NUT Exam 2023 PDF

WEIGHT & ERECTILE DYSFUNCTION AUTHOR: D R. M A R YA M YAVA R I , M D, P H. D. , N D NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance as it relates to this week’s case presentation: Diet Reduce Alcohol and smoking L arginine Life Style TREATME...

WEIGHT & ERECTILE DYSFUNCTION AUTHOR: D R. M A R YA M YAVA R I , M D, P H. D. , N D NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance as it relates to this week’s case presentation: Diet Reduce Alcohol and smoking L arginine Life Style TREATMENT GOALS Address presenting symptoms and improve patient comfort Support full and speedy recovery to return to regular activities Patient education Monitor and Prevent sequelae  VASCULAR HEALTH T2DM incidence in the US has increased. This increase is associated with sedentary lifestyle, obesity, and an aging population. Obesity is a major risk factor for ED in diabetics, with a prevalence of 32.2% in the US. Testosterone deficiency and Metabolic syndrome are strongly associated. https://www.sciencedirect.com/science/article/abs/pii/S1743609515310031  VASCULAR HEALTH Erectile dysfunction (ED) is common in patients with cardiovascular disease (CVD). ED affects quality of life and is an independent risk factor for future cardiovascular events. A 3-year time period between onset of ED symptoms and CVD event allows for risk mitigation. Sexual function should be included in CVD risk assessment for all men. https://academic.oup.com/eurheartj/article/34/27/2034/440049  DIET Eating a balanced diet help maintain sexual function and decrease the risk of ED. A study found that men who more strictly followed a Mediterranean diet had a reduced risk of developing ED. In particular, they consumed less red or processed meat and primarily ate: Fruits, vegetables, legumes, nuts, Fish Another study similarly found that eating more fruits, vegetables, and flavonoids lowered the risk of ED in men ages 18 to 40. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451697/ https://www.sciencedirect.com/science/article/abs/pii/S1743609515310031  DIET & FREE RADICALS Oxidative stress is involved in arteriogenic ED, which may result from lack of perfusion, antioxidant deficiency, and waste product accumulation. Oxidative radicals contribute to impaired endothelium- dependent smooth muscle relaxation, mitochondrial injury, endothelial structural damage, and erectile tissue fibrosis in arteriogenic ED. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451697/ https://www.sciencedirect.com/science/article/abs/pii/S1743609515310031  DIET & FREE RADICALS Antioxidant therapy can efficiently improve molecular and ultrastructural alterations in erectile tissue, but it may not have a significant effect on fibrosis and functional deficit. Long-term consumption of dietary antioxidants may improve erectile function by removing oxidative products and preserving NO bioavailability and endothelial and mitochondrial structural integrity. https://onlinelibrary.wiley.com/doi/full/10.1111/j.1365-2605.2010.01083.x https://www.foodingredientsfirst.com/news/rapid-testing-for-food-antioxidants-developed-by-researchers-in-japan.html  DIET & PAD A diet without the right balance of nutrients can contribute to the development and progression of Peripheral Artery Disease Following a heart-healthy diet is key, which involves reducing intake of saturated fats, simple sugars, fats, and trans fats, limiting sodium, and increasing fiber intake Certain diets like the Mediterranean diet and DASH diet can improve vascular health in people with PAD by increasing healthy fats, fruits and vegetables, nuts, and decreasing unhealthy fats, sodium, and sugar intake Following a healthy diet for PAD can lessen symptoms such as leg pain, numbness, or weakness and improve quality of life. https://jamanetwork.com/journals/jama/fullarticle/1817779 https://www.sciencedirect.com/science/article/abs/pii/S0021915018302922  ALCOHOL Studies have shown mixed results for the effects of alcohol on ED. Short-term consumption of alcohol can cause a temporary inability to get an erection by depressing the central nervous system, decreasing penis sensitivity, and limiting blood flow to the penis. Alcohol is a diuretic, leading to dehydration and increased levels of angiotensin, which can narrow blood vessels and limit blood flow to the penis. https://www.nature.com/articles/3901556  ALCOHOL Chronic consumption of large amounts of alcohol can damage nerves, increase the risk of cardiovascular disease, and damage blood vessels, all of which can impact erectile function. Chronic heavy alcohol users may experience dysfunction of the autonomic nervous system, with ED being a common symptom. ED is closely related to cardiovascular disease, and heavy alcohol consumption increases the risk of developing high blood pressure, which is a risk factor for sexual dysfunction. https://www.nature.com/articles/3901556  SMOKING Impotence is twice as likely to occur in smokers than non- smokers, with exposure to second-hand smoke being a significant factor. Smoking can affect the nervous system, hormones, and vascular system required for sexual functioning, leading to impotence. https://www.canada.ca/en/health-canada/services/health-concerns/tobacco/smoking-your-body/smoking-diseases/impotence-smoking.html  SMOKING Long-term smoking causes physiological damage and increases the risk of moderate or severe impotence. Quitting smoking can partially or fully recover erectile function, depending on the degree of damage inflicted and which system is affected. Heavy smokers (40+ cigarettes/day) had "softest" night-time erections, and smoking was related to an abnormal decline of blood pressure in the penis. Men who have reported losing their erections before orgasm have completely reversed this situation by quitting smoking. https://www.canada.ca/en/health-canada/services/health-concerns/tobacco/smoking-your-body/smoking-diseases/impotence-smoking.html  WEIGHT MANAGEMENT Obesity and overweight are independent risk factors of erectile dysfunction (ED). ED is significantly more common in men with obesity, who are overweight, or with a larger waist circumference. https://pubmed.ncbi.nlm.nih.gov/34644814/  WEIGHT MANAGEMENT Meta-analysis was performed to clarify the therapeutic effect of weight loss on erectile function: 5 studies with 619 participants were enrolled in the meta-analysis. It showed that weight loss can improve erectile function in overweight or obese men. Losing weight could serve as an adjuvant therapy for ED. https://pubmed.ncbi.nlm.nih.gov/34644814/  WEIGHT MANAGEMENT Being overweight is linked to erectile dysfunction (ED). Obesity lowers testosterone in men, which can affect sex drive. Extra weight can cause circulatory problems and heart disease, which can also lead to ED. Medications that treat conditions caused by extra weight can also cause ED. Stress, depression, and anxiety related to weight can also cause ED. Regular exercise can lower the risk of ED and boost mood and body image. https://www.sciencedirect.com/science/article/abs/pii/S0140673612605200 https://www.sciencedirect.com/science/article/abs/pii/S1743609515310031  L-ARGININE L-arginine is an amino acid obtained through dietary sources or produced from L-citrulline L-arginine may be more effective in patients with ED with low nitric oxide L-arginine can allow for long-duration treatment for ED. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8451697/ INDICATIONS Taking 2.5-5 grams of L-arginine daily by mouth may improve sexual function in people with ED. L-arginine, when taken with medications such as sildenafil and tadalafil, may work better than taking either L-arginine or the medication alone for ED. L-arginine by mouth may improve symptoms and exercise tolerance in people with angina but does not seem to widen narrowed blood vessels. L-arginine by mouth can reduce blood pressure in healthy people, people with high blood pressure, and people with slightly high blood pressure with or without diabetes. OTHER LIFESTYLE FACTORS Sleep Exercise Psychotherapy Stress reduction  CASE John is a 55-year-old man who presents to your naturopathic clinic with complaints of erectile dysfunction (ED) for the past year. He has no significant medical history, is not taking any medications, and denies tobacco or recreational drug use. He reports a healthy diet and moderate exercise routine. Physical examination is unremarkable. Laboratory testing reveals normal testosterone levels, lipid panel, and fasting glucose. As a naturopathic doctor, you decide to take a holistic approach to John's ED, incorporating both nutritional and lifestyle interventions to address the root cause of his condition. which of the following dietary changes would be beneficial for John? a) Eating a diet rich in fruits, vegetables, whole grains, and lean protein b) Reducing or eliminating processed foods and sugar c) Increasing intake of omega-3 fatty acids through fatty fish or supplements d) All of the above REFERENCES CDC: https://www.cdc.gov/ Online source Center for Disease Control and Prevention Updates 2022 Prousky J. Textbook of Integrative Clinical Nutrition. CCNM Press Inc.; 2012. Katz D. Nutrition in Clinical Practice. 2nd Edition. Lippincott Williams & Wilkins; 2008. Katsilambros N. Clinical Nutrition in Practice. WileyBlackwell; 2010. Pizzorno J and Katzinger J. Clinical Pathophysiology. Mind Publishing; 2012. Marz RB. Medical Nutrition from Marz. 2nd edition. Quiet Lion Press; 1999. Murray MT. Encyclopedia of Nutritional Supplements. Prima Health; 1996. Gropper S, Smith J. Advanced Nutrition and Human Metabolism. 7th Ed. Cengage Learning; 2018. Gaby A. Nutritional Medicine.; Perlberg Publishing 2011. Hoffer A, Prousky J. Naturopathic Nutrition: A Guide to Nutrient-Rich Food & Nutritional Supplements for Optimal Health. CCNM Press; 2006. Leisegang K, Henkel R, Agarwal A. Obesity and metabolic syndrome associated with systemic inflammation and the impact on the male reproductive system. Am J Reprod Immunol. 2019;82(5):e13178. Yafi FA, Jenkins L, Albersen M, et al. Erectile dysfunction. Nat Rev Dis Prim. 2016;2(1):16003. Cui T, Kovell RC, Brooks DC, et al. guide to ingredients found in top-selling nutraceuticals for men’s sexual health. J Sex Med. 2015;12(11):2105–2117. Loprinzi PD, Nooe A. Erectile dysfunction and mortality in a national prospective cohort study. J Sex Med. 2015;12(11):2130–2133. Ciocanel O, Power K, Eriksen A. Interventions to treat erectile dysfunction and premature ejaculation: an overview of systematic reviews. Sex Med. 2019;7(3):251–269. Ma M, Yu B, Qin F, et al. Current approaches to the diagnosis of vascular erectile dysfunction. Transl Androl Urol. 2020;9(2):709–721. Pastuszak AW. Current diagnosis and management of erectile dysfunction. Curr Sex Heal Rep. 2014;6(3):164–176. [PMC free article] [PubMed] [Google Scholar] Rosen RC, Cappelleri JC, Gendrano N. The International Index of Erectile Function (IIEF): a state-of-the-science review. Int J Impot Res. 2002;14(4):226–244. Cartledge J, Minhas S, Eardley I. The role of nitric oxide in penile erection. Expert Opin Pharmacother. 2001;2(1):95–107. THANK YOU! CARDIOLOGY, WEIGHT & LIPIDS AUTHOR: D R. M A R YA M YAVA R I , M D , P H. D. , N D NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance as it relates to this week’s case presentation: Diet Review on fiber, types, applications and its role in lipid management, weight management and CVD prevention TREATMENT GOALS Address presenting symptoms and improve patient comfort Support full and speedy recovery to return to regular activities Patient education Monitor and Prevent sequelae FIBERS FIBER & FIBER-RELATED COMPOUNDS Gums Cellulose Mucilage Hemicellulose b-glucans Lignins & lignans Fructans Pectins CELLULOSE Cellulose is a polysaccharide molecule, consisting of carbon, hydrogen and oxygen atoms. (Unbranched polymer of long chains) helping plants to remain stiff and upright Insoluble in water Humans cannot digest cellulose, Increases fecal volume Sources: bran, legumes, root veg, seeds HEMICELLULOSE Mixture of linear & highly branched polymers containing various sugars (short chains) Digested better than cellulose Most are insoluble but some are soluble Sources: Bran, whole grains, nuts, legumes, some fruits and vegetables PECTIN Complex group of polysaccharides called galacturonoglycans Found between plant cell walls & the intracellular layers and acts like a “glue” holding cells together Completely digested through microbial action Forms a viscous gel when mixed with water, used in marmalades, jams, and jellies Sources: Apples, pears, strawberries, and citrus fruit LIGNINS Highly-branched polymer composed of phenol units with strong bonding cell walls, especially in wood and bark (rigidity) Structural components of plants found in stems, seeds, and bran layer Antioxidant & phytoestrogenic properties Sources: Flax and other seeds, wheat, root veg, legumes  CLINICAL NOTE: FLAX SEED Linum usitatissimum § Contains 35–45 % of fiber: two-third is insoluble (cellulose, hemicellulose and lignin) and one third is soluble fiber (mucilage of seed coat). § Highest natural source of lignins (contains phytoestrogen) § One of the richest plant sources of the ω-3 fatty acid alpha-linolenic acid (ALA, C18:3 ω-3) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375225/#:~:text=It%20contains%2035%E2%80%9345%20%25%20of,the%20mucilage%20of %20seed%20coat. High ALA content  CLINICAL NOTE: FLAX SEED Clinical Application Chronic constipation May help inhibit growth & metastasis of breast & prostate cancers & melanoma Symptoms associated with menopause Therapeutic Dosage: 2-3 tablespoons of the ground seeds daily https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4375225/#:~:text=It%20contains%2035%E2%80%9345%20%25%20of,the%20mucilage%20of%20seed%20coat.%20High%20ALA%20content GUMS Group of substances secreted at site of plant injury e.g. tree exudate - gum arabic Composed of sugars & derivatives Sources: Oats, barley, legumes MUCILAGES & ALGAL POLYSACCHARIDES Thick glutinous substances, secreted by seed covers such as psyllium, flax, and certain seaweeds Storage of water and food, seed germination, and thickening membranes Water soluble Food additive to give foods a firmer texture: guar, carageenan, agar CLINICAL NOTE: PSYLLIUM High in soluble fiber & mucilage Derived from the husk of psyllium seeds Clinical Applications: Constipation or diarrhea Hypercholesterolemia Therapeutic Dosage: 1-2 tablespoons bid  b -GLUCANS Soluble fibers in the cell walls of bacteria, fungi, yeasts, and some plants. Might lower the CVD risk, BP and Cholesterol Immune stimulating (caution with immunosuppressant) or immune modulating Highly fermentable Sources: barley fiber, oats and whole grains, brewers yeast, reishi, maitake and shiitake mushrooms, seaweed, algae. https://pubmed.ncbi.nlm.nih.gov/27724985/ FRUCTANS A molecule consisting of a chain of fructose molecules joined together, and with a glucose molecule at the end. Are included in the FODMAP group of carbohydrates Fructan intolerance: gas, bloating, belching, constipation or diarrhea Function: prebiotics, immunomodulatory Sources: Chicory, onions, artichokes, asparagus, garlic, bananas PROPERTIES & PHYSIOLOGICAL EFFECTS OF FIBER Important properties of fiber include: Solubility in water Water-holding capacity & viscosity Adsorption or binding ability Fermentability  WATER SOLUBILITY Water Soluble Fiber Water Insoluble fiber Dissolves in hot water Mostly pectin & gums Does not dissolve in hot water Delays gastric emptying Cellulose, lignin, & most hemicelluloses Increases intestinal transit Decreases intestinal transit time time Decreases nutrient Increase fecal bulk absorption Higher hydration capacity Lower hydration capacity Higher adsorption capacity Lower adsorption capacity Higher fermentability Lower fermentability Fruits, oats, barley, legumes Vegetables & most grains CLINICAL INDICATIONS Soluble fibers Hyperglycemia Hyperlipidemia Diarrhea or constipation Insoluble fibers Constipation Maintaining bowel regularity in certain GI diseases Immunomodulation REQUIREMENTS Adequate Intakes Men 19-50: 38 g >50: 31 g Women 19-50: 25 g >50: 21 g DISEASES ASSOCIATED WITH A LOW-FIBER DIET GI diseases Diverticular diseases IBS Ulcerative colitis Hemorrhoids Colon cancer? Cardiovascular disease Obesity Type 2 diabetes TOXICITY Most common adverse effects: Increased gas & bloating Constipation Serious adverse effects: Intestinal or esophageal obstruction NUTRIENT INTERACTIONS Minerals Fiber may bind minerals & decrease their absorption especially iron, calcium, magnesium, zinc Vitamins Children given 10 g of supplemental fiber daily developed a vitamin A deficiency Long-term psyllium supplementation has been shown to decrease serum B12 levels over time in the elderly  DIETARY FIBER: AN OPPORTUNITY FOR A GLOBAL CONTROL OF HYPERLIPIDEMIA There are five primary mechanisms that are thought to contribute to the antihyperlipidemic advantages of dietary fibers (DFs). These mechanisms include the low-energy content of DFs, their bulking effect, their ability to increase viscosity, their capacity to bind, and their potential to ferment, all of which can help alleviate hyperlipidemia symptoms. From the molecular level, DFs could possibly affect the activities of HMG-CoA reductase, LDL receptors, CYP7A1, and MAPK signaling pathway as well as other lipid metabolism-related target genes. Nie Y, Luo F. Dietary fiber: An opportunity for a global control of hyperlipidemia. Oxidative Medicine and Cellular Longevity. 2021 Oct;2021.  FIBER AND WEIGHT MANAGEMENT Findings from 62 trials (n = 3877): Viscous fiber reduced mean body weight, BMI, and waist circumference, with no change in body fat. Greater reductions in body weight in overweight individuals and those with diabetes and metabolic syndrome. Dietary viscous fiber modestly yet significantly improved body weight and other parameters of adiposity independently of calorie restriction Jovanovski E, Mazhar N, Komishon A, Khayyat R, Li D, Blanco Mejia S, Khan T, L Jenkins A, Smircic-Duvnjak L, L Sievenpiper J, Vuksan V. Can dietary viscous fiber affect body weight independently of an energy-restrictive diet? A systematic review and meta-analysis of randomized controlled trials. The American journal of clinical nutrition. 2020 Feb 1;111(2):471-85.  FIBER AND CARDIOMETABOLIC SYNDROME 52 meta-analyses involving 47,197 subjects: Higher dietary fiber intake was significantly associated with reductions in parameters involving glycemic control, including fasting plasma glucose, fasting plasma insulin, homeostasis model assessment of insulin resistance (HOMA-IR) and glycosylated hemoglobin (HbA1c). Soliman GA. Dietary fiber, atherosclerosis, and cardiovascular disease. Nutrients. 2019 May 23;11(5):1155. Iversen KN. High fiber rye foods decrease body weight and body fat and affect metabolic risk markers. Chalmers Tekniska Hogskola (Sweden); 2021. Fu L, Zhang G, Qian S, Zhang Q, Tan M. Associations between dietary fiber intake and cardiovascular risk factors: An umbrella review of meta-analyses of randomized controlled trials. Frontiers in Nutrition. 2022 Sep 12;9:2153.  FIBER AND CARDIOMETABOLIC SYNDROME Higher dietary fiber intake was associated with significant reductions in the serum level of total cholesterol and low-density lipoprotein cholesterol but not triglycerides and high-density lipoprotein cholesterol. Soliman GA. Dietary fiber, atherosclerosis, and cardiovascular disease. Nutrients. 2019 May 23;11(5):1155. Iversen KN. High fiber rye foods decrease body weight and body fat and affect metabolic risk markers. Chalmers Tekniska Hogskola (Sweden); 2021. Fu L, Zhang G, Qian S, Zhang Q, Tan M. Associations between dietary fiber intake and cardiovascular risk factors: An umbrella review of meta-analyses of randomized controlled trials. Frontiers in Nutrition. 2022 Sep 12;9:2153.  FIBER AND CARDIOMETABOLIC SYNDROME Higher dietary fiber intake was significantly associated with improved tumor necrosis factor-alpha serum levels while no significant effect was observed for C-reactive protein. Blood pressure was significantly improved following higher dietary fiber intake. Soliman GA. Dietary fiber, atherosclerosis, and cardiovascular disease. Nutrients. 2019 May 23;11(5):1155. Iversen KN. High fiber rye foods decrease body weight and body fat and affect metabolic risk markers. Chalmers Tekniska Hogskola (Sweden); 2021. Fu L, Zhang G, Qian S, Zhang Q, Tan M. Associations between dietary fiber intake and cardiovascular risk factors: An umbrella review of meta-analyses of randomized controlled trials. Frontiers in Nutrition. 2022 Sep 12;9:2153. QUESTION Tina is a 58-year-old obese patient with a high cholesterol level and strong family history of CVD. Which one of the following options can help Tina improve her health status? Adding psyllium because it can reduce cholesterol levels. Taking beta-glucans as it may reduce heart disease risk. Taking fish oil to reduce triglyceride levels. All options are correct. REFERENCES CDC: https://www.cdc.gov/ Online source Center for Disease Control and Prevention Updates 2022 Prousky J. Textbook of Integrative Clinical Nutrition. CCNM Press Inc.; 2012. Katz D. Nutrition in Clinical Practice. 2nd Edition. Lippincott Williams & Wilkins; 2008. Katsilambros N. Clinical Nutrition in Practice. WileyBlackwell; 2010. Pizzorno J and Katzinger J. Clinical Pathophysiology. Mind Publishing; 2012. Marz RB. Medical Nutrition from Marz. 2nd edition. Quiet Lion Press; 1999. Murray MT. Encyclopedia of Nutritional Supplements. Prima Health; 1996. Gropper S, Smith J. Advanced Nutrition and Human Metabolism. 7th Ed. Cengage Learning; 2018. Gaby A. Nutritional Medicine.; Perlberg Publishing 2011. Hoffer A, Prousky J. Naturopathic Nutrition: A Guide to Nutrient-Rich Food & Nutritional Supplements for Optimal Health. CCNM Press; 2006. Gropper S, Smith J. Advanced Nutrition and Human Metabolism. 7th Ed. Cengage Learning; 2018. Gaby A. Nutritional Medicine.; Perlberg Publishing 2011. Hoffer A, Prousky J. Naturopathic Nutrition: A Guide to Nutrient-Rich Food & Nutritional Supplements for Optimal Health. CCNM Press; 2006. Katz, D.Nutrition in Clinical Practice. 2nd Edition. Lippincott Williams & Wilkins, 2008. Katsilambros, N Clinical Nutrition in Practice. Wiley-Blackwell 2010 Jones, D. Textbook of Functional Medicine: The Institute for Functional Medicine. Gig Harbour Washington. Pizzorno, J and Katzinger, J. Clinical Pathophysiology. Mind Publishing, 2012 Yang Y, Zhao LG, Wu QJ, Ma X, Xiang YB. Association between dietary fiber and lower risk of all-cause mortality: a meta-analysis of cohort studies. American journal of epidemiology. 2015 Jan 15;181(2):83-91. Acosta S, Johansson A, Drake I. Diet and lifestyle factors and risk of atherosclerotic cardiovascular disease—a prospective cohort study. Nutrients. 2021 Nov;13(11):3822. Pereira MA, O’Reilly E, Augustsson K, Fraser GE, Goldbourt U, Heitmann BL, Hallmans G, Knekt P, Liu S, Pietinen P, Spiegelman D. Dietary fiber and risk of coronary heart disease: a pooled analysis of cohort studies. Archives of internal medicine. 2004 Feb 23;164(4):370-6. Jesch ED, Carr TP. Food ingredients that inhibit cholesterol absorption. Preventive nutrition and food science. 2017 Jun;22(2):67. Rimm EB, Ascherio A, Giovannucci E, Spiegelman D, Stampfer MJ, Willett WC. Vegetable, fruit, and cereal fiber intake and risk of coronary heart disease among men. JAMA. 1996 Feb 14;275(6):447-51. Brown L, Rosner B, Willett WW, Sacks FM. Cholesterol-lowering effects of dietary fiber: a meta-analysis. The American journal of clinical nutrition. 1999 Jan 1;69(1):30-42. Institute of Medicine 2005. Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids. Washington, DC: The National Academies Press. https://doi.org/10.17226/10490. THANK YOU!  PERSISTENT GERD & GI symptoms AUTHOR: DR. MARYAM YAVARI, MD, PH.D., ND NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance as it relates to this week’s case presentation: Addressing underlying causes Improving gut health Promoting healthy digestion TREATMENT GOALS Addressing underlying causes (e.g., food sensitivities, stress) Improving gut health Promoting healthy digestion DIETARY STRATEGIES FOR MANAGING GERD Avoiding trigger foods (e.g., acidic, spicy, fatty) Eating smaller, more frequent meals Consuming low-allergen, nutrient-dense foods General Recommendations Avoid eating before bed Eat slowly and chew thoroughly Sit up straight while eating Wait to exercise after eating General Recommendations Avoid trigger foods: Certain foods can trigger GERD symptoms. Some common trigger foods include spicy or fatty foods, acidic foods (such as citrus fruits and tomatoes), caffeine, and chocolate. It's best to avoid these foods or limit the intake. Limit alcohol and carbonated beverages General Recommendations Avoid eating before bedtime: eating a large meal before bedtime can increase the likelihood of acid reflux symptoms. It's best to avoid eating at least three hours before bedtime. Raise the head of the bed Chew gum Drink water  RECOMMENDED FOODS A systematic review of dietary interventions for GERD: The study included 72 articles from 10 Western countries and 9 Eastern countries. Dietary factors were categorized into 20 items and lifestyle factors into 11 items. GERD is related to irregular dietary and lifestyle habits, such as midnight snacking, skipping breakfast, eating quickly, eating very hot foods, and eating beyond fullness. https://pubmed.ncbi.nlm.nih.gov/33883899/  RECOMMENDED FOODS Vegetarian diets and no intake of meat were negatively related to GERD, while daily meat, fish, and egg intake, as well as high-fat diet consumption, were positively related to GERD. An interval of less than three hours between dinner and bedtime was positively related to GERD, while proper physical exercise was negatively correlated with GERD. Smoking, alcohol consumption, and poor mental state were positively correlated with GERD. Antioxidant intake was generally negatively correlated with GERD. https://pubmed.ncbi.nlm.nih.gov/33883899/  RECOMMENDED FOODS Intermittent fasting may be recommended, especially in overweight-obese patients with GERD symptoms who are poor responders to gastric acid inhibitors. https://www.medscape.com/viewarticle/984377#:~:text=%22Intermittent%20fasting%20may%20be%20recommended,work%20in %20patients%20with%20GERD.%22 SPECIFIC NUTRIENTS FOR GERD MANAGEMENT Magnesium Zinc Carnosine Vitamin 12  MAGNESIUM A population-based case–control study: individuals consuming the highest amounts of Mg from foods had significant reductions in the odds of reflux oesophagitis and Barrett’s oesophagus compared with individuals consuming the lowest amounts of Mg. Dai Q, Cantwell MM, Murray LJ, Zheng W, Anderson LA, Coleman HG. Dietary magnesium, calcium: magnesium ratio and risk of reflux oesophagitis, Barrett’s oesophagus and oesophageal adenocarcinoma: a population-based case–control study. British Journal of Nutrition. 2016 Jan;115(2):342-50.  Zinc Carnosine Zinc carnosine supports the gastrointestinal system by protecting its mucus membrane , aiding in the repair of damaged epithelial cells, inhibiting inflammation, and exhibiting antioxidant-like properties. https://www.sciencedirect.com/science/article/pii/S2210740122000912 VITAMIN B12 Some studies have found an association between heartburn medications and increased risk of vitamin B-12 deficiency. OTHER SUPPLEMENTS FOR GERD MANAGEMENT Licorice root Slippery elm Ginger  ROLE OF PROBIOTICS Specific strains for GERD management Lactobacillus acidophilus and other Lactobacillus strains including: L. gasseri L. casei L. plantarum L. rhamnosus L. reuteri Bifidobacterium strains https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7019778/#:~:text=In%20conclusion%2C%20probiotic%20use%20can,efficacy%20i n%20alleviating%20these%20symptoms. Summary Eating Habits Trigger foods Magnesium, Zinc Carnosine, B12 Probiotics Clinical case David, A 35-year-old male presents with symptoms of heartburn, acid regurgitation, and a sour taste in his mouth. He has been experiencing these symptoms for the past few weeks and they seem to be worse after eating spicy or fatty foods. He has been taking over-the-counter antacids, but they only provide temporary relief. You recommend: High fiber diet Low fat diet Low spicy food diet All options are correct REFERENCES CDC: https://www.cdc.gov/ Online source Center for Disease Control and Prevention Updates 2022 Prousky J. Textbook of Integrative Clinical Nutrition. CCNM Press Inc.; 2012. Katz D. Nutrition in Clinical Practice. 2nd Edition. Lippincott Williams & Wilkins; 2008. Katsilambros N. Clinical Nutrition in Practice. WileyBlackwell; 2010. Pizzorno J and Katzinger J. Clinical Pathophysiology. Mind Publishing; 2012. Marz RB. Medical Nutrition from Marz. 2nd edition. Quiet Lion Press; 1999. Murray MT. Encyclopedia of Nutritional Supplements. Prima Health; 1996. Gropper S, Smith J. Advanced Nutrition and Human Metabolism. 7th Ed. Cengage Learning; 2018.  Cheng J, Ouwehand AC. Gastroesophageal reflux disease and probiotics: a systematic review. Nutrients. 2020 Jan 2;12(1):132. Pereira RD. Regression of gastroesophageal reflux disease symptoms using dietary supplementation with melatonin, vitamins and aminoacids: comparison with omeprazole. Journal of Pineal Research. 2006 Oct;41(3):195-200. Meletis CD, Zabriskie N. Natural approaches for gastroesophageal reflux disease and related disorders. Alternative & Complementary Therapies. 2007 Apr 1;13(2):64-70. Dore MP, Maragkoudakis E, Fraley K, Pedroni A, Tadeu V, Realdi G, Graham DY, Delitala G, Malaty HM. Diet, lifestyle and gender in gastro-esophageal reflux disease. Digestive diseases and sciences. 2008 Aug;53:2027-32. Gaby A. Nutritional Medicine.; Perlberg Publishing 2011. Hoffer A, Prousky J. Naturopathic Nutrition: A Guide to Nutrient-Rich Food & Nutritional Supplements for Optimal Health. CCNM Press; 2006. THANK YOU!  FUNCTIONAL GI (IBS) AUTHOR: DR. MARYAM YAVARI, MD, PH.D., ND NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance as it relates to this week’s case presentation: Diet Microbiome balance TREATMENT GOALS Address presenting symptoms and improve patient comfort Support full and speedy recovery to return to regular activities Patient education Monitor and Prevent sequelae  SIBO Common in people with irritable bowel syndrome (IBS). Some studies suggest that up to 80% of people with IBS may also have SIBO. Treatment for SIBO often involves antibiotics to eliminate the overgrowth of bacteria + dietary changes to support healthy microbiome and prevent future overgrowth. https://my.clevelandclinic.org/health/diseases/21820-small-intestinal-bacterial-overgrowth-sibo ROLE OF NUTRIENTS AND FOOD  Low FODMAP Diet - Fermentable oligosaccharides, disaccharides, monosaccharides, and polyols - Can be effective in managing symptoms of SIBO in patients with IBS. - This diet eliminates certain types of carbohydrates that are poorly absorbed in the small intestine and can be fermented by bacteria, leading to symptoms like bloating, gas, and diarrhea. Halmos EP, Power VA, Shepherd SJ, Gibson PR, Muir JG. A diet low in FODMAPs reduces symptoms in patients with irritable bowel syndrome and a probiotic restores Bifidobacterium species: a randomized controlled trial. Gastroenterology. 2014;146(1):67-75.e5. 2 Marsh A, Eslick EM, Eslick GD. Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr. 2016;55(3):897-906. https://charlestongi.com/news&events/the-low-fodmap-diet-for-irritable-bowel-syndrome/  Low FODMAP Diet - Several randomized controlled trials have shown that a low FODMAP diet can improve IBS symptoms in up to 75% of patients. - A systematic review and meta-analysis of 22 studies found that a low FODMAP diet was effective in reducing IBS symptoms, specially bloating and abdominal pain. Gibson PR, Shepherd SJ. Evidence-based dietary management of functional gastrointestinal symptoms: The FODMAP approach. J Gastroenterol Hepatol. 2010;25(2):252-258. Marsh A, Eslick EM, Eslick GD. Does a diet low in FODMAPs reduce symptoms associated with functional gastrointestinal disorders? A comprehensive systematic review and meta-analysis. Eur J Nutr. 2016;55(3):897-906 Alcohol If alcohol exacerbates the symptoms it should be reduced. IBS patients should be advised to consume alcohol in compliance with recommended safe limits. McKenzie YA, Bowyer RK, Leach H, Gulia P, Horobin J, O’Sullivan NA, Pettitt C, Reeves LB, Seamark L, Williams M, et al. British Dietetic Association systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults (2016 update) J Hum Nutr Diet. 2016;29:549–575. Caffeine intake Caffeine intake should be assessed in IBS patients. If related to symptoms, daily intake should be less than 400 mg caffeine, which is the safe limit for most adults McKenzie YA, Bowyer RK, Leach H, Gulia P, Horobin J, O’Sullivan NA, Pettitt C, Reeves LB, Seamark L, Williams M, et al. British Dietetic Association systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults (2016 update) J Hum Nutr Diet. 2016;29:549–575. Spicy foods intake If the IBS symptoms are triggered by spicy foods, the intake should be restricted. IBS triggers in spicy foods other than hot spices (e.g., fructans in onion and garlic) should also be assessed. McKenzie YA, Bowyer RK, Leach H, Gulia P, Horobin J, O’Sullivan NA, Pettitt C, Reeves LB, Seamark L, Williams M, et al. British Dietetic Association systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults (2016 update) J Hum Nutr Diet. 2016;29:549–575.  Fiber intake Some studies have suggested that increasing fiber intake may improve IBS symptoms, especially constipation. However, the evidence is mixed, and some people with IBS may find that high fiber diets exacerbate their symptoms. El-Salhy M, Ystad SO, Mazzawi T, Gundersen D. Dietary fiber in irritable bowel syndrome (Review). Int J Mol Med. 2017;40(3):607-613. 4 Bijkerk CJ, de Wit NJ, Muris JW, Whorwell PJ, Knottnerus JA, Hoes AW. Soluble or insoluble fibre in irritable bowel syndrome in primary care? Randomised placebo controlled trial. BMJ. 2009;339:b3154.  Fat intake If related to IBS symptoms during or after eating, fat intake should be assessed. According to FAO/WHO dietary recommendations, the total fat intake for an adult should range from 30% to 35% of total energy, without being under 15% of total energy. Patients with IBS should be advised to limit fat intake to no more than 40-50 g/d. Heizer WD, Southern S, McGovern S. The role of diet in symptoms of irritable bowel syndrome in adults: a narrative review. J Am Diet Assoc. 2009;109:1204–1214. Dairy intake Low-lactose diet only if they have a positive lactose hydrogen breath test. Gluten-free Diet Conflicting evidence Consider nutritional deficiencies Summary Diet and microbiome balance: Low FODMAP Avoiding the triggers: spicy foods, coffee, alcohol,... Fiber intake Fat intake Dairy intake Gluten intake Case Tina, a 26 year old woman is concerned about abdominal discomfort, bloating and constipation. She was diagnosed with IBS 2 years ago. You recommend Tina to: Increase fiber intake in her diet Decrease fiber intake in her diet Have a FODMAP rich diet Monitor her response to fiber intake  REFERENCES CDC: https://www.cdc.gov/ Online source Center for Disease Control and Prevention Updates 2022 Prousky J. Textbook of Integrative Clinical Nutrition. CCNM Press Inc.; 2012. Katz D. Nutrition in Clinical Practice. 2nd Edition. Lippincott Williams & Wilkins; 2008. Katsilambros N. Clinical Nutrition in Practice. WileyBlackwell; 2010. Pizzorno J and Katzinger J. Clinical Pathophysiology. Mind Publishing; 2012. Marz RB. Medical Nutrition from Marz. 2nd edition. Quiet Lion Press; 1999. Ducrotté P, Sawant P, Jayanthi V. Clinical trial: Lactobacillus plantarum 299v (DSM 9843) improves symptoms of irritable bowel syndrome. World J Gastroenterol. 2012;18(30):4012- 4018. Moayyedi P, Ford AC, Talley NJ, et al. The efficacy of probiotics in the treatment of irritable bowel syndrome: a systematic review. Gut. 2010;59(3):325-332. Murray MT. Encyclopedia of Nutritional Supplements. Prima Health; 1996. Gropper S, Smith J. Advanced Nutrition and Human Metabolism. 7th Ed. Cengage Learning; 2018.  Chey WD, Kurlander J, Eswaran S. Irritable bowel syndrome: a clinical review. JAMA. 2015 Mar 3;313(9):949-58. doi: 10.1001/jama.2015.0954. PMID: 25734736. McKenzie YA, Bowyer RK, Leach H, Gulia P, Horobin J. British dietetic association systematic review and evidence-based practice guidelines for the dietary management of irritable bowel syndrome in adults (2016 update). J Hum Nutr Diet. 2016 Oct;29(5):549-75. doi: 10.1111/jhn.12385. PMID: 27170209. Barbara G, Grover M, Bercik P, et al. Rome Foundation Working Team Report on Post-Infection Irritable Bowel Syndrome. Gastroenterology. 2019 Jun;156(8):e3-e14. doi: 10.1053/j.gastro.2019.02.014. PMID: 31071323. Zoppi G, Cinquetti M, Luciano A, Benini A, Muner A, Bertazzoni Minelli E. The intestinal ecosystem in chronic functional gastrointestinal disorders. J Clin Gastroenterol. 2014 Oct;48 Suppl 1:S70-2. doi: 10.1097/MCG.0000000000000192. PMID: 25291138. Muir JG, Gibson PR. The Low FODMAP Diet for Treatment of Irritable Bowel Syndrome and Other Gastrointestinal Disorders. Gastroenterol Hepatol (N Y). 2013 Sep;9(9):450-2. PMID: 24711715. Biesiekierski JR, Newnham ED, Irving PM, et al. Gluten causes gastrointestinal symptoms in subjects without celiac disease: a double- blind randomized placebo-controlled trial. Am J Gastroenterol. 2011 Mar;106(3):508-14; quiz 515. doi: 10.1038/ajg.2010.487. PMID: 21224837. Carroccio A, Mansueto P, Iacono G, et al. Non-celiac wheat sensitivity diagnosed by double-blind placebo-controlled challenge: exploring a new clinical entity. Am J Gastroenterol. 2012 Dec;107(12):1898-906; quiz 1907. doi: 10.1038/ajg.2012.277. PMID: 23147521. Moayyedi P, Quigley EM, Lacy BE, et al. The effect of dietary intervention on irritable bowel syndrome: a systematic review. Clin Gastroenterol Hepatol. 2015 Apr;13(4):750-8.e2. Staudacher HM, Whelan K. The low FODMAP diet: recent advances in understanding its mechanisms and efficacy in IBS. Gut. 2017 Jan;66 THANK YOU! NON-SPECIFIC LBP: Food and Inflammation AUTHOR: DR. MARYAM YAVARI, MD, PH.D., ND NMT150 2023 LEARNING OBJECTIVES Considerations for providing nutritional guidance as it relates to this week’s case presentation: Role of diet in reducing systemic inflammation TREATMENT GOALS Address presenting symptoms and improve patient comfort Support full and speedy recovery to return to regular activities Patient education Monitor and Prevent sequelae  Inflammatory markers and chronic disorders and LBP The Western dietary pattern has typically been linked to higher levels of inflammatory markers in the body. The Anti inflammatory diet is related to reduced inflammation levels. Higher levels of DII (from a proinflammatory diet) may play a role in the prevalence of LBP. 42% higher chances of having low back pain when comparing the group with the most proinflammatory diet to the group with the least pro-inflammatory diet. https://www.sciencedirect.com/science/article/abs/pii/S0165032722013106 https://www.rehabmedicine.pitt.edu/sites/default/files/enrico.pdf  What is an anti-inflammatory diet? Rich in vegetables, fruit, whole grains, nuts, legumes, unsaturated fats, spices and herbs A moderate intake of animal products A low intake of simple carbohydrates, processed foods, saturated fats and alcohol The Mediterranean diet, DASH diet and vegetarian dietary patterns have been described as examples of anti- inflammatory diets. Mukherjee MS, Han CY, Sukumaran S, Delaney CL, Miller MD. Effect of anti-inflammatory diets on inflammation markers in adult human populations: a systematic review of randomized controlled trials. Nutr Rev. 2022 Dec 6;81(1):55-74. doi: 10.1093/nutrit/nuac045.  The Dietary Inflammatory Index (DII) Describes the inflammatory potential of a diet. The DII has been used to examine associations of an inflammatory diet and multiple health outcomes. Shivappa N, Steck SE, Hurley TG, Hussey JR, Hébert jr. Designing and developing a literature-derived, population-based dietary inflammatory index. Public Health Nutr. 2014:17(8):1689-96. Abstract available from: https://pubmed-ncbi-nlm-nih-gov.ccnm.idm.oclc.org/23941862/ Liu FH, Liu C, Gong TT, Gao S, Sun H, Jiang YT, Zhang JY, Zhang M, Gao C, Li XY, Zhao YH, Wu QJ. Dietary Inflammatory Index and Health Outcomes: An Umbrella Review of Systematic Review and Meta-Analyses of Observational Studies. Front Nutr. 2021 May 19;8:647122. doi: 10.3389/fnut.2021.647122. PMID: 34095187; PMCID: PMC8169973. Abstract available from: https://pubmed-ncbi-nlm-nih-gov.ccnm.idm.oclc.org/34095187/  The Dietary Inflammatory Index (DII) Uses a point system to score an individual’s dietary pattern on a scale from low (anti-inflammatory) to high (pro-inflammatory). An individual’s overall dietary score is totalled, with a negative score indicating a more anti-inflammatory diet and a positive score indicating a more pro-inflammatory diet. Shivappa N, Steck SE, Hurley TG, Hussey JR, Hébert jr. Designing and developing a literature-derived, population-based dietary inflammatory index. Public Health Nutr. 2014:17(8):1689-96. Abstract available from: https://pubmed-ncbi-nlm-nih-gov.ccnm.idm.oclc.org/23941862/ Liu FH, Liu C, Gong TT, Gao S, Sun H, Jiang YT, Zhang JY, Zhang M, Gao C, Li XY, Zhao YH, Wu QJ. Dietary Inflammatory Index and Health Outcomes: An Umbrella Review of Systematic Review and Meta-Analyses of Observational Studies. Front Nutr. 2021 May 19;8:647122. doi: 10.3389/fnut.2021.647122. PMID: 34095187; PMCID: PMC8169973. Abstract available from: https://pubmed-ncbi-nlm-nih-gov.ccnm.idm.oclc.org/34095187/  Nutrient Effects on Inflammation Carbohydrates Consumption of refined, high glycemic– load carbohydrates can increase systemic inflammation. Regular consumption of high glycemic– load carbohydrates results in chronic hyperglycemia, which increases the production of free radicals and proinflammatory cytokines. GiuglianoDCerielloAEspositoK. The effects of diet on inflammation: emphasis on the metabolic syndrome. J Am Coll Cardiol. 2006; 48(4): 677– 685. EspositoKNappoFMarfellaR et al. Inflammatory cytokine concentrations are acutely increased by hyperglycemia in humans: role of oxidative stress. Circulation. 2002; 106(16): 2067– 2072. BrennerRR. Nutrition and hormonal factors influencing desaturation of essential fatty acids. Prog Lipid Res. 1982; 20: 41– 48. BrennerRR. Hormonal modulation of delta6 and delta5 desaturases: case of diabetes. Prostaglandins Leukot Essent Fatty Acids. 2003; 68(2): 151– 162.  Nutrient Effects on Inflammation Carbohydrates Insulin has an impact on the enzymes delta-6 and delta-5 desaturase, which are enzymes that regulate the conversion of linoleic acid into arachidonic acid. This results in an increase in arachidonic acid production. On the other hand, glucagon has a inhibitory effect on the desaturase enzymes, which leads to a reduction in the production of arachidonic acid. GiuglianoDCerielloAEspositoK. The effects of diet on inflammation: emphasis on the metabolic syndrome. J Am Coll Cardiol. 2006; 48(4): 677– 685. EspositoKNappoFMarfellaR et al. Inflammatory cytokine concentrations are acutely increased by hyperglycemia in humans: role of oxidative stress. Circulation. 2002; 106(16): 2067– 2072. BrennerRR. Nutrition and hormonal factors influencing desaturation of essential fatty acids. Prog Lipid Res. 1982; 20: 41– 48. BrennerRR. Hormonal modulation of delta6 and delta5 desaturases: case of diabetes. Prostaglandins Leukot Essent Fatty Acids. 2003; 68(2): 151– 162.  Nutrient Effects on Inflammation Fats The level of ω-3 and ω-6 fatty acids (FAs): ω-3 FAs are considered anti-inflammatory, while ω-6 FAs are proinflammatory. Research has demonstrated that maintaining a low ratio of omega-6 to omega-3 fatty acids, specifically below 5:1.12 can have beneficial effects on various health conditions such as cardiovascular disease, rheumatoid arthritis, and asthma. SimopoulosAP. Evolutionary aspects of the dietary omega-6:omega-3 fatty acid ratio: medical implications. World Rev Nutr Diet. 2009; 100: 1– 21. SimopoulosAP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002; 56(8): 365– 379. SimopoulosAP. Omega-6/omega-3 essential fatty acid ratio and chronic diseases. Food Reviews International. 2004; 20(1): 77– 90. IbargurenMLopezDEscribaP. The effect of natural and synthetic fatty acids on membrane structure, microdomain organization, cellular functions and human health. Biochemica et Biophysica Acta. 2014; 1838(6): 1518– 1528. SerhanCN. Resolution phase of inflammation: novel endogenous anti-inflammatory and proresolving lipid mediators and pathways. Annu Rev Immunol. 2007; 25: 101– 137. LevyB. Resolvins and protectins: natural pharmacophores for resolution biology. Prostaglandins Leukot Essent Fatty Acids. 2010; 82(4-6): 327– 332.  Nutrient Effects on Inflammation Fats Linoleic acid, which is an omega-6 fatty acid, is a precursor for several proinflammatory eicosanoids that are produced from arachidonic acid. Consuming a diet that is high in omega-6 fatty acids can lead to an increased risk of inflammation. Omega-3 fatty acids have anti-inflammatory effects. Unlike insulin, omega-3 fatty acids inhibit the delta-6 desaturase enzyme, which reduces the production of arachidonic acid. Omega-3 fatty acids can contribute to the production of anti- inflammatory eicosanoids called resolvins, which are involved in regulating the activation and movement of white blood cells. SimopoulosAP. Evolutionary aspects of the dietary omega-6:omega-3 fatty acid ratio: medical implications. World Rev Nutr Diet. 2009; 100: 1– 21. SimopoulosAP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002; 56(8): 365– 379. SimopoulosAP. Omega-6/omega-3 essential fatty acid ratio and chronic diseases. Food Reviews International. 2004; 20(1): 77– 90. IbargurenMLopezDEscribaP. The effect of natural and synthetic fatty acids on membrane structure, microdomain organization, cellular functions and human health. Biochemica et Biophysica Acta. 2014; 1838(6): 1518– 1528. SerhanCN. Resolution phase of inflammation: novel endogenous anti-inflammatory and proresolving lipid mediators and pathways. Annu Rev Immunol. 2007; 25: 101– 137. LevyB. Resolvins and protectins: natural pharmacophores for resolution biology. Prostaglandins Leukot Essent Fatty Acids. 2010; 82(4-6): 327– 332.  Nutrient Effects on Inflammation Fats Trans fats (TFAs) are mainly consumed through foods that contain partially hydrogenated vegetable oils, such as bakery goods. Hydrogenation converts naturally occurring cis double bonds of unsaturated fats into trans double bonds, producing a solid fat with a high melting temperature and longer shelf life. TFA consumption adversely affects serum lipids due to its impact on liver function and lipoprotein metabolism. SimopoulosAP. Evolutionary aspects of the dietary omega-6:omega-3 fatty acid ratio: medical implications. World Rev Nutr Diet. 2009; 100: 1– 21. SimopoulosAP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002; 56(8): 365– 379. SimopoulosAP. Omega-6/omega-3 essential fatty acid ratio and chronic diseases. Food Reviews International. 2004; 20(1): 77– 90. IbargurenMLopezDEscribaP. The effect of natural and synthetic fatty acids on membrane structure, microdomain organization, cellular functions and human health. Biochemica et Biophysica Acta. 2014; 1838(6): 1518– 1528. SerhanCN. Resolution phase of inflammation: novel endogenous anti-inflammatory and proresolving lipid mediators and pathways. Annu Rev Immunol. 2007; 25: 101– 137. LevyB. Resolvins and protectins: natural pharmacophores for resolution biology. Prostaglandins Leukot Essent Fatty Acids. 2010; 82(4-6): 327– 332.  Nutrient Effects on Inflammation Fats TFA consumption is inherently proinflammatory, and clinical trials and observational studies have linked it to increased markers of systemic inflammation, including tumor necrosis factor (TNF), CRP, and interleukin 6. TFAs can interfere with the metabolism of essential fatty acids involved in inflammatory pathways. SimopoulosAP. Evolutionary aspects of the dietary omega-6:omega-3 fatty acid ratio: medical implications. World Rev Nutr Diet. 2009; 100: 1– 21. SimopoulosAP. The importance of the ratio of omega-6/omega-3 essential fatty acids. Biomed Pharmacother. 2002; 56(8): 365– 379. SimopoulosAP. Omega-6/omega-3 essential fatty acid ratio and chronic diseases. Food Reviews International. 2004; 20(1): 77– 90. IbargurenMLopezDEscribaP. The effect of natural and synthetic fatty acids on membrane structure, microdomain organization, cellular functions and human health. Biochemica et Biophysica Acta. 2014; 1838(6): 1518– 1528. SerhanCN. Resolution phase of inflammation: novel endogenous anti-inflammatory and proresolving lipid mediators and pathways. Annu Rev Immunol. 2007; 25: 101– 137. LevyB. Resolvins and protectins: natural pharmacophores for resolution biology. Prostaglandins Leukot Essent Fatty Acids. 2010; 82(4-6): 327– 332.  Nutrient Effects on Inflammation Polyphenols Polyphenols can neutralize free radicals by conjugated double bonds with a free hydroxyl group and activate endogenous antioxidant defense through regulating Nrf2, a cellular redox transcription factor involved in detoxification. GonzalezRBallesterILopez-PosadasR et al. Effects of flavonoids and other polyphenols on inflammation. Crit Rev Food Sci Nutr. 2011; 51(4): 331– 362. SantangeloCVariRScazzocchioB et al. Polyphenols, intracellular signaling and inflammation. Ann Ist Super Sanita. 2007; 43(4): 394– 405. BiesalskiHK. Polyphenols and inflammation: basic interactions. Curr Opin Clin Nutr Metab Care. 2007; 10(6): 724– 728. ReulandDJKhademiSCastleCJ et al. Upregulation of phase II enzymes through phytochemical activation of Nrf2 protects cardiomyocytes against stress. Free Radic Biol Med. 2013; 56: 102– 111. RahmanIBiswasSKirkhamP. Regulation of inflammation and redox signaling by dietary polyphenols. Biochem Pharmacol. 2006; 72(11): 1439– 1452.  Nutrient Effects on Inflammation Polyphenols Polyphenols also inhibit inflammation by activating gene transcription factors that hinder the activation of NF-kB, a transcription factor responsible for activating inflammatory pathways. Evidence suggests that polyphenols contribute to reducing inflammation, and their deficiency in the diet may be detrimental to health. GonzalezRBallesterILopez-PosadasR et al. Effects of flavonoids and other polyphenols on inflammation. Crit Rev Food Sci Nutr. 2011; 51(4): 331– 362. SantangeloCVariRScazzocchioB et al. Polyphenols, intracellular signaling and inflammation. Ann Ist Super Sanita. 2007; 43(4): 394– 405. BiesalskiHK. Polyphenols and inflammation: basic interactions. Curr Opin Clin Nutr Metab Care. 2007; 10(6): 724– 728. ReulandDJKhademiSCastleCJ et al. Upregulation of phase II enzymes through phytochemical activation of Nrf2 protects cardiomyocytes against stress. Free Radic Biol Med. 2013; 56: 102– 111. RahmanIBiswasSKirkhamP. Regulation of inflammation and redox signaling by dietary polyphenols. Biochem Pharmacol. 2006; 72(11): 1439– 1452.  Nutrient Effects on Inflammation Caloric Intake Chronic inflammation is affected by caloric intake, particularly excess caloric intake in sedentary individuals Adipose tissue directly contributes to chronic inflammation through the release of proinflammatory cytokines such as TNF-α and interleukin 6 as adipocytes enlarge Excess adipose tissue leads to other proinflammatory alterations including increased insulin resistance and sympathetic nervous system activation RajalaMWSchererPE. Minireview: the adipocyte— at the crossroads of energy homeostasis, inflammation, and atherosclerosis. Endocrinology. 2003; 144: 3765– 3773. CancelloRHenegarCViguerieN et al. Reduction of macrophage infiltration and chemoattractant gene expression changes in white adipose tissue of morbidly obese subjects after surgery induced weight loss. Diabetes. 2005; 54: 2277– 2286. XuHYBarnesGTYangQ et al. Chronic inflammation in fat plays a crucial role in the development of obesity-related insulin resistance. J Clin Invest. 2003; 112: 1821– 1830. EngeliSNegrelRSharmaAM. Physiology and pathophysiology of the adipose tissue renin-angiotensin system. Hypertension. 2000; 35: 1270– 1277. XydakisAMCaseCCJonesPH et al. Adiponectin, inflammation, and the expression of the metabolic syndrome in obese individuals: the impact of rapid weight loss through caloric restriction. J Clin Endocrinol Metab. 2004; 89: 2697– 2703.  Nutrient Effects on Inflammation Caloric Intake Calorie restriction with adequate nutrition intake has important anti-inflammatory effects by reducing the number of adipocytes in the body and lowering the level of proinflammatory adipokines and cytokines Calorie restriction improves insulin sensitivity, reduces plasma glucose levels, and lowers the production of advanced glycation end products which dampens the activation of pathways that promote inflammation RajalaMWSchererPE. Minireview: the adipocyte— at the crossroads of energy homeostasis, inflammation, and atherosclerosis. Endocrinology. 2003; 144: 3765– 3773. CancelloRHenegarCViguerieN et al. Reduction of macrophage infiltration and chemoattractant gene expression changes in white adipose tissue of morbidly obese subjects after surgery induced weight loss. Diabetes. 2005; 54: 2277– 2286. XuHYBarnesGTYangQ et al. Chronic inflammation in fat plays a crucial role in the development of obesity-related insulin resistance. J Clin Invest. 2003; 112: 1821– 1830. EngeliSNegrelRSharmaAM. Physiology and pathophysiology of the adipose tissue renin-angiotensin system. Hypertension. 2000; 35: 1270– 1277. XydakisAMCaseCCJonesPH et al. Adiponectin, inflammation, and the expression of the metabolic syndrome in obese individuals: the impact of rapid weight loss through caloric restriction. J Clin Endocrinol Metab. 2004; 89: 2697– 2703.  Nutrient Effects on Inflammation Caloric Intake Calorie restriction enhances endogenous corticosteroid production, promoting anti-inflammatory effects in the body Calorie restriction may increase parasympathetic tone, contributing to the suppression of cytokine-mediated inflammation. RajalaMWSchererPE. Minireview: the adipocyte— at the crossroads of energy homeostasis, inflammation, and atherosclerosis. Endocrinology. 2003; 144: 3765– 3773. CancelloRHenegarCViguerieN et al. Reduction of macrophage infiltration and chemoattractant gene expression changes in white adipose tissue of morbidly obese subjects after surgery induced weight loss. Diabetes. 2005; 54: 2277– 2286. XuHYBarnesGTYangQ et al. Chronic inflammation in fat plays a crucial role in the development of obesity-related insulin resistance. J Clin Invest. 2003; 112: 1821– 1830. EngeliSNegrelRSharmaAM. Physiology and pathophysiology of the adipose tissue renin-angiotensin system. Hypertension. 2000; 35: 1270– 1277. XydakisAMCaseCCJonesPH et al. Adiponectin, inflammation, and the expression of the metabolic syndrome in obese individuals: the impact of rapid weight loss through caloric restriction. J Clin Endocrinol Metab. 2004; 89: 2697– 2703.  Diet Standard American Diet Anti-Inflammatory Diet Vegetables Fewer vegetables High consumption of vegetables: large diversity, and fruits including variety of colors to increase phytonutrients Protein Red meat Plant sources of protein: legumes, soy, nuts, and source seeds Dairy More fatty fish and some lean animal protein Carbohydra Refined carbohydrates; high- Whole grains in small amounts, high fiber, tes fructose corn syrup and added reduced refined carbohydrates sugar Fewer whole grains https://aspenjournals.onlinelibrary.wiley.com/doi/full/10.1177/0884533617700353?casa_token=qOqVaAO9uhIAAAAA% 3A JxmRGRM37F2rykfM5hYsYmcOb7JeZVh1BC9F4aSlYpzxZ8Ww9FzCoNQVSWgOtlm_RPyf8awwZ0KXSnCKJ6E  Diet Standard American Diet Anti-Inflammatory Diet Dairy High-fat dairy sources Fats Solid added fats, such as butter and Olive oil for added fat source sour cream Other Soda and added-sugar beverages Spices: turmeric, garlic, ginger, and other anti- features inflammatory herbs and spices Cultural Eating on the run, overeating Mindful eating approach; quality over quantity https://aspenjournals.onlinelibrary.wiley.com/doi/full/10.1177/0884533617700353?casa_token=qOqVaAO9uhIAAAAA% 3AJxmRGR M37F2rykfM5hYsYmcOb7JeZVh1BC9F4aSlYpzxZ8Ww9FzCoNQVSWgOtlm_RPyf8awwZ0KXSnCKJ6E  Vegetables and Fruits An anti-inflammatory diet focuses on consuming a large portion of vegetables and fruits. Vegetables and fruits are lower in caloric density and rich in beneficial nutrients, including vitamins, minerals, and phytonutrients. Vegetables and fruits should be consumed in large volumes, with every meal, and in a variety of colors and types. Polyphenols found in fruits and vegetables provide their anti- inflammatory properties. SearsB. Anti-inflammatory diets. J Am Coll of Nutr. 2015; 34(suppl 1): 14– 21.GallandL. Diet and inflammation. Nutr Clin Pract. 2010; 25(6): 634– 640.GrottoDZiedE. The standard American diet and its relationship to the health status of Americans. Nutr Clin Pract. 2010; 25(6): 603– 612.  Vegetables and Fruits Nonstarchy fruits and vegetables are high in fiber, reducing their glycemic index relative to other carbohydrates. An ideal anti-inflammatory diet should contain up to two- thirds of the total food volume in vegetables and fruits. Diets high in fruits and vegetables have been shown to correlate with lower levels of inflammatory markers in the blood. Vegetables should be prioritized over fruits due to their lower glycemic index. SearsB. Anti-inflammatory diets. J Am Coll of Nutr. 2015; 34(suppl 1): 14– 21.GallandL. Diet and inflammation. Nutr Clin Pract. 2010; 25(6): 634– 640.GrottoDZiedE. The standard American diet and its relationship to the health status of Americans. Nutr Clin Pract. 2010; 25(6): 603– 612.  Vegetables and Fruits Organic vegetables are preferred as they contain lower levels of pesticides and higher levels of antioxidants. Frozen fruits and vegetables, which are picked at peak ripeness and blanched immediately, can be a good alternative when eaten out of season. Vegetables can be easily prepared with small amounts of olive oil and anti- inflammatory spices. SearsB. Anti-inflammatory diets. J Am Coll of Nutr. 2015; 34(suppl 1): 14– 21.GallandL. Diet and inflammation. Nutr Clin Pract. 2010; 25(6): 634– 640.GrottoDZiedE. The standard American diet and its relationship to the health status of Americans. Nutr Clin Pract. 2010; 25(6): 603– 612.  Protein Sources Protein in an anti-inflammatory diet should come primarily from plant-based sources, with some fish and small amounts of lean natural meats. The type of fat in the protein source determines whether it is anti-inflammatory or pro-inflammatory. Animal protein has higher levels of pro-inflammatory ω-6 FAs, while anti- inflammatory protein sources have higher levels of ω-3 FAs. Fresh-water fatty fish, such as salmon, mackerel, halibut, sardines, and herring, are good sources of anti-inflammatory protein due to their high levels of ω-3 FAs. KozarskiMKlausAJakovljevicD et al. Antioxidants of edible mushrooms. Molecules. 2015; 20(10): 19489– 19525.GuillamonEGarcía-LafuenteALozanoM et al. Edible mushrooms: role in the prevention of cardiovascular diseases. Fitoterapia. 2010; 81(7): 715– 723.  Protein Sources Wild-caught fish and naturally grazing cattle are better sources of anti-inflammatory protein due to their lower ω-6:ω-3 ratios. Organically produced dairy and meats also contain higher levels of anti-inflammatory ω-3 FAs compared to non-organic sources. Cooking method is important, as high- temperature cooking or charring can produce pro-inflammatory compounds and increase cancer risk. KozarskiMKlausAJakovljevicD et al. Antioxidants of edible mushrooms. Molecules. 2015; 20(10): 19489– 19525.GuillamonEGarcía-LafuenteALozanoM et al. Edible mushrooms: role in the prevention of cardiovascular diseases. Fitoterapia. 2010; 81(7): 715– 723.  Protein Sources Soy legumes, non-soy-based legumes, and mushrooms are excellent sources of plant-based protein with anti-inflammatory properties. Soy has been shown to decrease inflammatory markers, while non-soy-based legumes have an inverse relation to high-sensitivity CRP. Phytoestrogens in soy, daidzein, and genistein contribute to its anti-inflammatory properties. Mushrooms contain polyphenols and other anti- inflammatory phytonutrients and should be cooked to reduce natural carcinogens and release more nutrients. KozarskiMKlausAJakovljevicD et al. Antioxidants of edible mushrooms. Molecules. 2015; 20(10): 19489– 19525.GuillamonEGarcía-LafuenteALozanoM et al. Edible mushrooms: role in the prevention of cardiovascular diseases. Fitoterapia. 2010; 81(7): 715– 723.  Carbohydrates An anti-inflammatory diet includes various types of carbohydrates, including whole grains. Whole grain carbohydrates with a low glycemic index are essential in an anti-inflammatory diet. It is important to choose whole grains that have all their original parts present, such as bran, germ, and endosperm. AjaniUAFordESMokdadAH. Dietary fiber and C-reactive protein: findings from national health and nutrition examination survey data. J Nutr. 2003; 134.5: 1181– 1185.KingDEEganBMGeeseyME. Relation of dietary fat and fiber to elevation of C-reactive protein. Am J Card. 2003; 92(11): 1335– 1339. JenkinsDJAKendallCWMarchieA et al. Type 2 diabetes and the vegetarian diet. Am J Clin Nutr. 2003; 78(3): 610S– 616S.  Carbohydrates Refined grains, which strip out much of the nutrients, should be avoided. Grains that have been processed via cracking or crushing should be limited due to their high glycemic index. Examples of whole grains include buckwheat, barley, rye, and wild rice. Whole grains are high in fiber, which has been shown to reduce inflammatory markers. AjaniUAFordESMokdadAH. Dietary fiber and C-reactive protein: findings from national health and nutrition examination survey data. J Nutr. 2003; 134.5: 1181– 1185.KingDEEganBMGeeseyME. Relation of dietary fat and fiber to elevation of C-reactive protein. Am J Card. 2003; 92(11): 1335– 1339. JenkinsDJAKendallCWMarchieA et al. Type 2 diabetes and the vegetarian diet. Am J Clin Nutr. 2003; 78(3): 610S– 616S.  Healthy Fats The anti-inflammatory diet emphasizes on anti- inflammatory fats, which can be present in fruits, vegetables, and protein or added through supplementation of ω-3 FAs. Cold-water fish like salmon, sardines, and anchovies are some of the protein sources with high levels of ω-3 FAs. Fish oil, which is a potent inhibitor of inflammation, can be added as a supplement to an anti- inflammatory diet with a recommended dosage of 1000 mg three times a day. RongYChenLZhuT et al. Egg consumption and risk of coronary heart disease and stroke: dose-response meta-analysis of prospective cohort studies. BMJ. 2013; 346: e8539. MozaffarianDPischonTHankinsonSE et al. Dietary intake of trans fatty acids and systemic inflammation in women. Am J Clin Nutr. 2004; 79.4: 606– 612. BulottaSCelanoMLeporeSMMontalciniTPujiaARussoD. Beneficial effects of the olive oil phenolic components oleuropein and hydroxytyrosol: focus on protection against cardiovascular and metabolic diseases. J Transl Med. 2014; 12: 219.  Healthy Fats Flax seeds, chia seeds, walnuts, and hemp seeds are plant sources of alpha-linolenic acid, which is a good source of ω-3 FAs. Trans fats, which are proinflammatory, should be avoided, and olive oil is the best choice when used at low temperatures for cooking, while oils like soybean, cottonseed, peanut, and corn oil should be avoided as they are proinflammatory. RongYChenLZhuT et al. Egg consumption and risk of coronary heart disease and stroke: dose-response meta-analysis of prospective cohort studies. BMJ. 2013; 346: e8539. MozaffarianDPischonTHankinsonSE et al. Dietary intake of trans fatty acids and systemic inflammation in women. Am J Clin Nutr. 2004; 79.4: 606– 612. BulottaSCelanoMLeporeSMMontalciniTPujiaARussoD. Beneficial effects of the olive oil phenolic components oleuropein and hydroxytyrosol: focus on protection against cardiovascular and metabolic diseases. J Transl Med. 2014; 12: 219. Clinical case A 35-year-old female patient with a history of low back pain presents to your clinic complaining of persistent pain despite current medication therapy. Which of the following dietary changes is most likely to have a beneficial effect on her symptoms? A) Increasing intake of processed carbohydrates with high glycemic index B) Avoiding all sources of fats, including omega-3 fatty acids C) Including more cold-water fish in the diet to increase intake of omega-3 fatty acids D) Adding trans fats from vegetable oils to the diet REFERENCES CDC: https://www.cdc.gov/ Online source Center for Disease Control and Prevention Updates 2022 Prousky J. Textbook of Integrative Clinical Nutrition. CCNM Press Inc.; 2012. Katz D. Nutrition in Clinical Practice. 2nd Edition. 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Journal of the American College of Nutrition. 2015 Sep 15;34(sup1):14-21. Wirth MD, Hébert JR, Shivappa N, Hand GA, Hurley TG, Drenowatz C, McMahon D, Shook RP, Blair SN. Anti- inflammatory Dietary Inflammatory Index scores are associated with healthier scores on other dietary indices. Nutrition research. 2016 Mar 1;36(3):214-9. MozaffarianDClarkeR. Quantitative effects on cardiovascular risk factors and coronary heart disease risk of replacing partially hydrogenated vegetable oils with other fats and oils. Eur J Clin Nutr. 2009; 63(suppl 2): S22– S33. ZapolskaDDBrykDOlejarzW. Trans fatty acids and atherosclerosis-effects on inflammation and endothelial function. J Nutr Food Sci. 2015; 5(6): 426– 432. Lopez-GarciaESchulzeMBMeigsJB et al. Consumption of trans fatty acids is related to plasma biomarkers of inflammation and endothelial dysfunction. J Nutr. 2005; 135: 562– 566. BaerDJJuddJTClevidenceBA et al. Dietary fatty acids affect plasma markers of inflammation in healthy men fed controlled diets: a randomized crossover study. Am J Clin Nutr. 2004; 79(6): 969– 973. THANK YOU!