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3
*
Division of Basic Medical Sciences and
The Department of Pediatrics, Mercer University School of Medicine, Macon, GA 31207 and
**
Dairy Management Incorporated, Rosemont, IL
3To whom correspondence should be addressed. E-mail: tobin.b{at}gain.mercer.edu.
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INTRODUCTION |
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 TOP INTRODUCTION Links among obesity, diabetes...The lack of published...Recent interdisciplinary...SUMMARYREFERENCES |
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). This initiative
calls for an interdisciplinary approach to education and solving
complex biomedical problems by utilizing the full potential of
knowledge available in the basic and clinical sciences. A centralized
vs. departmentalized approach is enumerated as a key educational
strategy to deal with the rapidly expanding knowledge found in the
biomedical sciences (Reynolds et al. 1995
).
Unfortunately, many academicians are unprepared to participate in
interdisciplinary education, research and problem solving.
A number of earlier symposia have dealt effectively with the individual
topics of population variability, nutrient-gene interactions,
obesity, cardiovascular disease
(CVD),4
diabetes and epidemiology. None, however, have approached the problem
of obesity, diabetes and cardiovascular disease within an
interdisciplinary effort. There is good reason to consider obesity,
diabetes and CVD as a topic best enumerated in an interdisciplinary
format. The comorbid associated conditions of obesity and diabetes
include many aspects of CVD (Montague and O’Rahilly 2000
). In addition, CVD is strongly associated with obesity and
diabetes (Timar et al. 2000
). It is becoming increasing
apparent that no one discipline can solve the complex genetic,
molecular, cellular, whole-body and population-based issues and
design research initiatives necessary to sustain continued progress in
this area.
The manuscripts included in this symposium profile genetic, molecular, subcellular, whole-body and statistical approaches to identify and understand specific examples of nutritional and metabolic variance in the human population. The authors represent a breadth of disciplines, including the clinical and basic sciences. Together and individually, these manuscripts provide a broad view and a focused perspective of research performed and future initiatives aimed at furthering our understanding of nutrition and metabolic diversity. We propose that a major advancement in the nutritional sciences will occur when we understand the biologic basis of nutritional individuality, identify the genotype and phenotype, and prescribe nutritional management appropriate to individual variation in obesity, diabetes and cardiovascular disease.
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Links among obesity, diabetes and CVD |
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TOPINTRODUCTIONLinks among obesity, diabetes...The lack of published...Recent interdisciplinary...SUMMARYREFERENCES |
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]. At present, 58
million Americans live with some form of CVD, and the estimated total
cost of CVD in the US in 1999 was $287 billion (CDC 2000
). The essential role of nutrition in the prevention and
treatment of cardiovascular disease, obesity and diabetes is supported
by numerous studies in the basic sciences, clinical sciences as well as
key multi-institutional multidisciplinary studies (American Dietetic Association 1995
, Kretchmer 1994
,
NRC 1989
, Public Health Service 1988
).
Several milestone studies have firmly established the relationships
among obesity, diabetes and cardiovascular disease. These seminal
investigations include the Framingham Study (Dawber et al. 1951
), the Bogalusa Heart Study (Freedman et al. 1987
), the Normative Aging Study (Parker et al. 1993
), and the Diabetes Control and Complications Trials
(DCCT 1993
, Santiago 1993
). These and
other investigations have provided key insights into the role of
individual risk factors and nutrition-related interventions as they
apply to the management of obesity, diabetes and CVD.
In 1961, the Framingham Study illustrated that cholesterol, blood
pressure and electrocardiogram abnormalities are associated with an
increase in the risk for heart disease (Kannel et al. 1961
). By 1967, it was apparent that physical activity could
reduce CVD, and obesity could increase the risk of CVD (Kannel 1967
). The role of high blood pressure as a contributor to
increased risk of stroke was later established (Kannel 1970
). The association of increased HDL cholesterol with a
reduced incidence of CVD was published in 1988 (Campos et al. 1988
, Castelli 1988
). Obesity has been
demonstrated to enhance the development of diabetes, increasing insulin
resistance, insulin secretion and CVD risk (Haffner 2000
). Thus, from an historical perspective, a robust body of
epidemiologic data links the coexistent conditions of obesity, diabetes
and cardiovascular disease (Hiller et al. 1988
).
The relationship between the secondary complications of diabetes and
the role of pharmacologic and dietary intervention in reducing these
complications was firmly established in the Diabetes Control and
Complications Trials (DCCT 1993
). Overall, >60% of the
morbidity and mortality of diabetes is attributable to CVD. However,
before the DCCT, it could not be stated that enhanced metabolic control
reduced the complications of diabetes. However, although improved
metabolic control reduced the incidence of microvascular renal, retinal
and neural complications by 40–60%, there were individuals in the
DCCT who did not improve, suggesting variability within the population,
i.e., glucose concentration alone did not completely explain the
variation in diabetes complications (Santiago 1993
).
Stern (1995)
later proposed that diabetes and
cardiovascular disease may coexist as a "common soil" condition,
yet may have mutually exclusive attributes.
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The lack of published literature on diversity and individuality |
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TOPINTRODUCTIONLinks among obesity, diabetes...The lack of published...Recent interdisciplinary...SUMMARYREFERENCES |
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Recent interdisciplinary nutrition initiatives |
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TOPINTRODUCTIONLinks among obesity, diabetes...The lack of published...Recent interdisciplinary...SUMMARYREFERENCES |
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). Accordingly, it was stated that
"coronary artery disease, hypertension, diabetes, cancer and other
chronic diseases tend to aggregate in families, and the risk for
relatives is much greater than that in the general population"
(Simopoulus1997
). The International Union of Nutrition
Scientists convened recently (June 1999), and at those meetings
proposed a model whereby genotype, environment and development
interactively influence phenotype (Fig. 1
; Chen et al. 1999
). Such interactions are scientifically
based and have been documented exhaustively by the National Institutes
of Health in a comprehensive document offering two evidence-based
models for the study and treatment of CVD (NIH 1998
).
One approach considers populations and includes variants of weight,
abdominal fat, high blood pressure, dyslipidemia and diabetes in the
development of CVD. The other, an individualized approach, considers
assessment of a person’s abdominal fat, weight and fitness as they
individually and collectively influence blood pressure, dyslipidemia,
glucose intolerance and ultimately, CVD (NIH 1998
).
|
). The Intersociety Professional
Nutrition Education Consortium is working on an interdisciplinary
medical-nutrition initiative with support from nine participating
nutrition societies and certification organizations (Heimburger 2000
). The National Heart Blood and Lung Institute has funded
21 medical schools nationwide to develop curricula for medical students
and physicians to learn nutrition principles; many of the institutions
involved have taken an interdisciplinary approach (McGaghie 2001
). However, despite these efforts, nutrition science has
lagged behind in its ability to proceed concurrently with educational
reform (Tobin 1997
). The necessity for
institutionalizing interdisciplinary approaches to solve biomedical
problems in the nutritional sciences has never been greater. |
SUMMARY |
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TOPINTRODUCTIONLinks among obesity, diabetes...The lack of published...Recent interdisciplinary...SUMMARYREFERENCES |
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).
Microanalytic tools that are available now allow us to measure multiple
metabolites or gene expression in response to a wide variety of changes
in nutrient/dietary intake (Roberts et al. 2000
). We
propose that health care costs might be reduced and nutritional care
could be more efficacious if we fully understood the effect of
nutritional individuality and diversity in medical-nutrition
therapy. We further hypothesize that a major advancement in the
nutritional sciences will occur when we work in an interdisciplinary
manner to understand the biologic basis of nutritional individuality,
identify the genotype and phenotype, and prescribe nutritional
management appropriate to individual variation in obesity, diabetes and
CVD. The manuscripts that follow illustrate a broad spectrum of approaches to understanding nutritional diversity. Our geneticist, Dr. Robert Eckhardt, argues convincingly that our fundamental knowledge of genetics dictates that a combination of biochemical individuality and allelic variants could be a basis for identifying an individual nutritional optimum. Dr. Ronald Krauss, physician and molecular biologist, provides substantive data that diet-gene interactions alter LDL subclass patterns, which contributes to substantial interindividual variability and thus dictates consideration of the fat content of a diet for CVD prevention and treatment. An international expert in diet-gene interactions, Dr. Carolyn Berdanier, nutrition scientist and genetics researcher, presents novel and innovative data on a variation in diabetes linked not to immunologically altered insulin secretion or genetic insulin receptor defects, but to a genetic defect in mitochondrial function, and subsequent energy metabolism pathways. From a diagnostic and clinical perspective, Dr. Steven Kahn, physician and diabetes researcher, provides one of the most unique and useful models to date, the disposition index, as a mathematical and physiologic tool to quantify individual variability in insulin secretion and insulin sensitivity and thus predict potential risk for developing diabetes and ultimately, CVD. Dr. Suzanne Murphey, nutrition researcher and statistician, provides the epidemiologic and statistical framework for understanding how current dietary recommendations are derived, and how those recommendations can overlook segments of our population who, on the basis of their nutritional individuality, do not fit population-based approaches to dietary prescription. The manuscripts that follow, thus, depict a portion of the data necessary to further an interdisciplinary approach to the nutritional sciences and present genetic, molecular, cellular, whole-body and population-based data that elucidate the biologic basis of nutritional individuality in the obesity, diabetes and CVD connection.
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FOOTNOTES |
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2 Dr. Tobin is funded by the National Institutes of Aging (AG13776), and the National Heart, Lung and Blood Institute (HL04305).
4 Abbreviations used: ASCN, American Society for Clinical Nutrition; CDC, Centers for Disease Control and Prevention; CVD, cardiovascular disease; DCCT, Diabetes Control and Complications Trials.
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REFERENCES |
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TOPINTRODUCTIONLinks among obesity, diabetes...The lack of published...Recent interdisciplinary...SUMMARYREFERENCES |
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