Diet

and Macronutrients in the

Metabolic Syndrome Patient
Shannon Christen, RD, CDE
University of Colorado Cardiac and Vascular Center &
Endocrinology and Diabetes

A little bit about me

Why is nutrition so
controversial???

Honest disagreement is often a good sign of progress

Social Reformer
Mahatma Gandhi

Where to begin.
The Early Warning signs of Metabolic
Syndrome
Time to get to know your patient
Ask questions??
What type of Nutrition Rx will you
recommend?

The Nutrition Rx Question?

Do those with metabolic syndrome
really need a dierent dietary strategy
than just good old fashion dietary
guidelines?
Or is dietary pattern more important?

Childhood dietary intervention prevented

metabolic syndrome in adolescence

Randomly assigned infants at age 6 months

Intervention group (n = 540)
Control group (n = 522)

Intervention was associated with lower risk for

high BP in boys and girls
(RR = 0.83; 95% CI, 0.70-0.99)

Lower risk for high triglycerides in boys

(RR = 0.71; 95% CI, 0.52-0.98).

Decrease in elevated waist circumference, it

was not signicant
(RR = 0.78, 95% CI, 0.59-1.03).
Circulation.2015;131:7 605-613

Nutrition Rx for Metabolic

Syndrome
TARGETS = Just enough calories to maintain a
healthy body wt. or create wt. loss

Women = 1,200-1,500 kcals/day

Men = 1,500-1,800 kcals/day
Or 500-750 kcals/day energy decit
General Macronutrient makeup:

CHO = 40-50%
Complex carbs higher in nutrition
Limit sugar sweetened beverages
Fat = 25-35%
Emphasis on unsaturated fatty acids
Protein = makes up the rest
Alcohol = Moderation

NHLBI Obesity Report and Nutrition Care Manual

2015 Dietary Guidelines

Moderate Evidence
Healthy body weight
Consume a diet high in produce, sh, legumes, and
unsaturated fats
Consume a diet moderated in low-fat dairy
Consume a diet low in red and processed meats,
rened grains, rened sugars, saturated fats,
cholesterol and sodium

Scientic Report for the 2015 Dietary Guidelines Advisory Committee

2015 Dietary Guidelines

Strong and Consistent Evidence
Lower CVD risk
Consume produce, whole grains, sh, low-fat dairy,
potassium and unsaturated fats
Reduce red and processed meats, rened grains,
rened sugars, saturated fats, cholesterol and sodium

Scientic Report for the 2015 Dietary Guidelines Advisory Committee

2015 DGAC Healthy dietary pattern

Higher in vegetables, fruits, whole grains, low
or non-fat dairy, seafood, legumes, and nuts;
Moderated in alcohol (among adults)
Lower in red and processed meat; and low in
sugar sweetened foods and drinks and rened
grains.
Vegetables and fruit are consistently identied
in every conclusion statement across the
health outcomes.
Should tailor to the individual's biological and
medical needs as well as socio-cultural
preferences.
Scientic Report for the 2015 Dietary Guidelines Advisory Committee

Dietary guidelines for saturated fat

and dietary cholesterol.
Year

Country

Dietary Fat
guidelines

2003

New Zealand

Limit sat. fat

No recommendation for
<12% total energy dietary Cholesterol

Dietary Cholesterol
guidelines

2006

United States

Limit sat. fat <7% <300 mg/day

2007

European
Countries

Limit sat. Fat

No recommendation for
<10% total energy dietary Cholesterol

2008

Korea

Total Fat <20%

No recommendation for
dietary Cholesterol

2009

Canada

Limit sat. fat

<10%

No recommendation for
dietary Cholesterol

2010

India

Limit sat. fat and

total fat

No recommendation for
dietary Cholesterol

2015

United States

10% upper limit

No recommendation for
for sat. fat intake* dietary Cholesterol

Adapted Fernandez & Calle: Atherosclerosis reviews 2010;4:259-269 and 2015 DGAC

Cholesterol how much is the

diet?
The body produces = 850 mg/d
Dietary Cholesterol = 400 mg/d
We absorb 60% = 240 mg/d
Total = 1090 mg/d
78% synthesis vs. 22% diet
Conclusion: Dietary Cholesterol is NOT
related to increased risk for cardiovascular
disease. Need to move the focus to dietary
fat intake. (saturated and trans fat)
Howell et al. AJCN 1997;1747-1764

Fats: Unsaturated Fats

Monounsaturated fatty acids (MUFAs)
Plant sources
Certain nuts, canola, olive, peanut and avocado oils

Polyunsaturated fatty acids (PUFAs)

Omega -6 (Linoleic acid)

Soybean, corn and saower oil

Omega-3 (Linolenic acid)

Alpha-Linolenic Acid (ALA) = walnuts, axseed
Eicosapentaenoic Acid (EPA) and Docosahexaenoic
Acid (DHA) = cold water sh (salmon, tuna, cod,
anchovies, sardines)

Omega 6 and 3 are essential to the diet

Scientic Report for the 2015 Dietary Guidelines Advisory Committee

Fats: Saturated and Trans

Saturated Fatty Acids (SFAs)
Solid at room temperature
Animal products found in meat and dairy
Tropical oils like coconut and palm oils

Trans Fatty Acids (TFAs)

Unsaturated fats vegetable oils
Natural from animal products

Scientic Report for the 2015 Dietary Guidelines Advisory Committee

Fats: They are NOT all created

EQUAL
Saower Oil
Coconut Oil
Palm Oil

SFA %

Lard

MUFA %
PUFA %

Butter
Canola Oil
Olive Oil
0

20
40
60
80
100
Percent of dierent fatty acids

Adapted from OSU Cooperative Extension Service T-3153

Butter vs. Coconut oil

Coconut oil is more than 90% saturated
fat
Butter is about 65% saturated fat
Each contains 120 calories per Tablespoon
Moderation in use is BEST.

Wow the wonders of Coconut oil?

FDA Warning to Coconut oil

marketer
FDA sent stern
warning to a
marketer of
coconut oil over the
brands misleading
and
unsubstantiated
health and
nutrition claims.

www.fda.gov

Academy of Nutrition and Dietetics

Coconut oils health benets are often
credited to the medium-chain triglycerides
it provides.
Coconut oil contains only 10-15% of all of its
fat is the benecial short-chain MCTs that
contain no more than 10 carbon molecules.
The major saturated fat in coconut oil is
Lauric acid (a 12-carbon molecule), there is
insucient published scientic evidence to
suggest Lauric acid provides any
meaningful health benets.

Here is where I think Coconut oil

belongs

Jame "Bualo Bill" Gumb: It rubs the lotion on its skin. It does this
whenever it is told.

The Function of Dierent Types of

Fats
Trans Fats

Saturated Fats

Unsaturated Fats

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

-
-
-
-
-
-
-
-

Very high melting

Sharp melting curve
Good process ability
Extremely stable
Long shelf life
Creamy mouth feel
Fast avor release
Provides good lift an
texture to the product

High melting
Flat melting curve
May require changes
Very stable
Long shelf life
Waxy mouth feel
Slow avor release
Provides fair lift

Low melting
Liquid oils
May require changes
Less stable
Shorter shelf life
Oily mouth feel
Too fast avor release
May require thickeners

- The food industry has removed more than 1 billion pounds of bad fats
from the North American diet.
- As a result circulating plasma levels of trans fat in Americans has dropped
by 58% since 2000.

Centers for Disease Control JAMA-AMA Feb 2012

Average American Daily Intake

Total fat = 33.6% of calories
Saturated fat = 11.4% of calories
Trans fat = 1.3 grams (industrially
produced)
PUFA = 7.0% of calories
MUFA = 12.3% of calories
So on a 1200 calorie meal plan = 403
calories spent on fat = ~45 gm/day
2007-2010 WWEIA data
Academy of Nutrition and Dietetics Position Paper J Acad Nutr Diet. 2014;;114:136-153

Comparing Guidelines for Fat

Intake
2015 Dietary
Guidelines for
Americans
Percent of calories
from fat

American
Heart
Association

Academy of
Nutrition and
Dietetics

WHO/ Food &

Agriculture
Organization

25-35%

20-35%

20-35%

Saturated Fat

<10%

< 5-6%

< 7-10%

< 10%

Trans Fat

Avoided

< 1%

< 1%

< 1%

Omega 3

Eat sh at least
2 x per week

0.6-1.2% as ALA 0.5-2% as ALA +

+ 500 mg EPA
250 mg EPA+DHA
+DHA

Omega 6

5-10%

3-10%

MUFA

Replace animal
fats in diet with
these

15-20%

2-3% (req.)
2.5-9%
(acceptable)

Health.gov/dietary guidelines, 2013 ACC/AHA Prevention Guideline on the Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults, Position of the Academy of Nutrition and Dietetics: Dietary Fatty Acids for
Healthy Adults, FAO Fats and Fatty Acids in Human Nutrition

AHA/ACC Guidelines GRADE A

Evidence
No evidence for specic LDL-C goals
Aim for dietary pattern that achieves 5-6% of
calories from saturated fat
Reduce percent of calories from saturated fat
Consume a dietary pattern that emphasizes
intake of vegetables, fruits and whole grains;
includes low-fat dairy products, poultry, sh,
legumes, nontropical vegetable oils, and nuts;
and limits intake of sweets, sugar-sweetened
beverages and red meats
2013 Report on Lifestyle Management to Reduce CVD Risk

What if we replaced the Bad fat

with the Good fat?
Monos replacing Polys replacing
Sat Fat
Sat Fat
Total Cholesterol

6-10% lower

8-12% lower

LDL Cholesterol

6-10% lower

8-12% lower

HDL Cholesterol

No change

Increase with
Omega-3 but
decrease with
Omega-6

Triglycerides

No change

Lowers with
Omega-3s

Insulin Sensitivity Increases

Increases

Sources: Mozaarian European Journal of Clinical Nutrition (2009) 63, S22-S33; Gillingham Lipids (2011) 46:209-228.
Additional info from Leah Gillingham

Unsaturated Fats and Metabolic

Syndrome
Both MUFAs and PUFAs improve cardio-
metabolic risk
They improve
Lipids
BP
Insulin sensitivity

Adapted from: Gillingham et al., Lipids 2011;46:209-28

Carbs: Where do we place them?

Complex carbs fruit, vegetables, legumes and
whole grains
The advantages of substituting complex CHO
for saturated fat calories
When total fat is 30-35% of total kcals, hard to keep
<10% saturated fat kcals
Complex carbs contain dietary ber, K+, Mag and
other micronutrients
Complex carbs are less likely to contribute to excess
kcals
Diet rich in Omega-3s and/or MUFAs and reduced
rened carbs help with reducing TGs w/o
impacting HDL

Nutrition Care Manual

What is a Whole Grain?

foods made from the entire grain seed,
usually called the kernel, which consists of
the bran, germ and endosperm. If the
kernel has been cracked, crusted or aked,
it must retain nearly the same relative
proportions of bran, germ, endosperm as
the original grain in order to be called
whole grain
Examples: brown rice, popcorn, bulgur, whole
wheat, oats and barley.

2015 Dietary Guidelines Adisory Committee

Proteins: Animal or Plant Based

Animal proteins
Beef, pork, wild game, poultry, sh, shellsh

Protein powders
Meat alternatives
High protein dairy
Cottage cheese, real cheese, Greek Yogurt

Eggs and egg whites

1 ounce = 7 grams of protein and range from
45-100 calories per ounce based on the fat
content of the food

Restaurant menu labeling

Likely to happen in 2015

Calories on menus
May nd other info like fat, carbs, sodium,
proteins, etc.
Will likely need to ask for this information or
check out website

Will this REALLY make a dierence?

Time will tell

I am sure this is how my patients

feel

Case Study 1 Not quite Metabolic

Syndrome
20 year old, Caucasian, male
BMI 24
Lives with Mother she handles all of his
care
Dx of Autism, Turrets and OCD
No other health problems

Case #1 Initial labs

Date

12/9/14

12/12/14

T. Cholesterol

548

601

LDL

467

530

TG

88

45

HDL

63

62

Case #1 First visit in the CVC

Family hx of high cholesterol
Parents LDL range 160-170s no meds

Listed allergies are gluten and milk

Family does not eat out, follows a very
healthy meal plan
Follows GAPS diet helps with Autism
Using coconut oil and likes lean meats to
include red meat

GAPS Diet = Gut and Psychology

Syndrome

www.gapsdiet.com

Labs possible hyper-responder???

Date

12/9/14

12/12/14

2/6/15

2/13/15

T. Chol

548

601

122

132

LDL

467

530

54

65

TG

88

45

55

43

HDL

63

62

57

58

Case study 2
54 year old, Caucasian, Male
Came to prevention clinic for rst appt. in
9/2014
No structured meal plan
No formal physical activity
Was on Lipitor 10 mg daily
Wanted to lose wt. and improve risk factors

Metabolic syndrome
BP = 130/84
Weight = 281#
Height = 72 inch
BMI = 38
Waist circumference >40 inches*
TG = 287 mg/dl *
HDL = 35 mg/dl*
LDL = 135 mg/dl
Glucose = 96 mg/dl
*risk factors for Metabolic syndrome

Case #2

Case #2 6 month f/u appt

Still on Lipitor 40 mg
Exercising 60 min 4-5 times per day on treadmill
On phase 3 of the SOS meal plan
Wt = 265# (was 281)
Wt loss % = ~5%
BMI = 35 (was 38)*
BP = 100/68 (was 130/84)
TG = 135 (was 287)
HDL = 33 (was 35)*
LDL = 72 (was 135)
Glucose 95 (was 96)
*risk factors for Metabolic syndrome

Strategies for success

Meet the patient were they are at make

small changes
Give targets to start again small changes
Dont ask them to do something you arent
willing to do yourself.

Tools
Hire a Dietitian or Refer to one
Calorie king book
Small font, large font, app gomeals (free) and www.calorieking.com
(website)

Use measuring cups and spoons

Food scale provides calories, fat, ber, sodium, carbs, protein
Book - State of Slim weight loss book
Apps mytnesspal, lose it, healthyout, mynetdiary
Website: healthydinningnder, calorieking, sparkpeople
Meal delivery systems greenchef, blueapron, plated, hellofresh
Meal building Dream Dinners, Supper Solutions
Personal Chef can prepare meals to special dietary restrictions

Conclusion
Whatever your belief system the PORTION
is what counts
The best meal planning might focus on the
QUALITY of the meal pattern instead of
targets

Questions?