Nutriceuticals: Nutrition for the New Millennium

Darwin Deen, Jr. MD, MS

Nutrition is a unique field because it is important to everyone. Everyone eats, we are all influenced on a minute by minute basis by the nutrients being delivered to our cells. Unfortunately, optimal nutrition is difficult to define and will only grossly be related in one individual to another. Each of us has slightly different nutrient needs for our individual genetic background.

Evidence Based

Decision Making

The is a lot of nutrition information available to consumers today. Some of it is accurate and important to health. Some of it is based on little scientific evidence and much of that is contradictory. Unfortunately, because our media is driven by “bad” news, many of our patients feel overwhelmed by the volume of information and depressed that there is nothing “safe” to eat anymore.

As health care professionals, our job is to interpret the latest scientific findings in light of their veracity and applicability to our individual patients and to help guide them to the healthiest diet they are able to achieve. Using techniques of evidence-based information gathering is key to this endeavor.

While much of the information we have about nutrition is applicable to most patients, there will always be exceptions. For example, while iron deficiency is common in toddlers and menstruating women, the gene for hemochromatosis is very common. Thus recommending iron supplements for everyone is not a good idea.

Another example: red wine is high in anti-oxidants. It may the reason that the French have a low risk of heart disease in spite of eating more saturated fats than they should (from cheeses and cream sauces). But if you have gout (with elevated uric acid levels), you should avoid it (and organ meats which are unusually good sources of nutrients).

Foods that contribute to your

health

Fruits and Vegetables

Data from nationwide surveys indicate that 80% of Americans aren’t getting 5 servings of fruits & vegetables per day. The National Cancer Institute has determined that

“5-a-day” will reduce the risk of certain cancers.

For more information see http://5aday.nci.nih.gov/

Broccoli

This green vegetable is a member of the cruciferous family. Members of this family have been shown to contain glucoseinolates (isothiocyanates, indoles). These sulfur containing organic compounds inhibit certain of the hepatic enzyme system (P450s) that can activate carcinogens in the body.

Other Crucifers

Broccoli-rabe Cauliflower Cabbage Brussel sprouts Kale Turnips

Citrus Fruits

Citrus fruits contain a variety of active compounds and many health effects.

Current research is aimed at elucidating those factors present in foods that are responsible for biologic effects.

Flavones and flavanones are cancer preventives found in citrus fruits. So far these compounds have only been evaluated in vitro.

Citrus Fruits

Bioflavonoids which help maintain the integrity of the vascular endothelium (and maintain capillaries).

Limonene induces glutathione transferase a part of the body’s detoxifying system.

Grapefruit juice has been shown to alter the pharmacokinetics of drugs metabolized in the liver.

Soy

Soybeans contain isoflavones which may have anti-cancer properties. They are weak estrogens (called phyto-estrogens) and may exert their biological effects by blocking estrogen binding sites on hormone sensitive tissues. Patients with PMS, menopause, and polycystic breast disease should consider making tofu a regular part of their diet. Interesting studies in animals have investigated the role of genistein (a soy isoflavone) in angiogenesis and endothelial cell function.

Soy

Breast tissue development is also being studied in rodent models and indicate that proliferation of mammary tissue end buds (susceptible to the most common form of breast cancer) are influenced by early exposure to soy protein. If borne out, we may want to give at least some soy formula to our daughters when they are infants to protect them from breast cancer later in life.

Garlic

Epidemiologic studies comparing patients with colon cancer to those who have not developed it indicate a protective role for garlic in cancer prevention. In China, where gastric cancer is more common, garlic consumption has been associated with reduced risk. This protection may be related to reductions in nitrite formation.

Garlic

Garlic contains a number of sulfur containing compounds with biologic activity at various stages of the tumorigenesis process and has been shown to have anticeptic properties as well (used effectively against TB memingitis in China). It is mildly active in lowering serum cholesterol levels and reducing clotting.

Nutrients that contribute to your

health

Fish Oil Oils from cold water fish contain two very

important long chain polyunsaturated fatty acids: EPA eicosapentaenoic acid & DHA docosahexanoic acid

People who consume at least 3 oz of fish per week have been shown to have a lower risk of heart disease. Higher doses of fish oil supplements are effective at reducing high serum triglyceride levels.

Fish oil reduces platelet agregation.

Fish Oil

Fish is healthy and should be consumed as part of your regular diet.

One serving per week is adequate. Examples: salmon, tuna, sardines, orange

roughy, & cod. If you do not like fish, you may get some of

the same benefits from a fish oil supplement.

Another very productive area of inquiry in recent years has been the relationship between long chain fatty acid consumption and prostaglandin formation. PGs are derived from fatty acids and serve as messengers between our cells. They determine platlet agregability and smooth muscle tone. They mediate pain and inflammation (e.g. ASA is a PG inhibitor).

We now know that the ratio of N6 to N3 fatty acids one consumes determines the ratio of inflammatory to anti-inflammatory PGs one produces. A practical application of this is the heart-healthy eggs being produced by feeding fish meal and leafy vegetables in addition to grains to hens (look for these eggs in the supermarket).

Fibers: Soluble and Insoluble

Soluble fiber reduces the rate at which carbohydrates are absorbed. Slow absorption is very important for diabetics and not a bad idea for everyone else.

Insoluble fiber intake has been related to colon cancer risk, hemmeroids, diverticulosis, and varicose veins.

Sources of Soluble Fibers Apples Pears Carrots Oats Soluble fibers include pectin, guar and other

gums, mucilages (think Okra) and some hemicelluloses. In addition to slowing absorption rates, soluble fibers bind bile acids and thus create the only mechanism by which cholesterol can be excreted by the body.

Sources of Insoluble Fibers Wheat Bran Dark Green Leafy Vegetables Raspberries, Blackberries Insoluble fibers are cellulose, hemicellulose, and

lignins: they increase stool bulk and decrease transit time. They prevent constipation and may reduce the risk of colon cancer by decreasing the amount of time that secondary bile acids spend in contact with the colonic mucosa. They also change the microflora of the gut reducing the production of secondary bile acids.

Supplements that contribute to your health

Psyllium Most popular fiber supplement (Metamucil). Derived from the husk of psyllium seeds. Absorbs water in the colon leading to bulkier

stools. Lowers LDL cholesterol levels by binding bile

acids & reducing cholesterol absorption. Helps control blood sugar in diabetics by slowing

the rate of carbohydrate absorption. May contribute to weight loss efforts by

increasing satiety (without contributing calories).

Anti-oxidants

Many compounds have anti-oxidant properties. The nutrients known to be important antioxidants are: Vitamin C, Vitamin E, Selenium, glutathione, Beta and other carotenes (lycopene).

Beta carotene and Vit e were tried in a clinical trial of Finnish smokers that showed an 18% increase in lung cancers in those on betacarotene alone (but not in those on both) and an 8% increase in total mortality.

Anti-oxidants

In China (where the baseline diet was not as good and there was less alcohol intake) a combination of beta carotene, selenium, and Vit E caused a significant reduction in cancer mortality (13%) (especially stomach cancer) and also a reduction in cerebrovascular mortality(10%).

Anti-oxidants are being studied in a variety of condition: macular degeneration, breast, colon and esophageal cancers, childhood leukemias, coronary heart disease, colconic polyps, degenerative & smoking-related diseases.

Beta Carotene

Beta carotene is a good example of the need for rigorous clinical trials.

Many epidemiologic studies and data from numerous lines of animal and in-vitro investigation support an important role for beta carotene in the prevention of cancer and heart disease. When tested in humans, however these expected results do not appear. The Chinese, with a poor baseline diet appear to benefit. Finns, who smoked and drank more than average Americans actually did worse with supplements. The Physician’s Health (in the US) study showed no increased risk but also no benefit.

Epidemiologic studies evaluate dietary intake not supplements. When individual nutrients are separated from their natural sources, we are judging the impact of pharmacologic agents which happen to come from food, rather than dietary benefits. A randomized control trial of diet change is very difficult to design (and double blind is impossible).

Vitamin C Vit C controversy: some get fewer colds but some

may get oxalate kidney stones Risks have probably been exaggerated but

benefits are unproven. While Vit C is an effective anti-oxidant, it can

also be a powerful oxidant. Too much may therefore be harmful. We encourage mothers to provide vit C sources to children with their iron supplements if they are anemic because of vit C’s well known ability to increase iron absortion.

We also know that excess iron is an oxidant stress for adults (males in particular) and that hemochromatosis is common in our gene pool. thus for many in this society (where we are well nourished) iron overload may be a potential problem and something you should consider before adding supplements of vitamin C.

As with betas carotene not all studies have been positive but unlike beta carotene, no harmful effects of Vitamin E have been shown. As beta carotene is but one of many natural occurring carotenoids, so Vit E (usually alpha tocopherol) is but one of many biologically active tocopherols. Synthetic Vit E is usually a racemic mixture of d&l alpha tocopherol. Look for supplements that contain mixed natural tocopherols.

Vitamin E

Long touted in the alternative nutrition literature as an anti-anginal agent, Vit E is currently being put to the test. Clinical trials have been moderately supportive of the notion that Vit E plays a role in claudication (leg pains) and CVD. No adverse effects appear from 400-800 IU per day. Those with high blood pressure should be aware that these high doses have been associated with elevations of BP.

Vit E supplements have been shown to improve glucose tolerance in diabetics.

Selenium

Selenium is a trace element that has antioxidant properties in biological systems.

Food sources include Brazil nuts, garlic, grains, and liver. Including dietary sources of selenium is important to a healthy diet.

Supplements are another story.

Selenium

Minerals may have a narrow therapeutic window (the difference between beneficial and toxic doses).

Those taking supplement should be cautious as toxicity may lead to loss of hair & nails.

Flavonoids

Flavonoids can lower cholesterol levels, prevent blood clots, and reduce cancer risk.

Food sources include apples, avocadoes, black & green tea, chocolate, corn, grapes, red wine, string beans, strawberries.

No known toxicity.

Isoflavones

Reduce the risk of heart disease and osteoporosis, reduce menopausal symptoms, may prevent some cancers.

Food sources include tofu, soy nuts, and soy cheese.

No known toxicity.

Isothiocyanates

Have been hypothesized to be an active ingredient in reduce cancer risk.

Foods include broccoli, bok choy, cabbage, and mustard seed.

Carotenoids

The family of compounds that beta carotene belongs to.

Biologically function to as antioxidants and in visual pigments: maintain night vision, may reduce risk of heart disease & some cancers.

Foods: carrots, sweet potatoes, tomatoes, watermelon, peppers (green, red, yellow).

Allum/Allicen

Lowers cholesterol levels and blood pressure, may prevent some cancers.

Food sources include garlic, onions, scallions, shallots.

Monoterpenes

May prevent some cancers and protect the heart from CVD.

Food sources include citrus fruits, vegetable oils, mint, and spearmint.

Dietary Changes for Specific Problems

Heart Disease

People who eat at least 5 servings of fruits & vegetables a day have a 31% lower risk of stroke than those who eat fewer than 3 servings.

People who drink 1-2 cups of green or black tea a day are 46% less likely to develop CHD, if they drink 4 cups, their risk drops 70%.

Women who eat 2-3 servings daily of whole grain foods (whole wheat bread, oatmeal, popcorn) reduce their risk of heart disease by 30%.

Those who eat at least 5 oz of nuts have 1/3 fewer heart attacks.

Men who eat at least 5 apples a week have stronger lung function than those who don’t.

To improve cardiovascular health, follow a Mediterranean style diet. Eat more cold water fish, add onions, garlic, and scallions to your diet. Drink tea (green and black). Eat whole grains whenever possible and add new grains to your diet (quinoa, bulgur, cous cous, etc.). Eat lots of green vegetables and fruit.Change to low fat dairy products. Reduce your intake of fatty red meats.

Diabetes

Eat beans for soluble fiberLima, chick peas, pinto beans, black beans, navy beans, soybeans

Prostate Cancer

Risk of prostate cancer is lower in those on low fat diets.

Tomatoes and green tea contain antioxidants that may prevent the development of prostate cancer.

Alternative vs.

ComplementaryMedicines

Alternative Healing Paradigms

Traditional Chinese Medicine Homeopathy Acupuncture Ayurvedic Medicine Crystal Therapy Aroma Therapy Chiropractic

Complementary Healing

Herbal Medicine Chiropractic Acupuncture Meditation Visualization Hypnosis Massage Therapy

Useful Herbs

St. John’s Wort Ginko Biloba Saw Palmetto Milk Thistle Echinacea Peppermint Licorice

Folk Remedies

Raspberry Motherwort Camomile Oat Straw Hops Slippery Elm Tea Tree Oil

Unlikely Claims

Pau d’Arco Gotu Kola Goldenseal Comfrey

Conclusions: So what should you eat: As little as possible: studies in all types of animal

models indicate that longevity is related to limited calories. No one knows why? It may be related to wear and tear on the immune system (from exposure to food antigens.

Eat a diet consisting of low fat, high fiber, including fresh food, most of it in its natural state.

As much variety as possible. Include fruits, vegetables, and whole grains.

Conclusions:

Balance energy intake with energy expenditure: you don’t have to exercise if you don’t ever eat.

Recognize the difficulty in maintaining resolve for behavior change.

Strive to do as well as you can, not to be “perfect.”

Supplements:

I tell my patients that I will help them to think about what supplements to take but that they are really an “n-of-1” experiment.

We do not have enough data on the role of isolated nutrients to be sure of what individual supplements are doing.

As Hippocrates said: “Let food be your medicine!”