Nutrition

• marasmus: calorie malnutrition
• kwashiorkor: protein malnutrition - importance of protein quality as well as quantity

• failure to grow
• behavioral changes
• edema (kwashiorkor)
• dermatitis
• changes in hair
• loss of appetite
• liver enlargement
• anemia
• osteoporosis

• increased caries
• enamel hypoplasia
• salivary gland hypofunction
• delayed eruption

• primary disorder: dietary deficiencies
• secondary disorder: secondary manifestation of an underlying primary condition or disorder

• -disorder of the hematopoietic system; the most common effect of nutritional deficiency. *any factor that decreases hematopoiesis can cause anemia*
• - gold standard: low total body red cell mass
• - practical standard: low hemoglobin concentration or hematocrit
• - Males Hb<14g/dl, Hct<41%
• - Females Hb<12g/dl, Hct<36%

• Iron deficiency
• Problem: rate of dietary uptake is close to rate of loss
• - 15 mg iron/day in the diet but only 4-7% is absorbed
• men have 1 gm stored iron (liver, spleen, BM)
• women have 0.5 gm stored iron

• dietary factors: availability of iron from different food sources and mixtures
• malabsorption: 1/3 of pts with IBS have recurrent anemia & 30% or more who've had a partial gastrectomy will develop iron deficiency anemia
• blood loss: menses, GI bleeding
• Increased demand: pregnancy, lactation, growth in children
• Congenital: attransferrinemia (transferrin used to transport iron in blood; this is secondary disease)

• Initially iron is metabolized from reticulo-endothelial stores and increased intestinal absorption occurs.
• total iron stores are depleted and serum levels fall
• In severe cases peripheral red blood cells become smaller (microcytic) and their hemoglobin content is reduced (hypochromic)
• *Hypochromatic Microcytic Anemia: most commonly associated w iron deficiency

• presence of abnormal WBCs (abnormal nuclei) as well as abnormal RBCs (larger cells: macrocytic).
• In severe cases, megaloblasts (abnormal RBC precursors) may be present
• - consequence of disordered DNA synthesis
• Associated deficiencies:
• - Folate (dietary deficiency; malabsorption - celiac disease, drugs - methotrexate, anticonvulsants, ethanol, etc, liver disease)
• - Cobalamin (B12) - lack of intrinsic factor (PERNICIOUS ANEMIA), malabsorption, parasitic - fish tapeworms
• B6 (pyridoxine) - alcoholism

• methotrexate
• AZT
• liver disease
• ethanol (most common)

• hemolytic anemia (decreased RBC lifespan)
• aplastic anemia (failure of marrow to produce new cells)

• soft tissues of the oral cavity are made up of epithelial cells that have rapid rates of replication, metabolism, and differentiation which require a steady supply of nutrients
• typically these cells turn over every 3-7 days
• makes tissues of oral cavity a sensitive indicator of adequate nutritional status

False. In developed countries acute or primary vitamin deficiencies are rare and probably over diagnosed. Vitamin deficiencies are more commonly secondary disorders associated w malabsorption conditions and chronic alcoholism.

• Vit A: retinoids; fat soluble compounds derived from B-carotene
• - deficiency causes night blindness due to decreased rhodopsin. Also skin lesions (rash on extremities w punctate erythematous lesions) & Bitot's spots on eye
• also decreased resistance to infections

• required for bone mineralization
• Rickets- deficiency in children --> failure to mineralize osteoid matrix
• Osteomalacia - deficiency in adults that results in decreased appositional bone growth
• Increased incidence of colon and prostate ca

• Tocopherols - act as anti-oxidants and decrease the peroxidation of fatty acids
• Very rare
• Occurs as secondary disorder in conditions w fat malabsorption (CF, pancreatitis, cholestasis (bile-flow obstruction))
• causes neurological disorder characterized by sensory loss, spinocerebellar ataxia, and retinitis pigmentosa (due to free radical mediated neuronal damage)
• mutations in gene encoding Vit E binding protein- tocopherol transfer protein (TTP) result in ataxia

• Phylloquinone - required for production of clotting factors (II, VII, IX, X)
• characterized by elevated clotting times (impaired coagulation), principally due to low prothrombin
• *Normal platelet count, elevated prothrombin time (PT), elevated Partial thromboplasin time (PTT)
• In adults occurs as 2ndary disorder (associated w use of anti-coagulants, liver disease, celiac disease, pancreatic disease, obstructive jaundice)
• Vit K produced by normal intestinal bact
• In newborns deficiency can occur b/c placental transfer is poor, breast milk low in Vit K, GI tract is nearly sterile

• Thiamine
• BERIBERI: "dry" - NS damage, "wet" - cardiomyopathy
• peripheral neuropathy that affects sensation in legs (demylination of peripheral nerves)
• in more severe cases of Korsakoff syndrome (impaired ocular motility, ataxia, mental confusion), edema and cardiomyopathy can occur

• Nicotinamide, Vit B3
• PELLAGRA- "rough skin"
• Most commonly associated w alcoholism
• Primary deficiencies associated w diets of a single, low quality protein source (ie corn)
• In developed countries, associated w alcoholism
• *3 D's: dermatitis, diarrhea, dementia -->
• - hyperketosis & vesiculation of skin (skin on neck, chest, and back of hands become brown and scaly)
• - nausea, vomitting, diarrhea
• - insomnia, depression, confusion, and rapid mood change

• Vit B12
• widely distributed in foods & produced by intestinal bact, so deficiencies almost always secondary disorders associated w gastric atrophy (and decreased uptake via intrinsic factor), microbial proliferation (AIDS), long-term antacids, chronic alcoholism, idiopathic (age-related)
• Primary clinical symptoms: pernicious anemia, polyneuropathy, sclerosis of spinal cord, atrophy of some mucous tissues (ie tongue papillae)

• Vit C
• SCURVY
• required for maturation of collagen --> deficiency results in inability to produce mature collagen (CT disorder)
• Inability to synthesize osteoid & dentin
• decreased wound healing and loss of blood vessel wall integrity
• fatigue, purpura, dermatitis --> in severe oral lesions

• Vit B6
• associated w megaloblastic anemia
• severe cases lead to peripheral neuropathy
• primary deficiencies rare, but sub-clinical deficiencies may be more common
• *most commonly associated w Multivitamin B deficiencies in malnutrition and alcoholism

• Na
• K
• Cl
• Mg

• Hypothyroidism & goiter
• essential for synthesis of thyroid hormones

• required for bone mineralization
• RDA for adults is 800 mg/day
• doses above RDA in elderly delay bone loss
• low dietary calcium associated w increased risk of periodontal disease

• Zinc - deficiency in total parenteral nutrition; can be secondary to acrodermatitis enteropathica (autosomal recessive trait). Characterized by alopecia, dermatitis, diarrhea
• Copper - deficiency associated w severe malabsorption syndromes or total parenteral nutrition. Resembles iron deficiency anemia and osteoporosis
• Fluoride - levels greater than 1 ppm can cause mottling of teeth; chronic fluorosis can produce abnormal calcification of tendons and ligaments

• •Many adults in the US receive less than the RDA for a variety of vitamins and minerals but do not exhibit overt deficiency symptoms.
• • Hundreds of retrospective studies have indicated some value for vitamin supplements, however.........
• • Recent large prospective studies have so far not shown any health benefit for healthy individuals who take vitamin supplements.

• Vit A: acute & chronic effects; intake 6-7x RDA can produce decreased bone growth, bone pain, liver damage (hepatotoxicity) & vision changes
• Vit D: hypercalcemia; severe cases - cardiomyopathy & renal damage associated abnormal calcification
• Vit E: daily doses +800 IU cause elevated serum lipids (hypertriglyceridemia) and depressed thyroxine (rare). *main effect: antagonize Vit K (increased bleeding times)

• • Nicotinic acid - used in large doses to treat hypercholesterolemia; skin flushing, itching & skin rashes. Some altered liver function (requires hundreds of mgs)
• • Thiamine - when injected, hypersensitivity reaction at site of injection
• • Vitamin C - G.I. disturbances & skin rash (very rare); ppl w pre-existing cystinuria, oxalosis, or hyperuricemia can develop kidney stones
• • Folic acid - may cause birth defects
• • Pyridoxine - sensory neuropathy

• Colon
• Endometrium
• Breast
• Ovary
• Prostate
• Kidney
• ** there does NOT appear to be a clear and simple relationship between dietary fiber and colon cancer**

• • Controls- epidemiologists have usually tried to associate exposure of a single variable compared with unexposed controls. However, in most nutritional studies there are no unexposed controls.
• • Multiple variables- some nutrients are highly correlated (so- called co-correlates).
• • Animal studies-
• -rarely duplicate the nutritional status of humans
• -are real physiological differences between species
• -must compress what happens in years to weeks or
• months
• • Accurate reporting- human diets are complex and constantly changing. Most individuals cannot accurately recall meaningful details for any reasonable period of time – limits the usefulness of “controlled case studies”.

The only clear association between these substances and human cancer is the conversion of nitrates to nitrosamines (known carcinogens).

True.

• Aflatoxins.
• Aflatoxins are among the most potent carcinogens that have been tested. Peanut butter can contain an average of 2 ppb aflatoxin.

Heterocyclic amines (HCAs)

Yes, especially of colon, rectum, and prostate, although mechanism is unclear (could be unrelated factors like SES as well)

• False. • Incidence of stomach cancer in Japan is high while stomach cancer rates in US are low and declining (has decreased 4-fold since 1930).
• • There is epidemiological evidence for a relationship between the intake of highly salted foods and stomach cancer
• There appears to be a correlation between the decline in stomach cancer and decline in use of salt-pickling to preserve food.

• Aerodigestive cancers: (oral cavity, pharynx, esophagus, larynx) & liver cancer
• Weak association w breast ca, colorectal, and lung ca

• plant derived foods (veggies, fruits, whole grains) that contain 1000s of chemically diverse phytochemicals
• • Carotenoids – carotene, lycopene, lutein
• • Terpenes – perillyl alcohol
• • Indoles – indole-3-carbinol
• • Soy isoflavones – genestein, daidzein
• • Polyphenols – curcumin
• • Organosulphur compounds – diallyl sulphide

• • There is a statistical relationship between being overweight and decreased longevity.
• • What is obesity? >/= 25% body fat in men, >/= 30% body fat in women
• • Body Mass Index (BMI) Wt (kg)/ ht2 (m)
• OR Wt in lbs x 0.454 / (ht in inches x 0.0253)^2
• Values greater than 25-27 indicate increased health risk
• Values of 30 or more are considered obese
• Overestimates fatness in muscular or athletic people
• Not a good index for adolescents or children

• • cardiovascular disease - leading cause of death in US
• • type II diabetes (maturity-onset)
• • cholelithiasis (gall bladder disease)
• • cancer-specifictypes
• • hypertension
• • osteoarthritis
• • thrombosis (abnormal clotting & obstruction of blood supply)
• While anemia may be the most common nutritional disorder, obesity is the most serious (in U.S.).

• Total cholesterol
• Less than 200 mg/dL ‘desirable' level that puts you at lower risk for heart disease. A cholesterol level of 200 mg/dL or greater increases your risk.
• 200 to 239 mg/dL ‘borderline-high.'
• 240 mg/dL and above ‘high' blood cholesterol. A person with this level has more than twice the risk of heart disease compared to someone whose cholesterol is below 200 mg/dL.
• LDL cholesterol
• Recommended goal is 100 mg/dL (new recommendation 70 mg/dL ?)
• HDL cholesterol
• Less than 40 mg/dL A major risk factor for heart disease
• 40 to 59 mg/dL The higher your HDL, the better
• 60 mg/dL and above is considered protective against heart disease.

• Drinking too much alcohol can raise blood pressure, cause heart failure and lead to stroke. It can contribute to high triglycerides, cancer and other diseases.
• The risk of heart disease in people who drink moderate amounts of alcohol (an average of one drink for women or two drinks for men per day) is 30-50% lower than in nondrinkers.
• One drink is defined as 1-1/2 fluid ounces (fl oz) of 80-proof spirits (such as bourbon, Scotch, vodka, gin, etc.), 1 fl oz of 100-proof spirits, 4 fl oz of wine, or 12 fl oz of beer.
• AHA does not recommended that nondrinkers start using alcohol or that drinkers increase the amount they drink.

• - some evidence that carb diets are associated w increased risk of CV disease --> CALORIES are MOST IMPORTANT
• - sucrose is important factor in growth of plaque forming microorganisms (dietary sucrose is directly related to incidence of caries but NOT to periodontal disease)
• - "Halloween effect" --> controlled experiments haven't been able to demonstrate a direct effect between dietary sucrose and hyperactivity in children

• Partially hydrogenated oils (trans fats or TFAs) are linked to coronary artery disease
• they increase LDL cholesterol and decrease HDL cholesterol levels (markers for CAD)
• Little is known about the mechanism of TFA action

• Niacin: can decrease serum cholesterol and triglycerides, increase HDL and decrease LDL. Contra-indicated for ppl w abnormal liver fnctn or HBP. May experience skin flushing rxn
• Omega-3 fatty acids: increase HDL cholesterol, decrease plasma triglycerides, reduce reactivity of platelets, monocytes, and neutrophils, reduce blood pressure, and have antiarrhythmic properties

• Yes! •There is a direct relationship between sodium intake and blood pressure but it isn’t as clear how much salt is required to produce a clinically significant increase. This relationship is more acute in renal dialysis patients.
• Human requirement is 4 gms NaCl/day
• In Japan, daily intake is >400 meq/day and CV disease is 2nd most common cause of death

• Individuals who do not produce enough ADH (adrenal insufficiency) should not be on low sodium diets.