Basics of a healthy diet Nutritional disorderssemmelweis.hu/nepegeszsegtan/files/2015/05/Nutrition-11.pdf · Nutritional disorders. Definitions ... Crohn’s disease Possible benefit

Basics of a healthy diet

Nutritional disorders

Definitions

• Nutrient: a food or other substance that provides energy or building material for the survival and growth of a living organism.

• Nutrient requirements: the daily quantity of essential nutrients needed to maintain health.

• Essential nurients: necessary for growth, normal functioning,and maintaining life that cannot be synthesized by the body.

• Energy requirements: the daily quantity of energy

required to sustain regular activity and physiological processes.

COMPONENTS OF ENERGY REQUIREMENTSBasal metabolism:• cell function and replacement;

• the synthesis, secretion and metabolism of enzymes and hormones to transport

proteins and other substances and molecules;

• the maintenance of body temperature;

• uninterrupted work of cardiac and respiratory muscles; and brain function.

• The amount of energy used called the basal metabolic rate (BMR), BMR represents

45–70 % of daily TEE (Total Energy Expenditure),

• it is determined mainly by the individual’s age, gender, body size and body

composition, lifestyle.

Metabolic response to food:• ingestion and digestion of food, absorption, transport, interconversion, oxidation

and deposition of nutrients.

• increase heat production and oxygen consumption � dietary-induced

thermogenesis.

• increases TEE ~10 % of the BMR

Physical activity: the second largest component of daily energy expenditure.

Humans perform obligatory and discretionary physical activities. http://www.fao.org/3/a-y5686e.pdf

Growth. two components:

1) the energy needed to synthesize growing tissues;

2) the energy deposited in those tissues.

~35 % of TEE during the first three months of age,

falls to ~5 % at 12 months and

~3 % in the second year,

remains at 1–2 % until mid-adolescence, and is negligible in the late teens.

Pregnancy. extra energy is needed for the

• growth of the foetus, placenta and various maternal tissues, (uterus, breasts, fat

stores)

• changes in maternal metabolism and the

• increase in maternal effort at rest and during physical activity.

Lactation. two components:

1) the energy content of the milk secreted;

2) the energy required to produce that milk.

COMPONENTS OF ENERGY REQUIREMENTS

http://www.fao.org/3/a-y5686e.pdf

Average daily energy

recommendations (WHO/FAO, 2004)

Sedentary lifestyle

Light/moderate activity

Vigorous activity

Extremely vigorous activity

Male Female

http://www.fao.org/3/a-y5686e.pdf

Functions of fats• Energy storage, mobilization, and utilization

• Prostaglandin, cytokine synthesis

• Cell differentiation and growth

• Cell membrane structure, myelination

• Signal transmission

• Hormone synthesis

• Bile acid synthesis

Essential fatty acids

• Humans cannot synthesize double bonds within the last nine carbons of the methyl end

(n) of any fatty acid chain

• Fatty acids with double bonds in those locations must therefore come from the diet—and

are considered essential

• EFA are (poly)unsaturated (there are no essential saturated fats)

• 2 fatty acids are essential: linoleic and alpha-linolenicacids (LA, ALA); both PUFAs

– ALA � EPA � � DHA

– LA �AA � prostaglandines, leukotrienes

Trans-fatty acids (TFA)

– Naturally present in small amounts (<1% of total calories) in animal food sources,

including human milk

– Mainly introduced in the food chain by the industrial process of hydrogenation

– This process is used to make oils solid at room temperature

– Increase CVD risk and mortality

FAO (2010): Fatts and fatty acids in human nutrition – Report of an expert consultation. ISBN: ISBN 978-92-5-106733-8

„Plant-based n-3 PUFA may reduce CHD risk, in particular when seafood based n-3

PUFA intake is low. This has implications for populations that consume little fatty fish.”


Recommended dietary intakes for total fat and fatty acid intake: Adults


Nutrient Proportion of total daily energy intake

Total fat (TF)

Min.15% (20% for women of reproductive

age and adults with BMI<18.5) – max. 30–

35%

Saturated FA (SFA) <10%

PUFA 6-11%

N-6-PUFA (linoleic acid – LA,

arachidonic acid – AA)

2.5–9%

N-3-PUFA(α-linolenic-acid – ALA,

eicosapentaenoic acid– EPA,

docosahexaenoic acid – DHA)

1–2%

MUFA TFA – (SFA + PUFA)

Cholesterol DRI <300 mg

Trans fatty acid (TFA) <1%

Dietary Recommended Intake (DRI) levels of fats and fatty

acids


„Although humans and animals have the capacity to convert ALA to EPA and

DHA, the efficiency of conversion is low, in particular to DHA. Generally, ALA

intake increases ALA, EPA and n-3 DPA, but there is very little increase in DHA in

plasma fractions (platelets, white cells and red blood cells) or breast milk.”

„In summary, the biosynthetic pathway in humans does not appear to provide

sufficient levels of ALA for it to be a substitute for dietary EPA and DHA. High

levels of EPA and DHA in blood or other cells are attained only when they are

provided as such in the diet and this would occur mostly from the consumption of

fish and fish oils, which are rich sources of these n-3 LCPUFA.”


Nutritionally

important

n-3 PUFA

Effects of n-3 PUFA in humansHealth problem

Level of

evidenceNote Intake

Asthma Possible benefit Only children

3g/dayCrohn’s disease Possible benefit

Rheumatoid arthritis Convincing

Colorectal cancer Probable Decreased risk500mg/day

Breast cancer Possible Decreased risk

Depression Probable benefit1–2 g/day

Bipolar disorder Possible benefit

Cognitive decline Possible benefit ?

Agression, hostility,

antisocial behaviorPossible benefit ?

Age-related

maculopathyPossible benefit ?

Alzheimer’s disease Insufficient DHA may be of benefit ?

Schizophrenia Insufficient Inconsistent results ?

Coronary Heart

Disease (CHD) eventsConvincing Decreased risk

500 mg/day

Fatal CHD Probable Decreased risk

Convincing

Probable

Possible

Insufficient

FAO (2010): Fatts and fatty acids

in human nutrition – Report of an

expert consultation. ISBN: ISBN

978-92-5-106733-8

PRODUCTION OF FISH OIL AND FISH

• Total production of fish oils: ~1 million MT per year, stabilised at this level (FAO/Fisheries

and Aquaculture Information and Statistics Service, 2007).

• In 2006, it was estimated that

– 87% of all fish oil was used by the aquaculture industry to produce feed,

– salmon farming alone used approximately 33% of all fish oil produced.

– The remaining 13% was processed into products for human consumption, mainly as

fish oil capsules.

• There has been a steady increase in the production (capture and aquaculture) of fish

since 1950, but a sharp decrease in production was recorded in 1998

In 2003 the total world production of fish

(capture and aquaculture combined) was 132.5

million MT (weight of fish and shellfish at capture

or harvest - freshwater, brackish water and marine

species of fish, crustaceans, molluscs and other

aquatic organisms) and of this 104.2 million MT

were available for human consumption, 24.4

million MT in developed countries and 79.8

million MT in developing countries


Salmon

Omega-3 FA content

(g/100 g fish)

1,9–2,3

Macarel 2,6

Herring 1,6–1,8

Sardine 1,0–1,4

Anchovy 1,4–2,0

Trout 0,6–2,0

Omega-3 content of fish

• http://seafoodhealthfacts.org/seafood_nutrition/practitioner

s/omega3_content.php

• http://www.health.gov/dietaryguidelines/dga2005/report/ht

ml/table_g2_adda2.htm

• http://ndb.nal.usda.gov/ndb/search

Recommendations (EPA+DHA)

• For adult males and non-pregnant/non-lactating adult females:

– 0.250 g/day of EPA + DHA is recommended.

• For adult pregnant and lactating females, the minimum intake for

optimal adult health and fetal and infant development is

– 0.3 g/d EPA+DHA, of which at least 0.2 g/d should be DHA.

• A daily intake of 500 mg EPA + DHA per day is recommended for the

primary prevention of coronary heart disease. � at least two portions

(90 g each) of oily fish will have to be consumed per week.

• (Two portions (90 g each) of cod per day, a low fat fish, will provide about

284 mg of EPA + DHA per day.)

• Fish oils for lowering triglyceride: 2–4 g/day

• Generally Regarded as Safe value of 3000 mg/day for n-3 LCPUFA.


Perk JP et al. (2012):European guidelines on cardiovasular diseaseprevention in clinical practice. European Heart Journal,

33:1635-1701. doi:10.1093/eurheartj/ehs092

Carbohydrates • 55-75% of total daily energy intake

Sugar <10%

• Simple carbohydrates

• monosaccharides (glucose, fructose)

• disaccharides (saccharose, lactose)

• ~refined, ~natural sugars

• Complex carbohydrates

• polysaccharides (starch, glycogen)

• non-starch polysaccharides – FIBRE (cellulose, hemicellulose, pectin,

beta-glucans, etc.)

• Fiber RDI: 25-35 mg

• Polysaccharydes that body can’t digest.

• Soluble fiber: dissolves in water, decrease gastric emptying, lower

glucose levels, delay glucose absorption, lower blood cholesterol. E.g.

oatmeal, nuts, beans, lentils, apples and blueberries.

• Insoluble fiber: does not dissolve in water, better intestinal passage,

decrease intestinal transit time, promoting regularity and helping prevent

constipation. E.g. whole wheat bread, brown rice, legumes, carrots,

cucumbers and tomatoes.

• Fruits and vegetables RDI >400g

Glycemic Index

The glycemic index (GI)

•a ranking of carbohydrates on a scale from 0 to 100 according to the extent to

which they raise blood sugar levels after eating.

•Foods with a high GI are those which are rapidly digested and absorbed and result

in marked fluctuations in blood sugar levels.

•Low-GI foods, by virtue of their slow digestion and absorption, produce gradual

rises in blood sugar and insulin levels, and have proven benefits for health.

•Low GI diets have been shown to improve both glucose and lipid levels in

people with diabetes (type 1 and type 2). They have benefits for weight control

because they help control appetite and delay hunger. Low GI diets also reduce

insulin levels and insulin resistance.

http://www.glycemicindex.com/foodSearch.php

Glycemic Index (GI)

• Low GI food GI < 55

• Intermediate GI food GI 56-69

• High GI foods GI >70

http://www.glycemicindex.com/

Type of starch

Physical entrapment

Viscosity of fiber

Sugar content

Fat content

Protein content

Acid content

Food processing

Cooking

Factors Influencing GI Ranking


Benefits of

Low GI Diet

BG levels

cholesterol levels

weight

heart disease risk

type 2 DM risk


What are the Benefits of the Glycemic Index?

• Low GI diets help people lose and manage weight

• Low GI diets increase the body's sensitivity to insulin

• Low GI carbs improve diabetes management

• Low GI carbs reduce the risk of heart disease

• Low GI carbs improve blood cholesterol levels

• Low GI carbs can help you manage the symptoms of PCOS(polycystic ovarium syndrome)

• Low GI carbs reduce hunger and keep you fuller for longer

• Low GI carbs prolong physical endurance

• High GI carbs help re-fuel carbohydrate stores after exercise


• Protein• 10-15% of total daily energy intake

• Found in muscle, bone, skin, hair, and virtually every other body part or tissue

• Essential / semi-essential / non-essential amino acids

• complete (animal): containing all the essential amino acids

• incomplete (plant): one or more essential amino acids (Val, Met, Tre, Leu, Ile, Phe, Trp, Lys, Arg, Hys) are absent or insufficient (except soya-bean)

• Red meat – increased CVD mortality, colorectal cancer

• High-protein diet – increased risk of osteoporosis

• Salt• <5g/day

Consumption of free sugars, e.g.sugar-sweetened beverages, may result in

• reduced intake of foods containing more nutritionally adequate calories

• increase in total caloric intake, leading to an unhealthy diet, weight gain and increased risk of noncommunicable

diseases (NCDs).

Role free sugars play in the development of dental diseases, dental caries.

• most prevalent NCDs globally

• great improvements in prevention and treatment have occurred in the last decades,

• continue to cause pain, anxiety, functional limitation and social handicap through tooth loss,

• for large numbers of people worldwide.

• The treatment is expensive—costing between 5 and 10% of health budgets in industrialised countries—and would

exceed the financial resources available for the whole of health care for children in the majority of lower-income

countries.

New draft guideline proposals

• WHO’s current recommendation, from 2002, is that sugars should make up less than 10% of total energy intake

per day.

• The new draft guideline further suggests that a reduction to below 5% of total energy intake per day would

have additional benefits.

• 5% of total energy intake is equivalent to around 25 grams (~6 teaspoons) of sugar per day for an adult of

normal BMI.

• The suggested limits on intake of sugars apply to all monosaccharides (such as glucose, fructose) and

disaccharides (such as sucrose or table sugar) that are added to food by the manufacturer, the cook or the

consumer, as well as sugars that are naturally present in honey, syrups, fruit juices and fruit concentrates.

• Sugars consumed are “hidden” in processed foods. (1 tablespoon of ketchup contains ~4 grams (~1 teaspoon) of

sugars.

http://www.who.int/mediacentre/news/notes/2014/consultation-sugar-guideline/en/

WHO: new guideline proposal for daily sugar intake

Vitamin D

• Fat-soluble vitamin and active hormone

• D-vitamin deficiency „epidemy” – globally ~1 billion people

• Sources– Produced endogenously: UV-rays � skin from 7-dehydrocholesterin: D3-

vitamin, cholecalciferol (active hormone: calcitriol)

• Direct sunlight 10-15 min/daily to face, arms and legs or back.

• Decreased synthesis: dark skin colour, older age, sun protective creme or

shading, above 35th latitude from November to February, clouds, air

pollution.

– Food: vegetables D2 (ergocalciferol); fatty fish (salmon, cod liver), milk (D3).

– Vitamin D supplementation. Fortified foods (milk, margarine, orange juice,

breakfast cereals, yogurt).

• RDA (in Hungary) : 1 IU=0,025 μg (cholecalciferol, D3)– Children: 10 μg/day (400 IU) (daily for infants, October to May for 1-3 year

olds)

– Adults: 5 μg/day (200 IU)[U.S. NIH: 600 UI; >70 years 800 UI]

• Optimal vitamin D supply: 75-100 nmol/l serum vitamin D (deficiency: <25

nmol/l)

Fig 2 Map of 137 vitamin D related outcomes: percentage of outcomes per outcome category

for all study designs.

Evropi Theodoratou et al. BMJ 2014;348:bmj.g2035

©2014 by British Medical Journal Publishing Group

What is already known on this topic

• The role of vitamin D has been explored both in a large number of observational studies and

randomised controlled trials and in relation to a multitude of health outcomes.

• The composite literature is often confusing and has led to heated debates about the role of

vitamin D, the optimal concentrations, and related guidelines for supplementation

• Recent reports have highlighted the lack of concordance between observational studies and

randomised controlled trials, concluding that vitamin D is more likely to be a correlate

marker of overall health and not causally involved in diseaseWhat this study adds

• This umbrella review collectively presents the evidence from systematic reviews and meta-analyses of

observational studies and randomised controlled trials in relation to 137 different outcomes covering a

wide range of diseases

• An association between vitamin D concentrations and birth weight, dental caries in children, maternal

vitamin D concentrations at term, and parathyroid hormone concentrations in chronic kidney disease

patients requiring dialysis is probable

• In contrast to previous reports, the findings cast doubt on the effectiveness of vitamin D only

supplementation for prevention of osteoporosis or falls

• This review highlights the absence of meta-analyses in relation to autoimmune disease and the absence

of meta-analyses of randomised clinical trials of vitamin D supplementation in respect of cancer,

cognitive, and infectious disease outcomes

Vitamin DTheodoratou E. et al.: Vitamin D and multiple health outcomes: umbrella review of systematic reviews

and meta-analyses of observational studies and randomised trials. BMJ 2014;348:g2035

Vitamin D

Physiological effects

• Calcium absorption, bone mineralization, bone growth and remodeling

• Modulation of

– cell growth

– Immune function

– Neuromuscular function

– Insulin production

– Renine production

Rickets (children):

failure of bone tissue to

properly mineralize,

resulting in soft bones

and skeletal deformities

Osteomalacia (adults)

weak bones, bone pain

and muscle weakness

Vitamin D deficiency


Cardiovasular diseases• AMI risk increase 2x

– Smooth muscle proliferation

– inflammation

– arteriosclerosis

– RAS, blood pressure

– increased se. parathyroid hormone level

• 18 RCT, ΣN=57 000, daily >500 NE vitamin D decreased the

mortality from CVD (Martins et al., 2007)

OsteoporosisLong-term insufficient vitamin D contributes to osteoporosis by reducing

calcium absorption.

Diabetes Mellitus

• Winter deteriorating type II DM

• Dose-dependent effect of vitamin D on DM

• Both type I and II DM

• Recommended se. level: 75 nmol/l

Obesity

• Influence fat cell development and maturation, energy

intake, energy expenditure, body weight regulator.

• Higher intake recommended for obese patients (storage

in fat tissue, difficult mobilization).


Immune system• Airborne infection, winter seasonality

• Development and maintenance of normal immune

function and tolerance

• Immune regulator (cellular and humoral immune

response)

• Risk factor of autoimmune diseases– SM, RA, IBD, respiratory allergies

Cancer• Inhibit the proliferation of cancer cells.

• Regulate cell growth, division, differentiation, maturation.

• Colorectal, breast and prostate cancers


Non-specific symptoms: headache, anorexia, weight loss,

polyuria, heart arrhythmias.

Raise blood levels of calcium � vascular and tissue

calcification (heart, blood vessels, and kidneys)

Toxicity treshold: 10 000 – 40 000 UI/day

Health risks from excessive Vitamin D

Age Male Female Pregnancy Lactation

0–6

months

1,000 IU

(25 mcg)

1,000 IU

(25 mcg)

7–12

months

1,500 IU

(38 mcg)

1,500 IU

(38 mcg)

1–3 years 2,500 IU

(63 mcg)

2,500 IU

(63 mcg)

4–8 years 3,000 IU

(75 mcg)

3,000 IU

(75 mcg)

≥9 years 4,000 IU

(100 mcg)

4,000 IU

(100 mcg)

4,000 IU

(100 mcg)

4,000 IU

(100 mcg)

Tolerable Upper Intake

Levels (ULs) for Vitamin D

http://ods.od.nih.gov/

• Risk << Benefit

• Optimal serum level: 75-100 nmol/l �

17,5-25 µg/day Vitamin D (700-1000 UI/day)

10 µg/day (600 UI/day) �� 15 µg/day (800 UI/day) vitamin D

supplementation for adults during winter.

Vitamin D


0–12

months*

400 IU

(10 mcg)

400 IU

(10 mcg)

1–13 years 600 IU

(15 mcg)

600 IU

(15 mcg)

14–18 years 600 IU

(15 mcg)

600 IU

(15 mcg)

600 IU

(15 mcg)

600 IU

(15 mcg)

19–50 years 600 IU

(15 mcg)

600 IU

(15 mcg)

600 IU

(15 mcg)

600 IU

(15 mcg)

51–70 years 600 IU

(15 mcg)

600 IU

(15 mcg)

>70 years 800 IU

(20 mcg)

800 IU

(20 mcg)

Recommended Dietary

Allowances (RDAs) for

Vitamin D


Vitamin A• fat-soluble retinoids, including retinol, retinal, retinoic acid, and retinyl

esters

• Physiological effects:– critical for vision, essential component of rhodopsin (dark adaptation)

– supports the normal differentiation and functioning of the conjunctival

membranes and cornea

– supports cell growth and differentiation, normal formation and maintenance

of the heart, lungs, kidneys, and other organs

– Immune system functions

– Skin and mucosa

– Antioxidant

– Stored in the liver

• Carotenoids (e.g. β-carotene): provitamin, plant sources (sweet potato,

spinach, carrot, pumpkin)

• Retinol (active form): preformed vitamin, animal sources (dairy products,

fish, meat, liver, egg)

• Lycopene, lutein, zeaxanthin � not converted to active vitamin A.

• 1 μg retinol activity equivalent (RAE) = 1 μg retinol = 6 μg β-carotene

• 800 μg/day, pregnants 1000 μg/day

Converted

to active

forms of

Vitamin A


0–6 months* 400 mcg RAE 400 mcg RAE

7–12 months* 500 mcg RAE 500 mcg RAE

1–3 years 300 mcg RAE 300 mcg RAE



14–18 years 900 mcg RAE 700 mcg RAE 750 mcg RAE 1,200 mcg RAE

19–50 years 900 mcg RAE 700 mcg RAE 770 mcg RAE 1,300 mcg RAE

51+ years 900 mcg RAE 700 mcg RAE

* Adequate Intake (AI), equivalent to the mean intake of vitamin A in healthy, breastfed infants.

Recommended Dietary Allowances (RDAs) for Vitamin A (U.S.)


Vitamin A deficiency

• Low income, developing countries

• Inadequate intake, limited access to foods

• Risk groups: infants, children, pregnant and

lactating women

• Symptoms:

– Xerophtahlmia: night blindness,

keratomalatia, preventable blindness

– increases the severity and mortality risk of

infections (diarrhea and measles)

– Xeroderma

• Prevents Age-related Macular Degeneration

(AMD): β-carotene, lutein, zeaxanthin

• Carotenodermia: yellow skin (palm, sole)

• Acut: nausea, vomiting, dizziness, blurred vision, coordination

problems

• Chronic: hair loss, peeling, headache, liver and bone damage

• Pregnancy: congenital malformations (spina bifida; malformations

of lips, mandibula, palate and extremities, lung, heart)

• Smokers: large supplemental dose � increased risk of lung cancer

and CVD

Hypervitaminosis A


0–12 months 600 mcg RAE

(2,000 IU)

600 mcg RAE

(2,000 IU)

1–3 years 600 mcg RAE

(2,000 IU)

600 mcg RAE

(2,000 IU)

4–8 years 900 mcg RAE

(3,000 IU)

900 mcg RAE

(3,000 IU)

9–13 years 1,700 mcg RAE

(5,667 IU)

1,700 mcg RAE

(5,667 IU)

14–18 years 2,800 mcg RAE

(9,333 IU)

2,800 mcg RAE

(9,333 IU)

2,800 mcg RAE

(9,333 IU)

2,800 mcg RAE

(9,333 IU)

19+ years 3,000 mcg RAE

(10,000 IU)

3,000 mcg RAE

(10,000 IU)

3,000 mcg RAE

(10,000 IU)

3,000 mcg RAE

(10,000 IU)

Tolerable Upper Intake Levels (ULs) for Preformed

Vitamin A


Iron• Heme iron: derived from hemoglobin, animal sources (red meats, fish,

poultry, liver) better absorption (10-25%),

• Nonheme iron: plant sources (bean, dark green vegetables, lentils,

soybeans) 3-8% absorption. Iron fortified foods (cereals)

• Absorption:

– Increase: ascorbic-acid

– Decrease: tannins (tea, coffee)

• Physiological functions:

– Oxygen transport (hemoglobin, transferrin, ferritine, hemosiderin)

– myoglobin

– Enzymatic oxidation and reduction

• RDA:

– Males: 8 mg/day,

– Females of childbearing age: 15 mg/day

– Tolerable UL for adults 45mg/day

• Storage site deficient

• Increased need: infancy, childhood, pregnancy, lactation,

blood loss, renal failure.

• Decreased intake or absorption:

– vegetarianism,

– Vitamin C deficiency

– Decreased absorption by foods (tannins, calcium, poliphenols)

– Gastrointestinal diseases (gastric ulcer, antacids, malabsorption,

Crohn’s disease, celiac disease)

• Cancer, chronic inflammation

Iron deficiency

Iron deficiency and overloadSigns of iron deficiency anemia

• feeling tired and weak

• decreased work and school performance

• slow cognitive and social development during childhood

• difficulty maintaining body temperature

• decreased immune function, which increases susceptibility to

infection

• glossitis (an inflamed tongue)

Iron overload

• excess iron is found in the blood and stored in organs (liver,

heart).

• associated with several genetic diseases including

hemochromatosis � absorb iron very efficiently � cirrhosis

of the liver and heart failure

Iodine

• Iodine deficiency is a public health problem in

Europe in isolated and mountainous areas in

Austria, Bulgaria, Croatia, France, Italy, Spain and

Switzerland

• Switzerland was the first European country to

introduce iodized salt (beginning of 19th century)

• 80% of the Hungarian population lives in iodine

deficient regions

• RDA: 150 μg/day (adults)

• Physiological effects

– essential component of the thyroid hormones thyroxine

(T4) and triiodothyronine (T3)

– Regulate metabolism

– Increase thermogenesis

– Increase carbohydrate metabolism and lipolysis

– proper skeletal and central nervous system

development in fetuses and infants

• Sources: seaweed, seafood, dairy products, egg, iodized

salt.

• Strumigenic materials: decrease the iodine content of the thyroid (cabbage, savoy, Brussels sprotus, radish, mustard, some tropical plants)

Iodine

Iodine deficiency• Goiter

• Hypothyreosis– obesity

– decreased mental functions

– fatigue

– depression

– dry skin

– Bradycardia

– impaired mental function and work productivity

– increased risk of the follicular form of thyroid cancer

• Childhood: preventable mental retardation, lower-

than-average intelligence

• During pregnancy: major neurodevelopmental

deficits and growth retardation in the fetus,

miscarriage and stillbirth. Chronic, severe iodine

deficiency in utero causes cretinism (mental

retardation, deaf mutism, motor spasticity, stunted

growth, delayed sexual maturation, and others).

Iodine deficiency disorders

WHO: Iodine deficiency in Europe, 2007

Iodine intake in

Europe, 1994-2006

WHO: Iodine deficiency in Europe, 2007

Health Risks from Excessive Iodine

• Some of the same symptoms as iodine deficiency

– goiter, elevated TSH levels, and hypothyroidism

• excess iodine in susceptible individuals inhibits thyroid

hormone synthesis and increases TSH stimulation, which can

produce goiter.


Birth to 6 months Not possible to

establish*

Not possible to

establish*

7–12 months Not possible to

establish*

Not possible to

establish*

1–3 years 200 mcg 200 mcg



14–18 years 900 mcg 900 mcg 900 mcg 900 mcg

19+ years 1,100 mcg 1,100 mcg 1,100 mcg 1,100 mcg

Tolerable Upper Intake Levels (ULs) for Iodine

Prevention

• Food iodization: salt, oil, bread, water, milk

• Tolerable UI level for adults:

– WHO: 1 mg

– EU: 600 μg

Iodine

European dietary reference values for

nutrient intakes (2010)

• The intake of total carbohydrates - including carbohydrates from starchy foods such as potatoes and pasta, and from simple carbohydrates such as sugars -should range from 45 to 60% of the total energy intake for both adults and children.

• For sugars there is good evidence that frequent consumption of foods high in sugars increases the risk of tooth decay. Data also show links between high intakes of sugars in form of sugar sweetened beverages and weight gain. The Panel however found there was insufficient evidence to set an upper limit for sugars.

• A daily intake of 25 grams of dietary fibre is adequate for normal bowel function in adults. In addition evidence in adults shows there are health benefits associated with higher intakes of dietary fibre (e.g. reduced risk of heart disease, type 2 diabetes and weight maintenance).

• Intakes of fats should range between 20 to 35% of the total energy intake.

• Limiting the intake of saturated and trans fats, with replacement by mono- and poly-unsaturated fatty acids.

• A daily intake of 250 mg of long-chain omega-3 fatty acids.

• For water a daily intake of 2.0 litres is considered adequate for women and 2.5 litres for men.

WHO – Healthy diet – 2014 • A healthy diet helps protect against malnutrition in all its forms, as well as

noncommunicable diseases (NCDs), including obesity, diabetes, heart disease,

stroke and cancer.

• Unhealthy diet and lack of physical activity are leading global risks to health.

• Healthy dietary practices start early in life – breastfeeding may have longer-

term benefits, like reducing the risk of overweight and obesity in childhood and

adolescence.

• Energy intake (calories) should balance energy expenditure. Evidence indicates

that total fat should not exceed 30% of total energy intake to avoid unhealthy

weight gain, with a shift in fat consumption away from saturated fats to

unsaturated fats, and towards the elimination of industrial trans fats.

• Limiting intake of free sugars to less than 10% of total energy is part of a

healthy diet. A further reduction to less than 5% of total energy is suggested for

additional health benefits.

• Keeping salt intake to less than 5 g per day helps prevent hypertension and

reduces the risk of heart disease and stroke in adult population.

http://www.who.int/mediacentre/factsheets/fs394/en/

For adults a healthy diet contains• Fruits, vegetables, legumes (e.g. lentils, beans), nuts and whole grains (e.g.

unprocessed maize, millet, oats, wheat, brown rice);

• At least 400 g (5 portions) of fruit and vegetables a day. Potatoes, sweet

potatoes, cassava and other starchy roots are not classified as fruits or

vegetables;

• Less than 10% of total energy from free sugars equivalent to 50g (or around

12 level teaspoons), but possibly less than 5% of total energy for additional

health benefits. Most free sugars are added to foods by the manufacturer,

cook or consumer, and can also be found in sugars naturally present in honey,

syrups, fruit juices and fruit juice concentrates;

• Less than 30% of total energy from fat. Unsaturated fats (e.g. found in fish,

avocado, nuts, sunflower, canola and olive oils) are preferable to saturated

fats (e.g. found in fatty meat, butter, palm and coconut oil, cream, cheese,

ghee and lard). Industrial trans fats (found in processed food, fast food, snack

food, fried food, frozen pizza, pies, cookies, margarines and spreads) are not

part of a healthy diet;

• Less than 5 g of salt (equivalent to approximately one teaspoon) per day and

use iodized salt.

Infants and young children

• In the first 2 years of a child’s life, optimal nutrition reduces

the risk of dying and of developing NCDs. It also fosters better

development and healthy growth and development overall.

• Advice on a healthy diet for infants and children is similar to

that for adults but these elements are also important.

– Infants should be breastfed exclusively for the first 6

months of life.

– Infants should be continuously breastfed until 2 years and

beyond.

– From 6 months of age, breast milk should be

complemented with a variety of adequate, safe and

nutrient dense complementary foods. Salt and sugars

should not be added to complementary foods.

How to promote healthy diets

• Diet can depend on an individual’s food choices, but also the

availability and affordability of healthy foods, and sociocultural

factors. Therefore, promoting a healthy food environment requires

involvement across multiple sectors and stakeholders, including

government, public and the private sector.

• Governments have a central role in creating a healthy food

environment that enables people to adopt and maintain healthy

dietary practices.

• Effective actions by policy-makers include:

1. Coordinate trade, food and agricultural policies with the protection

and promotion of public health

2. Encourage consumers demand for healthy foods and meals

3. Promote healthy nutrition in infants and young children:

1. Coordinate trade, food and agricultural policies

with the protection and promotion of public health:

• increase incentives for producers and retailers to grow, use and sell fruits and

vegetables;

• reduce incentives for the food industry to use saturated fats and free sugars;

• set and enforce targets to reformulate food products to cut the contents of salt, fats

(i.e. saturated fats and trans fats) and free sugars);

• implement the WHO recommendations on the marketing of foods and non-alcoholic

beverages to children;

• establish standards to promote healthy, safe and affordable food in public institutions;

• encourage private companies to provide healthy food in their workplaces;

• set incentives and rules so consumers have healthy, safe and affordable food choices;

• encourage transnational, national and local food services and catering outlets to

improve the nutritional quality of their food, create real choices, and review portion

size and price;

• consider taxes and subsidies to encourage food manufacturers to produce healthier

food and make healthy products available and affordable.

2. Encourage consumers demand for healthy

foods and meals• promote consumer awareness;

• develop school policies and programmes that encourage children to adopt

a healthy diet;

• educate children, adolescents and adults about nutrition and healthy

dietary practices;

• encourage culinary skills, including in schools;

• allow informed choices through proper food labelling that ensures

accurate, standardized and comprehensible information on food content

in line with the Codex Alimentarius Commission guidelines;

• provide dietary counselling in primary health care.

• implement the International Code of Marketing of Breast-milk Substitutes

• promote and support breastfeeding in health services and the community,

including through the Baby-Friendly Hospital Initiative.

3. Promote healthy nutrition in infants and young children:

• http://www.cdc.gov/nutrition/everyone/fruitsvegeta

bles/howmany.html

• http://www.choosemyplate.gov/supertracker-

tools/daily-food-plans.html

• http://ndb.nal.usda.gov/ndb/search

• http://www.choosemyplate.gov/food-

groups/downloads/Sample_Menus-2000Cals-

DG2010.pdf

www.safefood.eu/

Prebiotics and ProbioticsProbiotics

• live microorganisms (e.g., bacteria) that are either the same as or similar to microorganisms found

naturally in the human body and may be beneficial to health.

• available to consumers in oral products such as dietary supplements and yogurts, as well as other

products such as suppositories and creams.

• Possible mechanisms include altering the intestinal “microecology” (e.g., reducing harmful organisms in

the intestine), producing antimicrobial compounds and stimulating the body’s immune response.

• Lactobacillus and Bifidobacterium

• infectious diarrhea, diarrhea associated with antibiotics, IBS, and inflammatory bowel disease

(ulcerative colitis, Crohn’s disease), preventing tooth decay and for preventing or treating gingivitis and

periodontitis.

Prebiotics

• nondigestible food ingredients that beneficially affect the host by selectively stimulating the growth

and/or activity of one or a limited number of bacteria in the colon, thus improving host health.

• Lactobacilli and bifidobacteria are the usual target genera for prebiotics

• all prebiotics are fiber, not all fiber is prebiotic.

• Resists gastric acidity, hydrolysis by mammalian enzymes, and absorption in the upper GIT;

• fermented by the intestinal microflora;

• Selectively stimulates the growth and/or activity of intestinal bacteria potentially associated with health

and well-being.

• prebiotics are carbohydrate compounds, primarily oligosaccharides; inulin and oligofructose (OF),

lactulose, and resistant starch (RS), FOS,

• galactooligosaccharides (GOS), transgalactooligosaccharides (TOS), polydextrose, wheat dextrin, acacia

gum, psyllium, banana, whole grain wheat, and whole grain corn also have prebiotic effects.

BreastfeedingWHO recommends

• early initiation of breastfeeding with one hour of birth;

• exclusive breastfeeding for the first 6 months of life; and

• the introduction of nutritionally-adequate and safe

complementary (solid) foods at 6 months together with

continued breastfeeding up to two years of age or beyond.In addition:

• breastfeeding should begin within an hour of birth;

• breastfeeding should be "on demand", as often as the child wants day and night; and

• bottles or pacifiers should be avoided.

38% of infants aged 0 to 6 months worldwide are exclusively breastfed.

• Optimal breastfeeding is so critical that it

could save about 800 000 under 5 child

lives every year.

• In countries where stunting is highly

prevalent, promotion of breastfeeding and

appropriate complementary feeding could

prevent about 220 000 deaths among

children under 5 years of age.

http://www.who.int/mediacentre/factsheets/fs342/en/

Benefits of breastfeeding

• protection against gastrointestinal infections

• Breast milk is also an important source of energy and

nutrients in children aged 6 to 23 months. It can provide half

or more of a child’s energy needs between the ages of 6 and

12 months, and one third of energy needs between 12 and 24

months. Breast milk is also a critical source of energy and

nutrients during illness, and reduces mortality among children

who are malnourished.

• less likely to be overweight/obese

• better in intelligence tests

• reduces the risk of ovarian and breast cancer

• Protection against atopic diseases, diabetes, hypertension66

Complementary feeding• Around the age of 6 months, an infant’s need for energy and nutrients starts to

exceed what is provided by breast milk, and complementary foods are

necessary to meet those needs. If complementary foods are not introduced

when a child has reached 6 months, or if they are given inappropriately, an

infant’s growth may falter.

• continue frequent, on-demand breastfeeding until two years of age or beyond;

• practise responsive feeding (e.g. feed infants directly and assist older children.

Feed slowly and patiently, encourage them to eat but do not force them, talk to

the child and maintain eye contact);

• practise good hygiene and proper food handling;

• start at six months with small amounts of food and increase gradually as the

child gets older;

• gradually increase food consistency and variety;

• increase the number of times that the child is fed: 2-3 meals per day for infants

6-8 months of age and 3-4 meals per day for infants 9-23 months of age, with 1-

2 additional snacks as required;

• use fortified complementary foods or vitamin-mineral supplements as needed;67

Breastfeeding and HIV

• The evidence on HIV and infant feeding shows that giving

antiretroviral drugs (ARVs) to HIV-infected mothers can

significantly reduce the risk of transmission through

breastfeeding and also improve her health.

• This enables infants of HIV-infected mothers to be

breastfed with a low risk of transmission (1-2%).

• HIV-infected mothers and their infants living in countries

where diarrhoea, pneumonia and malnutrition are still

common causes of infant and child deaths can therefore

gain the benefits of breastfeeding with minimal risk of

HIV transmission.

Breastfeeding – Contraindications • An infant diagnosed with galactosemia, a rare genetic metabolic

disorder

• The infant whose mother:

– Has been infected with the human immunodeficiency virus (HIV)

– Is taking antiretroviral medications

– Has untreated, active tuberculosis

– Is infected with human T-cell lymphotropic virus type I or type II

– Is using or is dependent upon an illicit drug

– Is taking prescribed cancer chemotherapy agents, such as

antimetabolites that interfere with DNA replication and cell

division

– Is undergoing radiation therapies; however, such nuclear

medicine therapies require only a temporary interruption in

breastfeeding

http://www.cdc.gov/BREASTFEEDING/disease/index.htm

70

DIET RELATED DISEASES

• Chronic diseases

• Food-borne diseases

(intoxication, infection)

• Food allergy and

intolerance

Deficiency diseases

71

Deficiency diseases

malnutrition lack of protective

foods

Mineral Vitamin

deficiency deficiency

diseases diseases

Diseases caused due to the nutritional disorders in the body

72

Considerations involving energy intake

Etiological factors contributing to deaths among children under 5 years of age in

developing countries:

Malnutrition: 53%

Perinatal conditions: 23%

Pneumoia: 20%

Diarrhea: 15%

Malaria: 11%

Measles: 5%

Other: 22%

ENERGY INTAKE < REQUIREMENT

ENERGY IMBALANCE

UNDERNUTRITION

Protein-Energy/Calorie Malnutrition

(PEM /PCM)

ENERGY INTAKE > REQUIREMENT

ENERGY IMBALANCE

OVERNUTRITION

Obesity

73

DEFINITION

Malnutrition is a state that can result from

insufficient or excessive or unbalanced

diet

Secondary malnutrition can occur when

nutrients are adequately consumed in

the diet, but one or more nutrients are

not digested or absorbed properly

74

Nutritional disorders I.

Malnutrition (quantitative undernutrition type)

1. Primary (inadequate food intake)

2. Secondary (consequence of other disease)

� Manifestations range from weight loss or growth failure to distinct malnutrition

syndromes (Protein-Energy Malnutrition – PEM):

• Kwashiorkor (primarily protein deficiency)

• Marasmus ( primarily energy deficiency)

• Combination of the above (marasmic kwashiorkor)� In severe cases virtually all organ systems are affected.

� History includes decreased energy, protein or other nutrient intake, increased

nutrient loss and/or increased energy or nutrient requirement.

� Weight loss not exceeding 5-10% of the original bodyweight is

usually tolerated without significant physiological impairment,

while a weight loss of 35-40% of the original bodyweight usually

results in death.

75

MALNUTRITION

• starvation

• undernutrition

– nutrients are undersupplied,

• inadequate intake; malabsorption; abnormal systemic

loss of nutrients due to diarrhea, hemorrhage, renal

failure, or excessive sweating; infection; or addiction to

drugs.

• overnutrition

– nutrients are oversupplied.

76

FORMS

• Macronutrient deficiency

– Protein-energy malnutrition (PEM)

• Kwashiorkor

• marasmus

– Starvation

– Underweight

• Micronutrient deficiency

– vitamins

– minerals

77

Protein-energy malnutrition (PEM)

- definition

A deficiency syndrome mainly in infants

and children due to

inadequate intake of energy and protein.

•Forms:

• PEM with low weight

• nutritional dwarfism (stunting)

• kwashiorkor

• marasmus

• combined kwashiorkor and marasmus

Kwashiorkor Protein-deficiency > Energy-deficiency

Symptoms

– Oedema of legs and arms

– moon face

– enlarged liver

– pale, thin skin and hair

79

Marasmus Protein +Energy deficiency

Symptoms

• extremly low weight,

• extremly wasting,

• pot belly,

• old person’s face

80

Nutritional disorders II.

Malnutrition (quantitative overnutrition type) - obesity• Excess adipose tissue resulting in a body weight at

least 20% higher than desirable / optimal.

• Body Mass Index (BMI)

• Waist-to-hip ratio: (>1.0 in men; >0.8 in women)

• Upper body obesity (abdominal type) carries greater

health risks than lower body obesity (buttocks and

thighs)

• Visceral fat build-up carries greater health hazards than an

increase in subcutaneous fatty tissue

Eating disorders, body image disorders

• Psychosomatic disorders

• Eating disorders are abnormal eating habits that can threaten

health or even life.

• Etiology: biological, psychological, social, cultural factors.

1. Anorexia nervosa

2. Bulimia nervosa

3. Binge eating disorder

4. Orthorexia nervosa

5. Purging disorder

6. Muscle dysmorphia (reverse anorexia)

7. Exercise addiction

8. Bodybuilder type eating disorder

Eating disorders

• Anorexia nervosa: Individuals believe

they’re fat even when they’re dangerously

thin and restrict their eating to the point of

starvation.

• Bulimia nervosa: Individuals eat

excessive amounts of food, then purge by

making themselves vomit or using

laxatives.

• Binge eating: Individuals have out-of-

control eating patterns, but don’t purge.

Anorexia nervosa

Epidemiology

• 3Ws: white Western women

• Today: gender diferrences �

• Prevalence ~0.7% among adolescent girls

• Prevalence 2% among 18-25 years old females

• Incidence � (better diagnostics)

• Mortality ~8% (after 10 years the disease onset)

Anorexia nervosaDSM-IV diagnostic criteria

• Refusal to maintain body weight at or above a minimally normal weight for

age and height, (for example, weight loss leading to maintenance of body weight less

than 85% of that expected or failure to make expected weight gain during period of

growth, leading to body weight less than 85% of that expected).

• Intense fear of gaining weight or becoming fat, even though underweight.

• Disturbance in the way one's body weight or shape is experienced, undue

influence of body weight or shape on self evaluation, or denial of the

seriousness of the current low body weight.

• In postmenarcheal females, amenorrhea, i.e., the absence of at least 3

consecutive menstrual cycles. A woman having periods only while on hormone

medication (e.g. estrogen) still qualifies as having amenorrhea.

• Type Restricting Type; Binge Eating/Purging Type:

DSM-V: amenorrhea, or the absence of at least three menstrual cycles, will

be deleted. This criterion cannot be applied to males, pre-menarchal

females, females taking oral contraceptives and post-menopausal females.

Bulimia nervosaDSM-IV diagnostic criteria

Epidemiology

• Prevalence 1-2% among 16-35 years old females

• Prevalence �

DSM-IV

• Recurrent episodes of binge eating characterized by both

– Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of

food that is definitely larger than most people would eat during a similar period

of time and under similar circumstances.

– A sense of lack of control over eating during the episode, (such as a feeling that

one cannot stop eating or control what or how much one is eating).

• Recurrent inappropriate compensatory behavior to prevent weight gain, such as

selfinduced vomiting, misuse of laxatives, diuretics, enemas, or other medications,

fasting, or excessive exercise.

• The binge eating and inappropriate compensatory behavior both occur, on average, at

least twice a week for 3 months.

• Self evaluation is unduly influenced by body shape and weight.

• The disturbance does not occur exclusively during episodes of Anorexia Nervosa.

DSM-V: replaced with at least one a week

Binge eating disorder (BED)• Own category as an eating disorder.

• In the DSM-IV, binge-eating disorder was not recognized as its own disorder

but rather was diagnosable under the category Eating Disorder Not Otherwise

Specified (EDNOS).

• “Recurring episodes of eating significantly more food in a short period of time

than most people would eat under similar circumstances, with episodes

accompanied by feelings of lack of control.”

• Someone with BED may eat quickly and uncontrollably, despite hunger signals

or feelings of fullness.

• The person may have feelings of guilt, shame, or disgust and may binge eat

alone (sometimes at night) to hide the behavior.

• To be diagnosed with BED, the behavior will have typically taken place at least

once a week over a period of three months.

• Differences between BED and overeating: “recurrent binge eating is much less

common, far more severe, and is associated with significant physical and

psychological problems.” (APA)

Orthorexia nervosa

• Defined in 1996, indicates an unhealthy obsession with eating healthy food.

• Orthorexia begins as a desire to overcome chronic illness or to improve

general health.

• Over time, what they eat, how much, and the consequences of dietary

indiscretion come to occupy a greater and greater proportion of the

orthorexic’s day.

• The act of eating pure food begins to carry pseudo-spiritual connotations.

• The sufferer spends most of his time planning, purchasing and eating

meals. The orthorexic’s inner life becomes dominated by efforts to resist

temptation, self-condemnation for lapses, self-praise for success at complying

with the self-chosen regime, and feelings of superiority over others less pure

in their dietary habits.

• It is this transference of all life’s value into the act of eating.

http://www.orthorexia.com

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