Food Therapy

1. Food Therapy • Dr. Alex Alexander • Week 1- Components

2. Components of A healthy Diet • High in multiple, variously colored fruits and vegetables • 51% of Americans eat less than 3 veggies per day • 72% of Americans eat less than 2 fruits per day (USDA)

3. What do You Think? • New for 2011

4. USDA Recommendations • Balancing Calories: Enjoy your food, but eat less. Avoid oversized portions. • Foods to Increase: Make half your plate fruits and vegetables. Make at least half your grains whole grains. Switch to fat-free or low-fat (1%) milk. • Foods to Reduce: Compare sodium in foods like soup, bread, and frozen meals ― and choose the foods with lower numbers. Drink water instead of sugary drinks. 

5. Components • High in fiber • 93% of Americans eat less than 25 grams of fiber per day • fiber regulates pH and provides food for lacto- bacillus (prebiotics)

6. Components • Low in saturated fat • A meal high in saturated fat adversely effects blood sugar control, even after the next meal • Substitution of dietary saturated fat with a polyunsaturated fat improves blood sugar control. • Foods highest in omega 6 fa’s= (1) farm raised salmon, (2) chicken

7. EFAs • Essential Fatty Acid Basics • The body can synthesize some of the fats it needs from the foods you eat. However, two essential fatty acids cannot be synthesized in the body and can be taken in the diet from plant foods. Their names—linolenic and linoleic acid—are not important. What is important is that these basic fats are used to build specialized fats called omega-3 and omega-6 fatty acids.

8. Specific Fatty Acids • Omega-6 fats are found in leafy vegetables, seeds, nuts, grains, and vegetable oils (corn, safflower, soybean, cottonseed, sesame, sunflower). Other omega-6 fatty acids, such as gamma-linolenic acid (GLA), can be found in more rare oils, including black currant, borage, evening primrose, and hemp oils.3 Most diets provide adequate amounts of omega-6 fatty acids. • Omega-3 Fatty Acids • It is important for vegetarians to include foods that are rich in omega-3 fatty acids on a daily basis. Alpha-linolenic acid, a common omega-3 fatty acid, is found in many vegetables, beans, nuts, seeds, and fruits. The best source of alpha-linolenic acid is flaxseeds or flaxseed oil. For those seeking to increase their intake of omega-3 fats, more concentrated sources can be found in oils such as canola (also known as rapeseed), soybean, walnut, and wheat germ. Omega-3 fatty acids can be found in smaller quantities in nuts, seeds, and soy products, as well as beans, vegetables, and whole grains. Corn, safflower, sunflower, and cottonseed oils are generally low in omega-3s.

9. What about Trans Fats? • Trans fats (or trans fatty acids) are created in an industrial process that adds hydrogen to liquid vegetable oils to make them more solid.  Another name for trans fats is “partially hydrogenated oils."  Look for them on the ingredient list on food packages. • Trans fats raise your bad (LDL) cholesterol levels and lower your good (HDL) cholesterol levels.  Eating trans fats increases your risk of developing heart disease and stroke.  It’s also associated with a higher risk of developing type 2 diabetes.

10. Components • Low in trans-fatty acids→adding hydrogens to make fat more stable • Trans fats are bad for cholesterol • Although some people suspect trans fats cause coronary artery disease, evidence is still not clear • Dairy is the only food which contains naturally occurring trans fat (small amounts)

11. Components • Low in sugar • Added sugars account for 15.7% of total US calorie intake (USDA) • Even most conservative sources recommend less than 20% of calories from added sugars • Important not to confuse sugars and carbohydrates • Recommends pts get <5% of calories from refined sugars

12. Components • Moderate salt • Just getting rid of the salt shaker has little effect – most salt now comes from prepared or pre-packaged foods • As high as 80% of patients respond to a low salt intervention • Effect can be disappointingly modest • Most recommendations are from 2-2.3 grams sodium per day

13. Components • Adequate amounts of pure water • Vastly overrated recommendation in ND community, but still important • Increasing water intake is recommended for patients with history of kidney stones • Don't recommend distilled because mineral content is low • Recommend spring water or filtered • EPA has a searchable database where you put in zip code and it will tell you the mineral content of your water

14. Components • Moderate amounts of protein • ND profession has gotten a bit away from the conclusions of the research world on optimum protein intake • The published evidence supports the notion that Americans eat too much, not too little protein. • Research support for protein stabilizing blood sugar is weak, at best. • amino acids ↑ insulin secretion • Recommended protein intake is usually between 0.5 and 1.0 grams per kg body weight per day. • 2.0 g of protein/day/kg of body weight is thought to be a safe upper limit • Compared to fats and sugars, little is known about the long term effects of varying amounts of protein on physiological function

15. Components • Good variety • Mastication / slow down while eating • ↑parasympathetic • ↑salivary amylase

16. Components • Caloric moderation • Animal data are very clear that too many calories vastly shorten the life expectancy, likely in part by overproduction of free radicals • if you take a rat and feed it 30% more calories than it needs it will die sooner • biochemical process of burning calories creates free radicals

17. Nutritional Assessment • How do you determine if your patient’s diet is good?EVERYONE LIES! (or conveniently forgets to reports accurately) • When do you need to do a nutritional assessment?

18. Risk Factors • Risk Factors • There are numerous risk factors for poor nutritional status, including major trauma, burns, sepsis, substance abuse, recent weight loss, and many gastrointestinal disorders. Additional information learned through a careful medical history can also suggest possible risk factors for malnutrition. The factors listed below may place a patient at risk for developing, or may denote the presence of, nutrient deficiencies. • Age < 18 years or > 65 years (increased risk age >75 years) • Recent significant, unintentional weight loss: > 5% in 1 month or >10% in 6 months • Weight loss calculated as follows: • Percent weight loss = (UBW-CBW)/UBW • Where: UBW = usual body weight, CBW =current body weight • Excessive alcohol intake, other substance abuse • Homelessness, limited access to food • Limited capacity for oral intake (dysphagia, odynophagia, stomatitis, mucositis) • NPO > 3 days • Increased metabolic demands: extensive burns, major surgery, trauma, fever, infection, draining, abscesses, wounds, fistulae, pregnancy • Protracted nutrient losses: malabsorption syndromes, short gut syndrome, draining abscesses, wounds, fistulae, effusions, renal dialysis • Intake of catabolic drugs: corticosteroids, immunosuppressants, antineoplastics • Protracted emesis: anorexia nervosa, bulimia, hyperemesis gravidarum, radiation, cancer chemotherapy • Chronic disease (especially AIDS, diabetes, cystic fibrosis, stroke, cancer)

19. Detailed Diet History • A detailed diet history provides insight into a patient's baseline nutritional status and may detect subclinical nutrient deficiencies or toxicities. Assessment includes questions regarding chewing or swallowing problems, avoidance of eating related to abdominal pain, changes in appetite, taste, or intake, as well as use of a special diet or nutritional supplements.

20. Detailed Medical History • A review of past medical history includes identifying existence of conditions resulting in increased metabolic needs, altered gastrointestinal function and absorptive capacity, chronic disease states, organ failure, and levels of physical activity. A review of current medications may further elucidate at-risk nutrient status.

21. Nutritional Assessment • History • Still the best way to assess an ambulatory individual’s nutritional status • Self-reporting of dietary habits will often underestimate the bad and overestimate the good (Am J Clin Nutr. 2002 Oct;76(4):766-73) • Diet diary can be a useful tool, as long as limitations are understood

22. Nutritional Assessment • Diet Diary: • At least 4 days • Over one weekend

23. MOre on the Diet Diary • Food Allergies, Intolerances, Weight Loss Pitfalls • The evidence: August 2008 issue of The Journal of Preventive Medicine. Researchers at Kaiser Permanente found that when people used a food diary they lost twice as much weight. And that's without making any other changes. Just the diary. • So what happens when you write down what you eat? You face what you are doing. You face your weight/moods/allergies head on. Keeping a food diary isn't keeping notes. It's THERAPY! Once you face the facts -- whatever those facts are -- you will be able to take control.

24. Nutritional Assessment • Physical exam • Obvious stuff: vital signs (particularly weight), skin health, oral mucosa. Non-obvious stuff? • Oral mucosa changes w/ low Vit A, B-vit’s, folic acid, antioxidants • Skin changes w/FA deficiency and some vitamin defs

25. Nutritional assessment • Lab assessment • Standard tests will often reveal plenty • CMP/Chem panel, CBC, ferritin as first tests • Standard tests from large labs→covered by insurance and normals are based on more characteristic populations • Specific labs will be covered as appropriate under nutrients (e.g. methylmalonic acid for B12 deficiency) • Some ND’s advocate narrowing the reference range for interpretation of lab values. Very controversial • Tasting zinc has no predictive value of your RBC zinc status • When to check nutritional status: Fatigue, GI problems, Wasting • What can you find in a chem. Panel about someone’s nutrition: • ↓Protein→↓albumin, ↓BUN→may need hospital intervention • electrolytes→if high K think about kidney disorder • Look at liver function and kidney function • if ↓liv function then need to limit protein intake to prevent ↑ BUN and hepatic encephalopathy • Dx based on PE and Hx. Use labs to confirm. Not critical most times

26. Nutritional Assessment • Hair mineral analysis • Reliability for the most part better in toxic and/or higher weight minerals • Commercially available hair mineral analysis of questionable quality. This may be an artifact of poor sample preparation procedures. • compared 5 different labs and found no statistical correlation between any nutrient or any anti-nutrient so may not be a good use of patients $$$

27. Nutritional Assessment • Esoteric tests • Kinesiology (applied kinesiology- AK) is not apparently very reproducible or reliable as a screening tool. One study has found a positive correlation between results on objective tests and AK. • IgG food allergy tests have not been checked for reliability. The clinical significance of IgG antibodies to foods has been questioned in recent papers • Consider sending a split sample to any lab you are considering using and see if they can reproduce the same results on the same sample • Transdermal electro-impedance (Vega) testing is again not well documented. The best study showed the only predictor of test outcome was the operator of the machine [e.g not clinical symptoms, use of placebo as test substrate, etc]. Transdermal electro-impedance/Vega testing- measures changes in energy flow (electrical impedance) w/ introduction of various foods/allergens.

28. Discussion • Components of Healthy Diet Basics: • Problems with resources for eating right? • Other potential real-world considerations • Nutritional Assessment • Consider several options and pick one to stick with