BASICS OF DIETETICS W1.docx

**BASICS OF DIETETICS W1** Role of food in prevention and treatment of various diseases, including malnutrition, obesity, cardiovascular diseases, kidnley diseases, diabetes, diseases of the digestive system. Etiology, epidemiology and industrial diseases. Every day we make choices that will eith...

**BASICS OF DIETETICS W1** Role of food in prevention and treatment of various diseases, including malnutrition, obesity, cardiovascular diseases, kidnley diseases, diabetes, diseases of the digestive system. Etiology, epidemiology and industrial diseases. Every day we make choices that will either improve or worsen our health, each choice will have a small impact but when repeated over and over they will have a huge impact. The relationship between nutrition and health has always been known. A proper diet allowed us not only to develop civilization but also the creation of homosapeine. The story of human evolution apperas to be the story of what we eat. The first humanoid appeared 2/3 million years ago and thanks to the stone tools they used, they acquired chewing reflex and then, thanks to fire, they learned how to make a meal. Humanoids have evolved in an amazing short time, compared to other organisms. Cooking marked more than just our lifestyle for our ancestors, it helped fuel our evolution, give us bigger brains and later down the line, it became the centerpiece of the feasting rituals that brought communities together. All human societies eat cooked food and biologists generally agree cooking is what could have had a major effect on how the human body evolved. For example, cooked food tends to be more tender so human could eat it with smaller teeth.\ Cooking also increases the energy that humans can get from the food they eat. The use of fire in general, significantly developed our development. Starchy veggies like potatoes are not very digestible raw, but amazing source of carbs cooked. For almost 99% of human history, humanoids hunted and gutted to survive, and this was the basis of their nutrition. Homo sapien species appeared in the world about 300 thousand years ago and about 12 thousand years ago, humans started domesticating animals and plants. Did this change us for the better? Not really. Indeed, people had to work harder for their food and the diet was not so varied as before. The first recorded dietary advice, carved into babylonian stone tablet about 2500 before christ, cautioned those with stomach pain issues to avoid onions for three days.\ Scarvy, later found to be vitamin C deficiency, was first described in 1500 BC in the abbas papyrus. The proper study of nutrition probably began during the 6th century BC.\ Food was classified into hot food (meats, ginger, hot spices) and cold food (green veggies). This was done mostly in china, india, malaysia and persia. hippocratus was one fo the first great minds that spoke about food as a medicine. However, real science about food and nutrition is not that old. The first vitamins were discovered at the beginning of the 20th century. The development of science and food truly started 60/70 years ago. Food is a basic necessity of man. It's a mixture of different nutrients, such as carbohydrates, proteins, fats, minerals and vitamins. These nutrients are essential for growth, development and maintenance of good health through life. A healthy diet is a foundation for health, well-being, optimal growth and development. It will protect from all forms of malnutrition. We eat to love, however many foods play many other functions, - - **FOOD, NUTRITION AND DIETETICS** 1. - - - - 2. - - - 3. Nutrients are chemical substances inherently present in numerous food sources that the body used to obtain energy, build tissue and regulate biological function. We have over six major groups of nutrients: - - - - - - Each of these groups counts from several dozen, in the case of vitamins, to many thousands of compounds when we talk about proteins or lipids. each vitamin is also group of compounds. For example, vitamin C consist of ascorbic acid and ascorbic acid. When it comes to minor minerals, each yearn, both in food and in our body is bounded w.. 4. - - - - - By knowing the chemical composition of food, we can calculate its energy value. Depending on the nutrient content of the product, its nutritional value may be higher or lower. The knowledge of food composition and nutritional value is necessary to implement the principles of proper nutrition as well as being an important element of nutritional education of the society. The source of information on the composition of food products and dishes, and the content of individual nutrients in them are databases and tables of food composition and nutritional value. Databases and tables of food composition and nutritional value are prepared by teams whose goal is above all the most accurate compilation of information on their nutritional value of food in each country. Each country will consume a wide range of different products. It is important to remember that the data on these tables and databases are average data, so for example even in fruit, veggies and meat, it could vary depending on environmental factors for example, harvest season, genetics, irrigation, insulation etc. In addition, storage and processing can significantly affect the final nutrient content. It is important to note that the composition of both simple and complex foods has significantly changed over the years as a result of progress in agriculture and food processing, varieties of cultivated plants and farmed animals, new food additives, new recipes, etc. 5. Nutrition can be described as the science of the effects of food on the body at the molecular, cellular, tissue and whole-organism levels. Nutrition includes the study of processing food within the body for its utilization for provisions of energy, building of body tissues and their repair, protection from microorganisms. The goal of nutrition is to maintain health. According to the WHO, health is a state of well-being in which the individual realizes his or her own abilities, can cope with the normal stress of life, can work productively and contribute to his or her community. HEALTH IS NOT THE LACK OF DISEASES! Our health results from many factors: - - - - - Lifestyle It is the typical way of life of an individual group or culture. It includes diet, stress, physical activity and sleep. A healthy lifestyle is a way of living that lowers the risk of being seriously ill or die. At a certain age, our health starts to decline Every disease known to mankind has some connection, direct or indirect, to food. Infections for example are not caused by food, but a healthier diet could have led to a stringer immune system and avoided the infection. 6. 7. - - - - - - - - - - - A normal diet is planned to the recommended daily intakes which are designed to meet the needs of all healthy people and may not meet the needs of sick people. The nutritional requirements depend on the activity, increased or decreased demands for certain nutrients will need to be taken into consideration when planning a diet. The amount of each individual nutrient needs to maintain an individual's health is called nutrient requirement. These requirements vary depending on age, gender and level of PA. Physiological statuses like pregnancy, dietary habits or genetic backgrounds are also important. Nutritional requirements are presented in nutritional standards, One of the first nutritional recommendations comes from england from 1753 and said that sailors should introduce at least 28 grams of lemon juice per day to avoid vitamin C deficiency. The first attempts to develop recommendations of standard nature were made in the 19th century, which was associated with effective ways to combat hunger and malnutrition. DIETARY STANDARDS They define how much and energy and nutrients are necessary to meet all the nutritional needs of healthy people in a healthy population. Consumption of energy and nutrients in accordance to standards are useful to prevent on the one hand the deficiency and on the other hand the effects of excessive supply. Every nutrient introduced in excess can negatively effect our health. Dietary standards are widely used in many areas related to food and nutrition, in particular scanning and monitoring food supply on a national scale, planning day meals in individual nutrition, assessing food consumption at the individual and group level of an entire population, assessing the nutritional quality of food products, developing diets used in various diseases, developing nutritional education programs etc. Dietary standards have certain limitations that must not be forgotten: - - - - - - - They can be: - - - - - **ENERGY REQUIREMENTS** The development and functioning of the body, require ingredients necessary for the course of metabolic process and the construction, renewal of its structures. The basic element determining the implementation of this task is the availability of energy. Energy production is a key process in the body cell. Each cell produces energy for its own use, using substances from the food we eat. **Energy is produced primarily from carbohydrates and fats. Dietary proteins are mainly used to build body proteins,** which means that they become substances for energy production to a lesser extent. Energy requirement is defined as the amount of energy supplied with the food during the day, which is needed to balance the body's energy expenditure related to maintaining body mass and composition and physical activity which will ensure good health. Energy expenditure also includes the energy needed for optimal growth and development of children, for normal tissue growth during pregnancy and for milk product, milk production during breastfeeding, to ensure the good health of mother and child. Human demand for energy, and as a result for energy substances contained in food, depend on many factors. - These differences are mainly due to differences in weight and body composition. Men are characterized by higher content of muscle tissues and thus a higher content of water and lower content of adipose tissue in the body compared to woman. More muscle and less body fat are associated with higher energy expenditure. - - - - -**Physical activity:** one of the most important because energy related to PA is the most variable component of total energy expenditure. In people leading a sedentary life it accounts for about 15% of total energy expenditure but for very physically active people it can reach up to 50% and more of total energy expenditure. **-Endocrine factors and drugs:** it's important to mention that some hormones like the thyroid have effect on energy expenditure. In normal people, the effect is really small, just like some medications. **How to calculate energy expenditure?** The total energy expenditure is the sum of basal metabolic rate and energy spent on physical activity → BEE x PAL= TDEE BEE: basal metabolic energy expenditure is the energy needed to maintain basic physiological functions when the body is at rest, it's the energy spent on maintaining the right temperature, to make organs function, etc. How to calculate it? - - - **TDEE= BEE x PAL** Energy balance occurs when the amount of energy consumed equals the amount of energy we introduced with food. In this case our bodyweight will not change. Moving away from the energy balance will have an effect on our bodyweight. If we are in a surplus, so the energy intake is greater than the energy expenditure, the energy balance is positive and the result is weight gain. If we are in a deficit, so the energy balance is inferior to the energy expenditure, the energy balance is negative and the result is weight loss. Having a positive energy balance does not only lead to weight gain but also to diseases. A disturbed energy balance can lead to malnutrition, which is most common in the elderly, as well as people with IBS, respiratory diseases and tumors. Malnutrition is also observed in people with anorexia nervosa. The primary consequences of malnutrition include deterioration of the general condition, weight loss, reduction of muscle mass, weakness of muscle strength and psychomotor performance, impaired immunity, reduction of the protein concentration, especially albumin, in blood, disturbance of water and electrolyte balance and many other consequences. Secondary consequences include: increased incidence of infections, several illnesses leading to longer hospitalization. The human body, however, has several mechanisms to cope withh the deficit and the surplus of energy supplied with food. Over the century it has developed the facility to accumulate energy reserves, which increased the chance to survive in times of scarcity. For the majority of people living in "developed" countries, the basic problem is the fact of chronic accumulation of excessive energy reserves associated with the difficulty of getting rid of excessive energy reserves, which results in serious health problems. Proper nutrition is understood as the regular consumption of food that provide the body the optimal amounts of energy and recommended nutrients in the right proportions and frequency. Proper nutrition allows the use of genetically determined possibilities of the physical and mental development of a given person and also helps to maintain good health throughout life. Proper nutrition together with adequate physical activity is an essential element in the prevention of chronic non communicable diseases. RECCOMENDATIONS FOR HEALTHY NUTRITION According to the principles of healthy nutrition, the main source of energy should be carbs, especially complex starches, and they should provide 45-60% of energy to our body. The amount of energy from sugars, like monosaccharides like glucose or fructose, disaccharides like lactose or sucrose, should not be higher than 10%. Fat should provide between 20 and 35% of energy, the remaining should be covered by proteins, so between 10-20%. Proper nutrition also means frequency of meals, eaten at regular times of the day. This will ensure a better metabolism and optimal use of nutrients. Breakfast is particularly important, which should be properly composed nutritionally and is very important for the development of the body. A very important principle of proper nutrition is to diversify meals and the selection of food products from different groups in appropriate proportions. There are five basic groups of products: - - - - - The main group we consume should be fruits and vegetables, as they are the main source of vitamins like vitamin c, beta carotene, folates. They are also a good source of minerals, fibre and natural antioxidants. Antioxidants remove free oxidant radicals that are harmful to the body. It's best to consume them raw, because the process of cooking vegetables result in the highest loss of vitamins and minerals. Vegetables and fruit should be eaten several times a day as part of meals or as snacks. They differ in composition and nutritional value, their color is strongly associated with the content of certain components that affect health. Veggies are divided into three groups: - - - We then have cereals, which should be part of most meals. It is better to choose whole grain ones as often as possible (like flour, bread, rice, pasta), A valuable part of our diet can also be natural cereal flakes like oats, barley, rye as they provide complex carbs, they are an excellent source of energy for our body. They contain a good amount of protein and fats as well as vitamins B and various minerals like magnesium, zinc, and iron, which among others support physical development and have a positive effect on well-being and the ability to learn. They are also a source of dietary fiber, supporting the work of the digestive system while also facilitating the maintenance of normal body weight. Until a few years ago, cereal products were at the basis of the food pyramid, however, due to the decreasing levels of physical activity and decreasing energy demand of a large part of the population, vegetables and fruits have gained the first place in the diet. Although very often there are more vegetables by weight in the diet, cereal products provide more energy. Milk and its products are characterized by very good nutritional value: protein of excellent biological value, significant amounts of calcium, vitamin B. Adults should choose products with a reduced fat content, skimmed milk does not contain vitamins A and D whilst the amount of calcium, vitamin B2, and protein does not change. Milk is not well tolerated by some adults due to lactose intolerance resulting from a deficiency of lactase, the enzyme that breaks down the sugar into glucose and galactose. The incidence of lactose deficiency increases with age, in this case, choosing fermented milk products like yogurt or kefir, might be a good solution. Dairy products should be consumed twice a day. Appropriate consumption of products from this group is extremely important, especially due to the presence of well-absorbed calcium. The correct intake of this element prevents osteoporosis, hypertension, and obesity. From the data of observational studies, they show that there is an inverse relationship between calcium intake and blood pressure. In a very large prospective study, it was observed that people consuming 800mg of calcium per day had a lower risk of developing hypertension than people consuming 400mg of this element. It should also be noted that appropriate consumption of milk and its products, can lead to weight reduction, as shown by some studies. Meat and fish Products from this group should be consumed in the amount of 1 portion per day. In addition to high-quality protein, these products also contain vitamins and minerals. Since proper nutrition should aim at reducing the consumption of saturated fatty acids, we should select low-fat animal products. Poultry for example has a lower amount of fat than red meat. It is recommended to eta meats like poultry several times a week and red meat several times per month. It is also very important to consume fish, at least twice a week, as it contains some elements that are valuable for health like omega-3 polyunsaturated fatty acids, which play an essential role in the development and proper functioning of the brain, nervous system and vision. Fish is also an excellent source of protein and minerals, including iodine. In this group we also find eggs, which should be eaten several times a week. They are a concentrated source of nutrients including proteins, vitamins, minerals and fatty acids. Legumes are also part of this group, such as beans, peas, broad beans. They contain a lot of protein and very little fat. They are an excellent and healthy alterntaive to meat, in particular red meat. Of great importance for the proper functioning of the human body are fats supplied with food in the right proportions of individual fatty acids. A diet rich in fats, especially animal, increases the risk of developing cancer and cardiovascular diseases. Epidemiological studies indicate a strong positive correlation between the content of fats of animal origin in the diet and the incidence of cancer of the large intestine, skin, prostate, grat, lungs and leukaemia in man. In woman, this association has been observed for colorectal, breast and leukemia cancers. Fatty acids, depeing on the type, have different effects on risk factors for cardiovascular disease. A great source of fats are cold pressed oils, better used raw, to fry it's better to use oils like olive or rapeseed oils. A great source of fats are nuts and seeds. Walnuts, almonds, sunflower or pumpkin seeds, contain a number of substances beneficial to our health. Sugars and sweets are very caloric because they not only contain sucrose, glucose or fructose, they usually also contain fats, like in cookies, chocolate bars, chocolate products, ice cream. They are not a source of valuable vitamins and minerals, they just provide energy. The fat often found in sweets contains unhealthy fatty acids, including transisomers, which conduct to cardiovascular diseases and cancer, there are sweets that only have a sweet taste and provide calories, these promote overweight and obesity and contribute to the development of type 2 diabetes. In addition, sweets and sugars are the enemy of our teeth and the most serious factor is the development of caries. Just like sugar, an excessive intake of **salt**, due to its sodium content, can lead to health problems as it causes high blood pressure, stroke, obesity, cancer. Salty products and dishes should be eaten in moderation. Salt can be replaced with spices, for example. **Proper hydration of the body** Some scientists consider water as a nutrients as a nutrient, others do not. Nevertheless, water is essential for our existence and its content in food products significantly affects both the nutritional and energy value of food. Water should be supplied to the body regularly and in adequate amounts. Its deficiency quickly leads to dehydration and related weakening of the body, less ability to concentrate. It's important to drink AT LEAST 6 glasses of water per day. Water is also contained in the food we eat, especially in veggies and fruit. We need a higher intake when we perform physical activity or in places with higher temperatures and humidity. A healthy lifestyle requires not only a proper diet but also the right amount of physical activity. Doing at least 60 minutes of PA per day ensures good physical condition, mental fitness, and a correct figure. Product labelling under European legislation (EU Regulation No 1169/2011 (L304/18)  Reference intake values were developed by experts for purposes of only food labeling. Reference intake rules are close to the standards for adults with the exception of vitamin D, for which values have been adapted to many nutritional standards as well as potassium and chlorine. They should be treated as approximate values that intend to help consumers plan their diet. Typical energy value intake was adopted with a reference of 2000 kcal per day for an adult. This is the starting point for determining reference intake values for fats, saturated fatty acids, carbs, sugars and proteins. Nowadays we get products from every corner of the world. This leads us to try different cuisines and flavors and thanks to technologies we do not deal with seasonality of products. We are struggling with problems that didnt exist until 100/200 years ago, like environmental pollution, food contamination with pesticides, heavy metals and microplastics. Since we live a more hygienic conditions than before and our food is almost sterile, we are more affected than ever by diseases of the immune system like food allergies. It's not just our food habits that are changing in human history but also our overall lifestyle: hours spent in front of a laptop, lack of vitamin D exposure. **FACTORS REGULATING FOOD INTAKE** Food is essential for the survival of our body, but how does the body tell us it needs food? **Regulation of hunger and satiety** The main physiological center of consumption (hunger and satiety) regulation is in the hypothalamus (a small area in the center of the brain). The **ventromedial** hypothalamus is the **satiety** center whilst the **lateral** hypothalamus is the **hunger** center. If one of these two parts of the hypothalamus is damaged excessive consumption can occur. Homeostasis of food intake is a complex process, regulated among others through the physiological mechanisms of feeling hunger and satiety. Hunger triggers food-seeking and food-intake behaviors. The intensity of the feeling of hunger depends on the time interval since the last meal. Feeling the stomach weakening, the senses of taste and smell lead to the stopping of consumption. The feeling of satisfaction leads to satiety. Other areas of the brain that affect our satiety are in the cerebral cortex. These areas are also involved in the regulation of food intake to a lesser extent. The amount of time a person needs to feel full is related to the influence of motor, hormonal and metabolic factors. **Motor signals** are associated with the expansion and contraction of the stomach. The stretching of the walls of the stomach by ingested food gives a feeling of fullness and is a signal to stop consumption. On the other hand, stomach cramps that occur after eating a meal and can cause rambling are a signal that the stomach is empty and it gives us the prompt to start looking for food and start eating. Motor signals are received by the receptors of the stomach wall and are transmitted to the center of the hypothalamus through the gastric nerves and sometimes the vagus nerves. **Metabolic signals** are related to blood concentration of mainly glucose-free fatty acids and amino acids, as well as cheton bodies and organic acids. These signals are received by specific neurons in the hypothalamus or transmitted to it by neural pathways from other parts of the body that have appropriate receptors. The discovery of a close relationship between the level of a given ingredient in the blood and the feeling of hunger and satiety become the basis for the **glucostatic theory, lipostatic theory and aminostatic theory.** **Glucostatic theory:** it is based on the convergence of changes in eating sensations and behavior with fluctuations in blood glucose levels, which vary significantly depending on the supply of food. Eating food causes blood glucose levels to rise, accompanied by a feeling of fullness and a gradual loss of desire to eat. On the other hand, a drop in the level of this sugar in the blood (hypoglycemia), which occurs several hours after a meal, coincides with the onset of hunger. The hormones like insulin and glucagon, secreted by the pancreas, are responsible for the appropriate concentration of glucose in blood. Appropriate information about the supply of glucose in the blood is received directly by the hypothalamus or via the liver via the vagus nerve. Some scientists suppose that for the centers of hunger and satiety is not so much the absolute level of glucose in blood but is more important the difference between its concentrations in the venous and arterial blood and in the longer periods of time, glycogen reserved in the muscles and liver. **Lipostatic theory:** it is associated with the feeling of hunger and satiety with the content of fatty free acids in the blood, which are a substitute source of energy when there are difficulties in supplying cells with glucose. After a meal, when there is a feeling of satiety, and the supply of glucose is sufficient, the concentration of these acids in the blood is low. Free fatty acid levels increase over time after food intake, as blood glucose decreases, and this is a signal that stimulates the hunger center. Stimulation of hunger and satiety centers may be related to both the level of free fatty acids released from adipose tissue, the rate of their oxidation in the liver and the amount of adipose tissue. Voluntary food intake has been observed to increase when body fat reserved are depleted and decrease when they are replenished. In this case, a direct signal to the hypthalamus may be adipsin, a protein secreted into the blood by fat cells, neuropeptine, galanine or leptin, which is attributed an important role in long term control of food intake. **Aminostatic theory:** it bases the regulation of food intake on the ability of the brain to monitor the concentration of amino acids in the blood plasma. The influence of amino acids on the regulation of consumption is associated with the formation of various neurotransmitters. This theory is based on three observations: - - - The influence of amino acids on the regulation of consumption is associated with the formation of various neurotransmitters. Neurotransmitters are chemical substances secreted by neurons that are involved in the transmission of excitation from one nerve cell to another. Neurotransmitters include catecholamines, histamines, serotonin, gamma amino butryic acids, which are formed respectively by terosin, histidine, tryptophan and gleason. Consumed food determines the composition of the mixture of amino acids that goes to the blood and is available to neurons. Thus, it determines the ability to produce individual neurotransmitters influencing the transfer of internal signals of hunger and satiety to the hypothalamic center. In fact, not only the amount but also the multi proportions of amino acids are important for the functioning of hunger and satiety centers. It's evidenced by the fact that animal fit in an experimental diet containing unbalanced protein, significantly reduced food consumption. When lab animals have the choice, they will prefer a protein-free diet rather than one not balanced in prteins. **Hormonal signals** Another way for our body to regulate food intake is through hormonal signals, these hormones come from at least three sites: fat cells,classic endocrine organs and gastrointestinal tract. The first hormone that affects food intake is **leptin** which is a hormone produced mainly by adipose tissue cells and plays an important role in weight management. Secretion of leptin from adipose tissue occurs under the influence of insulin, in the postprandial period when the elevated concentration of glucose after a meal is lowered by insulin to the normal level. The most important target site of leptin action is the hunger and satiety center in the hypothalamus, where the reaction of the receptors (binding sites) with leptin results in the suppression of hunger and reduction of appetite. Leptin also accelerates metabolism, inhibits the deposition of adipose tissue and activates its decomposition. Due to the above properties, leptin is also called the anti-obesity hormone. The second hormone is **cholecystokinin** (the peptide hormone family)stimulates the secretion of bile and pancreatic juice. The stimulus to increase the secretion of cholecystokinin (among others, through the mucose of the duodenum and jejunum) are products of the partial digestion of fats and proteins. This hormone weakens intestinal peristalsis, allowing longer contact of fatty food with lipases. Cholecystokinin also has hunger-suppressing effect. The third one is **glucagone-like peptide 1 (GLP -1)** is a gastronintestinal peptide that is released in response to food intake. GLP-1 plays an important role in glucose homestasis, augments glucose-induced insulin secretion and inhibits glucagon secretion. GLP-1 is also proposed to act as a satiety factor. The fourth one is **Ghrelin** which is a hormone that is produced and released mainly by the stomach (small amounts are also released by the small intestine, pancreas and brain). the basic task of this hormone is to maintain energy balance - the appropriate level of adipose tissue and body weight. This hormone has the greatest impact on stimulating the hunger centerr among the proteins known so far in the human body. It easily penetrates the blood-brain barrier, reaching the receptors of the hypothalamus. The level of ghrelin increases during periods of fasting, before a meal and about one or two hours after its consumption. Elevated polypeptide levels may also be a sign of hyperglycemia and hyperinsulinemia. The last one is **insulin** which is a hormone secreted by the beta cells of the pancreatic islets of Langerhans. It maintains normal blood glucose levels by facilitating cellular glucose uptake, regulating carbohydrate, lipid and protein metabolism and promoting cell division and growth through its mitogenic effects. Insulin levels rise in response to an increase in blood glucose. It overcomes the blood-brain barrier and inhibits the secretion of neuropeptide Y and Agouti protein, giving a feeling of satiety. Prolonged levels of high insulin result in a disored in which the body's tissue becomes resistant to the actions of this hormone. This is common in obese subjects and it insulin resistance will lead to type 2 diabetes. There are also **other hormones like cortisol, thyroxine and estrogen** which act in bringing changes in food intake. However, the interpretation of this effect must be tempered by the fact that each has action across a range of other metabolically relevant tissue, such as liver and muscle. The last mechanism regulating food intake is based on **thermal signaling.** Thermal sighnals are transmitted by thermal receptors located on the surface and inside of our body. They contribute to the feeling of hunger and satiety together with the terotropic hormones, adjusting the amount of food intake to the body's energy needs related to maintaining constant body temperature. When we are cold, we usually feel hungry and on a very hot day we lose our desire to eat, especially fatty, high-caloric foods. Special role in this regulation is played by brown adipose tissue which produces the highest amount of heat and causes an increase in heat production in the body. When we talk about **post prandial thermogenesis (PPT)** or non-shivering thermogenesis or the heat forming effect of food, we refer to the net increase in energy expenditure following the ingestion of a meal. Thermogenesis depends on the amount of food consumed and its composition, it's a signal for the satiety center. The thermostatic theory assumes that the regulation of consumption is based on the amount of heat generated in the process of assimilation of ingested food and not on its energy value or energy balance. Studies conducted on young man have shown that post-prandial thermogenesis not only affects the end of a meal but can also determine the interval between meals nad the amount of food consumed in the next meal. **APPETITE** In the hunger satiety mechanisms, all the above-mentioned types of signals have their place and to a greater or lesser extent affect the amount of food consumed. Little is known so far about how the brain integrates all these types of signals and uses them to meet the body's needs for particular non-nutrients. It seems that in this regulatory system, necessary for survival, we are dealing with an excess of information, therefore, it's difficult to clearly determine the meaning of individual signals or determine the factor responsible for appetite and energy balance disorders. The sentences of taste and smell are closely related to the feelings of hunger and satiety. Hunger causes a clear increase in their sensitivity and thus facilitates the search for food and allows you to feel it's deliciousness for more fully. On the other hand, una persona sazia in whom the reaction thresholds of hemoreceptive centers are elevated, becomes less sensitive to the taste and smell of food and loses desire to eat more/does it without pleasure. The relationship between food intake and the feeling of pleasure, also has a psychological basis: pain, nervousness, fear, etc. stimulate the brain to produce endogenous opioids, which act similarly to painkiller drugs. They prolong the pleasure of eating and may cause overeating. The psychological hunger satiety mechanism is the most important, but not the only, factor responsible for the search of food and initiated the consumption of a meal in humans. The modifiers of psychological and sensory signals are cultural and social factors. Under certain conditions, food with desirable attributes can be eaten despite the lack of hunger, and food that is unknown, unpleasant or forbidden by religious order can be ignored even by a very hungry person. It should also be remembered that modern people, especially in developed countries, rarely know when they are or are not hungry. In most cases, the time of the day determines the consumption of a meal. Eating is largely conditioned by the customs prevailing in a given country and family, regarding the number and time of eaten meals. At the same time, many people eat between meals despite not feeling hungry, because they cannot refuse the "need". It is usually particularly liked in food with an attractive appearance or smell. Appetite is the expressed desire to eat a particular food, and it's associated with the choice of food and the regulation of food intake in the qualitative dimension. The fact that many species of animals have access to a wide range of food and are able to choose them in a way that ensures growth and efficient functioning of the body, proves the existence of instinctive mechanisms that for adjusting the structure of consumption to their needs. These mechanisms also plays a role in controlling human behavior This mechanism was examined in the example of young children who have unlimited access to several dozen basic food products, excluding sweets for several weeks. Children choose foods good for themselves and their diet is quite balanced. In adults, whose choice was determined largely by factors like product price, knowledge of nutritional value, advertising, religion, family, tradition, the operation of intuitive regulatory mechanism is less obvious. If we think about the product the products we choose and what we most like to eat, the answer is clear: we eat what we like and we avoid what we do not like. FACTORS THAT INFLUENCE FOOD CHOICES - - - - - - The power of one factor will vary from one individual or group to another. **WATER IN THE HUMAN BODY** Water is of major importance to all living organisms. Up to 60% of the human adult body is water, The water content changes at differents stages of life: in newborn water makes up 75% of their body weight. The % of water decreases between 6 and 12 months of age to 60%. From the age of 12 gender differences are noted, men hjave higher percentage of water % than women. In the elderly, only 50% of their body weight is constituted by water and it's 10% less in the case of young people. The decrease in water content is associated with the decrease of lean body mass. Water is a part of all cells, intracellular water consititues 35% of bodyweight, about 57% of total body fluids. Extra-cellular water constitutes about 26% of total body weight. There is a variation in the water content of various tissues. Body fluids, are the ones that contain the most water: bone marrow, blood plasma are comprised by 75% of water. The water content in the body guarantees the maintenance of constant body temperature and the proper course of processes that take place in the relatively small range of temperatures. It is also an excellent solvent for many ingredients and provides an environment for life process in the body. Water is necessary in the process of food digestion and absorbing nutrients, excreting metabolic products and toxins and regulating the water-electrolyte and acid-base balance of the body. The water content in the human adult should be kept at a constant level. The body normally maintains water balance, this means precisely that the amount of water ingested is equal to the water excreted or lost from the body. This water balance is maintained even through fluid intake. Positive water balance occurs only during growth and pregnancy. The water we drink is the main source from which maximum water is obtained by the human body. In addition to this, all beverages and food containing water, contribute to the water intake. Certain metabolic reactions carried on the inside of the body also release water and this is an additional source. In a study on water intake, it was found that of the total 2200 ml available in the system, 110 ml of water was obtained from drinking water, 900 from the diet and 200 from metabolic oxidation. WATER BALANCE IN A HEALTHY ADULT ---------------------------------- ---------------------------------------- water intake water loss water intake: 800 to 1100 ml urine 800 to 1000ml water in food: 600 to 900ml vapour: 600 to 1000ml (skin and lungs) metabolic water: 200ml faeces: 200ml tot. 1600-2200 ml 1600 to 2200ml There are different ways in which our body loses water: kidneys, sweating, intestines. The most importantw ater exchange happens in the kidneys, which filter approximately 140 liters of plasma per day, of this amount 99% of the water is re-absorbed in the renal tubes. The volume of urine excreted depends on the fluid intake and ranges from 400 to 1400 ml per day. The minimum urine output is of about 600ml per day. This amount ensures the removal of all unnecessary metabolic products, products of nutrients that must be extracted and dissolved in water. Water is lost in the form of steam through the skin and also in the form of visible sweating in hot water and during exercise. WATER HOMEOSTASIS  Fluid intake and urine outpit are contolled by homestatic mechanisms responsible for body water content. The regulation of water balance depends primarily on the hypothalamus, which controls thirst, and the antidiuretic hormone, vasopressin, produced by the hypothalamus and secreted by the pituitary gland. Two reactions of the body are used to maintain homeostasis: - - An increase in the osmolarity of the extracellular fluid as slow as 2% may stimulate thirst and give a signal for the release of antidiuretic hormone. The same happens when the volume of circulating extracellular body fluids decreases by 10%. The body's need for water depends on many factors, including composition of the diet, ambient temperature, climate and physical activity. This demand increases at elevated temperatures and reduced ambient humidity as water loss with sweat increase. Staying at low temperature and high altitudes may require a higher supply of fluids. Higher physiological activity requires more fluid intake and it promotes greater loss of water through sweat and through the lungs. The need for water increase increases with the increase of energy as larger amounts of nutrients must be metabolised. The content fo certain nutrients in the diet is also of additional importance: a high protein diet causes an increase in uresis, a high carb diet may reduce water requirement by preventing the formation of cheton bodies that must be excreted in the urine, consuming a lot of fiber cayses a greater water loss in faces and a high intake of sodium causes water loss in the urine. In addition, alcoholic beverages can increase water loss as alcohol has a diuretic effect due to the inhibition of vasipressin. The human body cannot store more water, so it must be constantly supplied with it to function properly. An insufficient supply of water can quickly lead to irritation which is the cause of serious health disorders. The first symptoms of dehydration may occur wuthh fluid floss of more than 1%, decrease in physical performance, appetite is lower and thermo regulation deteriorates. When the fluid loss is about 4% the decrease in physical capacity is accompanied by concentration disorders and headache drowsiness, increase in body temperature and respiratory rate. With a fluid deficit that exceeds 8%, we have dizziness, headache, speech disorders, cognitive and motor function disorders, electrolyte disturbance that can lead to arrhythmias and also ordinary excretion disorders, renal failure, changes in blood pressure, constipation, dru skin, weight loss, infections.. It can also lead to death. Infants are particularly sensitive to fluid deficiency,as their daily water rules can account for as much as 50% of their total body weight. The risk of water deficiency in the body may occur especially in infants who are malnourished, kept for a long time in elevated temperature or left with untreated diarrhea. The effects of dehydration may be more severe in children than in adults as the increase of temperature due to dehydration is greater in children. Elderly are also at an increased risk of dehydration, which results from feeling less thirst than the actual pathological need, reduced water consumption and lower efficiency of its absorption. Insufficient fluid intake by people suffering diahrrea, vomiting, fever, infections and some chronic diseases is very dangerous to health and can result in hospitalization. A constant dehydration is also dangerous as it does not cause major direct effects but over time it can lead to serious health consequences which include dryness of the skin and mucous membranes and related infections, constipation, kidney stones and cardiovascular disorders. People who habitually drink small amounts of fluids have an increased risk of developing bladder cancer. Some studies indicate that low fluid intake may also promote the development of colorectal cancer. Insufficient hydration can also be a risk factor for strokes. The risk of long-term persistence of this stance is aggravated by the fcat that the feeling of thirst decreases with age. Not only deficiency but also an excess of water can be harmful, excessive consumption of liquids with a low or too high concentration of electrolytes can cause a disturbance in the water and electrolyte balance. However, these adverse effects of excessive fluids\' intake in healthy people are very rare because their body can remove the excess water and thus ensure the maintenance of the balance. The risk may occur with a single intake of large amounts of fluids, significantly exceeding the maximum renal water excretion of 0.7 to 1lt per hour. Water in the body is present together with electrolytes, its deficiency or excess causes disturbance in the water and electrolyte balance and related changes in the volume of extra and intracellular water spaces and osmotic pressure. The main cations of the extracellular fluids are cations and the main ions are chlorine and bicarbonate. Composition of the intracellular fluid is significantly different from that of extracellular fluids. THe main cation here is potassium and the main ions are phosphates and proteins. Despite the differences in the total amount of cations and ions in the extracellular and intracellular fluids, their osmolarity remains the same. In order to maintain the body's water and electrolyte balance, the excretion of water and electrolytes must be balanced with their adequate supplies. Water and electrolyte regulation are closely related. The main organs responsible for regulating and maintaining the proper composition of body fluids are the kidneys. Since sodium is the most important cation present in the extracellular fluid, changes in its concentration determine disturbance in the balance. Serum sodium concentration represent the water balance and is the main determinant of osmolarity. The kidneys, the action of vasopressin, regulate water absorption, maintaning the concentration of sodium in the serum at appropriate level (1.35 to 1.45 ml per liter). Vasopressin, also regulates the retention of sodium, terribly maintaining the volume balance of extracellular and intracellular fluids. Sodium, with ions, constitutes the majority of osmolarity active serum substances which largely determine the movement of water between intra and extra cellular spaces. Serum sodium content is considered too low (hyponatremia), when it's below 135 milllimol per liter. Too low sodium content in this serum, especially below 112, carries many unfavorable symptoms for health like headaches, nausea, disorientation. When it's under 110 millimol per liter convulsions and coma may occur. When sodium deficiency is accompanied by water deficiency, hypotonic dehydration occurs, as the concentration of sodium ions in the plasma decreases, its osmolarity decreases and water from the extracellular spaces flows into the cells. With a large supply of electrolyte free water, the concentration of sodium ions in the plasma also decreases, this leads to hypotonic overhydration also known as water intoxication: increase in extracellular water space. Too much water in the sodium serum occurs when its concentration rises to 145 millimole per liter and it's called hypernatremia. This condition, which is also a health risk, is less common. Sodium concentration exceeding 160 millimole per liter can be the direct cause of that. With insufficient consumption or excessive water loss, hypertonic dehydration occurs. When the concentration of sodium ions in the plasma and its osmolarity increases, this leads to a reduction in the volume of extra and intracellular fluids. Water standards have been developed at the adequate intake level. In the case of adults, the European Food Safety Autority based their water on water consumption, and for children, an additional adjustment was made taking into account the energy volume of their diet. The values included in the standards civer the consumption of water in the form of pure water and other beverages like coffee and tea and also water cntainted in food products, The studies concern an average person from a given group living in a moderate environment, moderate temperature and moderate PA. : women should drink 2 lt per day and men 2.5lt per day. **ACID-BASE HOMEOSTASIS** It's a state of the body in which the **balance between cations and ions in the body fluids is maintained. This determined the correct pH and functioning of the body.** The **pH value is closely related to the area of the body**, the lowest reaction is in the stomach, it si associated with the digestive function of **gastric** juices. Such a low pH protects the body from **pathogens**. Our **skin** is quite **acidic** to create a protective coat against the penetration of microorganisms. The **body fluid pH**, including blood, is maintained between **7.35 and 7.45**, and it's optimal for carrying out most life processes and deviating from that range can be life-threatening. Many metabolic products are acids, which is why even in physiological conditions there is a tendency to acidify the body, so in the process of oxidation of carbs, fats and proteins, carbon dioxide is produces. Carbon dioxide dissolves in the fluid to give carbonic acid. As a result of the oxidation of methionine and systance, sulphuric acid is formed and organic phosporus compounds, for example phospholipids are metabolized to phosphoric acids. If the metabolism of carbs is not complete during excessive exercise, lactic acid is formed under conditions of incomplete liquid burning, which occurs during starvation or when the diet is high in fat and low in carbs. Acetate acid and bete hydroxy butryic acids are formed. Substances with alkaline reactions are primarily compounds of mono and divalent metals, taken with food or stored in the body, mostly in our bones. The **mechanism s that regulate our body fluid pH** are critical to survive. The pH of body fluids is controlled by three factors: - - - - - - **DIET-RELATED DISEASES** When our food choices are not correct, they can lead to diseases, which in Europe are the main cause of death. These deaths can be avoided with healthy food choices and lifestyle. These diseases are: - - - - - - - - These diseases account for 89% of premature mortaility, accoridng to one of the latest studies, and one in 5 could be attributed to an unhealthy diet. This growing burden continues to place an increasing weight on the health system, hampers for economic development of societies and negatively influences the overall well-being of the population. **Among the most common nutritional mistakes include:** - - - Very often, the primal problem is overweight and obesity. These are defined as abnormal or excessive fat accumulation that can impair health. BMI is a simple index of weight for height, commonly used to classify overweight and obesity in adults. It's defined as a person's weight in kg, divided by the square tìof the person's height in mt.\ WHO defines a subject to be **overweight when the BMI is greater or equal to 25 and obese when BMI greater or equal to 30.** BMI is not a perfect indicator and **shouldn't be used in children, elderly, people with disabilities and athletes.** According to WHO, obesity prevalence in Europe is higher than in any other region, except North America. Indeed, these problems have reached an epidemic proportion in Europe. WHO estimates that almost 59% of adults is overweight/obese. (63% males and 54% females are overweight and 22% females and 21% males are obese). The highest levels of both overweight and obesity are found in the Mediterranean and Eastern Europe. In Europe, inequalities in levels of ow and obesity are widespread and heterogeneous across social-economical determinants such as income, education, employment status and place of residence. Of great concern is the rapid increase in ow and obesity. They are prevalent not only among adults but also amongst children. In 2012, ow and obesity was a problem affecting 4.4 million children under the age of 5 (8%). This increases between children between 5 and 9 yo with ⅛ children living with obesity and nearly ⅓ (29%) living with ow.\ This data decreases for children in the age group 10-10 to 7% with obesity and 25% ow.\ Ow and obesity are more prevalent in boys and in the countries in the mediterranean basin. **CAUSES FOR OVERWEIGHT AND OBESITY** 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. CONSEQUENCES OF OBESITY Living with obesity increases the risk of certain diseases. Excessive adiposity is also found to increase mortality,with obese people having a 5 year shorter life expectancy. Ow and obesity cause 1.2 million deaths every year (13% of total deaths). These health issues arise in people living with obesity because **adipose tissue is metabolically active and doctrine organ with fay cells (adipocytes release and receive hormones).\ Adipocytes release substances called adipocytokines and these are associated with a range of systemic or local actions including glucose and lipid metabolism and cell development.\ Inflammation, oxidative stress, which can lead to a number of health problems.** **Visceral fat,** which surrounds the organs within the abdominal cavity, has a **greater impact** on health than under the skin fat/subcutaneous fat. Visceral fat is **more biologically active** and has a **higher density of cells, carries more blood flow and is located close to the portal vein** which results in an i**ncreased concentration of fatty acids reaching the liver.** Recently, evidence argues that the negative health effects of obesity is still not simple from an excess of fat, but from the decline of its ability to respond to changes=its plasticity, the make up of functioning of this tissue change in response to weight fluctuation is aging. As fat declines in plasticity due to aging and obesity, it loses its ability to respond to bodily cues. In the current model of this phenomenon, the rapid growth of adipose tissue at places is blood supply depriving the fat cells of oxygen and causing the accumulation of cells that no loner divide. This leads to metabolic issues like insulin resistance, inflammation and cell death. The mass and metabolic activity of adipose tissue results in it affecting almost everybody's system, with excess adiposity carrying health implications through the life course. Evidence shows that a child fetus in a mother's belly may suffer from exposure to suboptimal environment if the mother is obese, and will face early life adversities that may extend into adulthood.\ At the same time, excessive gestational weight gain is associated with pregnancy-related complications and short and long-term adverse effects in the offspring. **Obesity is linked to a cluster of diseases which greatly increase cardiovascular disease risk, these include: arteriosclerosis, hypertension, dyslipidemia, insulin resistance and inflammation.** As a consequence, those living with obesity are at substantial elevated risk of a range of cardiovascular diseases. In particular, obesity increases the risk for stroke and CHD, which are the two most common cardiovascular diseases mortality.\ For both these diseases, abdominal obesity has been shown to be a greater predictor than total fat mass, which indicated the higher risk associated with visceral fat accumulation. Ow and obese people are at increased risk of developing several types of cancers, with the risk of hormone-dependent cancers greater than those with abdominal obesity.\ While cardiovascular diseases are the most common cause of death across Europe, cancers now cause more deaths in several higher income countries.\ Excess bw increases the risk of many cancers, including breast, colorectal, pancreatic, liver, kidney, gastric, steroid, and blood cancers. At the same time, obesity is linked with the development of more surf forms cancers such as metastatic. **In addition to its link with these two chronic diseases, obesity may lead to a greater risk of many other metabolic diseases such as nonalcoholic fatty liver disease, type-2 diabetes, respiratory and reproductive issues, and various psychological and mental health problems.** At the same time, individuals living with ow and obesity, often experience weight bears and social stigma. These wide-reaching health implications for individuals living with obesity, lead to a large population health burden which also carries important financial implications due to the treatment of obesity-related illnesses. **People with obesity have been found to have 30% higher treatment cost than those without obesity.** While there may also be a direct cost due to **earnings lost as a result of premature mortality** and obese related disabilities, **obesity** alone was estimated to be responsible for as much as **8% of health cost in the EU.\ **The recent concern has focused the link between obesity also with COVID. People living with obesity were found to be at an increased risk of covid-19. **MALNUTRITION** Malnutrition is the other side of the coin of overweight and obesity. It's a condition in which a **deficiency of one or many nutrients has an adverse effect on cells, tissues, organs and the body understood as a whole, which is manifested in the deterioration of its functioning and a negative change in the overall clinical picture.** The European Society of Clinical Nutrition and Metabolic defines malnutrition is a **state of the body that is due to insufficient supply or incorrect absorption of essential nutrients, body composition changes, physical and mental impairment of the body and adverse effects on the outcome of the underlying disease.** Malnutrition is associated mostly with **reduced BMI, insufficient amount of food is associated with insufficient supply of all nutrients to the body.\ **The problem with hunger and malnutrition is still extremely serious around the world, but **recently** more and more people are talking also about **malnutrition in ow and obese people.**\ This is due to the fact that they consume foods with a high energetic density and poor in vitamins and other micronutrients. **There are different kinds of obesity associated with different phenotypes.\ **Obesity in an **android male**, shows a dominant visceral and upper throracic distribution of adipose tissue, whilst the **feminine genoid** type's adipose tissue is found predominantly in the lower part of the body.\ **Android** obesity is clearly a **cardiovascular risk factor,** more so than this female ginoid obesity. Hereditary factors contribute significantly to the occurrence of these patologies in families, although environmental factors plays a role in its development. Android obesity is associated with metabolic abnormalities which also characterize the so called **x metabolic syndrome : insulin, resistance to insulin, arterial hypertension, hypertension and dyslipidemia.\ **The predisposition of individuals with underweight obesity to come diabetic rest in part on genetic and in part on evironmental factors. Hyperinsulinemia and high flukes of fatty acids act at the level of the liver and endocrine pancreas to increase resistance to insulin and to decrease insulin secretion, so two determining factors for type 2 diabetes.\ Other functional abnormalities have been involved to explain android obesity, such as dysregulation of adrenal cortica and sexual steroids or a global agreement of stress mechanisms. **THERAPY** Lifestyle interventions including negative energy balance, provide the basis for the treatment of ow and obesity and are part of the standard recommendation. Different lifestyle approaches exist, where nutrition, psychology and behavior are the main components. 1. a. b. c. **Assumptions of a reduction diet:** - - - - - - - - 2. **Increasing energy expenditure is another effective way of reducing weight and preventing weight gain.** Additional benefits associated are a generalised increase of sense of well-being. Significant weight loss has been observed after 6-20 months with two to four workouts of aerobic activity between 20 and 45 minutes.  **Physical exercise alone is not an effective method for achieving initial weight loss.** Although most overweight and obese people tend to choose exercise as the first intervention, without calorie restriction, the reduction with only exercise is quite small. (about 0.1 kg per week) Although it is not effective for initial weight loss, it is **important for maintaining the weight loss achieved through dietary intervention**. (studies show that those who diet and excercise can maintain the lost weight better than those who relied on diet alone). Before starting an exercise program, patients should be advised of joint and muscle skeletal injuries as well as cardiovascular risks. The risk of exercise stress testing before an exercise program is quite controversial. The american College of Cradiology and Heart Associated recommended treadmill for asymptomatic subjects with diabetes and men older than 45 years and womer older than 55 years before embarking an exercise program. Other organizations recommend no stress testing for symptomatic subjects undergoing moderate intensity exercise with guidance in excercise intensity. It's important that the patient adopts this as a permanent change, not just a fast fix, they will be on a healthy diet for the rest of their life. Very low cal, intermittitent fasting, juice diets, exclusion diets will not provide healthy habits as they do not provide all required nutrients. The weight loss may be very fast initially but the patient will not succeed in keeping the weight off. It is a vicious cycle. Weight cycling (yo-do dieting) is the repetaed loss and gain of weight. To achieve the goal of losing weight and maintaining a healthy weight a **holistic approach is needed,** as an interdisciplinary approach to the disease of obesity contributes to more effective care for the patient suffering from it. It manifests itself in increasing his or her comfort in the process of changing eating habits, and it's also a much greater chance to improve the patient's health and permanently change the patient's lifestyle. **For an interdisciplinary approach, the therapeutic team should include different specialists that represent several fields: dietitian, psychologist, psychodietitian, doctor,etc.** A **dietitian** is defined as a qualified healthcare specialist who has knowledge on the field of nutrition for healthy and sick individuals. By choosing the right diet, he/she prevents diet-related diseases and is responsible for nutrition consulting in various disease states. A dietitian must be a team of the therapeutic team in the treatment of obesty and actively participate in the process of weight reduction.\ The dietitian **conducts gradual modifications of eating habits through nutritional education. Cooperation with the dietitian consists in setting the patient's nutritional goals and monitoring the effects of the weight reduction process.\ **The path of procedure is determined each time, together with the patient, taking into account his/her needs and preferences. Obesity treatment involves not only weight loss, but also reducing risk factors and improving overall health\ **Doctors** often indicate the need to treat obesity and support the treatment and support this treatment. Doctors often play a major role in the **diagnosis, diagnosting complicatoons due to obesity like hypertension, lover disorders or diabetes.** The role of an expert in the field of **psychology** in the process of weight reduction is very important, especially when the main cause of obesity if psychological.\ Their role in the treatment is to motivate the patient to start and continue the treatment. A **psycho-dietitian** is usually a person who has complected a high education in dietetics or psychology and has their knowledge by completing postgraduate studied in psychodietetics. This specialist will help break the circles of weight loss, verifying their knowledge on nutrition and finding for example new coping skills for stress that are not food related. The **psychologist** is responsible for the **diagnosis and treatment of eating disorders and for determining the psychological cause of obesity.** The psychologist, who is part of the therapeutic team, can also help other specialists understand the psychological factors behind the development of obesity and the relationship with the patient. However, when the problem with eating is more severe, is worth consulting a psychotherapist. Another important factor is **self-monitorinr: it is an effective behaviour change technique for weight management and is a core component of behavior obesity treatment.** **Digital tools** like **online tools and apps, tracking technologies or even internet based support** have become attractive for teaching and supporting long term behaviour change techniques.\ The scientist Carter and his co-worker have examined the acceptability and feasibility of self-monitoring of weight management provided by an app rather than a website or paper diet. The result showed that people that had the app lost more weight than traditional methods. Weight management apps may have a positive effect on weight related outcomes. Although the methodological quality of many studied is low, a study by willinger and his team, with more than 6k participants, showed that app based interventions can be effective for changing nutritional behavior and nutrition related outcomes.Digital tools like apps are time and cost-effective methods for collection of health related data with the potential of wide distribution and scalability.\ Many apps are available that are available for weight loss and digital offerings for weight management, rarely include evidence based strategies for behavioral changes. **PHARMACOTHERAPY IN OBESITY** Sometimes, in addition to diet and physical activity, a **pharmacological treatment and bariatric surgery** may be prescibed. Pharmacotherapy should not be the first choice for the treatment of obesity. Rather, it should be seen as an additional method, only for a limited period of weeks/months, used under special indications and supervision and subjected to a careful observation regarding the individual's reactivity and side-effects. In order to reduce the risk of side-effects, pharmacological treatment of obesity should be carried out only in the form of monotherapy. In Europe usually , pharmacotherpay is advised for weight loss and maintenance for individuals with a BMI of above 30. - - - - - **Sometimes the only way out of extreme obesity is a surgery intervention**, the easiest and safest intervention is the i**ntragastric balloon.** It is filled with fluid to reduce the max stomach volume and prevents the consumption of large meals. Weight loss is generally less effective than with other kess invasive surgical methods. This treatment is especially **recommended for patients with relatively low obesity and for patients who, due to other complication and co-existence of other serious diseases, cannot be operated by other methods.** This is usually a stage-one procedure where the gastric balloon is temporarily placed to reduce body fat. The stage two, which takes place after 6 months, is the gastric bypass or other weight loss surgeries known collectively as bariatric surgery, whose aim is to change your digestive system to help you lose weight. Bariatric surgery is performed when there is a bigger problem and the diet and exercises havent worked. Some proecedures will limit how much we can eat other will reduce our ability to absorb nutrients. While bariatric surgery can offer many health benefits, all forms of weight loss surgeries and major procedures can pose serious risks and health side-effects. Patients also need to make permanent healthy changes to diet and physical activity after the surgery to ensure the long term success. Bariatric surgery is done in the hospital using general anesthesia and the specifics of the surgery depend on the patient's individual situation, the type of weight loss and the hospital's or doctor's pratice. Some weight loss surgeries are done with traditonal large incisions, known as open surgery. However today's most are performed laparoscopically. 1. 2. 3. Most people (90%) after a bariatric surgery lose about 50% of their excess weight and keep it off. Different procedures have slightly different results: the average weight loss after a gastric bypass is 70% of excessive bw, duodenal switch 80%, gastric sleeve 30 to 80%. These results are all measured after 18 to 24 months. After the surgery, involves the need for dietary recommendations. Each patient after the surgery should have a broadly understood nutritional and supplementation support, personalized to satisfy his or her individual needs, health condition and test results.  The general diet is divided into several stages (look pic), the transition from phase to phase is actually not the same for every patient, as it depends on the condition of the body and its adaptation to changes. - - - - - The target diet for a bariatric patient is a low calorie diet with limited simple sugars and fats. essential to eat and chew slowly. Number of meals ranges from 5 to 8. Size of the meal ranges depending on the type of operation btw 50 and 150ml at a time. However, it is important that the patient finishes the meal when he feels satiated. The finite daily menu of a bariatric surgery patient should include 4 to 8 portions of high protein products, meat, fish, dairy products, 2 to 4 portions of vef, two portions of fruit, 2.3 portions of cereal products, 2 to 4 portions of good veg fats. **CARDIOVASCULAR DISEASE PREVENTION** 36.7% of deaths are due to cardiovascular diseases. These diseases include heart, arteries or veins. They can be born or acquired. The second option prevails. - - - - - - - In the prevention and treatment of cardiovascular diseases, attention should be paid to five basic elements: **diet, healthy body weight, smoking, physical activity, adequate amount of sleep.** **Role of fat** Fats are a huge and diverse group of compounds, usually of not very high molecular weight, even compared to proteins. This group includes **triglycerides, phospholipids, glycolipids, sterols (cholesterol), waxes, squalene, carotenoids, tocopherols, tocotrienols.etc.** Their **only common feature is hydrophobicity**, meaning that they do not like water. The largest part of fatty compounds are **triglycerides**. They are **esters made of 1 glycol molecule and three fatty acids residues**. **Glycerol** is the stomplest **stable trihydric alcohol.**\ **Fatty acids are simple hydrocarbon chains with a carbonyl group at the end of each chain.\ **Fatty acids **differ in the lenght of the carbon chain, the number of carbon atoms in the molecule as well as the number of position of double bonds.\ **The number of **carbon molecules ranges from 4 to 26**, depending on the length of the carbon chain they are divided in: - - - Short and medium chain fatty acids are less common in food fats than long chain fatty acids. Depending on whether there are double bonds in the fatty acids chain. we divide them in **saturated (without a double bond), monounsaturated (one double bond), polyunsaturated (more than 1 double bond).** The acids chain has an alpha end on the side of the carbonyl group and omega chain on the side of the metyl group. Therefore, when we talk about omega-3 polyunsaturated fatty acids, we mean the double bond at the third carbonyl counting form the side of the metyl group. Fatty acids constitute 95% of fat and determine the physical chemical properties and physiological role of this fat. **Fats in which unsaturated fatty acids predominate usually have a liquid consistency, on the other hand fats dominated by saturated fatty acids, usually have a solid consistency, for example coconut oil, lard, butter.** The **nomenclature** of fatty acids is **based on the number of carbon atoms in the chain and the number of double bonds and the position of the first double bond counting from the metyl end of the chain.** Unsaturated fatty acid can be in CIS configuration, when hydrogen atoms are on the same side of the cabron chain, double bond or in trans configuration when hydrogen atoms are on the opposite sude of the carbon chain double bond. The **most popular saturated acids include: palmitic acid (16 carbon atoms), stearic acid (18 carbon atoms), arachidonic acid (20 carbon atoms).**\ The most common **monounsaturated fats are palmitoleic and oleic acid with 16 and 18 carbon atoms respectively.** Among unsaturated acids, **long chain polyunsaturated acids play the greatest role in nutrition.** These **include essential fatty acids, linoleic acid and alpha linoleic acid**.\ The term essential fatty acids comes from the fact that **the human body cannot synthesize double bond in the N6 and in N3 position**. (N means the same as Omega) **Linoleic and alpha-linolenic acid are synthesized only by plants and must be supplied with food**. However, the body can remodel both of these acids, extend their carbon chain and introduce double bonds to it. Thus, the essential fatty acids belong to 2 families: N6 (omega 6) and N3 (omega 3). The **N6** linolenic acid families include the following acids: linoleic, gamma linolenic, arachedonic, and the ?? In these acids, the first **double bond occurs at the 6th carbon counting from the metyl group.** Other acids from the same family can be synthetized from linoleic acids supplied with food to the human body. **The N3 family includes, linolenic acid, EPA and DHA**.\ Essential fatty acids are tissue components and therefore must be supplied to the system early in life. **They are precursors of prostaglandins**, called tissue hormones with multiple effects. Prostaglandins **regulate the activity of the circulatory system, the secretion of digestive juices, platelet aggregation and many other body functions.** **Cholesterol** function in the body - - - - - - Cholesterol is a sterol found in animal tissue, from 60 to 80% of cholesterol found in food comes from endogenous synthesis, mainly in the liver and in the small intestine. The remaining comes from diet. Cholesterol is used to synthesize biological membranes and bile acids. It's a precursor of steroid hormones in the adrenal cortex and gonads and vitamin D in the skin. Endogenous synthesis is sufficient to cover the body's need, this means that the body does not need cholesterol from food to meet its physiological needs. For decades, it was believed that cholesterol in food plays a key role in the pathogenesis of cardiovascular diseases, but it is actually not like that.  **LIPIDS DIGESTION** Digestion of fats involves the **gradual breakdown of triglycerides into glycerol and fatty acids**. **It begins in the stomach under the influence of salivary and gastric lipase.** However**, a too acidic environment limits the action of these enzymes and only a part of the fat is broken down there.** The **proper digestion of fats takes place in the duodenum and in the beginning of the small intestine**. Here, bile is produced by the liver and stored in the gallbladder. Food containing fat leads to contraction of the gallbladder and the secretion of **bile which is used to emulsify dietary fat.** Fat is broken down into small spherical particles suspended in water, thanks to which the surface area of the digestive enzymes is increased. The principle of operation of bile is the same of dishwashing liquid**. Bile activates pancreatic** **enzymes,** lipase, and facilitates the movement of food content to a further section of the intestines. Pancreatic lipases hydrolyzes the ester bounds in triglycerides from 2 monoglycerides and 3 fatty acids. In the pancreatic juice there are also phospholipids and carboxylesterase, which breaks down fat into smaller particles. In the small intestine, intestinal lipase and alkaline phosphatase work to break down fats into glycerol and fatty acids. **Short and medium chain fatty acids, are absorbed from the intestine into the blood and through the portal vein to the liver.** On the other hand, long chain fatty acids are converted into tricglycerids in the intestinal wall. ???? and very low density lipoproteins are formed, which are then released into the lymphatic system from where they pass through the bloodstream and then through the arteries to the tissues. Lipoproteins are lipid transporters in theblood. As transporters, they deliver triglycerides, cholesterol, phospholipids to deliver spare adipose tissue and other tissues. There are **four main types of lipoproteins** containing triglycerides, phospholipids, cholesterol and protein called apoprotein, in varying proportions: - - - **Lipoproteins are spherical structures whose nucleus is made of triglycerides and cholesterol esters and the outer layer is composed of complexes of proteins, phospholipids and pre-cholesterol.** Lipoproteins transport about 100g of triglycerides, cholesterol and phospholipids daily in a healthy person. There are, however, disease states in which excessive production of a certain type of lipoprotein occurs, called **hyperlipoproteinemia.** **The lower the density of the lipoprotein, the higher the content of triglycerides**.In addition, lipoproteins differ in the transport capacity from where and to where they go. Chylomicrons transport dietary fats from the intestine to the body. VLDL transport lipid produced in the liver to other tissue. LDL circulates through the body and HDL transports lipids from perhiperal tissue back to the liver. **Although lipoproteins do not only contain cholesterol, they are often referred to as LDL cholesterol and HDL cholesterol.** **LDL is the bad one and HDL is the good one.** The release of fatty acids from triglycerides contained in the lipoprotein is carried out with the participation of lipoprotein lipase. The release of fatty acids after passing through the cell membrane, can be used as energy material for the synthesis of new triglycerides, which accumulate in the cytoplasma in the form of fat droplets or are used to build some membranes. **LIPIDS FUNCTIONS IN THE BODY** - - - - - - - - - - - - Although often fat and adipose tissue are used interchangeably, **adipose tissue is composed mainly of fat particles in adipocites** (cells that store fats) and **also contains proteins, minerals and water.** Fatty acids also participate in the complex process of energy metabolism of the central nervous system. Some studies show the effect of fatty acids on emoptional behavior, perhaps testing the level of circulating lipids may facilitate the diagnosis of people with depression.  The requirement for fat is between 20 and 35% of total energy. The requirement of linoleic acid sgould be 4% of energy, alphalinoleic acid should be 0.5%. Daily supply of EPA and DHA should be 250mg. **ATHEROSCLEROSIS** **One of the main causes of heart attacks and trombosis is atherosclerotic plaque inside the blood vessels**. Plaque is made-up of the position of fatty substances, cholesterol, cellular waste products, calcium and fibrine. As it builds up in the arteries, the walls become thickened and stiff. It's a slow and progressive disease that can start as early as childhood but can progress rapidly. **Artheriosclerosis has three stages:** - - - From the beginning, cholesterol reach LDL lipoprotein plays a critical role in this process. This lipoprotein can be accumulated in the vascular intima due to its ability to infiltrate into endothelium or to add her to extracellular matrix components like protoglycan. In the initial step, **plaques usually grows in the opposite direction of the vessel.** Artherosclerotic vessels are willing to grow in diameter. When plaque covers **more than 40% of internal elastic layer of the vessel, the arterial channel is considered to be occupied.** The first step of arteriogenesis is trapping the lipoprotein in the lace on site. LDL can rapidly enter the endoterian cell through endocitosis. **In normal conditions, there is balance between the plasma LDL and intracellular concentration of arterial walls**. Along with an increase in plasma little buts, many of these particles become trapped in the intima because of the direct correlation between serum LDL concentration and the amount of lipoproteins trapping in the lesion, its block levels can be considered an indicator of atherosclerosis. Low density liporptein trapping results in the concentration of LDL in the intima and in the increased duration of their stay during the lesion. Both such factors, lead to spontaneous oxidation and cell oxidation of the trapped particles. Cytokines and oxidized lipids play an important role in this process. Monoxide to macrophag differentiation cause them to take oxidized lipids such as oxidized LDL to form foam cells. **During the initual step of atherosclerosis, mononuclear leucocytes, monocytes and T cells enter the intact endothelium through vascular walls.** This process starts when pro-inflammatory cytokines being to the receptors of the endothelial surface. (macrophages are immune cells and foam cells are type of macrophage that localize fatty deposits on blood vessel walls, where they ingest low-density lipoproteins and become laden with lipids, giving them a foamy appearance). **The next stage is calcification leading to ateroscleriotic hardening of the arteries and the appearence of the endotheria defects above the arteriosclerotic focus.** Endoterial defects are the cause of local decrease in the concentration of prostacyclin, which is a factor that prevents the.... as a result of this process, arterioschlerotic ulcers occur in places exposed to the intima, which become areas of boundary platelet aggregation and growth of thrombosis. **Two elements are crucial:** - - Diet has a huge impact on both of these elements. But what is **oxidative stress? It reflects the imbalance between the systematic manifestation of reactive oxygen species and biological system's ability to readily detoxify the reactive intermeduates or to repair the resulting damage.** Disturbance to the redox state of cells can cause toxic effects through the production of peroxides and free radicals that damage all components of the cells including proteins, lipids and dna. **Oxidative stress from oxidative metabolism causes base damage as well as standard damage to DNA**. Base damage is mostly indirect and caused by the reactive oxygen species generated for example by superoxyude radical, hydroxyl radical and hydrogen peroxide. In addition, some reactive oxidative species act as cellular messengers in redox signalling. **Oxidative stress can cause disruption in normal mechanism of cellular signalling.** Stress organic factor are those that cause an increase in the level free oxygen radicals in our body. Apart from the psychological stress, active or passive smoking, environmental pollution, medication, lack or excessive physical activity are also factors. **Our diet contains ingredients that modulate oxidative stress. On the one hand, saccarydes and products of their thermal transformation have a pro-oxidative effect. On the other hand we have products that have a whole range of compounds that have the ability to scavenge free oxygen radicals such as some vitamins like vitamin C, vitamin E, vitamin A, polyphenols and carotenoids.** The physiological role of the dietary fat is determined by the presence of various types of fatty acids in it, which often have opposite effect on the human body. **How can the fats in our diet increase or decrease the risk of cardiovascular disease?** **SATURATED FATTY ACIDS**  They are present also in plants as well as animal origin food. Animal origin products are the main source of this kind of fatty acids in our diet. **Dietary saturated fat intake has shown to increase LDL cholesterol levels and has been associated with increased risk of cardiovascular disease**. Studies in animals have shown that **saturated fats increase LDL cholesterol by inhibiting LDL receptor activity and chasing apolipoprotein B containing liporpotein production.** The most common saturated fatty acid is **palmitic acid which is known to raise total serum and LDL cholesterol.** Replacing animal fats inn the diet with other fat sources rich in monounsaturated or polyunsatyrated acids reduces the risk of the formation and development of cardiovascular disease. **The best effect is observed when saturated fatty acids are replaced with polyunsaturated fatty acids of the N3 and N6 families.** The latest research indicates that some saturated fatty acuds may have a different effect on the body than described above. For example, a diet rich in short chain fatty acids, may increase the content of polyunsaturated fatty acid in tissues and regular intake of capric acid, may reduce the risk of bacterial diseases and fungal infections in the dugestive system. **It's worth noting that short chain fatty acids are characteristic only of milk fat. Although their content in this fat is only a few % of all fatty acids.** Important to remember that the type of product/source of fatty acids is crucial. A lot of studies and analysis show that milk fat is not harmful: consumption of full fat dary products is inversely associated with metabolic syndrome and cardiovascular disease. In turn, consumption of skimmed products is associated with lower risk of type 2 diabetes. Single studies, have shown that full fat milk compared to skimmed milk increases the level of LDL cholesterol passive particles. There is also emerging evidence that cheese consumption reduces both LDL and HDL cholesterol levels. **In turn, medium chain fatty acids present in significant amounts in coconut oil, are quite easily absorbed because they are passively absorbed from the intestines directly into the porter circulation.** In addition, they are used by the body to a greater extent for energy process than for deposition in the form of adipose tissue, which is why it is assumed that their consumption may contribute to weight loss. Compared to animal fats, coconut oil does not raise the level of total cholesterol and LDL fraction in the serum to the same extent as butter, but at the same time it does not increase HDL fraction to the same extent as vegetable oils. **A positive effect of a diet with an increased content of medium chain saturated fatty acids is observed in the treatment of patients with fat malabsorption and epilepsy, alzheimer's or parkinson's disease.** Medium fattu chain acids are also the components of formulas for infants born prematurely. On the other hand, the **high content of palmitic acids in palm oil, makes it similar to animal fats.** In animal models, **a diet rich with palm oil has been shown to result in impaired glucose tolerance.** Its potential impact on increasing risk of cardiovascular diseases on cancer is not clear and required more research. Tropical oils like palm oil and coconut oil, are NOT recommended in nutrition precisely because of the hugh content of saturated fatty acids compared to the content in animal fats. In conclusion,accoridng to a research from 2017, lower consumption of fats rich in saturated fatty acids combined with higher consumption of fats containing unsaturated fatty acuds, especially unsaturated ones, is associated with a reduction of the risk of development of cardiovascular diseases. **To sum up, a high intake of saturated fatty acids, especially palmitic and stearic acids, most often together with animal fats, is one of the most important factors in rising LDL cholesterol in the blood. There is a direct effect between intake of these fats and increase risk of cardiovascular disease.** Current dietary recommendations, recommend replacing animal fats rich in saturated fatty acids with vegetable fats and oils, which are a source of unsaturated fatty acids. MONOUNSATURATED FATTY ACID Monounsaturated fat such as **oleic acid, found in olive oil or rapeseed oil, canola oil, has been classified as heart healthy.** Olive oil is the main fat used in the Mediterranean diet, known for its low risk for cardiovascular diseases. Meals high in both monounsaturated fatty acids and saturated fat lead to what is called **postprandial lipemia or riso in chilomicrons remenants and triglycerides, which are known to be harmful to the arteries.** A study showed that compared with saturated fat, oleic acids cause a greater secretion of chilomicrons that are larger in size and contain a greater amount of triglycerides. Despite a higher peak, postprandial triglycerides content with the consumption of olive oil adhering to Mediterranean diet results in a faster decrease in triglycerides levels. In other words, the postprandial rise in triglycerides returns to baseline levels quicker with high monounsaturated fatty acids, especially oleic acid. Thus, while the peak triglycerides peak may be higher with olive oil, the level drops faster with oleic acids. In an extensive research has been found that a high in monounsaturated fatty acids Mediterranean diet, increased flow mediated dilation and reduced LDL cholesterol, apoliporprtein B and and P selection compared with baseline diet high in saturated fats. The studies suggest that monounsaturated fatty acids compared with saturated fats improves the lipid profile and the hypercoagulable state. However, the clear effect of monounsaturated fatty acids in the human health has not clearly been demonstrated. They can play a protective role in the prevention of atheroscletosis and heart disease when used as a substitute for saturated fats. It emphasized that olive oil, the basis of the benefits of the mediterranean diet, is high in monounsaturated oleic acids. POLYUNSATURATED FATTY ACIDS (PUFA)  It seems, however, that **polyunsaturated acids, both from N3 and N3 families, have the greatest impact in the prevention and dietary therapy of cardiovascular disease.** **The most common unsaturated fats in fod belong to three families:** - - - Due to the lack of enzymes in the human body capable of introducing double bond in the N3 and N6 position of the carbon chain, **alpha linoleic and linoleic acid cannot be synthesized and the diet is the body's only source.** **Both acids are precursors to the N3 and N6 families respectively.** The linoleic and alpha-linolenic acid supplied with the diet undergo transformations in the human body, catalyzed by many enzyumes which extend their structure and create double bonds. The place of metabolic transformation of these acids is the **endoplasmic reticulum of cells**. as a result of the action of enzymes, especially delta-5 and delta-6 desaturase and elongase, through successive transformations, alpha-linoleic acids from EPA and DHA.\ **Arachidonic acid is formed from linoleic acids.** The extent of conversion from alpha-linoleic acid to EPA varies between some population subgroups. For example, in man it ranges from 0.3 to 8%, in DHA it does't exceed 1%. In woman, up to 21% conversion to EPA and up to 9% to DHA has been recorded. It has also been shown that 9% of dietary DHA can be converted back to EPA by DHA beta oxidation. The ability to covert alpha-linoleic acid to long chain derivatives are consequently the level in plasma, phospholipids and red blood cells depends on the polymorphemes of genes according to delta 5 and 6 desaturase. It should be emphasized that the same enzymes participate in the transformation of fatty acids from N3 and N3 families in the human body. The above relationships indicate functional links between the pathways of their metabolic transformation based on the substrate competition, The advantage of linoleic acid in the diet is that it inhibits the synthesis of EPA and DHA and it increases the synthesis of arachidonic acid. In the case of deficienct of alpha linolenic acid and linoleic acid, changes catalyzed by desaturase enzymes and elongase enzymes are subject to oleic acids belonging to the omega-9 families. This means that improper balance opf fatty acids from N3 and N6 families in the diet may result inn the disturbance of the physiological balance of the body. In addition to the availability of necessary substrates and competition between them, a number of other factors regulating the metabolic pathway of alpha-linolenic and linoleic acids have been demonstrated, including other availability of trace elements including zinc, iron, insulin sensitivity and female hormone status. Polyunsaturated fatty acids are involved in the synthesis of eicosanoids, they are biologically active substances of the nature of tissue hormones which are transmitters that strengthen or weaken the regulatory activity of hormones or neuromediators in cells. They include prostaglandins (PG), thromboxanes (TX), leukotrienes (LT), and lipoxins (LX). It affects the function of many tissues and organs with a special role in the regulatory activity of the cardiovascular system. Prostacyclins have a strong effect on the coronary vasodilation and increase the strength of neocardial contraction. - Thromboxanes affect the aggregation of thrombocytes, the platelets and the formation of blood clots. Prostoglandins like PG2, PGG2, PGH2 and Tromboxan TXA have a strong pro-aggregtaing effect, whilst prostaglandin E has the ability to inhibit a platelet aggregation process. Prostacyclin PGE 2 has a strong antiaggregating/antitrombotic effect. Unsaturated fatty acids, apart from serving as a substrate for the synthesis of ???, perform many other important functionf for the body: - - - - - - -  The optimal N6 to N3 polyunsaturated fatty acid ratio seems to be critical in maintaining a healthy circulatory system. In the UK, experts compared 4 diets providing approximately 6% of energy as polyunsaturated fatty acids but with varying dietary Omega 6 to Omega 3 ratios. N6 amounts in tested diets was between 3 and 5 figures higher than N3 fatty acids compared with 10 to 1 ratio which was the controlled diet. The omega 3 enriched diet contained alpha linoleic acid, EPA and DHA, compared with the high omega 6 to omega 3 ratio diet which ended up being 11 to 1. The diet enriched in EPA DHA acids providing an omega 6 to omega 3 ratio of around 3 to 1, this diet caused a reduction in the fasting and postprandial triglycerides as well as LDL cholesterol level. Reducing the omega 6 to omega 3 ratio by giving EPA and DHA also reduced VLDL, increased LDL particle size and increased HDL cholesterol level. These benefits were not found with alpha linolenic acids. Moreover, increasing the intake of linoleic acid from 7.4% to 7% energy reduced the protective HDL cholesterol. In another trial in Europe, two isocaloric diets in 99 patoents with the metabolic syndrome were tested, The first diet contained 1.24g per day of high oleic sunflower oil and the second one had an additional 1.24g per day of long chain omega-3 polyunsaturated fatty acids. This test lasted 12 wweeks. In the second diet, the one with polyunsaturated fatty acids, the LDL density was...., triglycerides were also lowered in this group. The opposite effect was found in the diet with high oleic sunflower oil diet, which increased LDL density despite the later lowering cholesterol. This study demonstrated the efficiency of dietary omega-3 polyunsaturated fatty acids to modify pro-atherogenicto less atherogenic LDL phenotype in patients with metabolic syndrome consisting that LDL particle size predicts cardiovascular risk and progression of coronary heart disease. Omega-6 vegetable oils reducing LDL particle size may increase the risk of coronary heart disease and stroke. This because LDL particles are more suitable to oxidation due to the increased amount of omega-6 fatty acids. Locotriens, hydroxyl fatty acids and lipoxins are formed in larger quantities than those formed from omega 3 fatty acids, especially from docosopentaenoic acids. The ecosainoids from arachidonic acids are biologically active in very small quantities and if they are formed in large amounts, they contribute to the formation of tombus and ateromas to allergic and inflammatory disorders and to proliferation of cells. Thus, a diet rich in omega-6 fatty acids shifts the physiological stato to one that is protrombiotic and pro-aggregatory and a decrease in bleeding time. The anti-trombiotic aspects and the effects of different doses of fish oil on the prolongation of bleeding time were investigated by Seymour. A dose of 1.8g of ecosapentanoic acid did not result in any prolongation of bleeding time but wuth a dose of 5g/day, the bleeding time increased and the platelet count decreased without any adverse effects. In human studies, there has been a case of clinical bleeding even in patients undergoing angioplasty while they were on fish oil supplements. There is an agreement on the fact that ingestion of fish or fish oil has the following effect: platelet aggregation to epinephrine and collagen is inhibited, tromboxan A2 production is decreased, whole blood viscosity is reduced and enterocid membrane fluidity is increased. Fish ingestion oil increases the concentration of plasminogen activator and decreases the concentration of plasminogen activator inhibitor 1. Literal studies have demonstrated that this plasminogen activator inhibitor 1 is synthetized and secreted in hepatic cells in response to insulin and population studied indicate a strong correlation between insulinemia and this plasmogen activator inhibitor 1 level. A double blind trial in 42 adults found that 4g per day of ecosopentanoic acid and DHA for 12 weeks increased the density of LDL by 13%. Another study in 57 man with dyslipidemia were randomly assigned to one of the three diets enriched with flaxseed oils. Flaxseed oil provides about 25g of alphalinoleic acid per day. Sunflower oil provided 25 g of linoleic acid per day and fish oil provided around 3 grams of EPA and DHA per day. this was done for 12 weeks. All these diets reduced cholesterol level. Only the flaxseed and fish oil diets reduced their triglycerides levels, which was most pronounced in the fish oil group