The Power of Lifestyle as Medicine Gentry Dodd, MD, FAAPMR, DipABLM - PowerPoint PPT Presentation

The Power of Lifestyle as Medicine Gentry Dodd, MD, FAAPMR, DipABLM 9/13/2019 1

Learning objectives • Discuss and define Lifestyle Medicine • Focus on the impact of Lifestyle Medicine on the nation’s number one killer, heart disease • Review the economic impact of chronic disease on US healthcare and how to become involved in Lifestyle Medicine 2

My background • Indiana University School of Medicine • Physical Medicine and Rehabilitation residency • Occupational Medicine as a means of promoting wellbeing • Lifestyle Medicine as the key to a healthy and productive workplace 3

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Cholesterol • Dietary cholesterol has a limited impact on blood cholesterol levels in humans • Maybe a high cholesterol diet is indicative of other unhealthy lifestyle behaviors

Cholesterol • 27-OH cholesterol “can function • Can be involved in all stages of as an estrogen and increase the cancer development proliferation” of most breast • Initiation cancer cells • Promotion • Pro-oxidative • Progression • Pro-inflammatory • Potentially facilitating their metastasis • Pro-estrogenic • Stimulates angiogenesis for tumor • Explains the finding that women with blood supply heart disease risk factors are more likely to develop breast cancer • Oxycholesterols also related to the development of Alzheimer’s

Cholesterol • More aggressive tumors have higher levels of enzyme converting cholesterol à 27HC • ER+ tumors à 27HC content is increased in the breast overall • Women with low levels of the enzyme that degrades 27HC don’t live as long • “some estrogen-driven breast tumors may rely on 27HC to grow when estrogen isn’t available”

Cholesterol • >80% of breast cancers start out • Many ER+ tumors will relapse responding to estrogen with resistant tumors despite hormone therapy • Rationale for the use of • 27HC fuels breast ca growth • aromatase inhibitors (anastrozole, letrozole, exemestane) without estrogen • Inhibit conversion of androgens to estrogen • The good news is that • Common occurrence of diffuse MSK pain cholesterol is a highly amenable • SERMs (tamoxifen, raloxifene) risk factor à diet and lifestyle • Risk for thromboembolic events and endometrial cancer

Soy • Controversial topic • Exacerbated by misinformation found on Dr. Google • “Soy foods promote breast cancer” • Thought to be 2/2 phytoestrogen compounds called isoflavones • Estrogens stimulate breast ca growth, so must phytoestrogens

Soy • Two types of estrogen receptors • Two receptors • Alpha • Different tissue distributions • Beta • Often have different/opposite functions • Alpha in the breast à pro-estrogenic • Beta in the breast à anti-estrogenic • Soy phytoestrogens preferentially bind to and activate estrogen receptor beta • Antiproliferative effects on breast cancer cells • Found even after just a few servings of soy foods

Soy • Misconception stems from mice studies • The main phytoestrogen (genistein) stimulates mammary tumors in mice • Humans metabolize soy isoflavones (subgroup of phytoestrogens that bind to ER) differently • The same amount of soy will result in 20-150x higher concentrations in mice • If we ate 20-150 cups of soybeans daily, we would have some alpha activation…..

Soy • Just a few servings per day • Women who eat the most soy in results in excess beta activation their youth have less than ½ the risk • Actively helps prevent breast ca • Rates are much lower in Asia • Soy intake during childhood, compared to the US adolescence, and adult life is associated with decreased risk of • …..until they move to the US and breast ca adopt the Western lifestyle

Soy • What about those that already • Nutrition guidelines have the disease? • American Cancer Society • JAMA 2009, soy food intake and • Soy foods are beneficial for survival breast ca survival • “soy food consumption was • Five out of five studies, tracking significantly associated with >10,000 breast cancer patient, decreased risk of death and [breast cancer] recurrence.” have confirmed the benefit of • This has been repeated multiple adding soy for survival times, with the same conclusion • Reduced mortality • Reduced recurrence • For ER+ and ER- tumors, young women and older women

Fiber • Case control studies (retrospective) • Prospective cohort studies at Yale • 14% lower risk for every 20g fiber consumed per day • Premenopausal women who ate more than 6g fiber/day had 62% • Risk doesn’t really fall until 25g/day is lower odds of developing breast ca consumed than those who ate <4g/day • The fiber came from plant sources, not supplements • Dozen or so other studies • Higher fruit and vegetable intake à lower breast ca risk • Higher saturated fat (meat, cheese, dairy) à increased risk • Every 20g fiber per day associated with 15% lower risk

Flaxseeds • One of the richest plant sources of Omega 3 FAs • 100x more lignans than other foods • Lignans are phytoestrogens that dampen the effect of estrogen in the body • Flaxseeds contain the lignan precursors which are activated by the good bacteria in the gut

Flaxseeds • Breast ca survivors with higher • “dietary flaxseed has the levels of lignans have been potential to reduce tumor shown to survive longer growth in patients with breast cancer…[F]laxseed, which is • Double-blind, placebo-controlled inexpensive and readily randomized intervention à flax available, may be a potential muffins dietary alternative or adjunct to • Breast cancer patient who currently used breast cancer regularly consumed flaxseeds had: drugs.” • Decreased tumor cell proliferation • Increased cancer cell death rates • Decreased cancer cell aggressiveness scores

Take home points Dr. Dodd’s • Increase soy based food consumption Breast cancer • Does not necessarily need to be Obviating and every day Operational • Flax seed daily Banishment • Must be ground System • Eat a diet to lower cholesterol • Minimal to no animal based foods

Coronary artery disease • #1 killer of men and women in • Risk factors: Western civilizations • Age, gender • 596,339 in 2011 • DM • Treated with 40 years of • HTN aggressive drug and surgical • Lipids interventions • Goal lipid levels often targeted with statins • Cochrane Database Review 2011 • Reduced all cause mortality by 16% à Absolute reduction 0.45% à NNT 222 18

Coronary artery disease • J Family Practice 2014 • Whole, plant-based diet • Moderate sized, compliant population, self selected • NNT = 2 19

What’s the point? • Where’s the hammer? • Infectious disease used to be our largest health threat • Chronic diseases are our biggest danger presently • DM • HTN • CAD • HLD • All have underlying metainflammation 20

Anthropogens • “man made environments, their by-products, and/or lifestyles encouraged by these, some of which may be detrimental to human health” 21

Pro-inflammatory “inducers” of chronic disease 22

The cause of the cause 23

The cause of the cause of the cause 24

Behavioral determinants of health • 1 in 5 smokes • 4 out of 5 need to significantly improve their diet • 3 out of 4 do not get enough physical activity CDC, Morbidity Mortality Weekly Report AHA, Heart disease and stroke stats, 2008 25

Behavioral determinants of health • Few people demonstrate • Multiple studies have shown multiple healthy behaviors benefits to lifestyle changes • 3% have healthy levels of 4 • Framingham Heart 2006 – optimal lifestyle behaviors risk factors leads to 10 year longer life span than those with at least • Non-smoking two risk factors • Healthy weight • Multiple Risk Factor Intervention • 5 fruits/vegetables per day Trial (MRFIT) 1999 – those with • Regular physical activity low risk factor status had 73-85% Reeves and Rafferty, Arch Int Med , 2005 lower risk for CVD mortality and 40-60% lower mortality rate 26

Additional studies • Nurses’ Health Study 2000 • Health Professionals Follow Up Study • 5/5 healthy lifestyle factors (diet, exercise, BMI, smoking, EtOH) à • All five healthy lifestyle factors 83% risk reduction for CVD compared to none à 87% lower risk for CVD • 91% of DM cases could be eliminated • 3/5 à 57% reduction • 2/5 à 27% lower risk • 4/5 à 66% reduction 27

Additional studies Interheart study 2004 52 countries Smoking, lipids, HTN, DM, obesity accounted for 80% of the attributable risk for AMI 9 modifiable risk factors account for >90% of first MI risk worldwide Risk factors are the same despite geographic region and racial/ethnic group 28

Summary of studies 29

Leading causes of US deaths 2016 1. Heart disease: 633,842 2. Cancer: 595,930 3. Chronic lower respiratory diseases: 155,041 4. Accidents (unintentional injuries): 146,571 5. Stroke (cerebrovascular diseases): 140,323 6. Alzheimer’s disease: 110,561 7. Diabetes: 79,535 8. Influenza and pneumonia: 57,062 9. Nephritis, nephrotic syndrome, and nephrosis: 49,959 10. Intentional self-harm (suicide): 44,193 30