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PowerPoint Presentation - Dr.Jeffrey Tucker

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PowerPoint Presentation - Dr.Jeffrey Tucker Powered By Docstoc
					  Dr. Jeffrey Tucker
       Presents
The Program For Total Health
 The gold standard is health span

Of American women ages 45 – 54
• 33% suffer from hypertension
• 32% have lower back pain
• 20% have elevated blood pressure
• 22% have knee pain
• 21% have neck pain
• 12% have shoulder pain
• 11% have finger pain
 The gold standard is health span
Of American men ages 45 – 54:
• 30% suffer from hypertension
• 27% have lower back pain
• 20% have elevated blood pressure
• 19% have knee pain
• 15% have neck pain
• 13% have shoulder pain
• 7% have finger pain
• American diet: about 72% of the calories in the average
  American's diet come from foods that were not
  consumed by our recent hunter-gatherer ancestors.
  Consider that 23% come from grains (20.4% from
  refined grains), 18.6% from refined sugars, 17.6% from
  refined omega-6 seed oils (corn, soybean, sunflower,
  cottonseed, safflower, peanut, etc.), 10.6% from dairy,
  and about 1.4% from alcohol.
• Cordain L, Eaton SB, Sebastian A, et al. Origins and
  evolution of the Western diet: health implications for the
  21st century. Am J Clin Nutr, 2005;81(2):341-54.
• The remaining 28% come from a marginal intake
  of fruits, vegetables, nuts and legumes, and a
  substantial intake of domestic, feedlot, grain-fed
  meat. We know wild game is about 2% to 4% fat
  by weight, while modern feed-lot meat is 20% to
  24% fat by weight. Essentially, this means we
  are eating unhealthy, obese animals.
• Seaman DR. The diet-induced pro-inflammatory
  state: a couse of chronic pain and other
  degenerative diseases. J Manip Physiol Ther,
  2002;25:168-79.
• In short, our diet in America today consists of
  grains, sugars, omega-6 fatty acids, trans
  fats, and obese meat, and is substantially
  deficient in fruits and vegetables. The outcome
  of this pattern of eating is the typical inflamed,
  swollen-looking, overweight American, who is
  prone to osteoporosis, osteoarthritis, chronic
  pain, and other chronic diseases.
•
    Dr. Tucker’s Therapeutic Lifestyle
                 Program
•   Diet
•   Exercise
•   Supplement
•   Rest
      The Program Will Address
•   Making healthy food choices
•   Preventing chronic disease formation
•   Improving body composition
•   Reducing body fat storage
•   Increasing lean muscle mass
•   Reducing inflammation
•   Improving blood sugar management
•   Reducing hyperinsulinemia and hyperglycemia
•   Increasing exercise & physical activity = gentle
    movement therapy & strength training
           Charting Office Visits
            SOAP Note Format
•   Subjective
•   Objective
•   Assessment/Diagnosis
•   Functional abnormalities
•   Plan (diet modifications, exercise program,
    supplementation recommendations,
    relaxation techniques)
              Office Flow Algorithm
1. The doctor prescribes the program to the
   patient
2. Patient assessment (BIA, blood, FMS)
3. Patient consultation (ROF, establish
   goals, individualize the program)
4. Follow up visits
5. Retest
BIA = Bioelectrical impedance analysis
FMS = Functional Movement Screen
ROF = report of findings
                   Retest
• Program goals are       • Program goals are
  achieved                  not achieved
• Prescribe               • Return to step 3
  maintenance program       previous slide
• Send re-evaluation
  reminder card in 6-12
  months
           Timing of Return Visits
          Recommended Follow Up
•   Medical Doctor (weeks)             • Tucker (weeks)
1.  Forms/Assessment (blood, etc.)     1. Forms/Assessment/BIA
2.  Consultation/Refer to Tucker for   2. Diet/meal plan/supplements
    Total Health program
3.  Tucker                             3. Functional Movement Screen
4.  Tucker/Follow up visit MD          4. Education/exercise
5.  Tucker                             5. Education/exercise/BIA
6.  Tucker                             6. Education/exercise
7.  Tucker                             7. Exercise
8.  Tucker/MD                          8. Exercsie
9.  Tucker                             9. Retest FMS/BIA
10. Tucker                             10. Exercise
11. Tucker
                                       11. Retest FMS/BIA
12. Re-evaluation MD
                                       12. Re-evaluate Tucker/MD
                                       FMS = Functional Movement Screen
                                       BIA = Bioimpedance Analysis
      Charging for Programs
• Determine what method of payment will
  work best for patients.
• Determine cost of services.
• Supplements are charged for separately.
    Counseling For Patients With NO
     Medical Illness or Symptoms
Insurance codes:
• 99401 15 Minutes
• 99402 30 Minutes
• 99403 45 Minutes
• 99404 60 Minutes

•   Patients can call there own insurance company and ask them how much
    they will reimburse for these services.
 Individual and Group Counseling
WITH Medical Illness or Symptoms
•   For counseling GROUPS of patients 99078
•   For counseling INDIVIDUALS
•   99213 Consultation 15 min            ____
•   99214              25 min            ____
•   99215              40 min            ____
•   99244              60 min            ____
•   99245              90 min            ____
•   99354 Prolonged Care                 $150
  Bioimpedance Analysis (BIA)
• A4556 BIA Electrodes (2 sets @ 15 each)
• $30
• Provides: Body composition, fluid
  distribution, phase angle
• This test can be performed as often as
  necessary to document changes in body
  fat and lean muscle mass.
          BIA may be used
To assess:
- Body composition (estimate)
- Fluid balance
- Cellular performance (cellular health
  analysis)
     Body composition - BCM
• Loss of BCM (sarcopenia) is associated
  with a reduced quality of life, poor immune
  response, increased biological age,
  osteoporosis, and impaired healing.
    Body Composition - BCM
• It takes three times longer to accumulate
  BCM as to deplete it.
• To increase BCM you must remove
  catabolic factors (stress, anxiety,
  sedentary behaviors, insulin resistance,
  etc.), increase protein calories, and
  introduce resistance training.
 Trunkal Obesity/Central Adiposity
• Waist Circumference
• Waist to Hip Ratio
          Vital Signs
• BP
• Pulse
• Temp
         Hypertension Staging
• Pre-hypertension
   – Systolic BP: 120-139 mm Hg; diastolic BP: 80-89 mm
     Hg
• Stage I
   – Systolic BP: 140-159 mm HG; diastolic BP: 90-99 mm
     Hg
• Stage II
   – Systolic BP: 160-179 mm HG; diastolic BP: 100-109
     mm Hg
• Stage III
   – Systolic BP: 180+ mm HG; diastolic BP: 110+ mm Hg
                        Hypertension
• Stress – Adrenal hyper/hypo function
     i.e: addison/cushings or other adrenal tumor. Test with urine cortisol or 24
         hour urine test for vanillylmandelic acid and catecholamines (severe
         HTN)
•   Renal function (U/A)
•   Congestive heart failure/atherosclerosis
•   Hyperinsulinemia
•   Hypothyroid
•   Lymphatic congestion
•   Drug interaction/reaction
     – Especially contraceptive pills, steroids, decongestants, appetite
       suppressants
• Lifestyle
     – Alcohol, obesity, smoking, high sodium, lead toxicity (soft water),
       caffeine
           Lab: Cardiovascular
•   Lipids, fractionated lipid profile
•   Hs-CRP
•   Fibrinogen
•   Homocysteine
Highly Sensitive C-reactive Protein
• C-reactive protein – is an important independent
  marker for inflammation.
• High levels reflect over activity of inflammatory
  cytokines linked to coagulation and vascular
  endothelium damage.
• Evidence suggests that previous infection with
  pathogens such as Chlamydia pneumoniae or
  Helicobactor pylori may act as an initiating
  trigger for this chronic inflammation.
            C-Reactive Protein
• Marker of inflammation, infection and cell injury
   – Aspirin’s reduction of MI risk appears to be related to
     CRP levels
   – CRP activates complement which injures the inner
     layer of blood vessels leading to constriction of
     vessels, arrhythmia
• Strong predictor of the risk of future MI
   – Study of 2,037 healthy middle-aged men from the
     Quebec Cardiovascular Study:
   – 105 first cardiac events during 5 years of follow-up
     lead to 1.8 fold increased risk of ischemic heart
     disease when CRP was at least 1.77 mg/L
                        hs-CRP
• Is helpful in assessing risk for unstable
  plaque, myocardial infarction, and
  diabetes.
• Elevated levels of CRP and IL-6 predict
  the development of type 2 DM. these data
  support a possible role for inflamation in
  diabetogenesis.
• JAMA, 2001, Vol 286: 327-334
     Diseases Associated With
   Defective Methylation Capacity
• Atheroscelosis, coronary artery disease,
  deep vein thrombosis, stroke
• Neural tube defects, spontaneous
  abortion, placental abruption
• Cervical dysplasia, cervical cancer
• Colon cancer
• Cognitive impairment, depression, senility,
  Alzheimer’s disease
• Osteoporosis, RA, diabetes
               MTHFR
 Methylenetetrahydrofolate reductase
• MTHFR is involved in the conversion of
  homocysteine to methionine via the
  remethylation pathway
• Polymorphism associated with increased
  levels of homocysteine and defective
  methylation
      MTHFR – Intervention
• Folic acid/5-MTHFR
• Vitamin B12/Methylcobalamin
• Vitamin B6
• Roboflavin: precursor for FMN (flavin
  mononucleotide) (B6 to p-5-p), precursor
  for FADH2 (flavin dinuceotide), coenzyme
  for MTHFR
• Betaine/TMG
                 Fibrinogen
• Plays a key role in arterial occlusion by
  promoting thrombus formation, endothelial
  injury, and hyperviscosity.
• Increased fibrinogen levels are seen with:
  smoking, oral contraceptive use, obesity, stress,
  inflammation, insulin resistance, and aging.
• Higher risk: elevated fibrinogen with high total
  cholesterol or elevated LDL; elevated fibrinogen
  with high CRP.
Lab: Metabolic Syndrome/DMII
• Glucose-fasting and two hour
• Insulin-fasting and two hour
• HgbA1C
   Lab: Altered Endocrinology
• Adrenal Stress Profile – salivary cortisol
• Thyroid
                  Lab: Objective Goals
• Total cholesterol – under 200
• Triglyerides – under 150
• HDL – over 50 (male) and over 60 (female)
• LDL – under 130 (under 100 if blood risks are
  present)
• Trig/HDL ratio – under 3.0
Adults 3+ screen for IR
Children 2+ screen for IR

• Lipoproteins
A1 and B
 American Cholesterol education program expert panel’s
current policy on fasting blood triglyceride levels in adults:

Less than 150 mg/dl            Normal
(<1.7 mmol/L)
150 -199 mg/dl (1.7-2.3        Boderline-high
mmol/L)
200 – 499 mg/dl (2.3-          High
5.64 mmol/L)
Higher than 500 mg/dl          Very high
(>5.64 mmol/L)
How to Make the Program Flow
• Where I begin with a new patient:
  – Initial consultation
  – Charting the Subjective Intake
  – Establishing the patient’s health goals to start
    their Lifestyle Change Program
  – Objective findings: ordering or collecting data
  – Review of findings (first or second visit)
  – Developing their unique program
  – Follow up appointments
     Complete the Health Profile
       Questionnaire (HPQ)
• Anyone scoring over 50 points total or 10
  or more in any one section would benefit
  from a detoxification program.
• Even individuals scoring as low as 25-30
  will experience greater energy, clarity,
  vitality and find that nagging symptoms of
  unknown origin often get better.
• Go to www.DrJeffreyTucker.com to
  complete this form.
 The Initial Health Consultation
• Subjective interview
  – HCP Prescription
  – Health History
  – Health Profile Questionnaire (HPQ)
  – Diet/Exercise/Sleep/Stress Diary
  – Client’s Health Goals
  – Assessing Readiness to Change
 The Initial Health Consultation
• Objective Data Collection
  – BIA and vitals
• Review of Findings
• Begin Education and Health Coaching
     Lifestyle Change – How?
• It takes 45 days to change a habit or
  incorporate a new one.
                  Diet Diary/Exercise log
• Are you filling yours out daily?
• Keep track of:
     – Everything you eat
     – Everything you drink
     – Your Activity/Exercise
• People who self-monitor both eating and
  exercise behaviors, are more successful at
  reaching and maintaining their ideal
  weight.
•   The American College of Sports Medicine. (Med Sci Sports Exerc 2001 Dec;33(12):2145-56)
Portion sizes & eating frequency
• Don’t skip meals
- Skipping meals leads to increased production of
  glucagon & gluconeogenesis resulting in muscle loss
• Eat frequently
- 3 small meals and 2-3 snacks daily
- To maintain stable blood sugar and insulin levels
- Use high quality meal replacement to:
     Achieve frequency goals
     Increase nutrient intake while decreasing calorie
     intake
Do the body composition analysis to find out your body fat
  percent and lean muscle mass.
    Identifying the clients that will
      benefit from this program:
• Altered Body Composition
  – Sacropenic obesity
  – Weakness and Fatigue
• Inflammatory Conditions
• Abnormal Blood Sugar Regulation
  – Insulin Resistance/Hyperinsulinemia
  – Metabolic Syndrome
  – Type II Diabetes
• Cardiovascular Risks
  – Hypertension
  – Hyperlipidemia
     Inflammatory Related Chronic
              Disorders
•   Obesity (Adipocyte)
•   Sarcopenia (Muscular)
•   Atherosclerosis (Cardiovascular)
•   Type II Diabetes (Endocrine)
•   Osteo- and Rheumatoid Arthritis (Skeletal)
•   Inflammatory Bowel Disease
    (Gastrointestinal)
              Lifestyle Modifications and
                  Preventing Disease
• 3,234 non-diabetic subjects with elevated fasting and
  post-load plasma glucose concentrations were
  randomized to placebo, Metformin (850 mg twice daily),
  or lifestyle-modification program. Program goals of at
  least a 7 percent weight loss and at least 150 minutes of
  physical activity per week. Initial average BMI = 34.
• At average follow up of 2.8 years, the lifestyle
  intervention reduced the incidence of progression to
  diabetes by 58 percent vs. the Metformin reduction of 31
  percent (as compared with placebo).
•   Knowler, W.C. et al., Reduction in the incidence of Type 2 Diabetes with lifestyle intervention or Metformin. N Engl
    J Med. 2002. 346(6): p. 393-403
       The goals of the diet are
• Decrease insulin stimulation via dietary changes which
   decrease insulin release
- ‘Good’ (vs ‘bad’) carbohydrates
- Fiber
- Moderate protein
- ‘Good’ (vs ‘bad’) fat
- Portion size & meal frequency
• Increase cellular responsiveness to insulin:
Chromium            Green tea
Lipoic acid          Cinnamon
Magnesium
   Definition of Glycemic Index
• Glycemic Index (GI) is defined as the
  incremental area under the blood glucose
  curve in response to a standardized
  carbohydrate load. It is therefore an index
  of the blood glucose raising potential of
  the available carbohydrate in a food.
     Obesity as an Inflammatory
              Disorder
• Obesity reduces a lifespan by 8 to 20
  years.
• One of the most interesting discoveries of
  the past decade has been the recognition
  that the adipocytes produces inflammatory
  cytokines.
• Obesity, therefore, may be viewed as a
  low grade systemic inflammatory disease.
What does the Adipocyte secrete?
• Resistin is an adipose tissue-specific
  factor inducing insulin resistance linking
  DM to obesity.
• Adiponectin is an anti-inflammatory, insulin
  sensitizing adipocytokine.
• Adiposity is a form of chronic, low-grade
  inflammation.
     Mid-line trunkal obesity (VAT
               deposition)
• Cushingoid appearance –increased deposition
  in the visceral adipose tissue enhanced by
  increased levels of
   Insulin
   Glucocorticoids (cortisol)
• VAT contributes to:
   - Production of the release of TNFa, IL-1, IL-6
   - Altered insulin sensitivity and glucose
  tolerance
   -Thyroid hormone activity alterations
           LIPOPSUCTION
The New England Journal of Medicine June
 17, 2004
 Liposuction (avg of 20 lbs) did not
 significantly alter the insulin sensitivity of
 muscle, liver, or adipose tissue; did not
 significantly alter plasma concentrations of
 CRP, IL-6, TNFa, and adiponectin; and did
 not significantly affect other risk factors for
 coronary heart disease.
     General Features of Metabolic
              Syndrome
• Abdominal obesity
o Men – waist > 40 inches, or waist is larger than hips
o Women – waist > 35 inches, or waist is greater than 80% the size of
    hips
• Altered blood lipids (fats)
o High triglycerides , trig/HDL ratio
o Small LDL cholesterol particles
o Low HDL cholesterol
• Raised blood pressure
• Insulin resistance (+ glucose intolerance)
• Pro-thrombotic state (blood clotting tendency)
- Increased fibrinogen and PAI-1
• Pro-inflammatory state
- Increased IL-6 and hs-CRP
 Clinical Identification of the Metabolic
                Syndrome
Risk Factor          Defining Level
Abdominal obesity    Waist Circumference
   Men                 >102 cm (>40 in)
   Women               >88 cm (>35 in)
Triglycerides          >150 mg/dl
HDL cholesterol
   Men                 <40 mg/dl
   Women               <50 mg/dl
Blood pressure         >130/>85 mmHg
Fasting glucose        >100
Adult Dx: 277.7      NCEP ATP III
    Metabolic Syndrome Patients
•   Increased blood fat
•   Increased body fat
•   Increased muscle fat
•   Increased liver fat
•   Increased pancreatic fat
    Do you know someone at risk?
• Approximately 90 million Americans have
  insulin resistance.
• 18.2 million Americans have diabetes.
• Over 5 million undiagnosed diabetes.
• Average time from onset to diagnosis is 4
  to 7 years due to insidious nature in early
  stages.
•   National Institutes of Health and Centers for Disease Control and Prevention
    Insulin Resistance Syndrome
        Metabolic Syndrome
• Overweight or a waist circum.>40 inches for
  men, >35 inches for women.
• Elevated BP, blood glucose, blood lipids
  (triglycerides).
• Sedentary lifestyle.
• Family history of type 2 diabetes, hypertension
  or cardiovascular disease.
• A history of glucose intolerance or gestation
  diabetes.
• Polycystic ovary syndrome.
• Sleep apnea.
  Almost half of severely obese
children have metabolic syndrome
• “The overall prevalence of the metabolic
  syndrome was…
  49.7 percent in severely obese subjects”
• N Engl J Med 2004;350:2362-74
      Conditions related to insulin
    resistance (program candidates)
•   Cardiovascular disease
•   Type 2 diabetes
•   Hypertension
•   Hyperlipidemia
•   Polycystic Ovary Syndrome
•   Overweight/Obesity
•   Cancer (colon, breast, prostate)
•   Sarcopenia
•   Accelerated aging
•   Sleep apnea
•   Alzheimers disease
   Inflammatory Cytokines, Hyper-
  insulinemia, and Atherosclerosis
• A number of studies have domonstarted
  that increases in inflammatory mediators
  like IL-6 and hs-CRP are associated with
  insulin resistance and metabolic
  syndrome.
• Metabolic syndrome is strongly associated
  with the onset of endothelial dysfunction,
  which may explain why type-2 diabetes is
  a risk factor for atherosclerosis.
      American College of Cardiology
  53rd Scientific Sessions - March 9, 2004
• National clinical guidelines recommend
  therapeutic lifestyle changes (TLC) as a
  standard of care in the management of CVD risk
  factors.
• The value of TLC in actual practice is often
  discounted by clinicians and health insurers who
  instead frequently turn to widely available
  pharmacotherapeutic agents.
• Emory University Health Sciences Center
      American College of Cardiology
  53rd Scientific Sessions - March 9, 2004
• “Many patients with classic cardiovascular
  disease risk factors can achieve risk
  reduction goals without medications within
  only three months of initiating therapeutic
  lifestyle changes (TLC).”

• Emory University Health Sciences Center
  Weight loss does not always lead
           to better health
• “Weight and BMI do not evaluate body
  compartments and therefore do not reveal
  if weight changes result in loss of fat-free
  mass or gain in fat mass.”
• J Amer Diet Assoc 2002;102(7):944-955

• BIA is a reliable resource for assessing
  body composition and tissue
  differentiation.
Why body composition and BMI are
 associated with increased risks
• Muscle mass is the #1 Bio-Marker of aging
• Hence, the higher the muscle mass the greater
  the longevity
• Important for preventing
Sarcopenia
Obesity
Heart disease
Type II diabetes
Osteoporosis
          Body Mass Index
• Commonly used index of body
  composition
• Not useful for measuring percentage of
  body fat or lean body mass
• Patients with normal BMI may have
  sarcopenia or sarcopenic obesity
    One in every six of your patient’s
        children are now obese
• The American Obesity Association uses a
  reference point of -85th percentile of BMI
  as overweight
• -95th percentile for obesity
• The American Obesity Association
  estimates that over 30% of America’s
  children can be classified as “overweight”
•   US Department of Health and Human Services
   Developmental Origins of Health
           and Disease
• As compared with members of the cohort
  in whom heart disease outcomes did not
  develop, those who were hospitalized for
  or died from coronary heart had relatively
  small body size during the first two years
  of life, then grew more rapidly through 11
  years of age.
• Developmental Origins of Health and Disease, N Engl J
  Med;2005:353(17):1848
Trajectories of Growth Among Children Who
      Have Coronary Events as Adults
• On average, adults who had a coronary
  event had been small at birth and thin at
  two years of age and thereafter put on
  weight rapidly. This pattern of growth
  during childhood was associated with
  insulin resistance in later life. The risk of
  coronary events was more strongly related
  to the tempo of childhood gain in BMI than
  to the BMI attained at any particular age.
•   New England Journal of Medicine
  Clinical Importance of Obesity Versus the Metabolic Syndrome in
                   Cardiovascular Risk in Women
    A Report From the Women’s Ischemia Syndrome Evaluation


• The metabolic syndrome but not BMI
  predicts future cardiovascular risks in
  women.
• The prevalence exceeds 20% on
  individuals > 20 years of age and 40% of
  the population > 40 years of age.
   Waist Circumference Predicts
          Metabolic Risk
• Men with a waist circumference greater
  than 40” and woman with a waist
  circumference greater than 35” are at
  increased risk for metabolic diseases.
• Klein S. The case of visceral fat: argument
  for the defense. J Clin. Invest. 2004; 113
  (11): 1530-1532.
          Obesity & Cancer
• 14% of obese patients will go on to have
  cancer.
• In 2020 1 in 26 people will get cancer.
• 5lbs of body fat looks like a loaf of bread.
    Essential Fatty Acids (EFA’s)
•  …are called essential because we MUST
   ingest them.
• Basically two types:
1. Omega-3’s found in cold water fish, nuts,
   canola oil and flaxseed.
2. Omega-6’s found in meat, cheese, nuts,
   seeds, grains, leafy vegetables, corn,
   safflower & soybean oil.
     Clinical importance of EFAs
•   Structural: all animals’ cell membranes.
•   -membrane stability.
•   -membrane fluidity.
•   -membrane-bound enzyme activities.
•   -receptor action.
•   -Permeability.
•   -ion-channel modulation.
•   Eicosanoid formation.
•   Cholesterol transport and oxidation.
•   Regulation of gene expression: FAs ‘talk to our genes.”
     Classification of Fatty Acids
•   Saturated (SFA)
•   Monounsaturated (MUFA)
•   Polyunsaturated (PUFA)
•   Highly unsaturated fatty acids (HUFAs)
•   Trans fatty acids (TFAs)
   Classification of Fatty Acids
• Essential
-Linoleic acid (LA; omega 6)
-Alpha-linoleic acid (ALA; omega 3)

• Non-essential
-SFA, MUFAs, TFAs, few PUFAs.
           What do EFA’s do?
• Modulate the inflammatory responses.
• Dilate or constrict blood vessels, stomach,
  intestines, bronchial tree, uterus.
• Components of cell membranes:
• -involved in cell-to-cell communication
• -keep cell walls rigid or fluid
• -control the flow of nutrients in & out of cells
• Required for the production of RBC’s
    Suggested therapeutic effects of
                EFAs
•   Modulate autoimmune conditions.
•   Improve insulin resistance.
•   Improve lipids.
•   Reduce CAD.
•   Reduce arrhythmia.
•   CNS: depression, vision, possibly ADHD.
•   Cancer-prevention, metastases control,
    and adjunct to RX.
     Signs of EFA deficiency…
• All patients on the       • Psychological
  Standard American           disturbances
  Diet                      • Impaired or increased
• Dermatitis – dry, scaly     immune responses
  skin, follicullar         • Neuropathy
  hyperkeratosis            • Reduced visual acuity
• Dry hair, dandruff        • Increased
• Brittle nails               cholesterol/HDL ratio
• Decreased memory
  and mental abilities
 Likely markers of EPA deficiency
• CVD                  • Irritable Bowel
• Arthritis              Disease
• Syndrome X and       • Diabetes
  Insulin resistance   • Cancer
• Inflammatory bowel   • Skin diseases
  disease              • Autoimmune disease
    In general omega – 6’s…
• Are derived from linoleic acid and produce
  inflammatory prostaglandins that are
  associated with heart disease, cancer and
  other inflammation associated diseases.
-Enhance growth of precancerous cells
-Initiate tumor growth
-Increases rates of tumor growth
-Promotes metastasis via PGE2 promotion
-PGE1 from DGLA is protective
        In general omega-3’s
• Are derived from alpha-linolenic acid and are
  associated with anti-inflammatory properties.
-Smooth muscle relaxation (lower BP).
-Relaxation of intestines (enhances nutrient
  absorption).
-Enhanced ability for hormones to communicate
  with target cells, decreasing the need for total
  hormone.
-Enhanced cell-to-cell communication (decreases
  rate o cell growth).
         Dietary sources of EFAs
•   FoodOmega-3 (grams per 100g)   •   Omega-6 (grams per 100g)
•   Flax 20.3                      •   4.9
•   Hemp seeds 7.0                 •   21.0
•   Pumpkin seeds 3.2              •   23.4
•   Salmon 3.2                     •   0.7
•   Walnuts 3.0                    •   30.6
•   Rape seed 2.1                  •   9.0
•   Herring 2.0                    •   0.4
•   Soybeans 1.2                   •   8.6
•   Butter 1.2                     •   1.8
•   Olive oil 0.6                  •   7.9
•   Wheat germ 0.5                 •   5.5
•   Sunflower seeds 0              •   30.7
•   Almond 0                       •   9.2
•   Olives 0                       •   1.6
                     Other References
•   Metabolism 1998;47:106-112
•   Br J Nutr 2000;83:S59-S66
•   Annu Rev Nutr 1999;19:63-90
•   J Biol Chem 2000;275:30749-30752
•   J Nutr 1998;128:923-926
•   Am J Clin Nutr 1999;70:566-571
•   Biochimie 1998;79:95-99
•   Int J Obes 1997;21:637-643
•   J Nutr 1997;127:2142-2150
•   Am J Clin Nutr 1999;69:890-897
•   Am J Clin Nutr 1999;70:817-825
•   J Nutr 1990;120:544-552
•   J Biol Chem 1998;278:5678-5684
•   J Biol Chem 1999;274:23577-23583
•   J Biol Chem 1999;274:471-477
•   J Biol Chem 1999;274:37335-37339
•   J Biol Chem 2000;275:32379-32282
•   Natl Acad Sci USA 1999;96:1041-1048
•   Scand J Med Sci Sports, 7(1): 25-31, 1997
•   Eur J Appl Physiol, 87(3): 193-201, 2002
•   J Appl Physiol, 80(2): 464-71, 1997
•   J Nutr, 127(9): 1752-7, 1997
•   Am J Clin Nutr: 1991, 54:438-463
•   Food Standards Agency ‘Manual of Nutrition’ 10th edition
Omega-3 & Healthy Cardiovascular
           Function
• Omega 3 EFAs from fish support short-
  term as well as long-term cardiovascular
  health.
• “Our findings contradict the current belief
  in the medical community that increasing
  the intake of omega-3 fatty acids produces
  only long term cardiac benefits.”
   – Dr. Fernando Holguin
• Chest 127/4/April 2005
Omega-3s reduce the risk of heart
    attacks by up to 90%
• Siscovich et al. JAMA. 1995;274:1363-
  1367
           Omega-3 and healthy body
                composition
• Fish oil concentrates not only caused weight
  reduction in the mice but also appeared to stop
  the animals from gaining weight when given free
  access to food.
• Additionally, omega-3 concentrate reduced the
  number of fat cells, especially in the abdominal
  region.
• Researchers showed that concentrated fish oil
  increased oxidation of fat by activating genes
  that break down fat in the mitochondria and
  peroxisomes.
•   Lipids, Vol. 39, no 12 (2004)
  EFA imbalances predispose to
  chronic inflammatory conditions
• The inflammatory based chronic diseases that
  are increasing in incidence in menopausal age
  women and are statistically most likely to kill
  them:
 Arthritis
 IBD
 Auto-immune diseases
 Asthma
 Atherosclerosis
 Cardiovascular disease
 Cancer
       DHA Supports Mitochondrial
      Function & Energy Production
• Mitochondria, have a substantial
  concentration of DHA-containing
  phospholipids, suggesting that these are
  essential for the functional assembly of the
  respiratory chain complexes.

•   Infante JP, Hiszagh VA, secondary carnitine deficiency and impaired
    docosahexaenoic acid synthesis: a common demoninator in the
    pathophysiology of diseases of oxidative phosphorylation and beta-
    oxidation. FEBS Lett. 2000 Feb 18:468(1):1-5
   Omega-3s reduce “silent inflammation”
    A primary cause of chronic disease
                          Problem
• 75% of Americans may have “silent” inflammation
• Underlying cause of conditions such as Alzheimer’s and
   cardiovascular diseases
                          Solution
• Increase EPA-DHA consumption (AA/EPA 1.5 to 3):
-Displace inflammatory compounds such as PGE2
-Increase formation of anti-inflammatory compounds such
   as PGE1
• Reduce body fat; insulin increases stored AA which is
   pro-inflammatory
           Omega-3 and healthy brain
                   function
• “People who eat oily fish or take fish oil
  supplements score 13 percent higher in IQ tests
  and are prone to healthier brain aging.”
• “The results suggest that fish oil users have
  younger brains than non-users. The aging of the
  brain is being slowed down by a year or two.”
• Dr. Lawrence Whalley (AM J Clinic Nutrition,
  2004)
•   American J Clin Nut Vol, 80, no 6, pp 1650-1657
               Omega-3 fatty acids and
                  neuropsychiatry
   “Epidemiological evidence suggests that dietary
   consumption of the long chain omega-3 fatty
   acids EPA and DHA, commonly found in fish or
   fish oil, may modify the risk for certain
   neuropsychiatric disorders. As evidence,
   decreased blood levels of omega-3 fatty acids
   have been associated with several
   neuropsychiatric conditions, including Attention
   Deficit (Hyperactivity) Disorder, Alzheimer’s
   Disease, Schizophrenia and Depression…”
Young, G et al: Reprod Nutr Dev. 2005 Jan-Feb;445(1):1-28
 Adult Attention and Focus may be
       aggravated by stress
  Effect of randomized supplementation with high dose olive, flax or fish oil on
  serum phospholipid fatty acid levels in adults with attention deficit
  hyperactivity disorder. Young, GS et al Reprod Nutr Dev. 2005 Sep-
  Oct;45(5):549-58
These data suggest that in order to increase levels of EPA
  and DHA in adults with ADHD, and decrease the
  AA/EPA ratio to levels seen in high fish consuming
  populations, high dose fish oil may be preferable to high
  dose flax oil. Future study is warranted to determine
  whether correction of low levels of long-chain omega-3
  fatty acids is of therapeutic benefit in this population.
  DHA and Psychological Stress
DHA deficiency has been shown to
 -reduce catecholamine production
 -lower serotonin binding affinity
 -reduce the number of synaptic vessels
Administration of DHA influences behavior
 and plasma catecholamine levels at times
 of psychological stress.
Hamazaki T et al: Lipids. 1999;34 Suppll:S33-7
Anti-stress effects of DHA
Hamazaki T et al: Biofactors. 2000;13(1-4):41-5.
      Anti-Stress Effects of DHA
• In a similar double blind two month study (study 2), we measured
  plasma catecholamines and cortisol of students (3 females and 4
  males for the DHA group and the same numbers for the control) at
  the start and end of the study. In study 2 the students were under a
  continuous stress of final exams that lasted for two months
  throughout the whole study period.
• The plasma cortisol did not change in either group, but the
  norepinephrine concentration was significantly decreased in the
  DHA group (-31%), whereas it stayed at the same level in the
  control group. These effects of DHA intake may be applied to people
  under psychological stress.
• Hamazaki T et al. Biofactors 2000; 13(1-4): 41-45.
     What about depression?
• Severity of depression correlates directly
   with the AA:EPA ratio.
• DHA deficiency has been shown to:
-reduce catecholamine production
-lower serotonin binding affinity
-reduce the number of synaptic vessels
• DHA supplementation dramatically
   increases the number of synaptic vessels
   in nerves.
    OB/GYNs are recommending
           EPA/DHA
• Promotes brain and eye development
• Encourages fetal weight gain
• Prevents perterm labor and preeclampsia
• Increases the nutritional value of breast
  milk
• Stabilizes mood and prevent depression
  during and after delivery – “baby blues”
     DHA Reduces Post-natal Depression and
          May Promote Restful Sleep
•     Without sufficient dietary intake, mothers
      become depleted of DHA and may
      increase their risk of suffering major
      depressive symptoms in the postpartum
      period.
•     How much? – 500 mg/day pre-
      conception, 1st & 2nd Trimester
•     -1000 mg/day 4rd & 4th Trimester
1.    American journal of clinical nutrition 2002;76(3):608-13
    EPA-DHA Reduces Pediatric
            Asthma
• Maternal oily-fish intake during pregnancy
  was associated with reduced asthma risk
  among children whose mothers had a
  history of asthma.
• Among children of asthmatic mothers,
  maternal intake of oily-fish during
  pregnancy reduced asthma risk by 71%.
• M.T. Salam et al, Prevention Medicine
  USC 5/25/04
   Change your oil, improve your
             health!
• Goal: to achieve minimum 8-10% cellular
  EPA/DHA level
• Achieve by supplementing 1 gram EPA-
  DHA per day
             EPA-DHA Dosing
• Application:                • Daily Levels:
Adult Maintenance             1-2 grams EPA-DHA
Cardiovascular Health         1-2 grams EPA-DHA
Healthy Blood Fat Levels      2-4 grams EPA-DHA
Inflammation                  2-7 grams EPA-DHA
Mental Function               2-10 grams EPA-DHA
Prenatal Health               1-2 grams EPA-DHA
Children                      100 mg – 400 mg DHA
Adults under chronic stress   1000 mg – 2000 mg DHA
Blood sugar balance           Individual diet plan
              Functional Medicine
“Functional medicine focuses on the early
  warning recognition and intervention to improve
  physical, mental and physiological function prior
  to the onset of acute disease.” Gazela, KA: “Jeffrey S. Bland,
  PhD, FACN, CNS: Functional Medicine Pioneer”, Alternative Therapies in Health and
  Medicine, Sept/Oct 2004, VOL. 10, NO. 5.

Medical foods are designed to restore function
 during early phases of declining health as well
 as manage a variety of chronic conditions and
 disorders by addressing underlying causes.
     What is a Medical Food?
• A specific combination of whole food
  macronutrient derivatives, micronutrients
  and botanical extracts designed with a
  specific therapeutic goal in mind.
                 WHY SOY?
•   Healthy body composition
•   Insulin resistance
•   Favors “Good estrogen”
•   Body recognizes as safe, weak estrogen
•   Cardiovascular health
•   Bone health
•   Antioxidant protection
•   Cognitive function
•   Hot flashes, sweats, dryness, mood, etc.
       I support the use of soy
• Do to the large amount of reported safety and
  efficacy studies.
• Its long history of safe consumption by Asian
  populations.
• The FDA health claim regarding soy protein and
  its potential to reduce the risk of heart disease.
• Substantial data regarding the benefits of soy in
  cardiovascular health, prostate health,
  menopausal symptom relief, and bone health as
  well as other important areas.
          Understanding Soy
• Soy has been consumes by Asian culture for
  thousands of years.
• Soy is a legume that is so nutritionally complete
  that it sustained Eastern populations through
  drought and famine.
• Composed of:
- Protein                  - Carbohydrates
- Fat                      - Fiber
- Phytonutrients           - Isoflavones
- Other isoflavone rich foods include garbonzo
  beans and sprouts (Red Clover).
         The Forms of Soy
• Soy has been used and studied in various
  forms:
-Whole soybeans - raw and cooked
-Protein isolates - with balanced and
  unbalanced isoflavone content
-Balanced isoflavone isolates
-Single isoflavone isolates
• The more imbalanced the isoflavones the
  greater the chance for negative affects.
     Phytosterols and Human Lipid
              Metabolism
“Plant sterols have been known for several
  decades to reduce plasma cholesterol
  levels. These plant materials have been
  granted a health claim by the FDA
  regarding their effects in the general
  prevention of cardiovascular disease”.
Marie-Pierre
    Soy & Plant Sterol Research
“At a dosage of 1.8 g/day, LDL Cholesterol
  concentrations were 11.3% lower in the
  plant sterol group, and cholesterol
  absorption efficiency was 56% lower in the
  plant sterol group.”

Am J Clin Nutr 2002;76:1272-78
                    Soy
“…Moreover, it has been estimated…that
  introducing 2 g of plant sterols daily might
  reduce the risk of coronary heart disease
  by 25%...low dose of soy protein (8g)
  added in beta-sitosterol (2g) seems to be
  a practical and safe alternative for patients
  seeking reductions in LDL cholesterol
  (<15%).”
Effects of a Dietary Portfolio of Cholesterol –
   Lowering Foods vs Lovastatin on Serum
         Lipids and C-Reactive Protein
“In this study, diversifying cholesterol-
  lowering components in the dietary
  portfolio by use of a soy protein-based,
  plant sterol fortified diet was as effective in
  lowering LDL cholesterol as was the use
  of lovastatin…reductions in hsCRP were
  significant with this dietary regime”.
JAMA 2003;290:502-10.
Is soy beneficial for breast health?
• Research is far from conclusive on this
  issue and researchers are urging women
  to be cautious
• However, a distinction should be made
  between the clear benefit of soy protein for
  cardiovascular health and the inconclusive
  role of isoflavones for breast tissue health.
    Does soy benefit menopausal
             women?
• YES. The research shows a great correlation
  with reducing hot flashes and other menopausal
  issues by consuming soy products.
• Consumption of soy protein containing
  isoflavones decreased the intensity of hot
  flashes.
• The majority of studies in menopausal women
  have shown improvement of hot flashes
  following soy consumption.
Do soy products compromise male
          reproduction?
• NO. Studies done with balanced soy isoflavones
  do not show negative impact on male
  reproduction.
• Negative studies are done with one isoflavone or
  by injecting isoflavones directly into the blood
  create much of the negative concern on soy.
• Genistein was shown in cell cultures to
  negatively impact human sperm’s ability to
  fertilize the female egg.
• Only when plant estrogens are injected, leading
  to high blood levels are adverse effects seen in
  research animals.
Do soy products compromise male
          reproduction?
• Four published clinical trials investigating the
  effects of soy isoflavone consumption in men
  and reported that there are no adverse effects of
  soy isoflavone consumption on sperm quality.
• Consumption of isoflavone supplements at the
  level of 40mg daily had no effect on semen
  quality.
• There is no evidence of increased rates of
  fertility disorders among the Asian population
  due to soy consumption.
• Medical foods with soy deliver 17mg of balanced
  isoflavones per serving.
     Should soy be used for prostate
                health?
• YES. Research shows overwhelming evidence
  of the positive benefits in supporting prostate
  health without adverse effects.
•   Nagata C, Takatsuka N, Shimizu H, Hayashi H, Akamatsu T, Murase K. Effect of
    soymilk consumption on serum estrogen and androgen concentrations in Japanese
    men. Cancer Epidemiol Biomarkers Prev 2001;10(3);179-84.
•   Habito RC, Montaito J, Leslie E, Ball MJ, Effects of replacing meat with soyabean in
    the diet on sex hormone concentrations in healthy adult males. Br J Nutr
    2000;84(4):557-63.
•   Mitchell JH, Cawood E, Kinniburgh D, Provan A, Collins AR, Irvine DS. Effects of a
    phytoestrogen food supplement on reproductive health in normal males. Clin Sci
    2001;100(6):613-18.
•   Hussain M et al. soy isoflavones in the treatment of prostate cancer Nutr Cancer
    2003;47(2):111-7.
  Does soy inhibit thyroid function?
• Well designed human clinical studies have
  demonstrated that soy has a minimal
  effect on overall thyroid function in healthy
  individuals.
• Ultrameal Medical Food Program:
  Containing soy protein (15 grams) with a
  comprehensive vitamin/mineral blend
• Patients using the Ultrameal product had no change in their TSH
  levels after 10 weeks. Patients using the popular retail product
  showed a significant elevation (150% above baseline) in their TSH
  levels.
 Does soy inhibit thyroid function?
• Amounts greater than 200mg of isoflavones per
  day may inhibit thyroid hormone synthesis in
  susceptible people. (thyroid issues/low iodine)
• Certain studies suggest that soy and soy
  isoflavones inhibit the production of thyroid
  hormones in individuals with thyroid issues.
• Approximately 10 million Americans or 3% of the
  population have thyroid issues.
• Alternatives to soy based medical foods are
  available for these individuals (rice and whey,
  etc.)
 Is soy beneficial for bone health?
• YES. Studies have shown that the
  isoflavones that are found in soy stimulate
  bone formation and reduce bone
  breakdown.
• Soy isoflavones have been found to have
  a positive effect on bone health.
• Isoflavones stimulate osteoblastic bone
  formation and inhibit osteoclastic bone
  breakdown.
Metagenics options to benefit every
         type of person
• Thyroid issues & soy   • Breast tissue health
  allergy clients:         options:
UltraMeal WHEY          Estrium
UltraMeal RICE          UltraMeal WHEY
UltraClear              UltraMeal RICE
UltraClear Plus         UltraClear
UltraInflamX            UltraClear Plus
                         UltraInflamX
 Is soy beneficial for tissue health?
• YES. Soy contains various beneficial
  agents for tissue health.
• Cultures that eat soy have shown an
  improvement in colon and specific
  hormone-related tissue health issues.
• Human trials involving post-menopausal
  women demonstrate a significant shift in
  healthy estrogen metabolism.
         Isn’t it better to use a more
              complete protein?
• Early studies suggested that soy was not a
  complete protein source. These early
  findings have been shown to be
  inaccurate.
• Soy has the same “protein digestibility”
  score as egg white and milk protein.
• Sarwar G, McDonough FE, Evaluation of protein digestibility-
              n ’a
  corrected aꎜ’ o’ cid score method for assessing protein quality of
  foods. J Assoc Off Anal Chem 1990;73(3):347-56.
Isn’t soy more allergenic than other
             proteins?
• Soy proteins tend to be less reactive than
  many other food proteins. In fact, soy has
  been used as an alternative for infants
  with allergies to cow’s milk.
• A meta-analysis of 17 studies of allergy
  patterns in high risk infants revealed soy
  allergy occurs in 3% to 4% of subjects
  versus 25% for cow’s milk.
Do I have to use fermented soy products to
       achieve therapeutic benefits?
• No. The majority of studies around the
  world show beneficial effects of soy.
• Our research studies support those
  findings for areas including:
Blood sugar
Body composition
Preserving muscle mass during weight
  loss
Cardiovascular risk reduction
              Improve health with
• UltraMeal
-Altered Body Composition
-Early Onset Metabolic Syndrome with Altered Body Composition
• Central body obesity
• Insulin resistance
• Altered body composition

• UltraMeal Plus
-Metabolic Syndrome with Cardiovascular Syndrome
• Elevated Cholesterol
• Increased Triglycerides
• Hypertension
           UltraMeal Plus
• Combined with a low-glycemic-index
  dietary program and exercise regimen,
  provides nutritional support for the
  management of conditions associated with
  cardiovascular disease, including:
• Hypercholesterolemia
• Hypertriglyeridemia
• Metabolic Syndrome
• Altered Body Composition
              UltraMeal
• Combined with a low-glycemic-index
  dietary program and exercise regimen,
  provides nutritional support for the
  management of conditions associated with
  altered body composition, including:
• Dyslipidemia
• Metabolic Syndrome
• Hypertension
• Estrogen imbalance
                UltraMeal Plus 360
• Multi-mechanistic nutritional support for metabolic syndrome and CVD, with
  the added benefit of Selective Kinase Response Modulators (SKRMs).
• Clinically tested results: The UltraMeal Plus 360 Medical Food Program was
  recently shown to improve important CVD risk factors in patients with
  metabolic syndrome. In this clinical study, patients assigned to treatment
  with UltraMeal Plus 360 Medical Food Program, exercise regimen, and low-
  gylcemic-load (GL) diet vs. the same low-GL diet and exercise regimen
  alone showed:
• Statistically greater reductions in lipid parameters
• Statisitcally greater reduction in serum homocysteine
• Significant increase in HDL (“good”) cholesterol
• Persistent lowering effects on apoB and apoB/apoA1 ratio
o ApoB may be a better indicator of CVD risk than total cholesterol or LDL
o ApoB/apoA1 ratio is a newly recognized, increasingly significant indicator of
  CVD risk
    Dynamic Combination for Overall
        Cardiovascular Health
         Patient Profile                UltraMeal Plus
•   Patients on statin therapy   2 scoops BID along with a
•   Patients 35-64 under            low glycemic diet
    preventative care for CVD
•   Increased triglyerides               EPA/DHA
•   High C-reactive protein      Recommended: 1 to 3
•   High cholesterol               grams daily
    – Increased LDL
    – Low HDL                              CoQ10
                                 Recommended: 100 – 300
                                   mg daily
      Children & Young Adults
    (soy and whey combination)
• Ultracare FIRST START Medical Food
  Program
   UltraGlycemX Medical Food
• Nutritional support for individuals with
  Type 2 Diabetes and Hypoglycemia
               UltraGlycemX
• Combined with a low-glycemic-index dietary
  program and exercise regimen, provides
  nutritional support for the management of
  conditions associated with insulin insensitivity
  and elevated blood sugar levels, including:
• Type 2 diabetes
• Insulin resistance
• Hypoglycemia
• Hypertension
              Blood sugar
• Blood sugar refers to levels of glucose in
  the blood.
• Blood sugar concentration, or serum
  glucose level, is tightly regulated in the
  human body.
• Glucose transported via the bloodstream
  is the primary source of energy for the
  body’s cells.
Fasting & 2 hr postprandial glucose
 following a 75 gram glucose load
• Fasting           • 2 hour postprandial
• 80-90 optimal     • 80-120 optimal
                    • Below 80 =
                      hypoglycemia
• 105 and above =   • 120 and above =
  DMII                DMII
              Glucose levels
• 35 = extremely low, danger of unconsciousness
• 75 = slightly low, first symptoms of lethargy etc.
• 80-90 = optimal pre-prandial in non-diabetics
• 80-120 = ooptimal 2 hour post-prandial in non-
  diabetics
• Above 100 = look for Metabolic Syndrome
  criteria
• 400 = max mg/dl for some meters & strips
• 600 = high danger of severe electrolyte
  imbalance
   Blood sugar important points
1) “high fructose corn syrup,” which is simply a
   Pure fructose (what we use) is NOT the same
   as replacement for table sugar. Fructose is
   “natural” and is the typical carbohydrate found
   in fruits and sone vegetables.
2) The fructose in UltraMeal and UltraGlycemX is
   nutritive (ie, food) and is NOT used as a
   sweetener. It is there for its therapeutic benefit.
3) “Moderate” consumption of fructose is
   associated with POSITIVE blood sugar,
   triglyceride, and body composition benefits.
 Blood sugar important points con’t
1) Data from animal studies use fructose levels
   far higher than a human would consume in a
   day – the equivalent of up to 700 calories in a
   day from fructose alone.
2) We have the clinical proof in numerous studies
   that moderate fructose consumption shows
   health benefits.
3) The obvious problem is poor diet – one FULL
   of empty calories from processed foods and
   beverages and NOT from a quality, balanced,
   meal such as UltraMeal or UltraGlycemX.
   Definition of Glycemic Index
• Glycemic index (GI) is defined as the
  incremental area under the blood glucose
  curve in response to a standardized
  carbohydrate load. It is therefore an index
  of the blood glucose raising potential of
  the available carbohydrate in a food.
Many factors affect GI of a food:
• Carbohydrate type
-Simple: glucose, fructose, maltose
-Complex: amylose, amylopectin
• Fiber content and type
• Processing (the higher the processing, the
  higher the GI load)
• Physical nature
• Other macronutrients in food
-Protein
-Fat
            Glycemic Index
• The GI for a particular food is derived by
  expressing the individual glycemic index
  as a percent of a reference food, typically
  white bread or glucose.
   Glycemic Index and Obesity
Low GI foods control appetite and delay hunger.
Low GI diets reduce insulin levels and insulin resistance.
- High-carb, low-fat diets increase postprandial
  hyperglycemia and hyperinsulinemia.
Several human studies found that energy restricted low-GI
  diets produced greater weight loss than did equivalent
  diets based on high GI foods.

Brand-Miller JC et al. Glycemic index and obesity. AM J
  Clin Nutr, 2002. 76(1): p. 281S-5S.
           Glycemic Index and HDL-
                 Cholesterol
• Conclusion: dietary GI is a stronger
  predictor than dietary fat intake of serum
  HDL-cholesterol concentration.
•   Frost G et al. Glycaemic index as a determinant of serum HDL-cholesterol
    concentration. Lancet, 1999. 353(9158): p. 1045-8.
    A meta-analysis of Low-GI Diets in the
          Management of Diabetes
• 14 studies that met inclusion criteria
• Conclusions:
-Low GI diets have a clinically useful effect on
  medium-term glycemic control in patients with
  diabetes.
-The benefit is similar to that offered by
  pharmacological agents that also target
  postprandial hyperglycemia.
*Without drugs they get “similar” results on
  low GI diet
  Brand-Miller et al. Low-Glycemic Index Diets in the Management of Diabetes: A meta-analysis of
  randomized controlled trials. Diabetes Care, 2003 26(8): 2261-2267
     Glycemic Index
 Low GI         55 or less



Medium GI        56 to 69



 High GI        70 or more
    Glycemic Index of Selected Foods
         (referenced to glucose)
•   Watermelon          72
•   Pearled barley      25
•   White flour bread   70
•   Carrot              47
•   Cornflakes          72
•   Baked potato        85
•   Apple               38
•   Apple juice         40
              Glycemic Load
• The amount of carbohydrate often differs in a
  typical serving of a food.
• A measure termed ‘glycemic load’ (GL) has
  been introduced.
  (Salmeron J, Ascherio A, et al. Dietary fiber,
  glycemic load, and risk of NIDDM in men.
  Diabetes Care, 1997. 20(4): 545-50.
• The dietart glycemic load is defined as the
  product of a food’s glycemic index and its
  carbohydrate content.
GL=(GI divided by 100) x available
              carb
• Example: Watermelon (GL=4)
- Glycemic index = 72. A typical serving
  (120 grams or ¾ cup) has 6 grams of
  available carbohydrate.
- Glycemic load = (72 / 100) x 6 = 4.32
  (rounded to 4).
     Glycemic Load
 Low GL         10 or less



Medium GL       11 to 19



 High GL       20 or more
    GL=(GI/100) x available carb
   (available carbohydrate content of typical serving)

• Example: Carrot (GL = 3)
- Glycemic index = 47. A typical serving (80
  grams or ½ cup cooked) has 6 grams of
  available carbohydrate.
- Glycemic load = (47/100) x 6 = 2.82
  (rounded to 3)
         GI/GL Comparisons
FOOD           GI     GL

Baked potato   85     26

Watermelon     72     4

Apple          38     6

Apple juice    40     11

Carrot         47     3
  GI & GL values of hundreds of
   foods have been determined
• On the web:
www.glycemicindex.com
www.mendosa.com
     Effects of a Low-Glycemic Load
                    Diet
“Resting energy expenditure decreased less with the low-
   glycemic load diet than with the low-fat diet…participants
   receiving the low-glycemic load diet reported less
   hunger…”
“Insulin resistance, serum triglycerides, C-reactive protein,
   and blood pressure improved more with the low-glycemic
   load diet.”
“In conclusion, we found that the physiologic adaptations to
   a weight loss diet thought to antagonize weight loss,
   involving energy expenditure and hunger, can be
   modified by dietary composition.”


JAMA 2004:292(20)2482-2490
    High Glycemic Index Foods,
      Overeating, and Obesity
“Voluntary energy intake after the high-GI
  meal…81% greater than after the low-GI
  meal.”

Pediatrics 1999; 103(3):E26
                      GI Meals
“high-glycemic index meals produce an initial
  period of high blood glucose and insulin levels,
  followed in many individuals by reactive
  hypoglycemia, counter-regulatory hormone
  secretion, and elevated serum free fatty acid
  concentrations. These events may promote
  excessive food intake, beta cell dysfunction,
  dyslipidemia, and endothelia dysfunction.”
JAMA 2002:287(18);2414-2423
                                             Fiber
• Two isocalorically equal diets varying only in
  amount and type of fiber (50 g at 1:1
  soluble/insoluble vs 24 g at 1:2 soluble vs.
  insoluble) for 6 weeks in non-insulin diabetes
  patients.
• The high-fiber diet lowered the area under the
  curve for 24-hour plasma glucose and insulin
  concentrations by 10 percent and 12 percent
  respectively.
•   Chandala, M., et al., Beneficial effects of high dietary fiber intake in patients with type 2 diabetes
    mellitus. N Engl J Med, 2000. 342(19):1392-8.
                                            FAT
• High-monounsaturated-fat diets reduced fasting
  triglycerides (19%) and VLDL-cholesterol (22%),
  and caused a modest increase in HDL-
  cholesterol concentrations with no adverse affect
  on LDL-cholesterol.
• No evidence that high-monounsaturated fat diets
  induce weight gain in patients with diabetes
  mellitus provided that energy intake is
  controlled.
•   Garg, A., high monounsaturated fat diets for patients with diabetes mellitus: a meta-analysis. AM J
    Clin Nutr, 1998. 67(3 Suppl): p. 577S-582S.
        Healthy vs Unhealthy
• Normal Metabolism       • Metabolic Syndrome
 Healthy body             Mental fogginess
  composition              Low energy
 Great energy             Depression
 Healthy attitude         Increased fat
 Great mental function    Decreased muscle
                            mass
      Detoxification & Inflammation
       UltraClear UltraClear Plus
•   Fatigue
•   Food allergies
•   Environmental toxicity
•   Liver function
•   Health maintenance
       Elimination of Toxins
• UltraClear Plus
    Nutritional Support Is required for
      Proper Clearance of Toxins
• “Diets restricted in calories, protein, … as well as
  those having low quality protein or high sugar
  content, can affect the component enzymes,
  ctochrome P-450 and the cytochrome P-450
  reductase, … In addition, deficiencies of specific
  vitamins (riboflavin, ascorbic acid, and Vitamins
  A and E) and minerals (iron, copper, zinc, and
  magnesium) affect the components and
  activities of the system.”
•   Bidlack WR, Brown RC, Mohan C. Fed Proc. 1986 Feb;45(2):142-8.
             Detoxification
• UltraClear
• UltraClear Plus
• UltraClear Plus pH
• AdvaClear
These help with chemical toxicity, food
  allergies, liver function, fatigue
   GI Dysfunction: Increasing liver
               stress
• Patients with leaky gut, mediated food allergies,
  inflammation may have hepatic (liver) stress.
• In these scenarios, the liver is constantly
  burdened by toxins and allergens arriving from
  the gut.
• These patients will benefit from a program to
  restore normal gut barrier function to relieve the
  burden on the liver before they can become well.
      How the environment affects
          genetic expression
•   Poor diet
•   Stress
•   Fatigue
•   Lack of exercise
•   Drugs, alcohol, tobacco
•   Chemical exposure
            UltraClear Plus
•  A clinically tested detoxification program
   to:
1. Reduce toxic load (external sources of
   toxins)
2. Improve Biotransformation (supports
   cytochrome p450 phase 1 and
   conjugation phase 2 pathways
3. Support elimination (optimal excretion of
   toxins)
                  AdvaClear
• This formula is particularly valuable in patients
  who score over 100 on the MSQ as they often
  have overactive Phase 1 activity and depleted
  conjugation pathways. Ingredients include
- Pomegranate
- Watercress
- Artichoke
- Milk thistle
- Green tea
               Estrium
Scientifically designed to:
• Promotes healthy hormone cycles
• Relieves symptoms of PMS
• Promotes healthy estrogen metabolism
  and excretion
• Modifies the effects of circulating
  estrogens
                Estrium
Patient Benefits
• Reduction in PMS symptoms
• Case studies show effective for symptoms
  associated with menstrual tension,
  menstruation and endometriosis
• Easy to use – 2 scoops one to two times
  daily mixed with juice, milk or milk
  substitute as meal replacement or snack
 Ideal Foods That Modify Estrogen
           Metabolism
• Cruciferous vegetables:   • Beans
  broccoli, cabbage,        • Raw seeds and nuts: flax
  brussel sprout              seeds
• Fresh greens and          • Whole grain: oats, whole
  vegetables (assorted        wheat or rye berries
  colors)                   • Quality proteins: fish,
• Fresh fruit: berries,       (tuna, salmon, haddock),
  melons, citrus              hormone free chicken,
• Legumes: soy – tofu,        beef
  soymilk, miso, tempeh,    • Oils: flax seed (ALA,
  steamed soy beans           Omega-3), olive, sesame
  (edamane), garbanzo
        If you have Inflammation
             Use UltraInflamX
•   Rheumatoid arthritis
•   Inflammatory bowel disease
•   Fibromyalgia
•   Eczema & psoriasis
•   Asthma
Additional Inflammatory Support
•   Estrium
•   Kaprex
•   Kaprex AI
•   Inflavinoid
•   Inflavinoid Intensive Care
•   ChondroCare
•   Essential Fatty Acids
     Inflammatory Cytokines,
Hyperinsulinemia & Atherosclerosis
• A number of studies have demonstrated
  that increases in inflammatory mediators
  like IL-6 and hs-CRP are associated with
  insulin resistance and metabolic
  syndrome.
• Metabolic syndrome is strongly associated
  with the onset of endothelial dysfunction,
  which may explain why type-2 diabetes is
  a risk factor for atherosclerosis.
              If you have
• Altered body composition
• Abnormal blood sugar regulation
• Cardiovascular risks (atherosclerosis)

Consider UltraMeal Plus, UltraInflamX
 Nitric Oxide prevents Atherosclerosis and
        Promotes Circulatory Health
• Dilating the arteries and increasing blood
  flow support circulatory function for a
  healthy heart.
 Support healthy blood pressure,
circulation & heart muscle function
• Arginine
• 5-MTHF
• Magnesium Bonito Peptides
     Arginine Imperative for Heart
                Health
• Is an amino acid
• Is naturally found in red meat, poultry, fish, and
  diary
• Supports the production of nitric oxide, which is
  used to dilate blood vessels
• Maintain health of the circulatory system
• Is used for cardiovascular conditions:
   – Congestive heart failure
   – Hypertension
   – Coronary artery disease
              Magnesium & Folate
    most researched ingredients for the heart
          Magnesium                          5-MTHF
•   Supports healthy             •   Improves nitric oxide
    endothelial cells                status
•   Alleviates arrhythmias &     •   Lowers blood levels of
    heart palpitations               homocysteine
•   Essential for proper heart   •   Crucial for methylation
    muscle function              •   Reduces risk of heart
•   Lowers triglyerides              disease
•   Raises HDL                   •   Influences endothelial
•   Lowers cholesterol               function
 New Atherosclerosis Concepts
• Understanding the impact on the vascular
  tissue through inflammatory-
  immunological mediated trauma
• The association with the abnormal
  lipid/cholesterol panel and risks for MI
• The presence of inflammatory cytokines
Ornish D et al: JAMA. Vol. 280, No.
   23, pp. 2001, dec. 16, 1998
• Intensive lifestyle changes (10% fat, whole
  foods vegetarian diet, aerobic exercise,
  stress management training, smoking
  cessation and group psychosocial support)
  resulted in regression of coronary
  atherosclerosis over a five year period,
  whereas for those in the control group
  using the traditonal AHA approach CHD
  continued to progress and more than twice
  as many coronary events occurred.
  Using medical food shakes twice
               daily
• Predictability – clinically tested and utilized
  in thousands of clinics worldwide
• Well tolerated by the most sensitive client
  – easily digested and low allergy potential
• Convenient – good taste and easy to
  follow programs
        Cardiovascular support
•   EPA/DHA
•   Cardiogenic (CV Wellness Essential)
•   CoQ10
•   Lipid support
-   Lipogen
-   Meta sitosterol 2.0
-   Lipotain
-   Cholarest
   Therapeutic dosing levels for
      cardiovascular health
• Arginine       3000 – 6000 mg
• Magnesium       200 – 400 mg
• ActiFolate      400 – 800 mcg
                    CoQ10
• Ubiquinone (CoQ10) is a vitamin-like fat-soluble
  antioxidant found in all cells in the body.
• Statin therapy for cholesterol, lowers the body’d
  production of CoQ10.
• CoQ10 deficiency may cause increase risk of
  heart disease and high blood pressure.
• Adequate CoQ10 intake is vital for organs such
  as the heart, liver, kidney and pancreas.
• As you age the CoQ10 is depleted.
• CoQ10 is key for mitochondrial function.
       CoQ10: Dosage Range
         100-300 mg daily
• Protects patients on Statin therapy
• Effective nutritional treatment for
  congestive heart failure
• Antihypertensive effects
• High doses may reduce functional decline
  in early Parkinson’s disease
• May prevent migraine headaches
• Master antioxidant-may support breast
  tissue health
  Dr. Jeffrey Tucker’s Program
• Simple lifestyle changes
• Facilitates transition to healthy, whole food
  diet
• Replaces problem meals with a healthy
  shake
• Understand the relationship of health and
  food
• Food choices from every category (meats,
  vegetables, fruit, grains, etc)
   Dr. Jeffrey Tucker’s Program
          Diet & Exercise
• Low gylcemic index foods
• Small, frequent meals
• Medical food for body composition
• Quality EFAs, esp. omega 3 (EPA, DHA)
• Exercise –progressive body movement
-CORE, Gymstick, free weight training
• Additional supplementation as needed
    Why is this the most effective
              program?
• Better appetite control
• Delayed hunger
• Less cravings
• Better blood sugar control
• Improved insulin sensitivity
• Better reduction of elevated blood lipids,
  blood pressure & blood sugar
• The most specific exercise training
   Clients that will benefit from Dr.
          Tucker’s program
• Altered body composition (come in to the office
  and do a BIA test)
• Abnormal blood sugar regulation
• Cardiovascular risks (atherosclerosis,
  hyperlipidemia, dyslipidemia)
Consider: UltraMeal Plus for increased cholesterol
  and LDL.
UltraMeal + MetaglycemX/Insinase or
  UltraGylcemX + Insinase for increased Trig/HDL
  ratio
           Illness and Muscle Loss
• “…we found that fat-free mass was lower
  and fat mass was higher (Sarcopenia) in
  acutely ill and chronically ill patients than
  controls.”
•   J Amer Diet assoc 2002;102(7):944-955

•   The over-fat “ill” with sarcopenia include those with fatigue, arthritis, back
    pain, metabolic syndrome, cardiovascular disease, hypertension, diabetes
    and other health problems.
   Sarcopenia – understanding the
     Dynamics of Aging Muscle
• The damage caused by high glycemic
  meals insulin resistance, inflammatory
  immune factors and hormone changes
  acting primarily in the postprandial state
  are implicated as an important cause of
  sarcopenia.

• JAMA 2001:286(10):1230-31.
   10 week Doctor Supervised Program
                  vs.
        Un-supervised Program
           Total     Lean Body   Change In
           weight    Mass        Fat Weight


Dr.        -11 LBS   +4 LBS      -15 LBS
Supervised


Over The   -13 LBS   -11 LBS     -.91 LBS
Counter
    10 week Doctor Supervised Program
                       vs.
           Un-supervised Program
“Two statistically significant differences
  between the groups were changes in
  thyroid stimulating hormone (TSH) and
  body composition (BC). No change in TSH
  was observed in the DSP group pre- and
  post-intervention. Whereas a significant
  increase (150%) was observed in the OTC
  group. In addition, participants in the DSP
  group last significantly more fat than the
  OTC group.”
   UltraMeal has the science…
All Women:
• Lost body weight                              5.7-22 lbs
• Decline in % body at                          up to 10.1%
• Lost fat mass                                 up to 22.9 lbs
• Average fat loss                              14.1 lbs
• 12 of 18 showed
 increase in lean body mass                     .2 – 7.7 lbs
 Robert Hackman, PhD Associate Professor of Nutrition University of Oregon
 250 Esslinger Hall Eugene, OR.
  UltraMeal Soy Protein Source
• Conditions associated with
  Metabolic Syndrome
                                   • UltraMeal in
• Delicious Flavors & Variations     convenient Bar Form
- Banana Blast                     -Chocolate Raspberry
- Dutch Chocolate
- Strawberry Supreme               -Lemon Zinger
- Vanilla
                                   -Chocolate Fudge
- Country Peach
- Raspberry                        -Apple Cinnamon
- Mocha
- Also available in Rice & Whey
                                   -Chocolate Banana
  Protein
   UltraMeal: Additional Facts
• Glycemic Index of 31
• Optimal, foundation nutrition with all
  essential vitamins and minerals
• Dairy-free source of calcium for bone
  health (500mg per serving = 2 scoops)
• Features ActiFolate, a proprietary blend of
  active floates for healthy methylation
 Cardiovascular Disease Facts
• Cardiovascular disease is the #1 killer in U.S.
• Nearly 62 million have at least one type of CVD
• More Dr. office visits for hypertension or high
  blood pressure, than for any other reason
• Economic cost of CVD is approximately 298
  Billion, more than 28 Billion was spent on CVD
  Drugs.
  Soy & Plant Sterol Research
“At a dosage of 1.8 g/day, LDL cholesterol
  concentrations were 11.3% lower in the
  plant sterol group, and cholesterol
  absorption efficiency was 56% lower in the
  plant sterol group.”

Am J Clin Nutr 2002;76:1272-78
UltraMeal Plus Program Better Than AHA Diet For
     Reducing 14 Cardiovascular Risk Factors

• Human Clinical Trial Demonstrates…

Trial conducted at the Functional Medicine research Center, a research
   arm of Metagenics.
UltraMeal Plus & Dr. Tucker’s Workout Program in
Reducing 14 Cardiovascular Disease Risk Factors
• UltraMeal Plus          • AHA Diet
tChol           -16%      -1%
LDL-C           -15%      -2%
HDL-C           +6%       +1%
Trig            -45%      -24%
tChol/HDL-C     -20%      -4%
TG/HDL-C         -45%     -24%
Body weight     -14.8lb   -7.5lb
% Lean Mass      +2.8%    +1.23%
Hs CRP           -34%     -7%
HbA1C            -3.4%    -1.5%
Fasting Insulin -26%      -10%
BP systolic       -4.6    -2.3
BP dyastolic      -8.3    -6.0
    UltraMeal Plus & Dr. Tucker’s
              Program
• Reduction in 14 important cardiovascular
  disease risk factors including cholesterol,
  HDL, triglyerides, blood pressure.
• 97% greater weight loss tha aleading diet
  used by doctors worldwide (ADA diet).
• 110% greater fat loss than a leading diet
  used by doctors worldwide (AHA diet).
           UltraMeal Plus
• Patients lost weight while maintaining
  muscle, resulting in improved body
  composition.
• Promotes healthy blood sugar balance –
  low glycemic index meal.
• Preserves lean body mass – unlike most
  diet and weight loss programs, patients
  lose fat and maintain muscle.
    The Truth About Type 2 Diabetes
• 20.8 million children and adults have diabetes
- 14.6 million diagnosed
- 6.2 million are unaware
• Results from insulin resistance
• The body’s cells are resistant to the actions of
  insulin
• Pancreas produces too little insulin
• Diabetics usually develop the condition after age
  45
• About 18% of U.S. population 65 and older has
  diabetes.
             UltraGlycemX
          Glycemic Index of 36
• Nutritional support for individuals with Type 2
  Diabetes & Hypoglycemia
• Provides enhanced levels of:
-Cinnamon
-Vitamin E, biotin, vanadium, magnesium,
  chromium, and alpha-lipoic acid
• High quality protein, carbohydrates, and fat in
  shake form
• Inclusion of specific fibers
• Is free of dairy, lactose, wheat, gluten
    UltrGlycemX supportive vitamins &
                minerals
•   Alpha-lipoic Acid
-   Stimulation of Glucose Transport Proteins
-   Improves insulin receptor sensitivity
-   Increases glucose metabolism in mitochrondria
•   Zinc and Chromium Combination
-   Reduces oxidative stress in patients with blood sugar
    concerns
•   Vanadium
-   Activates cellular insulin receptor pathways
•   Taurine
-   Protects the beta cells in the pancreas
-   Stimulates insulin sensitivity
   Cinnamon in UltraGlycemX
“This study demonstrates that intake of 1, 3,
  6 g of cinnamon per day reduces serum
  glucose, triglyerides, LDL cholesterol and
  total cholesterol in people with Type 2
  diabetes and suggests inclusion of
  cinnamon in the diet of people with type 2
  diabetes will reduce the risk factors
  associated with diabetes and CVD.”
       Green Tea Therapy for
         Insulin Resistance
Green Tea in UltraGlycemX
• Antioxidant
• Appetite regulation
• Leptin receptor independent pathway
• Stimulates respiration and energy
  expenditure
• Stimulates adipose tissue thermogenisis
• Fat burning
     Green Tea in UltraGlycemX
“Epigallacatechin gallate (EGCG), a major
  ingredient in green tea…was reported to
  functionally act as antidiabetic. Injection of
  EGCG into lean and obese Zucker rats
  significantly lowered blood glucose and
  insulin levels, and green tea extract
  increased glucose metabolism in
  adipocytes (fat cells).”
Experimental and molecular Medicine Vol. 35, No 2, 136-139 April 2003
    UltraGlycemX supportive vitamins
               & minerals
•    Biotin
-    Supports metabolism of glucose without increased insulin secretion
-    Improves beta cell function
-    Enhances post-prandial glucose uptake by the liver and skeletal
     muscle
•    Alpha-lipoic Acid
-   Stimulation of Glucose Transport proteins
-    Improves insulin receptor sensitivity
-    Increases glucose metabolism in mitochrondria
•    Chromium
-    Enhances cell membrane fluidity
-    Stimulates glucose uptake
-    Allows for proper binding of insulin to receptors
 UltraGlycemX supportive vitamins
          & minerals con’t
• Zinc & chromium combination
- Reduces oxidative stress in patients with Type 2
  diabetes.
• Vanadium
- Activates cellular insulin receptor pathways
• Taurine
- Protects the beta cells in the pancreas
- Stimulates insulin sensitivity
                UltraGlycemX
•   Hypoglycemia
•   Dizzy after skipping a meal
•   Sugar cravings
•   Low energy

Parameters:
• Fasting glucose >100mg/dl and <110mg/dl
• Triglycerides >150mg/dl and <175mg/dl
• BP < 140/90
   Which Medical Food To Use
• BODY COMPOSITION MANAGEMENT
UltraMeal, First Start
• CARDIOVASCULAR DISEASE & BODY
   COMPOSITION
UltraMeal Plus
• DYSGLYCEMIA & INSULIN RESISTANCE
UltraGlycemX, UltraMeal 360
• INFLAMMATION
UltraInflamX, UltraInflamX 360
• DETOXIFICATION
UltraClear, UltraClear Plus, UltraClearPlus pH, Estrium
UltraGlycemX         UltraMeal Plus    UltraMeal
Type 2 Diabetes      Hypercholester-   Dyslipidemia
Insulin resistance   olemia            Metabolic
Hypoglycemia         Hypertriglycer-   syndrome
Hypertension         idemia            Hypertension
                     Metabolic         Estrogen
                     Syndrome          imbalance
                     Altered body
                     composition
Biochemical         Wellness           Medical Food           Micronutrients           Supportive
                    Essentials                                                         supplements
Challenge
Maintenance         Original,                                                          Ceralin forte
                    Woman’s,
General
                    Pregnancy, Men’s
Wellness
Body                Original           UltraMeal                                       EPA/DHA
composition
                    Blood Sugar
Insulin             Blood Sugar        UltraMeal Plus (pH),   MetaGlycemX EPA/DHA,
resistance                             UltraGlycemX                                    Insinase, Ceriva
Metabolic           Blood Sugar        UltraMeal Plus (pH),   MetaGlycemX EPA/DHA,
                                       UltraGlycemX                                    Insinase, Ceriva
Syndrome
Dyslipidemia        Cardiovascular     UltraMeal Plus (pH),   Metasitosterol           EPA/DHA,
                                       UltraGlycemX           2.0                      CoQ10, Lipotain
                    Blood Sugar
                                                                                       EPA/DHA, Kaprex,
Inflammation        Original, Joint    UltraInflamX           Inflavinoid              Kaprex AI, IsoD3,
                                                              Inflavinoid Int. Care    Trancor, Ceralin Forte

Biotransformation   Original           UltraClear Plus        AdvaClear                Silymarin,
(Detoxification)                       (pH), UltraInflamX                              Chloraclear

Methylation         Original           UltraMeal Plus (pH),   AdvaClear                Glycogenic
                                       Estrium                EstroFactors/Testralin

Female              Women’s            Estrium                EstroFactors             MetaI3C,
Hormones                                                                               Ceriva
Male Hormones       Men’s              UltraMeal Plus         Metasitosterol           Tribulus synergy,
                                                                                       Testralin
        Why Stress Reduction?
• Stress accounts for 75-90% of all primary care visits in
  the US (National Inst for Occupational Safety and Health)
• Almost all illness is stress-related
  - caused by stress
  - aggravated by stress
  - causes stress
• #1 reason why people eat poorly and quit healthy life
  style programs
• Conserves energy
• Restores sense of control
• Supports good choices
• Reduces cortisol
     What do people do to manage mental
                   stress
Self-medicate through…
• Drug or alcohol abuse
• Tobacco use
• Abnormal patterns
• Passive activities (couch potato, video games)
• Over-eating, over-working, over-sleeping
• Stimilants, e.g. coffee
   - Four or five cups daily can cause changes in blood
   pressure and stress hormone levels similar to those
   produced by chronic stress
(self-perpetuating the stress cycle)
         Or, go to their Doctors for Rx
    to manage mood or stress-related illness
•   Anti-depressants
   SSRIs
   SNRIs
   NDRIs
   Tricyclic antidepressants
   Receptor blockers
   MAOIs
•   Anti-anxiety medications
•   Anti-inflammatory
•   Anti-ulcerant
•   Cholesterol reducers
•   Anti-hypertensives
       Depression & Anxiety Disorders
National Institute of Mental Health, Information Resources and Inquires Branch
                                     website:
                               www.nimh.nih.gov

• Depression
In an given 1 year period, 9.5% of the population,
  or 18.8 million American adults suffer from a
  depressive disorder.
Affects about 12.4 million women and over 6
  million men in the US each year
• Anxiety Disorders
Approximately 19 million American adults
Chronic, relentless and grows progressively worse
  if not treated
  North America Top Selling Drug
            Category
• Central nervous system category
  (anti-anxiety, antidepressants, anti-
  psychotics)
2005 retail sales: $43.3 billion
Growth: 23.0%
12.2% of all drug sales

www.imshealth.com
              FDA Warning:
• Anti-depressants linked to suicidal behavior in
  depressed children and adolescents.
• The warning applies to both children and adults
  and includes the following drugs:
Prozac                     Lexapro
Zoloft                     Wellbutrin
Paxil                      Effexor
Luvox                      Serzone
Celexa                     Remeron
          What is Stress?
• A physiologic response to a demand for
  change
• “Fight or Flight” response
• General Adaptation Syndrome
• Sympathetic Nervous system Dominance
        Stress Physiology
      Hans Selye, M.D., Ph.D.
• “Without stress, there would be no life”
• “Stress = nonspecific response of the body
  to any demand.”
    How can stress cause so much
              damage?
                Selye’s General Adaptation Syndrome
                        The 3 Stages of Stress
• Arousal
 Rapid increases in catecholamines (alarm molecules)
 Slower increases of corticosteroids (stress steroids)
• Adaptation
Characterized by sustained increased levels of corticosteroids and
   alarm molecules
Altered glucose tolerance, blood pressure, thyroid hormone and sex
   hormone metabolism
• Exhaustion
Degenerative diseases characterized by the adverse influence of
   corticosteroids and alarm molecules
            Stress versus the
          Relaxation Response
Fight or Flight Response   Relaxation Response
• Sympathetic State        • Parasympathetic State
 Inc. Heart Rate           Dec. Heart Rate
 Inc. Blood Pressure       Dec. Blood Pressure
 Inc. Respiratory Rate     Dec. Respiratory Rate
 Dilated Pupils            Constricted Pupils
 Muscle Tension            Muscle Relaxation
 Inhibits Digestion        Enhances Digestion
                 Stress
• The basis for human stress related
  disease is the high percentage of time
  spent in the sympathetic dominant state.
          Sympathetic Dominance:
 Long-term Effects of Elevated Cortisol & Catecholamines
• GI distress: IBS, ulcers          • Cognitive impairment:
• Cardiovascular symptoms:            inability to concentrate, poor
  rapid pulse, pounding heart,        memory
  weakness, dizziness, chest        • Neuromusculoskeletal
  pain, high BP                       complaints: TMJ, bruxism,
• Mood changes: general               trembling, nervous ticks, back
  irritability, floating anxiety,     and muscle ache
  depression, impulsive             • Energy level: Fatigue of
  behavior, nervous laughter,         unknown origin
  increase startle response         • Adrenal architecture
• Hyper-kinesis or –excitation        changes: Adrenal hyperplasia
• Sleep disturbances:                 “burnout”: dryness of mouth,
  nightmares, insomnia                sweating, salt cravings
• Brain architecture changes:       • Immune impairment:
  Lower hippocampal volume            increased susceptibility to viral
  (inc cortisol)                      infections, autoimmune
                                      disorders
    Stress…Not Just An Adrenal
            Problem
• Stress triggers psycho-neuroendocrine-
  immune imbalances
Applied Nutrition Science Reports No. 576
Emotional trauma  Limbic system 
           Hypothalums
Locus Coenuleus Primary Afferent
  Nociceptor  Noxious Stimulus
  Emotional trauma Limbic system  Hypothalums 



Norepinephine (NE)          Corticotrophin
 Sympathetic               Releasing Hormone
 Nervous System             (CRH)  Anterior
                            Pitutiary 
                            Adrenocorticotrophin
                            Adrenal
                            cortexCortisol
                Cortisol
• Increases with age and can elevate blood
  glucose by up to 50%, contributing to
  insulin resistance and inflammation.
Cortisol Influences Neuroendocrine
               Function
• Inc. Epinephrine (E) &         • Inc. oxidative stress
  Norepinephrine                 • Inc. inflammation
• Inc. Cortisol                  • Inc. need for
• Inc. Insulin (due to inc.        detoxification
  glucose)                       • Impaired immunity
• Inc. visceral fat deposition   - Dec. Secretory IgA
• Dec. TSH, T4, T3               - Inc. Antigen penetration
• Dec. estrogen,                 - Inc. IgG
  Testosterone,                  - Dec. NK cell activity
  Progesterone
                                 - Dec. IL-2
• Altered neurotransmitter
  balance                        - Inc. bone loss
    Sympathetic Dominance Can Trigger
          HPA Hypoactivation
•  Glucocorticoid receptor insensitivity or under production of cortisol (adrenal
   insufficiency)
                           Symptoms and conditions
Fatigue/malaise
Risk of inflammatory conditions
Risk of autoimmune disease
Myocardial infarction
Unable to perform routine tasks
Inability to cope
Apathy
Anorexia
Weight loss
Restless sleep
Weakness
Chronic pain
Reduced libido
  Sympathetic Dominance Can Trigger
       HPA Hyperactivation
   •    Cortisol and catecholamine   Impaired memory learning
          excess and imbalance       Gastrointestinal disorders
       Symptoms and conditions
                                     Central obesity
Anxiety
Agitation/irritability               Neurologic disorders
Restless sleep                       Loss of muscle tone
Increased cholesterol                Decreased growth
Increased triglyerides               Protein wasting
Increased blood pressure             Bone loss
Insulin resistance                   Skin disorders
Reduced libido                       Reduced immune defense
Fatigue                              Poor injury/illness recovery
Depression
                                     Reduced sex hormone levels
                                     Reduced reproductive function
                                     Functional renal problems
Sympathetic Dominance Can Trigger…

• HPA Hypoactivation
• HPA hyperactivation
• Adrenal Exhaustion – adrenal gland
  hyperplasia and failure to respond.
                    Stress Physiology
    Conditions Linked with Overproduction & Underproduction of Cortisol


       Overproduction                       Underproduction
•    Cushing’s Syndrome               •   Seasonal depression
•    Depression & OCD                 •   CFIDS
•    Diabetes                         •   Fibromyalgia
•    Sleep deprivation                •   Hypothyroidism
•    Anorexia nervosa                 •   Tobacco withdrawal
•    Excessive exercise               •   Allergies/Asthma
•    Childhood abuse                  •   Rheumatoid arthritis
                                      B. McEwen. The End of Stress as We Know It.
•    Hyperthyroidism                      2002, p.64
  Identify Antecedents, Triggers &
         Biological Mediators
• Antecedents: genetics, experiences, past
  illnesses, occupational exposure, nutrition,
  lifestyle
• Triggers: psychosocial, work relations,
  trauma
• Biological Mediators: cortisol, insulin,
  catecholamines, cytokines, sex steroids
    Recognize signs of physical and
            mental stress
•   Anxiety               • Insomnia (disturbed
•   Back pain               sleep)
•   Constipation          • Relationship problems
•   Diarrhea                (i.e. loss of sexual desire)
•   Depression            • Shortness of breath
•   Exhaustion            • Stiff neck
•   Fatigue               • Upset stomach
•   Headaches             • Weight gain
•   High blood pressure   • Weight loss
                          • Worrying
 Identify Stress Arousal Triggers
Psychological Stressors   Metabolic Stressors
-Divorce                  -Nutritional (need beyond supply,
-Unemployment                 supply beyond need)
-Death                    -Oxidative
-Children, etc.           -Inflammatory
-Self-esteem              Physiological stressors
Environmental Stressors   -Structural
-Chemical/toxic           -Traumatic
-Infection                -Pain
-Endobiosis               -Excess exercise
-Noise                    -Poor sleep
-Light
-Vibration
     Stressors have different effects
            depending on…
•   Dose
•   Pattern
•   Duration
•   Gender: Fight vs. Flight contrasted with
    Tend & Befriend
       Subclinical Hypothyroidism
• Subclinical hypothyroidism is more
  common than overt hypothyroid in elderly,
  especially women
• Subclinical hypothyroidism (inc. TSH in the
  presence or normal T concentrations)
• Increasing evidence to suggest a
  predisposing factor for depression,
  cognitive impairment and dementia
Davis JD et al: Current Psychiatry Reports (2003)S:384-390
         Stress & Immunity
           Dynamic Balance = Health

• Th1 dominance = tissue/organ specific
  autoimmune disorders, delayed
  hypersensitivity reactions
• Th2 dominance = allergic & atopic
  conditions, systemic autoimmune
  disorders
• Th3 imbalance = immunosuppression in
  allergies and autoimmunity
               Th1, Th2, Th3
         Th1                      Th2
• IL-12               •   IL-4
• lL-2                •   IL-5
• TNF-alpha           •   IL-6
• IFN-y               •   IL-9
         Th3          •   IL-10
• Gut mucosal cells   •   IL-13
• Balance Th1 & Th2
                        Th1 and Th2
    Th1 Dominant Responses (Tissue            Th2 Dominant Responses
                   specific)                           (systemic)
•    Hashimoto’s thyroiditis           •   Allergies, hayfever
•    Multiple sclerosis                •   Rhinitis, Urticaria
•    Type 1 diabetes                   •   Systemic Lupus Erythaematosis
•    Acute allograft rejection         •   Haemolytic anaemia,
•    Vitilligo                             Thrombocytopenia
•    Alopecia                          •   Scleroderma, Sarcoidosis
•    Crohn’s disease                   •   Chronic Fatigue
•    Psoriasis                         •   IBS
•    Sjogrens syndrome                 •   Graves disease
•    Unexplained recurrent abortions   •   Asthma
                                       •   Eczema
                                       •   Infections
                                       •   Tumors
                                       •   Successful pregnancy
     Stress Hormones, Th1/Th2 patterns,
     Pro/Anti-inflammatory Cytokines and
           Susceptibility to Disease
• “Acute stress might induce pro-
  inflammatory activities of certain tissues
  through the neural activation of the
  corticotropin-releasing hormone-mast cell-
  histamine axis”


Ilia J. Elenkov and George P. Chrousos
Cytokine Hypothesis of Depression
“There is growing evidence that depression
  can directly stimulate the production of
  proinflammatory cytokines that influence a
  spectrum of conditions associated with
  aging…”
Kiecolt Glaser JK et al. Depression & immune Fnction. J Psychomsom Res.
   2002;53(4):873-6

“The ‘cytokine hypothesis of depression’ implies that proinflammatory
   cytokines represent the key factor in …depressive disorders.”
Schiepers OJ, et al. cytokines and Major Depression. Prog Neuropsycho Biol Psychiatry.
   2005;29(2):201-17
 Depressed Healing, Cytokines and
            Hostility
“Couples who demonstrated consistently
  higher levels of hostile behaviors across
  both their interactions healed at 60% of
  the rate of low-hostile couples.’
Kiecolt-glaser JK, et al Hostile marital interactions, proinflammatory cytokine production,
   and wound healing. Arch Gen psychiatry. 2005;62(12):1377-84


“Even a modest number of depressive symptoms may sensitize the
   inflammatory response in older adults and produce amplified and
   prolonged inflammatory responses.”
Glaser R et al. Mild depressive symptoms are associated with amplified and prolonged inflammatory responses after
    influenza vaccination in older adults. Arch Gen Pstch. 2003;60(10):1009-14
        Balanced Biological Mediators
       With Personalized Therapeutic Lifestyle Change
                         Programs
1. Dec. total load of HPA/HPT triggering factors
2. Reduce HPA/HPT hyper-reactivity
3. Improve detoxification of glucocorticoids and
   catecholamines
4. Improve cortisol sensitivity
5. Improve insulin sensitivity
6. Support thyroid hormone production,
   metabolism and tissue sensitivity manage
   cholesterol levels
Reducing stress hormones affects
             mood
• Antagonizing CRF (corticotrophin
  releasing factor) and glucocorticoid
  receptors may be effective in treating
  depression.
• Mechanism – interruption of reverberating
  neuroendocrine loops involving the HPA
  axis and several areas of the brain
  (prefrontal cortex, amygdala,
  hippocampus, and hypothalamus)
         Obesity and moods
• Obesity is associated with an approximately
  25% increase in odds of mood and anxiety
  disorders and an approximately 25% decrease
  in odds of substance use disorders. Variation
  across demographic groups suggests that social
  or cultural factors may moderate or mediate the
  association between obesity and mood disorder.

• Arch Gen Psychiatry. 2006;63:824-830
       Manage stress naturally-
       core functional approach
• Eating habits
• Diet
• Specific nutrients
• Plant adaptogens
• Cognitive techniques to alter stress
  perception
• Exercise
 Food Improves Mood by Buffering
       the Stress Response
• Skipping meals, GI Dietlow blood
  sugarHungry brain=inc. Cortisolinc.
  hepatic glucagon, inc. muscle
  breakdowninc. sugar, inc. insulin, inc.
  fats
 Food Improves Mood by Buffering
       the Stress Response
Reactive hypoglycemia       Inc. VAT (sarcopenia)
Carbohydrate cravings       Inc. Blood pressure
Mood swings                 Inc. Blood sugar
Shakiness, fainting, etc.   Inc. Triglyerides
                            Inc. Inflammation
                            Altered sex hormones
                            Cognitive function
                            Short term: Energy
                            Long term: CVD, Metabolic
                               Syndrome, Obesity,
                               Diabetes, Cancer
Recurring Micronutrient Themes &
 Stress Hormone Management
• Specific Nutrients
-EPA/DHA
-MVM
-B complex Vitamins B6, B12, Folate
-Magnesium
      Omega-3 fatty Acids and
     Neuropsychiatric Disorders
“…decreased blood levels of omega-3 fatty
  acids have been associated with several
  neuropsychiatric conditions, including
  Attention Deficit (Hyperactivity) disorder,
  Alzheimer’s Disease, Schizophrenia and
  Depression…”

Young, G et al: Reprod Nutr Dev. 2005 Jan-
 Feb:454(1);1-28
       Anti-Stress Effects of DHA
• In a double blind two month study, we measured plasma
  catecholamines and cortisol of students (3 females and 4
  males for the DHA group and the same numbers for the
  control) at the start and end of the study. Students were
  under continuous stress of final exams that lasted for two
  months throughout the whole study period.
• The plasma cortisol did not change in either group, but
  the norepinephrine concentration was significantly
  decreased in the DHA group (-31%), whereas it stayed
  at the same level in the control group. These effects of
  DHA intake may be applied to people under
  psychological stress.
•   Hamazaki T et al. Biofactors 2000; 13(1-4):41-45
Consequences of Magnesium deficiency on the Enhancement of Stress
   Reactions; Preventive and Therapeutic Implications (A Review)


• Mg deficiency intensifies adverse
  reactions to stress
• Such reactions are mediated by excess
  release of catecholamines and
  corticosteroids
• Low Mg and high Ca levels increase
  release of stress hormones, which further
  lower tissue Mg
J Am Coll nutr 1994; 13(5):429-446
                 Magnesium
  Metabolic Syndrome & Inflammation
• Mg intake is inversely associated with systemic
  inflammation and the prevalence of metabolic
  syndrome in middle-aged and older women
• Participates in reducing risks to top health
  challenges facing women: CVD, cancer, stroke,
  diabetes, obesity
• N=11,686 women > 45 yo participated in
  Women’s Health Study initially free of
  cardiovascular disease and cancer and had no
  use of postmenopausal hormones
        Stress Has Many Faces
•   Stressed & overworked
•   Stressed & tired
•   Stressed & wired
•   Stressed & inflexible
•   Stressed & hot
•   Stressed & cold
•   Stressed & depleted
•   Stressed & immune challenged
•   Disturbed sleep & mood
  How Adaptogenic Herbs Buffer Stress
Molecules and Protect the Nervous System
• Non-toxic – no change in normal
  physiology
• Helps the body adapt to stress
• Normalizes body function
           Plant Adaptogens
• Balance the way your brain and endocrine
  system process stress thereby reducing the
  damaging effects of prolonged exposure to
  catecholamines and glucocorticoids
• Increase the non-specific resistance of an
  organism without disturbing normal biological
  parameters
• Act as a nootropic – a substance that enhances
  cognition, protects the brain and has low toxicity
  and few side effects
     Disturbed sleep & mood
• 60 million Americans suffer from disturbed
  sleep, characterized by functional
  impairments during the day.
• Today, the widespread practice of “burning
  the candle at both ends” in western
  industrialized societies has created so
  much sleep deprivation that what is really
  abnormal sleep is now almost the norm
 Expressions of sleep disturbances
 www.cdc.gov/niosh/stresswk.html
• Difficulty falling asleep     • Preferring an early
• Difficulty waking up in the     bedtime – 8 PM and
  morning                         waking up early, around 5
• Waking up tired                 AM
• Microsleeps - very brief      • Clumsy and/or slower
  episodes of sleep, such         reactions times
  as “nodding off”              • Snoring (sleep apnea)
• “zoning out” in the middle    • Routinely falling asleep
  of a conversation or task       within 5 minutes after
• Preferring a late bedtime       lying down
  – 2-3 AM and waking up        • Waking up frequently
  late, around 10 AM              during the night with
                                  difficulty returning to
                                  sleep
               FDA Warning:
Commonly used RX for sleep disorders can disrupt
        performance and be addictive
•   Valium
•   Dalmane
•   Ambien
•   Restoril
•   Halcion
            Natural sleep cycle
Light sleep: Body movement decreases. Spontaneous
   awakening may occur.
Stage 1: dec. serotonin
Intermediate sleep: Most of the night is spent in this stage.
   Helps refresh the body.
Stage 2: dec. Melatonin
Deep sleep: Difficult to arouse. Most restorative stage,
   lasting 30-40 minutes in first few cycles, less in later
   cycles.
Stage 3 & 4: dec. Serotonin
REM: Dreaming occurs. Heart rate increases. Lasts about
   10 minutes in first cycle, 20-30 minutes in later cycles
Stage 5: inc.Acetycholine, dec. GABA, dec. Dopamine
          REM-NREM Balance
•   REM=Ergotrophic    •   NREM=Restorative
•   On-line, engaged   •   Off line, Autistic
•   Externalized       •   Internalized
•   Hypermetabolic     •   Hypometabolic
•   Cholinergic        •   Serotonergic and
                           GABAergic
   Neurotransmitters Involved in
             Sleep
• Serotonin-NREM
• Acetylcholine-REM
• GABA-inhibits brain arousal centers,
  reduces REM
• Histamine-stimulates brain arousal
  centers, “wake promoting
  neurotransmitter”
       Healthy Sleep Hygiene
• Create a relaxing bedtime routine:
Read a book
Listen to music
Practice a relaxation technique
Take a warm bath
Keep the temperature in your bedroom at a
  comfortable level: extremes can disrupt your
  sleep
• Go to sleep and wake at the same time each
  day – helps to develop a sleep-wake rhythm that
  encourages better sleep
       Healthy Sleep Hygiene
No daytime naps
Go to bed only when sleepy
Set a bed routine
Get out of bed if you are not sleeping. Get up
 after 15 to 20 minutes if unable to fall asleep.
Get back into bed only if you are sleepy.
Maintain a consistent wake up time, no matter
 how much sleep obtained.
Use bed for sex and sleep only.
        More Ways To Sleep Better
• Watch your diet – a heavy meal or spicy foods before
  bedtime can lead to nightime discomforts; fluids can
  require disruptive trips to the bathroom. A light snack can
  prevent hunger pangs and help you sleep better.
• Eat no closer than 2 hours before bedtime.
• Avoid caffeine (tea, cola, chocolate and coffee) and
  cigaraette smoking 4 to 6 hours before bedtime.
• Have no more than one serving of alcohol consumed 2
  hours or more before bedtime.
• Exercise regularly – exercising in the morning or
  afternoon – at least three hours before bedtime, so you
  won’t get too revved up – may help you get a deeper,
  more restful sleep.
Larzelere M. wiseman P. Anxiety, depression, and insomnia. Prim Care Clin Office Pract 2002;29:339-360
               Melatonin
• Reduced sleep onset
• Increased REM sleep compared to
  placebo
• Effective in children and adolescents with
  ADHD and insomnia
• Improves tinnitus
• Improvement in behavioral symptoms in
  dementia patients
• Cluster headaches
                  Melatonin
•   Short half life (approx 1 hour)
•   Metabolized by P450 cytochromes
•   Physiologic range between 8 to 3 mg
•   Modest decrease in sleep latency
•   Melatonin has thermoregulatory effects
    that assist in its sophoric effects, reduces
    core body temperature
    Melatonin: Human Studies
• Analysis of 17 different studies involving 284 pts;
  melatonin demonstrated reduced sleep onset
  latency, increased sleep efficiency, and
  increased total sleep duration (Wurtman et al.
  Sleep Med Review 2005(9);41-50)
• Two randomized studies demonstrated
  increased REM sleep percentage (J Clinical
  Endocrinology 2004; 89:128-134)
• Useful in patients with delayed sleep phase
  syndrome (Sleep 2005(10);1271-1278)
           Melatonin: Safety
• Generally regarded as safe with little risk of
  toxicity especially in short term use
• Side effects may include fatigue and dizziness
• High doses ( 8 mg or above) associated with
  reduced sperm motility
• Should not be used in pregnancy or breast
  feeding
• May reduce effectiveness in patients taking
  warfarin
 Recommended Use of Melatonin
• Administer 30 minutes to 1 hour prior to
  bedtime
• Dosing varies by age
• Administration of melatonin to older adults
  results in substantially higher blood levels
  “less is more”
• Exposure to light will inhibit the sleep
  promoting effects of melatonin
     Passionflower: Overview
• Traditional herb used for its sedative and
  anxiolytic properties
• Two biologically active flavanoids isolated;
  Apigenin and Chrysin which bind to
  benzodiazepine receptors
• Both Apigenin and Chrysin reduce behavioral
  measures of anxiety in animals in a manner
  similar to benzodiazepines (Pharmacol Biochem
  Behav 1994, 47(1):697-706
What is Casein Tryptic Hydrolsate?
• Pure tryptic hydrolysate from milk
  anxiolytic like profile (on label: “casein
  hydrolsate”)
• Standardized to 2.2% casein decapetide
  with molecular mass 1267 Da,
  corresponds to the peptide 91 to 100 of
  alphas1 casein by enzymatic hydrolysis
  using trypsin
• Can be concentrated or isolated by HPLC
     Casein Tryptic Hydrolysate
• Demonstrated to be efficacious for stress reduction using
  conditioned defensive burying test and elevated plus-
  maze in rats
• Aids sleep
• Helps to reduce cortisol
• Helps to keep blood pressure levels within the normal
  range (modify)
• Helps to control symptoms of physiological and
  psychological stress
• Casein tryptic hydrolysate produces a noticeable effect
  in as little as one hour and optimal results can be
  observed after 10 days of treatment.
Mind-Body & Cognitive Approaches
• Journaling
• Belly breathing
• Relaxation techniques
        Stress & Relaxation
• EVERYTHING to do with health
• Worry is the most common effect
• Type II stress is exhausting
• 80% serious illnesses preceded by high
  stress levels in previous year
• Animal research (Vernon Riley)
        Stress & Relaxation
• NOTHING to do with health
• Stress ‘tolerance’ is key
• ‘Stress hardiness’ – Kobasa
• Expand capacity reduce physiologic toll,
  connect with Inner Resources
• Improve problem-solving abilities
                    Breath & Back Pain
“Patients suffering from chronic low back pain
  improved significantly with breath therapy.
  Changes in standard low back pain measures of
  pain and disability were comparable to those
  resulting from high quality, extended physical
  therapy. Qualitative data suggested improved
  coping skills and new insight into the effect of
  stress on the body as a result of breath therapy.”
Mehling WE, et al. RCT of Breath Therapy for Patients with chronic low back pain. Altern Ther Health
   Med. 2005;11(4)44-52.
               Imagery
         Physiological Effects
• Heart rate, blood pressure, respiratory rate
  & rhythm
• Oxygen consumption, CO2 & lactic acid
  elimination
• Gastrointestinal motility and secretions
• Sexual arousal and function
• Muscle relaxation and function
• Immune system responsiveness
       Marketing Opportunities
•   Existing patients
•   Referrals
•   Events/local presentations
•   Media outreach
•   Corporate wellness
   JAMA 2005:294;2010-2011
“…what we do agree on is reduction of risk
  factors for heart disease and diabetes
  through lifestyle changes first, is an
  appropriate treatment.”
                Comparison
                Our Program   AHA Step 1
                              Diet
Triglycerides   -95 mg/dl     -49 mg/dl

T-chol          -43 mg/dl     -2.6 mg/dl

LDL-C           -28 mg/dl     +3.2 mg/dl

HDL-C           +2.8 mg/dl    -.5 mg/dl

Weight          -14.8 lbs     -7.8 lbs
   The Cost Effectiveness of Lifestyle Modification or Metformin in
Preventing Type 2 Diabetes in Adults with Impaired Glucose Tolerance


“The lifestyle intervention, compared with
  the metformin intervention, provided
  greater health benefits at lower costs and,
  from the prospective of a fiscally prudent
  policymaker, represents the intervention of
  choice.”

Annals of internal Medicine 2005; 142:323-332
 TLC is more effective, less expensive than
                Medication
                  Lifestyle     Metformin


Delay in          11 years       3 years
development of
diabetes
Reduced             20%            8%
incidence of
disease
Cost (per         $1,100         $31,000
QALY)

				
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