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The Black Box of Nutrition: Nutritional Intake & Testing
By Anna Esparham, MD
KU Integrative Medicine
KU Integrative Medicine
KU Medical CenterKU Integrative Medicine3901 Rainbow Blvd. Mailstop 1017Kansas City, Kansas 66160
E‐mail: [email protected] #: 913‐588‐6208
Objectives
• Identify importance of nutritional guidance in the medical system
• Identify reasons why nutritional insufficiencies are present in pediatric population
• Discuss importance and methods of nutritional intake and assessment among healthcare practitioners
• Describe nutrient testing for common disorders
Nutritional Medicine
• The importance of nutritional medicine and culinary medicine is reaching several medical schools.
• Poor nutrition is the leading cause of morbidity and mortality in the United States.
– Dietary risk competes with risk of tobacco and physical inactivity1
1. US Burden of Disease Collaborators. JAMA 2013.
Nutritional Medicine
• Nutrition‐related diseases account for more than 25% of visits to primary care providers1
1. Kolasa & Rickett. Nutr Clin Pract. 2010
How much training did doctors receive in medical school?
• 5‐7 hrs?
• What is requirement?
• ~ 37‐44 hrs1 in 1989, but 25‐30 hrs currently
• Medical schools provide 20 hrs, but only outside of required nutrition courses (electives, clerkships)2
• 75% of physicians feel their medical school training didn’t prepare them to speak with patients about diet & nutrition3
1. Weinsier RL et al. 1989, Adams 2010 2. KM Adams et al. Academic Medicine 2010 3. bipartisan policy: The White Paper 2014.
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Provided by: The Bipartisan Policy Center at bipartisanpolicy.org
Modeling Healthy Behavior
• As a clinician, practicing a healthful behavior oneself is a powerful predictor of counseling patients with these same behaviors
Eisenberg et al. JAMA Mar 2013Frank E. JAMA. 2004
Our sensitivity to develop insulin resistance traces back to our rapid brain growth in the past 2.5 million years. An inflammatory reaction jeopardizes the high glucose needs of our brain, causing various adaptations, including insulin resistance, functional reallocation of energy‐rich nutrients and changing serum lipoprotein composition…
With the advent of the agricultural and industrial revolutions, we have introduced numerous false inflammatory triggers in our lifestyle, driving us to a state of chronic systemic low grade inflammation that eventually leads to typically Western diseases via an evolutionary conserved interaction between our immune system and metabolism
Is Real Food on brinks of extinction?
Nutrient Depletion
D. Davis. Journal of the American College of Nutrition. 2004
Nutritional Insufficiencies
Cordain et al. Am J Clin Nutr 2005
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Robert P Heaney. Long‐latency deficiency disease: insights from calcium and vitamin D. EV McCollum Award Lecture, 2003. AJCN 2003
RDA, DRI, UL
• 1941 – Food and Nutrition Board of the National Research Council for military personnel
• RDA – recommended dietary allowance
• DRI – Dietary Reference Intake
– replace RDA. Includes RDA, EAR (estimated average requirement), AI (adequate intake), UL (upper tolerable limit)
U‐shaped Curve
Dietary Reference Intakes: The Essential guide to Nutrient Requirements. IOM. 2006
DRI
• DRI is the amount of selected nutrients considered adequate to meet the nutrient needs of HEALTHY PEOPLE (estimated in children due to minimal data)
• DRI is for PREVENTION of disease
• DRI is not for treatment of chronic disease
• Optimal intakes for chronic disease still need assessment in future research
B‐vitamin RDA for infants
• RDA for Vitamin B6 is based on average B6 content in breast milk of only 19 women
• 6 of those women did not consume the RDA for B6
– Their breast milk contained only 1/10 of B6 of other women
West KD. Influence of vitamin B6 intake on the content of the vitamin in human milk. Am J Clin Nutr. 1976 Sep; 29(9): 961‐9.
What is “Adequate Nutritional Intake?”
• Medicine is still centered on single nutrient models:
Disease and Deficiency:
– Rickets – Vitamin D
– Scurvy – Vitamin C
– Beriberi – thiamine
– Pellagra ‐ niacin
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Nutrients work Together
• Should single micronutrients be evaluated?
– Nutrients have Intricate & Complex metabolism
– Interact with each other
• Compete/Enhance for absorption – Vitamin C & Iron
– Iron & Calcium
• Compete/Enhance for utilization/enzymatic reaction– Fenton Reaction: Iron, Copper, Manganese
– Mitochondrial Metabolism: B‐vitamins/Magnesium/CoQ10/alpha lipoic acid
Individual dietary guidance
Individual
Are there special considerations?
NOoptimal health &
nutrition
Maintain healthy diet and RDA/AI
Yes(e.g. vegetarians/vegans, athletes,
socioeconomic status, poor diet, illness (overutilization of
nutrients/underabsorption of nutrients)
Plan for appropriate intake of specific nutrients based on special considerations
Table adapted from Dietary Reference Intakes: The essential guide to nutrient requirements. National Academy of Sciences. 2006
Micronutrient Supplements in Children
• Very little is known about micronutrient intakes in children
• More than 1/3 of infants, children and adolescents in United States use a dietary supplement
– Most commonly: multivitamin/mineral, Vitamins A, C, D, and calcium and iron
RL Bailey et al. The Journal of Pediatrics. 2012
Poor Micronutrients in Food
• Children have inadequate intakes for:
– Calcium/Vitamin D (low even when supplemented!)
– Magnesium
– Phosphorus
– Vitamin A
– Vitamin C
RL Bailey et al. The Journal of Pediatrics. 2012
Dietary Supplements improve Micronutrient Inadequacy
Table from: RL Bailey et al. The Journal of Pediatrics. 2012
Snacking has steadily increased in the population since the 1970s and snacks provide necessary nutrients. However, carbohydrates and added sugars tend to be overconsumed at snacking occasions. Replacement of current snack choices with nutrient‐dense foods could lower the risks of nutrient deficiencies and help lower excess nutrient consumption.
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Bottomline
• Children are not getting enough nutrients
• Dietary Supplements do improve nutrient status
• However, we need to implement a “real food” diet as healthcare professionals.
– Remove processed, packaged, microwaveable foods
– Replace with:
Identify Safe & Quality Supplements
• Manufacturers of Dietary Supplements should meet good manufacturing practices (CGMPs)– Insure quality– Insure purity
• ConsumerLab is a company that tests the quality and specifications of dietary supplements and vitamins. In 2008, this company reported that over 25% of the supplements it tests has problems and 50% of vitamins don’t meet the required guidelines. 19
Nutritional Intake:Accurate? Informative?
• Do you eat your fruit and veggies?
• Do you drink milk?
• Do you eat meat?
How to inquire about nutritional intake in a busy clinician’s schedule?
• What did you eat and drink yesterday?
• @Breakfast
• @Lunch
• @Dinner
• @Snacks
Brown Foods Most Common in Children’s Diets
Plates full of color
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The Old Food Pyramid
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Nutritional Therapy & Testing: Common Disorders
• Atopic Dermatitis
• Migraines
• Polycystic Ovarian Syndrome (PCOS)
Atopic Dermatitis
Food Allergy or Food Sensitivity
• Diagnosis for Food Sensitivity:
– Elimination Diet with food challenge is gold standard
– IgG/IgA food panel controversial except for very high levels
• Diagnosis for Food Allergy:
– Skinprick Testing, IgE RAST
– Gold standard is elimination diet with food challenge
IgA/IgG antibodies against gliadin and dairy protein
Atopic DermatitisFatty Acids• Evaluate for fatty acid imbalance:
– Dietary Intake– Serum Comprehensive Fatty Acid Panel – RBC Fatty Acid Profile
• FA Patterns in Atopic Dermatitis– Omega‐3 Fatty Acids may reduce risk3
– Low Gamma‐Linolenic Acid Levels1,2
• Found in evening primrose oil/borage oil
1. Simon D et al. Adv Ther. 2014. doi: 10.1007/s12325‐014‐0093‐02. Foolad N. et al. JAMA Dermatol. 2013; 149(3): 350‐53. Saadeh D et al. Nutrients. 2013; 5(9): 3399‐3423
Fats & Oils QuestionnaireSerum Fatty Acid Profile
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Atopic Dermatitis
• Fatty Acid Supplementation
– Gamma Linolenic Acid (GLA)
– 160‐320 mg twice daily evening primrose oil/borage oil
Chung BY et al. Ann Dermatol. 2013; 25(3): 285‐91
Atopic Dermatitis
• Zinc Levels lower in children with AD than controls1, 2, 3, 4
– Evaluate Dietary Sufficiency
– Serum Zinc Levels
– Hair Analysis
1. Kim J et al. Acta dermato‐venereologica. 2014; 94(5): 558‐622. Toyran M et al. J Investig Allergol Clin Immunolog. 2012; 22:341‐443. David TJ et al. Br J Dermatol. 1990; 122: 485‐4894. David TJ et al. Br J Dermatol 198; 111: 597‐601
Atopic Dermatitis
Zinc Food sources from: www.whfoods.com
Serum Zinc Levels:
Dietary Adequacy: Is the patient meeting 100% of their needs?
Atopic Dermatitis
Zinc Repletion
Children 2‐12 yo: 10‐50 mg daily
Adults: 25‐100 mg daily
Migraine
• Migraine attacks are result of inflammation at level of trigeminovascular connections1
• Mitochondrial dysfunction2
• Hormonal Imbalance/Menstrual Disorders3
• Dysfunctional stress response4
• Diet & Nutrition5
1. Akerman S et al. Nat Rev Neurosc. 2011; 12(10): 570‐842. Yorns WR & Hardison HH. Seminars in Ped Neurol. 2013;20(3): 188‐933. Hassan S et al. Pain. 2014. doi: 10.1016/j.pain.2014.08.0274. Parashar R et al. Int J Womens Health. 2014 24;6: 921‐55. Finkel A et al. Current Pain Headache Reports. 2013; 17(11): 373
Migraine
Integrative Nutrition Treatment
• Elimination Trial, Whole Foods & Anti‐Inflammatory Diet
• CoQ10
• Magnesium
• Riboflavin
• Vitamin D
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Migraines
• Dietary Therapy1
– Anti‐inflammatory diet
– Elimination Diet • Food allergies or foods high in histamine/tyramine
• Food sensitivities
• Food additives (i.e. MSG)
• Preservatives
• Chemicals
1. Finkel A et al. Current Pain Headache Reports. 2013; 17(11): 373
Migraines
• CoQ10 deficiency1
– Diagnosis: Plasma CoQ10 (Reduced and Total)
1. Orr S and Venkateswaran S. Cephalalgia. 2014; 34(8): 568‐583
Migraines
• COQ10 Repletion
– 1‐3 mg/kg/day in pediatric and adolescents
– Most common between 25‐300 mg
Hershey et al. Headache. 2007; 47: 73‐80
Migraines
• Magnesium Deficiency1
– Diagnosis:
• RBC Magnesium Level
1. Orr S and Venkateswaran S. Cephalalgia. 2014; 34(8): 568‐583
Magnesium Repletion
• Magnesium Malate/Glycinate/Taurate/Citrate/Oxide
– More commonly used form is now Magnesium Malate due to less gastrointestinal side effects (diarrhea)
– Dosage:
• Children 2‐12 yo: titrate up to 6 mg/kg/day or 50‐600 mg
• Adolescents and Adults: 350‐750 mg
Migraine
Vitamin B2: Riboflavin– 200‐400 mg/day for migraine prophylaxis1
– Riboflavin is in a B‐complex
– Diagnosis of Deficiency: • Red blood cell glutathione reductase activity• 24‐hr urine riboflavin excretion of less than 10%• RBC riboflavin• Serum riboflavin
– Common Signs/Symptoms of Deficiency:• Beefy red tongue, seborrheic dermatitis, cheilosis, and sore throat
1. Colombo B et al. Neurological Sciences. 2014; 35(1): 141‐42. Stipanuk MH & Caudill MA. Biochemical, Phys, & Molec Aspects Human Nutrition. 3rd ed. 2013
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Polycystic Ovarian Syndrome
• Most common endocrine disorder in women of reproductive age– Oligomenorrhea– Ovarian cysts/follicles– Clinical and/or biochemical hypdrandrogenism
• Chronic low‐grade INFLAMMATION is key contributor to pathogenesis of PCOS
• Adolescent PCOS associated with:– Insulin resistance– Hyperinsulinemia– Obesity– Metabolic syndrome– Sleep disorders
Rackow B. Current Opinion in Obst & Gynec. 2012; 24(5): 281‐7
Polycystic Ovarian Syndrome(PCOS)
Integrative Treatment
• Dietary Therapy• Lifestyle Modification (physical activity)• Vitamin D• Chromium• Copper• Magnesium• Balanced Omega‐6/Omega‐3 Ratio (1:1 to 4:1)• Inositol• Glutathione
PCOS
• Dietary Therapy1
– Anti‐inflammatory diet
– Low glycemic index/load
– Grain‐free
– Ketogenic Diet2
1. Liepa et al. Nutrition in Clinical Practice. 2008; 23(1): 63‐712. Mavropoulos JC et al. Nutr Metab. 2005;2: 35
PCOS
Vitamin D = Secosteroid
Not just a mediator of “calcium homeostasis”
Immunomodulatory
Antimicrobial Antiproliferative
Mediator in Chronic Disease
Metabolism & Glucose Homeostasis1
• Upregulates insulin gene transcription
• Improves insulin secretion and glucose tolerance
• Activates PPAR‐δ – a transcription factor implicated in regulation of fatty acid metabolism
1. N El‐Fakhri et al. Hormone Research in Paediatrics. 2014
Polycystic Ovarian Syndrome (PCOS)
Vitamin D
•Diagnosis: Serum 25(OH) D levels
•Deficiency1: <20 ng/ml
•Insufficiency1: 21‐29 ng/ml
•Maintain levels between 40‐60 ng/ml
1. Hollick MF et al. J Clin Endocrin & Metab. 2011; 97(7): 1911‐1930
Vitamin D: Pediatric Dosing
Table provided by: Vogiatzi et al. J Clin Endocrinol Metab, April 2014.
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PCOS
• Copper
– Higher levels in women with PCOS1,2
– Diagnosis:
• High Serum Copper
Note: obtain a serum zinc when obtaining serum copper
• Metabolic antagonists
• Should maintain a 1:1 ratio
• Supplement with zinc if copper elevated
1,. Chakraborty P et al. Biological trace element research. 2013;152(1): 9‐152. Kurdoglu Z et al. Hum Exp Toxicol. 2012; 31(5): 452‐456
PCOS
• Chromium
– Laboratories only diagnose for toxicity/occupational exposure
– Treatment:
• 200‐1000 mcg daily
Chromium. Natural Medicines Comprehensive Database. Nov 2014.
Nutritional TestingConcluding Thoughts: Real Food
Challenge
REAL FOOD GROWS
Resources Laboratory Assessment of Nutrition
Resources for Nutritional Management of Common Disorders
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THANK YOU!!
KU Medical CenterKU Integrative Medicine3901 Rainbow Blvd. Mailstop 1017Kansas City, Kansas 66160
E‐mail: [email protected] #: 913‐588‐6208