The IFM Cardiometabolic Plan; Using a Food First Approach to Supporting Metabolic Syndrome, Hypertension, and Dyslipidemia within the Functional Medicine Model

Kristi Hughes, ND February 2016 Learning Objectives

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©2012 The Institute for Functional Medicine Food Is…

©2012 The Institute for Functional Medicine Food is information, Food is medicine. “…we are witnessing food being redefined as “information” that alters cellular function in the post- prandial state…”

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Statin Three different anti-hypertensives Aspirin Folic acid

Fruits & vegetables Almonds Chocolate Wine Fish Wald et al., British Medical J 2003; 525: 1-6. Garlic Franco et al. Horm Metab Res. 2007 Sep;39(9):627-31. ©2012 The Institute for Functional Medicine Food is medicine.

“Let food be your medicine and medicine be your food.” - Hippocrates

©2012 The Institute for Functional Medicine Food is Medicine for the Heart

©2012 The Institute for Functional Medicine The Impact of Food on CVD Prevention “Broader adherence to recommendations for daily intake of fruit, vegetables, fish and fatty acid composition may take away as much as 20-30% of the burden of cardiovascular disease and result in approximately 1 extra life year for a 40-year-old individual.

Promotion of a healthy should be given more emphasis in the prevention of cardiovascular disease.”

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©2012 The Institute for Functional Medicine Choosing an IFM Food Plan

©2012 The Institute for Functional Medicine Considerations for Personalizing the Food Plans • Choose Food List Based on Features • Provide Tailored Food List – Consider Macronutrient Percentages – Targeted Calories when Appropriate – Provide Serving Allowances – Remove Triggering • Discuss Therapeutic Foods • Provide Practical Tools such as Weekly Menu Plan, Recipes, and Shopping List

©2012 The Institute for Functional Medicine Considerations for Personalizing the Food Plans • Choose Food List Based on Features • Provide Tailored Food List – Consider Macronutrient Percentages – Targeted Calories when Appropriate – Provide Serving Allowances – Remove Triggering Foods • Discuss Therapeutic Foods • Provide Practical Tools such as Weekly Menu Plan, Recipes, and Shopping List

©2012 The Institute for Functional Medicine ©2012 The Institute for Functional Medicine Foundational and First Step Intervention Considerations

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©2012 The Institute for Functional Medicine Functional Nutrition Patterns

 ),))&( &#'#(0)(#. ,#)'.)&# Food Nutrition History Seeking , All Ages, Allergies, Atopy, Asthma, GI Metabolic Syndrome, Type 2 Athletic, Pregnancy, Overweight, Distress, Pain and Fatigue, AI Diabetes, Hypertension, Overweight, Underweight. Diseases. Dyslipidemia, Timeline Seeking Healthy Diet, All Ages, Allergies, Atopy, Asthma, GI Metabolic Syndrome, Type 2 Athletic, Pregnancy, Overweight, Distress, Pain and Fatigue, AI Diabetes, Hypertension, Overweight, Underweight. Diseases. Dyslipidemia, Obesity Anthropometrics Non-specific Increased BMI, Increased ECW/ICW Incr: BMI, WC, WHR, Fat, Blood Pressure Biomarkers & Labs Normal screening values Incr. IgG or IgE food reactions, Incr: HgbA1C, FBS, insulin, hs-CRP, Celiac, Autoantibodies, Dysbiosis. Trigs Decr: HDL Clinical Indicators from Non-specific Dry Skin, thin eyebrows, Fluid Incr: WC and WHR Nutrition Physical Exam retention, and skin inflammation. Skin tags, acanthosis nigricans, peripheral neuropathy. Diet and Lifestyle Inadequate nutrients Food Triggers, Allergy Exposures. Excess simple sugar Prepared food Excess reliance on one food. High CHO intake, GI foods, low protein, excess alcohol, elevated trans fats. Functional Nutrition Status

©2012 The Institute for Functional Medicine Functional Medicine Patterns

 ),))&( &#'#(0)(#. ,#)'.)&# Medical History Seeking Healthy Diet, All Ages, Allergies, Atopy, Asthma, GI Metabolic Syndrome, Type 2 Athletic, Pregnancy, Overweight, Distress, Pain and Fatigue, AI Diabetes, Hypertension, Overweight, Underweight. Diseases. Dyslipidemia, Obesity ATMs Antibiotics, Multiple infections, Family History, T2DM, CVD, HTN, (Antecedents, Triggers, and Trauma, Stress, Familial allergies, Obesity, Sedentary Lifestyle, Sleep Mother with Group B strep, Acid Disorder (inadequate sleep and Mediators) Blocking Medication, Maternal use of Sleep apnea) PPI during pregnancy Matrix Patterns Non-specific Assimilation Structural Integrity Biotransformation Transport Communication/Defense and Repair Defend and Repair/Communication

©2012 The Institute for Functional Medicine Common Dietary Approaches Utilized in Addressing and Preventing Cardiovascular Disease

©2012 The Institute for Functional Medicine Plant-Based Diets: Cardiovascular Health Benefits for the Individual, Sustainable Nourishment for the Planet

©2012 The Institute for Functional Medicine 0(! 5**),0(! -*)(-#&9 5-.#(#&#.9 ©2012 The Institute for Functional Medicine The evidence for plant- based eating • Convincing body of evidence to suggest that a plant-based dietary pattern beneficially impacts cardiovascular health • Fruits & vegetables (F&V) are low in energy, sodium and fatty acids and high in nutrient density, providing significant amounts of fiber and micronutrients

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©2012 The Institute for Functional Medicine The evidence for plant- based eating • Fruit & vegetable intake > 5 servings/d is associated with the lowest risk of CVD • Highest risk with an intake <3 servings/d.

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©2012 The Institute for Functional Medicine Plant-Based Eating and Blood Pressure • F&V intake is associated with lower BP • Greater BP effect is due to higher potassium content • Limited evidence for an inverse trend between FV consumption and LDL levels • Greater LDL lowering effect is due to soluble fiber and plant-based sterols 3--/#-*.'-+>QOPP#.,95#&#(-),',#(-FDED> #'*&#0)(-),,#)6-5&,#--?'*&; -$.D/#-/*)>

©2012 The Institute for Functional Medicine The

©2012 The Institute for Functional Medicine Mediterranean-Style Diet

• A collection of dietary habits followed by countries bordering the Mediterranean Sea • High olive oil, vegetables, legumes, whole grains, fruit, nuts, spices, herbs • Moderate fish and poultry • Low red meat and dairy • Low to moderate alcohol (e.g., red wine)

©2012 The Institute for Functional Medicine Where did it originate from?

• Mediterranean Diet is best described as the dietary patterns adopted in the olive growing areas during the 1950-60s. • Diet reflects the post WWII era before fast food.

©2012 The Institute for Functional Medicine There is no “one” Mediterranean Diet

• 16 countries in the Mediterranean region • Italy 30% total intake • Greece 40%

©2012 The Institute for Functional Medicine How is the Mediterranean Diet assessed in research studies?

Modified Mediterranean Diet Score and Cardiovascular Risk in a North American

Working Population. PLoS One. 2014;9(2):e87539. ©2012 The Institute for Functional Medicine Prospective Design Studies on Mediterranean Diet and DM

• GISSI-Prevenzione Trial • SUN study • Health professionals follow-up study • EPIC • NHS II “reveal a 12-83% reduced risk of DM with highest adherence to the MD”

©2012 The Institute for Functional Medicine Lyon Diet Heart Study: Survival Without MI 72% Risk Reduction

P = 0.0001

Mediterranean Diet: ↑ Fruits / Veggies, Nuts, Olive Oil, Canola Oil, Fish

Prudent / AHA Step 1 ↓ Fats, Saturated Fat & Cholesterol; AHA Step 1

Circulation. 1999; 779-785 ©2012 The Institute for Functional Medicine Mediterranean diet & health status

• 4,172,412 subjects • Overall meta-analysis • A 2-point increase in adherence resulted in: – 8% reduction overall mortality – 10% reduced risk of CVD – 4% reduction neoplastic disease

Public Health Nutr.2013 Nov 29:1-14. [Epub ahead of print] ©2012 The Institute for Functional Medicine The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals.

Results from clinical studies revealed the protective role of the Mediterranean diet on components of MS, like:

 Waist circumference  High-density lipoprotein cholesterol  Triglycerides  Systolic and diastolic blood pressure  Glucose

J Am Coll Cardiol. 2011 Mar 15;57(11):1299-313. The effect of Mediterranean diet on metabolic syndrome and its components: a meta-analysis of 50 studies and 534,906 individuals. Kastorini CM, et al. ©2012 The Institute for Functional Medicine PREDIMED: Mediterranean Diet vs. Low-Fat Diet Three groups: 1. Med. Diet + EVOO (Extra Virgin Olive Oil) 2. Med. Diet + nuts 3. Low-fat diet

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N Engl J Med 2013;368:1279-90. DOI:10.1056/ NEJMoa1200303 N=7447 ©2012 The Institute for Functional Medicine

At 1 y, the MD groups had lower plasma concentrations of IL-6, TNFR60, and TNFR80 (P < 0.05), whereas ICAM-1, TNFR60, and TNFR80 concentrations increased in the LFD group (P < 0.002).

J Nutr. 2012 Jun;142(6):1019-25. Epub 2012 Apr 25. The Mediterranean diet pattern and its main components are associated with lower plasma concentrations of tumor necrosis factor receptor 60 in patients at high risk for cardiovascular disease. Urpi-Sarda M, et al. ©2012 The Institute for Functional Medicine Glycemic- balanced, nutrient-dense carbohydrate

©2012 The Institute for Functional Medicine Glycemic load (GL), glycemic index (GI) and risk of cardiovascular disease

• Dose-response meta-analysis found an increased RR of 1.18 per 50 unit increment of GL with cardiac event risk in Caucasians.

• High GL and GI were associated with significant increased risk of CVDs, specifically for women.

Atherosclerosis.2012 Aug;223(2):491-6. Epub 2012 Jun 6. Glycemic load, glycemic index and risk of cardiovascular diseases: Meta-analyses of prospective studies. Ma XY. et al. n= 229,213 participants ©2012 The Institute for Functional Medicine Meta-analysis of dietary GL and GI in relation to CHD risk

GL GI Men 1.08 0.99 Women 1.69 1.26 Combined 1.36 1.13

Unfavorable effects may be more pronounced in overweight and obese patients.

Am J Cardiol. 2012 Jun 1;109(11):1608-13. Epub 2012 Mar 20. Meta-analysis of dietary glycemic load and glycemic index in relation to risk of coronary heart disease. Dong JY, et al. ©2012 The Institute for Functional Medicine Systemic Effects of

Nat Med. 2014 Feb 6;20(2):120-1. doi: 10.1038/nm.3472. Increase in dietary fiber dampens allergic responses in the lung. Huffnagle GB. ©2012 The Institute for Functional Medicine Dietary Fibers and Cardiometabolic Diseases

• “Consumption of DF has been associated to lower risk of CVD for some time, but the hypothesis that DF intake could protect directly against CVD is relatively recent.” • “Experimental data from both animals and humans suggest and association between increased DF intakes and improved plasma lipid profiles, including reduced LDL-C concentrations.”

Int J Mol Scii.2012;13(2):1524-40. Epub 2012 Feb 2. Dietary fibers and cardiometabolic diseases. Riccioni G, et al. ©2012 The Institute for Functional Medicine Dietary fiber and cardiovascular health

Nutr Hosp.2012 Jan-Feb;27(1):31-45. Dietary fibre and cardiovascular health. Sánchez-Muniz©2012 The Institute FJ. for Functional Medicine How much fiber are people eating?

• Mexican Americans (18.8 g) • non-Hispanic whites (16.3 g) • non-Hispanic blacks (13.1 g)

Mean dietary fiber intake averaged 15.7-17.0 g

“Low dietary fiber intake from 1999-2010 in the US, and associations between higher dietary fiber and a lower prevalence of cardiometabolic risks suggest the need to develop new strategies and policies to increase dietary fiber intake.”

Am J Med.2013 Dec;126(12):1059-67.e1-4. doi: 10.1016/j.amjmed. 2013.07.023. Epub 2013 Oct 15. ©2012 The Institute for Functional Medicine Risk of CVD across increasing levels of total fiber intake

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©2012 The Institute for Functional Medicine Introducing the Cardiometabolic Food Plan

Implementing a low glycemic, anti-inflammatory, phytonutrient-rich diet to stabilize blood sugar, minimize insulin secreted, and reduce secondary inflammation

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©2012 The Institute for Functional Medicine When to Use this Plan

• Those with risk factors for cardiovascular disease (CVD) • Those with risk factors for dysfunctional metabolism such as metabolic syndrome and/or type 2 diabetes (T2D) • Those with CVD (includes high blood pressure, high cholesterol and elevated blood fats) • Those with metabolic syndrome (includes high blood sugar, increased belly fat) • Those with T2D

©2012 The Institute for Functional Medicine Considerations for Personalizing the Food Plans • Choose Food List Based on Features • Provide Tailored Food List – Consider Macronutrient Percentages – Targeted Calories when Appropriate – Provide Serving Allowances – Remove Triggering Foods • Discuss Therapeutic Foods • Provide Practical Tools such as Weekly Menu Plan, Recipes, and Shopping List

©2012 The Institute for Functional Medicine ©2012 The Institute for Functional Medicine ©2012 The Institute for Functional Medicine ©2012 The Institute for Functional Medicine Proteins

©2012 The Institute for Functional Medicine Legumes

©2012 The Institute for Functional Medicine Dairy & Alternatives

©2012 The Institute for Functional Medicine Nuts & Seeds

©2012 The Institute for Functional Medicine Fats & Oils

©2012 The Institute for Functional Medicine Non-Starchy Vegetables

©2012 The Institute for Functional Medicine Starchy Vegetables

©2012 The Institute for Functional Medicine Fruits

©2012 The Institute for Functional Medicine Whole Grains

©2012 The Institute for Functional Medicine Beverages

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©2012 The Institute for Functional Medicine ©2012 The Institute for Functional Medicine The Role of Calories and in CVD

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©2012 The Institute for Functional Medicine THE CARDIOMETABOLIC FOOD PLAN: Features, Food List, Modifications, & Guide

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©2012 The Institute for Functional Medicine THE CARDIOMETABOLIC FOOD PLANS with Caloric Targets

©2012 The Institute for Functional Medicine Comprehensive Guide Elements

THE CARDIOMETABOLIC FOOD PLAN

• Why the Cardiometabolic Food Plan? • Features of the Food Plan • Touring the Food Plan • Therapeutic Foods for Cardiometabolic Health • Frequently Asked Questions

25-page Comprehensive Patient Guide

©2012 The Institute for Functional Medicine Considerations for Personalizing the Food Plans • Choose Food List Based on Features • Provide Tailored Food List – Consider Macronutrient Percentages – Targeted Calories when Appropriate – Provide Serving Allowances – Remove Triggering Foods • Discuss Therapeutic Foods • Provide Practical Tools such as Weekly Menu Plan, Recipes, and Shopping List

©2012 The Institute for Functional Medicine ©2012 The Institute for Functional Medicine ©2012 The Institute for Functional Medicine Considerations for Personalizing the Food Plans • Choose Food List Based on Features • Provide Tailored Food List – Consider Macronutrient Percentages – Targeted Calories when Appropriate – Provide Serving Allowances – Remove Triggering Foods • Discuss Therapeutic Foods • Provide Practical Tools such as Weekly Menu Plan, Recipes, and Shopping List

©2012 The Institute for Functional Medicine THE CARDIOMETABOLIC FOOD PLAN

Weekly Planner and Recipes

©2012 The Institute for Functional Medicine THE CARDIOMETABOLIC FOOD PLAN

Sample Weekly Menu Plan

©2012 The Institute for Functional Medicine THE CARDIOMETABOLIC FOOD PLAN

Shopping Guide

©2012 The Institute for Functional Medicine THE CARDIOMETABOLIC FOOD PLAN

Recipe Index

©2012 The Institute for Functional Medicine CHANGING THE WAY WE DO MEDICINE, AND THE MEDICINE WE DO Additional Resources for Exploring Therapeutic Foods

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©2012 The Institute for Functional Medicine Identifying Metabolic Syndrome

©2012 The Institute for Functional Medicine ‘Lifestyle-induced metabolic inflexibility and accelerated ageing syndrome’

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©2012 The Institute for Functional Medicine Features of Metabolic Syndrome

At least 3 of the following: Women Men • TG >150 mg/dL • TG >150 mg/dL • HDL-C <50 mg/dL • HDL-C <40 mg/dL • Waist > 35” (88 cm) • Waist >40” (102 cm) • BP >130/85 or HTN on • BP >130/85 or HTN on meds meds • Fasting glucose ≥100 mg/ • Fasting glucose ≥100 mg/ dL dL

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©2012 The Institute for Functional Medicine Therapeutic Food Interventions for Metabolic Syndrome

©2012 The Institute for Functional Medicine Targeting the characteristics of metabolic syndrome through the “polymeal” rather than the “polypill” approach

©2012 The Institute for Functional Medicine Features within the Cardiometabolic Food Plan Tailored to Metabolic Syndrome

• frequency • Low glycemic index and glycemic load • Low in added sugars • Balanced quality fat • High in fiber

©2012 The Institute for Functional Medicine Foods to Avoid in Metabolic Syndrome

• Sucrose and fructose • Processed foods • Refined carbohydrates like white flour breads and pasta • Fast foods • Saturated, animal fat • Overly-cooked foods (e.g., meats) • Food or drink in plastic containers • Large meals ( aim for smaller meals) • Eggs (less than one per day if blood sugar is elevated) • Fruit juices

©2012 The Institute for Functional Medicine Foods to Include in Metabolic Syndrome

• Extra-virgin olive oil • Green tea • Mixed nuts (unsalted) • Cinnamon • Omega-3 fat sources from food and supplement sources (2 to 4 grams per day, especially if hypertriglyceridemia is present) • Fiber sources such as whole grains and legumes

©2012 The Institute for Functional Medicine Olive Bioactives

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• 10 to 30mL (about 2-6 tbsp) of polyphenol-rich olive oil per day has been shown to exert positive effects on systolic and diastolic blood pressure, endothelial function, inflammation and oxidative stress. • Neither safflower oil nor sunflower oil, both rich in monounsaturated fatty acids, have been found to have the same benefits. • The level of polyphenols appears to be important for enhancing the beneficial effects. • They are found at higher levels in unrefined, extra virgin olive oils and give certain olive oils their characteristic bitter, astringent taste.

©2012 The Institute for Functional Medicine Tree Nuts

©2012 The Institute for Functional Medicine Tree nuts inversely associated with metabolic syndrome & obesity

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©2012 The Institute for Functional Medicine Tree Nuts: Relationship to Metabolic Syndrome

• Strong evidence from large population studies and clinical trials supports nut consumption for cardiovascular health which may reduce risk by up to 35%. • Clinical studies demonstrate that 1 to 2 oz/d of nuts lowers LDL-C by 2% to 19%.* Obese subjects experience a smaller decrease in LDL-C from nuts compared with lean subjects. • Nuts can lower triglycerides, apo B, inflammation and LDL oxidation, as well as improve endothelial function and vascular

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• Cardiovascular benefit of nut consumption increase in a dose-dependent manner, improvements with consumption of 1 oz once a week. • Greatest benefits with 1 oz nuts 5 or more times per week. • Most potent cholesterol-lowering nuts: walnuts, peanuts, pistachios, almonds, pecans, and macadamia nuts. • Almonds and pecans shown to reduce oxidized LDL

©2012 The Institute for Functional Medicine Subset of PREDIMED Trial found favorable effects of MED Diet + nuts on lipoproteins

Lipoprotein subfractions are shifted to a less atherogenic pattern by consumption of Mediterranean diets enriched with nuts:

• Decreased concentration of med-small and very small LDL • Decreased LDL particle number • Increased LDL concentrations • With olive oil added, see increased HDL concentrations

Atherosclerosis. 2013 Oct;230(2):347-53. doi: 10.1016/j.atherosclerosis.2013.08.014. Epub 2013 Aug 21.

©2012 The Institute for Functional Medicine Green Tea

©2012 The Institute for Functional Medicine Protective Cardiometabolic Mechanisms of Catechins

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• Increases plasma antioxidant capacity and whole blood glutathione • Induces weight loss, reduces BMI & WC • Lowers lipid peroxidation

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©2012 The Institute for Functional Medicine The Hypertensive Web (* 7+-/).>QOPR )3-7<VGPH=UWEVS>*$=PO>POPUC%>%.#>QOPQ>PP>OOV

©2012 The Institute for Functional Medicine The Link Between Insulin Resistance & Hypertension

3--/#-*.'-+>QOPQ+-$'<PSQH=PUOEPUU> ©2012 The Institute for Functional Medicine Hypertension: Dietary Factors to Consider

 Studied dietary approaches: – DASH diet – Mediterranean diet – Vegetarian diet – Raw foods – Examine food allergy

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©2012 The Institute for Functional Medicine ©2012 The Institute for Functional Medicine Foods to Avoid in Hypertension

• Sodium (limit to 2,000 mgs-about 1 teaspoon-per day) • Processed foods (packaged, canned) and frozen meals • Fast foods • Soft drinks • Added sweeteners • Caffeinated beverages • Alcohol • Use of oils in high-heat cooking

©2012 The Institute for Functional Medicine #.,9 Foods to Include in Hypertension 2,(- (#6#5& ))- Proteins: • Soy, (fermented) 30 grams daily: natto, , tempeh, miso #)A 06- • Hydrolyzed whey (30 grams daily) • Legumes (vegetable protein) • Cold water fish: sardines, herring, haddock, salmon or trout • Foods high in L-: lentils, hazelnuts, walnuts, peanuts • Mixed nuts (unsalted) • Cocoa (30 grams dark chocolate per day, or about 1 square of baker’s chocolate)

Vegetables and Fruit: • Blueberries • Leafy greens high in nitrates • Seaweed (hijiki and wakame), 3 to 4 grams per day • Garlic, 1-4 fresh cloves/day • Mushrooms – ½ cup shitake, maitake • Celery, 4 stalks/day • Foods high in lycopene: tomatoes, guava, watermelon, apricots, pink grapefruit, papaya • Pomegranate juice

Fats and Oils: • Olive, flaxseed, and sesame oils

Carbohydrates: • Increase complex carbohydrates • Increase high fiber whole grains: oatmeal, oatbran, barley, wheat ©2012 The Institute for Functional Medicine • Fiber: psyllium 7gm ©2012 The Institute for Functional Medicine Beneficial effects of polyphenol- rich olive oil in patients with early atherosclerosis

• OO significantly improved endothelial function • Significant reduction in inflammatory parameters: – sICAM – White blood cells – Monocytes – Lymphocytes – Platelets

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©2012 The Institute for Functional Medicine Where to Focus with Food

• Inflammation • Oxidative Stress • Immune regulation

Nutrients.2013 Apr 12;5(4):1218-40. doi: 10.3390/nu5041218.

©2012 The Institute for Functional Medicine #.,9 2,(-

(#6#5& Foods to Avoid in Dyslipidemia ))- #)A 06-

• Sucrose • Processed foods • Fast foods • Refined carbohydrates • Trans fats (found in processed foods) • High saturated fats (e.g., creams, full-fat cheeses, fatty meat) • Margarine

©2012 The Institute for Functional Medicine #.,9 2,(-

(#6#5& Foods to Include in Dyslipidemia ))-

#)A 06- • Fish • Green leafy vegetables • Low-glycemic index fruits • Tomatoes • Extra-virgin olive oil (about 5 TBSP per day) • Green tea • Soybeans (e.g., soymilk, tofu, tempeh) • Dark chocolate • Pomegranate • Seeds and nuts (e.g., especially sesame) • Red wine (check with your healthcare practitioner) • Garlic (1 to 2 cloves per day) • Rice bran oil

©2012 The Institute for Functional Medicine Foods & reduction of LDL-C oxidation

   

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1. Meal frequency – Eating small, frequent A&$++$)"-&./;0)" meals compared with $)-,3)/'7GP('+- large, less, frequent 7H;)#4$)"$--"3'- meals may help lower ('-,3)7(7$)-. total- and LDL-C /*/')  D'4'.>B levels – Having a regular eating pattern

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7>3/-$0*)'$$);QOPP ©2012 The Institute for Functional Medicine Hypercholesterolemia: Dietary Factors to Consider • $-)*$'*)/$).#-/#'/#7 +#7/*#($'.G"((D*-78)*'; 4. Foods to include /**/-$)*'.H – Rice bran oil • 3/.=')3/.;'(*).; – Nuts +$./#$*.;+).;#8')3/.;) – Sesame seeds (($)3/. • .($)$)..(../*#'+ – Fiber 5$/#'*5-$)"  D/#-*3"# – Oat bran -3#*'./-*'.*-+0*)L – Barley & rye -3 D*04$/7> – Whole soybeans • $"# -..$./.5$/#$)-.$)" – Legumes '6-0*)*$'$.; – Grapefruit -.3'0)"$)$)-.*)4-.$*) *#*'./-*'/*$'$)/#'$4-> – Yogurt • *).3(+0*)*P-"-+-3$/ – Avocado +-7*-RO7.-3() – Fermented dairy/probiotics .-3(/*/')  D(*-/#) 7''*5"-+-3$/ "-$**#(>QOOU-W !,*,5#.*)-#06&9#( 5(--,5'.,#!&9,# &6&#(*0(.--5,#(!,)'),)(,9.",)-&,)-#->-.5#-#(6#.,)(#("5'(-?*-$)./$);/ '>3--#-(.>QOPP7>3/-$0*)'$$);QOPP&(.-.,)&-(-.()&-#(.".,.'(.)9-&#*#'#>(7 #(-#!".-#(.).,!.-('"(#-'-,&..),#)6-5&,,#-%?3("-/)-;/'> ©2012 The Institute for Functional Medicine Add More Spices When Cooking

©2012 The Institute for Functional Medicine Phytochemicals modulate intracellular communication processes related to cardiovascular risk

Howitz KT, Sinclair DA. Xenohormesis: sensing the chemical cues of other species. Cell. 2008 May 2;133(3):387-91. ©2012 The Institute for Functional Medicine CHANGING THE WAY WE DO MEDICINE, AND THE MEDICINE WE DO