December 14, 2021: Dr. Jeejeebhoy, Emeritus Professor of Medicine, Nutritional Sciences at the U of T. Topic: Diet-Exercise in Preventive Medicine: Evidence-based – ZOOM

Following in his grandfather’s footsteps, Dr. Jeejeebhoy received his medical degree in 1959 from Christian Medical College Hospital in Vellore, India. Dr. Jeejeebhoy is currently an Emeritus Professor of Medicine cross-appointed with the Department of Nutritional Sciences at the University of Toronto. He was previously the past Division Director of Gastroenterology at the University of Toronto and the Toronto General Hospital where he established as well as directed a postgraduate training program for clinical and academic gastroenterologists. Today, Dr. Jeejeebhoy is also the Director of the Home Parenteral Nutrition program and a staff physician at St. Michael’s Hospital, a teaching and research hospital located in Toronto. He continues to mold patient care by acting as the Executive of the Canadian Malnutrition Task Force which focuses on developing standards for nutrition care in hospitals. Finally, he practices gastroenterology at the Polyclinic and established the CHANGE program for the prevention of metabolic syndrome with Metabolic Syndrome Canada. Dr. Jeejeebhoy is internationally recognized for research in the fields of gastroenterology and nutrition as he has published over 500 peer-reviewed articles, abstracts, and book chapters. Dr. Jeejeebhoy’s passion for his field of work motivates him to expand the medical community’s knowledge of gastroenterology and nutrition by continuing to publish content that will shape the future of patient care. Furthermore, he received over 20 awards throughout his career from Canada, the United States, and the United Kingdom. In particular, he was elected a member of the prestigious American Society of Clinical Investigation. His commitment to shaping the future of medical care is also shown through his appointment as a senior member of the Canadian Medical Association in 2011. The Canadian Medical Association is a national, voluntary association of physicians that advocates on behalf of its members as well as the public for access to high-quality health care. Through all of his accomplishments, it is clear Dr. Jeejeebhoy is committed to the field of medicine. His passion for his field of work enabled him to not only make a positive impact on the quality of life for countless Canadians but also people all over the world.

Dr. Jeejeebhoy was introduced by Hugh Chaun.

Summary of Presentation.

Cancer, diabetes, musculoskeletal disease, and cardiovascular disease consist of almost 50% of all the conditions that afflict Canadians. All of these diseases are also affected by diet and exercise. This means that two of the leading causes of disease and death in the Western World are the Metabolic Syndrome and infirmity, which Dr. Jeejeebhoy refers to as “dysfunctional ageing.”

The basis of the Metabolic Syndrome is insulin resistance, an epigenetic trait that is acquired environmentally but then becomes inheritable. The basis of infirmity is creeping sarcopenia with age. Insulin resistance evolved in humans to protect against malnutrition and death during periods of famine. However, when food is plentiful for long periods of time, this survival adaptation becomes a liability.

In an insulin-sensitive state, glucose is converted into glycogen, whereas glucose is converted into adipose tissue in an insulin-resistant state. In an insulin-resistant state, muscles cells are depleted, and adipose tissue is increased. This process can lead to increased body fat (obesity), depleted muscle glycogen (fatigue), hyperglycemia, hyperlipidemia, hypertension, and inflammation (increased oxidative stress) of the coronary arteries.

The Metabolic Syndrome is characterized by five measurements relating to fasting blood glucose levels, blood pressure, triglyceride levels, HDL-C levels, and abdominal circumference. People with at least three of the five characteristics have the Metabolic Syndrome.

A study published in the European Heart Journal in 2013 found that obesity by itself is not a major risk factor, but metabolic resistance is. Once fitness is accounted for, the metabolically healthy but obese person has a benign condition. However, a metabolically obese person has a 30-50% increased mortality rate. Fortunately, the Metabolic Syndrome can be treated. Aerobic exercise and a low glycemic index diet can cause an insulin-resistant state to convert into an insulin-sensitive state. Dr. Jeejeebhoy shared and explained the results of multiple studies demonstrating how diet and exercise can help to reduce the effects of the Metabolic Syndrome and infirmity.

Many studies demonstrate that lifestyle interventions are more effective than drugs or surgery in combating the Metabolic Syndrome. The New England Journal of Medicine published an article in 2002 comparing the use of metformin and the adoption of a lifestyle modification program among 3234 nondiabetic persons with elevated fasting and post-load plasma glucose concentrations over four years. The lifestyle modification program prescribed a goal of 7% weight loss and at least 150 minutes of physical activity per week. In this study, the cumulative incidence of diabetes was significantly reduced by lifestyle modification, while metformin was not as effective.

In 2004, the same journal published an article comparing the effects of exercise and angioplasty among 101 patients. In this study, those who exercised had reduced rates of coronary disease compared to those who received the surgery.

When it comes to diet, an article published in 2013 in the New England Journal of Medicine looked at the effects of the Mediterranean diet among 7447 patients with Type II Diabetes and at least three major risk factors. The Mediterranean diet reduced the risk of myocardial infarctions, stroke, and death from cardiovascular causes by 30% compared to the control diet.

A study published in 1999 followed 642 men over 25 years. Those who lived an active life of vigorous activity demonstrated a significantly reduced risk of death.  In an article published in 1994 in the New England Journal of Medicine, 87-year-olds participated in high-intensity progressive resistance training of hip and knee extensors for ten weeks. The control group lost weight over time, whereas the group who participated in the resistance training saw reduced rates of sarcopenia and even an increase in muscle mass.

It is well documented that weight loss and loss of body fat reduce the risk of coronary artery disease. This can be achieved without going hungry with some simple diet substitutions. A 1991 study in the American Journal for Clinical Nutrition showed that swapping simple carbohydrates out for complex carbohydrates resulted in a much lower level of blood glucose, in turn reducing the amount of fat storage. Additionally, the Carmen Trial in 2000 demonstrated that people who eat complex carbohydrates instead of simple carbohydrates were less hungry and consumed fewer calories overall. The Montignac diet, which excludes foods with a glycemic index of over 50, was studied and showed a reduced level of calorie consumption compared to those on the American Heart Association diet and, therefore, a reduction of weight and waist circumference and insulin resistance.

Diets high in fruits and vegetables and low in meat, soluble carbohydrates, and salt have also been shown to lower blood pressure levels, demonstrated through the Dash Diet.

Most general practitioners today, unfortunately, neglect these evidence-based resistors. There is a high reliance on medications rather than promoting lifestyle changes. This led Dr. Jeejeebhoy to develop the CHANGE program (Canadian Health Advanced by Nutrition and Graded Exercise) centred on family physicians. The goal of the program was to show general practitioners that they could reverse the Metabolic Syndrome among patients through lifestyle changes over the course of one year.

Generally, aerobic exercise three days a week, resistive training targeting the extensor muscles and following a Mediterranean Diet are excellent guidelines to improve a person’s overall health; however, making individually tailored programs for patients part of the medical care system is essential in improving outcomes for all Canadians with, or at risk of developing, the Metabolic Syndrome.

Learn more about the Metabolic Syndrome and the CHANGE program at metabolicsyndromecanada.ca.

 

Q & A transcription

Question from Richard Spencer: Thanks for a very informative talk. Can you comment on whether stair climbing exercise is preferred for physical exercise? Is using an exercise bike for the same period of time as good as stair climbing?

Answer: The answer is yes. The advantage of stair climbing is that it preserves the quadriceps muscles, which is one of the things that was being exercised in that group that I showed you. So they did that, of course, by weight training, but walking upstairs does exactly the same thing. Yes, to some extent, it is beneficial.

 

Question from Jon Collins: What kind of foods contain complex carbohydrates?

Answer: Complex carbohydrates, by and large, are carbohydrates that do not contain sugar. For instance, rice is a complex carbohydrate, and wheat is a complex carbohydrate. All of these kinds of foods are.

 

Question from Bill Hooker: How about fairly rigorous cycling?

 Answer: Yes, whatever you do, as long as you raise your heart rate and you increase your aerobic use, it works. So it doesn’t matter whether you do rigorous cycling or whether you climb stairs. But the important things are time and effort. You have to increase your heart rate so that you are at something like 65 to 70% of your VO2 max. That should be the target. So if you take your age and subtract it from 212, that is what should be your VO2 max. Just a matter of interest, I still exercise vigorously, and I can maintain heart rates of approximately 125-130 for half an hour. That’s what I do myself.

 

Question from Tim Sehmer: You said that an exercise program should focus on extensor muscles rather than flexor muscles – why is that?

Answer: The main problem with ageing is the inability to use extensors. Try getting out of the chair, for example that is one of the biggest problems with ageing. So if you strengthen your extensor muscles, you can do those things which you can do with ageing

 

Question from Chris Finch: Thank you. Can you give us an idea of the extent of the financial and health care benefits of emphasis on diet and exercise. In practice. I guess the figure is in the billions of dollars.

Answer: Well, this is exactly what Laurie is trying to do in these studies that are being done in the Northwest Territories and other places where they got family practice groups to take on large groups. They are attempting to see the financial aspects.

 

Question from Richard Spencer: Where should we go to get individual advice on an exercise program?

 Answer: There is a website that’s been created called metabolicsyndromecanada.ca, all one word. It’s a huge long word because there were problems with getting metabolicsyndrome.ca. If you go into there, you will see some of the suggestions that were made there’s the program as such. In fact, you can get contacts of people who give you advice.

 

Question from Arun Mehra:  How much salt per day can be used?

 Answer: Well, the minimum of the taste really is what you need. The basic needs of salt are somewhere no more than about half a gram a day. But the North American diet is anywhere between 3-8 grams a day. So if you can cut that down to even one or two grams, that’s a major benefit.

 

Question from David Chandler: In the healthy senior, without significant comorbidities does Mineral & Vitamin supplementation help reduce mortality or morbidity?

Answer: I think mineral and vitamin supplementation may be beneficial in people who have restricted diets. But as I mentioned previously, the cause of morbidity and mortality is insulin resistance, and really paying attention to that is probably more important than eating vitamins.

 

Question from Jon Collins: How do you rate the diet and exercise information and programs of our school system in Canada?

Answer: Unfortunately, what’s happened is that our school system is running on politically correct motivation at the moment. And that is why there’s really no good program. But the problem is that diet and exercise do not often apply to children, at least early on. It applies as you get past your prime because what happens is that as a child, there is a natural tendency to exercise a lot – run, jump, to do all kinds of things that keep you active all the time. But as you get older, that’s when diet and exercise become an issue. You’ve got to be more like children, rather than sitting on your butt.

 

Question from Rick Brenner: Do you have a guide for daily intake of saturated fat?

Answer: In general, I think the issue of fat is not as important frankly as the issue of total calorie intake and the source of your fat. That’s why saturated fats, so maybe from foods such as preserved meats and red meats, etc., really do have a detrimental effect. So, on the other hand, if you eat fats from fish, it’s definitely beneficial. So really, when talking about what your daily intake is, it’s a question of changing your diet to take on more of the Mediterranean type of diet. That I think is the important thing.

There is a difference between intermittent exercise and continuous exercise, which increases heart rate. If you increase heart rate by climbing up the stairs for the first six minutes, that is no improvement in your metabolic status. It is the sustained increase in heart rate beyond six minutes that seems to be associated with a reduction in insulin resistance. So, unfortunately, you might get a lot of muscle training by going up and down the stairs, but if you go do it intermittently, if you do not sustain your heart rate, then it does not have that effect.

 

Question from Arun Mehra:  What is the role of salt substitutes?

Answer: Well, salt substitutes are usually potassium-containing substances. I don’t think that that in itself makes a difference to the outcome as far as I know, but certainly, if it reduces your intake of salt, it’s a good idea.

 

Questions from Jon Collins: Could you elaborate a bit on what the Montignac diet is?

Answer: So look up the glycemic index, and you will find there are foods that have a high glycemic index and those that have a low glycemic index. The Montignac Diet mainly says you can eat meat, you can eat fish and chicken, you can eat any kind of food as much as you want, but eat a low glycemic index. In other words, it is the type of carbohydrate that you eat that’s important. That’s the principle behind the Montignac Diet.

 

 

 


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