side
effect in individuals with widely metastatic disease (Langstein and Norton 1991; Shills 1999), sec-
ondary to chemotherapy and radiation therapy side effects, which lead to taste and smell changes,
nausea, and vomiting. Surgical treatments, such as esophagectomy and gastrectomy, may produce
early satiety and lead to reduced food intake (Rivadeneira et al. 1998). Common psychological
factors in cancer patients, including depression, loss of hope, anxiety, and morbid thoughts, may
be enough to bring about anorexia and result in PEM (Bruera 1997). Evidence-based recommenda-
tions have been published describing various approaches to the problems of cancer-related fatigue,
anorexia, depression, and dyspnea (Tisdale 1993). Other systemic or local effects of cancer or its
treatment that may affect nutritional status include sepsis, malabsorption, maldigestion, and intes-
tinal obstruction (Heber et al. 1986).
19.5.2 Carbohydrate Metabolism
Changes in carbohydrate metabolism, similar to those seen in type 2 diabetes, are common in
patients with cancer-associated malnutrition. Although glucose turnover is increased, glucose is
poorly utilized by peripheral tissues due to insulin resistance and glucose insensitivity (Rofe et al.
1994; Mutlu and Mobarhan 2000). Tumors have been demonstrated to increase the rate of glucose
utilization in a number of tissues, acting as metabolic traps (Argiles and Azcon-Bieto 1988; Heber
1989). Since there are only 1200 kilocalories stored in the body as liver and muscle glycogen,
blood glucose levels would be expected to fall. This does not occur since there is also an increase
in hepatic glucose production in cachectic and anorectic tumor-bearing animals and humans. The
regulation of protein metabolism is tightly linked to carbohydrate metabolism, since these processes
are critical to the normal adaptation to starvation or underfeeding. During starvation, there is a
decrease in glucose production, protein synthesis, and protein catabolism. The decrease in glucose
production occurs as fat-derived fuels, primarily ketone bodies, are used for energy production.
While there are 54,000 kilocalories of protein stored in the body cell mass, only about half of these
are available for energy production. In fact, depletion below 50% of body protein stores is incompat-
ible with life (Heber et al. 2006).
Early research demonstrated preferential metabolism of glucose through aerobic glycolysis,
as opposed to oxidative phosphorylation (i.e., Warburg effect), for tumorigenesis. Most aggres-
sive tumors exhibit a high rate of and dependence on glycolysis to meet their metabolic demands
(Richtsmeier et al. 1987; Sandulache et al. 2011). It has therefore been reasoned that diets restricted
in carbohydrates could target the altered metabolism of such glycolytic tumors (Seyfried and
Shelton 2010; Seyfried et al. 2014). Those diets result in a state of systemic ketone body production
and have thus been termed ketogenic diets. Indeed, there is some evidence that a ketogenic diet,
a high-fat, low-carbohydrate (CHO) diet that leads to the elevation of circulating ketone bodies
into the micromole range, may not only impair tumor cell metabolism and growth, but also fight
cachexia and therapy-induced side effects (Holm and Kämmerer 2011; Klement and Kammerer
2011; Klement and Champ 2014). To date, ketogenic diets have been the most widely studied and
rigorously explored, primarily in the management of medically refractory epilepsy, although stud-
ies are beginning to investigate their role in neurodegenerative conditions, migraine management,
and oncology. Despite increasing interest and popularity, formal scientific studies of the majority of
these interventions are lacking (Strowd and Grossman 2015).
19.5.3 Host–Tumor Interactions and Metabolic Abnormalities in the Cancer Patient

Based on autopsy studies performed in the 1920s (Terepka and Waterhouse 1956; Ogata et al. 2011)
and animal studies done in the 1950s (Fenninger and Mider 1954), it was postulated that tumors
acted to siphon off needed energy and protein from the host. In the 1970s and 1980s, specific
abnormalities of intermediary metabolism were identified in cancer patients that could account
for the common observation that such patients lost weight even in the face of apparently adequate
nutrition. Studies conducted in a number of laboratories, including our own, have demonstrated that
maladaptive metabolic abnormalities occur frequently in patients with cancer. In 1983, studies at
the University of California, Los Angeles (UCLA) demonstrated that adequate calories and pro-
tein administered to six patients with active localized head and neck cancer via forced continuous
enteral alimentation under metabolic ward conditions for 29 days failed to lead to significant weight
gain (Heber et al. 1986). The observed failure of these patients to gain weight despite adequate
caloric intake under metabolic ward conditions supports the concept that malnourished cancer
patients are hypermetabolic.
If metabolic abnormalities promote the development of malnutrition or interfere with renutri-
tion, then there should be some evidence of abnormally increased energy expenditure. A number of
investigators have used indirect calorimetry and the abbreviated Weir formula to calculate energy
expenditure at rest and then compared this with the basal energy expenditure (BEE) determined
using the Harris–Benedict formulas. Studies have used this method to compare cancer patients to
normal controls (Long et al. 1979). In one such study, 60% of a group of patients with advanced can-
cer had basal metabolic rates that were increased 20% above those predicted (Bozzetti et al. 1980).
Among 173 malnourished GI cancer patients, 58% had abnormally increased resting energy expen-
diture (REE) by indirect calorimetry compared with BEE, but a greater number of patients were
hypometabolic rather than hypermetabolic (36% vs. 22%) (Dempsey et al. 1984). In another study
of 200 patients with a variety of cancers, abnormal energy metabolism was found in 59%, but this
was more often hypometabolism than hypermetabolism (33% vs. 26%) (Knox et al. 1983). While
standard formulas such as the Harris–Benedict can be used to estimate metabolic rate in normal
individuals, the measured metabolic rates in patients with cancer have a much wider distribution.
Controversy remains concerning the importance of REE in cancer-associated malnutrition; how-
ever, tumor resection has been shown to normalize REE in hypermetabolic cancer patients (Fredrix
et al. 1997). Elevated REE and its role in the pathogenesis of cancer-associated malnutrition may
depend on the individual patient and disease characteristics. When energy expenditure was studied
in noncachectic patients with large localized sarcomas without prior treatment, weight loss, or his-
tory of decreased food intake, energy expenditure corrected for body cell mass determined by total
body potassium counting or body surface area was significantly greater in sarcoma patients than in
controls. This difference was due to both a decrease in body cell mass and an increase in REE in
these patients before the onset of weight loss (Peacock et al. 1987).
Therefore, it is likely that lean body mass, rather than fat mass, correlates with the individual
variations observed in measured REE. The hypothesis that the malnourished cancer patient may
be hypermetabolic relative to the amount of lean body mass remaining is also likely based on the
studies conducted in sarcoma patients.
One group of investigators have been studying short-term fasting as a means of enhancing the
sensitivity of tumors to chemotherapy so as sensitize target tumor cells while having relatively low
toxicity directed at normal cells and tissues (Safdie et al. 2009). This approach is still experimen-
tal and should only be considered within the context of a controlled clinical trial. However, the
concept is novel and worthy of consideration. Longo and coworkers have proposed that changes
in the levels of glucose, insulin-like growth factor 1 (IGF-1), insulin-like growth factor binding
protein 1 (IGFBP-1), and other proteins caused by fasting have the potential to improve the efficacy
of chemotherapy against tumors by protecting normal cells and tissues and possibly by dimin-
ishing multidrug resistance in malignant cells (Lee et al. 2012b). Starvation sensitized yeast cells
(Saccharomyces cerevisiae) expressing the oncogene-like RAS2 (val19) to oxidative stress, and 15
of 17 mammalian cancer cell lines were sensitized to chemotherapeutic agents.
Short-term starvation (or fasting) protects normal cells and tumor-bearing mice from the harm-
ful side effects of a variety of chemotherapy drugs. Cycles of starvation were as effective as che-
motherapeutic agents in delaying progression of different tumors and increased the effectiveness
of chemotherapy drugs against melanoma, glioma, and breast cancer cells. In mouse models of
neuroblastoma, fasting cycles plus chemotherapy drugs—but not either treatment alone—resulted
in long-term cancer-free survival. In 4T1 breast cancer cells, short-term starvation resulted in
increased phosphorylation of the stress-sensitizing Akt and S6 kinases, increased oxidative stress,
caspase 3 cleavage, DNA damage, and apoptosis. These studies suggest that multiple cycles of fast-
ing promote differential stress sensitization in a wide range of tumors and could potentially replace
or augment the efficacy of certain chemotherapy drugs in the treatment of various cancers, while
reducing side effects of therapy in cancer patients. This counterintuitive idea of using short-term
fasting prior to chemotherapy has yet to be tested and proven in humans (Lee et al. 2012a).
19.6 NUTRITION SCREENING
Nutrition intervention in cancer care embodies prevention of disease, treatment, cure, or supportive
palliation. Prudence should always be exercised when considering alternative or unproven nutri-
tional therapies for two reasons. First, these diets or supplements may prove harmful. Second, they
may delay prudent and effective therapies, as was the case for Steve Jobs, who had a treatable tumor
of the pancreas (insulinoma) that was not diagnosed promptly due to the use of ineffective herbal
treatments for many months. Moreover, some physicians provide patients with anticancer dietary
supplements while not emphasizing diet and lifestyle changes. Proactive nutritional care can prevent
or reduce the complications typically associated with the treatment of cancer (Dewys et al. 1980).
Whether the goal of cancer treatment is cure or palliation, early detection of nutritional prob-
lems and prompt intervention are essential. Nutrition screening and nutrition assessment should be
instituted by all members of the health care team caring for the cancer patient, including physicians,
nurses, registered dietitians, social workers, and psychologists (Tchekmedyian et al. 1992). The
Prognostic Nutrition Index (Dempsey and Mullen 1987; Dempsey et al. 1988) delayed hypersensi-
tivity skin testing, institution-specific guidelines, and anthropometrics are all tools that can be used
effectively to identify patients at nutritional risk. The selection of nutrition screening tools must
be individualized and interpreted in light of clinical factors, as the various biomarkers can be
affected by immune incompetence, inflammation, and hydration status (Sarhill et al. 2003).
The Patient-Generated Subjective Global Assessment (PG-SGA) is a simple and inexpensive
approach to identifying individuals at nutritional risk and in triaging cancer patients for nutritional
intervention (McMahon et al. 1998; Bauer et al. 2002). The PG-SGA is based on an earlier pro-
tocol called the Subjective Global Assessment (SGA) (Ottery 1994). With the PG-SGA, the indi-
vidual and/or caretaker completes sections on weight history, food intake, symptoms, and function.
Bioelectrical impedance analysis (BIA) is also used to assess nutritional status, as determined by
body composition (Lukaski 1999). Single BIA measures show body cell mass, extracellular tis-
sue, and fat as a percent of ideal, whereas sequential measurements can be used to show body
composition changes over time. BIA is increasingly becoming available in ambulatory settings, and
its use should be encouraged. With estimation of lean body mass, estimates of REE can be made by
multiplying lean body mass by 14. This can guide nutritional interventions for weight gain or weight
loss. The goals of nutrition intervention include
1. Preserving or increasing lean body mass

2. Reducing fatigue and improving quality of life
3. Correcting specific nutrition deficiencies
4. Improving tolerance of cancer therapy
5. Reducing side effects and complications related to nutrition
6. Enhancing immunity and decreasing the risk of infection
7. Promoting recovery and healing
19.7 SELECTING APPROPRIATE METHODS OF NUTRITION CARE

In patients with cancer, there is an association between poor nutritional parameters and worse over-
all morbidity and quality of life (Chlebowski et al. 1986). The benefits of initial and follow-up evalu-
ations and counseling by a registered dietitian, preferably in the context of a team approach, can
be enormous, although difficult to quantify (Ravasco et al. 2003). However, recent studies indicate
improved nutritional intake and quality of life after individualized dietary counseling (Wickham et
al. 1999; Ravasco et al. 2005). The main benefits relate to patient satisfaction, nutrition improvement
or maintenance, compliance with team or institutional management protocols and guidelines, and
a judicious use of risky and expensive treatments. The costs of nutritional counseling are modest
when compared with other interventions.
Nutritional evaluation and counseling, usually undertaken by a registered dietitian, is a first and
important step. Ideally, a dietitian should be an integral part of the cancer care team. Compliance with
dietary advice can be promoted by regular contact between the health care provider and the patient,
including regular nutritional assessments and advice (Parenteral and Enteral Nutrition Group 2004).
Dietitians typically obtain a 24- to 72-hour recall diet history either verbally or, preferably, as
recorded at home. The diet record is then examined to assess the adequacy of calories and protein,
utilizing food analysis tables, compared with estimated energy and protein needs. In addition to
assessing current food and fluid intake, the dietitian should note any recent changes, along with
food aversions, intolerances, or problems with feeding, such as taste changes. Alterations in protein
metabolism are common in the course of cancer, including whole body protein turnover, increased
protein synthesis and catabolism, and an increase in skeletal muscle breakdown. To account for
the stress induced by the disease and treatment, protein requirements of cancer patients can be
determined by adjusting the estimated requirement for healthy individuals to account for the stress
induced by the disease and treatment.
19.7.1 Oral Nutrition Support

The first rule of nutrition intervention is to use the gut when it is available, and the preferred method
of nutrition support is via the oral route using food. One goal of nutrition education and counseling
is to have the patient increase consumption of nutrient-dense foods to correct nutritional imbalances
and deficiencies in order to achieve and maintain a desirable weight. Calorically dense foods such
as nuts and nut butters can be used to increase the efficiency of calorie conversion to body fat stores.
One limitation of this approach is that malnourished cancer patients often are limited in their abil-
ity to absorb and digest fat due to the effects of malnutrition or enteritis as a result of radiation or
chemotherapy. Therefore, overconsumption of high-fat foods can, in some cases, lead to GI distress.
Liquid supplements are the most common types of nutritional supplements, are readily avail-
able for patient consumption, and are effective when patients are unable to meet requirements with
normal foods alone, despite dietary counseling (Ravasco et al. 2005). Patients may be anorectic
due to illness or be affected by disabling factors, such as difficulty in chewing, inability to prepare
foods for themselves, visual difficulties, decreased energy level, or poor access to foods. Nutritional
supplements may be homemade and are usually milk based, or they are commercially prepared and
packaged. Although somewhat expensive, commercial supplements provide balanced and fortified
(vitamin- and mineral-enriched) nutrition that requires little or no preparation. Oral supplementa-
tion with liquid concentrated food supplements providing high-calorie, high-protein, low-volume
nutrients is the simplest, most natural, and least invasive method of increasing nutrient intake. The
benefits of oral supplementation include increased appetite and weight gain, decreased GI toxicity,
and improved performance status (Nayel et al. 1992; Ovesen and Allingstrup 1992; Bell et al. 2003).
These products are particularly helpful when patients cannot maintain an adequate intake through
a regular diet but are able to swallow and have a relatively intact GI tract.
Dietitians can help patients select products based on tolerance and palatability. Commercially
prepared supplements are available in a variety of flavors (including unflavored) and in a variety
of nutrient compositions. Most commercially prepared supplements are available in ready-to-drink
cans or boxes and are usually lactose-free, which for the patient is often more acceptable due to the
increased incidence of perceived milk intolerance in this population. Vitamin- and mineral-fortified
protein meal replacements designed to be mixed with milk provide an inexpensive and generally
well-tolerated alternative for those who are not lactose intolerant. These supplements have vitamin,
mineral, calorie, fat, carbohydrate, and protein contents similar to those of most commercially pre-
pared supplements.
The success of supplementation depends on sufficient quantities being consumed over an
extended period of time. The volume and choice of supplement is based on the patient’s individual
nutrient needs and preferences, and GI tolerance. Supplements with fiber, generally soy or oat fiber,
are available and may be beneficial to the patient who has diarrhea or constipation. Nutritional
supplements are generally well accepted and may offer relief to a patient who has difficulties eat-
ing solid food. Tolerability can be enhanced by starting with small quantities and by diluting the
supplement with water or ice to decrease osmolality. A patient will usually accept one to three
8-ounce supplements per day, but there is great individual variability. Variety in supplements will
help patients avoid taste fatigue, which is one main drawback to oral supplementation (Wargovich
1999). Patients who have alterations in taste or nausea may better tolerate an unflavored supplement.
Dietary modifications can be employed with the help of a registered dietitian to reduce the symp-
toms associated with cancer treatments. Appetite stimulants may be used to enhance the enjoyment
of foods and to facilitate weight gain in the presence of significant anorexia (Seligman et al. 1998).
Suggestions for appetite improvement are shown in Table 19.1 (Ottery 1995).
TABLE 19.1
Suggestions for Appetite Improvement
1 Establish a daily menu and record food intake.
2 Eat small, frequent, high-calorie meals.
3 Arrange for help in preparing meals.
4 Add extra protein and calories to food.
5 Prepare and store small portions of favorite foods.
6 Consume one-third of the daily protein and calorie requirements at breakfast.
7 Snack between meals with nuts or other healthy foods when possible.
8 Seek foods that appeal to the sense of smell.
9 Be creative with desserts.
10 Experiment with different foods.
11 Perform frequent mouth care to relieve symptoms and decrease unpleasant tastes.
19.7.2 Enteral Nutrition
Enteral nutrition is often needed in patients with cancers of the head and neck regions, esopha-
gus, and stomach. Nasogastric tubes and tubes that extend into the duodenum or jejunum are best
suited for short-term support (<2 weeks) (Heys et al. 1999). Enteral feeding into the jejunum is
appropriate for patients at risk of aspiration. However, if the patient is at very high risk of aspirat-
ing, enteral nutritional support is contraindicated and parenteral nutrition should be considered.
Moreover, patients with mucositis or esophagitis, and those who are immunocompromised and have
herpetic, fungal, or candida lesions in the mouth or throat, may not be able to tolerate the presence
of a nasogastric tube.
Percutaneous endoscopic gastrostomy (PEG) tubes and percutaneous endoscopic jejunos-
tomy (PEJ) tubes are needed for long-term enteral feedings (for more than 2 weeks). Enteral
nutrition can be delivered at different rates and durations. Bolus feedings that mimic meals are
preferable because this method requires less time and equipment, offers greater flexibility to
the patient, and enables normal physiological and hormonal mechanisms to operate (Heys et al.
1999). When administering bolus or intermittent enteral feeding, the steps in Table 19.2 should
be followed.
Once the infusion method has been determined, a formula is selected. When a formula is being
chosen, the institution nutrition formulary for available preparations, modular formulas, and addi-
tions such as glutamine or fiber should be considered. Consideration should also be given to the
patient’s medical condition, GI function, and financial resources. Enteral formulas, from elemen-
tal preparations of predigested nutrients to more complete and complex formulas that mimic oral
nutrition intake, are available. More information on specific formulas and their ingredients and
properties can be obtained from the manufacturers. There are also specialized formulas designed
for specific disease conditions, including diabetes mellitus and compromised renal function, but
the additional benefits of these formulas may not justify their cost, and the need for these should be
carefully considered.
TABLE 19.2
Administering Bolus or Intermittent Enteral Feeding
1 Determine the calorie, nutrient, and free-water requirements in order to plan the feeding schedule. Dehydration
will occur if adequate water is not included in the formulation, typically at 1 mL/calorie administered.
2 Administer bolus feedings three to six times per day. It is possible to give 250–500 cc over 10–15 minutes, as long
as the patient tolerates these amounts without undue gastric distension.
3 Bolus feeding is only to be used when a nasogastric tube is in the stomach. Bolus feeding is contraindicated when
feedings are delivered into the duodenum or jejunum, since gastric distention and dumping syndrome can occur.
4 Administer the bolus feeding using a gravity drip from a bag or syringe or a slow push with the syringe.
5 Change the amount of formula given at time 0, the type of formula, or added ingredients in the formula if diarrhea,
a common side effect of this type of infusion, is encountered.
When instituting continuous or cyclic enteral feeding, the following steps should be followed:
1 Determine the calories per nutrient and free-water requirements in order to plan rate and timing recommendations,
whether continuous or cyclic infusions.
2 Utilize a controlled enteral feeding pump that provides reliable, constant infusion rates in order to decrease the risk
of gastric retention.
3 Initiate feeding into the stomach at rates of 25–30 mL/hour and start at 10 mL/hour into the jejunum (10 cc/hour),
and then increase rates as tolerated every 4–6 hours until the rate needed to deliver the required caloric/nutrient
needs is reached.
4 If continuous feed is used, it can be run at night to allow greater flexibility for the patient. In addition, night feeding
can be combined with bolus feedings during the day to provide a more normal lifestyle for the patient.
19.7.3 Parenteral Nutrition
Parenteral nutrition is only required in patients who are unable to use the oral or enteral route.
That is, if the gut is working, use it. Nutrients provided through the enteral route nourish the gut
epithelium and provide better overall nutrition, as well as involving the gut peptides, which enhance
insulin action. Patients with obstruction, intractable nausea and/or vomiting, short bowel syndrome,
or ileus may require parenteral nutrition. Other indications to use total parenteral nutrition (TPN)
in the cancer population include severe diarrhea or malabsorption, severe mucositis or esophagitis,
high-output GI fistulas that cannot be bypassed by enteral intubation, and/or severe preoperative
malnutrition (Heys et al. 1999). Despite some claims that TPN is a more aggressive form of nutri-
tion, there are no advantages to using TPN over enteral nutrition for cancer care. The decision to uti-
lize parenteral nutrition in patients with advanced cancer is difficult. The widespread use of TPN, as
was done in the 1970s and 1980s, is not advised, since there is no evidence of improved survival in
patients with advanced cancer (Chlebowski 1985; Bozzetti 1989). Most data point to the same con-
clusion: health care providers should not prescribe parenteral nutrition to patients with advanced,
incurable cancer. A meta-analysis summarized findings from 15 clinical trials. Parenteral nutrition
led to inferior survival, lower tumor response rates, and increased infection rates. The increased
infection rate persisted even after catheter-related sepsis was excluded. This observation bolsters
recommendations from recent guidelines that suggest parenteral nutrition may not be in the best
interest of patients with advanced, incurable cancer (Jeffcoat and Kirkwood 1987).
19.8 DIET AND CANCER PREVENTION: THE ROLE

OF COLORFUL FRUITS AND VEGETABLES
International studies of the food habits of a number of populations over the past 40 years have
clearly documented the diversity of human dietary patterns and defined those associated with a
lower risk of chronic diseases, including common forms of cancer (Glade 1999). In comparison with
the diet of Americans, dietary patterns including a consistently higher intake of fruits, vegetables,
whole grains, and plant proteins, such as soy, are associated with a markedly reduced risk of can-
cer. In the nutritional science and epidemiological literature, these dietary patterns have often been
characterized as simply low-fat, high-fiber diets, or the intake of vegetables was quantitated as a
single phytochemical, such as β-carotene (Garewal and Schantz 1995). Such simplified terminolo-
gies led to the concept that fiber or phytochemical supplementation could reproduce the benefits of
the healthy dietary patterns they represented.
The idea that a dietary pattern conferred its benefits through a single component led to trials that
purported to test one component of the diet in an American population, while all other variables were
held constant. When research based on these flawed concepts was conducted, the expected benefits
were not realized for fiber supplementation (Alberts et al. 2000) or β-carotene supplementation (The
Alpha-Tocopherol, Beta Carotene Cancer Prevention Study Group 1994). This led to a series of pub-
lications resulting from intervention trials, which have been interpreted as evidence that nutrition
simply does not work in cancer prevention. On the other hand, international studies suggest that
for some cancers of the aerodigestive tract, a 50% reduction in risk is associated with intakes of 400–
600 g/day of fruits and vegetables (Glade 1999). The challenge for nutrition scientists is to translate
this scientific information into dietary guidelines that result in healthful changes in dietary patterns.
Over the past 200 years, a series of uniquely American foods have been developed through
adaptation from other cultures: pizza made with oil added to the crust and large amounts of melted
cheese, potato chips, corn chips, peanut butter, hot dogs, hamburgers made with beef fat flavoring,
and profitable soft drinks made with corn sugar and artificial flavors (Schlosser 2001). Westernized
Chinese food is among the highest-fat foods in America because it was adapted from low-fat
Chinese versions to meet American tastes. Moreover, refried beans or frijoles have added lard or
vegetable oil in the Mexican American adaptation of beans eaten in Mexico and South America
without added fat. Special offers of larger portions delivering an extra 800 kilocalories for only an
additional 39 cents have made fast-food restaurants especially popular with teenagers, low-income
Americans, and the elderly. These foods have displaced the fruits, vegetables, and whole grains
recommended in the U.S. dietary guidelines, and consumers have increasingly reduced their com-
mitments to cooking healthy meals and eating as a family over the past few decades.
We are now separated from the system that enabled us to select foods according to color and
taste. Humans and a few primate species have trichromatic color vision, so that they are able to
distinguish red from green (Dominy and Lucas 2001). All other mammals have dichromatic vision
and cannot distinguish between the two colors. One hypothesis for the evolution of this visual
ability was that it conferred an advantage by enabling primates to distinguish red fruits from the
green background of forest leaves. We could joke that today colors are still used to promote food
choices, as most fast-food restaurants package their beige french fries in a red cardboard package.
Contrasting colors have been shown to be one of the key factors in food selection by Drewnowski
(1996). A new method for selecting fruits and vegetables based on colors keyed to the content of
phytochemicals is described as a way of translating the science of phytochemical nutrition into
dietary guidelines for the public. Most Americans eat only two to three servings of fruits and
vegetables per day, without regard to the phytochemical contents of the foods being eaten. Certain
phytochemicals give fruits and vegetables their colors and also indicate their unique physiological
roles. All the colored phytochemicals that absorb light in the visible spectrum have antioxidant
properties. In artificial membrane systems, it is possible to show synergistic interactions of lutein
and lycopene in antioxidant capacity, and there are well-known antioxidant interactions of vita-
mins C and E based on their solubility in hydrophilic and hydrophobic compartments of cells.
However, many phytochemicals have other functions beyond acting as antioxidants. For example,
lycopene stabilizes the connexin 43 gene product that is essential for gap junction communication
(Stahl et al. 2000) while also interacting with vitamin D in the differentiation of HL-60 leukemia
cells (Amir et al. 1999). In breast cancer cells, lycopene can interfere with IGF-1-stimulated tumor cell
proliferation (Karas et al. 2000). Lycopene levels in the blood are associated with a reduced risk of
prostate cancer (Gann et al. 1999), and lycopene administration may reduce proliferation and increase
apoptosis in human prostate tissue where lycopene is the predominant carotenoid (Kucuk et al. 2001).
Lutein is concentrated in the retina, where it may help prevent macular degeneration, the most com-
mon preventable form of age-related blindness (Mares-Perlman et al. 2001). Other studies have found
that lycopene, α-carotene, and β-carotene are associated with a reduced risk of lung cancer (Heber
2000). On the basis of a recent review of functional properties of foods (Milner 2000) and research
from our laboratories demonstrating that it is relatively simple to influence circulating levels of lyco-
pene with the administration of only 177 mL (6 fluid ounces) of mixed vegetable juice daily (Heber
et al. 2000), we developed a color code for a book aimed at helping consumers to change dietary
patterns to include more fruits and vegetables by including one serving from each of seven color groups
each day, selected on the basis of the family of phytochemicals they contain (Table 19.3) (Heber 2002).
TABLE 19.3
Color Code Relationship to Families of Phytochemicals
Color Phytochemical Fruits and Vegetables
Red Lycopene Tomatoes and tomato products, such as juice, soups, and pasta sauces
Red-purple Anthocyanins and polyphenols Grapes, blackberries, red wine, raspberries, blueberries
Orange α- and β-carotene Carrots, mangos, pumpkin
Orange-yellow β-Cryptoxanthin and flavonoids Cantaloupe, peaches, tangerines, papaya, oranges
Yellow-green Lutein and zeaxanthin Spinach, avocado, honeydew melon
Green Glucosinolates and indoles Broccoli, bok choi, kale
White-green Allyl sulfides Leeks, garlic, onion, chives
Although the color method is superior to the current system of simply encouraging increased
fruit and vegetable intake, it does not account for actual phytochemical delivery to the consumer.
Today, there is no labeling law that enables fruit and vegetable manufacturers to list the phyto-
chemicals in their products. Fruits and vegetables are developed and grown less for their flavor
and nutritional content and more to accommodate the need to transport these products over long
distances and extend their shelf life once they get to the market. Finally, research in this area needs
to continue on the >25,000 phytochemicals provided by fruits and vegetables, including those that
do not have color, such as isoprenoids (Elson 1996). These important phytochemicals are widely
distributed among different plant species, but the delivery of phytochemicals and their effects on
biomarkers relevant to cancer prevention need to be documented.
19.9 COMPLEMENTARY AND ALTERNATIVE MEDICINES

Vitamin, mineral, and herbal supplement use is reported by nearly half of all breast cancer patients
(DiGianni et al. 2002). There are two major concerns raised about the use of such supplements dur-
ing chemotherapy. First, antioxidants can become pro-oxidants and so may influence the action of
radiation or cytotoxic chemotherapy by enhancing or blocking oxidation in tumor cells (Sweet et al.
2016). This concern is theoretical and has never been demonstrated in clinical trials. Concentrated
radiation delivered to tumor tissue is not going to be inhibited by vitamin E, which has been shown
to reduce doxorubicin toxicity when provided pretreatment with nifedipine without impeding effec-
tiveness (Lenzhofer et al. 1983). In most cases, antioxidant vitamins in a rational range will not
affect chemotherapy or radiation, but may support the patient by reduction of side effects. Second,
substances in botanicals may influence the pharmacodynamics of a chemotherapeutic regimen
and thereby influence the effectiveness or safety of chemotherapy (Sweet et al. 2016). The most
important CYP pathways for the metabolism of oncology pharmaceutical drugs are those involv-
ing the cytochrome P450 enzymes. The CYP cytochrome P450 3A4 isoform (commonly known
as CYP3A4) is responsible for metabolizing greater than 50% of drugs that pass through the liver
(Delgoda and Westlake 2004; Saxena et al. 2008). Several herbs and other CAM substances influ-
ence CYP3A4’s function by either inducing or inhibiting the actions of these enzymes, and thus
have the potential to influence the dose of a drug present in a patient’s bloodstream (Delgoda and
Westlake 2004; Saxena et al. 2008).
In working with oncologists and radiation therapists, you will find varying opinions about the
use of supplements, ranging from recommending total abstinence to allowing multivitamins but
not herbals or megadose vitamins. It is best to suggest to patients that they follow their oncologist’s
advice. In cases where a response is not achieved, it is often nutritional supplements or diets that are
blamed by patients. If the patient follows the advice of oncologists even when the oncologist’s views
are contradicted by science, this is still the safest course of action for a primary care practitioner.
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20 Writing the Nutrition
Prescription
20.1 INTRODUCTION
In this book, our goal has been to arm you with the necessary knowledge and tools to incorporate
nutrition into your primary care practice. As a practical matter, this effort must be led by a dedicated
primary care physician with the help of motivated registered dietitians, nurses, psychologists, physi-
cal therapists, and office staff, whether within your practice or by referral to the community. It is
essential that the nutrition prescription provided by the physician be as efficient as possible. While
many team members have superior knowledge in the areas of nutrition, exercise, and psychology,
the doctor remains the focus of patient confidence in a therapy plan. Therefore, the endorsement
of the plan, rather than the implementation of the plan, is the most important task of the physician.
In this regard, we have provided detailed and referenced information on the role of nutrition in the
most common conditions encountered in primary care practice. Much of this information was new
and opposed to established teaching in American medical schools focused on drugs and surgery for
the treatment of disease. Advanced technologies and drugs are effective for the treatment of acute
disease, but many of the most common diseases, such as heart disease, diabetes, and cancer, are
not preventable with drugs and surgery. While there is mention of prevention of heart disease, this
largely relates to the use of statins, with some modest discussion of a healthy diet. Similarly, preven-
tion of type 2 diabetes is the early introduction of metformin or intensive insulin therapy. We realize
we are proposing a major change in attitude of primary health care providers in terms of the power
of nutrition in the prevention and treatment of common disease.
20.2 NUTRITION PRESCRIPTIONS BY CHAPTER

This chapter provides the nutrition prescription relevant to each chapter, so that you will be able to
initiate a plan within the difficult time constraints facing physicians today. As with prescriptions for
drugs, long-term adherence is the challenge that must be faced after the nutrition prescription has
been written. We will discuss how to engage your patients after they leave your office while main-
taining a connection with your staff. The reach of the primary care practice can also be extended
through commercial weight loss programs, Internet fitness and diet tools, and smartphone apps that
are available to help patients improve their diet and lifestyle.
349
Chapter 1: Incorporating Nutrition into Your Practice
1. Survey your practice population’s nutrition status and lifestyle.

2. Identify medical, nutritional, behavioral, and exercise resources available.
3. Obtain the equipment needed for primary care nutrition practice, including a bio-
impedance scale with at least four contact points from a reliable manufacturer.
4. Review your office floor plan to accommodate obese patients in exam offices and pro-
vide space for group counseling and body composition at intake.
5. Train your staff to be empathetic and supportive in their interactions with the aged, the
obese, and the nonadherent patients in your practice.
6. Modify routine practice steps to maintain efficient patient flow.
7. Provide Internet resources for self-monitoring and reporting progress to your practice.
8. Establish methods to obtain reimbursement for your services.
Chapter 2: Personalization of Nutrition Advice
1. Measure lean body mass by bioimpedance and provide patients with protein recom-
mendations and calorie recommendations for weight maintenance or weight loss to
optimize body composition.
2. Evaluate fitness and provide an exercise prescription or referral to a physical therapist
or certified trainer.
3. Through your registered dietitian, survey the diet and provide personalized food
choices within the general guidelines based on the U.S. dietary guidelines for a healthy
diet.
4. Optimize overall nutrition through diet and supplements.
5. Obtain information on botanical dietary supplements and provide advice.
Chapter 3: Nutrition and the Immune System
1. Determine if your patient has chronic inflammation complaints or frequent infections.

2. Optimize visceral fat measured by waist circumference through a combination of bal-
anced diet and healthy active lifestyle.
3. Measure fatty acid profile and increase intake of omega-3 fatty acids from ocean-
caught fish and seafood or fish oil or algae oil supplements. On a low-fat diet, about
2 g/day of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) should be
optimum for most patients.
4. Determine whether patients are eating seven servings a day of colorful fruits and veg-
etables containing phytonutrients that optimize immune function.
Writing the Nutrition Prescription 351
Chapter 4: Nutrition and Gastrointestinal Disorders
1. Determine if your patient has regular bowel movements or suffers from irritable bowel
syndrome, including chronic constipation or diarrhea.
2. Determine whether food allergies or food intolerances are present. Ask about gluten
sensitivity or enteropathy.
3. Assess whether there are any eating disorders or abnormal weight obsessions.
4. Optimize normal gastrointestinal function through hydration, fiber, and a regular bio-
rhythm of eating and activity, including adequate sleep.
5. Ask your dietitian to determine sources of 25 g of dietary fiber per day from fruits,
vegetables, and whole grains. Reduce intake of sugar and refined grains, as well as
foods that cause bloating or other gastrointestinal symptoms.
Chapter 5: The Overweight and Obese Patient
1. Determine the obesity phenotype.

2. Estimate energy expenditure and protein requirements.
3. Define a timescale for reaching the desirable weight range.
4. Provide structured diet programs that include the choice of using meal replacements
and/or portion-controlled foods.
5. Prescribe leisure time physical activity and exercise.
6. Review behavioral strategies, including stress reduction, stimulus control, relapse pre-
vention, social support, and self-monitoring.
7. Establish a plan for follow-up and social support individually or through groups.
Chapter 6: Nutrition and Evolution of Type 2 Diabetes
1. Determine the family history of type 2 diabetes and gestational diabetes to assess
which patients require an intensive approach beyond the usual dietary guidelines.
2. Institute an intensive personalized diet, increased physical activity, educational ses-
sions, and frequent follow-up patterned on the National Institutes of Health (NIH)
Diabetes Prevention Program, but using the concepts outlined in Chapter 2 to optimize
food and supplement intake.
3. In patients with excess body fat or metabolic syndrome, institute the program for weight
management outlined in Chapter 5 and consider using meal replacements shown to be
effective in the LOOK Ahead trial.
4. Reduce the consumption of sugar, especially from soft drinks and juices. Reduce high-
glycemic-index foods and educate the patient on which foods to avoid.
5. Institute a personalized exercise program, including resistance exercises to build mus-
cle, which will increase the uptake of glucose independent of insulin and reduce stress
on the pancreatic β-cells.
Chapter 7: Managing Diabetes without Weight Gain
1. Determine the duration of type 2 diabetes mellitus and the likelihood that there are
significant residual β-cell reserves of insulin. If necessary, conduct an oral glucose
tolerance test measuring glucose, insulin, and C-peptide, the connecting peptide chain
between the A and B chains of insulin and a validated measure of insulin reserves.
2. For patients with recent onset of diabetes or with significant insulin reserves, prescribe
metformin according to the manufacturer’s recommendations to spare pancreatic
β-cell stress.
3. Emphasize weight management, since 95% of these patients are overweight or obese,
over short-term tight glucose control.
4. When using insulin, incretins, or insulin secretagogue drugs to control blood sugar,
use the minimum needed to maintain blood sugar at a level where there are no symp-
toms or immune impairment, but not to some tight control target that is theoretical.
This is particularly dangerous in elderly patients or those with heart disease, where
hypoglycemia causes a greater risk than mild hyperglycemia.
5. Avoid increasing insulin in patients not adherent to diet recommendations since this
can result in a form of iatrogenic obesity due to high insulin levels promoting adipose
tissue accumulation.
6. Utilize the principles in Chapters 5 and 6 to minimize weight gain through balanced
diet and exercise prescriptions.
7. Institute a strong follow-up program, including exercise and food records, combined
with blood glucose monitoring, so that patients can detect impacts of nonadherence to
recommendations.
Chapter 8: Fatty Liver
1. Assess liver function to determine the degree of suspicion for nonalcoholic steato-
hepatitis (NASH) disease. While fatty liver is very common, it is not sufficient for the
diagnosis of NASH, which requires liver fat greater than 5% on MRI or, if clinically
indicated, a liver biopsy, which should be performed by a liver specialist or gastroen-
terologist due to the significant risks of the procedure.
2. Assess whether metabolic syndrome or diabetes is present and utilize the steps in
Chapters 6 and 7 if this is the case.
3. If there is no history of obesity, diabetes, or metabolic syndrome, consult a liver spe-
cialist to rule out other causes or contributors to the risk of liver failure or hepatocel-
lular carcinoma.
4. Consider using 800 IU of vitamin E per day, milk thistle, and omega-3 fatty acid sup-
plementation, together with the appropriate diet and exercise approaches emphasized.
While not proven in clinical trials, shared decision making with patients is appropriate
for these dietary supplements.
5. Institute a careful follow-up program to assess the impact of lifestyle changes on liver
function tests (aspartate aminotransferase [AST], alanine aminotransferase [ALT],
and gamma-glutamyltransferase [GGT]) and liver fat by MRI.
Chapter 9: Lipid Disorders and Management
1. Determine whether the patient has dyslipidemia with elevated triglycerides and choles-
terol or isolated hypercholesterolemia.
2. For isolated hypercholesterolemia, use statins or, in countries other than the United
States, where legal, Chinese red yeast rice.
3. Add soluble fibers like guar or β-glucan supplements and phytosterol supplements to
bind cholesterol in the intestine, which will reduce the size of the cholesterol pool and
lower blood levels of LDL cholesterol.
4. In dyslipidemia, the most common lipid disorder, use fish oil supplements to lower
triglycerides and β-glucan or phytosterols to lower cholesterol. Also, employ the same
weight management strategies used to prevent type 2 diabetes mellitus or treat the
metabolic syndrome, as these conditions often include hypertriglyceridemia.
5. In the diet, reduce excess sugar, refined carbohydrates, trans fats, and omega-6 fats to
make the fish oils more effective in lowering triglyceride levels. Use monounsaturated
fats from olive oil, avocados, and tree nuts to reduce inflammation, which promotes
hypertriglyceridemia.
Chapter 10: Nutrition and Coronary Artery Disease
1. In patients with a prior cardiac event, institute statin therapy or, in countries other than
the United States, Chinese red yeast rice. The statins and polyketides in Chinese red
yeast rice have anti-inflammatory effects, in addition to lowering cholesterol levels.
2. Institute a diet consistent with the guidelines of the American Heart Association, but
which incorporates a somewhat lower level of fat, in combination with restricted excess
sugar and refined carbohydrates.
3. Fats should emphasize monounsaturated fats and limit hidden omega-6 and trans fats
in processed foods. Fish oil from ocean-caught fish and fish oil supplements should
be used to reduce inflammation. Prescribe aerobic exercise for cardiac rehabilitation,
including behavior change strategies, such as meditation, combined with stress reduc-
tion and treatment of comorbid conditions, such as hypertension or type 2 diabetes
mellitus.
4. Recommend seven servings per day of colorful fruits and vegetables. Evidence has
been found for the benefits of lutein in stabilizing coronary arterial plaques, but other
phytonutrients and antioxidants may also be of benefit.
5. Beetroot extract can be recommended to increase nitrite storage in myocardium, which
is activated under conditions of hypoxia.
Chapter 11: Hypertension and Obesity
1. Diagnose and treat obesity—the most common cause of hypertension.

2. The Dietary Approaches to Stop Hypertension (DASH) diet, rich in nutrients from
fruits, vegetables, and dairy, with modest levels of sodium and omega-3 and omega-6
fatty acids, has emerged as a balanced dietary strategy for the management of
hypertension.
3. Soy protein rich in arginine can increase nitrite levels in the blood, as can beetroot
extract rich in nitrate that is converted to nitrite by oral bacteria, absorbed in the blood
as nitric oxide, and stored in the heart muscle and other organs as nitrite, which can be
converted to nitric oxide under hypoxic conditions.
4. For sodium control, reduce the intake of processed foods with hidden sodium and
increase potassium-rich fruits and vegetables. Excessive sodium restriction to levels
of 1500 mg/day may be harmful and unattainable. Reasonable sodium intake controls,
together with the DASH diet, are adequate to control blood pressure.
5. In obese patients not responsive to diet and sodium control, and in those with uncon-
trolled hypertension, adjunctive pharmacotherapy should be used, including agents
targeting sympathetic activation, increased renal tubular sodium reabsorption, and
overexpression of the renin–angiotensin–aldosterone system (RAAS) by the adipocyte.
Chapter 12: Nutrition and Renal Failure
1. Review the estimated glomerular filtration rate (GFR) from the lab analysis based on
serum creatinine, height, and weight. Check for proteinuria, microalbuminuria, and
coexisting obesity or diabetes.
2. If it is borderline low in an individual with increased lean body mass, order a 24-hour
urinary creatinine clearance test. If it is normal in an individual with a low lean body
mass and a comorbid condition associated with sarcopenia, order a 24-hour urinary
creatinine clearance.
3. If chronic kidney disease is found, concentrate on the treatment of hypertension, which
is the one factor that can affect the rate of change in GFR.
4. Optimize the treatment of coexisting hyperlipidemia or diabetes.
5. Treat with an RAAS inhibitor in the obese diabetic patient with chronic kidney disease.
6. Address overweight and obesity with diet and exercise recommendations.
Chapter 13: Nutrition and Heart Failure
1. Educate patients on the importance of adhering to their medication regimen using

inhibitors of the RAAS or sympathetic nervous system.
2. Use diuretics for symptomatic relief and minimize doses using B-natriuretic peptide
monitoring.
3. Restrict sodium to 2.8 g/day and fluid intake to 1–2 L/day.
4. Patients should weigh themselves daily to detect fluid shifts and be taught that each
quart or liter weighs about 2 pounds or 1 kg.
5. Supplement with omega-3 fatty acids and reduce omega-6 fats in the diet.
6. Supplement with coenzyme Q10 as ubiquinone or ubiquinol.
7. Supplement with a multivitamin or multimineral to compensate for vitamin and min-
eral losses through urine secondary to diuretic use.
Chapter 14: Pulmonary Function, Asthma, and Obesity
1. Ask obese patients about snoring and sleep quality. Conduct a formal sleep study if
indicated. Poor sleep promotes overeating and obesity, which leads to poor sleep and
sleep apnea.
2. Initiate weight management using the methods outlined in Chapter 5.
3. Initiate continuous positive airway pressure (CPAP) treatment at the same time, as they
act together.
4. Initiate a sleep hygiene program to promote good-quality sleep.
5. Stress the avoidance of nicotine and caffeine as appropriate.
6. Initiate an exercise and stress reduction program for weight management and improve-
ment of sleep quality.
Chapter 15: Frailty, Nutrition, and the Elderly
1. Increase protein intake to 1 g/pound of lean body mass and initiate a program of physi-
cal therapy and resistance training to combat sarcopenic obesity.
2. Increase fruit and vegetable intake, especially lutein-containing green vegetables, for
the prevention of age-related macular degeneration and for brain health.
3. Initiate supplementation with a multivitamin or multimineral, 2000–5000 IU/day of
vitamin D, and fish oils providing 2 g/day of EPA and DHA.
4. Survey taste changes and food preference changes to ensure that overall nutrition is
adequate.
5. Prescribe daily walking and assess walking speed as a variable over time in response
to physical therapy and resistance exercise, combined with protein supplementation.
6. Consider anabolic androgen treatment in advanced sarcopenia and assess the risks and
benefits with each patient individually.
Chapter 16: Nutrition and Neurodegenerative Diseases
1. Assess cognitive function using questionnaires. If cognitive impairment is present,

then initiate a program of mental and physical exercise, stress reduction, and social
engagement.
2. Initiate a nutrition program to supplement protein, increase antioxidant intake, and
reduce inflammation.
3. Initiate supplementation with a multivitamin or multimineral, 2000–5000 IU/day
of vitamin D, and fish oils providing 2 g/day of EPA and DHA. Consider bioavail-
able forms of curcumin to ameliorate inflammation in the brain, even though clinical
research is ongoing.
4. Increase intake of colorful fruits and vegetables, including cranberry, pomegranate,
and cocoa flavonols. Consider beetroot extract to improve endothelial function.
5. If there are no contraindications, consider green tea extract, caffeine, and gingko
biloba extract to improve concentration and attention.
6. Treat coexisting obesity and type 2 diabetes as indicated in Chapters 5 through 7.
Chapter 17: Gene–Nutrient Interactions
1. Recommend a multivitamin or multimineral supplement.

2. Measure homocysteine levels and supplement with folate, choline, and betaine as nec-
essary to reduce levels of homocysteine.
3. Measure iron and iron-binding capacity to detect hemochromatosis. Genetic testing is
not necessary to make the diagnosis.
4. Recommend cruciferous vegetable intake at three servings or more per week.
Alternatively, recommend a broccoli sprout extract.
5. Consume seven servings per day of colorful fruits and vegetables.
6. Initiate supplementation with 5000 IU of vitamin D daily.
7. Do not recommend a commercial genetic test for the purpose of generating dietary
recommendations.
Chapter 18: Nutrition and the Risks of Common Forms of Cancer
1. Assess family history of common forms of cancer. While usually sporadic, there are
some families with a strong history of genetic forms of cancer.
2. Obtain the history of cancer treatment and site in cancer survivors.
3. In cancer survivors, initiate a preventive nutrition program to prevent recurrence,
emphasizing achieving and maintaining a desirable body composition and weight,
increased intake of fruits and vegetables, and judicious use of dietary supplements.
Chapter 19: Nutrition and the Cancer Patient
1. Assess nutrition status in patients with advanced cancer and support them with enteral
nutrition supplementation after treatment. Work closely with oncologists on any dietary
recommendations and potential nutritional side effects of cancer treatment.
2. In cancer patients, utilize nutrition intervention to preserve or increase lean body mass,
reduce fatigue, improve quality of life, correct specific nutrition deficiencies, improve
tolerance of cancer therapy, reduce side effects and complications related to nutrition,
and enhance immunity and decrease the risk of infection.
3. In cancer cachexia, support the patient with enteral nutrition for basic needs and allow
food intake for pleasure without concern as to calorie intake.
4. Initiate a program for appetite improvement, as outlined in the chapter.
5. Consider using appetite-enhancing drugs such as megestrol acetate and marijuana or
cannabinoid extract supplements.
20.3 ENGAGING WITH PATIENTS USING WEARABLE

DEVICES AND SOCIAL MEDIA
The Internet has had a major impact on the lives of primary care physicians. While word
processing has been a feature of medical practice since the 1980s, it was mainly used for the
production of physical letters sent to patients or insurers. Today, virtually all communica-
tions about patients are conducted electronically, including widespread use of electronic health
records, which record all lab tests and visits. There are also patient-accessible services, allow-
ing them to see their medical records and empowering them to see the changes that result from
altering diet and lifestyle habits.
While there is no documentation yet, it is hoped that the use of electronic health records will
enable better communication among health care providers, greater accountability for therapeutic
decisions, and a greater ability to study the quality of care. In addition, the advent of PubMed, sup-
ported by the U.S. government, has made a major difference in the ability of physicians to access
research and clinical information relevant to their daily challenges in a timely fashion. Just 40 years
ago, it was necessary to go to the physical library and read or copy heavy bound books containing
annual collections of medical or scientific journal articles. Textbooks were only available in librar-
ies, and the general information that lives on Internet-accessible sites today was limited to physical
books. All the above advances fall under the heading of the internal Internet designed for the benefit
of the physician or primary care provider, with some benefit for the process of patient care. Most
physicians have used private e-mail or patient communication systems linked to their institution,
which patients can access independently to review lab tests or medical notes. The advent of these
services has made it easier to meet privacy requirements mandated in the United States in the 1990s
as the Health Insurance Portability and Accountability Act (HIPAA). Prior to the enactment of this
law, insurance companies and individuals could access medical record information without the
consent of the patient.
There is also an external-facing use of the Internet, including social media. Social media has
exploded over the past decade, as Facebook, Instagram, What’s App, and We Chat have become
a part of the American culture. Recently, the founder of Facebook, Mark Zuckerberg, launched
a multi-billion-dollar initiative to utilize social media in the battle for better health and new dis-
coveries that solve the most pressing chronic diseases to improve quality of life and health span.
Facebook now has the capability to host video and live TV shows, which enables primary care
providers to create a virtual community in which patient education can be provided efficiently to
large numbers of patients simultaneously using an interactive forum.
The power of big data to create information that can be mined by epidemiologists promises to
provide new clues to the prevention and treatment of chronic disease, much as we have opened
new avenues for primary care practices to use diet and exercise to reduce risk factors for disease in
multiple organ systems. As diet and exercise interventions become more common in primary care
practice, observations in clinical practice will form a new database for the evolution of controlled
clinical trials, which will also be carried out using social media. Using Instagram, it is possible to
take photographs of meals being eaten or supplements consumed, enabling better assessment of
adherence to treatment and research study protocols.
A Facebook page for the primary care practice can also accomplish several other objectives,
including providing patients with more information about their provider’s human side, including
interests and expertise. Primary care patient education can also be provided on a blog that is part
of your primary care practice website. In all these places, you can provide your patients with links
to controversial newspaper and magazine articles, with summaries and the doctor or primary care
provider’s opinions appended. This will start a conversation between patients and providers and
lead to a meeting of the minds on a central philosophy that motivates both providers and patients as
a mission for better nutrition.
Shared decision making has been emphasized for therapeutic decisions on pharmacotherapy but
has not been emphasized in nutrition and exercise, where the default position is the government’s
dietary guidelines, which do not provide adequate personalization since they were designed for the
average healthy population. As a result, more than 80% of the public do not meet either dietary
guidelines or the guidelines designed to encourage physical activity. Through social media, it is
possible for you to provide patients with special advice for different disease conditions, as discussed
in this text.
This chapter reviews the range of these types of opportunities for enhanced interaction between
patients, providers, and communities in order to enhance your ability to communicate your personal
philosophy of nutrition and chronic disease to your patients.
20.3.1 Wearable Devices
A major reason that guidelines do not change behavior is that there is no provision for patient
accountability to themselves or to the primary care practice. There is a coming revolution in
wearable devices to monitor physical activity, blood pressure, blood glucose, sleep quality, and
temperature throughout the day. From these measures, it will be possible to estimate total energy
expenditure or calorie burning during the day. While the accuracy of these estimates can be ques-
tioned by scientists studying these physiological functions in detail, the inaccuracies of the methods
are beside the point, as these devices are mainly intended to provide feedback to both patients and
the primary care provider as changes occur that indicate adherence with recommended nutrition
and exercise recommendations.
Wearable devices can be used to monitor the most basic aspect of physical activity passively.
Counting steps per day and increasing them gradually to 10,000 per day is a first step in incor-
porating a healthy active lifestyle into one’s daily routine. A walk after dinner can promote better
digestion. A brisk morning walk can serve to activate the body and prepare it for targeted muscle-
building exercises. There are a number of watches and other devices, including smartphones, that
have internal accelerometers. These devices register movements and record them, from simply
shaking up and down during walking to actually monitoring the movement involved in walking.
While these devices do not record all physical activity, they do a good job of monitoring walking
and running steps. They also often link to programs for monitoring food intake. The interesting
aspect of recording food intake is that it is not only a monitoring method but also an intervention to
change dietary patterns as a result of recording food intake.
All the above automated and interactive computer applications are wonderful, but they do not
substitute for personal contact. Office visits can be supplemented by group intervention lectures
involving up to 20 people. The interchange that results from a question-and-answer session can
build strong relationships between patients and primary care providers. Volunteering for media
opportunities on local television or speaking to local civic groups also enhances the prestige of a
primary care practice.
20.3.2 Social Media
The greatest opportunity provided by social media is to humanize a primary care practice for
patients. A Facebook page with photos of staff and physicians, along with some basic background
information, can help patients get to know their doctors better, which is not always possible during a
rushed office visit. Some of the posts can also be used to educate patients on health practices, nutri-
tion, exercise, and prevention. In addition to basic information, it is helpful to promote a dialogue on
controversial issues. This will engage patients and let them see how you make your decisions and
the specifics of your nutrition philosophy. Patients should be discouraged from posting information
on their own medical conditions, but should be encouraged to ask questions with regard to practice
services.
When social media is used strictly as a marketing tool with a one-way lecture on information
about a practice, it loses its appeal. Too much of a strong advertisement will defeat the community-
building purpose of social media by lacking authenticity. The goal of social media should be to
engage with patients and build trust. The marketing will flow naturally via word of mouth that your
site is worth visiting. The various social media platforms can be used together. For example, you can
promote a message on healthy lifestyles in a 60-second video. You can then incorporate it into your
Facebook page or link it into a 140-character Twitter message. There are applications that allow
you to post the same message on multiple platforms, including Facebook, Twitter, Google Plus, and
LinkedIn. You can post messages that link to a blog on your practice website. You can share inter-
esting information you may have read on various platforms. Patients may also follow your Twitter
account with links to other social media where you appear.
Millennials use social media, and although many physicians are not familiar with various plat-
forms, such as Instagram and Pinterest, these patients and their young families do use these ser-
vices. An online presence is going to be a routine way for medical practices to be noticed in their
communities, and it would be worthwhile to begin to get familiar with social media’s potential.
20.4 MANAGING INFORMATION OVERLOAD

TO KEEP UP WITH NUTRITION RESEARCH
Just 20 years ago, the typical busy practitioner would subscribe to several well-established medical
journals. Between patients or at lunch, there would be time to read at least the abstract and then clip
a few interesting articles to place in a file cabinet. Medical information management was so inef-
ficient as to make physicians dependent on continuing education courses. These courses were often
supported by the drug industry, and well-known authorities would cleverly transmit the messages
that the drug industry needed to promote sales of their products. There was much less to know and
far fewer controversies to handle.
Today, primary care providers are flooded with information and misinformation on nutrition,
medicines, and putative cures for chronic diseases by social media, television news, e-mail, and
print and online reports. In 2013, the Institute of Medicine acknowledged this problem, stating,
“The ever-increasing volume of evidence makes it difficult for clinicians to maintain a working
knowledge of new clinical information” (Mehta et al. 2016). The huge volume of information con-
fronting primary care providers today has meant that rather than try to maintain a routine habit of
professional reading, many primary care providers now seek information only when answers to
specific clinical questions are needed for patient care. The advantage of this approach, which is
reactive rather than proactive searching, is that it promotes the skills of problem-based learning.
The disadvantage is that it assumes that physicians and their associates are consciously aware
of the need to search for new information. It is also time-consuming to constantly scan sources for
new evidence in primary care practice nutrition to avoid the problem of knowing obsolete or contra-
dicted concepts. Physicians are expected to practice so-called evidence-based medicine relying on
meta-analyses of efficacy, which is often a valid approach for some forms of pharmacotherapy. In
general, the approach of looking at the Cochrane Library or PubMed for meta-analyses will only be
clear on well-established practices, but will be of less utility in nutrition. Nutrition does not easily
lend itself to the types of randomized placebo-controlled trials typical of the evaluation of a new
drug, Methods for assessing food intake in free-living populations are not yet adequate for this pur-
pose, relying on self-report or supervised dietary recall. Similarly, methods for assessing physical
activity are indirect, and outside the metabolic ward setting, they are difficult to quantitate.
20.5 INFORMATION MANAGEMENT STRATEGIES

A powerful information management strategy is a way to become aware of relevant new informa-
tion in primary care nutrition practice or research by setting up feeds of information from reliable
and authentic sources. These feeds can be browsed on any computer or smart mobile device. There
are several ways to establish these feeds. One option is to subscribe to the table of contents of rel-
evant journals via e-mail. Another option is a research site summary (RSS) feed reader. RSS is a
standard for publishing summaries of frequently updated content on the World Wide Web, such
as journal tables of contents and articles from medical journal news sites. Scientific societies such
as the American Society for Nutrition also release article summaries from their journal. You can
subscribe to these using feed reader software from Feedly (www.feedly.com) or Inoreader (www
.inoreader.com), which can be used with any browser on a desktop or laptop. They are also available
as apps for mobile devices such as smartphones and tablets. The feed reader periodically checks for
new content and automatically downloads it to the device. Thus, you do not need to check multiple
websites for updates. Instead, the content is delivered to your device for reading and scanning at
your convenience.
Patients will often ask about a news feature that they heard only briefly and often take away
incomplete or incorrect information. Surveys have found that up to one-third of local news is devoted
to health stories, and these are often about nutrition and weight loss. The Internet is full of misin-
formation associated with the sale of products promoting ideas that have no basis in science. You do
not have much control over these information streams, and so it is important to be able to determine
the information that is most important and most relevant to you and your practice. Accessing, read-
ing, organizing, storing, and retrieving useful medical information can both improve patient care
and provide you with a feeling of greater control over this information.
It is possible to create a personalized stream of relevant information that can be scanned regularly
and saved so that it is readily accessible. You simply have to dedicate some staff time up front to set up
the topics. This does not substitute for an understanding of the subject, but it will keep you updated.
20.6 CONTINUING EDUCATION AND CERTIFICATION

If you have developed a strong interest in clinical nutrition, there are opportunities for you to obtain
certification. Here, we provide just an overview of three examples.
20.6.1 American Board of Nutrition Physician Specialists

Originally founded as the American Board of Nutrition in 1948, Physician Nutrition Specialist
(NBPNS) administers the comprehensive Certification Examination for Physician Nutrition
Specialists (PNSs). The diplomats generally have backgrounds in the specialties of internal medi-
cine, pediatrics, family medicine, or general surgery, and sometimes in subspecialties such as
adult or pediatric gastroenterology, endocrinology, critical care, nephrology, or cardiology.
To be eligible to take the NBPNS exam, a candidate must meet three requirements:
1. Current licensure to practice medicine in the United States, or the equivalent in other
countries. All candidates for certification and recertification must be licensed to practice
medicine in the country in which they reside.
2. American Board of Medical Specialties (ABMS) certification or the equivalent outside the
United States.
3. Demonstrated expertise in nutrition defined by one or more of the following:
a. Mentored training in clinical nutrition (requires letter of recommendation from mentor)
b. Dedicated service on a hospital multidisciplinary nutrition team (requires letter of rec-
ommendation from hospital chief of staff or physician head of department)
c. Performance of research with publications in nutrition (provide documentation on cur-
riculum vitae)
d. Teaching position involving nutrition at an academic medical center (requires letter of
recommendation from department chairman)
e. Committee membership and/or leadership role in a national nutrition society (provide
documentation on curriculum vitae)
f. Completion of a minimum of 150 hours of continuing medical education (CME)
devoted to clinical nutrition (provide CME documentation)
g. Regional peer-recognized leadership role in nutrition (requires letter of recommenda-
tion from peer in community)
4. Completion and filing of an application for the Certification Examination for Physician Nutrition
Specialists, including copies of the candidate’s current medical license and board certification.
Unlike less rigorous certifications, NBPNS accepts only physician applicants. To qualify for the
exam, a physician must first be licensed in his or her state or jurisdiction and have boards in a pri-
mary specialty. Current diplomats hold primary specialty certification in either internal medicine,
pediatrics, family medicine, or general surgery. Many of the internists and pediatricians are also
subspecialists in either gastroenterology, endocrinology, or critical care. Many of the surgeons are
subspecialists in critical care, trauma, or burns. They must then complete an approved fellowship in
clinical nutrition, or a time-limited alternate pathway exists for demonstrating expertise in nutrition
based on mentored training and self-learning.
Approved fellowships are currently available at the following 13 institutions: University of
Alabama at Birmingham, Boston University, University of California at Los Angeles, University
of Chicago, Children’s Hospital of Philadelphia, Cleveland Clinic, University of Alberta, Canada,
University of Colorado, Columbia University Medical Center, Geisinger Health System, Harvard/
Massachusetts General Hospital, Memorial-Sloan Kettering Cancer Center, and Atlantic Health/
Morristown Medical Center. Fellowships are 1–2 years in duration.
An applicant who passes the NBPNS exam receives a PNS certification that is valid for 10 years,
after which the candidate must retake the certification examination or meet maintenance of certifi-
cation (MOC) requirements.
NBPNS is a collaboration of the eight major nutrition professional societies. These include the
American Society of Nutrition (ASN), American College of Nutrition (ACN), American Society of
Parenteral and Enteral Nutrition (ASPEN), Canadian Nutrition Society (CNS), The Obesity Society
(TOS), American Gastroenterological Association (AGA), American Association of Clinical
Endocrinology (AACE), and Society for Critical Care Medicine (SCCM). Each stakeholder has a
board seat.
Website: http://www.nutritioncare.org/NBPNS/
20.6.2 American Board of Obesity Medicine

The American Board of Obesity Medicine (ABOM) serves the public and the field of obesity medi-
cine by maintaining standards for the assessment and credentialing of physicians. Certification as
an ABOM diplomate signifies specialized knowledge in the practice of obesity medicine and distin-
guishes a physician as having achieved competency in obesity care.
To be eligible for the ABOM certification, a candidate must have three credentials:
1. Proof of an active medical license in the United States or Canada

2. Proof of completion of a residency in the United States or Canada
3. Active board certification in an ABMS member board or osteopathic medicine equivalent
A candidate must also have the required CME credit hours:
1. A minimum of 60 credit hours of CME recognized by the American Medical Association

Physician Recognition Award (AMA PRA) Category 1 Credits on the topic of obesity are
required for certification.
2. At least 30 credit hours must be obtained in person at a live meeting or conference.
3. The remaining 30 credit hours may be obtained by at-home CME activity.
All 60 CME credits must be earned within 36 months of the application deadline (e.g., from
August 30, 2013 to August 30, 2016). All CME credits must be earned and documented at the
time of application, except in the case of two specific meetings that take place each fall. CME
credit hours from the Obesity Medicine Association’s fall 2016 meeting and The Obesity Society’s
Obesity Week 2016 meeting will be valid for the 2016 ABOM exam with meeting registration docu-
mentation submitted with all other application requirements.
An applicant who passes the ABOM exam becomes a ABOM diplomate, and the certification
is valid for 10 years, after which the candidate must meet the recertification requirements to be
recertified.
Website: http://abom.org/
20.6.3 Specialist Certification of Obesity Professional Education

Specialist Certification of Obesity Professional Education (SCOPE) is a program supported by the
World Obesity Federation and is the only internationally recognized certification in obesity man-
agement, endorsed by the National Health Service (NHS) and more than 50 national scientific
obesity associations globally. It equips health professionals with up-to-date, evidence-based obesity
management resources, to better treat their obese patients and excel in their careers. This certifica-
tion is available not only to physicians but also to all professionals engaged in obesity treatment,
including psychologists, nurses, dietitians, and exercise specialists.
To be eligible for the SCOPE certification, a candidate must meet the following criteria:
1. Evidence of 6 months of practical experience related to obesity management within a med-

ical or allied health care professional setting.
2. At least 4 points from SCOPE e-learning modules.
3. Twelve points are required for certification. You may choose to accumulate the remaining
8 points through e-learning or combine e-learning with
a. SCOPE schools (4 points)
b. SCOPE-accredited instructor-led courses
SCOPE certification is renewable annually by completing two additional SCOPE modules and
submitting a renewal fee.
Website: http://www.worldobesity.org/scope/
There are separate certifications for dietitians through the Academy of Nutrition and Dietetics.
Beginning in 2017 Registered Dietitians will need to obtain a Masters’ Degree in Nutrition. Fitness
trainers can obtain certification through the American College of Sports Medicine. While certifica-
tion is not necessary, it may serve to establish the expertise of your primary care practice. Finally,
we hope you have enjoyed reading this text and will recommend it to your colleagues.
REFERENCE
Mehta, N. B., S. A. Martin, J. Maypole, and R. Andrews. 2016. Information management for clinicians. Cleve
Clin J Med 83 (8):589–595.
Index
A paradox in heart failure, 243–244

relationship between systolic and diastolic BP and, 208
ABOM, see American Board of Obesity Medicine SGLT-2 inhibitors and, 138
Acceptable macronutrient distribution ranges (AMDRs), women with breast cancer, 331
19, 20 Botanical dietary supplements, 52
ACE inhibitors, 241 Brain-derived neurotrophic factor (BDNF), 287
Action in Diabetes and Vascular Disease (ADVANCE) Brain health; see also Neurodegenerative disorders and
trial, 139 cognitive impairment
Adequate intake (AI), 19 aging and, 96
ADH, see Antidiuretic hormone alcohol and, 289–290
Aging, obesity and, 96 coffee and, 289
Alcohol dietary supplements and, 290
brain health and, 289–290 obesity and, 96
cancer and, 315–316 Buformin, 137
Alcoholic hepatitis, fatty liver interactions with, 159–160 Burproprion, 91
Aldosterone antagonists, 242
Alogliptin, 137
Alternate Mediterranean Diet Score (aMED), 196 C
Alzheimer’s disease, 290–291
AMDRs, see Acceptable macronutrient distribution ranges CAC, see Coronary artery calcification
American Board of Medical Specialties (ABMS) CAD, see Coronary artery disease
certification, 361 Cancer, obesity and, 93–94
American Board of Obesity Medicine (ABOM), 362 Cancer (common forms of), risk of, 309–328
American Society for Metabolic and Bariatric Surgery alcohol, 315–316
(ASMBS), 6 antioxidant supplements, 316–320
Amylin, 137 folic acid, 318
Angiotensin receptor blocker (ARB), 216, 241 glucosinolates from cruciferous vegetables, 318–319
Antidiuretic hormone (ADH), 211 green tea polyphenols, 319–320
Antioxidant-rich foods, 288–289 lycopene, 318
Antioxidant supplements, 316–320 microbiota metabolism of phytonutrients and immune
Arginine vasopression (AVP), 211 function, 321–322
Asthma, see Pulmonary function, asthma, and obesity nutrition and physical activity as risk factors, 310–311
Atkins diet, 195 obesity and cancer, 314–315
phytonutrients, 316
B risk factors versus statistical bad luck, 311–316
spices, 320–321
Basal energy expenditure (BEE), 335 Cancer patient, 329–347
BDNF, see Brain-derived neurotrophic factor appropriate methods of nutrition care, 337–340
Beriberi, 47 cancer survivors in primary care, 331–333
Biotin, 50 carbohydrate metabolism, 334–335
Biotransformation enzymes, 299 changing face of cancer, 330–331
β-Blockers, 241–242 complementary and alternative medicines, 342
BMI, see Body mass index diet and cancer prevention, 340–342
Body composition (personalization of nutrition advice), enteral nutrition, 339
22–41 host–tumor interactions and metabolic abnormalities,
carbohydrates and fibers, 32 335–336
dietary pattern that prevents weight gain, 40–41 nutrition screening, 336–337
fats and oils, 37–40 oral nutrition support, 337–338
glycemic index, glycemic load, and calories, 33–37 parenteral nutrition, 340
lean body mass, building a personalized diet based on, primary care oncology, 329–330
22–26 protein–energy malnutrition, 333–334
protein quantity and quality, 31 Cannabinoid extract supplements, 357
simple sugars and complex carbohydrates, 32–33 Carbohydrates
supplemented personalized protein, rationale for complex, 32–33
balanced diet based on, 26–31 fibers and, 32
Body mass index (BMI), 85 metabolism, 334–335
frailty and, 274 specific diet, 78
365
366 Index
Cardiac cachexia, protein in, 244 meal replacements, 142–143

Cardiovascular diseases, obesity and, 93 micronutrients, 146–147
Carotene and Retinol Efficacy Trial (CARET), 317 monounsaturated fats, 145
Catechins, 288 obesity and diabetes, 138
Cholesterol metabolism and transport, disorders of, 174 omega-3 fatty acids, 146
Choline, 49–50 pharmacological treatment of diabetes, 136–138
Chronic kidney disease (CKD) and kidney failure, physical activity to increase muscle mass, 143–144
223–236 spices and glucose control, 146
nutrition in chronic kidney disease and end-stage renal typical modern management of T2DM, 140–141
disease, 228–232 use of metformin in T2DM, 141–142
nutrition and prevention of chronic kidney disease, 228 weight management and weight reduction in T2DM,
obesity, fatty kidney, and chronic kidney disease, 139–140
224–225 Diabetes Prevention Program (DPP), 139
renal insufficiency and chronic kidney disease, Dietary Approaches to Stop Hypertension (DASH) diet,
225–227 196, 209
Chronic traumatic encephalopathy (CTE), 281 Dietary fibers, 32
Cirrhosis, NAFLD and, 157 Dietary guidelines, personalization of, 17
Coenzyme A, 50 (CoA), 50 Dietary Reference Intakes (DRIs), 19–20
Coenzyme Q10 (CoQ10), 239, 246–247 Dietary supplements, brain health and, 290
Coffee, brain health and, 289 Diethypropion, 91
Cognitive behavioral therapy, obesity and, 104 Digoxin, 242
Cognitive impairment, see Neurodegenerative disorders DIOGENES trial, 90
and cognitive impairment Diuretics, 242
Continuing education and certification, 360–363 DPP, see Diabetes Prevention Program
American Board of Nutrition Physician Specialists, DRIs, see Dietary Reference Intakes
360–361 Drug-metabolizing enzymes, 299
American Board of Obesity Medicine, 362 Dual-energy x-ray absorptiometry (DEXA), 268
Specialist Certification of Obesity Professional
Education, 362 E
Continuous positive airway pressure (CPAP) devices,
255 EAR, see Estimated average requirement
Coronary artery calcification (CAC), 192 Eating disorders, treatment of, 73–74
Coronary artery disease (CAD), 187–205 eGFR, see Estimated glomerular filtration rate
atherosclerosis and inflammation, cellular basis of, Elderly patients, see Frailty and the elderly
189–191 Endothelial dysfunction, 191
coronary artery calcification (CAC), 192 End-stage renal disease (ESRD), 223, 228–232
dietary pattern, 193–196 Epigallocatechin gallate (EGCG), 288
dietary recommendations, 193 Eplerenone, 242
endothelial dysfunction and nitric oxide, 191 Estimated average requirement (EAR), 19
low-glycemic-index diets, 197–198 Estimated glomerular filtration rate (eGFR), 223
nitrate-rich foods, 196–197
phytonutrients, 198–200 F
statin drugs, effects of, 192–193
type 2 diabetes, 192 Familial combined hyperlipidemia (FCHL), 175
unstable plaques and myocardial infarction, 188–192 Familial hypercholesterolemia, 177
weight management to reduce visceral fat, 193–200 Familial hypertriglyceridemia (FHTG), 175
Coumadin, 46 Family Smoking Prevention and Tobacco Control Act,
CPAP devices, see Continuous positive airway pressure 309
devices Fat-soluble vitamins, 42–47
C-reactive protein (CRP), 267 vitamin A, 42–43
CTE, see Chronic traumatic encephalopathy vitamin D, 43–45
Cyclooxygenase-2 (COX-2), 320 vitamin E, 45–46
vitamin K, 46–47
D Fatty acids
comparative ratios of omega-6 to omega-3, 38
Dementia, diagnosis of, 283–285 composition in commonly eaten fats, 40
Depression, obesity and, 94 omega-3, macrophage and, 60–61
DEXA, see Dual-energy x-ray absorptiometry polyunsaturated, 78, 239
Dexfenfluramine, 91 Fatty liver disease, 155–171
Diabetes, Alzheimer’s disease and, 290–291 alcoholic and viral hepatitis, fatty liver interactions
Diabetes management without weight gain, 135–154; with, 159–160
see also Type 2 diabetes mellitus, evolution of clinical presentation of significant liver damage,
diagnosis of T2DM, 135–136 160–161
low-GI foods, fiber, and resistant starches, 144–145 diagnostic dilemmas, 160
Index 367
fructose and fatty liver, 161–162 H

NAFLD and cirrhosis, 157
NAFLD and hepatocellular cancer, 157–158 HATs, see Histone acetyltransferases
NAFLD and metabolic syndrome, 157 HDACs, see Histone deactylases
obesity and, 96 HDLs, see High-density lipoproteins
pathophysiology of NAFLD, 155–156 Heart failure, 237–253
protein malnutrition in advanced liver disease, ACE inhibitors and angiotensin receptor blockers, 241
164–165 ADH antagonists, 242
vitamin E, fish oils, phytonutrients, and overall aldosterone antagonists, 242
nutrition, 162–163 balancing omega-3 and omega-6 fats in the diet, 245–246
FCHL, see Familial combined hyperlipidemia β-blockers, 241–242
FDA, see U.S. Food and Drug Administration BMI paradox in heart failure, 243–244
Fenfluramine, 91 coenzyme Q10 supplementation, 246–247
FHTG, see Familial hypertriglyceridemia diagnosis and medical treatment, 238–243
Fish oils, cognitive health and, 287 digoxin, 242
FODMAP diet, 78 diuretics, 242
Folic acid, 48, 318 etiology and clinical classification, 237–238
Food insecurity, low socioeconomic status and, 3–4 heart failure treatment (mechanical, revascularization,
Food intolerance and food allergy, 74–75 and heart transplant), 243
Frailty and the elderly, 265–279 hydralazine and nitrates, 243
epidemiology of frailty, 267–269 macronutrients, 244–246
immunosenescence, 266 micronutrients, 246–247
muscle protein synthesis, 270–271 nesiritide, 242–243
nature of aging, 266–267 preserved ejection fraction, heart failure with, 238–239
prevention and treatment of frailty, 272–274 protein in sarcopenia and cardiac cachexia, 244
protein requirements, 271 reduced ejection fraction, pharmacotherapy of heart
sarcopenia, 269–270 failure with, 239–240
smell and taste changes with aging, 271–272 sodium restriction in low-output heart failure, 240–241
thiamine, 247
treatment (medical therapy), 241–243
G Hepatocellular cancer, NAFLD and, 157–158
Gallstones and gout, obesity and, 96 Herbalife International, 107
Gastrointestinal disorders, 71–84 High-density lipoproteins (HDLs), 174
eating disorders, treatment of, 73–74 High-performance liquid chromatography (HPLC), 47
food addiction vs. craving, 72–73 Histone acetyltransferases (HATs), 301
food intolerance and food allergy, 74–75 Histone deactylases (HDACs), 301
gluten enteropathy and gluten sensitivity, 76–77 Hydralazine, 243
inflammatory bowel diseases, 77–79 Hypercholesterolemia, 177
irritable bowel syndrome, 75–76 Hypertension and obesity, 92, 207–221
GDM, see Gestational diabetes mellitus diet, 208–210
Gene–nutrient interaction, 297–308 epidemiology, 208
in cancer and aging, 302–303 mechanisms mediating obesity-related hypertension,
case study, 304–305 211–214
epigenetics and diet, 300–301 nutrition approaches, 214–216
genome-wide scanning and disease risk, 303–304 overall treatment recommendations, 216–217
human nutrition and, 298 pharmacological adjunctive treatment, 215–216
microbiome and metagenome, 304 sodium restriction, 214–215
nutrigenetics, 298–300
nutrigenomics, 300 I
Genome-wide association studies (GWASs), 124
Gestational diabetes mellitus (GDM), 125 IAPP, see Insulin-associated polypeptide
GI, see Glycemic index IBDs, see Inflammatory bowel diseases
Glipizide, 137 IBS, see Irritable bowel syndrome
Glomerular filtration rate (GFR), 142 Immune system, 57–70
Glucagon-like peptide 1 (GLP-1), 137 caloric restriction without malnutrition and immune
Glucosinolates, 318–319 function, 61
Glutathione S-transferase (GST), 299 fat cell as endocrine and immune cell, 57
Gluten, 76–77 gut microbiota, 62–65
Glyburide, 137 malnutrition, 58
Glycemic index (GI), 33–37, 143 modulation of immune function, 65–66
Green tea polyphenols, 319–320 obesity, 58–59
Guanidine, 136 omega-3 fatty acids and macrophage, interaction of,
Gut microbiota, 62–65 60–61
GWASs, see Genome-wide association studies vitamin and mineral balance, 59–60
368 Index
Immunosenescence, 266 Multiple Risk Factor Intervention Trial (MRFIT), 210

Infertility, obesity and, 94–95 Musculoskeletal disorders, obesity and, 96
Inflammatory bowel diseases (IBDs), 77–79
breastfeeding, 77–78 N
enteral and parenteral nutrition, 77
FODMAP diet, 78 NAFLD, see Nonalcoholic fatty liver disease
malnutrition, 77 Naltrexone, 91
omega-3 polyunsaturated fatty acids, 79 NASH, see Nonalcoholic steatohepatitis
specific carbohydrate diet, 78 National Cancer Institute Surveillance, Epidemiology,
vitamin D, 79 and End Results (SEER) data, 314
Western diet and obesity, 78–79 National Institutes of Health (NIH) Look Action for
Insulin-associated polypeptide (IAPP), 119 Health in Diabetes (AHEAD) trial, 140
Insulin-like growth factor 1 (IGF-1), 336 Nesiritide, 242–243
Insulin-like growth factor binding protein 1 (IGFBP-1), Neurodegenerative disorders and cognitive impairment,
336 281–296
International normalized ratio (INR), 46 age-related changes in the brain, 285–286
Intrauterine growth restriction (IUGR), 301 alcohol, 289–290
Irritable bowel syndrome (IBS), 75–76 antioxidant-rich foods, 288–289
Isothiocyanates (ITCs), 299 coffee and caffeine, 289
dementia, diagnosis of, 283–285
K diabetes, visceral fat, inflammation, and Alzheimer’s
disease, 290–291
Kidney failure, see Chronic kidney disease and kidney dietary supplements, 290
failure epidemiology, 281–282
exercise, 286–287
L inflammation and oxidative stress, 286
omega-3 fatty acids and fish oils, 287–288
LDL receptor-related protein (LRP), 175 primary care physician and case manager
LDLs, see Low-density lipoproteins collaboration, 291
Lean body mass, building a personalized diet based on, Niacin, 48
22–26 Nitrate-rich foods, 196–107
Lipid disorders and management, 173–185 Nitrates, 243
atherosclerotic cardiovascular diseases, prevention of, Nonalcoholic fatty liver disease (NAFLD), 49, 155;
178–180 see also Fatty liver disease
cholesterol metabolism and transport, disorders of, 174 Nonalcoholic steatohepatitis (NASH), 155
familial hypertriglyceridemia and secondary Nutrigenetics, 298–300
hypertriglyceridemia, 175–177 Nutrigenomics, 300
hypercholesterolemia and familial Nutrition prescription, see Writing the nutrition prescription
hypercholesterolemia, 177
hypertriglyceridemia and the unrecognized impact of O
visceral fat, 177–178
impact of nutrition on lipid disorders, 180–182 Obesity; see also Hypertension and obesity; Overweight
lipoproteins and lipid metabolism, 174 and obese patient, approach to; Pulmonary
Lorcaserin, 91 function, asthma, and obesity
Low-density lipoproteins (LDLs), 174 cancer and, 314–315
Low socioeconomic status, food insecurity and, 3–4 diabetes and, 138
LRP, see LDL receptor-related protein hypoventilation syndrome (OHS), 257–258
Lycopene, 318 immune function in, 58–59
phenotype, determination of, 96–98
M sarcopenic, 265
Western diet and, 78–79
Malnutrition, immune function and, 58 Obstructive sleep apnea (OSA), 257–258
Marijuana, 357 OHS, see Obesity hypoventilation syndrome
Maturity-onset diabetes of the young (MODY), 124 Omega-3 fatty acids
Megestrol acetate, 357 cognitive health and, 287–288
Meglitinides, 137 diabetes and, 146
Menadione, 47 Omega-3 polyunsaturated fatty acids, 239
Metabolic syndrome, 214 Oral glucose tolerance test (OGTT), 136
NAFLD and, 157 Ornish diet, 195
pulmonary function and, 255 OSA, see Obstructive sleep apnea
Metformin, 137, 141 Overweight and obese patient, approach to, 85–117
Mild cognitive impairment (MCI), 281 aging and brain health, 96
MODY, see Maturity-onset diabetes of the young behavioral strategies, 103–106
Monounsaturated fat (MUFA), 145 biological signals regulating food intake, 88–90
Index 369
bottom line on obesity and health, 96 Pick’s disease, 283

cancer, 93–94 Polycystic ovarian syndrome (PCOS), 94–95
cardiovascular diseases, 93 Polyunsaturated fatty acids (PUFAs), 78, 239, 287
depression, 94 Potassium-sparing diuretics, 242
drugs for obesity, 90–91 Prediabetes, 126–127
energy expenditure and protein requirements, 98–99 Primary care practice, incorporating nutrition into, 1–13
fatty liver disease, 96 efficient patient flow, modifying routines to maintain, 9
follow-up and social support, 106–109 equipment needed for primary care nutrition practice,
gallstones and gout, 96 6–7
genetic and environmental interactions in obesity, 87–88 food insecurity and low socioeconomic status, 3–4
hypertension and renal disease, 92 global nutrition transition, 2–3
infertility, 94–95 Internet resources for self-monitoring, 9–10
leisure time physical activity and exercise, 100–103 obese patients, outfitting your office to accommodate, 7
musculoskeletal disorders, 96 primary care algorithm, 11
obesity phenotype, determination of, 96–98 reimbursement for your services, methods to obtain, 10
pathophysiology of obesity, 85–92 relative food costs and calories per bite, 4–5
protein, effects of on satiety, 90 resources available, identification of, 5–6
pulmonary diseases (sleep apnea and asthma), 95–96 survey of practice population, 1–5
snacking, 104–106 training your staff to be empathetic, 7–9
structured diet programs that include choice, 99–100 Pritikin diet, 195
surgical approaches to obesity, 91–92 Protein
type 2 diabetes mellitus, 92 C-reactive, 267
–energy malnutrition (PEM), 333–334
P malnutrition in advanced liver disease, 164–165
quantity and quality, 31
PAH, see Phenylalanine hydroxylase in sarcopenia and cardiac cachexia, 244
Pantothenic acid A, 50 uncoupling, 246
PCOS, see Polycystic ovarian syndrome PUFAs, see Polyunsaturated fatty acids
PEM, see Protein–energy malnutrition Pulmonary diseases, obesity and, 95–96
Personalization of nutrition advice, 15–56 Pulmonary function, asthma, and obesity, 255–263
body composition, 22–41 asthma and obesity, 256–257
botanical dietary supplements, 52 obstructive sleep apnea and hypoventilation syndrome,
carbohydrates and fibers, 32 257–258
daily values and label reading, 22 poor-quality sleep in obesity, effects of, 258
dietary fibers, 32 primary care sleep hygiene recommendations, 259–260
dietary guidelines (2015–2020), 20–21 pulmonary function in obesity, 255–256
dietary guidelines and government advice, 16–22
dietary pattern that prevents weight gain, 40–41 R
Dietary Reference Intakes, 19–20
fats and oils, 37–40 RA, see Retinoic acid
fat-soluble vitamins, 42–47 RAAS, see Renin–angiotensin–aldosterone system
glycemic index, glycemic load, and calories, 33–37 Randomized controlled trials (RCTs), 90
lean body mass, building a personalized diet based on, RAR, see Retinoic acid receptor
22–26 Reactive oxygen species (ROS), 316
leveraging dietetic and nursing support, 52 Recommended dietary allowance (RDA), 18, 19, 246
patient choice, enabling, 52–53 Remnant removal disease (RRD), 175
personalization of dietary guidelines, 17 Renal disease, obesity and, 92
physical activity guidelines, 21 Renin–angiotensin–aldosterone system (RAAS), 211
protein quantity and quality, 31 Resting energy expenditure (REE), 335
recommended dietary allowances, 18 Retinoic acid (RA), 42
retrolental fibroplasia, 45 Retinoic acid receptor (RAR), 42
simple sugars and complex carbohydrates, 32–33 Retinoic acid X receptor (RXR), 42
supplemented personalized protein, rationale for Retrolental fibroplasia, 45
balanced diet based on, 26–31 Rimonabant, 91
U.S. dietary guidelines (2015–2020), dietary patterns ROS, see Reactive oxygen species
recommended by, 21 RRD, see Remnant removal disease
water-soluble vitamins, 47–50 RXR, see Retinoic acid X receptor
writing the exercise prescription and evaluating fitness,
51–52 S
Phenformin, 137
Phentermine, 90 Sarcopenia, protein in, 244
Phenylalanine hydroxylase (PAH), 299 Sarcopenic obesity, 265
Phenylketonuria (PKU), 297 SCD, see Specific carbohydrate diet
Phytonutrients, 198–200, 316 Semivegetarians, 196
370 Index
Sibutramine, 91 W
Sleep apnea, obesity and, 95–96
Social media, engaging with patients using, 359 Warfarin, 46
Sodium glucose cotransporter 2 (SGLT-2) inhibitors, 138 Water-soluble vitamins, 47–50
Specialist Certification of Obesity Professional Education biotin, 50
(SCOPE), 362 choline, 49–50
Specific carbohydrate diet (SCD), 78 folic acid, 48
Spironolactone, 242 niacin, 48
Statin drugs, effects of, 192–193 pantothenic acid and coenzyme A, 50
Sugar-sweetened beverages (SSBs), 196 vitamin B1 (thiamin), 47
Sulfonylureas, 137 vitamin B2 (riboflavin), 47
Sympathetic nervous system (SNS), 211 vitamin B6 (pyridoxine), 47–48
vitamin B12, 48–49
Wearable devices, engaging with patients using,
T 358–359
Take Off Pounds Sensibly (TOPS), 106 Weight Watchers, 106
The Obesity Society (TOS), 6 Western diet, obesity and, 78–79
Thiazolidinediones, 127, 137 Wet beriberi, 247
Third-generation agent, 137 Writing the nutrition prescription, 349–363
Tolbutamide, 137 chapter 1 (incorporating nutrition into your practice),
Tolerable upper intake level (UL), 20 350
Total parenteral nutrition (TPN), 340 chapter 2 (personalization of nutrition advice), 350
Tumor necrosis factor α (TNF-α), 257, 320 chapter 3 (nutrition and the immune system), 350
Type 2 diabetes, CAD and, 192 chapter 4 (nutrition and gastrointestinal disorders), 351
Type 2 diabetes mellitus (T2DM), evolution of, 119–133 chapter 5 (overweight and obese patient), 351
adaptation to starvation, 121 chapter 6 (nutrition and evolution of type 2 diabetes),
gene–environment interaction and risk for T2DM, 351
125–126 chapter 7 (managing diabetes without weight gain), 352
genetics of T2DM linked to multiple risk factors, chapter 8 (fatty liver), 352
124–127 chapter 9 (lipid disorders and management), 353
gestational diabetes mellitus, 125 chapter 10 (nutrition and coronary artery disease), 353
minority health disparities and risk factors (U.S.), chapter 11 (hypertension and obesity), 354
120–121 chapter 12 (nutrition and renal failure), 354
pancreatic β-cell exhaustion, 121–124 chapter 13 (nutrition and heart failure), 355
prediabetes, 126–127 chapter 14 (pulmonary function, asthma, and obesity),
social and economic determinants of risk, 119–120 355
Type 2 diabetes mellitus, obesity and, 92 chapter 15 (frailty, nutrition, and the elderly), 355
chapter 16 (nutrition and neurodegenerative diseases),
356
U chapter 17 (gene–nutrient interactions), 356
UDP glucuronosyl transferases (UGTs), 319 chapter 18 (nutrition and the risks of common forms of
UK Prospective Diabetes Study (UKPDS) Group, 140 cancer), 356
UL, see Tolerable upper intake level chapter 19 (nutrition and the cancer patient), 357
Uncoupling proteins (UCPs), 246 continuing education and certification, 360–363
U.S. dietary guidelines (2015–2020), dietary patterns information management strategies, 360
recommended by, 21 information overload, management of, 359–360
U.S. Food and Drug Administration (FDA), 90, 309 social media, engaging with patients using, 359
wearable devices, engaging with patients using,
358–359
V
Very low-calorie diet (VLCD), 140 X
Very low-density lipoproteins (VLDLs), 174
Vildagliptin, 137 Xenatide, 137
Viral hepatitis, fatty liver interactions with, 159–160 Xenobiotic response elements (XREs), 319
Vitamins, see Fat-soluble vitamins; Water-soluble vitamins Xenobiotics, 299

Writing The Nutrition Prescription

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Primary Care Nutrition

Writing the Nutrition Prescription

© 2017 by Taylor & Francis Group, LLC

No claim to original U.S. Government works

Printed on acid-free paper

International Standard Book Number-13: 978-1-1380-6226-9 (Paperback)

Library of Congress Cataloging‑in‑Publication Data

Names: Heber, David, author. | Li, Zhaoping, 1962- author.

Visit the Taylor & Francis Web site at

and the CRC Press Web site at

Chapter 1 Incorporating Nutrition into the Primary Care Practice............................................... 1

Chapter 2 Personalization of Nutrition Advice............................................................................ 15

2.4.1.2 Vitamin D............................................................................ 43

Chapter 3 Nutrition and the Immune System.............................................................................. 57

Chapter 4 Nutrition and Gastrointestinal Disorders.................................................................... 71

Chapter 6 Evolution of Type 2 Diabetes Mellitus...................................................................... 119

Chapter 7 Managing Diabetes without Weight Gain................................................................. 135

7.5 Nutrition and Diabetes Management.............................................................. 138

Chapter 8 Fatty Liver Disease.................................................................................................... 155

Chapter 9 Lipid Disorders and Management............................................................................. 173

Chapter 10 Nutrition and Coronary Artery Disease.................................................................... 187

Chapter 11 Hypertension and Obesity.........................................................................................207

Chapter 12 Nutrition, Chronic Kidney Disease, and Kidney Failure.......................................... 223

Chapter 13 Nutrition and Heart Failure....................................................................................... 237

13.3.3 Sodium Restriction in Low-Output Heart Failure..........................240

Chapter 14 Pulmonary Function, Asthma, and Obesity.............................................................. 255

Chapter 15 Frailty, Nutrition, and the Elderly............................................................................. 265

Chapter 16 Nutrition in Neurodegenerative Disorders and Cognitive Impairment..................... 281

16.4 Age-Related Changes in the Brain............................................................... 285

Chapter 17 Gene–Nutrient Interaction........................................................................................ 297

Chapter 18 Nutrition and the Risk of Common Forms of Cancer...............................................309

Chapter 19 Nutrition and the Cancer Patient............................................................................... 329

Chapter 20 Writing the Nutrition Prescription............................................................................ 349

David Heber, MD, PhD, FACP, FASN

Zhaoping Li, MD, PhD

1.2 SURVEY YOUR PRACTICE POPULATION’S

1.2.1 The Global Nutrition Transition and Your Practice

1.2.2 Food Insecurity and Low Socioeconomic Status

1.2.3 Relative Food Costs and Calories per Bite

1.3 IDENTIFYING MEDICAL, NUTRITIONAL, BEHAVIORAL,

1.4 OBTAINING THE EQUIPMENT NEEDED

1.5 OUTFITTING YOUR OFFICE TO ACCOMMODATE OBESE PATIENTS

1.6 TRAINING YOUR STAFF TO BE EMPATHETIC

BOX 1.1 SIGNS AND SYMPTOMS OF MALNUTRITION

1.7 MODIFYING ROUTINES TO MAINTAIN EFFICIENT PATIENT FLOW

1.8 PROVIDING INTERNET RESOURCES FOR SELF-MONITORING

1.9 ESTABLISH METHODS TO OBTAIN REIMBURSEMENT FOR YOUR SERVICES

Fatty liver and Common

PCP Referral to community

1.10 PRIMARY CARE ALGORITHM

2.2 UNDERSTANDING THE DIETARY GUIDELINES

2.2.1 Personalization of Dietary Guidelines

2.2.2 Recommended Dietary Allowances: A Brief History

1. Increase consumption of complex carbohydrates and naturally occurring sugars

2.2.3 Dietary Reference Intakes

1.0 EAR UL 1.0

Risk of adverse effects

BOX 2.1 Definition of the DRI Components

Acceptable macronutrient distribution ranges (AMDRs): Ranges of macronutrient

1.2 SURVEY YOUR PRACTICE POPULATION’S

1.2.1 The Global Nutrition Transition and Your Practice

1.2.2 Food Insecurity and Low Socioeconomic Status

1.2.3 Relative Food Costs and Calories per Bite

1.3 IDENTIFYING MEDICAL, NUTRITIONAL, BEHAVIORAL,

1.4 OBTAINING THE EQUIPMENT NEEDED

1.5 OUTFITTING YOUR OFFICE TO ACCOMMODATE OBESE PATIENTS

1.6 TRAINING YOUR STAFF TO BE EMPATHETIC

1.7 MODIFYING ROUTINES TO MAINTAIN EFFICIENT PATIENT FLOW

1.8 PROVIDING INTERNET RESOURCES FOR SELF-MONITORING

1.9 ESTABLISH METHODS TO OBTAIN REIMBURSEMENT FOR YOUR SERVICES

1.10 PRIMARY CARE ALGORITHM

2.2 UNDERSTANDING THE DIETARY GUIDELINES

2.2.1 Personalization of Dietary Guidelines

2.2.2 Recommended Dietary Allowances: A Brief History

2.2.3 Dietary Reference Intakes

2.2.4 The 2015–2020 Dietary Guidelines

2.2.5 Dietary Patterns Recommended by the 2015–2020 U.S. Dietary Guidelines

2.2.6 Physical Activity Guidelines

2.2.7 Daily Values and Label Reading

2.3 BODY COMPOSITION AND PERSONALIZATION

2.3.1 Rationale for a Balanced Diet Based on Supplemented Personalized Protein

2.3.2 Protein Quantity and Quality

2.3.3 Carbohydrates and Fibers

2.3.4 Simple Sugars and Complex Carbohydrates

2.3.5 Glycemic Index, Glycemic Load, and Calories

2.3.6 Fats and Oils

2.3.7 Dietary Pattern That Prevents Weight Gain

2.4 OPTIMIZING VITAMIN, MINERAL, AND MICRONUTRIENT

2.4.1 Fat-Soluble Vitamins: A, D, E, and K

2.4.2.8 Pantothenic Acid and Coenzyme A

2.5 WRITING THE EXERCISE PRESCRIPTION AND EVALUATING FITNESS

2.6 LEVERAGING DIETETIC AND NURSING SUPPORT

2.7 ISSUES AROUND BOTANICAL DIETARY SUPPLEMENTS

2.8 ENABLING PATIENT CHOICE IN NUTRITION

3.2 THE FAT CELL AS AN ENDOCRINE AND IMMUNE CELL

3.3 MALNUTRITION AND IMMUNE FUNCTION

3.4 IMMUNE FUNCTION IN OBESITY

3.5 IMMUNE FUNCTION AND VITAMIN AND MINERAL BALANCE

3.6 INTERACTION OF OMEGA-3 FATTY ACIDS AND MACROPHAGE

3.7 CALORIC RESTRICTION WITHOUT MALNUTRITION

3.8 GUT MICROBIOTA AND IMMUNE FUNCTION

3.9 PRACTICAL CONSIDERATIONS FOR MODULATING IMMUNE FUNCTION

4.2 FOOD ADDICTION OR SIMPLY CRAVING?

4.3 EATING DISORDERS: FROM BULIMIA TO ANOREXIA NERVOSA

4.4 TREATMENT OF EATING DISORDERS

4.5 FOOD INTOLERANCE AND FOOD ALLERGY

4.6 IRRITABLE BOWEL SYNDROME

4.7 GLUTEN ENTEROPATHY AND GLUTEN SENSITIVITY

4.8 INFLAMMATORY BOWEL DISEASES