Targeting cardiometabolic syndrome with nutrition

Photo Cred: Steve Buissinne/Pixabay

By Kellie Blake, RDN, LD, IFNCP

As we are working to prevent the spread of the novel coronavirus (COVID-19) with social distancing, mask wearing, and hand hygiene, it has become clear that educating our patients on how to improve cardiometabolic health is also an important strategy that can help mitigate the effects of the virus. Those with cardiometabolic syndrome have higher morbidity and mortality when it comes to COVID-19 and as reported in a 2019 review in Metabolic Syndrome and Related Disorders, only 12.2 percent of the American population has optimal metabolic health. Cardiometabolic syndrome can no longer be viewed from an individual lens but must be seen as a public health issue that affects our society in a tremendous way. With nutrition and lifestyle change we can improve our collective metabolic health.

Cardiometabolic syndrome includes a number of features such as insulin resistance, impaired glucose tolerance, dyslipidemia, high blood pressure, and abdominal obesity. While there can be a genetic component, the majority of cardiometabolic diseases arise from lifestyle. I focus on education and empowerment to help my cardiometabolic patients take control of their health.

Tailoring lifestyle strategies to the individual based on personal root cause(s) is vital. But, much of my nutrition-related focus for cardiometabolic syndrome involves balancing the microbiome, caloric restriction, a long-term Mediterranean meal pattern, and the addition of functional foods.

Balancing the microbiome

The microbiome should be a consideration in any chronic disease condition. When it comes to cardiometabolic syndrome, the gut flora have an impact on energy regulation and obesity, which are both risk factors for insulin resistance. In addition, as reported in The Journal of Clinical Investigation, the gut barrier is altered allowing for the passage of food antigens, bacteria and bacterial by-products, and lipopolysaccharides into the systemic circulation leading to inflammation and altered glucose regulation. The signature microbiome in cardiometabolic syndrome patients often includes lower microbial diversity and the depletion of butyrate-producing bacteria, akkermansia mucinophilia, and mucin-producing goblet cells. Initiating the 5-R protocol can help to rebalance the microbiome and make the other nutrition and lifestyle-related changes more effective.

Caloric restriction

As reported in Nutrition, Metabolism, & Cardiovascular Diseases, caloric restriction has been shown to be effective in the prevention of cardiovascular disease. Rather than severely restricting calories, as has been done in the past, I use a variety of intermittent fasting strategies. This allows the body to shift from a fat storage mode to one that increases fatty acid oxidation and ketone production while preserving muscle mass. I tailor my recommendations to the patient, but generally begin with a daily 12-hour overnight fast and as the patient becomes more comfortable, I recommend a longer 16 to 18-hour fast a few times per week.  Most of my patients find this strategy easy to implement and report they feel less restricted when compared to strict caloric restriction.

Mediterranean meal pattern

While there are a variety of meal pattern options for cardiometabolic syndrome, one plan that seems to be easily implemented with long-term success by my patients is the Mediterranean diet (MD). This meal plan has been studied extensively and is beneficial for many chronic conditions. As reported in Oncotarget, the MD is protective against cardiovascular disease and obesity, but also has the ability to reverse these conditions. The MD includes an abundance of vegetables, fruits, fish, nuts, whole grains, and olive oil, is moderate in red wine, and contains minimal dairy and meat. When tailoring the MD for my cardiometabolic syndrome patients, I often eliminate gluten and dairy, and significantly reduce all sources of grains.

Functional foods

Functional foods provide a variety of nutrients but also contain specific compounds known to improve overall health and reduce disease risk. Some examples of functional foods for cardiometabolic syndrome include fruits, vegetables, legumes, nuts, green tea, dark chocolate, and fish. The long-term MD encourages patients to shift from thinking about individual foods to the quality of the dietary pattern on the whole, but there are some specific functional foods particularly beneficial for those with cardiometabolic syndrome.

1. Flax seeds are an important source of fiber and omega-3 fatty acids and have been shown to positively influence cholesterol and inflammation levels, act as antioxidants, and have antithrombotic effects. I recommend two to four tablespoons of ground flaxseeds per day.
2. Extra virgin olive oil (EVOO), a staple of the Mediterranean diet, has been shown to significantly improve insulin sensitivity and glucose levels. In addition, this polyphenol-rich oil reduces inflammation, improves endothelial cell function, lowers blood pressure, promotes healthy clotting, and reduces the oxidation of LDL cholesterol. I recommend two to four tablespoons of high-quality EVOO each day but educate patients to avoid the use of EVOO in high-heat cooking.
3. Cinnamon has been shown to improve insulin efficiency and decrease inflammation by decreasing the expression of mRNA involved in the production of pro-inflammatory factors. I recommend one-half teaspoon cinnamon daily.
4. Walnuts contain polyunsaturated fatty acids, fiber, antioxidants, and phytosterols, which have been associated with less insulin production and better glucose regulation. According to a 2019 study in Nutrition Research and Practice, subjects who consumed 45 grams of walnuts per day for 16 weeks, with no other diet change, had significantly improved fasting glucose and HgbA1c levels. I recommend one-quarter cup walnuts per day.
5. Fatty fish contain omega-3 fatty acids that have been shown to be protective in many capacities. For cardiometabolic syndrome, omega-3 fatty acids can lower triglycerides levels and have positive effects on lipid transport and atherosclerosis development as reported in Nutrition, Metabolism, and Cardiovascular Diseases. I recommend high-quality fatty fish at least twice per week and often utilize high-quality omega-3 fatty acid supplements.

Case Study

My patient, a 63-year-old male with a stressful career, long commute to work, and little time for exercise reached out for nutrition counseling to reduce his cardiometabolic risk and enable him to keep up with his grandchildren. His diet consisted of processed foods and sweets like donuts, pastries, chocolate candy, and diet soda. He suffered from sleep apnea and used a C-pap machine, and had numerous sinus symptoms and seasonal allergies.

His initial fasting lab work indicated cardiometabolic dysfunction with total cholesterol of 197 mg/dl HDL of 36 mg/dl, LDL of 127 mg/dl, glucose of 107 mg/dl, HgbA1C of 5.7  percent, and triglycerides of 159 mg/dl. Despite abdominal obesity, he had normal blood pressure.

The initial treatment plan included:

1. Cardiometabolic meal plan emphasizing omega-3 fatty acids, EVOO, walnuts, cinnamon, flaxseed, and non-starchy vegetables
2. Walking for 10 to 15 minutes after every meal
3. Elimination of added sugar, simple carbohydrates, and soda
4. Berberine 500 milligrams BID to target the blood glucose and lipids
5. Multivitamin including vitamin D3
6. Use C-pap machine as ordered
7. Meditation daily for at least 10 minutes to manage the stress response

After eight weeks, my patient reported feeling much better and had lost 18 pounds. He was unable to tolerate the berberine, but was taking the multivitamin and following his initial goals. I added intermittent fasting, with a goal of a 12 to 16 hour-overnight fast at least twice per week and encouraged him to continue with all previous goals. After four months his fasting labs had all improved. The glucose was down to 98mg/dl, HgbA1c down to 5.5 percent, triglycerides down to 144mg/dl, and LDL down to 83mg/dl. His fasting insulin level was checked at this time and found to be in the optimal range at 6.69mcU/ml. His vitamin D was suboptimal at 36.5 ng/ml. He reported walking an average of 6,000 steps per day with 14,000 steps on busy days and 4,500 steps on slower days. He was still taking the multivitamin and an additional 5,000 international units of vitamin D3 was added. Since this patient was not eating fish routinely, 1,000 milligrams of omega-3 fish oil was added daily.

At the one-year follow-up, his fasting lab work showed continued improvement with total cholesterol of 167 mg/dl, HDL of 41 mg/dl, LDL of 104 mg/dl, glucose of 97 mg/dl, HgbA1c of 5.4 percent, and triglycerides of 111 mg/dl. My patient reported feeling much more energetic and said in addition to the weight loss and improved labs, his constant sinus and allergy issues were much improved. He was also happy with this ability to play outdoors with his grandchildren and not feel exhausted.

While my patient’s initial lab work was not alarming, significant risk was on the horizon had he continued on his previous path. By making some targeted nutrition and lifestyle-related changes, my patient reduced his cardiometabolic risk, experienced improvement in quality of life, and he is now much less likely to experience severe symptoms should he contract the COVID-19.  

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