Nutrition

Nutrition Micronutrients and Macronutrients • Micronutrients • Macronutrients • Nutrients we need in small amounts • Nutrients we need in large amounts • Usually measured in milligrams (mg) or micrograms (mcg) • Usually measured in grams (g) • Contain micronutrients • Essential vitamins and minerals • Examples: • Examples: • Calcium • Vitamin C • Iron • Zinc • Vitamin D • Carbohydrates (CHO) • Fats • Proteins • Fiber • Water Energy Metabolism • • Kcal (“Calorie”): amount of energy required to raise the temperature of 1 Kg of water by 1℃ • Proteins: 4 Kcal/g • CHOs: 4 Kcal/g • Fats: 9 Kcal/g Caloric Control • Caloric intake is controlled by appetite • Hunger and satiety centers in hypothalamus • • • • Calorie use is controlled by metabolic rate • Thyroid hormones [controls all things metabolism aka all the chemical reactions in our body] • Activity levels 90% of energy is stored in adipose tissue • White adipose tissue • Brown adipose tissue [more common in newborns] Hunger, Appetite, and Satiety • Hunger: motivates the consumption of food • Orexigenic hormones stimulates appetite • Satiety: absence of hunger; the sensation of feeling full • Appetite: the desire to eat food • All are controlled by a complex group of neurohormones, many of which are produced in the gastrointestinal tract • • Anorexigenic hormones are appetite depressors Neurohormones and Food Intake • Two centers in the brain interact with various hormones and neurotransmitters to help control food intake and energy output. • These centers receive neural input from the gastrointestinal tract that provides information about stomach filling, chemical signals from nutrients in the blood, and input from the cerebral cortex regarding the smell, sight, and taste of the food. Protein Energy Malnutrition – Primary • Marasmus – severe malnutrition, energy deficient = low calories • Total deficiency of ALL Macronutrients [proteins, carbs, fats] • “Wasted” emaciated [weak] appearance • Wrinkled skin, dry hair, ↓ VS • No subcutaneous fat, muscle wasting • Adaptive response to starvation • Starts off w/ taking muscle then fat • Immune system impairment → Body depends on nutrients to make the immune cells • Growth failure in children • Excellent to voracious appetite when food is available [basically they’ll eat a lot if presented w/ food but won’t search for it on their own] • Kwashiorkor – severe malnutrition by protein deficient • Deficient protein • They’re intaking proper amount of calories but getting nutrition from all the wrong sources [bad eating habits, high carbs and fats] • More severe form of malnutrition (maladaptive response – learned behaviors of coping that becomes a habit, such as drinking alcohol when sad or eating tons of junk food when stressed) • Hypoalbuminemia → Edema • • Distended abdomen → firm • Pitting edema in extremities • Discolored hair and skin [light pigments in skin, rusty colored hair] • Apathy [lack of interest], irritability, poor appetite [even w/ access to food they don’t eat] • SQ fat normal (caloric intake OK) • Anemia → Tachycardia [heart trying to overwork to get blood to tissues] • Fatty liver [need proteins to transport fat out of liver via apoprotein = fatty built = fatty liver] • Skin lesions • • Albumin → Plasma protein, keeps fluid in intravascular space → Low protein = Low albumin → less pull of water back into intravascular space = build up of fluid in interstitial space [space between tissues, yes its part of the ECF] Due to lack of HGB because of the lack of protein → Lack of O2 = Anemia Cachexia – secondary energy protein deficiency • Muscle wasting similar to marasmus • Later loss of SC fat • Occurs with or after chronic illness • Not responsive to nutritional therapy • Cancer, AIDs, respiratory disorders, etc. Malnutrition Associated with Trauma and Illness • Hypermetabolic states – Trauma, burns, sepsis & Chronic illness • During illness and trauma metabolism increases → Increases rate of protein & fat breakdown • Protein rebuilding disrupted • Serum proteins decrease = malnutrition • • Decrease in immune cells → Poor wound healing, decrease in the ability to fight off infection, GI tract loses filaments which negatively impacts the absorption of nutrients Chronic illnesses • COPD, CHF, cancer, AIDS • • • • • Undernutrition, which includes stunting (low height-for-age) and underweight (low weight-for-height) • Overweight - overnutrition, obesity and diet-related noncommunicable diseases (heart disease, stroke, diabetes) • Micronutrient-related malnutrition, which includes micronutrient deficiencies (a lack of important vitamins and minerals) or micronutrient excess. Food Insecurity • Skipped meals and cheap non-nutritious food • Social determinant of health • Disproportionately affects lower SES • Low-quality food available [note how whole foods are only seen in wealthy, suburban neighborhoods] • Lack of food overall Malnutrition in Children • First 1000 days of life is critical • Nutrition during the first 1000 days of life is a fundamental building block to their physical, cognitive, and mental growth • Unable to “catch-up” → No amt of foods in the world can make up for the lost during this timeframe • Key nutrients: protein, zinc, choline, folate, iodine, Vitamins A, D, B12 • If malnourished during this time → low IQ, increased risk of obesity, diabetes, HTN • • Time of conception to the 2nd birthday • Stunts neurodevelopment • Stunts physical growth • Increases risk for long-term health complications Malnutrition in Young Adults • Overweight and obesity • Reduces productivity and life expectancy • Increases risk of chronic health conditions • • Can lead to cachexia Malnutrition in the U.S. CV disease, HTN, obesity, diabetes, gallbladder diseases, some cancers Malnutrition in Older Adults • Increased risk as a result of aging • Limited income • • Increased risk of hospitalization • Increased risk for falls and fractures • Weakened immune system • Increased mortality Most Common Nutrient Deficiencies in the U.S. • Calcium → Bone strength, nerve communications, contractions, muscular movements • Caffeine and alcohol decrease calcium absorption • Need vitamin D to absorb calcium • Essential fatty acids • Folic acid → healthy RBC & important in pregnancy, prevent anemia and heart disease • Iron • Magnesium → regulates muscle & nerve function • Vitamin A → Skin cells, optimal vision, immune cells • Less intake of veggies, alcohol consumption • Deficient = increased risk for infections • Children under 5 need lots of vitamin A • Vitamin B12 → RBC, enhances neuro function, building block for DNA • Vitamin C → Antioxidant less cellular damage by free radicals, hormone building block, helps absorption of iron, regulates collagen production • Vitamin D → SUN produces it, regulate Calcium absorption, supports bone, CV heart, immune function • • Vegans, patients w/ GI issues, heart burn meds are at risk for B12 deficiency Deficiency can lead for Scurvy – s/s include bleeding gums, bruising, weakness, fatigue, & rash Food Sources of Nutrients • Calcium: • • Dairy products (milk, yogurt, or cheese) • Sardines • calcium-fortified orange juice • dark green leafy vegetables Folic acid: • • Eggs [remember it’s a good source of folic acid and iron but can also inhibit absorption of iron] • Leafy green vegetables • Fruits • Dried beans and peas Essential fatty acids: • Cold water fish Flaxseed Olive oil • • • Iron: • • Fortified dairy products • Fatty fish • Egg yolks • Red meat • Poultry • Fish • Beans or legumes Magnesium: • • pumpkin seeds • Leafy green vegetables • Beans, legumes, and whole grains Vitamin A: • • Spinach • Chard • Sweet potatoes • Squash, pumpkins, carrots • Mangoes, papayas • Eggs and milk Vitamin B12: • • Meat, fish, poultry • Eggs, and dairy products Vitamin C: • • Citrus fruits • Broccoli • Cantaloupe • Cauliflower • Kiwi • Sweet potatoes • Tomatoes • Kale, bell peppers • Strawberries Vitamin D: • • • • Fatty fish Beef liver Egg yolks, or a number of fortified foods It’s almost impossible to achieve optimal vitamin D levels solely through diet Assessing Nutritional Status • • • Body weight • Body mass index • Percentage of body fat • Waist : hip ratio Obesity • Energy imbalance (consumption > expenditure) • Contributing causes • Genetics • Metabolism rate • Behavior • Environment • Culture • Low SES Upper- vs. Lower-Body Obesity More complications • Clinical Complications of Obesity Pharmacotherapies Used to Treat Obesity APPETITE SUPPRESSANTS • Liraglutide “Saxenda” • • • • • • Glucagon-like peptide-1 receptor agonist • Stimulates insulin secretion and reduces glucagon secretion → delays gastric emptying. Subcutaneous administration Contraindicated in patients with personal or family history of MTC [thyroid cancer] and in patients with multiple endocrine neoplasia syndrome type 2 Can cause acute pancreatitis Increases risk of hypoglycemia Requires a lot of patient education • Naltrexone/bupropion “Contrave” • • • • • Combination drug • Aminoketone and opioid antagonist PO Contraindicated: uncontrolled HTN; seizures; opioid use May cause suicidal thoughts Multiple drug interactions • Phentermine + Topiramate “Qsymia” • • • • • • Combination drug • Anorexiant (sympathomimetic) and anticonvulsant PO Stimulant effect Avoid abrupt discontinuation Contraindicated with severe hepatic or renal impairment Controlled substance: Drug is only available through certified pharmacies ANTI-OBESITY MEDS • Orlistat “Alli” “Xenical” • • • • • Lipase inhibitor • Forms a bond with active site of gastric and pancreatic lipases, inactivating them. As a result, enzymes can’t hydrolyze dietary triglycerides into absorbable free fatty acids and monoglycerides. The undigested triglycerides are not absorbed, resulting in caloric deficit. PO May cause anal leakage or incontinence Monitor liver function Decreases absorption of fat-soluble vitamins (A, D, E) • Nutraceuticals • Alternative to pharmaceuticals which claims physiological benefits Usually called “dietary supplement” in US Contain vitamins, minerals, herbs or other botanicals Do not need FDA approval in the US • may only be marketed to support the structure or function of the body, and may not claim to treat a disease or condition • > 70% of adults report taking at least once in last 12 months Common Nutraceuticals • • • • • • • • • • Vitamin and mineral supplements Fiber supplements Omega-3 polyunsaturated fatty acids Chondroitin and glucosamine Herbals and botanicals Benefits of nutraceuticals • • • • • Evidence suggests that many are safe Can provide supplementation to prevent vitamin/mineral deficiencies Usually cheaper than pharmaceuticals Do not require prescription May support health • Risks of nutraceuticals • • • • Not disclosing usage to healthcare providers Interactions with medications • Goldenseal has been shown to inhibit two major metabolic enzymes, CYP2D6 and CYP3A4, which are responsible for metabolism of more than one-half of currently used pharmaceutical agents • St. John's wort has been shown in multiple human studies to be a potent inducer of CYP3A4 Few poorly conducted studies to determine efficacy Contamination