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Chapter 11

Nutrition and Chronic Diseases

Sizer and Whitney, Nutrition: Concepts and Controversies, 15th Edition. © 2020 Cengage. All Rights Reserved. May not be scanned, copied or duplicated, or posted to a publicly accessible website, in whole or in part.

Learning Objectives

Discuss the relationship between risk factors and chronic diseases

Describe cardiovascular disease and identify its risk factors

Summarize the causes, consequences, and management of type 2 diabetes

Describe the relationships between diet and cancer

Outline strategies for including sufficient fruit and vegetables in a diet

Describe the emerging science of nutritional genomics

Introduction

Two types of diseases

Infectious and chronic

Nutrients and our body’s defenses

Natural immunity

Preventive measures provided by public health services

Vaccines and sanitation

Leading causes of death

Cardiovascular diseases

Diabetes

Cancer

Figure 11.1: The Ten Leading Causes of Death in the United Statesa

aRates are age adjusted to allow relative comparisons of mortality among groups and over time.

bAlcohol increases the risks for some cancers and strokes.

cMotor vehicle and other accidents are the leading cause of death among people aged 15–24, followed by homicide, suicide, cancer, and heart disease. Alcohol contributes to about half of all accident fatalities.

Source: Data from National Center for Health Statistics: K. D. Kochanek, and coauthors, Deaths: Final data for 2014, National Vital Statistics Reports 65, 4 (2016): 1–122.

Figure 11.1: The Ten Leading Causes of Death in the United States

Many deaths have multiple causes, but diet influences the development of several chronic diseases—notably, heart disease, some types of cancer, strokes, and diabetes.

The Concept of Risk Factors (Slide 1 of 2)

Risk factors are correlated with diseases

Traits, conditions, or lifestyle habits that increase people’s chances of developing diseases

Infectious diseases have a single cause

Exposure to a specific pathogen

The Concept of Risk Factors (Slide 2 of 2)

The chronic diseases have many risk factors in common

Excessive alcohol intake

Lack of physical activity

Smoking or tobacco use

Diet

Table 11.1: Chronic Disease Risk Factorsa (Slide 1 of 3)

Risk Factors/Diseases	Atherosclerosis	Hypertension	Diabetes, Type 2	Cancers	Obesity
Advancing age (unmodifiable)	x	x	x	x	N A
Family history, or heredity (unmodifiable)	x	x	x	x	x
Atherosclerosisb	N A	x	N A	N A	N A
Diabetesb	x	x	N A	N A	N A
Hypertensionb	x	N A	N A	N A	N A
Obesityb	x	x	x	x	N A
High blood L D L and triglycerides; low H D L	x	N A	N A	N A	N A

Table 11.1: Chronic Disease Risk Factorsa

Of all of these risk factors, the first two are unalterable: you cannot change your age or heredity. As for diseases as risk factors, if you already have one, you may or may not be able to slow or reverse it. The other risk factors have to do with your lifestyle choices and therefore are, to a great extent, under your control. Your choices can be powerful preventive measures against chronic diseases.

Table 11.1: Chronic Disease Risk Factorsa (Slide 2 of 3)

Risk Factors/Diseases	Atherosclerosis	Hypertension	Diabetes, Type 2	Cancers	Obesity
Excessive alcohol intake	N A	x	N A	x	x
Physical inactivity	x	x	x	x	x
Smoking/tobacco use	x	x	N A	x	N A
Diet high in added sugars	N A	N A	N A	N A	x
Atherogenic diet (high in saturated and/or trans fat and low in vegetables, fruit, and whole grainsc	x	x	N A	x	x

Table 11.1: Chronic Disease Risk Factorsa (Slide 3 of 3)

Risk Factors/Diseases	Atherosclerosis	Hypertension	Diabetes, Type 2	Cancers	Obesity
Diet high in salty/pickled foods	N A	x	N A	x	N A
Diet low in vitamins and/or minerals	x	x	N A	x	N A

aEnvironmental factors such as contamination are not included in this table.

bNote that atherosclerosis, diabetes, hypertension, and obesity are shown both as risk factors and as diseases in their own right.

cAn atherogenic diet produces high blood L D L and V L D L and low blood H D L. Such a diet is a C V D risk factor, and these blood-lipid test results, themselves, are also considered risk factors (see Table 11-3, p. 410).

Figure 11.2: Interrelationships among Chronic Diseases

Many chronic diseases are themselves risk factors for other chronic diseases, and all of them are linked to obesity. The risk factors highlighted in blue define the metabolic syndrome (defined on p. 412).

Cardiovascular Diseases (C V D)

Disease of the heart and blood vessels

Leading cause of death in the United States

Examples: Hypertension, coronary heart disease, and stroke

Atherosclerosis (Slide 1 of 3)

Hardening of the arteries

No one is completely free of all signs of atherosclerosis

Question is how far it has advanced and what can be done to slow or reverse it

Hypertension and atherosclerosis are interrelated and accelerate each other

As most people age, atherosclerosis progresses steadily

Figure 11.3: The Formation of Plaques in Atherosclerosis

Most people have well-developed plaques by the time they reach age 30.

Atherosclerosis (Slide 2 of 3)

The development of atherosclerosis involves:

Plaque development

Blood clot formation

Hypertension

Blood clots

Thrombus: Stationary clot

The tissue death caused is called thrombosis

Embolus: A clot broken loose

Embolism: Clot remains stuck in a narrow artery

SPL/Science Source

Figure 11.4: A blood clot

A blood clot in an artery, such as this fatal heart embolism, blocks the blood flow to tissues fed by that artery.

Atherosclerosis (Slide 3 of 3)

When an artery is blocked, it may swell and burst, causing an aneurysm

Hemorrhage: Blood leaks rapidly when a blood vessel bursts

Atherosclerosis raises blood pressure

High blood pressure accelerates atherosclerosis

Risk Factors for C V D (Slide 1 of 2)

Nonmodifiable risk factors

Increasing age

Male gender

Family history (heredity)

Modifiable risk factors

High blood L D L cholesterol

Low blood H D L cholesterol

High blood triglyceride (V L D L) levels

High blood pressure (hypertension)

Diabetes

Figure 11.6: Know Your Blood Pressure

The most effective single step you can take against hypertension is to learn your own blood pressure.

Risk Factors for C V D (Slide 2 of 2)

Obesity

Especially central obesity

Physical inactivity

Cigarette smoking and excessive alcohol consumption

High intake of sodium

An atherogenic diet

High in saturated fats and trans fats and low in vegetables, fruit, and whole grains

Metabolic Syndrome

Metabolic syndrome includes any three or more of the following:

High fasting blood glucose

Central obesity

Hypertension

Low blood high-density lipoprotein (H D L)

High blood triglycerides

Figure 11.5: Adult Standards for Blood Lipids

Category	Total blood cholesterol (milligrams/deciliter)	L D L cholesterol (milligrams/deciliter)	H D L cholesterol (milligrams/deciliter)	Triglycerides, fasting (milligrams/deciliter)
Healthy	<200	<100a	≥60	<150
Borderline	200–239	130–159b	59–40	150–199
Unhealthy	≥240	160–189c	<40	200–499d

a100–129 milligrams/deciliter of L D L indicates a near optimal level.

bL D L cholesterol-lowering medication may be needed at 130 milligrams/deciliter, depending on other risks.

c>190 milligrams/deciliter of L D L indicates a very high risk.

d>500 milligrams/deciliter of triglycerides indicates a very high risk.

Figure 11.5: Adult Standards for Blood Lipids

Figure 11.8: The American Heart Association’s Heart Attack Risk Calculator

American Heart Association

Figure 11.8: The American Heart Association’s Heart Attack Risk Calculator

This online calculator can assess your risk of having a heart attack. For a meaningful assessment, you’ll need some information about your blood lipids, blood pressure, and fasting blood glucose. To access the calculator, visit the American Heart Association website: https://professional.heart.org/professional/GuidelinesStatements/ASCVDRiskCalculator/UCM_457698_ASCVD-Risk-Calculator.jsp

Think Fitness: Ways to Include Physical Activity in a Day (Slide 1 of 2)

Benefits of physical activity

Coach a sport

Garden

Hike, bike, or walk to nearby stores or to classes

Mow, trim, and rake by hand

Park a block from your destination and walk

Play a sport

Play with children

Take classes for credit in dancing, sports, conditioning, or swimming

Take the stairs, not the elevator

When diets are rich in whole grains, vegetables, and fruit, life expectancies are long.

Think Fitness: Ways to Include Physical Activity in a Day (Slide 2 of 2)

Walk a dog

Walk every day

Wash your car with extra vigor, or bend and stretch to wash your toes in the bath

Work out at a fitness club

Work out with friends to help one another stay fit

Give away two labor-saving devices to someone who needs them

Lift small hand weights while talking on the phone, reading e-mail, or watching TV

Stretch often during the day

Recommendations for Reducing C V D Risk (Slide 1 of 3)

Estimate heart disease risk

Lifestyle changes

Increase physical activity

Lose weight if overweight

Implement dietary changes

Treat diseases you already have

Reduce exposure to tobacco smoke

Control alcohol intake

Learn your family history

Know your blood pressure

Recommendations for Reducing C V D Risk (Slide 2 of 3)

Recognize a heart attack

Pain or discomfort in the jaw, neck, or back

Feeling weak, light-headed, or faint

Chest pain or discomfort

Pain or discomfort in arms or shoulders

Shortness of breath

Recognize your salt/sodium intake

Increase potassium intake

Recommendations for Reducing C V D Risk (Slide 3 of 3)

Diet to reduce C V D risk

Reduce fat intake

Saturated and trans fats

Limit refined starches and added sugars

Eat fruits, vegetables, and whole grains

Eat foods rich in omega-3 fatty acids

Nutrient supplements, drugs, herbal remedies

Manage lifestyle changes

Table 11.5: How Much Does Changing the Eating Pattern Lower L D L Cholesterol?

Diet-Related Component	Modification	Possible L D L Reduction
Saturated fat	<7% of calories	8–10%
Weight reduction (if overweight)	Lose 10 pounds	5–8%
Soluble, viscous fiber	5–10 grams/day	3–5%

Table 11.5: How Much Does Changing the Eating Pattern Lower L D L Cholesterol?

For those who need to lower low-density lipoprotein (L D L) cholesterol, this table offers a perspective on the magnitude of results that may be possible.

Diabetes (Slide 1 of 2)

Well over one-third of U.S. adults have prediabetes

Exhibiting warning signs of diabetes to come

Two common forms of diabetes

Type 1

Type 2

Type 1 diabetes accounts for 5 to 10 percent of all cases

Sets in during childhood or adolescence but it can begin at any age, even late in life

Increasing in prevalence by about 3 percent each year

Autoimmune disorder

Diabetes (Slide 2 of 2)

Type 2 diabetes is responsible for 90 to 95 percent of cases in both adults and children

Predominant type closely linked with obesity

Been on the rise among children and adolescents

Insulin resistance: An inadequate response of the body’s cells to the hormone insulin

How Does Type 2 Diabetes Develop? (Slide 1 of 2)

Insulin resistance causes glucose and insulin to build up in the bloodstream

The blood glucose concentration rises

The overtaxed cells of the pancreas begin to fail and reduce their insulin output, while blood glucose soars farther out of control

How Does Type 2 Diabetes Develop? (Slide 2 of 2)

Symptoms

Intense hunger

Frequent urination

Intense thirst

Recognizing the symptoms of diabetes and seeking treatment are important steps for protecting health

Harms from Diabetes

Atherosclerosis tends to develop early, progress rapidly, and become severe in people with diabetes

Risk factors for type 2 diabetes are:

Advancing age

Family history (heredity)

Overweight and obesity

Impaired kidney, eye, and nerve function

Diminished blood circulation and nerve function

Tendency to develop slow-healing injuries and infections

Reduced blood flow to the kidneys damages them

Poor circulation to the eyes impairs vision and leads to blindness

Diabetes Prevention and Management (Slide 1 of 2)

Know your family history

Diagnosis can be made using any of several tests

Fasting plasma glucose test

Nonfasting A 1 C test

Lose weight if overweight

Be physically active

Choose your diet with care

Control carbohydrate intake

Anna Kucherova/Shutterstock.com

Diabetes Prevention and Management (Slide 2 of 2)

Reduce saturated fat intake to less than 10 percent of calories and limit trans fat as much as possible

Protein intake should be individualized

Alcohol intake should be moderate

Pay strict attention to the Dietary Guidelines for Americans, particularly concerning intakes of nutrient-dense foods, sodium, saturated fats, and added sugars

Cancer

Second leading cause of disability and death in the United States

Prevention of cancer is preferable to potential for cure

Risk factors

Lifestyle factors

Environmental exposures

Diet

Dietary components

Overeating

The Cancer Disease Process (Slide 1 of 2)

Cancer arises in the genetic material inside a person’s cells

The process is called carcinogenesis

Begins when a cell’s genetic material sustains damage from a carcinogen

Radiation, a free radical, or another cancer-causing chemical

Damage occurs everyday and is repaired by the cell

On failure to repair itself, the cell dies by cellular suicide, preventing its progeny to inherit faulty genes

The Cancer Disease Process (Slide 2 of 2)

When a damaged cell doesn't die, the immune system destroys such cells

When the immune system falters, a tumor is formed

Life-threatening cancer begins with an event called initiation

Promoters stimulate tumor growth

Figure 11.10: Risk-Benefit Relationships

Figure 11.11: Cancer Development

Cancer Risk Factors (Slide 1 of 2)

Advancing age

Family history (heredity)

Chronic inflammation

Diet

Weakened immunity

Infections

Obesity and estrogen

Alcohol with smoking

Fats and fatty acids

Many consumers appreciate the availability of bacon without added nitrites or nitrates.

Cancer Risk Factors (Slide 2 of 2)

Carcinogens in red and processed meats

Cooking methods

Iron

Fried foods

Environmental factors

Overexposure to the sun and exposure to radiation

Cancer Prevention (Slide 1 of 2)

A key to evaluating the safety of foods is the frequency of consumption

Balanced and varied diet must be followed

Evidence continues to accumulate in favor of fiber-rich foods

Whole foods and phytochemicals reduce oxidative damage to cell structures

Some phytochemicals are thought to act as anticarcinogens

Shulevskyy Volodymyr/Shutterstock.com

Lisa S./Shutterstock.com

Figure 11.12: Examples of Cruciferous Vegetables

Cruciferous vegetables belong to the cabbage family: arugula, bok choy, broccoli, broccoli sprouts, brussels sprouts, cabbages (all sorts), cauliflower, greens (collard, mustard, turnip), kale, kohlrabi, rutabaga, and turnip root.

Regular intake of whole foods like these, not individual chemicals, lowers people’s cancer risks.

Cancer Prevention (Slide 2 of 2)

Supplements of vitamins and nutrients have not been proved to prevent cancer

Use alcohol sparingly or abstain from use

Achieve and maintain a healthy body weight throughout life

Engage in regular physical activity

Whenever people’s food intakes are limited, the onset of cancer is delayed

Known as the caloric effect

Steps to Minimize Carcinogen Formation during Cooking

Marinate meats before cooking, and roast or bake them in the oven

When grilling, line the grill with foil, or wrap the food in foil

Take care not to burn foods

Limit intakes of crispy, browned French fries and chips and other well-browned foods

Table 11.9: Recommendations and Strategies for Reducing Cancer Risk (Slide 1 of 3)

Recommendations	Strategies
Body fatness. Achieve and maintain a healthy body weight throughout life	Follow the Healthy U.S.-Style Eating Pattern for your appropriate energy level Engage in regular physical activity Limit consumption of energy-dense foods and avoid beverages with added sugars Consume “fast foods” sparingly, if at all
Physical activity. Adopt a physically active lifestyle	Engage in at least 150 minutes of moderate-intensity physical activity or 75 minutes of vigorous-intensity physical activity or an equivalent combination throughout the week Limit sedentary behaviors such as sitting, lying down, watching television, and other forms of screen-based recreation

Table 11.9: Recommendations and Strategies for Reducing Cancer Risk

Table 11.9: Recommendations and Strategies for Reducing Cancer Risk (Slide 2 of 3)

Recommendations	Strategies
Plant-based foods. Consume a healthy diet with an emphasis on whole foods from plants	Eat at least the daily amounts of vegetables and fruit recommended by the U S D A Eating Patterns Choose whole grains instead of refined grain products Limit intake of red meat and avoid processed meats Limit refined starchy foods
Alcoholic drinks. If you drink alcoholic beverages, limit consumption	Drink no more than two drinks a day for men and one drink a day for women

Table 11.9: Recommendations and Strategies for Reducing Cancer Risk (Slide 3 of 3)

Recommendations	Strategies
Preservation, processing, preparation. Limit consumption of salt-cured foods and processed meats	Avoid salt-preserved, salted, or salty foods Limit consumption of processed foods with added salt to ensure an intake of less than 6 grams of salt (2.4 grams of sodium) a day Avoid processed meats
Dietary supplements. Aim to meet nutritional needs through diet	Dietary supplements are not recommended for cancer prevention

Sources: L. H. Kushi and coauthors, American Cancer Society guidelines on nutrition and physical activity for cancer prevention, CA: Cancer Journal for Clinicians 62 (2012): 30–67; World Cancer Research Fund/American Institute for Cancer Research, Food, Nutrition, Physical Activity and the Prevention of Cancer: A Global Perspective (Washington, D.C.: AICR, 2007), pp. 373–390.

Deciding about C A M (Slide 1 of 2)

Stands for complementary and alternative medicine

A group of diverse medical and health care systems, practices, and products that are not considered to be a part of conventional medicine

C A M best bets are:

Herbal medicines

Acupuncture

Deciding about C A M (Slide 2 of 2)

A C A M worst case

Use of the drug laetrile, a C A M treatment for cancer, which was a hazardous choice because of its high cyanide content

A curious case of anosmia, a loss of the sense of smell, occurred due to zinc gel being squirted into the nose

C A M products are not tested for safety

Other issues with C A M

Mislabeled herbs

Lack of knowledge

The D A S H Diet: Preventive Medicine

People who consume the adequate, balanced, calorie-controlled, moderate, and varied diet recommended by the Dietary Guidelines for Americans enjoy a longer, healthier life than those who do not

To lower saturated fat intakes, the Dietary Approaches to Stop Hypertension (D A S H) diet emphasizes fruit, vegetables, whole grains, and fat-free or low-fat milk and milk products

Figure 11.13: Proper Nutrition Shields against Diseases

A well-chosen diet can protect your health.

Controversy 11 - Nutritional Genomics: Can It Deliver on Its Promises? (Slide 1 of 2)

Genomics: The study of all the genes in an organism and their interactions with environmental factors

Genome: The full complement of genetic material in the chromosomes of a cell

Once a disease-associated variant is observed in the genetic profile, the health care provider can employ lifestyle choices and treatment options to minimize the potential for harm

Controversy 11 - Nutritional Genomics: Can It Deliver on Its Promises? (Slide 2 of 2)

Genes influence nutrition and disease

Small variations in D N A sequences, called mutations, dictate many of the differences among human beings

The most common mutations are single nucleotide polymorphisms (S N Ps)

Figure C11.1: Nutritional Genomics

Two branches of nutritional genomics may have similar-sounding names—nutrigenomics and nutrigenetics—but they oppose each other in scope. One branch studies how genes affect nutrient metabolism. The other branch studies how nutrients affect the genes.

Epigenetics (Slide 1 of 2)

Epigenome

Proteins and other molecules associated with chromosomes that affect the expression of genes

Turning genes “on” and “off”

Inherited or altered

Plays a role in cell differentiation

Regulation includes the workings of large globular proteins

Histones

Methyl groups

Future generation effects

Embryonic development

Epigenetics (Slide 2 of 2)

Modifying your epigenome

Health implications

Bioactive constituents in whole foods

Figure C11.2: Two Epigenetic Factors and Gene Activity

This figure depicts histones, large globular protein “spools” that wrap lengths of D N A. Other epigenetic factors also exist, such as the methyl groups in this illustration, tiny one-carbon structures that attach directly to a D N A strand, modifying its activity. Another is a form of R N A (not shown).

Figure C11.3: An Epigenome Timeline

Environmental influences, including diet, most profoundly alter the epigenome during the earliest stages of development, but some changes are probably still possible later in life.

Arguments Surrounding Genetic Testing (Slide 1 of 2)

For nutritional genomics to be of practical value, people must undergo genetic testing

Helps detect gene variations that affect nutrition or nutrition-related diseases

For a few hundred dollars, consumers can easily order D N A tests for themselves over the Internet

Questions on whether testing translates into better health or whether it is a waste of health care dollars

Arguments Surrounding Genetic Testing (Slide 2 of 2)

Even when D N A tests are legitimate, interpreting the results is complex

Without the will to improve health behaviors, it is unlikely that personal genetic testing alone can improve the health of the population in the future

These two mice share an identical gene that tends to produce fat, yellow mice. The mother of the lean, brown mouse received supplemental B vitamins that silenced the gene.