Applied Nutrition 2024 PDF

Applied Nutrition By Prof. Atef Gouda Hussien Professor of Medical Biochemistry and Nutrition 2024 1  Food Fortification Food fortification or enrichment is the process of adding micronutrients (e...

Applied Nutrition By Prof. Atef Gouda Hussien Professor of Medical Biochemistry and Nutrition 2024 1  Food Fortification Food fortification or enrichment is the process of adding micronutrients (essential trace elements and vitamins) to foods. This process aims to reduce numbers of people with dietary deficiencies. The most common fortified foods are: - Cereals and cereal based products. - Milk and milk products. - Fats and oils. - Tea and other beverages. - Infant formulas. Types of food fortification: 1- Biofortification (creating new crops using generically modified breeding techniques). 2- Microbial biofortification (addition of probiotic bacteria to foods). 2 3- Commercial and industrial fortification (flour, rice, pils, cooked foods). 4- Home fortification (vitamin D drops). Rationale of food fortification 1- To replace nutrients which were lost during manufacturing the products. 2- To act as public health intervention. 3- To ensure the nutritional equivalence of substitute foods (to make butter and margarine similar in content). 4- To ensure the appropriate vitamin and mineral nutrient composition of foods for special dietary purpose (gluten free products). Examples of fortified foods: - Iodized salt. - Addition of folic acid to flour. - Addition of vitamin D to margarine, vegetable oils and dairy products. - Addition of calcium to fruit juices and carbonated beverages. 3  Dietary Supplements Dietary supplements are products taken by the mouth that contains a dietary ingredient to supplement the body. They can come as pills, capsules, powders and liquids, soft gels. They are not considered drug. Dietary supplement include: - Vitamins - Minerals - Essential amino acids - Essential fatty acids - Herb or other botanical - Phytochemicals Botanicals; plants (including their leaves, flowers, stems, rhizomes, or roots) that are used for medical purposes, are formulated in a wide variety of forms, including teas, infusion, extracts, pill forms (capsules, tablets and soft gel). Phytotherapy, the science of using plant-based medicine to prevent or treat illness. Food Processing 4  Food processing is the set of methods and techniques used to transform raw ingredients into food or to transform food into other forms for consumption by humans or animals either in the home or by the food processing industry. Food processing typically takes clean, harvested crops or butchered animal products and uses these to produce attractive, marketable and often long shelf-life food products. Benefits of food processing include 1- Toxin removal 2- Preservation 3- Easy marketing and distribution tasks 4- It increases seasonal availability of many foods 5- Enables transportation of delicate perishable foods across long distances 6- Makes many kinds of foods safe to eat by de-activating spoilage and pathogenic micro-organisms. 7- The act of processing can often improve the taste of food significantly.  Processed foods are usually less susceptible to early spoilage than fresh foods and are better suited for long 5  distance transportation from the source to the consumer. When they were first introduced, some processed foods helped to alleviate food shortages and improved the overall nutrition of populations as it made many new foods available to the masses.  Processing can also reduce the incidence of food borne disease. Fresh materials, such as fresh produce and raw meats, are more likely to harbor pathogenic micro- organisms (e.g. Salmonella) capable of causing serious illnesses. Hazards of processed food 1. Cancer: Some cancers are known to be caused by carcinogenic properties which are included in processing foods. 2. Obesity: Processed foods are most often high in fat, sugar and salt, which lead to excessive weight gain. 3. High carbohydrates content: 4. Heart disease: 6  The Trans fat in many processed foods will spike the cholesterol level and lower the HDL. 5. Hypertension: Hypertension may be due to the high salt and fat content in foods. 6. Diabetes: The high sugar products and fast acting carbohydrates will raise the glucose to unhealthy levels. 7. Food additives and unknown effects: For color, consistency, taste, shelf life and more, processed foods include additives while the effects are unknown. 8. Unknown fillers: Several foods like hot dogs and processed meats are filled with unknown parts. 9. Lack of nutrients: If processed foods are the main part of the diet, the body will be lacking the nutrients needed to fight disease. 7  Nutrition and Cancer The National Cancer Institute and the American Cancer Society estimate that 30 to 35% of all cancers are diet related. This means that many cancers can be prevented by dietary management. Dietary recommendations developed by the American Institute of Cancer Research and the World Cancer Research fund are suggested to reduce risk of cancer. Recommendation I: Maintain a healthy body weight - Ensure that body weight through childhood and adolescent towards the lower and end of the normal body mass index (BMI) range at 21 years of age. - Maintain body weight within the normal range after 21 years of age. - Avoid age-related weight gain and increases in waist circumference throughout the adulthood. Obesity increases the risk of colorectal , endometrial, post- menopausal breast, pancreatic and esophageal cancers. Recommendation 2: Be physically active 8 - Limit sedentary habits such as watching television. - Physical activity decreases the risk for colo-rectal cancer and endometrial cancer. - Weight gain resulting from physical inactivity can contribute to breast-cancer. - Be moderately physically active for 30 minutes, then as fitness improves, aim for 60 minutes. Recommendation 3: Limit consumption of energy dense foods and sweetened beverages - Avoid sugary drink. - Avoid consumption of fast food and high energy dense foods to avoid weight gain and obesity. Recommendation 4: Eat mostly foods of plant origin - Increase consumption of fruits and non starchy vegetables (spinach, broccoli, carrots,) may decrease the risk for cancers of mouth, esophagus, lungs and stomach. - Consumption of high-fiber foods probably decreases risk of colorectal cancer. 9 - Limit refined starchy foods. The mechanisms by which increased consumption of plant-based foods helps decrease cancer risk include: First, plant foods are good sources of many essential vitamins and minerals needed to maintain healthy cells. In other words, they are nutrient-dense. These vitamins and minerals can act as anti-cancer. For example, the antioxidant function of vitamin C, vitamin E, and selenium may inhibit free radical formation or repair damaged DNA, thus inhibiting the initiation phase of cancer. Also, many different vitamins are needed for maintaining a healthy immune system. Second, in addition to the "traditional" nutrients, some plant foods also are rich sources of phytochemicals that might influence cancer. Phytochemicals-potentials cancer fighters: There are thousands of biologically active compounds found in plants called phytochemicals that are important to decrease the risk for cancer. There is an estimate that approximately 50-60% of cancer patients in the United States utilize agents derived from different parts of plants or nutrients (complementary and 10 alternative medicine), exclusively or concomitantly with traditional therapeutic regimen such as chemotherapy and/or radiation therapy. These include curcumin from tumeric, genistein from soybean, tea polyphenols from green tea, resveratrol from grapes, sulforaphane from broccoli, isothiocyanates from cruciferous vegetables, silymarin from milk thistle, diallyl sulfide from garlic, lycopene from tomato, rosmarinic acid from rosemary, and gingerol from gingers. The sources and role of phytocehmicals as anticarcinogenics are listed in table 1. 11 Table (1): Some potentially anticarcinogenic phyto- chemicals. Phytochemical Some food sources Some proposed actions -carotene Carrots, pumpkin, Antioxidant; cell sweet potatoes cycle; antibacterial Caffeic acid phenethyl Honey Immune modulation; ester antioxidant Capsaicin Chili peppers Immune modulation; apoptosis Curcumin Tumeric Anti-inflammatory Induce apoptosis Diallyl sulfide Garlic, onions Modification of enzymes; antibacterial Gingerol Ginger Antioxidant; immune modulation Isoflavones Soybeans Anti-estrogenic activity,anti-oxidant, Tyrosine-kinase inhibitor Isothiocyanates Broccoli, Brussels Modification of sprouts, cauliflower enzymes; antioxidant Limonoids Organs, lemons, Apoptosis limes, grapefruit Lignins Flaxseed Estrogen antagonist Lutein Tomatoes, spinach Antioxidant Lycopene Tomatoes, pink Antioxidant grapefruit Phenylpropanoids Cinnamon, cloves, Antioxidant; vanilla antibacterial Polyphenols Green tea Immune modulation; apoptosis Resveratol Grapes Antioxidant; anti- metastases 12 Recommendation 5: Limit intake of red meat and processed meat - Limit the consumption of red meat to not more than 500 gm each week. - Avoid processed meat if possible. Processed meat refers to meat preserved by smoking, salting or addition of chemical preservatives and includes sausage, hot dogs. These recommendations are based partly on data suggesting that the risk of some cancer such as colorectal cancer is lower among those who consume vegetarian diets compared to those who eat meat. Nitrites added to processed meats to preserve color and enhance flavor may be carcinogenic. This is because they are converted to nitrosamines which are known to cause cancer. Also, small amounts of other carcinogens called polycyclic aromatic hydrocarbons are produced when meat is grilled. There is also evidence that high intake of iron from red meat may be the factor related to increased cancer risk. Moreover, cooking meat at high temperature may produce heterocyclic amines which are carcinogenic. 13 Recommendation 6: Limit Alcohol Alcohol consumption can increase risk for oral, esophageal, colo-rectal, and breast cancers. Recommendation 7: Eliminating tobacco. Smoking and tobacco are the main cause of cancer lung and may contribute to cancers of mouth, throat, pancreas, and bladder. Recommendation 7: Limit salt and avoid moldy grains and legumes - Consume salt at levels within the ranges suggested by the dietary reference intake. - Do not consume any cereal grain or legume that might have been improperly dried. Consumption of salt and salt-preserved foods is a probable cause of stomach cancers. Also, intake of inadequate drying foods-in particular grains and some legumes such as peanuts can lead to growth of a fungus (mold) that produces dangerous toxins such as aflatoxin. Aflatoxin has been shown to cause liver cancer. 14 Special recommendation 1: Women should breast their infants Breast feeding helps both protect a women from breast cancer (premenopausal) and prevent the latter development of obesity in the infant that may lead to cancer in later life. Special recommendation 2: Cancer survivors should follow same recommendations Except in special situations, the panel recommends that cancer survivors follow the same dietary recommendations as those suggested for the general population. Nutritional Implications of Cancer 1- Cancer Cachexia As cancer progresses, appetite and food consumption are likely to decrease, resulting in a form of malnutirion and emaciation called cancer cachexia which is characterized by progressive weight loss, anorexia, generalized wasting and 15  weakness, immunosuppression, altered metabolic rate and energy metabolism. Cachexia may develop from several reasons. Cytokines like tumor necrosis factor (CTN-), IL-6, and IL-1 and may have an anorexia-induced effect. Altered carbohydrates, lipids and protein metabolism were implicated. Anorexia from chemotherapy Dysphagia nausea pain, surgery, radiation vomiting diarrhea Decreased nutrient intake Cancer cachexin Tumour competition for nutrient 2- Altered metabolism: Cancer cells use a lot of energy, primarily glucose. This can lead to loss of energy to healthy cells and lower blood glucose-levels. There is generally a hypermetabolic state associated with cancer that can lead to weight loss. 16 Increased rate of protein breakdown, lipolysis was present together with a state of insulin resistance. Cancer treatment and nutritional implications: Cancer is usually treated by surgery, radiation and chemotherapy, used alone or in combination. These methods have different effects on nutritional state which include: - Fatigue - Altered taste - Loss of appetite - Nausea and vomiting - Stomatitis or esophagitis - Diarrhea - Dysphagia - Constipation Nutritional care of the cancer patient Good nutrition is especially important for cancer patient due to the impact of illness and its treatments. Benefits of good nutrition during cancer treatments: -Feel better. -Maintain body weight. -Better tolerate treatment-side effects. -Lower the risk of infection. -Heal and recover faster. 17 General dietary recommendation for cancer patient: - The diet must supply enough proteins, fats, carbohydrates, vitamins, minerals, and fluid to meet the increased energy demands of a high metabolic rate to prevent weight loss, to rebuild body tissues. - Plant-based foods are recommended. -2 1/2 cups of fruits and vegetables a day including citrous fruits, dark-green and deep-yellow vegetables. -Limit high fat diet from animal sources. -Low –fat milk and dairy products. -Limit the amount of salt and smoked foods. -Snacks are recommended to provide extra calories especially a protein rich snake like yogurt, cereals and milk. -Intake of high calorie and high protein beverage like milk. - Adequate fluid intake is necessary to ensure adequate hydration, tissues perfusion and electrolytic - Antioxidant supplements (vitamins A, C, E, -carotenes, zinc, and selenium) should be avoided during radiation 18  therapy because they appear to reduce the effectiveness of treatment. Nutrition and Bone Health The skeleton begins to grow early in fetal life and this growth continues throughout our life. It is important to develop and maintain healthy bones in childhood and even early adulthood. Many nutrients like proteins, calcium , phosphorus, vitamins (D, K ,C) are needed for bone growth, remodeling, and maintenance. Recommendations for bone health: (1) Foods to encourage: - Dairy products to provide sufficient amounts of calcium. Consumption of 2 to 3 cups of milk each day are recommended. - Exposure to sunlight for at least 15 minutes especially for individuals over the age of 50 years to get vitamin D3 19 - Fish, dark green leafy vegetables such as spinach, broccoli, provide the highest amount of vitamin K. - Sea foods, legumes, nuts, and unprocessed (brown) rice are rich in manganese. - Phosphorus is found in almost all foods especially those high in proteins e.g. fish , eggs and milk products. - Consume 1 to 4 cups of vegetables and 1 to 2.5 cups of fruits to ensure good amounts of vitamin C. (2) Foods to consume only in moderation: - Food rich in fiber, oxalates and phytates such as green leafy vegetables, whole grains, nuts can decrease absorption of calcium. People with osteopenia or osteoporosis should not consume large amounts of these compounds. However, because these foods are nutrient rich, so it must be taken in moderate amounts. - Coffee/tea. Drinking more than three cups of coffee every day may interfere with calcium absorption and cause bone loss. - Soft drinks. Some studies suggest that colas, but not other soft drinks, are associated with bone loss. The carbonation in soft drinks does not cause any harm to bone. The caffeine commonly found in colas may contribute to bone loss. 20 -Salty foods. Eating foods that have a lot of salt (sodium) cause calcium loss and can lead to bone loss. Sodium intake must be 2.4 g or less per day. Beans (legumes). While beans contain calcium, beans contain magnesium, fiber and other nutrients, they are also high in phytates which interfere with calcium absorption. Phytate level can be reduce by soaking beans in water for several hours and then cooking them in fresh water. Osteoporosis: It is a systemic skeletal disorder characterized by low bone mass, micro-architectural deterioration of bone tissue, bone becomes more fragile and consequent increase in fracture risk. It is the most common reason for a broken bone among the elderly. Causes of osteoporosis: -Aging -Menopause -Low sex hormones -Sedentary lifestyle -Diseases:chronic kidney diseases -Medications: chemotherapy and glucocorticoids. Dietary rcommendation for osteoporosis : 1-Adequate calcium intake: from foods and supplements. RDI of calcium in cases of osteoporosis is about 1500 mg/day. Food sources e.g. wheat bread, dairy products, broccoli and soy beans are recommended first for 21  supplying calcium needs because of the coingestion of other essential nutrients, dairy products, calcium fortified foods, legumes are good sources. Individuals over 50 y needs a calcium supplement of about 500 – 600 mg/day. Calcium citrate is better than calcium carbonate because it is absorbed more easily than calcium carbonate and can be taken on an empty stomach and are more readily absorbed by people who take acid-reducing heartburn medications. But because calcium citrate is only 21% calcium, you may need to take more tablets to get your daily requirement. 2-Vitamin D : from food, supplements and sun exposure. Dietary sources such as oily fishes and fortified milk or margarine. But diet alone cannot maintain serum 25 hydroxy vitamin D ,so a daily supplement of 800 IU of vitamin D3 is recommended. Exposure to sunlight is very important for vitamin D biosynthesis, but typically insufficient source for elderly people and who live far from equator. The skin of older individuals is less efficient in producing vitamin D following exposure to UV because the skin is thinner in the elderly and it contains fewer cells that can synthesize vitamin D. 3-Protein intake : Proteins have an anabolic effects on bone. Adequate protein intake of 1 g/kg/day is necessary to maintain PTH concentration. High protein diet can increase urinary loss of calcium. On the other hand , a 22  chronic low protein intake contributes to low levels of serum albumin and serum calcium. Animal proteins increases urinary losses of calcium, whereas a plant proteins has little effect on urinary calcium losses because of the production of a neutral or basic urine. 4-Vegetables and fruits : are recommended because it provides:  Vitamin C and antioxidants.  Vitamin K from green leafy vegetables which is essential for osteocalcine formation.  Potassium in the form of potassium bicarbonate which decrease calcium excretion in urine.  Phytoestrogen.  Polyphenols and magnesium which have been associated with bone health. 5-Vitamin B12 : Recent studies associate low vitamin B12 intake and/or high level of serum homocysteine with increased bone fracture risk. Older adults may have insufficient vitamin B12 due to loss of stomach acid, so vitamin B12 supplement is recommended. 6-Foods to be avoided:  Salty foods : Sodium increases calcium excretion.  Limiting coffee intake to 3 cups.  Soft drink. 23  Nutrition and Cardiovascular Health Hypertension : Hypertension (high blood pressure) is when the pressure in your blood vessels is too high (140/90 mmHg or higher). It is common but can be serious if not treated. People with high blood pressure may not feel symptoms. The only way to know is to get your blood pressure checked. Risk factors for hypertension include: -Older age -Overweight or obesity 24  -Sedentary lifestyle -High-salt diet Nutrition of hypertensive patients: - Low sodium diet. - Low-calorie diet - Diet rich in vegetables, fruits and low fat dairy products. These foods contain potassium, calcium and magnesium which are important for maintaining healthy blood pressure. - Limit liqorice intake because liqorice leads to hypertension and hypokalaemia, because it suppresses the hormone aldosterone, which is responsible for controlling sodium levels in the body. The DASH diet (Dietary Approaches to Stop Hypertension) is a dietary pattern promoted by the U.S.- based National Heart, Lung, and Blood Institute to prevent and control hypertension. The DASH diet: -Is low in salt, saturated fat, cholesterol and total fat. -Emphasizes fruits, vegetables, and fat-free or low-fat milk and milk products. -Includes whole grains, fish, poultry and nuts. -Limits the amount of red meat, sweets, added sugars and 25 sugar-containing beverages in your diet. -Is rich in potassium, magnesium and calcium, as well as protein and fiber. Controlling blood lipid levels with diet: - Weight reduction. - Diet high in soluble fiber (such as bran, oatmeal, legumes, barley,and strawberries) may help lower LDL-cholesterol. 26 - Limit consumption of trans- fats because they decrease HDL and promote inflammation. - Consumption of olive oil (rich in monounsaturated fatty acids) and fish, flaxseed oil (rich in W-3 fatty acid) may decrease VLDL and triglyceride synthesis in the liver. Also, W-3 fatty acid may reduce the risk of atherosclerotic plaque rupture and have anti-inflammatory properties. - Exercise of at least 60 minutes three times a week. Dietary factors associated with lower risk for cardiovascular disease - Diets rich in vitamin B6, vitamin B12 and folic acid help maintain a healthy cardiovascular system. A deficiency in any of these vitamins can cause accumulation of homocysteine in blood which increase the risk for cardiovascular disease. - Anti-oxidant nutrient such as vitamins C, E, -carotenes and selenium may help to decrease chronic inflammation and inhibit oxidation of LDL, thus decreasing the risk for cardiovascular disease. 27 - Phytochemicals such as plant sterols, isoflavones soy products, grapes and polyphenols of green tea may influence heart health. Mediterranean diets and heart disease: Mediterranean diets are not "diets" per se, but rather eating patterns of those living in countries surrounding the Mediterranean sea. These diets emphasize fruits, fish, vegetables, whole grains, nuts, and seeds as well as olive oil and red wine; meats are consumed in moderation. Many studies show that people consuming a Mediterranean-type diet have lower rates of heart disease. General recommendation for cardiac patients: - Calorie restricted-diet. -Weight loss. 28 - As regard carbohydrates: consume  3 servings of whole-grain products daily; complex carbohydrates such as those found in vegetables, fruits, and whole grains rather than refined carbohydrates, such as table sugar. - Lipids: Consume fish (rich in W-3 fatty acids) at least twice weekly; people with heart disease or elevated blood triglyceride should consume more. - Saturated fat intake should be  10% of total calories; people who already have heart disease should consume