Section 5: Nutrition Science, Assessment, and Prescription Flashcards
Dietary Guidelines for Americans years update
Every 5 years
- Allows public comments
Dairy
- No or weak inverse relationship with cardiovascular disease
- Positive relationship with bone health and dairy intake in children
- Yogurt may have protective effect on lowering inflammation
- Cheese leads to a pro-inflammatory state with higher plasma inflammatory biomarkers
- Eggs have mixed studies results
- There is direct relationship between cholesterol consumption and CVD in px with DM
Advise on Egg Consumption
- Mixed evidence
- Egg contains 200mg chlesterol
- Egg found to increase LDL cholesterol with more than 1 per day
- Advised to eat as little cholesterol as possible
- Prior it used to be <300mg a day
Over-consumed sugars
- Cane sugar
- High fructose corn syrup
- Fructose
- Sucrose
- Dextrose
- Lactose
- Honey
- Brown sugar
- Turbinado sugar
- Beet sugar
- Raw sugar
- Malt syrup
- Maltose
- Rice syrup
- Agave
- Molasses
- Florida crystals
- Fruit juice
- Others
WHO sugar recommendation
- Less than 10% of total calories or goal of less than 5% of total calories
- Current intake in US adult and children > 6 years old is 14.1% of total calories
American Heart Association recommended sugar
- Maximum of 100 calories per day for women, children, and teens
- No more than 150 calories of sugar per day for men
Top sources of cholesterol in US
- Meat, eggs, grain products, and milk account for 96%
Saturated fat
- No double bonds, saturated with hydrogen molecules
- AHA recommends 5-6% of total calories
High Saturated fat foods
- Fat cuts of beef
- Pork
- Lamb
- Salami
- Sausages and processed meats
- Fast food (i.e. cheeseburgers
- Lard
- Butter
- Cheese
- Coconut, palm oil, palm kernel oil
- Nuts and seeds
- Avocado
- Eggs
- Fish varies
Top sources of saturated fat in US
- Cheese
- Beef
- Other fats and oil
- Milk
- Frankfurters, sausages, luncheon meats
Top source of sodium in US
- Added to food outside home
- Inherent to food
- Added in home preparations
- Added at the table
Sodium consumption
- Keep at 2,000mg or less (1.5 to 2.3g)
- If sodium per serving is less than or equal to the calories per serving, then intake will be approximately same as daily calories (e.g. 2,000 calories)
- If plant based, may fall to 1,500 mg per day
Trans Fats
- Unsafe for human consumption
- Mostly found in partially hydrogenated plant oils
Top sources:
- Animal foods, red and processed meats
- Butter
- Refined grain such as doughnuts, cookies, crackers, muffins, pies, and cakes
Under-consumed nutrients in US
- Calcium
- Choline
- Fiber
- Iron
- Magnesium
- Potassium (ass. with health concern)
- Vit A
- VIt C
- Vit D (ass. with health concern)
- Vit E
Calcium Sources
- Cheese
- Tofu
- Soybeans
- Cornmeal
- Fortified plant milks
- Spinach or collard greens
Fiber Sources
- Black beans
- Split peas
- Lentils
- Avocado
- Raspberries
- Dried figs
- 3 tablespoons flaxseeds
- Oeatmeal
- Whole wheat pasta
Magnesium Sources
- Brazil nuts
- Almonds,
- Cashews
- Pine nuts
- Peanuts
- Spinach
- Amaranth
- Edamame
- Dark chocolate
Potassium sources
- Yams
- Avocado
- Beans
- Fruits and vegetables
Vit. A sources
- Sweet potato or spinach
- Raw carrots
- cantaloupe or butternut squash
- Beef liver
- Dairy and plant milks
Vit. C Sources
- Bok choy
- Parsley
- Daikon radish
- Broccoli
- Canaloupe
- Brussels sprouts
- Pineapple
- Cabbage
- Cauliflower
- Mustard greens
- Papaya
- Green peas
- Kale
- Tomatoes
- Strawberries
- Turnip greens
- Orange
- Guava
- Kiwi
- Mango
- Red pepper
- Leafy green vegetables
Vit. D
- Salmon
- High fat fish
- fortified milks, either dairy or non dairy
- Fortified cereals
- Sunlight between 10am to 3pm without sunscreen for 5-30 min 2 days a week, if darker skin pigmentation, require longer amounts of time in the sun
Vit. E sources
- Sunflower seeds
- Almonds
- Hazelnuts
- Sunflower oils
- Olive oils
- Corn oil
- Peanut butter
Top foods to consume based on nutrient per calorie
- Vegetables, including mushrooms
- Herbs and spices
- Fruits
- Legumes
- Whole Grains
- Nuts
- Seeds
Dietary Portfolio for Tx of Hypercholesterolemia
Diet: very low saturated fat, high in plant sterols, soy protein, viscous fibers, and almonds
Results: decreased in LDL by 28.6%, not statistically different from tx of 20mg losartan (dec. by 30.9%)
Dietary approach to Stop Hypertension (DASH Diet)
Diet: rich in vegetables and fruits, and low fat dairy and reduced saturated fat, total fat, and choleserol
Results: decreased blood pressure
Ornish Lifestyle Intervention (Lifestyle Heart Trial) for Coronary artery disease (CAD)
Intervention: 10% fat vegetarian diet, mod. aerobic exercise, stress management training, smoking cessation, group psychological support
Results: reduction in coronary artery stenosis that improved over 5 years
Ornish Lifestyle Intevention for Prostate Cancer
- 30 men with low risk prostate cancer showed intervention may modulate gene expression in prostate
- Ornish and colleagues’ research focuses on prostate cancer and gene expression (not glucose uptake), and they found that the intensive nutrition and lifestyle changes down-regulated 453 genes and up-regulated 48 genes that play critical roles in tumorigenesis and prostate cancer.
Lyon Diet Heart Study
Secondary prevention of coronay heart disease with a Mediterranean diet vs American Heart Association Step 1 Diet
- Mediterranean diet had fewer composite cardiovascular disease vs prudent Western diet
Esselstyn plant based diet
Plant based diet for coronary artery disease
- Very low fat, plant based shows reverse and prevent major cardiac events
Complete Health Improvement Program (CHIP)
- Effective in tx T2DM and positive return on investment within a few months
Recommendation for Nutrition Prescription
B recommendation (benefit will be moderate to substantial): intensive behavioral health nutrition counseling and physical activity for overweight people WITH CHRONIC DISEASE risk factors.
C recommendation (service should be offered in selective manner based on professional assessment and px preference): Counseling for people with NO CHRONIC DISEASE
Nutrition Assessment
- Can be performed by a provider followd up by an RD or RD in a team
Basic Assessment (ABCD)
ANTHROPOMETRIC Data
- Weight, heaith, BMI, waist circumference
- BMI less precise for very short people
- BMI adjust for race
- High density muscle and bone mass may give bias results
- Bioelectrical impedance analysis is common, but not that accurate
- Skinfolds not recommended as results can vary by gender and user
BIOCHEMICAL Data
- Lab work such as:
sodium, potassium, hemoglobin, hematocrit, glucose, HbA1c, albumin, lipid profile, calcium, vit D, vit b12, iron, ferritin
CLINICAL Assessment
- Age, gender med/surgical history, activity level, nutrition history, vital signs, PE
DIETARY Assessment
- Daily intake of solids and liquids
- 24 hour recall (what they ate during last 24 hours)
- 3 Day food record (often given as assignment to bring on next appointment, be specific like brand name, portion size, etc)
- Mini Nutritional Assessment (MNA) for elderly
Role of Physician in Nutrition Assessments
- Obtain baseline history and PE
- Determine px risk factors for chronic conditions and current diagnoses
- Create framework for treatment
- Lead multidisciplinary care team
- Help px set short and long term dietary and other lifestyle goals
- Oversee recommendations made by RD
Role of RD
- Assess and monitor nutrition status
- Determine macronutrient and micronutrient needs/deficiencies
- Develop individualize dietary recommendations
- Coach px toward personal goals with consideration of med history
- Track progress in conjunction with Physician
- Provide support and education
- Provide medical nutrition therapy
Recommended intake of nutrients
CARBS
- 130g/day
FIBER
- Men: 38g/day
- Women: 25g/day
(based on 14g/1,000 calories consumed)
PROTEIN:
-0.8/kg
FAT (n6 fatty acids)
- Men: 17g
- Women: 12g
FAT (n3 fatty acids)
- Men: 1.6g/day
- Women: 1.1g/day
Protein
- Soybean: only plant source of complete protein
- Plant proteins are limited in either LYSINE or SULFUR Containing amino acids (i.e. METHIONINE, only essential AA)
- There might be diet derived metabolic acidosis where meat consumption causes it. Calcium is extracted from bones to generate buffering substrate. Some evidence exist that it can contribute to poor bone health.
Fat
POLYUNSATURATED
- Omega 3s (anti inflammatory)
- Omega 6s (usually pro inflammatory, but not all)
- Arachidonic acid (one type of omega 6)
MONOUNSATURATED
- Generally liquids at room temp (i.e. olive, canola, peanut, safflower, and sesame oils)
SATURATED
- Sources in US or Western Diets:
a. Lauric acid (found in coconuts) - increase total cholesterol, HDL, LDL
b. Stearic acid (found in cheese, meat, poultry, and dairy)
Stearic Acid Effects
- Correlated with CHD
- Associated with increased endothelial damage and cell death, decreased function of endothelial progenitor cells essential to vascular repair
- Associated with increased risk of colorectal cancer
Palmitic acid, which is harmful
- Found in palm oil, butter, cheese, milk, and meat
- MOST COMMON saturated fat
- May lead to increase heart disease risk and associated with insulin resistance
Myristic Acid, which is harmful
- Found in dairy products and tropical oils
- Is hypercholesterolemic
- Associated with CVD, risk of all cause mortality, and T2DM
Trans Fat
- Associated with inc. CHD
- Found in partially hydrogenated oils, fried foods, coffee creamer, naturally found in meat and dairy products
Carbohydrates
Components:
- Fiber, high intake associated with low risk of coronary artery disease, insulin resistance, colonic diseases.
- Insoluble fiber, not absorbed but increases stool bulk. Ingested by intestinal bacteria to producte SCFA
- Fiber increases stool viscosity and holds extra water, avoids leaky gut and inc. immune defese.
- Soluble fiber is absorbed, slows digestion, increases insulin sensitivity and carries out cholesterol.
Increase in fiber improves:
- Stool consistency, decrease constipation
- Lowers cholesterol
- Stabilize glucose
- Increase satiety and decrease cravings
- Decrease risk of diabetes
- Decrease risk of colon cancer
Daily Fiber Recommendations
- 14g per 1000 calories per day
- Women: 25 grams per day, more benefit if >40 grams per day
Men: 38 grams per day, more benefit if more than 45 grams per day
Anti Oxidants Foods
- Are anti inflammatory, not essentials for life but valuable for health
Sources:
CRUCIFEROUS VEGETABLES
(contain sulforaphane and indole 3 carbinols)
- Such as broccoli, cauliflower, brussels sprouts, bok choy, kale, chinese cabbage, dark berries and f
DARK BERRIES AND FRUITS
(polyphenols such as ellagic acid, anthocyanidins, anthocyanins)
- Such as berries
ALLIUM VEGETABLES
- Rich in organosulfurs
- Garlic, onions, leeks
ORANGE, YELLOW, DARK GREEN VEGETABLES AND FRUITS
(carotenoids that stimulate natural killer cells)
- Carrots, yams, mango
DARK GREEN LEAVY VEGETABLES
- High in potassium, calcium, magnesium
- Spinach, collards, swiss chard, dark lettuces
AGE
Advance Glycation End Products
- Product produced by chemical reaction between amino acid and monosaccharide
- Associated with oxidative stress and inflammation
- Small amount of AGEs are produced in the body daily.
AGE occur in:
- Protein rich foods and carbs rich foods
- High temperatures
- Longer amount of heating time
- When food is dry, moisture lowers AGE formation
- When pH is acidic or basic
- Presence of higher amount of trace minerals
- Increased with grilling, broiling, roasting, searing, frying
- AGEs accumulate at higher amounts with increasing age (i.e. human eye and skin collagen)
- Body can detoxify AGE but slowly
- Directly related to: Diabetes type 1 and 2, atherosclerosis, kidney disease, slow wound healing
- AGEs form at temp beyond 248F (120C)
- Better prepare food by moist cooking (i.e. boiling, stewing, broiling)
- Avoid grilling, baking, frying
Nutrition Prescription Format (Diet Strategy for Prescription)
- Use SMART goals format
- Core prescription components (TAF):
1. Type of food (be specific)
2. Amount of food to be eaten (be exact)
3. Frequency of food should be eaten (i.e. once a day for 2 weeks) - Positive prescription (eat more of one type of food), more accepted by px
- Negative prescription (eat less of something), it’s easier if swapping food than no food at all
Nutrition Diet For Diseases
HYPERLIPIDEMIA
- Decrease meat, more plant foods, replace trans and saturated fat with unsaturated, increase nuts (a handful each day), omega 3 fat intake
HYPERTENSION
- Increased plant foods, reduce sodium, limit alcohol intake
- Inc. intake of potassium, calcium, magnesium, garlic, water only fasting
T2DM
- Increase high fiber foods, reduce fat and refined carbs, reduce saturated and trans fat, reduce calorie intake
- Correlated with fat just as strongly as it is with sugar
Cancer
- Antioxidant rich, high fiber diet, lower total protein, lower animal protein (very biased)
Anti Oxidant Rich Foods
- Beta carotene (carrots, sweet potatoes, spinach, kale)
- Lycopene (tomatoes, watermelon, guava, pink grapefruit)
- Resveratrol (red grapes, blueberries, peanuts, soy)
- Selenium (brazil nuts, sunflower seeds, fish, mushrooms)
- Vitamin C (cantaloupe, citrus fruits, kiwi, mango, berries)
- Vitamin E (almonds, peanuts, green leafy veggies)
*Antioxidant supplements do not seem to help reduce cancer risk, whereas whole foods do.
- Increase fiber diet
Other cancers
BREAST CANCER:
- Increase risk: Obesity, inc. meat
- Decrease risk: Soy, fruits, vegetables (decrease IGF-1 since it is cancer promoting), exercise (50% reduction in mortality)
PROSTATE CANCER:
- Decrease risk: lycopene and selenium, whole food soy
COLON CANCER:
- Increase risk: Red meat (very biased) and processed meats
- Decrease risk: High fiber, calcium, folate
GASTRIC CANCER:
- Increase risk: Processed meat
- Decrease risk: Fruits and vegetables
other cancers: no clear evidence yet
Cataracts: plant based diets, lowerst risk of cataracts
COPD: Inc. of fruit to 100grams ass. with 24% lower disease mortality
Immune function: frutis and vegetables increase immune response without over stimulating immune system in pneumonia vaccine
Chron’s Disease:
- Semivegetarian diet produce 80% remission in Chron’s px.
Multiple Sclerosis:
- No progression with restriction to saturated fat from 34 yrs of diagnosis
Heart Disease Facts and Principles
- Main (and only DIRECT) risk factor for heart disease is CHOLESTEROL. The others are indirect.
- Optimal LDL (50-70mg/dL) 1.293-1.810 mmol
- Atherosclerosis does not progress when LD is less than 70
- Plaque progression ceases when cholesterol is less than 150mg/dL (3.879 mmol/L)
Mediterranean Diet
- High monounsaturated to saturated fat ratio
- High fruits and vegetables
- High consumption of legumes
- High grain and cereal intake
- Mod. red wine consumption
- Dairy consumption
- Low meat and meat products with increased fish
*limited evidence if healthy if no restriction of fat intake
DASH Diet
- Low sat and trans fat
- Rich in potassium, calcium, magnesium, fiber, and protein
- Lower sodium (1,500-2,300 mg per day)
Diets Used in LM
ORNISH PROGRAM
- Exercise
- Low fat Diet
- Smoking Cessation
- Stress Management Training
- Group support sessions
PRITIKIN PROGRAM
- Specific diet (10-15% fat, 15-20% protein, 65-75% carbs)
- Exercise
- Counseling lasting 21-26 days
- Option for residential component
DR. ESSELSTYN’s PREVENT & REVERSE HEART DISEASE PROGRAM
- Avoid all animal products
- Avoid all oils
- Reduce or avoid soybeans, nuts, avocados
COMPLETE HEALTH IMPROVEMENT PROGRAM (CHIP)
- Activity
- Nutrition (whole plant food diet)
- Sleep
- Risky substances
- Social connection
- Stress management
Epigenetics
- Genes are not your destiny, your lifestyle is.
- Epi: near, upon, at
- Genetics: hereditary material
Non DNA sequence components that modify gene expression:
- DNA methylation
- Micro RNA
- Histone Acetylation
- Growing number of other molecular changes
Dutch Hunger Winter
- Famine occured in 1944-1945
- Children born to mothers who were pregnant during that time, had increase rates of obesity, diabetes, schizophrenia, fingerprint alterations, decreased fertility
- Subsequent 3 generations have all been affected
Agouti Mice Research
- In mice, obesity, heart disease, diabetes genetic expression could be turned off thru lifestyle changes
Maternal Diet And Methylation
- Maternal diet influences methylation status of promoter region (RXRA), strongly correlated with adiposity and metabolic syndromes in children.
Key epigenetic aspects of Diet and Exercise
- Variations of minor alleles like PGC-1a are associated with an increased susceptibility to T2DM
- Exercise induced expression of GLUT4 in skeletal muscle regulates glucose uptake, hence improve glycemic control. BUT, 3-5 yrs of glycemic control may not reduce risk of macrovascular complications, since it takes longer than 5 years to correct it.
- Sleep deprivation alters more than 700 genes in adults.
- If altered DNA methylation or histone micro RNA changes, it can lead to altered insulin sensitivity (called subclinical phenotype change), then it leads to acquisition of T2DM (called clinical phenotype change). T2DM is associated with altered DNA methylation and further changes in histone micro RNA.
- Hyperglycemia induces epigenetic changes by increasing production of inflammatory proteins by acting on the NF KB p65 promoter unit. Inflammatory proteins lead to endothelial cell damage of blood vessels, resulting into vascular injury and disease.
Influencers of epigenetic expression in pregnancy/childhood
- Maternal nutrition during pregnancy
- Presence or absence of breastfeeding
- Early child nutrition
- Gut microbiota
- Chemical food contaminants
Key lifestyle influencers
- Diet
- Physical activity
- Smoking and Alcohol consumption
- Sleep habits
- Chronic stress
- Obesity infections, exposure to environmental chemicals contaminants
DM Intensive Med Management
- Current conventional med aimed at: delaying progression, not remission.
ACCORD (Action to Control Cardiovascular Risk in Diabetes) study done in 2008, found that intensively reducing blood glucose below guidelines with medication produce harm in high risk px with T2DM
- Increase insulin dosing associated with increased risk of cancer, CVD, weight gain.
Pathogenesis of T2DM
A. excess calories > inc. adipose tissue, fatty infiltrate in muslce and liver cells, leptin production > WEIGHT GAIN and INC. inflammation. Western diet and other factors disrupt microbiota > no production of SCFA such as butyrate > no assist in blood glucose management.
B. Fatty deposits in liver increase blood glucose levels (which cannot suppress gluconeogenesis) and inc. TAG.
C. Insulin resitance begins > inflammatory mediators cause damage to liver and beta cells. Intramyocellular fat accumulation dirupts receptor via production of lipotoxic mediators > more insulin resistance
D. Pancreas increases insulin production due to insulin resistance.
E. Insulin increases appetite > more calorie intake consumption, repeating A to D)
F. Beta cells of pancreas are damaged by TAG (triacylglycerols), thus insulin secretion is damaged. Glucose in blood rises.
G. Inc. blood glucose detected with lab HbA1C etc.
H. Px becomes insulin dependent either thru T1DM (autoimmune) or T2DM.
Time Sequence of Pathogenesis of T2DM
- Muscle insulin resistance determines rate of fatty liver progression
- Fatty liver progression and fatty acid deposit in pancreas are reponsivle for hepatic insulin resistance and beta cell dysfunction
Insulin Resistance Cascade
- Weight gain occurs > adipocytes undergo hyperplasia and hypertrophy > accumulate in liver and muscle cells and other ectopic tissues.
- Impaired insulin signaling happens due to the accumulation > adipocyte growth inc. inflammation and lipolysis > more production of inflammatory mediators and macrophage recruitment.
- Increase inflammation and FFA occurs > adiponectin decreases > lipolysis and lipotoxicity occurs > leads to production of DAG (diacylglycerol), ceramide and sphingosine (associated with increased insulin resistance).
- Adipocyte produce leptin (marker related to obesity and inflammation) > resistance can occur, thus inability to detect satiety signals. Leptin is proangiogenic, triggers new blood vessels growth to adipocytes.
Department of Agruculture research and American Journal of Clinical nutrition results of US food consumption calories
- 63% of diet is Processed food
- 25% is from animal foods
-12% is from plant foods (6% processed plant like almonds in candy, 6% unprocessed vegetables)
US Diet over 100 years ago
- Sugar intake increased from <10lbs to >140 lbs
- Oil intake from 4 lbs to 70 lbs
- Cheese by 25 lbs
- Television from 0-4 hours
American College of Lifestyle Medicine Definition
- Reversal of T2DM means NORMALIZATION of blood glucose and DISCOUNTINUATION of all diabetes meds (oral and injectable)
- Remission requires HbA1c of <5.7 for AT LEAST ONE YEAR with NO ACTIVE PHARMACOLOGY OR PROCEDURES.
Table:
Partial: <6.5, 100-125 FBS, more than 1 year
Complete: <5.7, <100 FBS. more than 1 year
Prolonged: <5.7, <100 FBS, more than 5 years
- Diet is corenerstone of T2DM control, can undo almost all medical treatments
- Exercise can help, ACUTELY lowers blood glucose, improves weigh control, help with insulin resistance, lowers muscle and liver fat
- Stress management can help by decreasing exposure to cortisol
- Fasting mimicking diet can promote beta cell regeneration
High protein, low carb diet in px with Diabetes
- can achieve weight loss, reduce insulin requirements, reduce HbA1c
Mediterranean diet in px with DM
- Shown to reduce HbA1c levels, reduce DM, improve insulin sensitivity
- 20-30% risk reduction in developing T2DM
Key Dietary Research
- Vegan diet improved HbA1c more than traditional ADA diet in 22 week trial
- Low fat vegan associated with reduction in glucose and weight loss
- Eight year follow up nurse study > consumption of meat five or more times per week associated increased diabetes thru (nitrite exposure, inflammation, heme iron stores)
- Adventist Health Study
- Regular meat consumption nearly doubled risk of having diabetes
- Adventist who ate meat had 97% increased risk of DM for men, 93% of risk for women. - EPIC study
- Every 5% of calories from animal protein resulted in 30% increased risk of DM
- Vegetable protein not associated with increased risk of DM - Nurse Health Study (research on eggs)
- People with DM who ate more than one egg a day double their risk of cardiovascular disease compared to those who ate less than one egg a week.
- Eating more than 5 eggs per week, inc. DM risk
- Carnitine and choline found in meat and eggs, produced inflammatiion that may contribute to DM - National Institute of Health Plant Based Diet vs ADA Diet Recommendation
- HbA1c dropped 3 times as much on plant based diet
- LDL droped twice as much
- Weight dropped more than two times
- Med requirements dropped 2 times - Vegetarian versus ADA diet
- Vegetarian diet had: reduction in meds and weight, improvement in insulin sensitivity, increased adipnectivn, vitamin C, superoxide dismutase, decreased leptin - Meat consumption and T2DM
- Risk of forming DM is 16-35% lower if one serving of red meat replaced with one serving of nuts, low fat dairy, whole grains.
Diabetes Prevention Program (DPP)
- 12 month intensive program designed to reduce progression of pre diabetes and at risk group
- Weekly meetings with research team for 6 months, then monthly for 6 months
- Instructions to meet PA guidelines of 150min of mod exercise via walking or body weight resistance
- Focused on sustainable lifestyle change (no need for membership or intensive PA)
- Diet was less fat, fewer calories
- Support was virtual or live
CONCLUSIONS:
- Lifestyle habits can prevent DM
- DPP offers effective clinical applications
- Lifestyle is preferable in managing DM, no neg effect from meds
Clinical application of lessons learned from DPP
- Talk with px about prediabetes and need to treat it
- Screen lab
- Discuss long term implications
- Include honest conversations about medical and lifestyle intervention
- Focus on positive aspect of lifestyle
A whole food plant based diet can:
- Change epigenetics
- Normalize angiogenesis reducing comorbid disease
- Protec beta cells by: normalizing lipid profiel, leptin adiponectin pathway, down regulating inflammation, normalizing glucose, stabilizing immune system
- Improve glycmic control and optimize microbiom via SCFA
- Butyrate enhances: insulin sensitivity, mineral absorbption, decrease cholesterol and triglycerides, decrease glycolysis in liver, improve satiety
- Reduce pain ass with peripharal neuropathy
- Reprogram taste buds and break habits
- Reduce total cost
- Reverse diabetic retinopathy
Take home:
- Encourage px to endure withdrawal symptoms, as they will eventually normalize
Solubel vs Insuluble Fiber Sources
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Studies
Adventist Health Study
Breast Cancer Study
Nurse Health Study
