NMDP 720 - Clinical Nutrition I Lecture Notes (2024) PDF

NMDP 720 – Clinical Nutrition I (2024) Lecture 1 Introduction to Nutrition Jeffrey Sepúlveda, N.D.  The Fundamental Pillars of Health H E A L T H Mental Sleep Nutrition Exer- Toxicity Social State cise Avoidance...

NMDP 720 – Clinical Nutrition I (2024) Lecture 1 Introduction to Nutrition Jeffrey Sepúlveda, N.D.  The Fundamental Pillars of Health H E A L T H Mental Sleep Nutrition Exer- Toxicity Social State cise Avoidance Life Overall drawing by Jeffrey Sepúlveda using pillar drawing by denisik11 ©123rf.com (edited, licensed use).  Let food be thy medicine, and medicine be thy food. Hippocrates, 460-377 BC Photo from iStockphoto.com. Licensed use. Photo from iStockphoto.com. Licensed use. Photo from iStockphoto.com. Licensed use. Photo by Olga Miltsova (duskbabe) Photo by Marco Mayer © 123RF.com. Licensed use. © 123RF.com. Licensed use.  Importance of Nutrition Aqui Nutrition is the most important pillar of health. It is essential for prevention and treatment of disease, and for optimization of health. – When we give our body the nutrients it needs, we optimize its biochemistry & physiology. – In many health problems, the cause is poor or inadequate nutrition. To practice according to our naturopathic princi- ples (like “treat the cause”) & our therapeutic order, it is essential to master nutrition.  Importance of Nutrition This course teaches you the ABC of nutrition. – However, is this course just an introductory one? Your mastery of the other nutrition courses, as well as of clinical courses like cardiology, gas- troenterology, endocrinology, oncology, neurolo- gy, urology & dermatology (among others) will de- pend on how well you learn the material in this course.  Importance of Nutrition Nutrition = The study of nutrients and other substances in foods, & their inges- tion, digestion, absorption, transport, metabolism & excretion. Nutrients = Substances that promote growth, provide energy & maintain life.  Importance of Nutrition What is Malnutrition? Deficient intake of nutrients. Excessive intake of nutrients. Malnutrition may be caused by – Poor dietary habits. – Physiologic or pathologic problems (e.g., Celiac disease, pancreatic insufficiency). – Restricted access to good quality food (e.g., poverty). – Environmental toxicity &/or use of certain medications that deplete some nutrients.  Importance of Nutrition Nutrition & Genetics Epigenetics tells us that the expression of genetic risk factors (even in those gene- tically predisposed) is af- fected by our interaction w/ the environment & by our mind). Good nutrition is a critical part of our environmental interaction (nutrigenomics). Photo of dust cover of book by Bruce H. Lipton, PhD Hay House (Publisher). Fair use.  Importance of Nutrition Nutrition & Genetics (continued) Epigenetics has been associated w/ many health conditions including cancer, endocrine disorders (e.g., diabetes), autoimmune Dz, COPD (e.g., asthma), nervous system disorders (incl. behav- ioral) & metabolic disorders, among others.  Why Focus on Nutrition? A man with a 10-year history of severe de- pression (in spite of treatment w/ antidepres- sant medications & psychological counseling) visits a naturopathic clinic. He is given a treatment to correct nutritional deficiencies. A month later the patient shows up at the clinic, with no signs of depression.  Why Focus on Nutrition? Á An elder woman who has progressively become very cognitively impaired is taken to a neurolo- gist, who diagnoses advanced Alzheimer’s & tells her family that nothing can be done to improve her cognition. The woman is evaluated by a naturopathic doc- tor, who gives her family recommendations to correct nutritional deficiencies. A month later the cognitive impairment has disappeared. aumentando su capacidad deRecuperar  Why Focus on Nutrition? A post menopausal woman who takes an antacid medication to treat her GERD is diagnosed with osteoporosis by her doctor. The doctor advises her to take Caltrate (a calcium supplement) daily to help protect her bones. Unfortunately, this product will not do much good to her. A clerk at a local health food store tells a man that zinc is a very important nutrient to keep his im- mune system strong. He follows his advice and starts taking 50 mg daily. Unfortunately, he is likely increasing his risk of cardiovascular disease.  Why Focus on Nutrition? A woman with a family history of heart disease and breast cancer goes to see a cardiologist. The cardiologist reviews her latest labs and finds out her HDL is low. He advises her to drink one glass of red wine daily to increase her HDL. The following week she visits her rheumatologist who, after checking her DEXA bone scan, deter- mines she has osteopenia. He advises her to eat decalcio en los huesos yentones se cheese every dayperdida to give her bones the calcium they need. Va a presentar un flamean What is wrong with both recommendations?  Why Focus on Nutrition? A man with a strong family history of myocardial infarctions reads in the newspaper that chocolate has been found to help improve CVD risk factors. The next day he goes to the supermarket and buys a whole bunch of chocolate bars and has been eating them every day. Although he has been gaining weight, he is very happy because he believes that he is protecting his heart. Unfortunately, he is very likely increasing his risk of a heart attack. mucha asacar otra ingesta por lo que te va ase nmat  Why Focus on Nutrition? A woman who loves the beach is worried about her deteriorating skin. She visits a local health food store, and a clerk advises her about the importance of supplementing the diet with essential fatty O acids and collagen to protect her skin from damage. matrixextracelular tienecanon inflamatorios The clerk sells her an omega-3, 6 and 9 supple- ment, and a collagen supplement. The woman goes home very happy, believing that these sup- plements will be very beneficial for her skin. Unfortunately, she just threw away her money.  Why Focus on Nutrition? It is also important to focus on nutrition so that if you have an opportunity to make a public or professional presentation, or write an article about nutrition, you present accurate information.  Why Focus on Nutrition? The industrialized food system is the leading cause of illness & early death around the world (Dr. Felice Jacka, nutritional psychiatry researcher, 2023). “Unhealthy diets & lack of physical activity in the U.S. cause more health loss than smoking, alcohol, or drug use” (Dr. Ali Mokdad, University of Washington, 2013). Photo by Stan Zemanek, CC BY-SA 3.0, Wikimedia Commons (close up, edited)  Why Focus on Nutrition? Very few adults (5.8%) in the U.S. during 2005-2008 were following a heart-healthy lifestyle, including a healthy diet regular exercise normal weight ideal blood cholesterol ideal blood pressure ideal blood glucose not smoking American Heart Association annual meeting, Nov. 9, 2015.  The Obesity Epidemic Aquí From 2015-2016, the obesity prevalence among U.S. adults was 39.8% (47.0% among Hispanics, 46.8% among non-Hispanic African Americans & 37.9% among non-Hispanic white adults). Adoles- cents aged 12–19 yrs had 20.6% prevalence (CDC, National Center for Health Statistics, Oct 2017). Additionally, ≈ 1/3 of U.S. adults are overweight. If the trend continues, by 2030 1 in 2 adults will be obese. Obesity is the main reason behind the current epidemic of diabetes and hypertension. Being overweight or obese accounted for many deaths (18.2%) of US black & white adults bet- ween 1986 & 2006 (Am J Public Health. 2013 Octo- ber; 103(10): 1895–1901).  The Obesity Epidemic Agur The overweight & obesity crisis in more detail Obesity in adults aged ≥ 20 yrs. was 32% in 2003-2004. In 2015-2016 it was 39.8% (CDC, 2019). 71.6% of adults aged ≥ 20 yrs. were over- weight or obese in 2015-2016. Obesity in children aged 6-11 yrs was 18.4% in 2015-2016. It was 13.9% for children aged 2-5 yrs. Childhood obesity has increased dramati- cally worldwide (> 10x) since 1975 (Lancet, Oct. 10, 2017).  The Obesity Epidemic in the USA Obesity then Obesity more recently Early 1970s: 2007–2008: 5% of children 2 - 5 yrs 10% of children 2 - 5 yrs 4% of children 6 - 11 yrs 20% of children 6 - 11 yrs 6% of teens 12 - 19 yrs 18% of teens 12 - 19 yrs Late 1970s: 2008: 15% of adults 34% of adults Early 1990s: 2008: No State had an adult 32 States had an adult obesity rate > 25%. obesity rate > 25%. www.cnpp.usda.gov/Publications/DietaryGuidelines/2010/PolicyDoc/Chapter2.pdf  Anything Wrong with Nutrition Today? Obesity found to cause ≈ 18% of all deaths among adults aged 40 – 85 yrs in the U.S. (Am J Public Health, Aug 2013). Obese children have been found to have 2x risk of death before age 55 than normal-weight children (NEJM, Feb 11, 2010). A significant number of these deaths are caused by obesity-induced diabetes & HTN. Many believe that children outgrow their obesi- ty w/ NO consequences. However, in children w/ type 2 diabetes, serious comorbidities (incl. kidney disease & heart disease) have been found to progress more rapidly than in adults. Other comorbidities (e.g., retinopathy) progresses at same rate as in adults. Evidence of serious compli- cations in children found only a few years after diabetes Dx (Diabetes Care, May 2013).  Why the Obesity Epidemic? A Cornell University stu- dy found out junk food, fast food & soda are not the root cause of the US obesity epide- mic. They found out the root cause is that we eat too much! Photo from NASA / Kennedy Space Center We also do too little exercise … Photo from iStockphoto.com. Licensed use.  Why the Obesity Epidemic? We eat & drink too much pro- cessed, energy-dense food (high in refined sugar, starch, fat, & low in fiber). We eat larger servings – in- creased portion sizes (esp. su- persizing) = more calories. – 600 more kcals were sold daily per person in 2008 than in 1970 (esp. from added fats and oils, grains, dairy products and sweeteners). Photo from iStockphoto.com. Licensed use.  Anything Wrong with Nutrition Today? Most daily calories (57.9%) in USA come from ultra pro- cessed foods (BMJ Open. 2016 Mar 9;6(3): e009892). Photo by Djelita Priata Japan, CC BY-SA 4.0, Wikimedia Commons Photo by Jul Lllll, CC BY-SA 2.0, Wikimedia Commons (close up) Photo by Tamorlan, CC BY-SA 3.0, Wikimedia Commons (close up)  Anything Wrong with Nutrition Today? In 2013, 2/3 of potatoes consumed were used for French fries, potato chips, & other frozen or pro- cessed potato products (USDA, 2013). Photo by Hayford Peirce, CC BY-SA 3.0, Wikimedia Commons (close up)  Anything Wrong with Nutrition Today? The radical changes in nutrition in developed Western countries over the last century have been the most dangerous social experiment we have ever undertaken. For instance … Ready-to-eat cereals are among the top sources of vita- mins and minerals in children’s diets (Pediatrics 1998 Oct; 102(4 Pt Photo by Evan-Amos, CC0 1):913-23). Wikimedia Commons  Anything Wrong with Nutrition Today? The #1 and #2 sources of carbohydrates for U.S. children aged 2–18 years (Nutrients. 2013 Jan 22;5(1): 283-301). Photo from Istockphoto.com. Photo 84998345 © Oleksandr Panchenko Licensed use. Dreamstime.com. Licensed use.  Anything Wrong with Nutrition Today? We consume a lot of sugar (esp. refined). On average, a person in the U.S. w/ a 2,500 kcal/day diet consumes 70 lbs of ADDED sugar yearly, equivalent to ≈ 21 teaspoons daily (CDC, 2020). ▪ A regular 12-ounce Coca Cola has 39 g (9.3 tsp) of sugar. ▪ 12-ounces of Starbucks White Chocolate Mo- cha have 41 g (9.8 tsp) of sugar. ▪ A 12-ounce serving of grape juice has 53 g (12.6 tsp) of sugar. ▪ A 12-ounce serving of orange juice has 32 g (7.6 tsp) of sugar.  Anything Wrong with Nutrition Today? Mean % of daily kcals from added sugars, USA (CDC / NCHS Nat. Health & Nutr Exam Survey, 2005-2010).  Anything Wrong with Nutrition Today? Sugary drinks are assoc. w/ many (25,000) deaths per year in the U.S. – due to diabetes, heart Dz and some cancers (Am. Heart Assoc, 2013). Photo by Wilfredor, CC BY-SA 4.0, Wikimedia Commons (close up)  Anything Wrong with Nutrition Today? Photo by Roger Smith, CC BY-NC-ND 2.0, Flickr.com Photo by Steve Koukoulas, CC BY-NC-ND 2.0, Flickr.com Low-sugar, low-carb, High-sugar, high-carb, high-protein, high-fiber. no protein, no fiber.  Anything Wrong with Nutrition Today? 4 of the top 6 causes of death (heart disease, cancer, stroke & diabetes mellitus) are asso- ciated with poor diet. Photo from iStockphoto.com. Licensed use. Photo from iStockphoto.com. Licensed use. Photo from iStockphoto.com. Licensed use. Photo from iStockphoto.com. Licensed use. Photo by picsfive © 123RF.com. Licensed use. ≈ Many cancers (1/3) assoc. to poor eating habits & obesity. Photo by FotoosVanRobin, CC BY-SA 2.0, Wikimedia Commons (close up, edited) Photo from iStockphoto.com. Licensed use. Photo by Inga Tihonova (nevada31) © 123RF.com. Licensed use. Photo by Vitalii Netiaga © 123RF.com. Licensed use. Photo from iStockphoto.com. Licensed use. Anything Wrong with Nutrition Today? 50 years ago, it was very rare to see children with type 2 diabetes or high cholesterol. Today we often see such cases.  Some consequences of poor nutrition Poor nutrition increases the risk of – Obesity – Diabetes desee – CVD audirvainer – Cancer – Osteoarthritis – Osteoporosis – Early aging – Gout Photo from iStockphoto.com. Licensed use.  Some consequences of poor nutrition Poor nutrition increases the risk of (continued) – Mental health disorders (e.g., ADHD, depression, anxiety, dementia). – Immunosuppres- sion. – And many others … Photo from iStockphoto.com. Licensed use. Anything Wrong with Nutrition Today? In 1973, 2 out of 40 women developed breast cancer dur- ing their lifetime in the U.S. Today, 5 out of 40 women do (a 250% increase). Why such a large increase in breast cancer over the last 50 yrs? See next page. Photo from iStockphoto.com. Licensed use.  Anything Wrong with Nutrition Today? Meat consumption (esp. grilled or barbecued) & alcohol are 2 of the most important dietary factors responsible for the increase in breast & other cancers. Photo by Woodleywonderworks Photo by Evan Swigart, CC BY 2.0, Wikimedia CC BY 2.0, Flickr.com (close up, edited) Commons (close up, edited)  Anything Wrong with Nutrition Today? Worst restaurant meal in America in 2013 - Long John Silver's Big Catch, w/ 7-8 oz of fried had- dock, hush puppies and onion rings – 19 g of saturated fat, 33 g of trans fats, 3,700 mg sodium & 1,320 kcal (Center for Science in the Public Interest, 2013). Photo from Center for Science in the Public Interest. Fair use.  Anything Wrong with Nutrition Today? Fortunately, addition of trans fats to processed food was forbidden starting in summer 2018. So, we are … Back to the Future! Back to where we were in the early 1980’s (back to palm oil & other sources of unhealthy saturated fats). Photo © Universal Studios. Fair use.  How the Way We Eat Has Changed We eat more food when away from home (esp. in fast food restaurants).  in daily calories eaten when away from home is assoc. with weight gain.  availability of fast- food restaurants is assoc. with  body mass index (BMI). Today the average person eats more frequently between meals. Why?  Why People Eat the Way They Do? i Taste preferences – Genetic (energy-dense, high-fat & high- sugar foods for “survival”). – Adaptive – e.g., salty, fatty & sweet food – “The pleasure trap” concept (Douglas J. Lisle, PhD). – Overstimulation – e.g., flavor enhancers, esp. monosodium glutamate (MSG). Learned – Parents, family, friends – Ethnic traditions – Mass media advertising  Why People Eat the Way They Do? Cost Convenience Emotional comfort Health seeking – Organic diet. – Vegetarian diet. – Extreme, absurd diets. Personal beliefs – e.g., animal rights. Eating disorders – Anorexia, bulimia. – Orthorexia. Conventional vs. Naturopathic Nutrition There is a lot of common ground b/w conven- tional & naturopathic nutrition. However, sig- nificant areas in which they differ include: Nutritional strategies for Dz prevention. Nutritional strategies for Dz treatment. Use of supplements. Avoidance of many food ingredients & conta- minants: monosodium glutamate (MSG), as- partame, preservatives (esp. nitrites), addi- tives (e.g. aluminum, artificial colorings & fla- vors), pesticide & herbicide residue, etc. The long-term safety of some cooking me- thods (grilling, babecueing, sauteing). The long-term safety of many foods (e.g. farmed seafood, tuna, milk products).  Nutrition & Botanical Medicine Keep in mind there is some overlap between nutri- tion & botanical medicine. Photo by Min Lee, CC BY-NC-ND 2.0, flickr.com Photo by Cjboffoli, CC BY 3.0, Wikimedia Commons What are we going to study about nutrients? Types (e.g., fats, protein, vitamins, minerals) Their various forms (e.g., vitamin A forms) Dietary Reference Intakes (DRI) Functions of nutrients in the body. Metabolism – including digestion, absorp- tion, transport, storage & excretion. Consequences of deficiency. Consequences of toxicity. Interactions w/ nutrients or medications. Therapeutic use Sources Laboratory tests for assessment. Unit conversion  Sources of Nutritional Information Scientific studies In vitro Animal Human observational studies – Epidemiological studies – Longitudinal studies (cohort studies)  Sources of Information Clinical studies – Open studies – Double-blind, randomized & placebo-con- trolled ▪ Best to demonstrate cause & effect. ▪ However, reductionistic approach – ignores beneficial synergism b/w nutrients. ▪ Often too simplistic design – Studies a single intervention for a multi-factorial condition (like cancer). ▪ Poor study design – e.g., 400 IU daily of Vit D for cancer prevention; Vit E for CVD prevention. ▪ Problems with reporting bias – e.g., “lyco- pene no good to prevent prostate cancer”.  Sources of Information Traditional naturopathic treatments – Long tradition of some ND treatments. – Many have little clinical research behind them but are effective – e.g., elimination diet. – Some not effective or safe – e.g., liver flush. This is why we need to understand basic science & question what we are taught. Internet as source of information – There is good information in the internet & a lot of bad Iinformation – e.g., cancer is a fungus & use of bicarbonate for cancer Tx. – Need to be very selective. Be suspicious of any source of information that tries to sell you a product (infomercials).  Types of Foods Whole foods ▪ Foods in their natural state or that have been processed as little as possible & contain NO additives or artificial substances. Processed foods ▪ Defined as foods that have undergone any changes to their natural state (USDA). But based on this definition, almost all food we buy is processed. For this reason, a system called NOVA classification organizes food in 4 categories based on their level of processing.  Types of Foods Processed foods (continued) ▪ The 4 NOVA classification categories are: oUnprocessed or minimally processed oProcessed culinary ingredients – These are minimally processed foods that we use for cooking (e.g., oil, flour). oProcessed foods – Foods from previous 2 groups that contained added sugar, fat or salt. oUltra-processed foods – Foods that not only have added sugar, fat or salt, but also have additives, preservatives, artificial colors & artificial flavors. Reference: The Nutrition Source, Harvard School of Public Health.  Types of Foods Functional foods (often known as designer foods & as nutraceuticals). – Provide health benefits beyond their basic nutrition. – Can be a whole food, or a fortified or pro- cessed food. Cholesterol-lowering oatmeal, nuts or phytostanol-fortified margarine. TG lowering fish oil. Calcium fortified orange juice. Oat bran cereal. Yogurt with live cultures. Photo from benecolusa.com  Types of Nutrients Essential (indispensable) – We cannot make them & thus we must consume them. Non-essential (dispensable, we can make them). Examples – Fats – Essential & non-essential fatty acids – Protein – Essential & non-essential amino acids. – Vitamins – Essential – But there is one ex- caption. Which? vitamin D – Minerals – Essential – Water – Essential – Cholesterol – Non-essential.  Types of Nutrients Organic (carbon based) – Carbohydrates, fat, protein & vitamins. Inorganic – Minerals & water Macro nutrients – Carbohydrates, fat, protein, macrominerals. panel celan Micronutrients construye – Microminerals & vitamins cofactmesitocondrales principalmente  Types of Nutrients Energy yielding nutrients Carbohydrates Fat Protein (esp. during fasting or if too little carbs are consumed. Structural nutrients Protein Lipids Minerals Supportive nutrients Vitamins – enzyme cofactors Minerals – enzyme cofactors, fluid balance, other cellular functions. Water – solvent, chem. reactions medium, etc.  Non-Nutrients Includes other substances such as: Fiber (the vast majority are nondigestible carbohydrates). Alcohol (although it yields calories). Phytochemicals (e.g., antioxidants, anti- carcinogens, phytosterols, phytoestrogens).  Food Energy Measurement Food energy yield measured in kilocalories (kcal). 1 calorie = qty of heat that increases the temperature of 1 gram of water by 1C. Energy yield of nutrients – Carbohydrates = 4 kcal/gram (except fiber) – Protein = 4 kcal/gram – Fats = 9 kcal/gram Energy yield of non-nutrients – Alcohol = 7 kcal/gram In the International System of Units (SI), energy yield is measured in kilojoules (kJ) – Energy in kJ = kcals x 4.2  Food Calorie Calculation Calculate calories from following snack: Whole wheat bread, 1 slice (30 g) Fruit preserve, 1 tbsp 1% milk, 1 cup (8 oz) Bread kcal = (23.6 g x 4 kcal/g) + (3.9 g x 4 kcal/g) + + (2.5 g x 9 kcal/g) = 132.5 kcal Food Carb Carb Prot Prot Fat Fat Total (g) Kcal (g) Kcal (g) Kcal Kcal Bread 23.6 94.4 3.9 15.6 2.5 22.5 132.5 Preserve 13.8 55.2 0.1 0.4 0 0 55.6 Milk, 1% 12.2 48.8 8.2 32.8 2.4 21.6 103.2 Total of calories for whole snack 291.3  Energy Density Measures energy per unit of mass of food (kcal/g). Energy density of fat > carbs = protein. Energy dense food – has a high qty of kcal/g. High intake of energy dense foods → obesity risk. Foods rich in fiber & water = lower energy den- sity. Food item Grams Kcal Kcal/g Broccoli, raw (½ cup) 46 15 0.33 Apple raw with peel 138 72 0.52 Banana (fresh) 118 105 0.89 Rice, white, long grain, boiled 79 103 1.30 Black beans, boiled (½ cup) 86 114 1.33 Avocado, California (½ cup) 115 192 1.67  Energy Density Food item Grams Kcal Kcal/g Ice cream, chocolate (½ cup) 66 143 2.17 Frankfurter (chicken or turkey) 45 100 2.22 Whole wheat bread (1 slice) 46 128 2.78 Burger King French fries 116 360 3.10 Doughnut, glazed 60 242 4.03 Cheddar cheese 28 114 4.07 Hershey‘s Symphony milk 91 483 5.31 chocolate bar Almonds, raw ( ¼ cup) 36 211 5.86 Olive oil (1 tbsp) 14 119 8.5 Dietary Reference Intakes (DRI) Nutrient intake recommendations for heal- thy people, established by the Food & Nutrition Board of the Institute of Medicine (IOM) of the National Academy of Sciences. They include: Estimated Average Requirements (EAR) Recommended Dietary Allowance (RDA) Adequate Intakes (AI) Tolerable Upper Intake Level For DRI summary tables, see downloadable files at the bottom of the following address: – http://www.nationalacademies.org/hmd/Activities/Nutr ition/SummaryDRIs/DRI-Tables.aspx  Estimated Average Requirements (EAR) Estimated level of a nutrient that covers the needs of 50% of the healthy population. Is used to calculate the Recommended Dietary Allowance (RDA). Different values for males & females, & for dif- ferent age groups.  Estimated Average Requirements (EAR) 50% of Healthy Population Vitamin C requirements for men 19 yrs & older. Drawing by Jeffrey Sepúlveda 75 mg Recommended Dietary Allowance (RDA) RDA = Recommended intake of a nutrient that covers the needs of ≈ 98% of the healthy population. Have strong scientific evidence to back them up. Different values for males & females, for dif- ferent age groups & for pregnant or lactating females. Their value is based on EAR (e.g., EAR + 2 stan- dard deviations).  EAR vs RDA EAR RDA 50% 98% Daily vitamin C requirements for males 19 yrs. & older. Drawing by Jeffrey Sepúlveda 75 mg 90 mg  Adequate Intake (AI) Used when lack of scientific evidence does not permit to determine an EAR and RDA. AI = Recommended intake of a nutrient that is believed to cover the needs of most of the healthy population. Actual % of people covered is not pre- cisely known. Different values for males & females, for dif- ferent age groups & for pregnant or lactating females.  Adequate Intake Daily potassium requirements AI for females 19 yrs. & older. Drawing by Jeffrey Sepúlveda 2,600 mg  DRI & Reference Man & Woman Some recommendations (e.g., protein RDA) are based on the physical characteristics of a refer- ence man & reference woman. Reference Man – 5’ 10”, 154 lbs. Reference Woman – 5’ 4”, 126 lbs.  Tolerable Upper Intake Level (TUIL) The highest daily intake of a nutrient con- sidered safe for the vast majority of healthy people (unlikely to produce adverse effects in them). Note that this is not safe for everyone. After the TUIL the risk of toxicity increases significantly. A nutrient toxicity is unlikely from ingestion of foods in reasonable quantities. Example? Toxicity more likely when using high-dose dietary supplements or high intake of fortified foods. tipo Different values for males & females, for dif- ferent age groups & for pregnant or lactating females. Increasing nutrient intake The Big Picture Drawing by Jeffrey Sepúlveda TUIL RDA or AI  risk of Safe for  risk of deficiency healthy people toxicity  Example: Vitamin D Drawing by Jeffrey Sepúlveda RDA & TUIL of Vit. D for males & females 19-70 yrs. old. Increasing nutrient intake TUIL 4,000 IU RDA 600 IU  risk of Safe for most  risk of deficiency healthy people toxicity  RDA / AI Notes RDA / AI recommendations are not considered minimum requirements by the IOM. However, the RDA / AI recommendations are not necessarily optimal intakes (e.g., vitamin C, vita- min D & vitamin B12). RDA & AI recommendations are for healthy people. They do not take into account nu- trient deficiencies in those with health pro- blems (e.g., impaired digestion, intestinal mal- absorption, chronic diseases), in those taking medications that interfere w/ nutrients, etc.  RDA / AI Notes There is significant variabi- lity in nutrient content of foods (esp. minerals) de- pending on where it was grown. – Why especially minerals? Foods that we eat daily suffer significant nutrient loses during storage, transport & cooking. A significant % of people Photo courtesy of the USDA have dietary nutrient defi- ciencies like calcium, mag- nesium, potassium & iron.  Daily Value (DV) Established by the FDA for use in food labels to aid consumers to compare food products & choose healthy ones. Assumes 2,000 kcal/day estimated energy re- quirement. Only one value in food labels specified for each nutrient, which covers all sexes & age groups ≥ 4 years old. Some values shown are based on obsolete data & vary significantly from the RDA & AI (e.g., % DV for potassium based on 4,700 mg daily, % DV for sodium based on 2,300 mg daily). See the Daily Value recommendations at: https://www.fda.gov/food/nutrition-facts-label/daily-value- nutrition-and-supplement-facts-labels  Food Labels with % Daily Values Source: fda.gov  Acceptable Macronutrient Distribution Range (AMDR) Range of intake of a calorie-yielding nu- trient that provides adequate nutrition &  risk of chronic disease. Each range of intake is based on % of total daily kcals. AMDR for males & females ≥ 19 yrs. old: – Carbs = 45-65% of total daily kcals – Protein = 10-35% of total daily kcals – Fat = 20-35% of total daily kcals Exceeding the AMDR may risk of chronic dis- ease. There are AMDRs specific for children.  Acceptable Macronutrient Distribution Range (AMDR) Use of AMDR guidelines may not be appro- priate if caloric intake is too low. For ins- tance: – Recom. daily protein intake: 56 g (M) & 46 g (F). – Protein AMDR = 10-35% of total daily kcals – If a woman consumes 2,000 kcals daily, then 10% of total kcals as protein = 200 kcals = 50 g of daily protein intake (adequate). – However, if a woman consumes only 1,000 kcals daily, then 10% of total kcals as protein = 100 kcals = 25 g of daily protein intake (deficient). Intake of protein based on AMDR can be quite high (up to 175 g/day for 2,000 kcal/day).  Estimated Energy Requirements (EER) The energy intake needed to maintain energy balance in healthy people of specific gender, age, weight, height & level of physical activity. EER is more specific than nutrients RDA or AI. EER for reference adults 19 yrs & older: – Males: 5’ 10”, 154 lbs, physically active = 3,067 kcal/day – 10 kcal/day x (age – 19) – Females: 5’ 4”, 126 lbs, physically active = 2,403 kcal/day – 7 kcal/day x (age – 19)  RDA vs. AI vs. TUIL vs. DV Examples for Adults 19-50 yrs old Iron DRI – RDA (M): 8 mg RDA (F): 18 mg TUIL: 45 mg DV: 18 mg Chromium DRI – AI (M): 35 mcg AI (F): 25 mcg TUIL: ND DV: 35 mcg Final thought – While high technology advances in conventional medicine have made great con- tributions to the treatment of diseases … Photo from iStockphoto.com (close up). Licensed use.  Nutritional preventive stra- tegies should be given the public health priority they deserve. For this to happen, we need to educate our- selves, our patients & the public. Photo from Jasper Greek Golangco Photo by Bill Ebbesen, CC BY 3.0, Copyrighted-Free Use, Wikimedia Commons Wikimedia Commons (close up, edited)