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NUTRITIONAL ASSESSMENT

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					UNIT NAME: CLINICAL DIAGNOSIS AND MANAGEMENT 7
UNIT CODE HHD 5187
YEAR: 2007(1)

Subject: Nutrition and Diet 1
Lecturer: Dr Catherine Sicurella
Phone: 93864009
Email: c_sicurella@hotmail.com

Week       Week of       LECTURE TOPIC Content                               Readings; Activities    Additional information

                         Nutritional Assessment                              Background              Lecture notes to be purchased.
1          2nd Mar       (Australian dietary guidelines discussed)           knowledge quiz          Assignment 1 distributed

                         Digestion & Absorption                                                      Tutorial: Nutritional assessment
2          9th Mar       Gastrointestinal Nutrition                                                  skills applied. Dietary variety
                         Drug/Nutrient interactions                                                  discussed.
                         Energy                                                                      Tutorial: Gastro nutrition case study
3          16th Mar      Clinical focus: Obesity                                                     Herbs in nutrition.

                         Fats                                                                        Tutorial: Obesity case study
4          23rd Mar      Clinical focus: Arthritis & omega 3s                                        Label reading. Dieting aids.


                         Cardiovascular disease & dietary                    Is your saturated fat   Tutorial: Healthy eating case study
5                        recommendations.                                    intake in line with     NHF resources & pick the tick
           30th Mar                                                          NHF guidelines?
                                                                             Assignment 1 due


6          6th April
           Good Friday
           no class
                         Carbohydrates                                                               Tutorial: CVD case study
7          27th April    Clinical focus: fibre & health, Diabetes                                    Lower your cholesterol with
                         Mellitus                                                                    lifestyle changes

                                                                                                     GI and probiotics
                         Protein                                                                     Tutorial: Diabetes case study.
8          4th May       Clinical focus: vegetarianism; high protein diets                           Prevention of diabetes by lifestyle
                                                                                                     discussed.

                         Fat soluble vitamins                                Does vitamin C          Tutorial: vegetarian case study
9          11th May      Clinical focus: vitamin deficiency diseases         prevent colds?          “Health foods” & organic foods


                         Water soluble vitamins                                                      Tutorial::vitamin deficiency case
10         18th May      Clinical focus: vitamin deficiency diseases                                 study. New research into vitamins.



                         Minerals: (Na, K, Ca, P)                                                    Tutorial: vitamin deficiency case
11         25th May      Clinical focus: hypertension, osteoporosis                                  study. Foods that fight disease.


                         Minerals: (Fe, Selenium, Zn, Iodine, Mg)                                    Tutorial: osteoporosis case study
12         1st Jume      Clinical focus: anaemia                                                     Eating for exams.




                                                                                                              1
                                 Week 1: NUTRITIONAL ASSESSMENT

          Nutritional status = amount physiological needs for nutrients are being met. It is
          influenced by many factors that may change as we age:

          Eating behaviour
                                                                              Growth
                                                                                           Maintenance
                       Emotions
Disease                                      Poverty


                   Food Intake
                                                   Infection/disease/stress


  Absorption


               Nutrient intake                                            Nutrient requirements




                                            Optimal Nutrition


                                      Development of Malnutrition
                                                                                       Nutrition Screen,
  Well                           Inadequate dietary intake                             Diet History
  nourished                      Impaired absorption
                                 Increased nutrient loss




                                 Depletion of tissue levels and body stores             Biochemical
    At risk                                                                             changes


                                 Altered physiological function


                             Deterioration in capacity of cells to function normally


                                                                                       Clinical signs and
  Malnourished               Clinical Symptoms                                         symptoms



                                 Morbidity/ Mortality



                                                                                                2
Diagnosing risk of malnutrition
A. Nutritional screening
Used to discover if a client is at risk of a nutrient imbalance.
Typical questions:
“ Are you following a special diet?” “Do you drink about 8 glasses of fluid/day?” ;
“Have you lost or gained any weight recently?”; “Have you had a recent change in
appetite?”; “Are you taking supplements?”; “What foods are you allergic to?”

      Using either informal or validated screen, decision is made whether patient at
       risk of not having an optimal nutritional status.
      Next step is a nutritional assessment to determine what nutritional intervention
       is appropriate.

Recap:
    Optimal nutritional status is our aim for each client
    This is achieved by balancing nutrient intake with nutrient requirement. When
       this doesn‟t happen eventually malnutrition will occur.
    The first stage of malnutrition is poor diet, then abnormal biochemistry, then
       clinical symptoms
    Nutritional screening should detect clients at risk of sub optimal nutrition
    Nutritional assessment determines what nutritional intervention is appropriate

B. Nutritional Assessment
Measures several parameters & compares each with a standard.

1.Anthropometry
       Collect height, current weight, weight history.
Calculate Body Mass Index (weight in kg/ [height in m]2 ) and compare with
Australian standards:

Body Mass Index Standards
<16         severe thinness
<17         moderate thinness
17-18.5     mild thinness
18.5-25     normal weight range (this becomes 23-28 for elderly)
25-29.9     overweight
30-39.9     obese
>40         morbid obesity

These BMI measures are not suitable for Aboriginal and Torres Strait Islander
peoples, whose healthy BMI range may be lower than that for Australians of
European descent. This is due to their ancestry as traditional hunter-gatherers who
were lean and physically fit.

Similarly, for Asian people cut-off points for health risks appear to be lower than for
other Australians.

Weight history: Unintentional weight change of +/-5kg or more over 6 months is
significant and should be investigated.


                                                                                          3
2. Biochemistry:
     Blood plasma, serum & urine often sampled for nutrient concentrations but
       generally reflect recent intake, not longer term nutritional status.
     Tissues indicate nutrient storage status but cannot be sampled routinely
     Interpretation can be confounded by: presence of disease; failure in sampling;
       incorrect test choice; other factors (recent transfusion, altered fluid balance,
       recent vitamin/mineral supplement etc)

EG Low Albumin = Poor protein intake/malnutrition OR impaired digestion/liver
disease/overhydration/oedema/chronic disease
High albumin = dehydration

Urea & Electrolytes:
    Low Sodium = 90% of time due to diuretic
    High Sodium = almost always due to dehydration
    Low Potassium = almost always due to increased K loss (vomiting, diarrhoea,
       diuretics)
    High Potassium = almost always due to decreased K loss (eg acute renal
       failure )
Urea & creatinine = elevated in renal failure (normal creatinine levels rise as we age
because our kidney function decreases during ageing).

3. Clinical signs & symptoms of malnutrition

Potential risk factors for poor nutrition: anorexia, difficulties chewing & swallowing,
nausea, vomiting, constipation

Examples of clinical signs of malnutrition:
Overnutrition                                                   Ascorbic Acid
Excess body weight             Thiamin deficiency               deficiency
Excess fat under skin          Confusion                        Spongy bleeding gums
                               Muscle weakness                  Bleeding under skin
Protein Energy                 Muscle tenderness                Enlarged end of bones
malnutrition                   Sensory loss
Hair & skin changes            Loss of reflexes                 Iron deficiency
Loss of fat & muscle           Enlarged heart                   Pale eye membranes
Enlarged liver                                                  Bleeding under skin
Apathy                                                          Spoon shaped nails
Oedema                         Vitamin A deficiency
                               Dry eye membranes
                               Dull soft cornea
                               Rough skin




                                                                                          4
4. Diet history.
Establish WHAT and HOW MUCH the patient usually eats. Ask about what eaten in
past 24 hours, then go through a checklist of common foods and ask how often these
are eaten. Note: we all under report!
Standards for comparison:
     The quantitative standard is the recommended dietary intakes (RDIs) set for
        each nutrient.
     The qualitative standard is Australian dietary guidelines

                       Recommended Dietary Intakes (RDIs)
“RDIs are the levels of intakes of essential nutrients, considered in the judgement of
the NH & MRC, on the basis of available scientific knowledge, to be adequate to
meet the known nutritional needs of practically all healthy persons”




RDIs include a large safety margin to account for individual variations in absorption
& metabolism (should cover 97.5%).

RDIs most useful at a population level. Recent national diet surveys showed the
average Australian:

      Consumes above the RDI for protein, total & saturated fat, refined
       carbohydrates, sodium
      Consumes below the RDI for fibre, zinc, magnesium, folate, iron (women
       only), calcium (women only)

This is a reflection of low intakes of fruit, vegetables, legumes, nuts and fish, and a
high intake of animal products.

RDIs were replaced by “Nutrient Reference Values” in May 2006

EAR (Estimated average requirement): the daily nutrient intake level estimated to
meet the requirement of half the healthy individuals in a life stage / gender group.
This is used to plan diets for GROUPS not individuals.




                                                                                          5
RDI (Recommended Dietary Intake): The average daily intake that is sufficient to
meet the nutrient requirements of nearly all (97-98%) healthy individuals in a life
stage/gender group. These are calculated using the EAR plus 2 standard deviations.

AI (adequate intake): used instead of an RDI when the RDI cannot be determined.

UIL (upper intake limit): highest intake of a nutrient on a daily basis likely to pose
no adverse health outcome to almost all individuals.

Suggested Dietary Targets (SDTs) for disease prevention: These are a new set of
nutrient intake recommendations. They are set higher that the RDI and aim to help
prevent chronic diseases such as heart disease or some cancers. They correspond to
what high consumers of a given nutrient already eat. For example, vitamin C‟s RDI is
45mg, but the SDT is 220mg for men, 190mg for women. They apply to healthy
adults only, not children.

Major changes to RDIs in the 2006 review:

       RDI for folate has doubled to 400micrograms for women and men of all age
    groups
       RDI for calcium has increased both men and women to 1000 –1300mg which
    means 4-5 serves of dairy a day.
       The iron range for women is broader at 8-18mg compared to 12-16mg
    previously. The RDI for men has increased by 1mg, to 8mg.
       The zinc RDI for men has increased by 2mg, from 12mg to 14mg. The zinc
    RDI for women has decreased from 12mg to 8mg.
       Sodium’s range of intake has been reduced. The upper limit is now 920mg,
    down from 2300mg. (Average sodium intake is over 4000mg!)

RDIs would be used on individuals as a quantitative standard when doing a
computer dietary analysis.

Example of a practical application of RDIs:

For weight maintenance:

Female = 7000-9000 kJ per day
Male = 10 000-13 000 kJ per day

Protein                                       Women = 45g/day
                                              Men = 55g/day
Carb                                          45-60% of total energy (230-310g per
                                              day)
Fat                                           30% of total energy (70g per day)
Saturated fat                                 Less than 10% of total energy (<23g per
                                              day)
Fibre                                         25-30g
Iron                                          12-16mg if female under 54, 7mg for
                                              over 54 females & men
Calcium                                       800mg women under 54, 1000mg women


                                                                                         6
                                              over 54 & men



The qualitative standard we use when examining diet is the Australian dietary
guidelines.

To help educate the public on how to make healthy food choices these guidelines
were first prepared by the NH & MRC in 1992. They summarise current knowledge
regarding diet & disease in Australian adults and the nutrients in our food supply.
They provide a means of comparing a patient‟s diet to the recommended dietary
guidelines.

           The NHMRC Dietary Guidelines for Australian Adults 2003

Enjoy a wide variety of nutritious foods:
    Eat plenty of vegetables, legumes and fruits
    Eat plenty of cereals (including breads, rice, pasta, noodles), preferably
      wholegrain
    Include lean meat, fish, poultry and/or alternatives such as legumes and nuts
    Include milks, yoghurts, cheese and/or alternatives
    Drink plenty of water

And take care to:
   Limit saturated fat and moderate total fat intake
   Choose foods low in salt
   Limit your alcohol intake if you choose to drink
   Consume only moderate amounts of sugars and foods containing added sugars

Prevent weight gain: be physically active and eat according to your energy needs
Care for your food: prepare and store it safely
Encourage and support breast feeding

(A 2004 Melbourne study found that of 10,500 women surveyed, only 2 met all these
guidelines!)



5. Physical activity Need to know to estimate energy requirements. Bed rest =
1.2xBMR light activity = 1.3xBMR moderate activity=1.4xBMR heavy
activity=1.75xBMR

6. Social situation: to evaluate social barriers to good nutrition

7. Medications: to evaluate drug/nutrient interactions




                                                                                      7
To summarise:
    Nutritional screen alerts you to patients at risk of suboptimal nutritional status
    Nutritional assessments then done on these patients to define what dietary
      intervention is appropriate
    Nutritional assessments involve collating information on anthropometry,
      biochemistry, clinical data, diet data, social details, physical activity &
      medications.
    This information is compared with standards to determine what goals should
      be set to attain the patient‟s optimal nutritional status.

Setting Nutritional Management Goals
     Goals should be clear, realistic, achievable and negotiated with patient
     Should have a measurable outcome (eg to reduce bodyweight by 5kg over 12
       months)
     Interventions are how the patient will achieve the nutritional mx goals
     Interventions should reflect patient tastes, culture & lifestyle (eg increase fruit
       & veg in your diet, change to fat reduced products, increase your fish intake
       to 2 meals/week).To help negotiate goals with clients or explain interventions,
       there are many educational tools – see below.




                                                                                        8
Australian Guide to Healthy Eating
Developed 1998 by the Commonwealth Department of Health & Ageing to help
Australians develop the “skills and knowledge necessary to choose a healthy diet”.




                      12345+ Food & Nutrition Plan




                                                                                     9
    12345+ Food & Nutrition Plan
     Developed by CSIRO in 1991
     It uses the old pyramid model for a healthy diet
     1 serve should come from meat & meat alternatives, 2 serves from milk &
        milk products, 3 serves from fruit, 4 serves from vegetables and at least 5
        serves from breads and cereals




Food variety
    We are moving from a “nutrient” based approach, towards a “food” based
      approach. Food contains about 12000 components beyond nutrients.
    These phytochemicals appear to play a role in protecting the body from CVD,
      cancer, promote longevity. Therefore it makes sense to have as much variety
      as possible.
    Some overseas dietary guidelines are already using this approach eg Japanese
      guidelines suggest eating 30 or more different foods each day.

Summary of Australian & International dietary guidelines
(Wahlqvist 2002)

    1. Include at least 2 varied fish meals/week
    2. Include several varied lean red meat meals/week; vegetarians need legumes or
       nuts daily with wholegrain cereals to ensure adequate iron and zinc
    3. Include lean poultry or pork about once a week
    4. Include at least 1-2 varied legume meals/week


                                                                                      10
   5. Include a handful of nuts several times/week, preferably in vegetable dishes
   6. Include eggs & egg dishes weekly
   7. Include several portions of reduced fat/high calcium milk and milk products or
       calcium fortified soy milk/tofu daily
   8. Try to have several cups of a variety of vegetables daily, especially onion,
       garlic and herbs
   9. Try to have 2 pieces of fruit/day
   10. Try to have mainly wholegrain, reduced salt cereals (about 5 serves/day)
   11. Choose lean meat and reduced fat dairy products
   12. Prefer unrefined natural fat in nuts, seeds, soy, olives, avocado as the fat is
       accompanied by other phytochemicals
   13. Prefer cold pressed monounsaturated oils for cooking
   14. Increase water and tea intake, avoid soft drinks and limit juices to 1/day,
       alcohol to 2 standard drinks/day
   15. Limit indulgences to 2/day

                                     TUTORIAL

Practice Exam Question

Fiona is a 30-year-old administrative assistant being treated for wrist pain. Fiona‟s
weight is 60kg (slowly increased from 52kg over past 10 years), height is 155cm. No
recent biochemistry/pathology results available. She reports a good appetite, mild
chronic constipation. Lives alone and has a sedentary lifestyle. Her usual diet consists
of 4 slices white toast with butter and jam for breakfast, a packet soup or ham
sandwich for lunch, chocolate biscuits and coffee during the afternoon and for dinner
she has takeaway noodles, pizza or just toasted cheese sandwiches if she has worked
late. Drinks water, cordial or tea (with milk and sugar). Fiona is considering taking a
multivitamin as “insurance.”

   1. Do a nutritional assessment. (6 marks)
   2. Using this assessment, suggest 3 nutritional goals. (3 marks)
   3. Should Fiona be taking a multivitamin as a form of “insurance”? (3 marks)
   4. What are 3 interventions to assist with Fiona‟s constipation? (3 marks)


   When are supplements needed?
Special Needs Group                          Supplement
Before Conception                            Folic Acid (500ug)
During Pregnancy                             Iron, folic acid, calcium, omega 3 fats
Breastfeeding                                Calcium, omega 3s, water
Vegans                                       B12, Iron, zinc, calcium, omega 3s
Alcoholics                                   B groups vitamins, especially thiamin and
                                             folic acid
Elderly                                      Calcium, vitamin D. B12 may be poorly
                                             absorbed.
During illness or surgery                    Protein, vitamin C




                                                                                      11
                            Dietary analysis ( worth 40%)
                 h
DUE DATE: 18 March 2008
The aims of this project are
    To gain a better understanding of the nutrient content of food
    To learn how to follow the recommended nutrient intake for Australians
    To appreciate the difficulties associated with dietary change
Method
           1. Keep a food diary for 3 days, recording everything that you ate and
               drank. Don‟t forget to include the quantity eaten, as well as the item.
           2. Download Foodworks from www.xyris.com.au onto your computer
               (go to “downloads” on the top menu bar of the home page, choose
               “foodworks professional 2007” & follow the instructions – requires
               12MB of free space.)
           3. Create a new food record in Foodworks. Enter your age, sex, weight,
               height, activity status (open “help” menu, choose “terms and
               definitions” in content, then choose “physical activity levels
               explained”). Record your BMI and estimated energy expenditure. Then
               enter day 1‟s intake (under “Foods”). Repeat this with a new day‟s
               intake on the same food record.
               Set the right hand “analysis” column to “AvgDay” ; with “All
               components” listed below that and comment on:
               – how close your average kJ intake over 3 days was to your average
               “estimated energy expenditure” . If there is a large discrepancy, is this
               supported by recent weight loss or gain? Or were there inaccuracies in
               the food diary or in estimating energy expenditure?
               - which nutrients, if any, were on average consumed below the RDI
               (use “NRV - all” option on RHS of page). Remember to allow for any
               dietary supplements you take regularly.
               - the % energy derived from carbohydrate, fats and protein and the
               proportions of saturated, monounsaturated and polyunsaturated fats
               eaten. If possible, comment on the glycemic index of your diet.
               Note: if you want to look at a single day individually, right mouse
               button click on that day‟s foods, choose “select” then choose “day”.
               This information can help you write up your results or plan a new
               menu.
           4. Use “Foodworks” to help you plan a daily menu for yourself that
               follows the recommended composition of 50-60% carbohydrate, <30%
               fat (including <10% saturated fat & <10% polyunsaturated fat), 10-
               20% protein, at least 30g fibre & meets all RDIs. (To get the fat ratio
               correct, first adjust your diet so total fat is under 30%, then alter the
               polyunsaturated/monounsaturated/saturated fat ratios to be 25-33%
               polyunsaturated/33-50% monounsaturated/ 25-33% saturated.) Note
               you can click on individual nutrients displayed in the right hand side
               (eg “saturated fat”) to see which food items are responsible for the
               greatest or least amounts of this nutrient in your diet.
           5. Submit this menu as the second part of your results.
           6. Follow this 1 day diet plan.
Discuss the differences between your usual diet and the “ideal” diet you have planned.
Discuss any difficulties you encountered when changing your diet. What advice
would you give patients to assist them in making changes to their diet?


                                                                                     12
   Week 2: DRUG-NUTRIENT INTERACTIONS & GASTROINTESTINAL
                          NUTRITION

                            Drug-Nutrient Interactions
      Short term: Acute toxic reactions may occur b/t food & drugs
      Long term: Changes in appetite, nutrient absorption, metabolism & nutrient
       excretion.

High risk patient groups for interactions
1.Elderly: Drug-nutrient interactions occur most commonly during long term
treatment of chronic disease, so elderly most vulnerable group. They tend to take
more drugs, absorb nutrients less well, and more likely to have a poor diet.

2. Developing fetus, infants & pregnant women have elevated nutrient requirements
so at greater risk.

3. Malnourished patients are vulnerable to drug-nutrient interactions as protein losses
and changes in body composition alter protein binding and the volume of distribution.

4. Specific nutrient deficiencies can alter the mixed function oxidase system and
hence drug transformation. EG iron deficiency increases activity, magnesium
deficiency decreases activity.

5. High % body fat: obese & elderly have increased distribution of fat soluble drugs as
greater proportion of adipose tissue.

Drugs that affect appetite
    Decrease appetite: most drugs of abuse (amphetamines, cocaine, methadone),
      Ritalin (may see “catch up growth” when discontinue), cytotoxic agents,
      metformin
    Increase appetite/cause weight gain: see handout

Drugs that affect absorption
    Laxatives – can cause steatorrhea & faster transit so losses of calcium &
      potassium
    Aspirin – chronic use damages mucosa & affects iron & calcium absorption
    Antacids – raised stomach pH means decreased absorption of calcium, iron,
      magnesium, zinc.
    Colchicine (anti inflam. treats gout) impairs B12 absorption
    Neomycin – alters gut mucosa so malabsorption of fat, protein, Na, K, Ca.

Antivitamins
    Folic acid antagonist: Methotrexate – used in cancer treatment & RA. Folic
       acid is displaced from dihydrofolate reductase by methotrexate, so instead
       excreted. DNA synthesis inhibited so rapidly dividing cells die



                                                                                     13
      Vitamin B6 antagonists – penicillamine, Ldopa
      Vitamin K antagonists – warfarin

Monoamine Oxidase Inhibitors
2 classes of biologically active amine – psychoactive amines (neurotransmitters eg
noradrenalin & dopamine) and vasoactive amines (pressor amines eg tyramine,
serotonin, histamine). This second class present in some foods but usually deactivated
by monoamine and diamine oxidases. However if on monoamine oxidase inhibitors
(some antidepressants) must avoid foods containing these vasoactive amines (mainly
tyramine). They could cause restriction of blood vessels & elevated BP (cheese,
smoked fish, wine, beer, preserved meat, broad beans, meat/yeast extracts).

Common drugs
Phenytoin (anti convulsant) - chronic treatment causes folate depletion hence
megaloblastic anemia

OCP – Originally thought that women on pill needed more vitamin B6 but not
generally the case. Some women do have lower serum & rbc levels of folate but
supplementation is not justified. Women coming off the pill with the intention of
getting pregnant should however be very conscious of taking adequate folate
supplements.

Glucocorticoids: long term can cause osteoporosis in 50% of patients as calcium
absorption is reduced and calcium excretion is increased. Also decreased glucose
tolerance.
Should take lowest possible dose, adequate calcium, vitamin D, physical activity &
restrict sodium.

Antihypertensives – if on diuretics at risk of K and Mg depletion & calcium & zinc. If
on B- blocker then increased TG and decreased HDL may be seen & glucose
tolerance decreased.

Effect of food on drug absorption & metabolism

Presence of food can reduce therapeutic dose by slowing so reducing absorption.
Stomach & intestinal pH, rate of gastric emptying can influence drug absorption.

Most drugs are absorbed by passive diffusion across the GIT epithelium into the
bloodstream so pH is critical as ionization status of drug must be correct to allow
diffusion to occur. Thus hypochlorhydria in the elderly significant.

High protein diets can accelerate drug metabolism by increasing MFOS activity.




                                                                                      14
Food or Beverage             Drug                          Effect
Caffeine-containing drinks   Theophylline                  Increased intake may
                                                           enhance drug side effects
                                                           (nervousness, insomnia)
Grapefruit juice             Drugs known to be             Excess intake can increase
                             affected by grapefruit        blood levels of drug
                             include those taken for
                             anxiety, depression, high
                             blood pressure,
                             HIV/AIDS, cancer,
                             irregular heart rhythms,
                             infections, psychotic
                             problems, erectile
                             dysfunction, angina,
                             convulsions,
                             gastrointestinal reflux,
                             high cholesterol and
                             immuno-suppressants
Bran                         Digoxin                       May reduce drug
                                                           absorption
Food in general              propanolol                    Increases drug absorption
                             aspirin                       May decrease absorption
                             Antimicrobial agents          May reduce drug
                                                           absorption
High protein diet            L-dopa                        Amino acids from diet
                                                           inhibit absorption of drug
Licorice                     Antihypertensive agents &     Large amounts tend to
                             diuretics                     induce hypokalemia and
                                                           Na retention
Milk & milk products         tetracyclin                   Calcium inhibits drug
                                                           absorption
Salt                         lithium                       Low salt diets may
                                                           enhance drug activity, high
                                                           salt inhibit activity
Vegetables (onions,          warfarin                      Vitamin K rich foods can
broccoli, lettuce )                                        inhibit action

Drugs that cause weight gain – see handout

                       Nutrition & Gastrointestinal Disease

Function of Gastrointestinal Tract

   1. Mouth
Chewing assists with digestion by breaking foods into smaller pieces. Saliva contains
 amylase which begins to breakdown starch. A bolus of food of formed which is
swallowed under voluntary control. Peristalsis moves food into stomach.

   2. Stomach


                                                                                   15
4 functions:
     storage of food (in upper portion of stomach – up to 1.5L can be stored)
     secretion of enzymes (eg pepsin)
     secretion of acid. Gastric acid secretion is stimulated by gastrin, which is
        triggered by distention of stomach, impulses from vagus nerve (eg sight &
        smell of food) or presence of food in stomach.
     mixing before release to SI in form of chyme. This allows easier digestion &
        absorption in the SI.

Stomach empties in 1- 4 hrs. CHO, protein exit more rapidly than fat, liquids more
rapidly than solids, small particles more quickly than large particles and isotonic food
more quickly than hypertonic foods.

3.Small Intestine
    Most of the digestive process is completed in duodenum
    Remaining small intestine used for absorption of nutrients
    The stomach acidifies the chyme to a pH of about 2. This is neutralized by
       secretion of bicarbonate secreted in bile from liver and pancreatic secretions.
    The pancreas secretes digestive enzymes directly into the SI as well as
       bicarbonate.
    SI surface is covered in villi, which consist of epithelial enterocytes which
       absorb nutrients.
    The villi capillary blood supply carries the nutrients via the portal vein to the
       liver.
Some of the pancreatic enzymes:
Enzyme Type                Substrate            Product
Carbohydrase
Amylase                      Starch              Maltose
Proteases
Trypsin                      Protein             Peptides
Chymotrypsin                 Protein             Peptides
Elastase                     Elastin             Peptides
Carboxypeptidase             Peptides            Amino acids
Aminopeptidase               peptides            Amino acids
Lipases
Lipase                       Triglyderides       Fatty acid + 2 monoglycerides

        A major portion of nutrients are stored or metabolised in the liver. Sugars are
         stored as glycogen, amino acids built into protein or metabolized. Some
         vitamins & minerals are stored in liver.
        Glucose taken up by many tissues in body eg brain, heart, muscles, kidneys.
         Calcium mainly taken up by bone, iron by bone marrow etc.

Carbohydrate Digestion Summary
Site                       Digestive action
Mouth                      Alpha amylase begins starch digestion
Stomach                    Acidification & mixing but no significant breakdown of
                           polysaccharides


                                                                                       16
Liver-bile secretion           Pancreas enzyme secretion
SI                             Pancreatic amylases:
                               Starch - maltose
                               Enterocyte-bound disaccharidases:
                               Maltase – maltose to glucose
                               Sucrase – sucrose to glucose & fructose
                               Lactase – lactose to glucose & galactose
LI                             Some fermentation of fibre to SCFA; absorption of Na,
                               SCFA & water

Summary of protein digestion
Site                         Digestive action
Stomach                      HCl & pepsin begin protein digestion
Liver-bile secretion         Pancreas-enzyme secretion of inactive protease
                             precursors
SI                           Activation of pancreatic proteases: trypsin,
                             chymotrypsin, elastase
                             Amino/carboxypeptidase: protein to peptides or amino
                             acids
                             Enterocyte-bound peptidases:
                             Peptides to AA

Summary of fat digestion
Site                           Digestive action
Stomach                        Gastric lipase: only minor fat digestion
Liver-bile secretion           Pancreas-enzyme secretion
SI                             Bile salts
                                facilitate emulsification of fat to micelles
                               Lipase = TG fat to monoglycerides + glycerol + free
                               fatty acids
                               Absorbed FFA resynthesised to TG and secreted into
                               lymph

The body‟s ability to digest meals is very adaptable and pancreatic secretions can
easily be altered to suit high protein vs high carbohydrate diets, 6 meals vs 1 meal etc.

4.Large Intestine
    Principle function is to extract remaining Na, K, water from chyme that enters
       it.
    Microorganisms (mainly bacteria) gain their energy by fermenting dietary
       fibre (the food residues that cannot be broken down by pancreatic enzymes).
    End product of fermentation includes short chain fatty acids (acetic, propionic,
       butyric acids). These act as an energy source for colonic epithelial cells and
       butyrate may be protective against cancer as promotes differentiation.

Gastrointestinal Disease




                                                                                       17
Dysphagia
Principle causes: neuromuscular disorders (eg CVA, head injury, Parkinson‟s disease,
multiple sclerosis); physical obstruction (stricture), infection

Stages of dysphagia
1. Some swallow reflex:
Thickened liquid diet, pureed diet, minced diet or soft diet required depending on
strength of swallow & cough reflex.
2. No swallow reflex:
Nil orally, enterally fed
Swallow status determined by speech pathologist

Symptoms of dysphagia:
Marked slowness in eating, fatigue/drooling during meals, frequently clearing throat,
complaint of food sticking in throat, unexplained respiratory symptoms/infections

Nutritional consequences of dysphagia:
   1. Weight loss. Due to reduced food intake (fatigue during meal) or nutrient
        dilution
   2. Constipation. Due to reduced fibre intake
   3. Dehydration. Reduced intake of thickened fluids

Gastro-Oesophageal Reflux
Common causes:
   1. Oesophageal neuromuscular disorders affecting LES pressure
   2. Abdominal obesity/pregnancy increasing back pressure in stomach
   3. Excessive consumption of foods which lower LES pressure (fat, alcohol,
       chocolate)
   4. Smoking lowers LES pressure

Nutritional management:
   1. Weight reduction (if obese)
   2. Avoidance of large meals
   3. Avoidance of food or drink 3 hours before bed
   4. Avoidance of poorly tolerated foods by individual (fatty foods, acid foods,
        very hot/cold foods)
   5. Avoidance of bending, stooping after eating and eating upright. Elevation of
        bed head by 15cm/use of pillows


Gastric & Duodenal Ulcer
    Symptoms include severe abdominal discomfort (related to meals), vomiting,
        heartburn, nausea, weight loss.
    Reduction of mucosal resistance to stomach acid through Helicobacter pylori
        infection primary cause.
    Treated medically
Nutritional advice:
   1. Avoid foods that cause pain and discomfort (eg alcohol, spicy food, excess
        coffee)
   2. Avoid large meals & chew well to minimize stomach distension


                                                                                     18
   3. Avoid fried foods if pain is acute.

Irritable Bowel Syndrome
Medically defined as abdominal discomfort or pain (>12 weeks) in past 12 months:
      Relief with defecation &/or
      Change in frequency of stools
      Change in appearance of stools

Supportive symptoms:
    Abnormal stool frequency or form
    Straining passage of mucus
    Bloating

            Very prevalent condition (15% of Australians, 75% of patients female)
            Must be diagnosed by symptoms
            Affects QOL
            Can be triggered by abnormal intestinal motility, inflammation/post
             infection, brain-gut interactions, stress
            Reassurance, dietary change and stress management can help

Common food triggers:
Wheat, Fructose…avoid apple, pear, honey, fruit juice (eg juice bars), dried fruit.
Lactose (due to lactose intolerance), Polyols (sensitive to laxative effect)…avoid
sugar free gums and lollies, Fat (enhanced gastrocolonic response), Caffeine
(stimulates colonic motor activity)…avoid caffeine

Diverticular disease
   Common condition predominantly occurring in the sigmoid colon. Small pouch-
   like protrusions develop in the bowel wall. Occurs in about 30% of over-65‟s.
   Cause unknown, linked to diets low in fibre hence increased bowel pressure.
   More common in meat eaters. Inflammation = diverticulitis.
   Nutritional management
   1. Softening of stools to allow easier expulsion. Diets high in wheat fibre best.
       Wheat bran needs to be introduced slowly to prevent abdominal gas.
   2. Adequate fluid (>2L/day) & exercise will assist.
   3. Chew food well and avoid nuts, seeds, spices during acute attacks.

Coeliac disease
Lining of intestine is damaged by gluten (an immune reaction causes inflammation &
villous atrophy). Gluten is in wheat, oats, rye, barley.
Adult clinical symptoms – diarrhoea, anemia, weight loss, fatigue, abdominal
discomfort. Less common – infertility, dermatitis herpetiformis, bone & joint pains.
Child clinical symptoms – bulky, foul stools; diarrhoea or constipation; poor weight
gain; anemia; retarded growth; abdominal discomfort.

Diagnosed only by duodenal biopsy, followed by histological improvement 6 months
after gluten withdrawal.
Gluten found in many products containing derivatives of wheat, oats, rye & barley.

Nutrition assessment checklist:


                                                                                      19
      Usual nutritional assessment PLUS
      Has patient had diagnosis confirmed by small bowel biopsy?
      Symptoms & weight loss?
      Biochem of Fe, Folate, B12 done?
      Diet history – esp iron, calcium, fibre
      Lactose intolerance present/suspected?
      Fat intolerance present/suspected?

Nutritional Intervention Checklist:
    Patient understands disease & its effects
    Strict gluten free diet for life
    Educated re: food labels (gluten in wheat & barley derivatives eg malt extract,
        yeast extract, starches, thickeners, maltodextrin)
    Educated re:contamination
    Nutritionally adequate diet
    ?Need for micronutrient supplements
    ?Bone densitometry test
    Medications checked for gluten
    Joined Coeliac Society
    Relatives screened (10% +ve)

Inflammatory Bowel Disease: Crohn‟s disease & Ulcerative Colitis

IBD can affect people at any age, most common age group is 15 to 30 years. About
23,000 Australians affected.
Characterised by periods of active flare ups followed by remission.
UC = Inflammation of the mucuous membrane or superficial lining of the large
bowel.
Crohn‟s = Inflammation of the full thickness of the intestinal wall, can involve any
part of the GIT.

Dietary Management:

In active flare ups:
Individual treatment plans may include high energy/protein supplements drinks to
meet increased nutrient needs and replace lost protein.

Low residue diets may be recommended if the flare up affects the large bowel or
terminal ileum, to help reduce irritation to the bowel. Breads and cereals may be
limited to white bread, white rice, pasta, cornflakes and vegetables to potatoes,
carrots, pumpkin.

Enteral (tube) feeding using elemental formulae may also be used to rest the bowel
and produce remission.

In remissions:
Eat a well balanced diet and aim to replace nutrients lost during previous flare ups.
Exclusion of whole food groups is not recommended unless under medical advice.



                                                                                        20
Prebiotics and probiotics may help improve the health of the gut to maintain
remission. They stimulate the growth/activity of bacteria in the bowel which produce
short chain fatty acids, which are important for maintaining colonocyte integrity. This
is an area undergoing further research.

Fish oil seems to have an anti inflammatory effect in IBD (some trials have shown it
helps achieve and maintain remission; the Japanese have a high intake of fish and low
rates of IBD). Amounts used in clinical trials were 6-10 fish oil tablets (2-3gm of
EPA/DHA) a day. Having oily fish regularly should also be of benefit.

Drug-nutrient interactions may mean vitamin or mineral supplements are needed eg
folic acid, vitamin D, calcium.



                                         TUTORIAL
Practice Question
John is a 45-year-old administrative assistant being treated for wrist pain. His weight
is 100kg, waist circumference is 120cm, height is 180cm. No recent
biochemistry/pathology results available. He reports having symptoms of gastro-
oesophageal reflux most days. Lives alone and has a sedentary lifestyle. His usual diet
consists of 6 slices white toast with butter and jam for breakfast, 4 cheese or ham
sandwiches for lunch, several chocolate biscuits during the afternoon and for dinner
he has takeaway noodles, pizza or fish and chips. Has recently switched to diet soft
drinks as his main beverage.

   1. Do a nutritional assessment. (6 marks)
   2. What are 3 common causes of gastro-oesophageal reflux? (3 marks)
   3. What are 6 lifestyle interventions that could assist with management of John‟s
   reflux? (6 marks)


                    Herbs and Herbal Supplements
Herbs & Safety
   1. Take herbs only for minor illness. If taken in conjuction with other
      medication, inform your GP.
   2. Buy reputable brands with guaranteed concentrations of active ingredients
   3. Be aware contaminants (eg pesticide residue) may be present
   4. Remember side effects can still occur (natural does not equal safe)
   5. Don‟t take herbs if pregnant or breastfeeding
   6. Get advice from a qualified herbalist

Weight for weight, herbs and spices generally contain more antioxidants than fruits
and vegetables. This may help them protect us from cardiovascular disease and
cancer. They also add variety and flavour without extra salt or fat.




                                                                                      21
Ginger
Used for nausea & morning sickness. Shown more effective than standard anti nausea
drugs in some studies, no effect in others. Safe & may be effective. A small trial
found it modestly effective in arthritic knee pain relief (Osteoarthritis Cartilage 2000;
8:9)

Evening Primrose oil
Used for PMS. Some studies support its use, but final proof is lacking. Check quantity
of GLA per tablet as each brand varies – more is better. It increases clotting time so
avoid if taking an anticoagulant.

Echinacea
Promoted as immune booster and has been shown to stimulate activation of T cells
hence stimulating immune system action. It does have anti viral and anti bacterial
properties. Should not be taken for long periods due to its effect on the immune
system.

Garlic
Can slow growth of bacteria, yeasts, fungi so act as broad spectrum antibiotic. Only
fresh garlic, not supplements, act in this way. Consuming 1 clove/day may reduce
total cholesterol by 9% (JAMA 1994; 271:1660-61). It may reduce blood pressure
slightly and lower clotting (J Hypertens 1994; 12:463) Garlic also contains a variety
of antioxidants. Again fresh garlic best choice, or buy a supplement high in allicin &
avoid odourless garlic tablets as they are ineffective.

Ginseng
Appears to have a wide range of effects (stimulant, immune booster, BP normaliser)
but most studies done in animals. Buy only from a reputable herbalist & expect to pay
for high quality ginseng. 4 recent studies of ginseng supplements suggest it may
reduce glycemia but bigger trials on diabetics needed (Diabetes Care 2004; 27:839)

Ref: Saxelby “Nutrition for life” 2002 Hardie Grant Books, Victoria

    Review questions:

    1. Why is it important to monitor drug/nutrient interactions?
    2. What drug/nutrient interactions would you be concerned about if a patient was
       taking prednisolone?
    3. Which drug/nutrient interaction would you be concerned about if a patient was
       taking insulin?
    4. What advice would you give a woman who has been on the OCP about to try
       to become pregnant ?
    5. Which nutrient does warfarin interact with?
    6. What dietary restrictions are necessary if taking monoamine oxidase inhibitors
       and why?
    7. What are the 4 major functions of the stomach?
    8. What are the 3 main classes of pancreatic exocrine enzymes?
    9. What are 3 nutritional consequences of dysphagia?



                                                                                       22
   10. Which lifestyle interventions are appropriate for managing irritable bowel
       syndrome?
   11. Which 2 sugars do IBS clients sometimes malabsorb?
   12. What are the 4 main classes of grain that a person with Coeliac disease must
       avoid?
   13. What are 3 co-morbidities associated with untreated or poorly managed
       coeliac disease?


                                  Week 3: ENERGY

The energy equation: energy in = energy out

1. ENERGY IN
Fuels for energy
The body can oxidise carbohydrate, protein, fat or alcohol for energy production.

C6H12O6 + O2 = H2O + CO2 + Energy
Energy + ADP + Pi = ATP. ATP is used to provide energy to contract a muscle.

The amount of energy available to the body from a food can be calculated by igniting
the sample of food inside a bomb calorimeter and measuring the heat released. In
reality digestion & absorption are not 100% efficient processes (some nutrients are
lost in the faeces). This is especially true for bulky vegetarian diets which are less
accessible to digestive enzymes.

Taking these losses into account the following energy values are accepted:

Macronutrient                                Net energy
carbohydrate                                 16 kJ/g
fat                                          37 kJ/g
protein                                      17 kJ/g
alcohol                                      27 kJ/g
water                                        0 kJ/g

Fat is the most energy dense nutrient, followed by alcohol, so generally
recommended reducing fat and alcohol in the diet to lose weight - can eat twice as
much CHO than fat and still eat the same number of kJ!
The fat content and the water content have the largest impact on the kJ content of any
food.

A knowledge of macronutrient net energy values & a knowledge of the macronutrient
composition of foods allows you to calculate your daily energy intake.

EG 100g milk = 3g protein, 4g fat, 9g CHO, 84g water = 200kJ

Easy in theory, hard in practice as if you weigh your food to record what you are
eating, you will probably alter your usual intake. If you recall what you ate instead
this is less accurate.



                                                                                        23
2. ENERGY OUT
There are 3 components of energy expenditure: the resting metabolic rate, the
thermogenic effect of food and physical activity.

Resting Metabolic Rate (RMR)
When measured after at least 8 hours rest & 10 hours since last meal, this is called the
basal metabolic rate, otherwise it is the RMR – the energy needed for the mechanical
processes to sustain life (respiration, circulation etc).
Nervous tissue generally responsible for about half of the RMR, the liver consumes
29% as it metabolises nutrients, muscles at rest about 20%.

Determinants of BMR:

Body size: larger people have more metabolising tissues so a higher BMR
Sex: Females are smaller so have a lower BMR than males
Bodyfat: Fat tissue has a lower metabolic rate as it is primarily a storage tissue, unlike
muscle which is an active tissue
Hormonal & nervous controls: metabolic rate is influenced by hormones eg
thyroxine, adrenalin, growth hormone & insulin can also influence metabolic rate.
Infection or illness: severe infection, illness or injury increases BMR so sick are more
prone to weight loss.
Fasting Reduces BMR by 15%.
Drugs: Caffeine, nicotine will raise metabolic rate about 10%
Menstrual cycle: BMR is highest just before menstruation, and lowest 1 week before
ovulation. Average of extra 630kJ/day required in second half of cycle
Pregnancy: BMR increased by increased cardiac work & growth
Growth: children have a higher BMR as have a greater surface area in relation to
volume so lose heat more rapidly, so BMR set higher to maintain heat. Also must
meet demands of growth. After maturity our BMR falls about 10% each year partly
due to loss of muscle mass.

Thermogenic effect of food (TEF)
Metabolic rate rises after eating, due to the additional energy expended in peristalsis,
synthesis & secretion of digestive acids, active transport of nutrients into cells,
excretory processes. Proteins cause the greatest rise and fats the least. Thermogenic
effect of food adds 10% to total energy expenditure (unless diet is high in protein,
which adds 15% to total energy expenditure).

Energy Expenditure in Physical Activity
Component of energy expenditure that varies the most between individuals (eg energy
expended at rest is about 1.2 x BMR; heavy activity is about 5 x BMR). Energy
expended will vary according to body size and fitness level.

Calculating total energy expenditure via Schofield Equation

Step 1. Calculate BMR:
Males 10-18 years = 0.074 x weight +2.754
               18-30 years = 0.063 x weight + 2.896
               30-60 years = 0.048 x weight +3.653


                                                                                        24
              over 60 = 0.049 x weight +2.459
Females       10-18 years = 0.056 x weight +2.898
              18-30 years = 0.062 x weight +2.036
              30-60 years = 0.034 x weight + 3.538
              over 60 = 0.038 x weight +2.755
Answer is in MJ/day. Gives an estimate of BMR that is reasonably accurate for 2/3 of
population

Step 2. Multiple BMR by appropriate activity factor (1.2 = bedrest, 1.5 = light, 2.0 =
heavy activity) to get estimate of energy expenditure (MJ/day).

Recap:
    Calculate energy intake by nutrient composition consumed
    Calculate total energy expenditure by estimating BMR and multiple by
       average activity factor. This should equal total energy eaten if weight is stable.

       Ingested energy
                                              Faecal energy losses

       Metabolisable energy
                                              Dietary thermogenesis

       Net energy value
                                              Energy used to maintain BMR
                                              Energy used for activity
                                              Energy used for production of maternal
                                              milk

       Retained energy (energy stored as fat, glycogen, used to build protein)

3. ENERGY BALANCE
     Mechanisms governing energy intake to match energy expenditure are
        complex and not fully understood
     Yet we are able (without conscious effort) to maintain our weight over long
        periods of time.
     Energy intake is influenced by appetite and satiety. Appetite stimulates us to
        begin eating, satiety signals we have consumed enough.
Short term control of appetite & satiety signals appears to be via the vagus nerve and
several hormones. Presence of protein or especially fat in the intestine stimulates
cholecystokinin release, which acts as a satiety hormone via its receptor. Stretching
the stomach beyond 400ml also appears to stimulate release of satiety hormones in the
gut which act on the hypothalamus to decrease appetite.
Long term control of our energy intake also exists, as demonstrated by the many
people who lose large amounts of weight then gradually regain the weight to return to
their original weight.
Leptin is one of the hormones though to influence long term energy intake. It is
produced by adipocytes. As adipocytes grow larger they produce more leptin, which
acts on the hypothalamus to suppress appetite. Deficiencies in leptin production or
leptin receptors can result in morbid obesity.


                                                                                       25
4. ENERGY IMBALANCE: OVERWEIGHT & OBESITY
Key features of overweight & obesity:
     It is a complex, multifactorial, chronic disease
     It has genetic and environmental components
     It is linked to substantial co-morbidity
      It requires long term management

Prevalence of overweight/obesity in Australia
    Australians are getting larger
    By 50, approximately 75% of Australian males and 60% of Australian females
       are overweight or obese




      Rates of obesity doubled 1980 – 1995
      35% of Australian report gaining weight in past 12 months
      Australian gaining 1gm/day per person on average.
      Obesity increasing worldwide

“ there is an escalating epidemic of excess weight gain and obesity…affecting all
ages…in all regions of the world” (WHO, 1997)

Defining overweight and obesity
    Occurs when energy intake exceeds energy expenditure over a sustained
       period of time
    Energy is dynamically balanced in free living organisms
    Can use          Body Mass Index
                      Waist/hip ratio
                      Waist circumference

       Body Mass Index (BMI)
      Bodyweight doesn‟t give an indication of body composition
      BMI devised in an attempt to related weight to height
      BMI = Weight/Height 2 (kg/m2)
      BMI gives an indirect measure of adiposity


                                                                                    26
      Is not relevant for the extremely muscular or children

   BMI categories
     Underweight                      BMI <18.5
     Normal                           18.5–25
     Overweight                       25-29.9
     Obese                            >30

Note: These BMI measures are not suitable for Aboriginal and Torres Strait Islander
peoples, whose healthy BMI range may be lower than that for Australians of
European descent. This is due to their ancestry as traditional hunter-gatherers who
were lean and physically fit. Similarly, for Asian people cut-off points for health risks
appear to be lower than for other Australians. Overweight range = 26-31.0; obese
range = >32 for Maori and Pacific Islanders.

Waist/Hip ratio
    Measures the fat distribution pattern of the individual
    Central adiposity is associated with an increased risk for CVD and NIDDM
    WHR= waist (cm)/hip (cm)
    WHR > 1.0 in men and >0.85 in women = increased health risk

Waist circumference
    Indicator of health risk
    Optimal for men of European descent = > 94cm, higher risk > 102cm
    Optimal for women of European descent = > 80cm, higher risk> 88cm
    These targets may be 10cm lower in Asian and Indian populations
    For women, hip size is an independent predictor of good health – bigger is
       better!

                        Bodyweight, morbidity and mortality

Obesity & mortality
Impact on health influenced by
    Extent of obesity
    Location of the body fat
    The magnitude of weight gain during adulthood
    Sedentary lifestyle
    Wt gain in early adulthood

Obesity often occurs with smoking, excess alcohol consumption, hypertension and
insulin resistance so is it an independent risk factor for mortality?

Obesity & morbidity
Associated with NIDDM, CHD, hypertension, gall bladder disease, certain cancers,
osteoarthritis, psychosocial disturbances. Most improve with weight loss.

Obesity & NIDDM
   Strongly linked in all populations studied


                                                                                       27
    Risk of NIDDM increases as BMI increases
    Nurses study – obese 40 x increased risk of NIDDM
   Components of obesity most associated with development of NIDDM are obesity
   during childhood and adolescence, progressive weight gain from 18 years and
   central adiposity

Obesity & Osteoarthritis
  Mechanical stress, metabolic changes or diet causative?

Obesity & CHD
       Moderate risk factor eg Framingham study
       Found occurrence and death from CHD predicted by amount of
          overweight at study entry
       Link independent of age, cholesterol, smoking, BP and glucose tolerance

Obesity & Psychosocial problems
       Discrimination Q.O.L
       Complete fewer yrs schooling
       Less likely to enter prestigious professions, reduced income

   Obesity & Children
   Causes:
       Poor parental knowledge of nutrition
       Using food as reward or a substitute for attention
       Grandparents are often guilty
       Families eat together less often
       Lack of physical activity also impacts –less walking, more sedentary
          activities
       (MJA 2006 184:64) Watching more than 2 hours/day of TV assoc. with 1
          or more serves/day of high energy drinks; 1 or more serves/day or high
          energy snacks; less than 2 serves/day of fruit; less likely to do organized
          PA

   Management:
    Obese children have a 25-50% chance of becoming obese adults, and suffer
     social discrimination, poor self esteem, depression
    Weight maintenance is encouraged
    All the family to change their pattern of eating and activity
    Foods high in nutrients but low in energy encouraged
    The family needs to become more active together.
    Children are more likely to eat healthy meals if
             * they have been involved in the preparation of the meal eg shopping
             * helped with the cooking
             * they are allowed to serve themselves
             * presentation is VERY important, as is the influence of peers
    A healthy child will not let themselves starve
    Parental responsibility to provide a nutritious meal, but it is the child‟s
     responsibility to eat it.
    Limit meal times to 20 minutes


                                                                                    28
      New foods need to be introduced to children up to 10 times

                                 Aetiology of Obesity
Weight loss is difficult
  Body opposes changes in weight
  Initial weight loss is rapid because
               1. Water is lost with glycogen
               2. Dieters are more rigid
               3. Metabolism has not slowed

Diet don‟t work for 3 major reasons:
    Weight loss causes the metabolic rate to fall (as lean tissue is also lost)
    Weight loss causes hunger & appetite to increase
    Weight loss causes fat to be preferentially stored not burned

      Result: weight loss very rarely continues beyond 4 or 6 months. Weight then
       regained at same rate it was lost as body fights to return to its natural
       “setpoint”.
      Most commercial weight loss programs “weight cycle” people. Their failure
       rate is about 95%.
      Weight cycling is more dangerous to health than being obese but at a stable
       weight (eg Framingham study, American Journal of Epidemiology
       2002;156:132-138. ).
      Weight loss is associated with higher overall mortality (Framingham, MRFIT,
       Harvard Alumni). Could be because of the loss of organ, muscle and bone
       mass.

Factors influencing body fat levels
Things that can be changed:                     Things that can’t be changed:
Food: fat/sugar/alcohol                         Genes
Drink: soft drinks/fruit juice                  Age
Movement: work/leisure/recreation               Gender
Metabolism
Habits
Stress


   Age & sex
       Australians gain weight as they age (25–40 M, 50+ F)
       Men more likely to become overweight
       Women more likely to become obese

   Genetics
    several genes involved evidence: lean parent/child , twin studies
    weight gain has a genetic basis 25-70% of bw determined genetically.
    Recent increase cannot be due to genetic change – environment is allowing us
      to meet our genetic tendency to obesity




                                                                                   29
         Test your genes                                              (by Garry Egger)
         1. Were either or both parents obese (BMI >30) or very obese (BMI>40) for most
            of their lives?
                                         Obese                           Very Obese
         No                              0                               0
         Yes, 1 parent                   7                               14
         Yes, both parents               14                              28

         2. Do you have any first degree relatives who have been obese for most of their
            lives?
         Score 2 points for every immediate family member up to a maximum of 10 points.

         3. How would you describe the average BMI of your siblings?
         Not obese=0; obese= 6; very obese= 12

         4. When did you first become overweight or obese?
                                         Overweight                      Obese
         Never                           0                               0
         Before age 10                   20                              30
         Before age 20                   10                              20
         Before age 30                   5                               10
     Scores
     <20 = Your weight problem is not significantly genetically related, so means lifestyle
     is the main cause which is relatively easy to address.
     20-50 = Moderate hereditary component to your weight problem, which makes it
     slightly harder to lose weight.
     30-100 = Significant hereditary component to your weight problem, so close attention
     from a dietitian is needed with a long term plan to get results.

   Diet
    Focus on kJ to lose weight
    Fat stores come mainly from dietary fat (CHO not converted to fat)
    Fat = 37kJ/gm, costs 3-5% of this to store it
    CHO =17 kJ/gm, costs 25% of this to store it
    Body prefers to burn CHO and to store fat
    Fat is slow to produce satiety
    Fat is a flavour carrier
    Decreasing fat intake may be effective ( kJ) & achievable ( more acceptable
      than intake)

Nutrition knowledge and education
    No link for females
    Some link for males
    Men prefer group wt loss programs BUT alcohol must be allowed!

Physical Activity
    Not solely to blame as sedentary lifestyle is norm
    Less opportunities for activity today
    TV & childhood obesity link? (displaces activity, reduces metabolism and
      eating awareness)


                                                                                          30
      50% of Australians do no activity for health

Pregnancy
Higher weight gain in pregnancy, gaining more weight early in pregnancy & stopping
smoking increases risk of obesity .Women retain 86% of weight gained in first 20
weeks (Int J Ob 1996;20:526-32)

Alcohol
Major source of energy in the diet (27kJ/g).
Alcoholic drinks also high in sugar, further increasing kJ
Body burns alcohol & spares fat for storage
Alcohol promotes abdominal fat deposition

Fat cell metabolism
LPL promotes fat storage in adipose and muscle cells.
More active in breast, hips, thighs in women, abdomen in men.
LPL activity increases after weight loss, most dramatically in those heaviest prior to
weight loss.
Energy expenditure also decreases, which promotes weight regain.

                              Management of obesity
Long term weight loss requires a combination of behavioral changes, activity changes
and diet changes

Behavioural changes
   1. Change negative feelings, particularly depression & anxiety
   2. Focus on overcoming the pressure of social situations, such as traveling and
      entertaining
   3. Self monitor your behaviour to see what triggers overeating
   4. Increase your internal motivation
   5. Build a network of social support
   6. Carry out regular physical activity
   7. Set goals at very gradual increments
   8. Set realistic goals

Exercise changes:
   1. Don‟t confuse using exercise to increase fitness with exercise for fat loss. To
       increase fitness high intensity exercise 3-4 times/week is needed; to lose fat
       physical movement everyday is required.
   2. All movement contributes to energy expenditure! Aim to walk for at least 30
       minutes. It is the distance you cover that is important for weight loss, not
       whether you ran or walked that distance.
   3. Irregular exercise classes will do little to contribute to fat loss, especially if
       you relax more than usual after the class.
   4. Physical activity needs to increase as weight comes off, to counteract the
       slowing in metabolism or weight loss will not be maintained. Either type,
       duration or intensity need to change as weight is lost to continue weight loss.
   5. Swimming is not as effective for weight loss as other weight bearing activity.
   6. Exercise before breakfast as you blood sugar & glycogen stores are lowest, so
       a greater proportion of fat is accessed for the fuel mix.


                                                                                         31
   7. Don‟t eat immediately after exercise so circulating blood fats can be used by
      muscles and not returned to adipose cells.
   8. Spot reduction of fat does not work as fat is mobilised from all over the body.




Diet changes
Step 1: Decrease fat & increase fibre                                   Increase variety


       Increase the proportion of protein


Step 2: Decrease glycemic index & energy density


Step 3: Decrease portion size

               If this doesn‟t work:

Step 4:Reduce alcohol and

Step 5:Measure kJs in food and reduce total intake by 2100kJ/day




                                TUTORIAL
Practice Question

   You are helping with a health promotion project at the local primary school. The
   project aims to address childhood obesity, by introducing nutrition into its
   curriculum and revamping the canteen. The canteen used to offer a range of pies,
   sausage rolls, vegemite or cheese sandwiches, fruit juice drinks, muesli bars, fruit
   roll ups and savoury biscuits. It is now introducing some salads, fruit and healthy
   wraps. It is also adding an extra hour per week of physical education into the
   curriculum.

   2a) What is the percentage of Australian children estimated to be overweight or
   obese? (1 mark)
   2b) Why is important to prevent or treat childhood obesity? (4 marks)
   2c) Comment on the canteen‟s old menu in relation to childhood obesity (4
   marks).
   2d) How could you encourage the children to try the new canteen items? (2
   marks)




                                                                                     32
Dieting Aids                                  (Ref Saxelby Nutrition for life)

Fibre Supplements
     Sold as powders, granules or tablets, made from psyllium, cellulose, guar gum or
    citrus fibre. Taken with water before a meal to swell in the stomach and create a
    feeling of satiety. Can be helpful if people have trouble stopping eating when full.
    Not so good for binge eaters. Cheaper, healthier option is increase fruit and
    vegetable content of meals.

Chitin or Chitosan
   Chitin is found in the shells of crustaceans. Sold as a “fat binder” which “soaks up
   dietary fat” and then excretes it in the stool. It does attract fat in the stomach
   through its ionic charge, so works in theory. In practice 1 teaspoon binds 8g of fat,
   which won‟t make a lot of difference to the typical 70-100g/fat eaten each day.
   Therefore a low fat diet essential to see any results. Avoid if allergic to shellfish.

   Grapefruit
   Regarded as a ”slimming” food, but has no special slimming powers.

Artificial Sweeteners
    Sweetner                      Used in                    Comments
    Saccharin                     Tablets for tea, coffee    Unpopular as potentially
                                                             linked to cancer but
                                                             studies inconclusive
   Cyclamate                      Tablets for tea, coffee    Banned in USA as very
                                                             large doses in rats cause
                                                             bladder cancer
   Aspartame (Nutrasweet,         Diet soft drinks, gum      Not suitable for
   Equal)                                                    phenylketonurics
   Acesulfame-K (Sunnette)        Diet yoghurt               Long term safety
                                  Flavoured milk             established
   Sucralose (Splenda)            Sugar substitute           Non toxic, non
                                                             carcinogenic. Unlike
                                                             other sweetners can be
                                                             used in cooking
   Sorbitol/Xylitol/Mannitol      Used in sugar free lollies Laxative in high doses

Chromium Picolinate
   Claimed to lowers blood sugar & insulin levels, so prevents fat storage.
   Chromium needed for metabolism of CHO, protein, fat & helps insulin in glucose
   transport. Picolinate said to increase chromium absorption. No proof it works.

Chinese Slimming teas
   Generally contain diuretics or laxatives, hence their “slimming” ability!

Ephedra/Ma Huang & Guarana
    Herbal extracts that “eliminate wastes and toxins” so “trapped cellulite can be
   released” or digestive system cleansed are very popular. Ephedra used in Chinese
   medicine for asthma, but also sold for weight loss. Can increase BP and heart rate
   so dangerous if have heart disease, diabetes, HT. Guarana also sold as a weight


                                                                                      33
   loss aid as increases metabolic rate – also dangerous if have high BP or heart
   disease, or pregnant.

   Caffeine
   Increases metabolism & mobilizes free fatty acids to increase fat burning

   Chilli
   Increases metabolism through the action of capsaicin

   Brindleberry
   Claimed to prevent the conversion of carbohydrate to fat in the body, however this
   does not occur in the body under normal circumstances. Claimed to reduce
   hunger.

Reading Food Labels
What’s low in fat?
Aim for <3g fat/100g serve on nutrition information panel
Look for Skim
                  Non-fat
                  Low fat
                  Reduced fat
 “lite” can mean the food is low in fat, low sugar, low salt or light in colour (eg olive
oil) so has little meaning.
 “low cholesterol” does not mean low fat! Eg vegetable oils have no cholesterol but
are high in fat
“Baked NOT fried” does not mean there is less fat than the same product in the fried
variety
Foods labeled creamed, toasted or roasted will generally be high fat foods

What’s low in sugar?
Look for       low calorie
               Diet
               Artifically sweetened
“Unsweetened” or “no added sugar” foods can still contain naturally occurring sugar.
Sugar can be listed as sugar, maltose, lactose, sucrose, fructose, glucose, dextrose,
syrup, honey, fruit juice concentrate
“Carbohydrate modified” products still often high in fat

What’s low in salt?
Look for       No added salt
               Salt reduced
               Low sodium
               Low salt
What’s high in fibre?
Look for
               High fibre
               Wholemeal
               Wholegrain
Wholewheat
Fibre Enriched


                                                                                        34
Ingredient list: Ingredients are listed in order of quantity. If fat is one of the first 3
ingredients the food is not a good choice. Fat can appear as vegetable oil, copha,
coconut, shortening, cream, lard, dripping, mono or diglycerides.

Some examples of what to look for:
Cereal:                    Sugar: <30g per 100g serve
                           Fibre: > 10g per 100g serve
                           Sodium:< 300mg per 100g serve

Dry biscuits:                    Fat:<10g per 100g serve
                                 Fibre: >7g per 100g serve

When trying to lose weight, aim to keep meals to less than 1200kJ, snacks less than
600kJ. Energy dense products contain more than 1000kJ per 100gm so should be
consumed with caution!

Multiple Choice
  1. With weight loss, fat cells:
  a. decrese in size only
  b. decrease in number only
  c. decrease in both number and size
  d. decrease in number, but increase in size

    2.   Obesity is caused by:
    a.   overeating
    b.   inactivity
    c.   defective genes
    d.   multiple factors

    3.   The biggest problem associated with use of drugs in treating obesity is
    a.   cost
    b.   chronic dosage
    c.   ineffectiveness
    d.   adverse side effects

    4.   A realistic weight loss goal is to reduce body weight to
    a.   Your weight at 25
    b.   BMI in 20-25 range
    c.   By 10% over 6 months
    d.   By 15& over 3 months

    5.   Successweight loss depends on
    a.   avoiding fat and increasing water intake
    b.   taking supplements and drinking 8 glasses/day
    c.   increasing protein and reducing carbs
    d.   reducing kJ intake and increasing physical activity




                                                                                             35
   Review Questions
   1. A male athlete is 25 years old and weight 85kg. What is his estimated energy
       requirement (assume he averages light activity) ?
   2. A training diet should consist of at least 60% carbohydrate. If his energy
       intake is equal to his energy expenditure, how many gm of CHO does he
       need/day?
   3. What is a bomb calorimeter used for/?
   4. Which nutrients contribute the most energy to our diet?
   5. What are some of the determinants of our BMR?
   6. How much of our total energy expenditure is taken up by the process of
       digestion & absorption?
   7. Which hormone regulates our weight in the long term?
   8. What % of the Aus population is obese?
   9. How much weight is the average Australian gaining per person per day?
   10. Which aspects of obesity are linked with increased mortality?
   11. What are some comorbidities linked to obesity?
   12. Which are the danger ages for weight gain in males and females?
   13. Why is dietary fat thought responsible for most weight gain?
   14. Why are low birthweight babies thought to be at higher risk of obesity?
   15. Why do most people lose weight quickly when they first start a diet?




                                   Week 4: LIPIDS

Simple lipids include fatty acids and their esters with glycerol (triglycerides or
triacylglycerols).

LIPID CLASSIFICATION
Fatty Acids
Straight chain hydrocarbons containing a methyl group at one end and a carboxyl on
the other:

CH3(CH2)16COOH

Most fatty acids consumed by us have 4- 22 carbons; 16 and 18 carbon chains are the
most common.
Fatty acids are classified by:
     no. of carbons
     the position of the 1 st double bond (counting from methyl end the 1 st double
        bond is termed “”or “n”)
     the number of double bonds.


                                                                                     36
EG Linoleic acid is C18:2 n-6    (or C18:2

Saturated fatty acids (SFAs)
No double bonds in the carbon backbone. Prevalent in meat, dairy and palm &
coconut oils. In general the more saturated an oil is, the firmer it is at room
temperature.

Monounsaturated fatty acids (MUFAs)
Only 1 double bond. Oleic acid (found in high levels in olive oil) is the most prevalent
in food. Canola, avocado, peanuts & almonds are rich in monounsaturated fatty acids.

Polyunsaturated fatty acids (PUFAs)
Contain 2 or more double bonds. Most prevalent PUFA in diet is linoleic acid – found
in vegetable seed oils.
PUFAs are especially vulnerable to rancidity as O 2 attacks the double bonds to form
peroxides, which produce off flavours and smells. Vitamin E protects against
rancidity as it is preferentially oxidised. Most foods high in PUFAs are also high in
vitamin E. Manufacturers protect high fat foods from O 2 as much as possible, eg
adding antioxidants or packing in N2 .
There are 2 families of PUFAs – omega 3 (n-3) and omega 6 (n-6). They are not
interconvertible and have very different roles in the body.

Essential fatty acids (EFAs)
    Linoleic acid (n-6) and alpha linolenic acid (n-3) cannot be synthesised by the
       body so must be provided by diet.
    They are precursors for other fatty acids and give rise to different classes of
       eicosanoids (prostaglandins, thromboxanes, leukotrienes) which are hormone
       like compounds that assist in the regulation of BP, heart rate, vascular dilation,
       blood clotting, immune response & lipid metabolism.
    Deficiency of linoleic acid=dermatitis, poor growth in infants. Deficiency of
       alpha linolenic acid = neurological symptoms, learning & vision problems.
    Long chain omega 3s are EPA are DHA, and these are most important for
       maintaining good health. These are found in oily fish.
    ALA is another omega 3 fat which is found in some plant foods eg flaxseed
       oil, legumes
    ALA can be converted into EPA and DHA in the body but a high intake of
       omega 6s will suppress this conversion. A typical western diet with a lot of
       fried and processed foods will be very high in omega 6s.




                                                                                      37
         Omega 6 fatty acids:                                 Omega 3 fatty acids:
         Linoleic acid                                        Alpha linolenic acid
         Sunflower oil, safflower oil,                        Green leafy veg, broccoli, legumes
         vegetable & seed oils




           Gamma linoleic acid                                 Eicosapentaenoic acid
           Early brain development?                            Fish oils




             Dihomo-gamma-
            linolenic acid primrose
            oil, blackcurrant seed oil


                                                         Docosahexanoic acid
                                                         Fish Oils
                                                         Retinal function, brain dev
  Arachidonic acid
  Early brain dev; dermatitis




Prostanoid 2 series                Prostanoid 1 series                     Prostanoid 3 series
Pro-aggregation,                                                           Anti-aggregatory, vasodilator
vasoconstriction



         Trans fatty acids
         In nature most unsaturated double bonds are in the cis form. In processing liquid oils
         are hydrogenated to solidify them which produces trans fatty acids. Margarines and
         high fat baked goods can have trans fatty acids; check label of margarines for
         “contains virtually no trans fatty acids”

         2 reasons why undesirable:
             1. Inhibit conversion of linoleic and linolenic fatty acids to other EFAs so fetal
                development in the pregnant woman make be compromised
             2. Increase serum cholesterol levels

         Used by manufacturers as extends the shelf life, since trans fat is more stable.




                                                                                                  38
Triglycerides
Contain 1 molecule of glycerol and 3 fatty acids. Because of their high energy density
are the major storage form of energy in the body (yield 2.5 x more ATP post
oxidation than glycogen). Also has structural, protective and insulating roles in the
body, and required for absorption & transport of fat soluble vitamins.


       H

H      C       OOC             R1

H      C       OOC             R2

H      C       OOC             R3

       H
Medium Chain Triglycerides
Synthetic lipids that are digested in the GIT then absorbed directly into the portal
bloodstream, unlike other fatty acids which enter the lymph. Used clinically for
patients that are malabsorbing fat.

Compound lipids:

Cholesterol
Essential component of structural membrane of cells, esp brain and nerve cells.
Required for synthesis of bile acids and steroids. Only found in animal foods. Can be
synthesised by the body. Precursor of vitamin D.
Plant sterols (phytosterols) resemble cholesterol, hence interfere with absorption of
cholesterol from the intestine.

Phospholipids
Phospholipids – 2 fatty acids linked by a phosphorous containing substance.
All cell membranes consist of an impermeable bilayer of phospholipids which allows
proteins to move within it and accommodates exocytosis, endocytosis. Its degree of
fluidity is dependent on the length and degree of saturation of the fatty acids in the
bilayer (longer, more saturated fatty acids = less fluid & permeable membrane). The
fatty acid composition of the bilayer is a direct reflection of dietary fatty acids. Hence
the function of the bilayer is affected by diet.
Proteins within the bilayer need it to be flexible to allow them to function properly, eg
to allow substrate docking into a receptor or to endocytose. EG insulin resistance in
animals can be engineered by feeding them a highly saturated fatty acid diet, which
prevents the insulin receptor functioning normally. This is probably the underlying
mechanism of insulin resistance in humans.

Lecithin
Type of phospholipid. Assists with the transport & utilisation of cholesterol, but can
be synthesised by the body so supplements are unnecessary.



                                                                                         39
Fat replacers
Fat substitutes contain fatty acids with chemical bonds that cannot be digested by the
body eg Olestra. Fat mimetics are starch, cellulose or protein based compounds that
have the same mouthfeel as fat but fewer kJ.

LIPID METABOLISM
Lipid Transport & Storage
Dietary lipids are absorbed into the lymphatic system, and carried in the lymph as
chylomicrons (large particles of TG, cholesterol & phospholipids). Chylomicrons
enter the plasma, and encounter lipoprotein lipase on the endothelial cells lining the
capillaries. The TGs are cleaved to free fatty acids & glycerol, which enter the cell
and are re-esterified to TGs.

Lipid Metabolism
Most tissues can use FFA for energy (not brain, blood cells, skin). Glycerol is
oxidised for energy in the liver. The liver is responsible for regulating lipid levels in
the body. It synthesises TG from fatty acids, CHO or protein, it synthesises
cholesterol & phospholipids, it catabolises TG for energy production.

If fatty acids are needed for energy then TGs in the adipose tissue ares hydrolysed to
FFA and glycerol. FFA is bound to albumin for transport in the blood to the liver. FAs
in the liver are metabolised by  oxidation. Final product of oxidation is acteyl CoA,
which enters the citric acid cycle with oxaloacetic acid from carbohydrate
metabolism. Glycerol returns to the liver for oxidation or formation into new TGs.

Excess acetyl CoA is converted in the liver to acetoacetic acid which is carried to
peripheral tissues for conversion back to acetyl CoA. When the body is relying almost
entirely on stored fat for energy (eg very high protein diet, prolonged fast, diabetes)
the amount of acetoacetic acid produced exceeds the ability of peripheral tissues to
oxidise it to acetyl CoA. Some of the acetoacetic acid becomes hydroxy butyric acid,
acetone (ketone bodies). Ketone bodies not used by skeletal muscle or heart for
energy need to be excreted in urine coupled to a base. This depletes the body of bases,
which eventually lowers the pH of body fluids (ketoacidosis) and can lead to coma,
then death.

The body can store unlimited amounts of fat, which is used for energy. About 60% of
the body‟s energy during rest comes from fat. The liver can convert excess CHO and
protein to fat. Without carbohydratesm fats break down to ketone bodies. After the
prolonged absence of glucose the brain and nerve cells develop the ability to obtain
about 2/3 of their minimum energy needs from ketone bodies. However this is not
enough to sustain life in the long term, and even people with high body fat levels will
die after prolonged fasts. Ketosis also induces a loss of appetite. Lean muscle
(protein) is converted to glucose and metabolism slows so much that the loss of fat
eventually becomes less than would be seen on a low KJdiet.

Recommended dietary intakes
Australian fat intakes = 12.5% SFA, 11.5% MUFA, 4.5% PUFA
Epidemiological evidence suggests the “ideal” fat intake is similar to 7% SFA, 15%
MUFA, 7% PUFA with a n-6:n-3 ratio between 5-1 and 10-1.



                                                                                            40
When looking at food labels, check the per 100gm column. Anything with less than
10gm of fat and 5gm of saturated fat is good.


FATS THROUGH THE LIFECYCLE

Pregnancy & the first year

      High birthweights, rarity of pre-term deliveries in populations that eat large
       amounts of fish led to suggestion EFAs from fish could delay spontaneous
       delivery and increase birthweight. Mechanism: EPA/DHA are altering
       eicosanoid/cytokine balance to delay the initiation of labour & cervical
       ripening.
      10 trials have examined the ability of fish oil supplementation in pregnancy to
       prolong gestation. A small positive effect is seen, particularly in women at
       highest risk of preterm birth (no effect for twin pregnancies). No beneficial or
       harmful effects on the fetus as a result of supplementation were measured.
      All these trials used fish oils, which have much more EPA than DHA.
      DHA is required for cerebral cortex and retinal development. The fetus and
       newborn require a good supply of DHA via the placenta or breastmilk.
      Preterm infants are the most vulnerable to DHA deficiency if they are denied
       the placenta and breast milk. 12 trials have shown preterm infant formula
       supplemented with DHA improves visual acuity, and possibly psychomotor &
       language development. Therefore preterm formulas are supplemented with
       DHA and AA.
      Breast fed babies: receive DHA & AA from breast milk. This may explain the
       5 point increase in adult IQ seen in 1 recent study of breast fed vs formula fed
       babies. The level of DHA will vary with the mother‟s diet (eg vegan women
       who consume no animal products have least, regular fish eaters most).
      Formula fed babies: Trials of DHA-supplemented formula on full term babies
       have shown either small positive or neutral effects on developmental outcome,
       so WHO recommendation all formulas be supplemented.
      Weaning diets are generally low in fat, especially DHA. Omega 3 enriched
       eggs (“Veggs”, “Omegga”) are one way of significantly increasing DHA
       intake during weaning. Whether this influences development is unknown.

Toddlers to Preschoolers
Need for nutrients is very high in this age group, and appetite & capacity can be
limited.
High fat foods valuable as they are energy dense, but should also provide many other
nutrients to support growth and tissue development. Total fat requirements recently
drafted as 30% energy, with not more than 10% saturated.
Reduced fat milks are not suitable for children under 2 as milk is a key food & energy
source for this group, and fat is needed to absorb the fat soluble vitamins .
To date there is no evidence linking deficiencies in EFAs and ADHD. Currently
studies underway to investigate whether exposure to n-3 fatty acids in utero or
postnatally influences immunological development and hence asthma and allergy risk.
So far no evidence that asthma sufferers should modify their n-3 intake to improve
control.



                                                                                     41
Primary school children
Influence of family eating patterns very strong. Fat intake levels from early childhood
tend to track into adulthood, so important to establish good patterns. Children under 5
are not influenced by serving size, but over 5 children will begin to eat more if
serving sizes are increased. Draft guidelines suggest 30% of energy from fat, with
10% as saturated fat.
Early primary years =a high risk period for onset of obesity, and this has been linked
to fat & energy intake. Offer lower fat foods (eg sandwiches not pastries, fruit based
desserts not ice cream) and use mono or polyunsaturated spreads. Encourage healthy
snacks, fish intake & fruit and veg. Long chain omega 3‟s may help with childhood
asthma but evidence for this is not conclusive.

Adolescence
Another danger period for obesity onset due to reduced physical activity. Obese
teenagers more likely to be obese adults than obese children are. Amount of dietary
fat important in maintaining energy balance. Type of fat important for reducing heart
disease risk. Low fat foods are suitable, should also avoid hidden fats in baked
products & fats foods and include mono and polyunsaturated fats. 30% energy from
fat recommended.

Adulthood
Long chain omega 3s are associated with:
           Lower BP, lower TG levels, prevention of heart arrhythmias
           Possibly protecting against Crohn‟s disease, rheumatoid arthritis (see
             below) and psoriasis
           Reducing risk of Alzheimer‟s
           Reducing risk or severity of post-natal depression
           Reducing risk of macular degeneration

The proportion of omega 3 to omega 6 fats in the diet seems to be very important, as
omega 6 fats will suppress the action of omega 3s.
A typical Australian diet is high in vegetable cooking oil, fried and processed foods so
many people have a ratio of omega 6: omega 3 fat of 20:1. Ideally it should be 4:1 or
lower.
Switching to a monounsaturated cooking oil and having more oily fish, whilst also
reducing saturated fat intake helps restore the ratio.
The new Australian SDTs for long chain omega 3s are 430mg/day for women,
610mg/day for men.

Rheumatoid Arthritis
Lipids responsible for symptoms of inflammation in RA are mainly omega 6‟s: these
allow the formation of prostaglandins and leukotrienes (series 2). Studies have shown
omega 3 fatty acids, esp fish oil, are able to inhibit the production of these
prostaglandins, leukotrienes and also cytokines.
 Epidemiological evidence for the effect of fish oil in RA: Japanese prevalence of RA
is 0.4% vs Australia‟s 1%, even though there is a large occurrence of a genotype
linked with increased susceptibility to RA. Thought to be because the Japanese
consume much greater amounts of seafood




                                                                                     42
A 1996 case control study found that women who ate more seafood were less likely to
develop RA – if >1.6g omega 3 fat eaten daily then risk of RA was decreased by
approximately 70%.
Intervention studies have supported this finding. 13 double blind placebo controlled
studies all found benefits for patients with RA when supplemented with fish oil, with
the most common improvement being in tender joint pain. 12 weeks was the
MINIMUM time to effect. The median intake of omega 3 fatty acids was large (3.3g),
but these patients had long standing disease.
Appears:        Fish intake is useful in prevention of RA
                Fish oil intake can have a role in treatment.
Also RA patients are at higher risk of CVD, so fish intake should also be encouraged
from this point of view (omega-3s reduce blood clotting)

CVD
See CVD lecture

To summarise:
Key points for all patients:
    Fat is an essential nutrient – our bodies need some fat
    Reduce the saturated fats which Australians overconsume
    Choose mono or polyunsaturated fats from oils, spreads, avocados, nuts, seeds
    Consume some omega – 3 fats
    Low fat diets appear safe after 2 years of age for children at high risk of
      obesity /CHD

Key points for infants & under 2‟s:
    Babies need fat to fulfill their energy requirements for growth
    Encourage breastfeeding for at least 6 months
    Low fat diets are not appropriate for children under 2
    From 6 months of age fat can be obtained from foods such as vegetable oils,
      spreads, eggs, full fat milk and meat

   Tips for patients
How to reduce saturated fat
   Limit intake of obvious sources of saturated fat such as butter, cream, sour
      cream, marscapone, coconut cream/milk, fat selvage on meat, skin on chicken
   Limit intake of foods with hidden saturated fats, such as sausages, bacon,
      devon, salami & other deli meats, meat pies, sausage rolls, potato crisps, corn
      chips, hamburgers, pizza, fried fast food, gravy, rich sauces, full fat dairy
      products (milk, cheese, yoghurt) cakes, muffins, pastries, doughnuts, biscuits,
      chocolate, icecream.
   Check labels for saturated fat

How to increase mono and polyunsaturates in diet
   Use a variety of oils for cooking
   Swap butter for a margarine
   Consider alternative spreads eg avocado, hommus, peanut butter
   Replace potato chips with nuts as a snack


                                                                                   43
         Sprinkle lecithin or wheatgerm on cereal

How to increase omega-3 polyunsaturated fats
   Eat fish twice a week (frozen, fresh or canned)
   Choose vegetable oils that are a good source of omega-3 fats (flaxseed and
      canola)
   Choose plant sources of omega 3

Sources of omega-3 fats (in descending order of magnitude)
Source           Example
Animal
sources
Oily fresh fish           Atlantic salmon (600mg per 100g), smoked salmon, trevally,
                          yellowtail, mackerel, tuna
Canned fish               Salmon, sardines, tuna* see table below
Eggs                      Omega-3 enriched eggs eg “Veggs”
White fresh fish Snapper, perch, gemfish, flounder, whiting, John Dory, flathead,
                          bream
Seafood                   Oysters, prawns, mussels, scallops, squid, crab, octopus
///////////////////////// ////////////////////////////////////////////////////////////////////////////////////////////////
Plant
sources
Oils                       Flaxseed, canola, wheatgerm, soybean
Spreads                    Canola-based
Seeds                      Linseeds (ie flaxseeds), soy and linseed bread
Nuts                       Walnuts, pecans
Legumes                    Soybeans, tofu, soymilk, other beans and lentils
Wholegrains                Wheatgerm, rye, barley, brans
Vegetables                 Most green leafy vegetables


Type of Canned fish                      Brand                                     Amount of LC-omega 3
                                                                                   per 100gm
Sardines                                 John West Scottish                        2500mg
                                         Sardines
                                         King Oscar Sardines                       2000mg
Salmon                                   John West pink salmon                     1560mg
                                         Paramount pink salmon                     1450mg
                                         Ally pink salmon                          1300mg
Tuna                                     Greenseas sandwich tuna                   260mg
                                         flakes
                                         Solemare tuna                             108mg
                                         Sirena tuna                               135mg




                                                                                                                      44
TUTORIAL
Practice Question

Rosemary is a 33 year old woman who has been referred to you. She has had
rheumatoid arthritis for the past year. She weighs 50kg. She lost 5kg prior to
diagnosis with RA but is now responding well to a new medication regime and slowly
regaining the weight. Her usual eating pattern consists of vegemite on toast with
polyunsaturated margarine for breakfast, a fruit bun for morning tea, a cheese
sandwich on wholemeal bread spread with margarine and a piece of fruit for lunch,
yoghurt or rice crackers as an afternoon snack and beef, lamb or chicken in a stirfry or
pasta sauce with vegetables for dinner. Beverages include fruit juice and water. Her
doctor has suggested that boosting her intake of omega 3 fats may help her manage
the rheumatoid arthritis.

6a) Why are long chain omega 3s sometimes recommended to RA patients? (4
marks)
6b) Name 2 marine long chain omega 3 fats (abbreviations are fine). (2 marks)
6c) Suggest 4 dietary changes to improve Rosemary‟s intake of long chain omega 3s.
(4 marks)
6d) Rosemary‟s SDT for omega 3s is 430mg. What does “SDT” mean and what is the
role of SDTs in public health? How do SDTs differ from EARs? (5 marks)


Big Fat Myths (MJA pS123 vol176, 2002)

   1.   I don‟t need to eat any fat
   2.   Fats don‟t give us anything except calories
   3.   I must eliminate all fat from my diet to lose weight
   4.   Canola is the same as rapeseed
   5.   Canola oil is toxic/ contains a poison
   6.   Olive oil is the best to use
   7.   Light oils reduce your fat intake
   8.   I can‟t eat red meat because I have high cholesterol


   Omega-3 supplemented products
Bread, margarine, milk, eggs, fish, small goods, baby formula


Pick the Tick Campaign
The "Tick" is the Heart Foundation's guide to help people make healthy food
choices quickly and easily. It also encourages food manufacturers to develop
or modify food products that support the Heart Foundation's Guidelines for
Tick Approval. In general, "approved" foods are relatively lower in saturated
fat, sodium and added sugar, and higher in dietary fibre.

A healthier choice
Tick approved products represent a healthier choice within a particular food


                                                                                     45
category. For example, the Tick Program approves some meat pies, as they
are lower in total fat and sodium than their regular counterpart. Pastries
(sweet and savoury) are currently the third highest source of saturated fat in
the Australian diet1.

High fat foods included
The Tick can appear on foods that are high in fat, like margarines, oils and
nuts. This is because the type of fat in these products have less saturated fats
and a greater proportion of unsaturated fats. The Tick is also found on dairy
foods, like cheese and ice cream, to help people choose the ones that are
lower in total fat, saturated fat and sodium when compared to standard foods
in these categories

Earning the Tick
All foods, without exception, must meet the Heart Foundation's Guidelines for
Tick Approval. Food companies must have their products independently (from
the manufacturer) chemically analysed, and meet the nutrient criteria before
they can use the Tick on their products. If a product fails to meet the
Guidelines, the Heart Foundation may work with the food manufacturer to
improve the nutritional profile of that product.

Changing the food supply
Many products have been intentionally formulated or reformulated to meet the
nutrient criteria. Tracking data shows that the Tick Program significantly
reduces the amount of saturated fat and sodium in the food supply each year.

Freedom to choose
As the Tick Program is a voluntary program, companies can choose whether
or not to have their products tested. Some companies choose not to
participate, even though their products would qualify for the Tick. Others
simply don't meet the nutrition guidelines or companies prefer to position their
product in a different market niche.

Food companies pay a royalty fee
Fee based on wholesales turnover of their Tick product As a non-profit, non-
government organisation, the Heart Foundation needs these fees to run the
Tick Program;




                                                                                 46
            Week 5: NUTRITION & CARDIOVASCULAR DISEASE

Check how well your diet matches the National Heart Foundation guidelines by
ticking the areas you could improve:


Do you:                                                                   Could be
                                                                          improved
Use margarine spreads instead of butter or dairy blends
Use a variety of oils for cooking – some suitable choices include
canola, sunflower, soybean, olive and peanut oils.
Use salad dressings and mayonnaise made from oils such as canola,
sunflower, soybean and olive oils.
Choose low or reduced fat milk and yoghurt or „added calcium‟ soy
beverages.
Try to limit cheese and ice-cream to twice a week
Have fish (any type of fresh or canned) at least twice a week.
Select lean meat (meat trimmed of fat and chicken without skin).
Try to limit fatty meats including sausages and delicatessen meats
such as salami
Snack on plain, unsalted nuts and fresh fruit.
Incorporate dried peas (e.g. split peas), dried beans (e.g. haricot
beans, kidney beans), canned beans (e.g. baked beans, three bean
mix) or lentils into two meals a week.
Make vegetables, and grain based foods such as breakfast cereals,
bread, pasta, noodles and rice the major part of each meal.
Try to limit takeaway foods to once a week, takeaway foods include
pastries, pies, pizza, hamburgers and creamy pasta dishes.
Try to limit snack foods such as potato crisps and corn crisps to once
a week.
Try to limit cakes, pastries and chocolate or creamy biscuits to once a
week.
Try to limit cholesterol-rich foods such as egg yolks and offal e.g..
liver, kidney and brains.


.
Australian Statistics for Cardiovascular Disease
    Is the leading cause of death in Australia
    Accounts for 40% of all deaths
    One Australian dies every 10 minutes of CVD




                                                                                     47
More than 80% of the adult population has at least one of the following preventable
cardiovascular risk factors: tobacco smoking, physical inactivity, high blood pressure,
or overweight.
     22% Australians aged 14 years and over smoke on a regular basis.
     43% Australians do little or no meaningful physical activity
     Over seven million adult Australians are overweight; 2 million are obese
     Three million Australians have high blood pressure. High blood pressure
       increases the risk of cardiovascular disease by two to four times.
     Six million Australians have hypercholesterolaemia
     CVD death rates falling in industrialized countries, increasing in newly
       industrialized countries
     Aboriginal and Torres Strait Islanders die from CVD at twice the rate of other
       Australians
     CHD is the most common form of CVD
     At 40 years, CHD risk = 1 in 2 (M); 1 in 3 (F)

Lipid Transport in the body

Because lipids are hydrophobic they must be bound to a transport molecule to
circulate in the blood (lipoproteins).
                                           Receptor activity =
       LIVER CELL
                                           + PUFA, soy protein
                                           - SFA
                       LDL


                                                      HMGCoA

                       Cholesterol



               ACAT                                 Receptor
                                                    synthesis

      60% LDL is taken up via receptors on liver, adrenals etc
      Some of remainder may be oxidized by free radicals or glycosylated if diabetic

Atherosclerosis process

   1. Initial injury to endothelium of vessel wall occurs. Can be physical damage
      (blood flow), chemical damage (oxidized/glycosylated LDL), interaction with
      activated cells eg platelet




                                                                                     48
   2. Macrophages attach to injured endothelium, enter the sub-endothelial space &
      accumulate cholesterol ester from oxidized LDL to become foam cells ---
      lesion = fatty streak

   3. Smooth muscle cells migrate to lesion and proliferate to form a connective
      tissue matrix. There is accumulation of lipid and cholesterol in the matrix to
      form a raised fibrous plaque (atheroma).

Platelet aggregation at this site can lead to thrombus formation and occlusion of artery

    coronary heart disease, stroke

Epidemiology & CVD

Seven countries study (1980)
1st linking serum cholesterol level to CHD
Measured Greeks, Finns, Italians, Japanese, Dutch, Yugoslavs, Americans
Compared with national incidence of CHD
      Linear relationship -graph
      Migration of Japanese to USA shows variation not due to genetics
      ? due to diet
      % dietary fat vs coronary death – some correlation
      Ratio SFA and PUFA vs serum cholesterol – good correlation

Multiple Risk Factor Intervention Trial (MRFIT, 1986)
   351,000 men / 6 year period
   Serum cholesterol          coronary heart disease mortality is strong and
      continuous from cholesterol levels of 4.7mmol/l
   There is no threshold concentration of serum cholesterol at which risk
      suddenly increases.

Cholesterol lowering interventions
   Simvastatin (1994), Pravastatin (1998)
   Oslo trial (1981) – dietary intervention
   1% reduction in mortality for each 1% reduction in total cholesterol
   1% increase in LDL cholesterol may cause a 2-3% increase in CHD risk.
   Every 0.25mmol/l increase in HDL decreases CHD risk by 2-3%

Recommended serum lipid levels:
National Heart Foundation recommendations for serum lipid levels have been revised:
                            Normal                      High Risk
Total cholesterol           <5.5 mmol/l                 <4.0 mmol/l
LDL cholesterol             <3.5 mmol/l                 <2.5 mmol/l
HDL cholesterol             >1.0 mmol/l                 >1.0 mmol/l
Triglycerides               <2.0 mmol/l                 <2.0 mmol/l

High risk patients are those which have:
    Existing cardiovascular disease
    Diabetes Mellitus


                                                                                       49
      Chronic renal failure/transplantation
      Aboriginal or Torres Strait Islander Ethnicity
      Familial Hypercholesterolaemia
      Familial Hyperlipidaemia
      Total cholesterol >6.0 or LDL cholesterol >4.0 AND 2 or more of the risk
       factors here: HDL cholesterol <1.0, significant family history, HT,
       overweight/obesity, smoking, impaired glucose tolerance, renal impairment,
       age >45 years.

      Low HDL concentrations seem to be a more significant risk factor in women
       than men.
      Over 6 million Australian adults have a total cholesterol over 5.5.

OTHER RISK FACTORS FOR CVD
   CVD occurs as a result of 2 processes: atherosclerosis and thrombosis.
   Accelerants of either are a risk factor for CVD
   These risk factors can be divided into modifiable and non modifiable.

Modifiable
Smoking
   Causes more than 1/5 of deaths from CVD
   Seems to increase the levels of fibrinogen, tendency of blood to clot
   Smoking decreases HDL levels

Dyslipidaemia
    Low HDL, high LDL accelerates atherosclerosis
    Ratio of LDL:HDL cholesterol = CVD risk
    Elevated TG levels occur with lowered HDL

Obesity
   (Central) obesity increases risk of diabetes & HT, which both accelerate
      atherosclerosis
   Continuous relationship between BMI, total and LDL cholesterol
   Obesity increases production of VLDL (as endogenous TG increased) and
      hence LDL

Hypertension
   Accelerates atherosclerosis
   Major risk factor for stroke
   HT is itself increased by obesity and excess alcohol intake and possibly salt.

Inactivity
    Physical activity will help reduce weight and BP, it has also been shown to
       improve lipid profiles.

Poorly controlled diabetes
    Diabetics are at increased risk of developing CHD
    Insulin resistance / HT / increased tendency for thrombosis / dyslipidemia are
       common in diabetics


                                                                                     50
Non modifiable

Genetic predisposition
    Sensitivity to the effects of dietary cholesterol
    Can effect levels of homocysteine too, although deficiencies in folate, B6 and
      B12 will also cause this
    High levels activate platelets and cause damage to the endothelial lining of the
      vessels.
    Hypertension = increased risk

Age
         As atherosclerosis develops over many years

Sex
         Pre-menopausal women have higher levels of HDL – decreased CHD
         LDL-C less significant than HDL-C levels in pre-menopausal women.
         HRT reduces risk of CHD for post menopausal women, by increasing HDL
          and decreasing LDL and total cholesterol levels (oestrogen upregulates the
          LDL receptor).
         HRT increases risk of other morbidities

DIET AND CARDIOVASCULAR DISEASE

Saturated fatty acids

Sources in diet: Animal derived (meat, dairy products).
Plant sources = coconut oil, palm oil

Effect on lipids: (ie atherogenic effect)
The Seven Countries study - saturated fat NOT total fat = serum cholesterol levels.
EG Greeks = high fat intake, but mostly MUFA so low CHD mortality.
Mechanism: suppress LDL cholesterol receptor activity, although the exact
mechanism is unknown.

Effect on thrombosis:Long chain saturated fatty acids increase the tendency of blood
to clot as they stimulate the aggregation of platelets, so are thrombogenic.

NHF recommendation: saturated and trans fatty acid intakes together do not exceed
8% of total energy in the diet.

Trans fatty acids
Unsaturated fatty acids generally occur in nature in the cis form. Small amounts occur
naturally in dairy products. Trans form produced in food processing when oil is
hydrogenated to solidify it

Sources in diet: Some margarines




                                                                                       51
Effect on lipids: Compared with unsaturated fatty acids, trans fatty acids significantly
increase total and LDL cholesterol, and lower HDL cholesterol, although less potently
than some saturated fatty acids.

NHF recommendation: saturated and trans fatty acid intakes together do not exceed
8% of total energy in the diet

Monounsaturated fatty acids

Sources in diet: Olive oil, canola, avocado, nuts

Effects on lipids: Neutral effect on LDL cholesterol, slightly increase HDL
cholesterol, so will lower the LDL/HDL ratio
No effect on thrombosis. Substituting MUFA for SFA will decrease LDL cholesterol
and total cholesterol, and increase HDL cholesterol. Monounsaturated fatty acids are
the predominate fatty acid eaten in the Mediterranean area, and CHD incidence is
fairly low. However other protective factors could be involved.

NHF recommendation: a proportion of dietary saturated fatty acids should be replaced
by mono-unsaturated fatty acids as a strategy for reducing the intake of saturated fatty
acid

Polyunsaturated fatty acids
n-6 PUFA
Sources in diet: margarines and oils (sunflower, safflower, corn, soya bean); walnuts,
brazil nuts, pumpkin seeds, sesame seeds, sunflower seeds

Effect on blood lipids: Lowers total and LDL cholesterol, as increases activity of LDL
receptor and raises HDL cholesterol. No effect on thrombosis or BP.

NHF recommendation: n-6 polyunsaturated fatty acids contribute 8 to 10% of total
energy intake.

n-3 PUFA
Eskimos - high fat diet but CHD death rate low, partly attributed to their high intake
of n-3 PUFAs. Also bruise and bleed very easily due to high intake?

Sources in diet: Polyunsaturated margarines, linseed, oily fish (herring, salmon, tuna,
makeral, sardines, gemfish)

Effect on blood lipids:
Little on LDL, HDL or total cholesterol
Potent effect on triglycerides – 3gm in diet can reduce TGs by 30%.
Mechanism- eicosapentaenoic acid and docosahexanoic acid effect the synthesis and
clearance of VLDL cholesterol and chylomicrons (the TG rich lipoproteins) hence
decreasing TG levels.

Effect on thrombosis: Decreases thrombosis, by 2 mechanisms:
    1. Via thrombocytopenia



                                                                                         52
   2.   Via reduced platelet aggregation




Omega-3                                                      Omega-6
EPA                                                           AA




                          Cyclo-oxygenase



 3-series thromboxanes                                         2-series thromboxanes
 (neutral)                                                     (aggreg.)

 3-series prostacyclin                                         2-series prostacyclin
 (anti-aggreg)                                                 (anti-aggreg)


NHF recommendation: At least two fish (preferably oily fish) meals per week are
consumed; both plant and marine n-3 polyunsaturated fatty acids are consumed since
it is possible that -linolenic acid and marine n-3 polyunsaturated fatty acids protect
against CHD by different mechanisms; and plant n-3 polyunsaturated fatty acid
intakes be at least 2g per day

Dietary Cholesterol
Sources in diet: Only found in animal products. Eggs, offal, prawns rich sources

Effect on blood lipids: Varies b/t individuals. IF sensitive, LDL and HDL cholesterol
will increase, with the LDL fraction more affected

NHF recommendation: people at low coronary risk can reasonably eat moderate
quantities of cholesterol-rich foods; and people with plasma cholesterol levels greater
than 5.0mmol/L or with other risk factors should restrict the intake of cholesterol-rich
foods.




                                                                                      53
Dietary Fibre
Sources in diet: insoluble fibre (found in wholegrains, brown rice, fruit and veg).
Soluble fibre = bran, wholegrains, legumes, fruit and veg.

Effect on lipids: Insoluble fibre – none. Soluble fibre - lowers total cholesterol and
LDL cholesterol around 3-5% if 15gm/day eaten.
It binds bile acids in the gut which means an increased fecal excretion of bile acid and
possible alters hepatic cholesterol synthesis.
Fibre also tends to reduce fat and cholesterol in the diet as high soluble fibre foods
are low in these nutrients.

NHF recommendations: The consumption of dietary fibre, especially cereal fibre, is
associated with a lower risk of CHD.

   1. Foods rich in soluble fibre reduce the level of plasma cholesterol.
   2. Although insoluble fibre such as wheat bran does not lower plasma cholesterol
      levels, the epidemiological data do not distinguish between the two forms of
      fibre and fibre-rich foods.
   3. A target of 30g fibre daily for Australian adults is to be encouraged.

Antioxidants
These include vitamin C, E, beta carotene, carotenoids (lycopene), flavonoids
Source in diet: Vegetables, fruit, vegetable seed oils, nuts, soybeans, tea, red wine

Effect: Populations that eat diets rich in antioxidants have lower rates of CHD. Does
not prove it is the antioxidants, could be that these diets are rich in fruit and
vegetables.
Studies where a vitamin E supplement was given showed reduced CHD mortality.
Mechanism: ?prevent the oxidation of LDL-cholesterol. ?reduce platelet adhesion and
inhibit smooth muscle cell proliferation

NHF recommendations:

   1. Foods rich in vitamin E and flavonoids are recommended components of a
      healthy diet. These foods include vegetables, fruits, vegetable seed oils, nuts
      and probably soybeans, tea and grape products.
   2. Possible benefits of supplemental antioxidants are limited to vitamin E on
      current evidence, although even in this case there are still no intervention trials
      showing unequivocal benefit.

Salt

Linked to HT for over 50 years
No clear association as some more sensitive to Na than others

Sources in diet: bread, cheese, margarine, soups, sauces, processed foods NOT added
in cooking or at table
Effect on BP: The largest scale study of salt intake and BP included 10,000 people /32
countries. Found reduction of sodium intake of 100mmol/day will reduce BP by
3.5(systolic)/1.5(diastolic).


                                                                                        54
Meta analysis = reduction by 3gm salt/day in the 50-59 age group would lower BP
5/2.5mmHg and reduce the incidence of stroke by 26% in the western world

NHF Recommendation: weight loss and sodium, alcohol restriction is best for
hypertensives

Vegetarianism
Evidence = vegetarians have a decreased LDL-C, BP so risk of CHD compared to
meat eaters.
Possible mechanisms: Vegetarian diets are generally lower in total and saturated fat,
higher in fibre and antioxidants, and have a higher potassium:sodium ratio

NHF recommendations: The benefits of a vegetarian diet are not unique. An omnivore
diet that is low in total and saturated fat and contains plenty of fruits, vegetables and
wholegrain cereals may be just as effective as a vegetarian diet in terms of reducing
CHD risk.

Iron
Sources in diet: Meat, egg, dark green leafy veg, wholegrains

Effect: Promotes LDL oxidation reactions so may accelerate CHD

   1. NHF recommendations: The evidence for or against a role of iron in the
      development of CHD is extremely limited at present.
   2. Iron deficiency is a significant problem in our society, especially in infants,
      premenopausal women and the elderly. Limiting the iron intake in such groups
      is not recommended.
   3. Further research is required to establish whether or not there is a relationship
      between iron and CHD.

Alcohol
Effect: Any level of consumption will raise blood pressure.
High energy nutrient so contributes to obesity.
It also raises TG levels by stimulating hepatic synthesis.
Moderate intake does not increase mortality - ? due to increased HDL levels,
antiaggregatory effects of ethanol or antioxidants in wine.

.NHF recommendation: On cardiovascular and other health grounds, there is no
justification for recommending that non-drinkers of alcohol should take up the habit
or that any drinkers should increase their intake.

On those same grounds, there are strong reasons for all people who drink alcohol to
limit intake to moderate levels.

Those whose blood pressure or blood cholesterol levels are high, or who are
overweight, have additional reasons for moderating or avoiding use. Alcohol
consumers on medication to lower their blood pressure, should either stop drinking or
restrict their intake to one or two drinks per day at most, with the hope of reducing the
need for such medication.



                                                                                       55
Soy & CVD
    1995 meta analysis found soy protein lowers LDL cholesterol by up to 12.9%
    Whole soybean products preferable to soy protein isolates as they also contain
      fibre, vitamin E, omega 3 fatty acids, phytoestrogens.
    Therefore: antioxidant properties; an anti inflammatory effect in blood vessels
      so minimise plaque formation; reduces blood clotting
    USA food manufacturers may claim “25g of soy protein a day as part of a diet
      low in saturated fat and cholesterol may reduce the risk of heart disease”
    Aim for 3-4 serves/day: soy milk, soy yoghurt, soy beans, tofu, soy breakfast
      cereal, soy & linseed bread

How much is a serve of soy?

One serve is:
1cup of soy milk
1 tub of soy yoghurt
1 carton of soy smoothie
1/3 cup soy beans, canned and drained
2 slices soy and linseed bread
60g hard tofu
45g soy breakfast cereal

3 or 4 serves/day will give 25gm of soy protein.


Wholegrains & CVD
   4 large scale studies in the late 1990s have shown as consumption of
      wholegrains (NOT refined cereal) increases, CHD incidence declines.
   Appears due to combination of soluble fibre, folate and antioxidants &
      phytoestrogens present in grains.
   Oat bran, whole oat flour and rolled oats have been shown to modestly reduce
      total and LDL cholesterol due to soluble fibre. Wheat fibre has no effect.
   2005 CSIRO study found 20-40% reduction in CVD risk if having
      wholegrains regularly.
   USA food manufacturers allowed to use the health claim “Diets rich in
      wholegrain foods and other plant foods and low in total, saturated fat and
      cholesterol may reduce the risk of heart disease and some cancers”

Plant sterols & CVD
Plant sterols (sitosterol & campesterol) found at high levels in unrefined vegetable
oils
An LDL-cholesterol reduction of at least 10% is seen in 90% of people when 1.6-2.4g
of sterol/day eaten. This effect is additive to reductions from statins that inhibit
cholesterol synthesis

A 2005 study ( Nutr Med Cardiovas Dis 2005 15: 337) found that lowering total and
saturated fat int the diet reduces LDL-cholesterol by about 12%, but adding a plant
sterol to this diet further lowered LDL-C by 20%.




                                                                                  56
Summary
Foods to ask CVD clients about when evaluating their diet:
    Saturated fat (meat, dairy
       products, commercial cakes,
       pastries, takeaways)
    Cooking techniques
    salt

      Fruit & Veg intake
      Fish intake
      Alcohol
      Wholegrains




                                                             57
Basic Interventions:
    Reduce SFA fat in diet (cheese & icecream 2/week, takeaways, cake, chips
       1/week)
    Substitute MUFA, PUFA (olive oil, canola, avocado, fish) for SFA (meat, full
       cream dairy, butter & lard)
    Have 2+ fish meals/week
    Increase fruit, veg, wholegrain intake
    Have 2+ legume meals/week
    Try soy products
    Decrease alcohol if TG elevated
    Maintain BMI>25
    Increase physical activity
    Plant sterol spreads if on statins
    Reduce cholesterol (<2eggs/week, occ. offal, shellfish)
    Reduce salt if HT

When to refer to dietitian
   Recent AMI/CVA/HT and not seen
   Interventions not working
   Not consuming balanced diet

                                     TUTORIAL

Practice Question
Jenny is a 59 year old client who recently had her total cholesterol measured during a
check up and was told it is 6.0 mmol/l. Her weight is 82kg, height 170cm. She is a
busy senior manager so has no time for cooking and eats takeaway pasta, curries, fish
and chips or pizza most nights. Breakfast is usually skipped, and lunch is often a
quick sandwich or roll filled with ham or cheese and salad. She doesn‟t do any regular
exercise, does not smoke or drink.

3a) Do a nutritional assessment of Jenny (5 marks)
3b) What are 4 lifestyle interventions you could suggest to help Jenny lower her
cholesterol? (4 marks)
3c) What should her total cholesterol ideally be? What should her HDL cholesterol
be? (2 marks)
3d) Jenny has been reading about foods that can help lower cholesterol. Describe 3 of
the foods that can lower your cholesterol and the mechanism by which they do this. (6
marks)
3e) Why is a moderate alcohol intake thought to be protective against CVD? (2
marks)

                          8 foods that can lower cholesterol

1.Fruit and Vegetables
Those who consume a lot of fruit and veg have a lower risk of CVD. No longer
attributed to the antioxidants vitamin E, C and beta carotene. Many other antioxidants
being researched: carotenoids in green and orange veggies, catechins in tea,



                                                                                    58
anthocyanins in berries, rosemary and oregano, flavonoids in leafy green veg. Also
increases fibre & folate in diet which decreases homocysteine.

2. Red wine
“French paradox” is that the French eat large amounts of saturated fat but have low
rates of CVD. Thought to be because they have red wine with meals. Moderate
amounts of red wine can cause a decrease in LDL-C levels, but not white wine.
Polyphenols in red wine may act as antioxidants, and alcohol intake does increase
HDL-C levels.

3. Garlic
0.9g garlic appears to lower total (12%) and LDL-C (14%). Combining garlic with
fish oil tablets will also lower TGs (34%). (Am J Clin Nutr Brown et al1997)

4.Nuts
Contain mainly monounsaturated and polyunsaturated fats. Study of 30,000 7 th Day
Adventists found people who eat nuts more than 4 times/week have 50% fewer heart
attacks than those who rarely eat nuts. Nuts also contain vitamin E, fibre and arginine.
Arginine is converted to NO which causes smooth muscle to relax.

5. Fish
Omega-3‟s reduce TG levels, prevent platelets clumping & clotting, reduce platelet
number so enhance blood viscosity, minimise cardiac arrhythmias. Oily fish highest
in omega 3‟s.

6. Tea
Green and black tea both contain flavonoids which act as antioxidants. High tea
consumption has been linked to reduced heart disease. Green tea is very rich in
antioxidants so suggested as the reason for little CVD in Japan and China. Adding
milk to tea does not affect absorption of the antioxidants.

7. Soy
25 gm soy protein/day (eg 1 L of soy milk) can reduce total cholesterol by 9%, LDL-
C by 12.9%, TG by 10% if hypercholesterolaemic. No effect if normal cholesterol.
Additional benefits from eating who soy beans, not protein isolate.

8. Oats and Psyllium
Oat bran, barley and rice bran contain soluble fibre so can bind to bile acids and
sterols and prevent their reabsorption from the bowel. Need about 1 heaped cup/day
of oat bran to see a benefit, less of psyllium as contains more soluble fibre. Rye bread
(>6 slices/day) can also slightly lower cholesterol in men (Rye bread decreases serum
total and LDL cholesterol in men with moderately elevated serum cholesterol.
J Nutr. 2000 Feb;130(2):164-70)..

Portfolio Diet
Used to lower cholesterol by Prof.David Jenkins – reduced LDL by 35%
1.Soy protein – 40g/day – soy milk, yoghurt & tofu
2.Plant sterol cholesterol lowering margarine
3.Oat based breakfast
4.10-15 raw almonds/day


                                                                                      59
5.Increase in consumption of fruit & veg

Multiple choice questions:

   1. Modifiable risk factors in coronary heart disease are:
        a. age, lowered LDL cholesterol, obesity, hypertension
        b. android obesity, diabetes, smoking, family history
        c. high plasma triglycerides, diabetes, male sex, elevated cholesterol
        d. diabetes, android obesity, hypertension, lowered LDL cholesterol

   2. Antioxidants are thought to be protective against cardiovascular disease
      because
         a. They prevent oxidation of LDL cholesterol by joining with free
             radicals
         b. They are found in fruits and vegetables and wholegrains so increase
             the fibre content of the diet
         c. They form free radicals to help oxidize LDL-cholesterol
         d. They form vitamin E, C and beta carotene, which have beneficial
             effects

   3. In regard to the function of trans fatty acid, which is incorrect:
          a. they have similar effects on the body to saturated fatty acids
          b. they are found naturally in ruminant fats
          c. are found in large amounts in Australian margarines
          d. are formed during the hydrogenation of oil

4. The most effective way of reducing a person‟s cholesterol is to
          a. Change the type of oil they use to a vegetable oil eg palm oil
          b. Reduce organ meats, shellfish, eggs in diet
          c. Reduce fatty meats and full cream dairy products in diet
          d. Increase fish consumption to twice a week
          e. Increase consumption of wheat bran and wholegrains

   5.Weight reduction is beneficial in cardiovascular disease as
         1. the body has less fat to contribute to the blood lipid profile
         2. there is a fall in LDL-cholesterol and triglycerides
         3. there is less oxidation of LDL-cholesterol
         4. HDL-cholesterol levels are maintained while LDL-cholesterol levels
              fall

   6. Hypertension control is best achieved by
         a. reducing salt intake
         b. decreasing LDL-cholesterol
         c. weight reduction if overweight and exercise
         d. increasing potassium in diet



                          Week 6: CARBOHYDRATES


                                                                                  60
      Recommended that CHOs contribute >55% energy for optimal nutritional
       status
      Hunter-gatherer ancestors ate 25-40% energy from CHOs
      Many traditional societies consume >55% of energy from CHOs. Food
       sources high in CHOs generally also good sources of fibre, moderate sources
       of protein and contain B group vitamins, vitamin E, Fe, Zn, Mg, P.
      Diet high in CHO can be preventative against CHD, obesity & some cancers.
      Generally store well, are relatively cheap and make best use of the world‟s
       resources (few input resources compared to nutrient output)
      CHO provides the largest source of energy to most Australians (about 45% of
       energy – 200gm/day for women, 300gm/day for men).



Physiological functions of carbohydrates:
    Provision of energy
    Effects on satiety
    Effects blood glucose
    Protein glycosylation
    Fermentation – production of
   hydrogen, methane and short chain fatty acids
    Control of colonic epithelial cell function
    Effects on bowel habit, laxation
    Effects on large bowel microflora


CHO formula is C n H2nO n. Only CHOs containing 6 or 5 carbons and their polymers
are significant for human nutrition.
These are synthesised in plants via photosynthesis through the combining of CO 2 and
water.




                                                                                  61
Types of carbohydrate:
Carbohydrate            Food Sources                            End products of digestion
Monosaccharides

Glucose                 Fruit, honey                            glucose
Fructose                Fruit, honey                            fructose/glucose
Disaccharides

Sucrose                 Sugar, maple syrup                      glucose + fructose
Lactose                 Milk & dairy products                   glucose + galactose
Maltose                 Small amounts in some cereals           glucose
Polysaccharides:
indigestible
Cellulose &             Vegetable stalks, leaves & seed coats   H2, CH4, CO2 & SCFA
hemicellulose
Pectins                 Fruits                                  As above
Gums and mucilages      Plant secretions & seeds                As above
Polysaccharides:
Partially digestible
Inulin                  Artichoke, garlic, onion, mushroom      fructose (digestion incomplete)
Raffinose & stachyose   Lentils & beans                         glucose, fructose, galatose
                                                                (“flatus factors”)
Polysaccharides:
digestible
Starches & dextrins     Grains, tubers, legumes                 glucose
Glycogen                Meat & seafood                          glucose

Monosaccharides
    Single sugars eg glucose, fructose.
    Glucose is oxidised in human cells to produce energy and stored as glycogen
      (chains of glucose) in liver and muscles. CNS can only use glucose as its
      energy source.
    ½ sweetness of sucrose so used in drinks if ill
    Fructose is the sweetest of the sugars & cheap to produce from corn starch, so
      often used commercially
Metabolism of monosaccharides:
    Cells receive most of their CHO as glucose, since fructose is converted to
      glucose in the liver.
    Much glucose is oxidised to meet energy requirements, but some is converted
      to other essential CHOs eg ribose, deoxyribose, glucosamine, and to the
      carbon skeletons needed for production of non essential amino acids.
    Excess CHO can be stored as glycogen or converted to fatty acids
    The cellular entry of fructose is not insulin dependent, however it can still
      eventually cause a rise in BGL if it converted to glucose, especially if person
      is insulin impaired/deficient.
Glucose levels are regulated biochemically in the body by:
   1. Liver breaking down its glycogen stores to glucose (glycogenolysis)
   2. Muscle glycogen is broken down into lactic acid, which liver converts to
      glucose or glycogen (Cori cycle)
   3. If adequate glucose not available, amino acids are converted to glucose
      (gluconeogenesis)
Glucose levels are controlled hormonally by:



                                                                                             62
   1. Insulin – released in response to high BGL. Increases rate of glucose
      oxidation, glycogenesis, lipogenesis. Facilitates entry of glucose to muscle,
      adipose cells, storage of glucose in liver & muscle, conversion to fat
   2. Glucagon – stimulates glycogenolysis & gluconeogenesis.
   3. Adrenalin – provides extra glucose for fight/flight response by promoting
      glycogenolysis & inhibiting insulin release.

Disaccharides
    Sucrose (sugar) =glucose + fructose.
    Maltose =glucose + glucose. Created during digestion of starch either in our
      body or when a cereal grain sprouts starch breakdown occurs in the plant.
    Lactose =glucose + galactose. Milk sugar, 1/6 sweetness of sucrose. Most
      adults lack lactase so can only digest small amounts of lactose. Large
      quantities cause osmotic diarrhoea & abdominal upset. Surgery to the GIT
      often results in short term lactose intolerance.
    Trehalose = glucose + glucose. Source = mushrooms, insects. Humans still
      possess trehalase.

Sugar alcohols
    Include sorbitol, mannitol, xylitol.
    Less sweet than the sugars, but more slowly absorbed so do not increase BGLs
      as quickly.
    Xylitol used in sugarless gums as it is not a substrate for cariogenic bacteria.

Honey
   Created from nectar, which consists of sucrose & water. Most honey (except
      “organic”) has been heated to prevent crystallization & yeast fermentation
      during storage. This does not destroy botulinum spores so infantile botulism
      can occur through honey ingestion. Honey is not recommended for children
      under 1.
   Honey has no nutritional advantage over sugar. Slightly fewer kJ than sugar as
      contains water & does contain some vitamins and minerals not in sugar but in
      trace amounts.

“Eat moderate amounts of sugar and foods containing added sugar”
 Australians obtain about 15-20% of their energy from sugar. Overall this is
compatible with a healthy diet, but at higher intakes sugar begins to displace more
nutritious foods from the diet.
     Adolescents get about 25% of their energy from snacks, adults about 20%, and
        it is snacks that tend to be higher in sugar than meals (eg tea with sugar,
        biscuits).
     Sugar can add extra energy to the diet. Although in general there is no
        relationship between high carbohydrate diets and obesity, a high consumption
        of soft drinks by children was correlated with risk of obesity.
     Evidence for the role of sugar in the development of dental caries is strong,
        but otherwise there are no diseases linked with sugar consumption. Daily
        consumption of xylitol in sugar free gum by children has been shown to
        prevent the formation of dental caries, possibly by stimulating saliva
        production. Cheese also appears to have a natural anticariogenic effect.


                                                                                      63
      No evidence sugar causes hyperactivity in children

Where‟s the sugar in food?
Food                  Sugar (%)              Food                  Sugar (%)
Sugar                 100                    Chocolate biscuits    41
Honey                 82                     Fruit cake            40
Sultanas              76                     Nutrigrain cereal     35
Golden syrup          75                     Liqueurs              30
Boiled sweets         74                     Ice cream             22
Jam                   67                     Biscuits, sweet       22
Dates                 66                     Bananas               16
Milk chocolate        56                     Grapes, white         15
Dried apricots        41                     apples                12

Where‟s the sugar in drinks?
Drink                          Serve size                   Teaspoons of sugar
Soft drinks                    1 can (375ml)                10
Cordial (made up)              1 glass (250 ml)             5.5
Fruit juice 100% orange        1 glass (250 ml)             4.5
Fruit juice drink, orange      1 glass (250 ml)             7
Flavoured milk                 1 carton (300 ml)            7
Milkshake                      350ml                        10
MacDonald thickshake           340 ml                       9
Port /sherry                   60ml                         1.5

Polysaccharides-digestible
The major polysaccharides in nutrition are generally polymers of glucose (eg starch,
glycogen & cellulose).

Starch
     Found in plants and occurs in the amylose (straight chains of glucose) and the
       amylopectin (branched) forms.
     Amylopectin is more easily digested than amylose.
     Ratio of amylose: amylopectin that gives each plant starch its properties - eg
       Arborio vs long grain rice.
     Starch granules are encased in cellulose. Cooking causes the starch granule to
       swell and gelatinise eg porridge.

Where‟s the starch?
Food                  Starch (%)             Food                Starch (%)
Flour, white          73                     Rice, white, cooked 28
Rice bubbles, corn    71-76                  Pasta, cooked       25
flakes
Flour, wholemeal      52                     Sweet corn            17
Scone, plain          51                     Potatoes, boiled      13
Biscuit, sweet        49                     Baked beans,          11
                                             kidney bean
Bread, white          45                     Rolled oats, cooked   9
Bread, wholemeal      38                     Bananas               3-7


                                                                                   64
Crumpet               38                     Pumpkin, boiled        3
Fruit loaf            36                     Plain cake             22-34

Dextrin
Product of hydrolysis of starch. As starch molecules become smaller, their sweetness
and solubility increases, so dextrin often used as a sweetener in commercial foods.

Glycogen
Storage form of CHO in humans. Has branched chains of glucose polymers.

Polysaccharides- indigestible (Dietary fibre)
Chemically defined as “non starch polysaccharides” as same chemical structure as a
polysaccharide but is different to starch. It can be further divided into insoluble and
soluble fibre.
Fibre covers all dietary components not digested and absorbed in the small intestine.
These may be fermented by bacteria in the large intestine.
Adults should have 25-30g/day of fibre. Children need (age of child + 5)g.

Food                                         gm Fibre per serve
Bran cereal 1 cup                            7.2
Baked beans ½ cup                            6.6
Rolled Oats 1 cup                            3.4
Weetbix, 2 biscuits                          3.2
Banana 1 medium                              3.1
Carrots ½ cup                                2.4
Peanuts ¼ cup                                2.4
Orange 1 medium                              2.4
Bread wholemeal 1 slice                      2
Pasta white ½ cup                            1.6
Rice brown ½ cup                             1.5
Tomato 1 medium                              1.5
Rice white ½ cup                             0.8
Bread white 1 slice                          0.8


Cellulose
Makes up structure of plant walls, and consists of glucose molecules that are linked
by enzyme-resistant bonds. Wholegrains, dried fruit, bran good sources. Insoluble but
capable of taking up water and swelling so will contribute to bulkier, softer stools

Hemicellulose
Wide variety of compounds that also contribute to plant cell wall structure. Insoluble
but also has high water binding capacity.

Lignin
A woody non-CHO substance in bran and some vegetables, that is resistant to
fermentation so completely undigested.




                                                                                      65
Pectin
Pectin is a non cellulose plant polysaccharide made of units of galactose derivatives.
Absorbs water and forms a gel so is used in jams. Forms gel in SI so slows
absorption, which assists BGL control and cholesterol absorption.

Gums and Mucilages
Gums are similar to pectin but include other sugars with the galactose units. Psyllium
= mucilage. Algal polysaccharides in seaweed and algae used for processing eg
carageenan used to thicken and stabilize many processed foods.

Insoluble & Soluble fibre
Insoluble: mainly cellulose, lignin, hemicelluloses. Aids bowel function by increasing
stool bulk & speeding transit. Also has potential to act as “prebiotic”

Cellulose                     Hemicellulose                 Lignin
Wholemeal flour               Bran                          Mature veg
Bran                          Wholegrains                   Wheat
Vegetables                                                  Fruit with edible seeds

Soluble: Can hold water, form a gel & is a substrate for fermentation by bacteria. Can
remove cholesterol from body by binding bile acids & preventing reabsorption. Also
slows the rate of digestion of nutrients so assists with diabetes.

Gums                          Pectin
Oats                          Apples
Legumes                       Citrus fruits
Guar                          Strawberries
Barley                        Carrots

Physiological effects of fibre:
    Stimulate chewing so saliva and gastric acid secretion
    Fill stomach so provide sense of satiety
    Increases fecal bulk so decreases luminal pressure
    Normalises intestinal transit time
    Becomes a substrate for colonic fermentation
    Soluble fibre delays gastric emptying and slows rate of digestion & absorption
       of nutrients
    Soluble fibre lowers serum cholesterol
    Alters gut epithelium, possibly increasing cellular proliferation


Prebiotics & Probiotics
Prebiotics: Non digestible food ingredients that selectively stimulate the growth or
activity of 1 or a limited number of bacteria in the colon, thereby improving health.
EG oligosaccharides inulin, raffinose & stachyose. These have been shown to
stimulate growth of bifidobacteria in the colon. Role for prebiotics in prevention of
inflammatory bowel disease recurrences & bowel cancer under investigation.




                                                                                        66
Probiotics: Strains of bacteria added to food that are capable of surviving digestion &
exerting beneficial effects on their host. EG L. Acidophilus. Lactose intolerance &
antibiotic associated diarrhoea can benefit from certain probiotics. Research into
preventative role in irritable bowel syndrome, dental caries & bowel cancer is
continuing.

Fibre & disease

Because dietary fibre is not absorbed during its transit through the GIT, it has the
opportunity to interact with the intestinal surface & the products of digestion to assist
in the maintenance of good bowel health.

    1. Constipation
Constipation - adequate dietary cellulose is an important factor in preventing
constipation as is insoluble so increases faecal bulk. Sufficient water needs to be
consumed with cellulose to prevent dry stools.
Soluble fibre absorbs water which also increases faecal bulk & softens stool. This
speeds the transit of the stool through the intestine. Gas produced during fermentation
of soluble fibre also assists stool passage.
Insoluble fibre tends to “normalise” intestinal transit times – hastens it if constipated,
slows it during diarrhoea.
Foods known as laxatives: prunes, prune juice, pear juice, dried figs, raisins, liquorice.

   2. Colon cancer
          Burkitt, 1974: Observed Africans who eat a very bulky high fibre diet
             do not have the same rates of colon cancer as seen in Western society.
          Hypothesised that dietary fibre prevents colon cancer by reducing the
             time the colon is exposed to mutagens by increasing transit time, and
             by increasing bulk hence diluting mutagen concentration.
          Also fermentation of fibre produces short chain fatty acids (propionate,
             acetate, butyrate). This makes the bowel more acidic. Butyric acid
             promotes the differentation of immature colonocytes & inhibits growth
             of cancerous cells.
          High fibre foods generally high in antioxidants, phenols and indoles,
             all of which can lower the risk of colon cancer by destroying free
             radicals.
          Folate has also recently been implicated as protective against colon
             cancer.
          Wholegrains also contain phytate, which has the capacity to bind non
             heme iron or copper (pro oxidants), phenolics (antioxidants), lignans
             (weak phytoestrogen). European consensus: “a diet rich in high fibre
             cereal foods is associated with a reduced risk of colorectal cancer”.
          Some large scale epidemiology studies have found dietary fibre does
             prevent colorectal cancer (Health Professionals Follow Up Study)
             whilst others have found no protective effect (eg USA nurses study but
             in this study little fibre was consumed even by the highest intake
             group).
          Intervention studies in which fibre was given to prevent polyp
             recurrence have also often failed to show a protective effect eg
             Australian polyp prevention trial gave 25g wheat bran/day over 4 years


                                                                                       67
               to patients who had a history of polyp removal, but no power in study
               as very low rates of polyp recurrence in the control group.
              Fibre supplement possibly ineffective as fibre is generally consumed as
               part of plant food which contributes other protective agents.

3. Diabetes
     Soluble fibres tend to slow gastric emptying, shorten intestinal transit, reduce
       glucose absorption so reduce rises in BGLs and demand for insulin. Studies of
       diabetics given large doses of soluble fibre allowed them to normalise their
       BGLs and reduce medication in the short term.
     High fibre foods also requires more chewing and increase satiety, which can
       reduce intake and aid in weight loss in diabetics, which improves BGLs.

                 Classifying Carbohydrates: The Glycemic Index
      The glycemic index is a method of assessing the blood glucose response to
       carbohydrate foods.
      Foods that give a slower, flatter blood glucose profile after digestion and
       absorption assist in blood glucose control.

How Glycemic Index is measured
   1. An amount of test food containing 50g of CHO is given to a volunteer to eat.
EG To test spaghetti, 200gm would be eaten as this contains 50g of CHO.
   2. Blood sugar measurements are then taken every 15-30 minutes over the next 2
      hours.
   3. The blood sugar level is plotted and the area under the curve calculated.
   4. The person‟s response to spaghetti is compared to their response to 50g of
      glucose or white bread containing 50g/glucose

GI =
[Incremental blood glucose area after test food (50gm of CHO)
Corresponding area after equicarbohydrate portion of standard CHO food ]        x 100.

The substance which produces the greatest rise in blood sugar is glucose, so this is
given the arbitrary value of 100, and all other foods are given a value from 0 -100.

High GI foods > 70; low GI foods < 55.
The higher the GI factor, the higher the blood sugar levels after consumption of the
food.
 The incorporation of low GI foods into diets has shown improvements in blood
glucose control, lipid profile and satiety.

Factors which influence the GI of a food will affect the rate of digestion or absorption.
Factor                        Mechanism                       Examples
Low degree of starch          The less gelatinized            Spaghetti, porridge
gelatinisation                (swollen) the starch, the
                              slower the rate of
                              digestion
                              Swollen (cooked) starch
                              granules are easier to
                              digest as larger surface


                                                                                       68
                                   area for SI enzymes
Intact grains (except rice)        Fibrous outer coat prevent       Legumes
                                   enzymes breaking down
                                   starch
High amylose:amylopectin           The more amylose a food          Basmati rice
ratio                              contains, the slower its
                                   rate of digestion
Fibre                              Soluble fibre increases the      Rolled oats, apples
                                   viscosity of intestinal
                                   contents so slows
                                   digestion.
Fat                                Fat slows down the rate of       Potato crisps have a lower
                                   stomach emptying hence           GI than baked potato
                                   digestion
Anti-nutrients                     Some foods contain               Soybeans
                                   substances that inhibit
                                   digestion of starch eg
                                   phytates, tannins
LOW                                  MEDIUM                           HIGH
                                     Breakfast Cereals

AllBran, Fruit „n oats, natural   Special K, natural muesli, Bran   Sugared cereals, puffed
muesli, rolled oats, porridge,    Buds, Just Right, Mini Wheats,    rice creals* Cornflakes*,
Guardian, oat bran, Komplete      Vitabrits, Nutrigrain, Sustain,   Sultana Bran, Branflakes,
oven baked muesli, oat/rice       Weetbix, Honey Smacks,            Cocopops,
bran                              shredded wheat




                                            Breads

all breads which are both         light rye bread, sourdough        wholemeal bread*, white
wholemeal and wholegrain (e.g,    white*, pita bread, crumpet,      bread*,
Helga's Classic Grain,            hamburger bun, pizza*.
Performax, Burgen, 9 grain
mutigrain, fruit loaf,
pumpernickel, dark rye,
sourdough rye




                                        Grains/Pasta




                                                                                                69
Wheat pasta*, egg fettucine*,        long grain white rice*,          Sunbrown quick rice*,
Chinese vermicelli*, meat            Buckwheat, taco shells,          Calrose shortgrain rice*,
ravioli, macaroni*, tortellini,      gnocchi, couscous, maize         pre-cooked rice, tapioca,
spaghetti*, brown rice,              cornmeal, semolina               Corn chips, millet, rice
Doongara/clever rice*, Basmati                                        pasta*, noodles*,
rice*, parboiled ricepearl barley,                                    popcorn*.
buckwheat, bulgur, cracked
wheat

                                          Legumes/nuts

Soya beans, kidney beans,            Green gram dahl, green pea       Broad beans, lima
lentils, butter beans, chick         soup, split pea soup.            beans, pinto beans.
peas, haricot beans, lentils,
baked beans, bengal gram,
blackeyed beans
all nuts

                                           Vegetables

Green peas, sweet corn (not          New canned potatoes, new         cooked carrots, French
super sweet), sweet potato,          potatoes, beetroot, potatoes     fries, baked/boiled/
raw carrots, eggplant,               boiled in their skins            mashed potatoes*
brocolli, cauliflower,                                                (especially pontiac,
cabbage, mushrooms,                                                   sebago, desiree,
capsicum, tomatoes, lettuce,                                          instant), parsnip,
green beans                                                           supersweet corn,
                                                                      pumpkin, turnip,tapioca

                                               Fruit

Cherries, plums, grapefruit,         Mango, paw paw, sultanas*,       watermelon*, very ripe
peaches, apples, pears, fig,         bananas (just ripe), raisins*,   “medium fruits”*.
dried/fresh apricots, grapes*,       canned fruit in syrup.           dates, pineapple,
kiwi fruit, oranges, jam,                                             cantaloupe
canned fruit (no syrup).

                                           Dairy Foods

Whole milk, skim milk,               Icecream (full fat).             Tofu frozen dessert
chocolate milk, full fat                                              Vitari frozen fruit, gelati,
yoghurt, low fat flavoured                                            low fat icecream
yoghurt, artificially
sweetened yoghurt, custard,
soy milk

                                           Sweet foods

Fructose (fruit sugar).              Lactose (milk sugar), jam        sugar, Glucose,
Nutella, dark chocolate,                                              Glucodin, jellybeans,
sorbet                                                                lifesavers, honey,
                                                                      maltose, chocolate
                                                                      bars*.

                                            Beverages




                                                                                                     70
Apple juice*, grapefruit juice,   Cordial, orange juice*     all soft drinks*,
Sustagen.                                                    Lucozade*, Gatorade*,
                                                             Sports Plus*,
                                                             beer*
(from The GI Factor, Brand-Miller)

Clinical uses for glycemic index:
    1. Low GI diets reduce risk of heart attack (Harvard nurses study)
    2. Low GI diets reduce risk of developing diabetes (Harvard nurses study)
    3. Low GI diets can increase HDL levels (British study on 1400 subjects)
    4. High GI diets encourage overeating
    5. High GI foods after sport rapidly replenish glycogen levels
    6. ? High GI diets linked to myopia


Glycemic Load

GL is a measurement of both the amount of CHO in a serve of food AND its GI. By
measuring both parameters a better estimate of the food‟s effect on BSL can be made.

Glycemic load is calculated as no. of grams of CHO in the serve x GI/100.

Therefore:

High GI food x large portion = high GL
High GI food x small portion = med or low GL
Low GI food x large portion = med or high GL

This means some foods with a high GI but that contain little CHO in a normal serve
will end up with a low GL (eg watermelon). Other foods with a low GI but a lot of
CHO in a normal serve will have a medium GL (eg spaghetti).

Low GL = less than 10
Medium GL = 11-19
High GL = 20 or more – these foods will raise BSLs most.



    How to reduce the glycemic load of your diet
    1. Bread: Choose wholegrain breads (eg BurgenTM, pumpernickel, sourdough,
       multigrain)
    2. Rice & pasta: Choose Basmati rice or rice noodles. Most pasta is low GI
    3. Potato: choose sweet potatoes
    4. Breakfast cereal: choose wheatbran, psyllium or oat based cereals
    5. Use more beans (including soy), peas, lentils, nuts instead of rice, potato, pasta
       staples



                                         TUTORIAL


                                                                                      71
Practice Question
Phyllis is 75 years old and recently had a polyp removed from her bowel. Her doctor
has advised her to follow a high fibre diet but she isn‟t certain what this means. Her
weight is 65kg (stable for past year) and height is 150cm.She is taking captopril for
her BP – currently 130/100. Sedentary lifestyle & supportive husband Reports good
appetite and yesterday ate: Orange juice, white toast and Rice Bubbles for breakfast;
sweet biscuit for morning tea, cheese sandwich on white bread for lunch, plain cake
for afternoon tea, roast chicken with white rice, green beans, grilled tomato for dinner,
ice cream for dessert, fruit juice for supper.
    1. Do a nutritional assessment of Phyllis
    2. What interventions might you suggest to meet the nutritional goal of
        increasing fibre intake?
    3. Phyllis has a list of questions for you about fibre:
            A. Which bran is best: wheat oat, barley or rice?
            B. Is a high fibre diet OK for my daughter (she has IBS)?
            C. Is wheat germ as good as bran?
            D. Will a high fibre diet help me lose weight?




   Example of increasing fibre in the diet:

   Low fibre                                        High fibre
   Breakfast              Fibre (g)            Breakfast             Fibre (g)
   Orange juice           0                    Whole orange          2.0
   Rice Bubbles           1.0                  Weet Bix              4.1
   Milk                   0                    Milk                  0
   Toast, white           0.7                  Wholemeal toast       2.1

   Morning Tea                                 Morning Tea
   Sweet biscuit          0.7                  Fruit cake            1.4

   Lunch                                       Lunch
   Cheese sandwich,       1.3                  Cheese and salad      4.7
   white bread                                 sandwich,
                                               wholemeal bread

   Afternoon Tea                               Afternoon Tea
   Plain cake             0.3                  Apple or pear         3.4

   Dinner                                      Dinner
   Roast chicken          0                    Roast chicken         0
   Rice, white            0.8                  Baked jacket          2.1
                                               potato
   Green beans            2.0                  Green peas            6.7
   Grilled tomatoes       1.4                  Corn on the cob       4.0


                                                                                      72
   Ice cream              0                     Fresh fruit salad     3.0

   Supper                                       Supper
   Fruit juice            0                     Fresh fruit           3.0
   TOTAL                  9.0g                  TOTAL                 36.5


Some tips for increasing fibre intake:

      Eat whole fruits instead of drinking fruit juices
      Substitute white rice, bread, pasta with brown and whole wheat versions
      Incorporate whole grain cereals for breakfast
      Snack on raw vegetables instead of chips, crackers or chocolate bars
      Substitute legumes for meat 2 to 3 times per week in chili and soups,
      Experiment with international dishes (such as Indian, middle-eastern) which
       use whole grains and legumes as part of the main meal (Indian dahls) or as
       part of salads (tabouli).

Prebiotics & Probiotics
Probiotics: Live microbes which can help restore the microbial balance in the intestine
and also induce beneficial effects (eg reduction of diarrhoea, boosting of immunity,
reduction of lactose intolerance, anti cancer activity). Consumed in fermented foods
or as freeze-dried supplements.
Yakult
Probiotic = Lactobacillus casei Shirota. Been used as a probiotic since 1955 and has
been shown to survive digestion and reach the large bowel intact. Most studies done
in animals. Promising for: diarrhoea prevention, stimulation of immune system,
prevention of listeria monocytogenes infection. Contains as much sugar as a small
apple to feed culture.

Nestle Yoghurt
Probiotic = Lactobacillus acidophilus johnsonii (sold as LC1). Effective for
gastroenteritis prevention, antibiotic associated diarrhoea, possibly reduces activity of
Helicobacter pylori.

Vaalia Yoghurt
Probiotic = Lactobacillus GG, L.acidophilus, Bifidobacterium. LGG is best studied &
appears most effective probiotic so far identified. Shown to decrease rate of dental
caries in children (inhibits growth of mutans Streptococci) and reduce GI and
respiratory infection in children. Most consistent probiotic in preventing
gastroenteritis.

Prebiotics: Selectively stimulate the growth or activity of one of the microbes in the
colon, therby improving health.

Vaalia Yoghurt
Prebiotic: Inulin. Oligosaccharide that is fermented to SCFA. This lowers the colonic
pH and has been shown to increase the solubility and hence absorption of calcium and


                                                                                         73
magnesium. Also stimulate growth of probiotics such as bifidobacteria. Currently
being researched for potential to reduce cholesterol levels.

Burgen‟s Rye for digestive balance
Prebiotic:Hi-Maize. Form of starch that is resistant to digestion. Instead fermented to
form SCFA.

See June 2001 American Journal of Clinical Nutrition for review of Probiotics.



Review Questions
What % of energy should CHO contribute to the diet?
What % of energy do most Australians get from CHO?
What are the 3 major classes of carbohydrates?
Is honey nutritionally superior to sugar?
Justify the dietary guideline “ Eat moderate amounts of sugar and foods containing
added sugar”
What is cellulose made of?
What are some of the physiological effects of fibre?
What are 3 diseases/conditions that a high fibre intake can assist?


                   Week 7: NUTRITION & DIABETES MELLITUS

Diabetes is the disease state caused by impaired carbohydrate metabolism. Can be due
to
   1. Insulin deficiency (Type I/ juvenile/ IDDM)
   2. Increased insulin resistance at the cellular level (Type II/ mature onset/
       NIDDM)
Other types include Gestational Diabetes Mellitus, drug induced diabetes and
malnutrition related diabetes.

Insulin          - is both anticatabolic and anabolic
                 - facilitates cellular transport
                 - has the opposite effect to the counteregulatory hormones
                      (glucagon, growth hormone, cortisol, adrenalin, noradrenalin)

The Effect of Insulin Deficiency
Glucose
    Reduced entry of glucose to muscle cells for glycogen synthesis and usage
    Reduced entry of glucose to adipose cells for synthesis of triglyceride fat
    Reduced activation of enzymes of glucose metabolism in hepatic cells
    Glucagon and adrenalin stimulate the liver to release glucose by converting
       glycogen to glucose

Fat
         Loss of stimulation of fatty acid synthesis
         Increased mobilization of fatty acids from triglyceride


                                                                                      74
      Rise in plasma lipids as lipoprotein lipase not activated

Protein
    Reduced transport of amino acids into cells
    Reduced aggregation of ribosomes so decreased protein synthesis
    Increased gluconeogenic enzymes
    Insulin/glucagon ratio falls, so increased gluconeogenesis
    Decreased rate of entry of K into cells

Rates of diabetes in Australia are increasing:
    Approximately 4% of the Australian population has diabetes
    For every diagnosed case there is thought to be one undiagnosed case.

Why are there so many cases of undiagnosed diabetes?

The normal blood glucose levels are 3.5 – 8 mmol/L. Symptoms only appear if blood
glucose is consistently above 15mmol/L.

Symptoms of high blood glucose levels:

1. Polyuria, polydipsia and glucosuria
            a) At BSLs >10mmol/l renal tubules no longer resorb glucose so glucose
               enters the urine
            b) Glucose is an osmotic diuretic so promotes the excretion of larger
               volumes of water and salts
            c) This excessive diuresis can cause dehydration and hence triggers the
               symptom of thirst.

2. Blurred vision
        a) High BSLs will cause fluid shifts in the chamber of the eye
        b) This affects the accommodating capacity of the lens
        c) Vision improves when BSLs decrease.

3. Fatigue and Hunger
    Lack of glucose in the cells = decrease in available energy for the body = fatigue
        Hunger = ? caused by the lack of glucose transport to the hypothalamus

4. Increased risk of infection
        High BSLs have a toxic effect on leukocytes so lower the body‟s resistance to
        infection.

5. Weight loss, ketonuria and ketoacidosis
        a) Glucose is no longer an adequate energy source for the body in states of
insulin deficiency
    b) Fat stores are mobilized so weight loss occurs.
    c) Ketone bodies are excreted by the kidneys as by-product of fat metabolism
        d) Ketone bodies must be excreted in the urine coupled to a base, so bases are
lost from the body and pH of tissues falls, acidosis develops.




                                                                                     75
       e) Untreated acidosis coupled with dehydration and electrolyte imbalances
(caused by the osmotic diuretic effect of excess glucose) will lead to a coma and
possibly death.

Diagnosis Criteria
In the presence of symptoms diabetes can be diagnosed as a fasting plasma glucose
>7mmol/L OR a random blood glucose > 11mmol/L.
In the absence of symptoms a glucose tolerance test should be done and should show
a fasting plasma glucose >7mmol/L, 1 hour plasma glucose > 11mmol/L and 2 hour
plasma glucose > 11 mmol/L.

Ideal blood glucose control
                     Ideal                 Intermediate          Poor
Preprandial BG       <6                    <8                    >10
(mmol/L)
Postprandial BG      <8                    <11                   >13
(mmol/L)
Urinary glucose      0                     0                     +
HbA1c                <7.0%                 7.1-9.0%              >9.0%
(glycohemoglobin)

HbA1c         - is the proportion of glucose – linked Hb
              - indicates the average blood glucose level over the previous 2
                   months
              - measures long term control of BSLs.
              - Two large intervention trials found the risk of diabetic
                   complications decreases as HbA1c falls.




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Classes of diabetes
Type 1 Diabetes (IDDM)
                         Genetic
                         susceptibility



 Viruses                                               ?Chemicals
                                                       ?Nutrition



      Autoimmune response


      Beta cell destruction



       Severe insulin deficiency


       Hyperglycemia & mobilization of fat stores


                           Production of Ketoacids

The typical characteristics of Type 1 diabetes are:
               - Ketonuria or ketoacidosis present
               - Rapid onset before 30 years
               - Moderate to severe symptoms
               - Significant weight loss
               - Lean
               - Immune markers of beta cell destruction eg GAD (glutamic acid
                   decarboxylase on surface of beta cells) autoantigen and GAD
                   antibodies present
These patients are dependent on insulin for survival.

Type 2 diabetes (NIDDM)
    Affects about 90% of Australian diabetics


                                                                                 77
      Genetics may predispose to the condition - certain populations (eg
       Aborigines, southern Europeans, Indians) more susceptible
      Lifestyle factors are also important as diabetes rates increase in traditional
       societies that change to a Western lifestyle of high fat food and little exercise.
      Beta cells are not destroyed and insulin continues to be produced.
      The key factor is insulin resistance.
      If body weight is reduced, symptoms improve

Disease progression:
            1. A reduction in available insulin receptor sites (common in obese
               people)
            2. A reduction in insulin binding to its receptor site
            3. Impaired glucose transport following attachment of insulin to receptor
            4. These cause peripheral insulin resistance & reduced glucose uptake
            5. Hyperglycemia evident
            6. Increased insulin secretion
            7. “Beta cell exhaustion” eventually occurs
            8. Impaired insulin secretion
            9. This causes increased FFA & glucose production
A state of complete insulin absence does not occur and hence Type 2s are not
dependent on insulin for survival. However diabetes inevitably progresses and may
eventually require insulin.

Characteristics of Type 2 diabetics
     Later onset of symptoms
     Central obesity (about 80% of cases have this)
     Dyslipidemia
     Hypertension
Approximately half the people diagnosed are asymptomatic and may be undiagnosed
for up to 6 or 7 years before long term complications will emerge and result in
diagnosis.

Syndrome X (the “metabolic syndrome” or “insulin resistance syndrome” )
At least 1 in 4 Australians has Syndrome X
It is characterized by:
              High insulin levels
              Excess fat around the abdomen
              Hypertension
              High blood TGs
              Low HDL cholesterol levels

Obesity is thought to be the cause of these symptoms:

   1. Adipose cells in the abdomen are more metabolically active, so release more
      TGs into the circulation. The TGs interfere with the activity of the insulin
      receptor, pushing insulin levels up. High insulin levels prevent adipose cells
      from efficiently extracting and storing TGs from chylomicrons and VLDL,
      further boosting TG levels.
   2. Obesity can also directly cause a rise in insulin levels. Adipose tissue in
      obesity produces less adiponectin (which increases insulin sensitivity) and


                                                                                       78
      more resistin (which decreases insulin sensitivity). Central adiposity is the best
      clinical marker of insulin resistance.
   3. Insulin resistance interferes with the normal dilation of blood vessels. High
      insulin levels promote sodium resorption, causing fluid retention and an
      increased blood volume. All these factors can promote high blood pressure.
      Syndrome X can lead to type 2 diabetes and CVD.


Impaired Glucose Tolerance
    IGT - blood glucose levels outside the normal range but it is not elevated
      enough to meet the criteria for diabetes.
    Often coupled with other components of the metabolic syndrome such as HT,
      obesity and dyslipidemia.
    10 year follow up studies have found that 1/3 of IGT patients will progress to
      type 2 diabetes, 1/3 will return to normal and 1/3 will remain IGT.

   Gestational Diabetes Mellitus
    Defines glucose intolerance that first occurs during pregnancy
    Onset is during the 2 nd or 3rd trimester
    Presents as marked insulin resistance
    Appears to be mainly due to the hormones human placental lactogen, human
      chorionic gonadotropin, progesterone and glucocorticoids.
    These have an anti-insulin action, thus preventing the uptake of glucose by
      cells.
    Maternal age, adiposity and inactivity can also contribute
    Occurs in about 3% of pregnancies in Westernised countries but up to 20% in
      populations with high rates of diabetes. At greater risk if relative has diabetes.

Risks of Gestational Diabetes
1.Foetal macrosomia
Glucose crosses the placenta so high maternal glucose levels can trigger the release of
insulin in the fetus, which stimulates growth. Fetal macrosomia is defined as a birth
weight above 4.5kg which increases risk of fetal death in utero, birth trauma,
respiratory distress syndrome, rebound hypoglycemia and jaundice.

2.Future risk of diabetes
About 50% of women who had GDM will develop Type 2 diabetes over the next 10
years.

Complications of Diabetes Mellitus

A. LONG TERM COMPLICATIONS

Microvascular Changes
    Occur as a result of damage to the capillary wall.
    Non insulin dependent tissues accumulate glucose during hyperglycemia.
      Rising intracellular levels of glucose leads to accelerated protein
      glycosylation.




                                                                                      79
      Microangiopathy is the result of the accumulation of glycosylated collagenous
       protein in the basement membrane of capillaries which thickens it and reduces
       its permeability to oxygen.

Retinopathy
    Causes about 25% of blindness in Australia
    Result of microangiopathy in the retina. This encourages the formation of new
       capillaries which tend to burst with consequent retina haemmorhage.
    Yearly eye checks are advised for diabetics.

Nephropathy
    Diabetic nephropathy causes about 25% of all renal failure in Australia.
    This is also caused by thickening of the basement membrane of the capillaries
      and will lead to microalbuminuria, then proteinuria and finally renal
      impairment.
    Control of hypertension delays progression.

Neuropathy
    Peripheral and autonomic neuropathy can result from the damage to the
      myelin sheath by elevated blood glucose levels. Peripheral neuropathy
      commonly leads to loss of sensation to the feet and toes which can cause
      injuries to go unnoticed/untreated.
    Healing of injuries is slowed by poor blood supply and infections are common
      in states of hyperglycemia.
    This increases the risk of gangrene and amputation.
    Autonomic neuropathy can result in postural hypotension, delayed gastric
      emptying and nausea, intermittent diarrhoea, bladder atony and impotence.

Macrovascular changes
   Main vessels affected are coronary, cerebral & peripheral arteries so increased
      risk of AMI, stroke, peripheral vascular disease.
   Dyslipidemia will further increase the risk of CVD.

Large studies in the UK and USA have shown that good control of BGLs is effective
at reducing risk of long term complications.

B. SHORT TERM COMPLICATIONS

Hyperglycemia
This is a BGL above 10mmol/l. The causes can include:
    medications which increase blood glucose (eg steroids)
    other illnesses and infections
    missed or insufficient insulin or OHA
    not enough exercise or changes to the eating pattern
    emotional stress

Hypoglycemia
This is a BSL below 3.5mmol/L. Only people treated with insulin or sulphonylureas
are at risk of hypos. The causes include:
     insufficient food or delayed meals


                                                                                    80
    physical activity without sufficient food
    excess insulin or sulphonylureas
    excess alcohol without food
Lack of glucose to the nervous system causes double vision, headache, tremor,
confusion and the sympathetic nervous response increases pulse, sweating and anxiety

Hypoglycemic unawareness can occur in people with long standing diabetes or
repeated episodes of hypos.

Treatment:
   1. If possible take a blood test to confirm hypoglycemia
   2. Take about 15 g of a fast acting carbohydrate (preferably glucose)

Eg 150 ml lucozade, 3 glucose tablets, 5 jelly beans or 150mls of lemonade. Repeat
after 5 minutes if symptoms not improving

   3. Take a slow acting carbohydrate to stabilize blood glucose eg piece of fruit or
      wholemeal bread.

If consciousness lost, intramuscular glucagon is required.

Management of Diabetes

MEDICAL MANAGEMENT

This is instigated immediately for Type 1 patients and when diet and lifestyle
changes have not improved BSLs of Type 2 diabetes patients.

Oral Hypoglycemic Agents:
Are used on Type 2 patients to stimulate the pancreas to release insulin
(sulphonylurea group eg gliclazide) or improve insulin action at the cellular level
(biguanide group eg metformin).
As diabetes progresses control of BGLs worsens and eventually Type 2 patient may
require insulin.

Type 1 patients depend on insulin. A typical regime may be 3 injections of rapid
acting insulin before each meal and 1 injection before bed of slow acting insulin. This
approximates physiological insulin production.

NUTRITIONAL MANAGEMENT

    1. Physical activity
Strongly encouraged for people with Type 1 and especially Type 2 diabetes as
associated with:
     Increased energy expenditure
     Improved insulin sensitivity
     Reduced hepatic glucose production
     Appetite suppression
     Changes in lipid levels
     Lowering of BP


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   Improved well being.




                           82
Exercise Guidelines
     Get medical check up first & start slowly
     Improved insulin sensitivity decreases after 48 hours so regular exercise is
        needed
     Blood glucose monitoring pre and post exercise allows the individual to adjust
        insulin or carbohydrate intakes.
     Type 1 diabetics should not exercise if BSL >15mmol/L
     Moderate exercise of <30 minutes rarely needs additional CHO or decreased
        insulin, but a snack is recommended if BSL is <6mmol/L
     1 hour of exercise requires an additional 15g of CHO (eg piece of fruit or
        sandwich either before or after exercise)
     Strenuous exercise requires an additional 30gm of CHO and a small decrease
        in the insulin dose for that time period
Diabetic athletes should keep training diaries to monitor BSLs before, during and
after exercise, food and fluid consumed, duration & intensity of exercise, insulin
dosage.

   2. Weight loss
    Weight loss is the first line of treatment for Type 2 diabetics
    Weight loss is associated with improved insulin sensitivity Small weight
      losses of only 4-5 kgs can still improve insulin sensitivity and improve lipid
      profiles and hypertension
    Clients should be reassured that improvements in diet and exercise will still be
      beneficial in reducing their risk of complications, even if they do not manage
      to lose weight.
    Type 1 diabetics also should avoid becoming overweight because of the
      increased tendency of hyperlipidemia, hypertension and increased risk of
      atherosclerosis.

High carbohydrate, low fat diets
Diets low in fat (<30% of energy), high in fibre (>30gm/day) and carbohydrate
decrease fasting and average BSLs, increase insulin sensitivity, increase satiety and
maintain or reduce lipid levels. This type of diet is not easy to follow. Aimed at
reducing weight & chol but often pushes up TGs

High monounsaturated fat diets
Epidemiology studies have shown Mediterranean diets decrease post prandial BG,
decrease mean BG, increase insulin sensitivity, decrease fasting and postprandial
TGs, maintain HDL cholesterol, decrease BP, reduce weight and abdominal weight
and are easier to comply with.

A Mediterranean diet includes:
    Red meat 1-2 times/month
    Sweets, eggs, poultry, fish a few times/week
    Cheese, yoghurt, olive oil, fruit, legumes, vegetables, breads, rice, pasta,
      polenta or couscous / everyday
    Good choice if not overweight or similar to usual diet




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                              High carb, low fat diet       Mediterranean diet
Total fat                     20-30%                        40-50%
Saturated fat                 10% or less                   10% or less
Polyunsaturated fat           10% or less                   10% or less
Monounsaturated fat           10% or less                   20-30%
Carbohydrate                  50-60%                        30-40%
Protein                       10-20%                        10-20%

Protein
It is recommended that diabetics have at least 0.8 g/kg bodyweight and protein
contribute 10-20% of their energy intake.

Fat
Limiting fat intake is important for 2 reasons:
1. The most common complication of diabetes is CVD, and saturated fat in particular
has been linked to the progression of CVD.
2. A high fat intake is associated with increased weight, and excess weight decreases
insulin sensitivity

Saturated fat intake should be less than 10% of energy intake as it is associated with
increased total and LDL cholesterol and triglycerides.
Polyunsaturated fats should also make up less than 10% of energy intake.
Same recommendations as CVD.
Fish intake recommended as shown to reduce clotting tendency and reduce risk of
CVD. Omega 3‟s can help insulin resistance.

How to maximize omega 3‟s:
  1. Eat oily fish (tuna, salmon, sardines, trout) regularly. White fish has about ¼
      the omega 3 content so still of some benefit
  2. Use canola or flaxseed oil for cooking
  3. Use canola margarine as a spread instead of saturated fat in butter, cream,
      cheese
  4. Also minimise omega 6 polyunsaturates (use less safflower, sunflower, corn
      oil, polyunsaturated margarine)
  5. Eat dark green leafy veg each day, as part of 5 serves of fruit and veg
  6. Include soy foods, omega enriched eggs, walnuts, pecans, linseeds, all of
      which are high in omega 3‟s.


Sucrose
    Sucrose is no longer a focus for management as it does not provoke a large
      rise in blood sugars in moderation.
    Recommended sucrose contribute <10% of overall energy
    Preferably eaten in nutrient dense foods (small quantity of jam on wholemeal
      bread) rather than lollies or soft drinks.
    “Non nutritive” sweetners recommended
    They provide very little extra energy, don‟t affect BSLs.



                                                                                         84
      Include saccharin, cyclamate (these no good for cooking) aspartame,
       sucralose, alitame, acesulfame K.
      “Nutritive” sweetners can affect BSLs, so not recommended. Include sorbitol,
       mannitol, xylitol, isomalt, polydextrose, fructose, lactose.

Carbohydrate
Starchy carbohydrates (eg porridge, bread, rice, pasta, potato, legumes)   - should
be included in each meal
               - should make up at least ¼ of that meal
               - should be spread evenly throughout the day.
Therefore regular meals are important for diabetics.
They also must have a bedtime snack if taking insulin to avoid hypos in the night.
Timing of meals and activity can be varied but the insulin regime must also be varied.

Glycemic Index
Practical advice: Include 1 low GI food in each meal, but remember fat lowers the GI
of foods, and foods high in fat are not recommended for diabetics. Also each person
responds individually to various foods so the GI value is only a guide.

Fibre
    ? soluble fibre slows the rate of digestion and absorption of carbohydrate and
      hence assists with BGL control and improves lipid profiles.
    Fibre increases satiety without a large increase in energy intake, which assists
      with weight loss
    Recommended: At least 30g fibre/day. Wholegrains, fruit and vegetables, high
      fibre breakfast cereals etc promoted.

Alcohol
    Alcohol causes hypoglycemia in people taking insulin or sulphonylureas. This
      is because alcohol inhibits gluconeogenesis and augments the action of
      insulin. Hypoglycemia is more likely if alcohol is consumed without CHO or
      after exercise.
    Recommended: A limit of 1-2 standard drinks/day with 2 alcohol free days a
      week. Consumption of CHO with alcohol, preferably as a meal but if no other
      sources of CHO are available chips, corn chips or regular soft drinks can be
      used as a source of CHO. Alcohol should be avoided when diabetes is
      unstable.

Summary
    NIDDM can initially be managed by a healthy diet (low in fat, high fibre,
     regular CHO) & exercise, without needing medication.
    Newly diagnosed diabetics need to see a dietitian or can do a Diabetes
     Education course (see local hospital or community health centre).
    Timing of meals important: aim for 3 meals and 3 snacks spread evenly
     throughout the day so carbohydrate intake even.
    Weight loss will improve blood glucose and may reduce medication needed.
      Regular daily exercise is essential to help reduce abdominal fat and insulin
       resistance of muscle tissue.



                                                                                      85
                                     TUTORIAL

Practice Question
Steven has come in for a consultation and his medical history shows that he is being
treated for the metabolic syndrome by his GP. His waist measurement is 120cm, his
weight is 125kg, height 190cm. His usual diet consists of skipping breakfast, coffee
and cake for morning tea, a takeaway from the local Indian restaurant for lunch, a
large portion of red or white meat for dinner with a salad, 3 or 4 glasses of wine with
dessert and chocolate in the evenings. He does no organised physical activity.

4a) Besides abdominal obesity and raised triglycerides, list 3 other symptoms of the
metabolic syndrome? (3 marks)
4b) Explain how obesity can contribute to the metabolic syndrome. (9 marks)
4c) What is a specific dietary change that may lower TG levels? (1 mark)
4d) Why is it important to identify and treat the metabolic syndrome? (2 marks)

   What is Glycemic Index and Glycemic Load?

                  GI is a way of classifying foods containing carbohydrate. Since
                   there is no rate limiting step in the conversion of polysaccharides
                   into glucose, foods high in polysaccharides (“complex
                   carbohydrates” or “starchy” foods) can be capable of increasing
                   blood glucose levels to the same extent as simple sugars.
                  GI is formally defined as the incremental area under the blood
                   glucose curve after consumption of 50g of CHO from a test food
                   divided by the area under the curve after eating a control food
                   containing 50g of CHO. Therefore GI is a meaure of how quickly a
                   food is digested and absorbed. High GI foods cause a rapid rise in
                   blood sugar levels, and a corresponding large release of insulin.
                  In general, refined grain products have a high GI, legumes and
                   unprocessed grains have a moderate GI and nonstarchy fruits and
                   vegetables have a low GI.
                  Glycemic load is the GI x carbohydrate content, which takes into
                   account some foods may have a high GI but contain little CHO (eg
                   carrots), hence have little effect on BSL.

           Evidence supporting consumption of low glycemic load diets:
               High glycemic load diets consumed long term shown to increase
                 risk of developing type 2 diabetes & CVD (Harvard Nurses study);
                 increase HbA1c in type 1 diabetics (European study)
               Low GI diets linked to higher HDL cholesterol measures.
               High GI diets associated with low HDL, high TG,
                 hypercoagulation, colon cancer, breast cancer.
               Diabetics shown to improve HbA1c on low GI diets, CVD patients
                 improve lipids on low GI diets.

           Arguments against use of GI:
               Mainly a political stance in USA – because most GI research was
                done in Canada & Australia, Americans dismissed it.



                                                                                       86
                  Also some concerns that high fat foods have low GI values so
                   might seem to promote these.
                  No very long term prospective trials done on GI yet as relatively
                   new area of research.
                  GI is used in Australia to help diabetics, athletes, CVD patients,
                   obesity patients with weight loss, but not supported by American
                   Diabetes Association or American Heart Foundation.

GI needs to be used to compare food choices within the same food group (in the same
manner as the Healthy Heart Tick).

Review questions:

1.What are the acute physiological problems of a patient who has just developed type
1 diabetes?
    2. What are the possible long term complications which may develop over a
        period of years in the patient with poorly controlled diabetes?
    3. What are the signs and symptoms of hypoglycemia?
    4. What are the causes of hypos?
    5. How would you treat hypoglycemia?
    6. How would you decide if the BSL control of your client was satisfactory?
    7. Why is fat an important macronutrient in diabetes management?
    8. Why is weight control the central plank of T2 diabetes management?
    9. Should sucrose be consumed by diabetics?
    10. Should artificial sweetners be used by diabetics?
    11. What are the risks associated with gestational diabetes?
    12. What are some exercise guidelines for diabetics?
    13. Which diet is better for diabetics – high CHO, low fat or high MUFA,
        moderate CHO?
    14. Your client wants to take fish oil supplements to help his RA. Given he is also
        diabetic, what advice would you give him?
    15. How is GI calculated?
    16. What are some of the factors that influence GI values?

Multiple Choice

   1. Insulin acts to: (Choose the false answer)
          a. Increase gluconeogenesis
          b. Increase glucose entry into the cell
          c. Increase amino acid uptake by the cell
          d. Increase fat metabolism


   2. Information required to help differentiate the diagnosis of Type 1 and Type 2
      diabetes include
          a. age at diagnosis, weight at diagnosis, blood glucose levels
          b. blood glucose level, age at diagnosis, presence of ketones
          c. age at diagnosis, weight at diagnosis, presence of ketones
          d. urine glucose level, insulin levels, presence of weight loss



                                                                                        87
3. The initial treatment plan for an obese person with Type 2 diabetes should be the
introduction of:
    a. An oral hypoglycemic agent
    b. A weight reduction program
    c. Both a and b
    d. A controlled CHO intake

           4. In all cases of Type 1 diabetes it is important to monitor blood glucose
               and:
   a.   Serum potassium
   b.   Serum cholesterol & triglycerides
   c.   Pancreatic amylase
   d.   Urinary ketones
   e.   Both b and c
   f.   Both b and d

  5. Choose the true statement:
   a. GI is a method of measuring an individual glucose and insulin response to a
      CHO containing food
   b. GI is an alternative way to measure CHO intake
   c. A high GI food should give a slower, flatter response than a low GI food
   d. GI research shows that equivalent amounts of CHO from different foods elicit
      different glycemic responses.




                                 Week 8: PROTEIN



                                                                                       88
Protein Structure

      Proteins consist of amino acids linked by peptide bonds.
      The primary structure of a protein is the amino acid sequence. Secondary
       structure refers to helices, coils or pleats that form as they fold up.
      The overall structure is its tertiary structure.
      “Simple” proteins consist only of amino acids.
       “Conjugated” proteins: a non protein component is attached to help facilitate
       its function eg iron in haemoglobin, lipid in lipoproteins.

Protein Function

Used for anabolic process of building/maintaining tissues; as an energy source
(17kJ/g); formation of enzymes and hormones; as antibodies; in transportation eg
lipoproteins, albumin; maintain normal osmotic relations in body fluids (eg low
albumin will cause oedema).

Essential and Non Essential amino acids
Essential             Conditionally Essential              Non Essential
Arginine              Proline                              Glutamate
Leucine               Serine                               Alanine
Isoleucine            Tyrosine                             Aspartate
Valine                Cysteine                             Glutamine
Tryptophan            Taurine
Phenylalanine         Glycine
Methionine
Threonine
Lysine
Histidine

Essential = body synthesis inadequate to meet metabolic needs. Deficiency causes
weight loss, impaired growth, and amino acid specific symptoms.
Non essential = can be synthesized from essential amino acids or from other
precursors
Conditionally essential = Essential under some clinical conditions eg taurine, cysteine
for preterm babies.

Special functions of amino acids

Tryptophan = precursor of niacin and serotonin
Methionine = required for synthesis of choline and carnitine
Phenylalanine = precursor of tyrosine, thyroxine, adrenalin
Tyrosine = precursor for melanin
Glycine = combines with toxic substances to convert them before excretion
Histidine = precursor of histamine


Hormonal regulation of protein levels




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      Growth hormone stimulates protein synthesis
      Insulin stimulates protein synthesis by accelerating amino acid transport
       across cell membranes
      Testosterone stimulates protein synthesis during growth periods
      Glucocorticoids stimulate gluconeogenesis & ketogenesis from proteins
      Thyroxine increases rate of metabolism of all cells, so protein metabolism is
       increased

Protein metabolism

  Food proteins                     Synthesis                    Tissue proteins,
                                    of non                       hormones,
                                    essential aa                 enzymes etc
            Digestion,
            absorption


                               Amino Acid pool


       Renal excretion                                        conversion


                                                                  Essential nonprotein
  Excess                                                          nitrogenous tissue
                                Transamination,
  amino acids                                                     constituents
                                Deamination


                                Keto acids

                                Oxidation                                       Ammonia
                                Glucose, ketone                                 Urea
                                bodies
                                                                                Urine
                                Acetyl CoA, citric
                                acid cycle

                                        ATP




                                                                                       90
Complementary proteins
   Animal protein sources (meat, egg, milk, fish) are of very high quality (a small
     amount in the diet will provide adequate levels of all amino acids).
   For vegetarians the issue of protein quality is more important. Plant sources of
     protein tend to contain a limiting amino acid, the amino acid present in the
     smallest quantity.
   Eating a combination of protein sources reduces the risk of deficiency in an
     essential amino acid.
   EG cereal protein is low in lysine, rice is low in threonine, whilst legume
     protein is limited in methionine, so by combining grains with legumes
     adequate protein is consumed.
   This is known as the complementary protein principle.

Recommended dietary intakes
Based on nitrogen balance studies done pre-1985.
0.75g/kg of high quality protein was felt sufficient to meet the needs of 97.5% of the
adult population (includes large safety margin).
Unethical to do such studies on children so their requirements RDIs based on
measured intake of protein.
Infants under 6 months = 2.0g/kg ideal bodyweight/day
7-12 months = 1.6g/kg day, 1-3 years=1.2g/kg,
4-18 years= 1.0g/kg.
Athletes may need higher protein intakes – up to 2.5g/kg day if increasing muscle
mass. Easily obtained by diet.
During illness or injury a hypercatabolic state can occur, which causes an increase in
metabolic rate and an accelerated loss of body protein. There is increased production
of stress hormones, cytokines, eicosanoid hormones, and increased production of
acute phase proteins.
 Coupled with a poor food intake, a deficiency in energy intake and protein can occur
& inhibit recovery.
Therefore patients with injury/mild trauma require 1.0-1.5g /kg bodyweight/day;
severe stress/trauma 1.5-2.0g/kg bw/day; surgery/fractures/growth period/pregnant
1.0-1.5g/kg bw/day.

Food sources of protein
    Animal: milk, eggs, meat, fish
    Legume: peanut, soybean, beans, peas, lentils
    Cereals: rice, wheat
    Fruits & vegetables: small amounts

Conditions of low protein intake

1.Kwashiorkor (word from Ghana)
Not be seen in Australia but is the classic disease of protein deficiency.
Age of onset typically 1-4 years.
Caused by diets low in protein, which is of poor quality. Extreme protein deficiency
leads to hypoalbuminaemia, oedema, enlarged fatty liver. Muscle wasting that occurs
is often masked by the oedema.
Often occurs in conjunction with energy deficiency, in which case called Protein
Energy Malnutrition.


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2. Vegetarianism
Part of several religious faiths or philosophical movements (Seventh Day Adventists,
Buddhists, Catholic Trappist monks, Hare Krishnas). Also chosen for ecological
beliefs, health reasons, economic reasons or opposition to animal cruelty.

In general, vegetarians have lower LDL cholesterol, are less likely to suffer heart
disease, breast, bowel and lung cancer, have lower BP, weigh less and have a lower
risk of type 2 diabetes.
Reasons: ?higher intake of fibre ?lower intake of fat ?lower intake of high GI foods
?more antioxidants ?less likely to smoke ?drink less alcohol & caffeine ?less stressed

Types of vegetarian diets:

Vegans – avoid all food of animal origin. Diet based on grains, nuts, legumes, fruit
and vegetables. May also avoid products made from or tested on animals.
Lacto vegetarians – avoid meat and eggs but include dairy foods
Lacto ovo vegetarians – avoid meat, but include eggs and dairy foods. Best choice for
vegetarians who are pregnant, breast feeding, or still growing as easiest to meet
nutrient requirements
Semi vegetarian – Has occasional fish or chicken in diet.
Fruitarian – Eats only fruits and nuts. Real risk of nutrient deficiencies.
Macrobiotic – Excludes all animal foods, dairy products, eggs. Uses only
unprocessed, unrefined, organic cereals, grains, fruits and vegetables.

Potential nutrient deficiencies in a vegetarian diet:
    1. Protein
Most vegetarians have sufficient protein to easily meet the RDI, especially if they
include eggs or dairy products. Vegans may be potentially at risk of protein
deficiency, especially if pregnant, breastfeeding, a baby, child, teenager or an athlete.
Important 2 different plant protein sources are eaten in combination to complement
each other, as each will be limiting in a different amino acid. Mixed proteins sources
should provide a sufficient quality & quantity of amino acids. Legumes should
probably comprise about 15% of dietary energy as they are a good quality source of
protein & complement cereal by providing lysine. A mixture of 70:30 cereals to
legumes has been suggested as ideal. Nuts and seeds are also a good source of protein
to include. Examples of good protein combinations: pea soup with bread, pasta with
bean and vegetable sauce, Lebanese bread dipped in hommous, Indian lentil dhal with
rice or chappati.
Key message is have a variety each day of protein foods. Child vegans need energy,
protein dense foods – nuts, cereals, legumes, with less emphasis on fruit and
vegetables.

   2. Vitamin B12
             Found in milk cheese, yoghurt and eggs, vegans especially at risk of
    deficiency, many vegetarians low.
             Frank deficiency causes pernicious anemia and nervous system
    degeneration. Mild deficiency can elevate homocysteine levels and hence CVD
    risk.




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              3-5 year‟s supply stored in the liver, so deficiency rare in adults, but
     can occur in breast fed babies of vegan mothers. Pregnancy will deplete her
     stores, and result in B12 deficient breast milk.
              Vegans need B12 fortified soy milk or a supplement (2
     micrograms/day sufficient). Vitamin B12 in supplements is derived from
     bacteria.
              Fallacy that mushrooms are “meat for vegetarians” and contain
     adequate amounts of B12 due to bacterial contamination present on them.
     Mushrooms, tempeh, seaweed, Guinness, spirolina etc are not reliable sources of
     vitamin B12. No vitamin B12 in vegemite.

3. Iron
      Vegetarian diets usually high in vitamin C, helps with the absorption of non
        haem iron, although those with high iron needs (menstruating women,
        pregnant women, young children) may need a supplement.
      Vegans may struggle to obtain adequate iron and calcium, so a fortified soy
        milk should be chosen.
      Vegetarian iron sources: iron enriched breakfast cereals, dark green leafy
        vegetables, beans, lentils, dried fruit, cocoa powder.

4.Calcium
Non dairy calcium sources: fortified soy milk, green leafy veggies, tahini, almonds,
Brazil nuts, hazelnuts, tofu, dried figs.

5.Zinc
Vegetarian zinc sources: wholemeal and grain breads, bran, wholegrain cereals, zinc
fortified breakfast cereals (eg CocoPops, Sultana Bran), pulses, nuts.

Vegan diets can be used by children, but adequate supplies of B12, protein, energy,
iron, zinc, calcium need to be given – most vegan children are at the low end of
normal for growth. Use small meals and frequent snacks to help children meet their
requirements. Include full cream soy milk & chop or grind nuts and seeds to aid their
digestion. Emphasise grains, nuts, legumes over fruit & veg.

Example of adequate diet for Vegans
Food group                                   Serving number for adults (add 1 extra
                                             serve in each group if pregnant)
Breads preferably wholegrain (1 slice = 1    5
serve )
Cereals:wheat flakes, flour, bulgur,
wheatgerm, rice, oatmeal, pasta, breakfast
cereal (1 serve = 100g when cooked)
Citrus fruits (including juices) (1 serve=  1
120g fruit or 120ml juice)
Dark green or deep orange veg (broccoli, 1
kale, dried apricots, carrots etc) (1 serve
= 100g cooked)
Other fruits and veg (apple, potato,        5
tomato, banana, raisin, sweetcorn,



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avocado) (1 serve= 100g cooked or raw)
Pulses:lentils, soya, beans, split peas,      2
tofu, tempeh, peanuts (1 serve =100g)
Nuts and seeds: sunflower, sesame,
pumpkin seeds, tahini (1 serve=30g)
Fortified soya milk (1 serve = 250ml)         2
Vegetable oils and spreads: soya, olive,      3
canola (1 serve = 1 teaspoon)
B12 vitamin supplement                        1

High protein diets (based on work of Dr Neil Mann, RMIT)

A true high protein diet consisting almost solely of protein will kill you. American
early settlers who ate only wild rabbit suffered nausea, diarrhoea, death due to
hyperammonemia & hyperaminoacidemia.

Many so called “high protein diets” are really low carb or high fat or low energy,
combined with a moderate protein intake.

EG Atkins diet = 27% protein, 5% carb, 68% fat
Zone diet = 34% protein, 36% carb, 29% fat
Sugar Busters = 27% protein, 52% carb, 21% fat
Compare to
Paleolithic diet (est.) = 37% protein, 41% carb, 22% fat

Some interesting facts:
    1. During 2002 recognition that “high fat diets cause heart disease” has no good
        scientific evidence to support it. Furthermore it ignores other dietary factors
        and the importance of genetics in CVD.
    Saturated fat causes an increase in cholesterol, and this increases the risk of
    cholesterol contributing to atheroma formation and hence heart disease, but there
    is no evidence that a diet high in saturated fat by a person not already at high risk
    of CVD will shorten their lifespan.
2. High protein, controlled fat diets reduce cholesterol levels
3. High CHO diets increase the proportions of small dense atherogenic LDL, increase
TGs and decrease HDL.
4. Prospective cohort study of 80,000 women found that replacing high GI
carbohydrate choices with protein foods reduces IHD.

All these facts support a shift away from promoting low fat diets, and towards
promoting a diet more similar to that which we evolved on (low GI foods, moderately
high in meat & protein, low in saturated fat, relatively high in omega 3 fats, low salt).
Our ancestors also had a low stress, smoke free, active lifestyle which also decreased
their risk of Syndrome X conditions (obesity, diabetes, HT) prevalent in industrialised
societies.

Diets in human evolution:
Primitive stage (2 million years): low saturated fat, mod. high protein, low GI diet (no
grains, legumes or dairy)



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Agriculture (10,000 years) : high unrefined CHO, low fat, low GI diet (wholegrains,
some meat & dairy)
Industrial revolution (200 years): high refined CHO, high GI
Fast food revolution (40 years): high refined CHO, high saturated fat
Modern hunter gatherers: Have a high reliance on animal foods plus high fibre wild
plant foods. Similar macronutrient content to Paleolithic diet.
Almost all modern hunter gatherers experience Type 2 diabetes if follow a Western
diet (ie shift from moderately high protein to high CHO diet).
Hypothesised this is because they are prone to insulin resistance. During feast/famine
cycles it is a survival advantage to be insulin resistant as this means excess energy is
more easily stored as fat. Also redirects glucose to brain and fetus instead of muscle
cells.
This suggests we are genetically unsuited to a Western style diet. Example of „modern
Paleolithic” diet:

Breakfast                                       Dinner
Half cantaloupe,                                2 lean pork chops, broccoli, salad
200g salmon                                     Dessert
Lunch                                           Fresh blueberries & almonds
Shrimp (7) & vegetable salad
Late snack:
Nuts, fruits and cold lean chicken

Nutrient               Daily Intake          %Energy
Energy                 8820kJ
Protein                170g                  32
Carb                   142g                  27
Fat                    100g                  40
Saturated fat          17g                   7
MUFA                   50g                   20
PUFA                   33g                   13
thiamin                4.6g                  417
riboflavin             3.6g                  281
Vit C                  559g                  932
Vit D                  0                     0
Vit A                  6860 RE               850
Vit E                  26.5mg                330
sodium                 813mg
potassium              8550mg
calcium                890mg                 110
iron                   21.5mg                143
zinc                   19.8mg                165
fibre                  47g




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Potential concerns with a high protein intake:
    Safety of protein intakes above 2.5g/kg bodyweight is unknown
    High protein metabolism results in increased urinary urea load and increased
       potential renal acid load hence subsequent calcium loss in urine is possible. A
       high intake of fruit and vegetables will make urine more alkaline to prevent Ca
       loss. Mineral waters high in bicarbonate (eg Evian) will also counteract acid
       urine.
    Does high protein intakes increase homocysteine levels - untrue
    Does high meat intake means high saturated fat intake as meat is fatty –
       Australian meat is lean
    Is a state of ketosis is dangerous? – ketosis is a normal state for humans in
       response to a food shortage. Ketone bodies are a more efficient fuel for the
       CNS & heart than glucose. It is ketoacidosis which is dangerous.

High protein diets and weight loss
    Fat loss requires lipolysis and oxidation
    For lipolysis of fat stores to occur, need low levels of insulin
    High GI CHOs most effective at increasing insulin levels
    As a result CHOs are oxidized in preference to lipids.
    Lipids are oxidized most efficiently when blood glucose and glycogen stores
       are low, hence insulin is low
    This can be achieved by fasting, exercise and/or limiting CHO intake
       (especially high GI carbohydrate)
    Paleolithic diets had low GI



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      Remember, a “diet” will probably cause weight to yoyo. Instead need to
       commit to a lifestyle change of eliminating refined CHO and replacing with
       fruit, veg, nuts, fish and meat

                                     TUTORIAL

Practice Question
Julia is 13 years old and has decided to become a lacto ovo vegetarian. Her mother
has brought her to see you, as she is very concerned Julia won‟t be meeting all her
nutrient requirements if she cuts meat & fish out of her diet. Her weight is 45kg,
height 155cm. She eats a yoghurt and 1 slice of toast with Vegemite for breakfast, has
biscuits with milk for morning tea, lunch is a cheese & salad sandwich, after school
snacks are fruit & muesli bars, and for dinner she has been eating the family meals but
avoiding the meat. She participates in school sports for an hour twice a week.

   1a) Which nutrients are vegetarians at higher risk of deficiency? Suggest a good
   food source of each nutrient that would be acceptable to a lacto ovo vegetarian. (5
   marks)
   1b) Explain the complementary protein principle, and how Julia could apply it to
   her evening meals. (3 marks)
   1c) How can she ensure an adequate iron intake as a vegetarian? What are 2
   components in food that can inhibit iron absorption? (4 marks)
   1d) What are 3 diseases that vegetarians are at lower risk of developing? (3 marks)


                                 Vegetarian Athletes

      Endurance type athletes tend to become vegetarian to meet high CHO
       requirements or help with weight control.
      Be aware some female athletes use vegetarianism as an excuse to mask an
       eating disorder.
      Encourage a wide intake of foods high in protein and CHO in each meal.

Always check:
1.Why an athlete has become vegetarian (may have erroneous dietary beliefs). Moral
or religious beliefs need to be respected.
2. Style of vegetarianism athlete follows. Vegan diets should be closely checked for
nutritional adequacy.

Nutrients of concern
A.Energy
If recent vegetarian, may struggle to maintain energy intake as vegetarian diets
generally less nutrient dense. Ask if been maintaining weight on vegetarian diet.
Energy dense, low bulk foods include tofu, TVP, fruit juices, dried fruit & nuts, nut
spreads, honey and jam.
B. Protein
Tends to be lowest for lunch. Athletes have limited cooking time, so baked beans,
tahini or peanut butter sandwiches, luncheon meat substitutes made from wheat gluten
are quick, high protein lunch choices.



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C. Calcium
Recommend fortified soy milks, yoghurts & custards, fortified breakfast cereals,
broccoli, kale, bok choy.
D. B12
 Fortified soy milk or a supplement required.
E. Iron
FBE (Hb, transferrin, ferritin) should be checked for all vegetarian athletes. Fortified
breakfast cereals, some breads, gluten based meat substitutes, dried fruit, dark green
leafy veg. Consume with vitamin C.

More information: www.sanitarium.com.au.

                                    Health foods
Generally understood to be foods which are grown organically, processed as little as
possible and contain no added preservatives, artificial colours or flavours.
All foods could be regarded as “health” foods if part of a balanced diet - a food
legally cannot use the word “health” as part of its brand name for this reason
Most Health Food shops also sell a wide range of vitamins, minerals and other dietary
supplements.

How Health foods are marketed:

      Labelled “natural” “wholesome” “pure”
      Claimed our soils are depleted of nutrients (untrue)
      Claimed vitamin & food supplements needed because our food supply is
       deficient in nutrients (untrue)
      Claimed our food supply contains chemicals which are poisons
      Use of testimonials from customers
      Use of celebrities/sportspeople for endorsements
      Supported by books by health food gurus

Types of “Health” Food:

Complementary Medicines
   Are allowed to be presented as alternatives to Western medicines & can make
      medicinal claims.
   The strength of the claim on label must match the supporting evidence eg
      strong claim = randomised clinical trial.
   Must have AUST-R or AUST-L number on label.
   AUST-R = registered medicine: pre market safety, quality & EFFICACY
      established
   AUST-L = listed medicine: pre market safety & quality established
   If AUST number not on label, AVOID as safety & quality unproven.

Organic food
    Method of farming that is sustainable and environmentally sensitive.
    Food is pesticide free (independent yearly surveys show non organic food
       contains either zero or trace quantities of pesticides)


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      No difference in nutrient composition to non organic food

Yeast
    Dried yeast is the richest source of 7 B group vitamins
    However it doesn‟t match our vitamin B requirements perfectly – eg 1tbsp
      bakers yeast has 20% of our biotin RDI but 400% of folate RDI
    Cheaper sources of B group vitamins are wheatgerm and unprocessed bran

Royal jelly
     Secretion from the salivary glands of bees
     Used as rejuvenator. Severe allergic reactions can occur & can take 2 or 3
        exposures before they occur
Spirulina
     A plankton, claimed to be a rich source of vitamin B12.
     Actually high in vitamin B12 analogues which are of no value to humans

Kelp
Rich in iodine, claimed to help slimmers burn fat (no evidence). Occasionally batches
withdrawn due to high levels of arsenic.

Carob
    From dried pods of the Middle Eastern carob tree.
    Carob powder has less fat then cocoa powder & no caffeine or theobromine
      (stimulants in cocoa).
    Carob chocolate bars have as much fat and kJ as chocolate.

Coffee substitutes
    Made from roasted barley or chicory. Useful if sensitive to caffeine.

Muesli bars
   More fibre, vitamins & minerals than chocolate bars
   Honey, glucose & other sugars usually make up about 50% of bar by weight

Guarana
Made from guarana seeds. Contains caffeine like substances which have same effect
on body, so can decrease perception of fatigue, increase heart rate.

Laetrile
Extract of apricot kernels, also known as amygdalin or vitamin B17. Has been
claimed to cure cancer. Can be metabolized to cyanide so dangerous to humans.

Aloe vera
Known to be beneficial externally, but benefit of eating it as general tonic unproven.




                                                                                     99
                       Week 9: FAT SOLUBLE VITAMINS

      Vitamins (“vital amines” 1912): organic compounds found in small amounts
       in food. Each has a specific & essential function in the body.
    Vitamins (except D) cannot be synthesised by the body, so a dietary
       deficiency will cause a vitamin deficiency disease.
    Frank vitamin deficiencies are very rare in Australia, however the extent of
       subclinical deficiency is very hard to define and hence determine. This
       subpopulation is at nutritional risk in that they are consuming suboptimal
       doses of vitamins – whether this is having a functional effect is hard to
       quantify.
    Deficiency in one vitamin can interfere with the function of another, whilst
       excessive intake of a vitamin can have toxic effects.
    In the Asia Pacific region, people with frank deficiencies in vitamin A, B1, B2
       and folate can be still be found.
    Individuals with hypervitaminosis also exist.
    Ideally should obtain vitamins from food as they are provided in conjunction
       with other complementary nutrients & there is little chance of overdosing.
    Vitamin pills are consumed regularly in Australia by about 25% men, 35%
       women. Why?
           o May feel food supply is nutrient depleted
           o May feel their diet is inadequate
           o May believe benefits come from higher doses
           o Appeal to both “natural medicine” and “evidence based medicine”
               supporters
So many contradictory studies can pick and choose those you like to support vitamin
supplement use, and be reassured that what are taking is “natural” so must be good for
you.

Vitamin classification
    Classified by their solubility in water – fat soluble (ADEK) and water soluble
      (B-complex, C).
    Could also classify by function: B complex vitamins tend to be involved in the
      metabolism of nutrients for energy release, vitamins B12 and folate are
      required for synthesis of DNA; vitamins AEC are antioxidants.

                                 Fat Soluble Vitamins
      These are digested and absorbed in the same manner as fat, so any conditions
       of fat malabsorption will limit absorption of these vitamins.
      Can be stored in the body (generally in the liver) so deficiency states take
       longer to set in than for water soluble vitamins. However this also means large
       doses are more likely to produce toxic outcomes as they are stored not
       excreted.


                                                                                  100
      Also tend to be more robust in cooking and are not lost in cooking water.

Vitamin A
     Is present in 2 forms in food – as the preformed vitamin itself (known as
       retinol) and in the provitamin form, the carotenoids. Most common carotenoid
       is beta carotene.
     Retinol is found almost exclusively in animal foods containing fat, such as
       dairy products and especially liver.
     Provitamin A is found in deep yellow and green plants as carotenoids. Beta
       carotene is the most abundant and has the highest vitamin A activity, being
       equal to about 1/6 the activity of retinol. It is less efficiently used than retinol
       in the body as less well absorbed.
     Vitamin A activity is quoted as “retinol equivalents” to take into account
       absorption and degree of conversion to vitamin A.
     The liver produces a retinol binding protein which carries retinol to tissues, so
       liver dysfunction from PEM or liver disease can affect vitamin A status. About
       90% of vitamin A in the body is stored in the liver.
     Vitamin A roles: in vision, growth, reproduction, immunity, epithelial tissue
       maintainence. Particularly important during periods of rapid cellular
       proliferation.
     Deficiency causes keratinisation of mucous membranes eg skin & eyes. Major
       cause of blindness in the 3 rd world.
     Each form of vitamin A has a different role:
     Retinol – supports reproduction and is major transport/storage form
     Retinal – reduced form, intermediate in conversion of retinol to retinoic acid.
       Used in vision
     Retinoic acid – intracellular hormone and transcription factor so influences
       cellular differentiation, growth, embryonic development – thus excessive
       amounts are teratogenic.
     Beta carotene – antioxidant. Role in vision is as a component rhodopsin which
       is used for dim light vision. “Night blindness” is therefore a symptom of
       vitamin A deficiency, although zinc deficiency can also cause this (as zinc
       needed for RBP production).
Vitamin A deficiency very rare in Australia, more common in Asia, where it causes
blindness by xerophthalmia.
“Liver cleansing diets” do not mean the person needs additional vitamin A

Supplements:
    High levels of vitamin A as retinol are toxic. A single large dose (ie 100 x RDI
      for adults, 20 x for children) can cause acute toxicity (nausea, vomiting,
      dizziness, headache) whilst much more common is daily large doses of 10 x
      RDI can cause chronic toxicity (headache, hairloss, joint pain, dry itchy skin,
      enlarged liver).
    Pregnant women must avoid taking more than 2400ug/day (from food,
      fortified food and supplements) as linked with spontaneous abortion, gross
      fetal abnormalities or severe learning disabilities. All multivitamins containing
      vitamin A must carry a warning on the label re: pregnancy.
    OCP users have higher vitamin A levels in their blood so should not take
      vitamin A supplements.


                                                                                       101
      A recent study of 72,000 American women found that over an 18 year period
       those with the highest intake of retinol (from supplements or fortified milk &
       breakfast cereal) had double the risk of hip fracture due to osteoporosis. Long
       term vitamin A toxicity causes thinning of bones.
      2 case studies from the Royal Children‟s Hospital on vitamin A toxicity
       published 2001. Featured a 2 year old girl and a 4 year old boy. Both were
       being treated with preparations from naturopaths which were very high in
       vitamin A for leg pain & lack of appetite. Once the supplements were
       discontinued the inflammation of the bone resolved in the girl but the boy was
       left with permanent vision loss from vitamin A toxicity.
      High levels of beta carotene in food are not harmful (but will cause yellowing
       of skin). High intakes of beta carotene supplements are linked with an increase
       in lung cancer (Finnish male smoker trial) and bowel polyps in those at high
       risk. Choose a beta carotene supplement made from D.Salina (natural form).

VITAMIN A SUMMARY:
Food sources: high = cod liver oil, palm oil, liver; medium = carrot, spinach, sweet
potato, egg yolk, milk

RDI = 750ug RE for adults in Australia.

Functions:
   1. Vision. Essential component of rhodopsin in the retina which is used for
      vision in dim light
   2. Epithelial surfaces. Essential for maintenance of specialised epithelial cells in
      the body
   3. Bone growth. Essential for normal bone formation, needed for bone cell
      differentiation.

Deficiency symptoms (primary):
   1. Night blindness – usually first symptom
   2. Keratinisation of epithelial surfaces – when occurs in cornea of eye leads to
       xerophthalmia and blindness
   3. Poor dental health (needed for development of enamel forming epithelial
       cells).

Deficiency of vitamin A rare in Australia but may occur secondary to:
1. Malabsorption of fat eg coeliac disease, cystic fibrosis
2. Severe liver disease so loss of stores
3.Zinc deficiency which reduces transport of vitamin A to tissues
In developing countries up to 5 million children are affected, with resultant
respiratory disease & diarrhoea.

Possible benefits:
   1. May reduce risk of breast, lung, colon, prostate, cervical cancer
   2. May reduce risk of heart disease and stroke (AO function)
   3. May retard macular degeneration (AO function)

Toxicity (in XS of 1000ug/kg bodyweight for adults, less for children)



                                                                                    102
   1. 1 study on smokers found lung cancer rates markedly INCREASED when
      given beta carotene in high doses. Will also cause yellowing of skin
   2. Loss of appetite, headache, blurred vision, irritability, hair loss, dry skin, bony
      growths, haemorrhages, bone fractures, liver damage, death
   3. Congenital abnormalities can occur if excessive amounts taken in pregnancy.


Vitamin D
               Discovered when searching for a cure for rickets that cod liver oil will
   prevent it. In 1920s found a substance in the skin produced after exposure to UV
   light also gave protection.
               As long as have access to sunlight there is no dietary requirement.
   Suggested exposure: hands, arms, face for 5-10 minutes, 3 times/week (without
   sunblock)
               The darker your skin, the longer you need to spend in the sun to attain
   adequate vitamin D. Solariums that produce UVB rays are efficient at triggering
   vitamin D production. Exposure to UVA rays from solariums will destroy B
   vitamins such as folate so dangerous for pregnant women.
               2 major forms in nature – vitamin D-2 (ergocalciferol, found in yeast
   and fungi) and vitamin D-3 (cholecalciferol, animal origin).
               In humans, provitamin D-3 is synthesised in the liver from cholesterol
   and carried to the skin. The action of UV light converts it to 25-hydroxy
   cholecalciferol (calcidiol). This enters the circulation and is converted to active
   vitamin D (1, 25 hydroxy cholecalciferol or calcitriol) in the kidney.
               Small amounts of vitamin D are found in fatty fish, butter, eggs, and
   fortified margarine (the major dietary source of vitamin D).
               Sufficient exposure to sunlight negates the need for dietary vitamin D.
   Amount of vitamin D synthesised in skin depends on length & intensity of
   sunlight. Also destroyed by sunlight.
               Those at risk of vitamin D deficiency are infants in cold climates,
   Islamic women, elderly & institutionalised. In adults this manifests as
   osteomalacia, in children as rickets
               Vitamin D works with PTH to increase Ca and P levels in the blood by
   stimulating absorption of Ca and P from the small intestine, resorption in the
   kidney and withdrawal from bones.
               Formation of the active form of vitamin D is therefore strictly
   controlled. This is via the existing levels of calcitriol itself, and blood levels of
   PTH, calcium, phosphorus.
               Most cells have a nuclear vitamin D receptor, which raises the question
   as to vitamin D‟s general role in cells. EG children with rickets are more
   susceptible to infection, so is vitamin D needed for immune function? Also now
   suggested that vitamin D required for insulin and prolactin secretion, stress
   responses and cell differentiation.

Vitamin D deficiency in Australia
One Melbourne study in 2000 found 46% of elderly people in nursing homes were
vitamin D deficient. Another study (Glover et al, 2001) noted that 80% of veiled, dark
skinned pregnant women attending a Melbourne ante-natal clinic were vitamin D
deficient. The main sources of vitamin D are sunlight, margarine (provides 55% of



                                                                                     103
dietary intake), fish and eggs. Margarine consumption has fallen by 25% in the last 10
years as we try to cut the amount of fat in our diet, and we are constantly warned to
limit our exposure to sunlight to avoid skin cancer. The overall result has been a
decrease in vitamin D intake, which is a concern for the elderly. Low vitamin D status
in the elderly has been linked with increased risk of falling and fracture. Some elderly
are potentially being misdiagnosed with fibromyalgia, when they actually have
osteomalacia from vitamin D deficiency.
Solutions? Vitamin D supplements for elderly? Fortify milk?

Supplements
    Should only be taken if blood levels of vitamin D shown to be low eg as in
      hypothryroidism or some kidney diseases. Much better to expose skin to
      sunlight for short periods as vitamin D lives longer in the body if made in the
      skin rather than taken orally.
    Most toxic of all vitamins – even 5 x RDI can give symptoms. Causes too
      much calcium to be absorbed, so some is deposited in soft tissues & kidneys.
    Supplements in elderly appear to reduce osteoporosis fractures. Safe upper
      dose =20ug

VITAMIN D SUMMARY
Food sources: high = cod liver oil; medium = fatty fish, margarine, egg yolk, butter

RDI = 5ug for children and adults under 50.

Function:
   1. Absorption of calcium and phosphorous
   2. Increases rate calcium and phosphorus form and maintain bone, with vitamin
      A and C.
   3. Reduces excessive cellular division, so promotes differentiation
   4. Modulates immune function.

Deficiency:
Clinical signs: Rickets in children, osteomalacia in adults. Due to impaired
mineralisation of bone matrix and defective collagen synthesis.
Deficiency can occur secondary to:
     Malabsoprtion syndromes
     Gastrectomy
     Diseases of liver & kidney
     Skin disorders
At risk populations: dark skinned, veiled women, elderly, “skin cancer aware”

Possible benefits
1 May help prevent osteoporosis
2 May reduce cancer risk and enhance immunity

Toxicity
Excessive intake in children can lead to loss of appetite, headache, nausea, vomiting,
intense thirst and polyuria, calcification of soft tissues, bone disease, death. Large
doses of cod liver oil can cause toxic levels of vitamin D.



                                                                                    104
Vitamin E
    Is an antioxidant. Exists in at least 8 different forms in nature, with 
     tocopherol being the most abundant.
    Richest dietary source is commercial vegetable oil, in which vitamin E
     protects the PUFAs from breakdown.
    Nuts next best source, and all vegetables and meats contain some vitamin E.
     The requirement for vitamin E by the body increases according to intake of
     PUFAs. Since foods high in PUFAs are also good sources of vitamin E, it is
     very hard to become deficient in this vitamin.
    Potentially over-refining oils could lead to reduction of vitamin E levels so
     this should not be encouraged.
    Evidence of vitamin E deficiency is sometimes seen in intestinal
     malabsorption syndromes and in low birthweight infants. Otherwise
     supplementation does not appear necessary in a normal diet.
    Recent evidence suggests vitamin E may protect against atherosclerosis by
     protecting LDL from oxidation (oxidized LDL taken up more readily by
     macrophages to form foam cells so fatty streaks).
    Some intervention studies have found a reduction in risk from CHD if taking a
     100mg vitamin E supplement, others have not.

Vitamin E & disease:
Cancer: Vitamin E is present in the membranes around every cell to help prevent
oxidation of PUFAs and possibly proteins in membrane. Possibly prevents damage to
RNA and DNA (hence anticancer activity). To date 5 large trials looking at
supplements and colon and lung cancer have not shown a preventative effect.

CVD: Vitamin E thought to prevent LDL oxidation hence atherosclerosis . In tissue
culture vitamin E appears to prevent LDL accumulating in foam cells.
Epidemiological studies have shown that populations with a higher intake of vitamin
E have a lower incidence of CHD. The 2 biggest studies were the Health
Professionals study (39910 men) and Nurses Health Study (87245 women). Both
showed reduced risk of CHD (40% and 34% respectively) in groups with highest
blood levels of vitamin E. The European MONICA study also showed that groups
who ate food high in vitamin E had lower risk of CHD. However intervention studies
to determine which dose of vitamin E reduces LDL oxidation have produced unclear
results. Indeed at least one study of Iowa women has shown that those taking high
level supplements had a 25% increased risk of death from CHD.
The concern is (inconsistent) effects are seen at doses much higher than would be
obtainable from food, so vitamin E is probably acting in a role outside its usual
nutrient action.

Alzheimer’s: Two recent trials have shown diets rich in vitamin E and C (but not
supps) have been linked to a reduction in Alzheimer‟s, (one in Netherlands, one in
US) which suggests the antioxidant action of the nutrients is preventing oxidative
damage (causing lesions) to the brain.

Supplements:
    Vitamin E supplements sell very well as widely credited with many roles and
      people seem unaware of food sources.



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      Despite some positive trials in reducing CVD incidence with a supplement,
       there are other trials that do not support this conclusion. Beneficial dose is still
       to be agreed on too. Therefore safest bet is to have a diet high in vitamin E, or
       stick to a low dose supplement. Safe upper dose =130-270mg or 200-400 IU
       of d alpha tocopherol (avoid dl alpha tocopherol supplements)
      Check if taking fish oil tablets vitamin E has been added.
      Linseed oil potentially risky source as the PUFAs in it are so unstable and
       oxidise so quickly the vitamin E may be rapidly used up mopping up the
       oxidative products that form after pressing. Eating linseeds is a better choice
       as the seeds stick to the bowel wall for up to 10 days whilst bacteria break
       them down and release the PUFAs.
      Athletes AT HIGH ALTITUTES on 800mg vitamin E supplements had lower
       lactic acid in their blood. Possibly there is greater breakdown of the fats in the
       membrane around the rbc in low oxygen environments which is counteracted
       by vitamin E antioxidant action. At normal altitudes no benefit seen.

VITAMIN E SUMMARY
Food sources: polyunsaturated vegetable oils (high); peanut oil, olive oil, nuts, seeds,
wholegrains (medium).

RDI: 7-10mg/day for everyone over 8 years.

Functions:
   1. As an antioxidant to protect the lipid membranes of cells, integrity of red
      blood cells from oxidative damage. Also protects beta carotene and
      unsaturated fatty acids from oxidative breakdown.
   2. May be involved in haemoglobin formation
   3. In food prevents the breakdown and oxidation of PUFAs.

Deficiency symptoms:
Not reported in Australian adults. May occur in low birthweight infants given formula
low in vitamin E, causing haemolytic anemia.
Theoretical risk of deficiency in malabsorption syndromes eg cystic fibrosis

Possible benefits
    May reduce risk of heart attack and angina
    May slow macular degeneration
    May prevent spinal cord damage in CF patients

Toxicity
Relatively non toxic. 300mg/day may cause severe influenza, malaise, fatigue, gut
disturbances. Imbalance between vitamin E and K can impair blood clotting.

Vitamin K
2 naturally occurring forms: vitamin K-1 (phylloquinone, in green plants) and vitamin
K-2 (menoquinone, synthesised by intestinal bacteria). Approx ½ our vitamin K needs
are met by bacterial production in our gut, the rest comes from diet. Vitamin K is
found in green leafy veg, soybeans, wheatgerm, but fruit and animal products contain
little.



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VITAMIN K SUMMARY:
Food Source: broccoli, spinach, soybeans, cabbage (high); wheatbran, green beans
(medium)

AI: men = 70ug, women = 60ug

Function:
   1. Involved in synthesis of clotting factors II, VII, IX and X
   2. Through the action of these clotting factors may influence calcium metabolism

Deficiency:
      Hemorrhage occurs as clotting time is delayed
      Prophylactic dose given to all newborns to reduce risk of hemorrhage. This is
   because of poor placental transfer of vitamin K and absence of vitamin K
   producing bacteria in newborn gut. Newborns to be breastfed have higher risk of
   vitamin K deficiency as less vitamin K in breast milk than formula and intestinal
   flora slower to develop.
      Malabsorption syndromes may prevent adequate absorption
      Liver diseases may reduce synthesis of clotting factors
      Warfarin can cause a bleeding tendency if vitamin K intake is poor.
      May be important in prevention of osteoporosis

Possible benefits
?role in cancer prevention
Regulation of bone metabolism
Toxicity
Toxic if given over long periods. Safe upper dose = 30mg

                                     TUTORIAL
    Practice Question
Janette works the night shift and sleeps during the day while her husband cares for her
child. She is 30 years old, with a BMI of 22. She is lactose intolerant so avoids dairy
products, and is also allergic to seafood. She recently fractured a bone in her wrist
while lifting a box.

   1.   Which nutrient could Janette be deficient in?
   2.   How could she correct this deficiency?
   3.   What are the key roles of vitamin D in the body?
   4.   Are any foods fortified with vitamin D?


Fat soluble vitamins: Multiple Choice

   1. Which foods are rich sources of vitamin E
        a. liver, eggs, butter
        b. fatty fish, egg yolk, margarine
        c. wheat germ oil, almonds, vegetable oils
        d. broccoli, cabbage, spinach




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   2. Which of the options below best describes the absorption of fat soluble
      vitamins?
          a. requires emulsifications by bile and micelle formation for maximal
             absorption
          b. requires the action of amylase
          c. requires the action of proteolytic enzymes
          d. all of the above

   3. The main function attributed to vitamin K is
         a. The visual cycle
         b. Blood clotting
         c. Antioxidant activity
         d. Maintenance of bone integrity

   4. Which factors contribute to haemorrhagic disease of the newborn?
        a. low capacity for synthesis of prothrombin in neonatal liver
        b. poor placental transfer of lipids and low content of vitamin K in breast
            milk
        c. absence of bacteria in neonatal intestine
        d. all of the above

   5. Which of the following groups are at risk of vitamin D deficiency?

           a. elderly confined to nursing homes with no access to sunlight
           b. children and women who inadvertently avoid sunlight for religious or
              cultural reasons
           c. people with chronic renal failure
           d. all of the above

   6. Which of the following statements about supplementation with fat soluble
      vitamins is correct?
          a. supplementation with any fat soluble vitamin at doses greater than the
             RDI poses a health risk because they are not excreted in the urine
          b. vitamin E supplements equivalent to 10 x RDI have no demonstrated
             toxic effect
          c. vitamin A supplements have no side effects and can be recommended
             for any age group
          d. fat-soluble vitamins are readily metabolized by the liver and excreted
             in the faeces.
          e.

Choosing Takeaways

Burgers
Extra salad, hold the egg, cheese, bacon. Avoid the big ones – Big Macs, Whoppers.
If making own burgers, rinsing with warm water after cooking reduces fat content.

Pizza
Serve with salad to give better balance to meal. Easy to over consume – avoid by
ordering a small or thin/crispy crust.


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Woodfired pizza toppings often lower in fat than regular toppings
Olives, anchovies, ham, cheese, salami all add a lot of salt to pizzas

Chicken
Go for BBQed or rotisserie over fried
Balance KFC with corn cob, coleslaw, bean salad or mashed potato & gravy

Lebanese Doner Kebab
Generally healthy, although meat is sometimes coated in fat to keep it moist during
cooking. Shish kebab is better choice.

Fried Takeaway
Very high in saturated fat & salt
Ask for no salt & grilled not fried fish

Chinese
Avoid sweet & sour, deep fried & lemon sauce dishes – high fat
Get steamed not fried rice
Avoid adding extra soy sauce as already high in salt

Mexican
Choose dishes based on beans and salad.

Meat pies, sausage rolls
Go for meat & vegetable pies as lower in fat. If kept warm for a long time will have
lost some B vitamins.

Best & worst takeaway choices
MacDonalds
Worst Choice:          Big Mac (24g fat) with large fries (28g fat)
Best choice:           Filet –o-Fish (16g fat) or Junior burger (8g fat) with salad

KFC
Worst choice:          2 pieces chicken (29g fat), chips (20g fat)
Best choice:           Tender roast chicken(16g fat), mashed potato & gravy (1.8g fat

Pizza Hut
Worst choice:          super supreme pan pizza (30g fat/2 slices)
Best choice:           thin & crispy vegetarian (18g fat/2 slcies)

Red Rooster
Worst choice:          chicken & chips (47g fat)
Best choice:           ¼ chicken, no skin, no stuffing (9g fat)

Hungry Jacks
Worst choice:          Whopper with cheese (46g fat)
Best choice:           Aussie burger (32g fat); Vegie burger (32g fat)




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Subway
Worst choice:         6‟‟ meat ball sub (13g fat)
Best choice:          6‟‟ turkey breast sub (4g fat)
                                                             (Nutrition for life, Saxelby 2002)

                    Week 10: WATER SOLUBLE VITAMINS

Thiamin (vitamin B1)
Function: Co-enzyme in many enzyme systems mainly involved in releasing energy
from CHO, protein and fat.

Deficiency: Frank deficiency causes beri beri. Only seen in chronic alcoholics.
Symptoms:
a. GI = loss of appetite, indigestion
b. Nervous system = impaired sensation, loss of reflexes, difficulty moving (dry beri
beri). If oedema also present = wet beri beri. If brain involved = Wernicke‟s
encephalopathy (involuntary eye movement, muscular uncoordination). Progresses to
Korsakoffs pyschosis if untreated (memory defect & confabulation).
c. Cadiovascular symptoms = cardiac failure

RDI
0.1mg/1000kJ for all ages. The more CHO and alcohol you have, the more thiamin
you need so RDI is quoted in terms of energy intake.

Good food sources
Vegemite, pork, wholegrains, fortified cereals, bread, legumes, seeds, salmon

Effect of cooking
     Heat and water destroy thiamin so moist heat is very destructive. Typically
        about 25% lost during cooking.
     Refining of cereal products also causes losses so bread, cereal often fortified.

Supplements
Essential for recovery from chronic alcoholism. Otherwise unnecessary in a balanced
diet.
The body doesn‟t store much thiamin so a constant supply from the diet is needed.
Thiamin as an occasional supplement is not well absorbed. Often included at high
doses in multivitamins because it is so cheap and not toxic at high doses.

Riboflavin (vitamin B2)
Function: Part of a group of enzymes (flavoproteins) which are involved in cell
respiration & release of energy from CHO, fat, protein.

Deficiency: No evidence of deficiency in Australia. Symptoms = cracking of lips and
corners of mouth; smooth tongue; visual disturbances; conjunctivitis.

Good food sources: vegemite, cornflakes, milk, cheese

RDI: 0.12mg/1000kJ for all ages. Linked to energy requirements as used to help
release energy from food. Physical activity may increase riboflavin needs, but few



                                                                                                  110
athletes would be at risk of deficiency. Less riboflavin needed during sleep so people
getting less sleep may have higher requirements.

Effect of cooking
Causes some losses. If vinegar or lemon juice present losses are high, so should be
added just before serving. Milk exposed to light for 2 hours loses about ½ its
riboflavin.

Supplements
Chronically high alcohol intake causes a need for riboflavin supplements. Otherwise
the rapid appearance of it in the urine (turns a bright greenish yellow) demonstrates
most amounts taken are far in excess of what the body needs. Aftertaste of
multivitamins is due to riboflavin. Some research suggests it may help prevent
migraines, traditionally prescribed in combination with magnesium & feverfew.

Niacin (vitamin B3)
Function: Part of the coenzyme nicotinamide adenine dinucleotide (NAD)& is
involved in cell respiration & metabolism of CHO, protein, fat

Deficiency: Frank deficiency causes pellagra
Symptoms: dermatitis, diarrhoea, dementia.

Good food sources: vegemite, wheatbran, ovaltine, peanut butter, beef

RDI: 1.6mg niacin equivalents/1000kJ for all ages. In practice about half our niacin
intake comes from food, half is made in the body from tryptophan. 60mg tryptophan
can be converted to 1mg niacin, hence use of niacin equivalents

Effect of cooking
Up to 75% may be lost during cooking. Niacin in traditional varieties of corn is bound
in an unusable form, so was traditionally soaked in lime juice to make tortillas and
hence release the niacin.

Supplements
Niacin supplements have been made popular as a means of increasing HDL
cholesterol levels, and at pharmaceutical doses they are effective at doing this.
However there are a number of side effects at this dosage (flushing, GI disturbances).
During pregnancy tryptophan conversion to niacin increases 3 fold, due to the
influence of oestrogen increasing the enzyme used for conversion. That is why
women on the pill should not take niacin supplements.

Pantothenic acid (vitamin B5)
Function: Part of the acetyl carrier co-enzyme A & involved in many chemical
reactions in the body eg energy release via metabolism of CHO, fat, protein; synthesis
of amino acids, fatty acids, sterols, vitamin D.

Deficiency: Only able to be induced under experimental conditions.

RDI: Unknown as so abundant in the food supply would be deficient in many other
vitamins too if excluded B5 from diet.


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Food sources: egg yolk, broad beans, apricot, beef, milk all good sources. Can be lost
from grains during milling.
Supplements
Often promoted as being in royal jelly, but no evidence to support claims. Some
sports studies have reported improvements with supplements, others have not.

Pyridoxine (vitamin B6)
Function: Required by over 100 enzymes in the body. Required for synthesis &
metabolism of serotonin; synthesis of niacin from tryptophan; formation & growth of
rbc, release of energy from CHO and fat.
B6 can also bind to steroid receptors, so displace oestrogen. OCP users did need extra
B6 but no longer required in the lower dose format.

Deficiency: Non specific symptoms eg irritability, depression, dermatitis.

RDI: 1.0-2.2mg/day

Good food sources: vegemite, walnuts, bananas, egg yolk, chicken, potatoes

Supplements
Large doses have sometimes been prescribed for PMS, leading to peripheral neuritis.
Max safe dose is only 10mg/day, some people take up to 50mg or more.
Some women find relief from morning sickness with B6 supplements, others do not.
Because of B6‟s role in production of glucose, some athletes take B6 supplements.
Many researchers have now concluded athletes should not take B6 supplements
because they cause glycogen muscle stores to be broken down more quickly during
exercise – obviously undesirable. Also B6 lowers circulating fatty acids during
exercise which may be used as fuel – again undesirable.

Folate
Family of more than 30 compounds. Folate is the form found in food, folic acid is the
form used in supplements or fortified foods, folacin is the provitamin converted to
folic acid in the body.

Function:
CVD: Folate acts with B12 and B6 to convert homocysteine (risk factor for CVD) to
cysteine and methionine. Many studies have shown that when our levels of B6, B12
or folate are low, homocysteine levels are high so risk of CVD increases.

Neural tube defects: Early 1980s showed 200-400ug folate supplement lowered
incidence of neural tube defects. Must be taken before the 6 th week of pregnancy
when the neural tube closes. Mechanism unsure – folate required in conjuction with
B12 to deliver methionine to fetus. Also environment appears to play a role – much
higher rates of spina bifida in Australia than the US or UK. Mexican women have
high rates but only if they are pregnant in Mexico, not in the USA. Farming families
seem more commonly affected in 1 study. One UK study (Lancet) found for every
1000 women on folate there were 10 fewer birth defects but twice as many
miscarriages as usual.



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Cancer: Folate required for synthesis of DNA so methotrexate, the folate antagonist,
is an anticancer drug. Good evidence that high intake of folate prevents colon cancer
was gathered by the US Nurses study – 3 fold higher incidence in women with lowest
intake of folate from foods. Replicated in animal studies.

Deficiency: Causes macrocytic anemia. Rapidly dividing cells also affected. Most
common vitamin deficiency in Australia. Seen in institutionalised elderly, chronic
alcoholics, pregnant women.

RDI: 200ug/day for adults; 400ug/day for pregnant women

Good food sources: green leafy veggies, peanuts, peas, egg yolk, oranges, wholemeal
bread, fortified cereal

Effect of cooking
V. unstable vitamin. Destroyed by heat and oxidation over 100C. Raw veggies least
losses, but steaming causes fewer losses than boiling.

Supplements
For prevention of neural tube defect: Clear evidence of benefit of supplement for all
women with potential to become pregnant, as supps important so early in preg.
400ug/day is recommended, which can be achieved by a diet high in fresh fruit, veg,
wholegrains, nuts, legumes, fortified cereal. If a supplement is prescribed it should be
specifically for pregnancy and have 500ug of folic acid in it (some multivitamins have
very low folate levels). If the woman has an affected child or a family history of
neural tube defect, supplements of 5mg/day recommended.
Folate supplements not recommended in elderly as can mask symptoms of pernicious
anemia (due to B12 deficiency).
For high homocysteine levels: One study showed a reduction if 200ug/day taken, but
this increase can easily be done by altering diet.
For osteoarthritis: One study gave 6400ug folic acid and 20ug B12 supps to
osteoarthritis patients. They reported improved grip strength and hand tenderness over
group taking NSAIDS.

Vitamin B12
Function: If B12 is absent the body cannot use folate. B12 assists folate in production
of DNA. Also needed for production of rbc with folate – if lacking folate bone
marrow cells become megaloblasts. On its own B12 used for production of myelin.
To be absorbed from the SI, B12 must first be bound to intrinsic factor produced in
the stomach.

B12 and vegans: Plant sources of B12 only contain B12 as a result of microbial
contamination. For example mushrooms may have some contaminating B12 from
their compost, but it is far less than the required amount. Spirulina and comfrey
contain forms of B12 than are inaccessible to humans. Best source is fortified soy
drinks or supplement. If pregnant vegan woman should definitely take a supplement
so baby‟s nervous system can develop normally. Even vegetarians who eat milk &
eggs tend to have fairly low levels of B12, so supplementation during pregnancy &
lactation may be advisable. Vegetarians usually have diets high in folate so this masks
deficiency until nerve damage apparent.


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Deficiency: Pernicious anemia, neurological disturbances. Vegans , newborns of
vegans, gastectomy patients at greatest risk.

Drugs: Of note: cochicine (used in gout & joint inflammation) & biguanides (used in
diabetes) may warrant an occasional B12 injection if taken long term. Metformin also
inhibits B12 absorption but if taken with milk or calcium carbonate tablets this is
overcome.

Good food sources: sardines, oysters, egg yolk, beef, fish, cheese

RDI: Much larger intakes of B12 recommended than needed to allow for low
absorption and for the fact body stores tend to increase over lifespan possibly to
compensate for low absorption by elderly. RDI for adults = 2.0ug/day.

Supplements
Unnecessary if consume animal products. Supplements may be needed if a vegan and
not having fortified products, and especially if still growing. Pregnant vegans and
vegetarians should take supps, especially if not eating large amounts of fortified soy
drinks.
Elderly can become deficient as insufficient intrinsic factor made in the stomach for
absorption, or poor absorption as lack of gastric acid and pepsin (acid + pepsin act to
free B12 from food), in which case oral supplements are useless and injections
needed.
No data to support B12 supplementation of athletes – placebo effect only!

Vitamin C
Function: Cofactor for 8 enzymes in body. 3 involved in collagen production; 2
involved in carnitine production (used to make energy in muscle cells); 1 in making
norepinephrine and 1 to make serotonin from tryptophan.
Converts non heme iron from Fe3+ to Fe2+ so it can be absorbed.
Acts as an antioxidant

The common cold: Taking megadoses of vitamin C to ward off or treat colds was
popularised by Linus Pauling in the 1970s. He won a Nobel prize in chemistry in
1954 and one for peace in 1962. He somehow managed to calculate that if early man
ate a diet high in vitamin rich plant food he would eat 2300-12000mg/day. Today it is
agreed the amount is more like 350-400mg. He felt he developed fewer colds on
megadoses of vitamin C. More than 60 trials have failed to show any benefit in
reducing incidence, although some do show a reduction in duration (eg by 19% in 1
Australian trial with identical twins). Vitamin C manufacturers still use this angle to
promote their product.

Cancer: Vitamin C was claimed to assist the treatment of cancer by Pauling in
conjuction with a physician. However they used a cohort labeled “untreatable” much
earlier in their disease than is usual. The Mayo clinic ran a trial giving patients
10000mg/day, and found no benefit. It is true that vitamin C prevents the conversion
of nitrites to nitrosamine so vitamin C containing foods such as tomato should be
eaten with preserved meats to prevent stomach cancer. Fruit & veg are protective



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against cancer, but it is not single vitamins within them responsible, but the array of
phyotchemicals interacting together.

Antioxidants: Although has capacity to work as an antioxidant, uncertain under which
conditions it does in the body. EG does not appear to reduce LDL oxidation. Large
doses of antioxidants can cause these substances to act as pro oxidants eg 1 UK trial
showed doses of 500mg.day caused people to have an increase in DNA damage
compared with the placebo. This could predispose to cancer, CVD, RA.

Deficiency: Frank deficiency causes scurvy (defective collagen synthesis, bruise &
bleed easily, delayed wound healing, susceptibility to infection, anemia, fatigue).
Uncommon in Australia. Most vulnerable groups = newborns of mothers taking
megadoses, institutionalised elderly, chronic alcoholics, women who smoke & take
the OCP.

RDI: Some dispute as to how much is needed. Australian RDIs (men 40mg/day,
women 30mg/day) reflect the quantity needed to prevent scurvy plus a large safety
margin to allow for people like smokers who require greater amounts. When intake
exceeds 130mg/day the tissues are saturated and unmetabolised vitamin C appears in
the urine. If we ate the recommended amount of fruit and veg we would have
200mg/day, so some argue this should be the recommended intake.

Good food sources: blackcurrants, capsicum, oranges & lemons.

Effect of cooking: rapidly destroyed by heat, light, oxygen so losses during cooking
inevitable. Least losses by microwaving, greatest when boiled for long periods. Even
greater losses in alkaline conditions eg adding bicarb to veg.

Supplements: No evidence to support high doses of vitamin C for anyone, so should
avoid supplements >500mg. Depending on individual tolerance, diarrhoea will occur
after consuming 1000-10 000mg. Because the excess is excreted, little toxicity.
Possibly could increase kidney stone development as oxalate is metabolic by product
of vitamin C metabolism.
? high doses may increase absorption of mercury and a few reports of mothers taking
megadoses of vitamin C during pregnancy then baby developing scurvy soon after
birth as they had become dependent on high doses of vitamin C.
A supplement of 500mg taken at the first sign of a cold may reduce duration slightly.
No performance benefit seen for athletes compared with placebo except for athletes
with low levels of vitamin C.
If you suffer from haemochromatosis (population rate =1/300, common if of Irish
descent) large doses are hazardous as promote iron absorption. Many unaware they
have the condition – seen in men, as women lose blood regularly.

Biotin
Function: Coenzyme, needed for synthesis & breakdown of fatty acids and amino
acids.

Deficiency: The only susceptible group are people who eat large amounts of raw
eggs as the avidin in egg white binds to biotin and prevents its absorption. Cooking
alters the shape of avidin so it no longer binds biotin. Body builders who take skim


                                                                                     115
milkshakes with 6 or more raw egg whites added to increase their protein intake over
several months are at high risk of deficiency. An oral supplement won‟t help as it
will not be absorbed – an injection is needed. Breast feeding women should also avoid
raw egg white as well. Symptoms include lethargy, loss of appetite, nausea, vomiting

Good food sources: yeast, egg yolk, soy beans

RDI: None in Australia. 100ug/day estimated to be safe and adequate.

                                    TUTORIAL
Practice Question
Kate is 30 years old and referred for mild neck pain (no significant past medical
history). She weighs 58kg and is 160cm tall. She reports a good appetite and generally
eats a fruit salad & yoghurt for breakfast, a fruit smoothie for morning tea, salad or
sushi for lunch, a piece of fruit & some wholewheat crackers with cheese for
afternoon tea, a salad or cooked vegetables with fish or meat for dinner, and a fruit
based dessert. She drinks water, tea or juices. She works at a computer terminal all
day but does a circuit class 3 days/week and a yoga class once/week. Kate lives alone
and does all her own cooking & shopping. She takes 2x500mg vitamin C tablets/day
“for health maintenance”.
    1. Do a nutritional assessment of Kate. (6 marks)
    2. What are 3 roles of vitamin C in the body? (3 marks)
    3. What are 2 risks associated with very high doses of vitamin C? (2 marks)
    4. Give an example of when a vitamin C supplement is justified. (1 mark)

                           Supplement Summary
Ideally not used BUT there are some special needs groups:
Special needs groups                       Supplement needed
Before conception                          400ug can protect against birth defects
During pregnancy                           Extra iron, folate, calcium, omega-3s
Breast feeding                             Extra calcium & omega-3s
Vegans                                     B12, iron, zinc, calcium
Smokers (& passive smokers)                Doubles vitamin C requirement CO
                                           destroys circ vit c & may need more
                                           antioxidants, folate
Alcoholics                                 B group vitamins (especially thiamin),
                                           zinc, potassium, vitamin E
Athletes                                   May need extra vitamin C & E, iron
Elderly                                    Absorption generally declines but
                                           requirements for B12, B6, calcium &
                                           vitamin D increase
During illness or after surgery/burns      Vitamin C and protein for tissue synthesis

Side effects of high supplement doses:

Vitamin or Mineral                          Side effect of high doses
Vitamin A                                   >2400ug/day can be teratogenic. Can also
                                            cause nausea, liver damage, hair loss,


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                                             headaches
Vitamin D                                    >50ug causes vomiting, nausea, liver
                                             damage. Causes calcium to be deposited
                                             in soft tissues
Vitamin C                                    >2000mg/day cause upset stomach,
                                             diarrhoea, cramps. Increases risk of iron
                                             overload
Vitamin B6                                   >2000mg/day may cause numbness or
                                             tingling in hands and feet
Niacin                                       Can cause mild flushing reaction at over
                                             1000mg/day
Beta carotene                                Turns skin yellow
Iron                                         May cause constipation or GI upset
                                             May interfere with absorption of zinc
                                             Keep away from toddlers – can kill!
Selenium                                     Hair & nail loss, irritability, nerve
                                             damage
calcium                                      Can interfere with iron absorption


Food…an alternative to supplements

Broccoli
People with a high intake of broccoli & related vegetables (cabbage, cauliflower,
brussel sprouts) have a reduced risk of several cancers (esp prostate & colon). The
indoles and isothyacynates are thought to activate tumour suppressors and block
carcinogen uptake from foods. Also good source of vitamin C, beta carotene, folate.

Garlic & chilli
Populations (mainly Asian) with high garlic & chilli consumption have low rates of
obesity, even after allowing for higher levels of physical activity & lower calorie
intakes. Chilli is thought to increase metabolic rate by increasing heat production –
same as caffeine. Garlic seems to reduce fat & CHO intake.

Tomatoes
Source of lycopene, which is a powerful antioxidant and gives tomatoes their red
colour. 1995 study by Harvard Medical school looked at 48,000 men & found that
those with a high intake of lycopene has a much lower risk of prostate cancer.
Tomatoes, tomato sauce & pizza were the main sources of tomato eaten. Having 10 or
more serves/week of tomato based foods was associated with a 35% reduction in
prostate cancer risk, having 4-7 serves/week of tomato based food was associated
with a 22% reduction in prostate cancer risk. Lycopene is fat soluble so best to cook
tomatoes in olive oil.

Almonds
A 1994 CSIRO study showed almonds significantly lower blood cholesterol BUT
they were eaten instead of spreads and fatty foods, not as an extra. High in vitamin E,
fibre, arginine & calcium.
So far, five large prospective cohort studies (the Adventist Health Study, the Iowa
Women Health Study, the Nurses' Health Study, the Physicians' Health Study, and the


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CARE Study) have examined the relation between nut consumption and the risk of
CHD and all have found an inverse association. In addition, several clinical studies
have observed beneficial effects of diets high in nuts (including walnuts, peanuts,
almonds, and other nuts) on blood lipids. The beneficial effects of nut consumption
observed in clinical and epidemiologic studies underscore the importance of
distinguishing different types of fat. Most fats in nuts are mono- and polyunsaturated
fats that lower low-density lipoprotein cholesterol level. Based on the data from the
Nurses' Health Study, we estimated that substitution of the fat from 1 ounce of nuts
for equivalent energy from carbohydrate in an average diet was associated with a 30%
reduction in CHD risk and the substitution of nut fat for saturated fat was associated
with 45% reduction in risk.

Cranberry juice
Recent trial comparing women taking probiotic LGG and cranberry juice for 6
months. Found cranberry juice but not LGG prevented urinary tract infections by
inhibiting the attachment of E coli to the bladder wall.


   Water…how much do we need?

August 2002 American Journal of Physiology issue has review on water needs.

Water myths:
“Drink 8 glasses/day” probably stems from muddled interpretation of a 1945 Food
and Nutrition Board report. That report said the body needs about 1 milliliter of water
for each calorie consumed - almost 8 cups for a typical 2,000-calorie diet - but most
of this quantity is contained in prepared foods. No research done that shows the
average person needs to drink 8 glasses/day.

“If you feel thirsty you are already dehydrated” Only true for elderly with diminished
thirst sensation & serious athletes. Otherwise the advice “drink when thirsty” is a
good guide to fluid needs.

“Water blocks dieters' hunger”. Studies show water with food can help you feel full
faster, but that just drinking water between meals has little effect.

“ Coffee, tea, cola don‟t count toward fluid intake as they are diuretics” A University
of Nebraska study that found coffee, tea and sodas are hydrating for people used to
caffeine and thus should count toward their daily fluid total.

American Institute of Medicine currently researching water requirements for normal
people. People with kidney stones & athletes have higher fluid requirements.
Otherwise urine colour is good guide to hydration status.



                         Week 11 and 12: MINERALS
Minerals make up 4-5% of our bodyweight (1/2 of this is calcium).
Macrominerals: calcium, phosphorous, magnesium, sodium, chloride, potassium &
sulfur.


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Micro or trace minerals: iron, zinc, copper, iodide, manganese, fluoride, molybdenum,
cobalt, selenium, chromium, tin, nickel, vanadium, silicon.

Iron
Functions of Iron:
Iron is a very reactive mineral so must be bound to proteins to prevent undesirable
reactions occurring in the body.
     Our bodies contain about 3g of iron, mainly in the form of haemoglobin. Iron
        is required by haemoglobin for its structure and function. The heme portion of
        the molecule contains iron which combines with oxygen in lungs or CO 2 in
        other tissues.
     Myoglobin also contains a heme group to help it store oxygen in the muscles.
     Production of ATP in the mitochondria requires iron –dependent
        oxidation/reduction reactions to occur.
     Cytochrome P450 (which converts water insoluble drugs to water soluble
        drugs for excretion) contains iron.
     Iron also influences immune system – an excess of iron will increase risk of
        bacterial infection, as bacteria require iron for growth. A deficiency reduces
        concentrations of circulating T lymphocytes and NK cell activity. Transferrin
        and lactoferrin may protect from infection by withholding iron from access by
        bacteria.The immune response of healthy elderly was enhanced with iron
        supps in one study.
     Iron is essential for brain function at all ages – required for function and
        synthesis of neurotransmitters, myelin.
     Effect of iron deficiency in children delays development significantly. Eg
        delayed sensory motor skills, attention, learning, memory.

Types of iron
    Haem iron: found in animal foods (chicken, beef, fish and offal). Generally
       only about 5-10% of dietary iron, but absorption can be up to 25%. Absorption
       is enhanced by the animal proteins present in these foods, but mechanism is
       unknown. Gastric acid is required for the absorption of iron as it enhances its
       solubility. Iron in breast milk is more readily absorbed than iron in formula,
       mechanism again uncertain.
    Non haem iron is found in plant food (legumes, wholegrains, green leafy veg,
       eggs). Makes up most of our dietary iron but only about 5% may be absorbed.
    Improved by up to 50% by eating the non haem iron with vitamin C. Non
       haem iron needs to be solubilised to be absorbed. It is reduced in the acid of
       the stomach to Fe2+ then solubilised by binding to substances such as vitamin
       C or sugars. It is then absorbed by mucosal cells.
    Other factors that assist in non haem iron absorption include malic acid and
       citric acid, both are found in vegetables so are more reason to eat varied meals.
       Vitamin A and beta carotene also have been shown to improve absorption of
       iron from rice, wheat and corn.
    States of iron deficiency, pregnancy and growth also increase iron absorption.
    Absorption appears to be inhibited by phytates (found in high fibre foods),
       tannins (in tea – if anemic don‟t have tea with meals), phosphate (in egg),
       oxalate (in some veg), polyphenols (in red wine). These can combine with iron
       and inhibit absorption.


                                                                                    119
      Calcium rich foods or supplements may inhibit absorption of haem and non
       haem iron (eg young children given too much cow‟s milk).

Excretion of iron
Lost only by bleeding and in small amounts via sweat, faeces (mainly unabsorbed
dietary iron), skin. Normally about 1mg iron lost/day. During menstruation losses can
be additional 0.5 to 1.4mg/day.

RDI for Iron
                                            mg Iron
Men                                         7
Women                                       12-16
Pregnant women                              22-36
Breast feeding women                        12-16
Post menopause women                        5-7
0-6 months breast fed                       0.5
0-6 months bottle fed                       3
7-12 months                                 9
1-11 years                                  6-8
12-18 years                                 10-13

Sources of Iron
Food                                        Iron (mg)
Red meat 100g                               3.7
Fortified breakfast cereal    (1 bowl)      3.0
Lentils 2/3 cup cooked                      2.5
Cashews 25 nuts                             2.5
Wholegrain bread 1 slice                    1.6
Dried apricots 10 halves                    1.6
Baked beans 100g                            1.6
Fish 100g                                   1.2
Rolled oats 30g                             1.1
Almonds 25 nuts                             1.0
Eggs 50g                                    1.0
Broccoli 100g                               1.0
Chicken 80g                                 0.6
White bread 1 slice                         0.3

Deficiency
Iron deficiency is the most common nutritional deficiency in the world. Symptoms =
weakness, tiredness, inability to maintain a constant body temperature (causing chills
and hot flushes), impaired immune system. Eventually hypochromic microcytic
anemia will arise. Diagnosed as low Hb, high transferrin, low ferritin and pathology
of blood. This means less O2 to tissues.

At risk groups: menstruating females, pregnant women, infants, preschoolers,
adolescents, long distance runners, vegetarians on inadequate diets.




                                                                                   120
Deficiency in children will hinder development and behaviour, whilst deficiency in
pregnancy will increase risk of pre term delivery and low birthweight babies.

Iron overload
Haemochromatosis affects about 1/300 Caucasian people. Genetic condition of iron
absorption causing a build up of iron in the liver, pancreas and heart, which can lead
to cirrhosis, diabetes, CVD or arthritis. Treatment is phlebotomy to reduce iron levels.
Iron supplements, vit C supplements and high intakes of red meat should be avoided.
Iron may act as a pro oxidant to increase risk of CVD, but whether this is a
confounding effect is uncertain.

Calcium
Functions
    Most abundant mineral in the body. Can be subdivided into skeletal calcium
       and serum calcium. Skeletal calcium is further broken down into exchangeable
       (available for short term calcium homeostasis) and non exchangeable calcium
       pools.
    Bone is constantly being synthesised and resorbed, with the person‟s age
       determining which process predominates. Peak bone mass is achieved in our
       20s, but inadequate calcium intake during childhood may prevent us attaining
       this. Bone loss commences in our 50s, with females losing bone more quickly
       as oestrogen levels suddenly drop.
    Bone loss after menopause seems to be genetically determined to a large
       extent, and calcium intake alone will not influence rate of bone loss. Other
       factors that influence progression of osteoporosis include consuming adequate
       calcium as a child and teenager to support bone growth, consuming sufficient
       calcium during adult life, regular exercise and HRT in the 5 years post
       menopause.
    Roles of calcium include assisting transmission of ions across membranes,
       releasing neurotransmitters at synapses, function of protein hormones,
       activation of enzymes. Ionised calcium initiates the formation of a blood clot
       by stimulating thromboplastin release from platetlets & converting
       prothrombin to thrombin. Also used with Na, K, Mg to regulate heart beat and
       muscle tone.
    Serum calcium is maintained at homeostasis by parathyroid hormone and
       calcitonin and vitamin D.
    When calcium levels in blood drop, PTH promotes release of calcium from
       bone, renal tubular resorption and indirectly stimulates absorption in intestine.
       If levels too high calcitonin inhibits bone resorption. Resorption also triggered
       by falls in oestrogen and inhibited by testosterone.

Absorption
    Most absorbed in ileum. Usually 20-30% absorbed, sometimes as little as
      10%. Absorbed by 2 methods. One is by active transport and controlled by
      vitamin D. Vitamin D stimulates calcium uptake of the intestinal mucosal cell
      by promoting the production of a calcium binding protein. The second method
      is by passive diffusion along the length of the SI.
    Calcium absorption increased by: calcium deficiency, growth, pregnancy,
      lactation, high impact exercise that stimulates bone density.



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      Sufficient vitamin D and an acid environment needed for absorption. Lactose
       enhances calcium absorption.
      Calcium absorption decreased by: lack of vitamin D, oxalic acid (in rhubarb,
       spinach), phytates (in cereals), fibre, medications that interfere with calcium
       absorption (glucocorticoids inhibit both active and passive absorption; iron
       supplements), ageing.

Excretion
Excess is excreted in the faeces and urine in roughly equal amounts. A high urinary
excretion is triggered by a high salt or protein diet and low calcium & phosphorus
intakes. Caffeine may increase calcium excretion (eg 1994 study showed a low
calcium diet plus 2-3 cups brewed coffee increased bone loss in post menopausal
women) but a glass of milk may offset this risk.

RDI for Calcium
                                            Calcium mg
Men                                         800
Pre menopausal women                        800
Pregnant women                              1100
Breast feeding women                        1200
Post menopause women                        1000
0-6 months breast fed                       300
0-6 months bottle fed                       500
7-12 months                                 550
1-11 years                                  800
12-18 years (boys)                          1200-1000
12-18 years (girls)                         1000-800

Sources of Calcium
Food                                        Calcium mg

Milk 1 glass                                290
Fortified low fat milk 1 glass              400-500
Yoghurt 200g                                305
Cheese 30g                                  260
Cottage cheese 100g                         75
Almonds 50g                                 125
Sesame seeds 20g                            200
Salmon 100g                                 185
Tuna 100g                                   10
Soya beans 1 cup                            130
Fortified soy milk 1 cup                    290
Broccoli 100g                               125
Baked beans ¼ cup                           50
Most cereals per 20g serve                  15

Deficiency
3 major conditions:



                                                                                    122
   1. Bone deformities. Abnormalities in bone structure occur in osteoporosis (bone
      density reduced), osteomalacia (usually occurs with vitamin D deficiency and
      imbalance in calcium:phosphorous ratio) and rickets (can occur in presence or
      absence of vitamin D – 2 different forms) .
   2. Tetany. Very low levels of calcium in the blood may increase irritability of
      nerve fibres, causing spasms and cramps in the legs.
   3. Hypertension. An inverse relationship between low calcium intake and high
      BP has been highlighted by studies such as the DASH study (see sodium
      lecture).

Reducing risk of osteoporosis
   1. Diets high in salt & protein accelerate bone loss, as they promote excretion of
      calcium in the urine
   2. Excessive caffeine also promotes loss of calcium
   3. Aluminum inhibits calcium absorption, so avoid overuse of antacids
   4. Vitamin D is required for calcium absorption – housebound elderly may be at
      risk
   5. Consume adequate calcium (3 serves dairy/day) during growth & before
      menopause as peak bone mass reached in 20s, and bone becomes less capable
      of storing calcium as it ages.
   6. Weight bearing exercise encourages good bone density
   7. Avoid excess alcohol and smoking, which accelerate bone loss

Supplements
Calcium citrate not calcium carbonate better for elderly as more soluble (elderly lack
acid to solubilise carbonate). High calcium intakes can inhibit iron absorption and
zinc absorption so these supplements should be taken at different times. See lecture 2
for discussion of calcium supplements.

Phosphorous
Function
About 80% found as calcium phosphate in teeth and bones. Remainder found as
DNA/RNA, ATP, cyclic AMP (2 nd messenger), phospholipids, phosphoproteins,
phosphosugars. Also phosphorylation reactions important for activating enzymes by
kinases.

Absorption.
    Generally about 65% of dietary phosphate is absorbed. It is absorbed along the
      length of the GIT but mainly in the SI where active transport and passive
      diffusion are used.
    Absorption is promoted by vitamin D but inhibited by the insoluble complexes
      it forms with phytates and calcium. Large amounts of dietary calcium can also
      repress vitamin D levels so further decrease absorption.
    What are the ideal proportions of calcium to phosphorous to maximise
      absorption of both minerals? The high levels of phosphates in cows milk
      inhibit calcium absorption, but the lower levels of phosphate in human milk
      facilitate calcium absorption.




                                                                                   123
Excretion
Primarily renal. Excretion regulated by dietary intake, amount absorbed, plasma
phosphate concentrations. Reduction in urinary excretion caused by low dietary
intake, increases in plasma insulin, thyroid hormone, growth hormone,
metabolic/respiratory acidosis.

RDI
1000mg. Safe upper limit = 4500mg.

Sources
Generally good sources of protein are sources of phosphate eg meat, poultry, fish,
eggs very high in phosphate. Dairy products, nuts, cereals, legumes, grains are good
sources.

Deficiency
Found in such a variety of foods that a deficiency is only seen in cases of starvation.
Very serious outcome of deficiency – neuromuscular, skeletal, hematological and
renal abnormalities due to its wide range of functions.
Refeeding starved patients without providing sufficient phosphate, alcoholism or
premature babies fed unfortified human milk can cause clinical phosphate deficiency.

Magnesium
 Functions
About 60% of Mg is in bone, 26% in muscle, rest in soft tissue & body fluids. Is an
intracellular cation. Stabilises the structure of ATP in the ATP-dependent enzyme
reactions. Mg is a cofactor for many enzymes used in metabolism of macronutrients
and synthesis eg synthesis of fatty acids and protein, phosphorylation of glucose
during glycolysis.
Important for nerve transmission & neuromuscular activity (calcium generally acts to
cause muscle contraction, Mg causes muscle relaxation).
Excess Mg inhibits bone calcification, and causes CNS depression, anaesthesia,
paralysis.

Absorption
Generally 35-45% of Mg is absorbed in the SI. Facilitated diffusion occurs at low
concentrations, whilst simple diffusion occurs at high concs. Amount absorbed
depends on the Mg level of the person, amount of Mg in the diet, and the composition
of the diet. Levels of Mg kept constant in the serum by alterations in excretion and
absorption. The kidney conserves Mg if intake is low, whilst promoting urinary
excretion if intake is high. Lactating women tend to excrete less Mg to meet their
increased need.

RDI
270mg (women); 320mg (men). Safe upper limit = 350mg
Most young people easily meet their requirements; elderly may be at slight risk of
deficiency according to 1995 NNS.

Sources
Good sources are seeds, nuts, legumes, wholegrains, dark green veg. Fish, meat, milk
are poor sources. Lost during refining of grains and flour.


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Deficiency
Widely distributed so deficiency is rare. Clinical deficiency can be caused when there
is a shift in electrolyte balance eg due to renal disease, diuretics, malabsorption,
diabetes, post surgical stress.

                                     TUTORIAL

Practice Question
Jane is 27 years old and a new patient. During your initial assessment she mentions
that her mother was recently diagnosed with osteoporosis and Jane is keen to reduce
her risk of developing it. Her weight is 59kg (stable over past 3 years) and height is
162cm. No recent biochemistry/pathology results available. She used to enjoy netball
but has not played recently due to the long hours she works as an account manager.
According to her diet history she often has coffee, cereal, whole milk & fruit for
breakfast. Morning tea may be coffee & a muffin. Noodles or sushi with Diet Cola
may be eaten for lunch. Dinner is often eaten in restaurants with work colleagues, and
she will usually have at least one glass of wine. She smokes about 5 cigarettes/day.
She also takes a calcium supplement everyday.

5a) Do a nutritional assessment of Jane. (6 marks)
5b) What are some dietary or lifestyle interventions you can suggest to help Jane
minimise the likelihood of osteoporosis? (7 marks)
5c) What advice would you offer about the formulation and time of day she takes her
calcium supplement? (2 marks)

Should I aim to get calcium from food or a supplement?

Calcium from food:
    Safest, cheapest and best absorbed source of calcium. Calcium is better
       absorbed in the presence of lactose in dairy products but the exact reason is
       unclear
    Even more calcium in reduced fat/high calcium milks eg PhysiCAL so better
       choice than whole milk to increase calcium intake
    Soy milk with added calcium also good choice as phytoestrogens are present –
       these can mimic action of oestrogen which assists in preventing bone
       resorption.
    Calcium in sesame seeds, nuts, prawns, dark green veggies and figs not as well
       absorbed as dairy calcium as phytates (in bran and wholegrains) and oxalates
       (in vegetables) inhibit calcium absorption.

Calcium from supplements:
    Check label for amount of elemental calcium in tablets (<200mg elemental
       calcium is a waste of money) (eg Blackmore‟s Bio-calcium = 360mg
       Ca/tablet; Blackmore‟s Total Calcium = 64mg Ca/tablet)
    Take before bed as calcium uptake by bone peaks during the night
    A supplement containing vitamin D is helpful if elderly or bedridden
    If allergic to seafood avoid supplements made from oyster shell
    If you are also taking an iron supplement, take it at a different time as they
       interfere with each other


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      Do not exceed recommended doses
      Calcium citrate not calcium carbonate better for elderly as more soluble
       (elderly lack acid to solubilise carbonate).
      High calcium intakes can inhibit iron absorption and zinc absorption so these
       supplements should be taken at different times.
      Calcium supplements taken over several years can slow bone loss in
       osteoporosis IF combined with HRT and physical activity, but cannot replace
       lost bone



Eating for Exams
When studying:
   1. Eat regular meals
Try to have healthy regular meals, even if feeling too stressed to be hungry

   2. Get plenty of iron and zinc
These will improve memory and concentration- needed for function of
neurotransmitters. Lean meat, fish, nuts, brown rice, wholegrains all good sources.

    3. Top up omega-3 fats
Required for production of serotonin and dopamine. Need adequate amounts to
increase ability to deal with stress & concentrate. Also high intake of omega 3‟s will
reduce cortisol production, which inhibits short term memory. Use canned tuna,
salmon, omega-3 enriched bread, eggs, spreads or fish oil capsules (check vitamin E
present in capsule).

   4. Get plenty of B vitamins
Vegetables, legumes, vegemite, cereals good sources. Adequate amounts needed for
peak mental performance.

    5. Eat plenty of nutritious snacks
Small snacks fuel the brain with glucose. EG Yoghurt, nuts & dried fruit, milk &
cereal, raisin toast, rice cakes with peanut butter or cheese.

   6. Stay well hydrated

   7. Try to maintain your usual sleep routine so the night before the exam you are
      more likely to sleep well.

    8. Limit the caffeine
Too much will leave you irritable, anxious and unable to sleep. Keep to 3-4 cups of
instant coffee or 2 cups of percolated coffee. Save it for the time of day you have least
enthusiasm for study, and don‟t drink it after 6pm if it keeps you awake.

9. Get some moderate exercise everyday
Moderate exercise increases blood flow to the brain. Strenuous exercise causes the
production of cortisol, hence inhibition of short term memory.



                                                                                      126
  10. Meditate
Meditation for 20 minutes before bed will assist in sleeping & stress management

For the EXAM
     Before the exam, have a meal that includes carbohydrate and protein – carbs
        provide fuel for the brain, whilst protein will sustain your energy levels longer.
        EG cereal & milk, cheese on toast, etc.
     Try to stick with old favourites.
     Don‟t have a large, high carbohydrate meal before an afternoon exam or you
        will feel sleepy, stick with a light lunch.
     If you are too nervous to eat before an exam, have a milk shake or smoothie.



                                     MINERALS 2

Sodium
Function: found in extracellular body fluids.
Involved in maintaining volume & osmotic balance of body
fluids; needed for electrical activity of muscles & nerves; transport of amino acids &
glucose.
Kidneys regulate sodium levels by excreting excess. High intakes of sodium cause
fluid retention, and can add up to 1kg to body weight. This extra fluid can increase
blood pressure.

Sources: 90% of sodium in the diet comes from salt (sodium chloride). Other sources
include monosodium glutamate (MSG), baking powder (sodium bicarbonate),
effervescent tablets (Asproclear, Eno, Berocca) and some soda waters.

Recommended salt consumption:
                   Sodium (mg)                Sodium (mmol)          Salt (g)
Body requirement   200                        8.5                    0.5
RDI                920-2300                   40-100                 2.3-6
Average intake     2300-4600                  100-200                6-12

High salt consumption:
Risk of stroke & CVD increases continuously with increased BP, as shown by 9 large
prospective cohort studies. Sodium reduction has been shown by many trials to reduce
BP. A reduction of 3g/day of salt intake would result in an average decrease of
5mmHg (systolic)/2.5 mmHg (diastolic) for those over 50 years, and reduce age
specific stroke mortality by about 22%. Excess sodium intake also increases risk of
gastric cancer, heart failure, oedema, osteoporosis (as promotes excretion of calcium).

A high salt diet is thought to increase arterial blood pressure in susceptible
individuals. In about 70% of cases of hypertension an extremely low salt diet will
improve BP. A meta analysis has noted the full effect of a low salt diet on BP is not
seen for at least 5 weeks. Populations who habitually consume a low salt diet do not
record increased BP as they age.



                                                                                      127
Most patients with hypertension have an underlying genetic predisposition. Their
hypertension is then triggered by:
   1. Being overweight
   2. Heavy alcohol intake
   3. Stress
   4. Sedentary lifestyle
   5. High salt diet

Smoking will aggravate established hypertension.

Treating hypertension by lifestyle changes
Lowering of systolic BP by 5mmHg can be achieved by each of the following:
   1. Weight loss of 5kg if overweight (greatest contributor to hypertension)
   2. Reduce alcohol intake from 4-5 drinks to 1-2
   3. Exercise (40 min, 3-4 x week)
   4. Reducing salt intake from 12g to 6g/day
   5. DASH diet

Preferable to treat hypertension by lifestyle changes as they can minimise or alleviate
use of medication. They also have benefits beyond BP reduction, such reduction of
risk of diabetes & CVD.

DASH diet (Dietary Approaches to Stop Hypertension)
Resulted in an average reduction of 11.5mmHg (systolic blood pressure).
DASH diet promotes a balanced intake of protein, fat, CHO. Low in sodium, high in
magnesium, potassium, calcium because magnesium works with calcium, potassium,
sodium to regulate heart beat, muscle contraction & bone building. Calcium has been
shown to lower blood pressure in human trials & shown to counteract the increase in
BP that occurs in a high sodium diet. Potassium complements sodium & is important
for normalising BP. Diet includes omega-3s as they are able to lower BP, and reduce
blood clotting. In food terms the diet is rich in fruit & vegetables, fish, nuts, legumes,
low fat dairy & monounsaturated fats. It limits sweets & sugary drinks. Best results
were seen when sodium intake was restricted.

How to limit salt intake:
High salt foods (use sparingly or buy salt reduced)
Bread, hard cheeses, margarine/butter, processed meat, sauces, gravy powders,
vegemite, some breakfast cereals (see below), canned soup, takeaways, potato crisps,
soda water.

Low salt foods (use freely)
Some breakfast cereals (see below), rice, pasta, fruit & veg, milk, soy, meat, fish,
mineral water

Sodium content of breakfast cereals:
Low sodium (<120mg)                           Sodium (mg/100g)
Mini Wheats                                   3
Puffed Wheat                                  3
Rolled Oats                                   10
Honey Smacks                                  17


                                                                                       128
Just Right                                   49
Natural Muesli                               30-100
Sustain                                      98
Medium sodium (120-400mg)
Weetbix                                      280
Weeties                                      340
Good Start                                   350
All Bran                                     380
Sports Plus                                  395
Bran Flakes                                  397
Vita Brits                                   400
High sodium (>400mg)
Froot Loops                                  469
Frosties                                     506
Special K                                    536
Coco Pops                                    564
Nutrigrain                                   600
Rice Bubbles                                 720
Corn Flakes                                  800

Salt substitutes such as potassium chloride not recommended as they perpetuate the
taste for salty food & they can be dangerous for people taking potassium-sparing
diuretics or ACE inhibitors, and renal patients.

Do not add salt to baby food, and be careful about introducing solids that might be
high in salt (eg gravy). A baby‟s kidneys are too immature to cope with high salt
levels.

High sodium on blood biochemistry: dehydrated

Potassium
Function: Found in intracellular fluids. Controls water balance via interactions with
sodium and chloride ions. Also involved in the stimulation of muscles & nerves.
Absorbed in SI, excretion controlled by kidneys.

RDI = 50-140mmol/day for everyone over 8 years. Safe upper limit: no firm data but
>10g in 1 dose can cause cardiac arrest

Rich dietary sources are fruit, vegetables, legumes, nuts, lean meat. As food is
processed the potassium content falls & the sodium content rises. Read labels & aim
for 1:1 ratio of sodium to potassium in product, as potassium counteracts the effect of
sodium on BP.

Low potassium on blood biochemistry: generally due to diarrhoea, vomiting, diuretics
High potassium on blood biochemistry: acute renal failure or hyperaldosteronism
(usually drug induced)




                                                                                      129
Zinc
Function: part of many metalloenzymes involved in various metabolic processes such
as CHO metabolism, DNA synthesis, protein synthesis, bone metabolism (required
for osteoblast activity & calcification), synthesis of neurotransmitters.
Also required for wound healing; essential for normal taste, smell, sight; needed for
sexual maturation & reproduction.

Rich food sources: lean meat, chicken, seafood, milk, wholegrains, legumes, nuts.

RDI: 12mg (adults). Safe upper limit = 40mg.

Absorption of zinc requires the acidity of the stomach to solubilise the zinc salts in
food, and allow their absorption in the SI. Like iron, several factors affect the
bioavailability of zinc:

Promoters                                      Inhibitors
Low zinc status                                High phytate content of food
Low dietary zinc                               Dietary fibre
Animal protein                                 Iron & calcium supplements
Fermentation/germination of cereals
(destroys phytate)
Red wine

Zinc deficiency: Rare in Australia. Mild deficiency may occur in 3 rd world countries,
particularly if eating little meat & a lot of fibre (so vegetarian children at higher risk
of zinc deficiency). Symptoms = impaired growth, delayed sexual maturation,
increased susceptibility to infection, impaired neurophysiological function.
Zinc deficiency often occurs in conjunction with iron deficiency, so young women,
pregnant women & breastfeeding women tend to be affected.
Trials of zinc supplements to treat colds & flu have been conducted for a decade but
results are inconclusive.

Selenium
Function: part of the antioxidant enzyme glutathione peroxidase, which neutralizes
free radicals. Therefore being studied for a role in cancer & CVD prevention. Can
protect against heavy metal poisoning from cadmium, mercury & silver.

Rich food sources: nuts (especially Brazil), seafood, lean meat, eggs, mushroom,
garlic, grains. Levels of selenium in food reflect the amount of selenium in the soil.

Deficiency: In the Keshan region of China selenium levels are low in the soil and
locals develop Keshan disease (cardiomyopathy associated with low plasma selenium
levels).

RDI = 70ug (women) or 85 ug (men). Safe upper limit = 400ug

Iodine
Function: most iodine in body is concentrated in the thyroid gland, where it is used to
manufacture thyroxine (T4) and triiodothyronine (T3), which control growth,
thermogenesis & metabolism of all tissues.


                                                                                         130
Rich dietary sources: iodine is very soluble so easily lost from soil eg mountainous
areas usually low in iodine, so foods grown in these soil are low in iodine. Sea is
iodine reservoir, so seafood is a good source. Other sources of iodine in our diet are
iodine fortified salt & food products from animals given iodine supplemented feed.
Iodised salt was used to counteract iodine deficiency, which was common in Australia
in the past. As we reduce our salt intake iodine deficiency is again emerging.
Absorption: in SI, excreted in urine. Goitrogens in food inhibit the uptake of iodine by
the thyroid gland. Brassica vegetables (cabbage, brussel sprouts) contain goitrogens
which are metabolized to thiocyanate, which interferes with iodine uptake by the
thyroid.

Deficiency of iodine: iodine deficiency disorders include symptoms of abortion, still
birth, infant mortality, congenital abnormalities, cretinism, goiter, hypothyroidism

RDI: 120mg (women); 150mg (men). Safe Upper limit: 1000mg

Copper
Functions: Component of several enzymes involved in energy production, collagen
synthesis, manufacture of neurotransmitters. Partners iron in erythropoiesis, aids in
melanin formation.

Rich food sources: oyster, crab, lobster, mussels, nuts, cocoa powder, wholegrains

RDI: 0.9mg/day suggested, upper safe limit 10mg

Deficiency: a dietary deficiency has not been clearly identified in otherwise healthy
people. In specific disease states copper deficiency can occur, resulting in anemia,
neutropenia and abnormal bone formation & vascular abnormalities.

Chromium
Functions: required for normal growth. Also forms part of the Glucose Tolerance
Factor which enhances the action of insulin so helps regulate blood glucose

Rich food sources: yeast & yeast extract, egg yolk, lean meat, wholegrains, cheese,
wine, oysters

RDI: 25ug (women); 35ug (men). Safe upper limit = 1000ug
Deficiency: will result in insulin resistance. Does not mean all cases of insulin
resistance are due to chromium deficiency.

Fluoride
Functions: its incorporation into bone & teeth increases the crystallinity of these
tissues. Adequate fluorine hardens and increases resistance of tooth enamel to decay.
Under investigation for a role in prevention of osteoporosis.

Rich food sources: fluoridated drinking water, small amounts in fish & tea.
Fluoridated drinking water is associated with reduced incidence of childhood dental
caries. High intakes of fluoride can cause a mottling of tooth enamel.



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RDI: 3mg (women), 4mg (men). Safe upper limit = 10mg.




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