Nutrition Flashcards
Describe the main nutritional requirements for infants at six months.
Iron
Energy and protein - due to early rapid development
Why is exclusively breastfeeding recommended for the first six months of a baby’s life instead of formula?
Whilst both are completely nutritional complete, breast milk in the first few days of life known as colostrum also has secreted IgA which paints the GI tract with protection.
Although recommended for six months, any breastfeeding will have some benefit.
Describe the recommended formula milk from a Newborn to a Toddler at 3 years old.
From Newborn up to the age of one, Newborn formula milk can be recommended which is nutrient rich. However at six months it is recommended to switch to a formula that has a higher iron content known as follow on milk as iron stores at six months begin to become depleted from birth.
From the age of 1 to 3 toddler milk is recommended.
Give a couple of examples of each type of formula (Newborn, Follow on and Toddler).
Newborn - SMA PRO 1, SMA Extra-Hungry, C&G first milk
Follow on- SMA PRO 2, C&G follow on
Toddler milk- SMA PRO or C&G toddler milk
What milks are available for babies with a cow milk protein allergy?
Soya based milks such as SMA Soya, Infasoy
However there are concerns about using these milks before six months because soya can be allergenic and the immune system has not developed before six months
When is extensively hydrolysed formulas recommended?
These formulas are hypoallergenic and therefore recommended for babies with lots of allergies
Example Nutramigen
When else would you recommend specialised formulas?
Lactose free milks
Anti-reflux
Higher energy milks if premature
Colic
Why is it recommended at six months to wean?
Babies have higher nutritional requirements that can no longer be met by breast or formula milk alone
Introduce solid foods
What foods should be avoided if you wean before six months?
Due to the potential of creating allergies:
Wheat and gluten
Fish and shellfish
Fruit juices
Soya and eggs
What foods should be avoided in the first year of life?
Salt
Sugar
Honey
What nutritional requirements are recommended for pre-school children?
Increase in energy, protein, vitamins and mineral requirements
They should have a varied diet, with smaller portions but are nutrient dense
Whole milk is required
What are some of the common diet related complications in pre school children?
Fussy eating
Toddler diarrhoea
Constipation
Anaemia
Dental caries (avoid fruit juice)
Describe the main nutritional requirements for school aged children.
Healthy eating with a varied diet
Protein, Calcium, Iron, Vitamin A and D
Adjunct to diet, physical activity is also important
Describe the main nutritional requirements for adolescent girls.
Iron - due to menstruation onset
Calcium and Vitamin D - peak bone mass towards the end of adolescence, lack of Calcium and Vitamin D during adolescent leads to a low peak bone mass, which increases the risk of osteoporosis onset post-menopause. Physical activity also increases muscle mass
Energy and protein - due to growth spurts, (boys have extra nutrient requirements due to increased muscle mass)
What are the main nutrient requirements for adults (aged 19-64 years)?
Dependent on exercise, but the average is:
Energy-
Males- 2772kcal per day
Females - 2175kcal per day
Protein-
0.75g/kg of body weight
Carb-
50% of total energy, less than 5% from sugars
30 grams/day of fibre
Fat-
35% total energy, 11% of total saturated
Increase OMEGA-3 from fish and are bio-active- essential fatty acids and anti-inflammatory effects
What are some of the alcohol recommendations?
14 units per week maximum spread over 3 days a week
Several drink free days a week
Increased risk of cancer
Describe the main nutritional requirements during pregnancy.
Energy - only increases by 200kcal a day
Protein - only increases by 6 grams a day, during lactation an increase of 11 grams a day
Iron - particularly important in the last semester due to increase in blood volume and foetus size, more red blood cells going around the body
Folic acid - 400 micrograms during first trimester (usually as a supplement) after than then the foetus has fully developed and is just growing
What nutrients should be avoided during pregnancy?
Avoid shark, marlin, tuna as methyl mercury can accumulate in these foods which are teratogenic
Avoid alcohol and limit caffeine
Avoid Vitamin A (more than 1500 micrograms), liver and liver products
Describe the main nutritional requirements for old industrialised people.
Vitamin D - due to lack of sunlight
Calcium - only if osteoporotic
Energy and protein - decrease with age but malnutrition can occur
Micronutrients stay the same
Why does Malnutrition occur in the elderly population?
Inadequate intake of dietary energy leading to loss of body weight
Nutrient deficiencies - may be due to chronic disease
Widespread metabolic physiological and functional adaptations occur
Describe the main nutritional requirements for smokers.
Anti-oxidant rich diet - Vitamin C due to pro-oxidants in cigarettes so to neutralise them
What are dietary reference values?
They are a series of estimates of the energy and nutritional requirements of different groups of healthy individuals in the UK population.
What are the four types of dietary reference values?
Estimated average requirements (EARs)
Reference nutrition intakes (RNI)
Lower reference nutrition intakes (LRNI)
Safe intake
Define the estimated average requirements.
The EAR is an estimate of the average requirement of energy or a nutrient needed by a group of people (i.e. approximately 50% of people will require less, and 50% will require more)
When is estimated average requirements used in preference to the reference nutrition intake?
In regards to energy as energy requirements are dependent on so many factors such as exercise frequency, basal metabolic rate and therefore an average should be set rather than a reference nutrition intake (enough for 97.5% of the population) as for some people with would be a significant over-estimate of how much they require and would lead to obesity.
Define the reference nutrition intake.
The RNI is the amount of a nutrient that is enough to ensure that the needs of nearly all a group (97.5%) are being met.
This is the most commonly used dietary reference value.
Define the lower reference nutrition intake.
The LRNI is the amount of a nutrient that is enough for only a small number of people in a group who have low requirements (2.5%) i.e. the majority need more
Define the safe intake.
When there is insufficient evidence to set an EAR, RNI or LRNI.
The safe intake is the amount judged to be enough for almost everyone, but below a level that could have undesirable effects. For example Vitamin E
If you extracted anti-oxidants out of fruit and vegetables would you still experience the benefits if you took them as individual supplements?
No, it is theorised that vitamins and minerals have a synergistic effect and therefore work together to provide benefit to the individual.
Is Vitamin D beneficial for preventing the infections?
Some evidence to say it has some benefit
Is Vitamin C beneficial for the common cold?
No, there is no direct benefit taking Vitamin C for the common cold. However it is important to maintain optimal levels for Vitamin C as it is uptake in white blood cells
Do B vitamins help reduce the risk of CVD?
Do not need to take supplements, just maintain optimal levels within the diet.
What is the purpose of taking folic acid during pregnancy?
Folic acid fortification of food reduces the risk of neural tube defects in the first trimester of pregnancy?
What are phytosterols and the purpose of taking them?
Phytosterols are plant sterols and they have good evidence for reducing cholesterol
What is chondroitin sulfate taken for?
Improve joint health, but there is limited evidence behind it
Why is iron so tightly regulated in the body?
Pro-oxidant activity and therefore can cause damage within the body
Aside from haemoglobin, what else is iron incorporated into?
Myoglobin (found in muscle)
Cytochrome P450
Catalase
Peroxidase
Cell growth and differentiation
Describe the absorption and stores of iron within the body?
Only 10% of the dietary intake of iron is absorbed (roughly 1mg), must either be heme iron form or ferrous iron form to be absorbed from the intestinal tract into the epithelial cells of the villi. Some iron will not be absorbed into the bloodstream but will remain as ferritin in the epithelial cells.
When absorbed into the bloodstream it is transferred around the body where needed it (roughly 3-4mg) bound to transferrin.
Iron then is transferred to:
- Roughly 300-1000mg is stored in the liver as ferritin or haemosiderin (ideally want iron in this store and not free due to its pro-oxidant activity)
- Red blood cell precursors in the bone marrow, so that they can start transferring oxygen around the body. Circulating red blood cells store approximately 2500mg of iron.
Red blood cells are broken down in the spleen by reticulo-endothelial macrophages, transferred back to tranferrin bound iron.
The same amount of iron that is absorbed is lost daily through sweat, faeces, tissue shedding (GI epithelial cells shed cells every couple of days)
What are the dietary requirements for iron?
Dietary requirements for iron:
8.7mg for men 19 years and over and non-menstruating women over 50
14.8mg for women between 19-49 years
How is iron eliminated from the body?
1mg of iron is lost each day through:
Bilirubin from the liver
Skin
Reticulo-endothelial system from the spleen
What are the transporters that allow iron to enter the villi epithelial cells?
Heme carrier protein 1 (Heme iron)
Divalent metal transporter 1 (Ferrous iron)
What foods contain heme iron?
Red meat, fish, poultry
What foods contain non-haem iron?
Plant foods, lentils, beans, iron enriched, fortified foods
What substances increase and which decrease the absorption of iron?
Increase absorption- Vitamin C, red meat, organic acids
Decrease absorption- Soy, Phytates, Tannins, Calcium, Dietary fibre
Can ferric iron be absorbed into epithelial villi cells?
Ferric iron is the oxidised form of iron, it cannot enter epithelial cells until its in the reduced form (ferrous iron).
What Vitamin converts ferric iron to ferrous iron?
Vitamin C converts iron to its reduced form ferrous iron which allows it to be absorbed into the epithelial cells and potentially into the bloodstream.
What transporter (exporter) allows iron to enter the bloodstream from epithelial cells?
Ferroportin
What is anaemia and specifically iron deficiency anaemia?
Anaemia is when there is a decrease of healthy red blood cells in circulation. Red bloods cells become hypochromic and microcytic (small and pale). In iron deficient anaemia this is a clinical consequence of depleted iron levels in the body after stores have been depleted and there is a negative iron balance.
Is iron deficient anaemia common?
Most common form of anaemia worldwide. 80% of the world’s population are thought have low iron levels
Describe the structure of haemoglobin.
Red blood cells consist of haemoglobin. Each haemoglobin molecule is made up of four heme molecules. Each heme molecule contains a central iron atom which is essential for binding to oxygen. Therefore each haemoglobin molecule is capable of binding to four oxygen molecules, and then can transport oxygen around the body.
Which demographics are most likely to suffer with anaemia?
Teenage girls, Women of a childbearing age, during pregnancy, toddlers, older infants, premature babies and babies of a low birth weight
Which conditions may also have anaemia?
Kidney failure, Chronic malabsorption, GI disease
What are some of the clinical consequences of anaemia?
Pallor, tired or weak, poor work performance
Slow cognitive and social development
Decreased immunity
Heart failure if severe
Which Vitamin deficiency can occur alongside iron deficient anaemia?
Vitamin A which helps the absorption of iron
When are iron supplements given?
When iron deficient anaemia cannot be corrected by diet within a reasonable time
Clinical deficiency
What are some examples of supplemental iron and when do you take them?
Ferrous fumarate, Gluconate, Sulphate
Ferric iron
Dose spread possibly three times a day as the amount absorbed decreases with an increasing dose
What are some of the side effects of iron supplements?
GI- nausea, vomiting, diarrhoea
(Usually start with half a dose and titrate upwards)
What are examples of chronic iron toxicity diseases?
Thalassaemias
Haemochromatosis
What is Thalassaemias?
A group of inherited conditions that cause production of little to no haemoglobin, making them severely anaemic
Usually blood transfusions are required
What is Haemochromatosis?
A group of genetic conditions that cause the build up of iron in the body over a number of years and deposits of iron within tissues causing inflammation.
What are some of the treatments for chronic iron toxicity?
Iron chelators such as Desferrioxamine - complexed with ferric iron so it becomes unavailable and is eliminated from the body
Also Desferiprone (Thalassemia) and Deferisarox but these have more side effects
When does malabsorption occur?
Malabsorption occurs when one of the processes require for intestinal absorption is dysfunctional.
This could be:
Pancreatic secretion of digestive enzymes
Liver secretion of bile acids
Surface area of the intestine such as the villi
Brush border enzymes
What are some conditions that affect pancreatic secretion of enzymes?
Cystic fibrosis
Pancreatic insufficiency
Pancreatic cancer
What are some conditions that affect liver secretion of enzymes?
Gallstones
Liver disease
What are some conditions that affect surface area of the intestine?
Crohn’s disease
Coeliac disease
What are some conditions that affect brush border enzymes?
Lactose intolerant (75% of the world’s population)
What are the common symptoms of malabsorption syndrome?
Abdominal distension
Stunted growth
Diarrhoea
Most common cause of malabsorption?
Coeliac disease
What type of disease is Coeliac disease?
Auto-immune disease, attacks transglutaminase
Where is Coeliac disease most prevalent?
More common in Eastern and Northern Europe
What are the histological changes that occurs in Coeliac disease?
Atrophy of the villi due to abnormal sensitivity to gluten
Due to this poor absorption this leads to malabsorption of nutrients in the damage area of the intestine
There is a histological improvement when gluten is avoided in the diet
Describe the appearance of normal villi vs the villi in Coeliac disease.
In a healthy individual there is protruding upward villi like tentacles that increase the surface area. However in Coeliac disease the damage and inflammation caused as a result of the auto-immune attack on transglutaminases results in flattening of the villi, meaning there is a decreased surface area and leading to the malabsorption of nutrients.
What is the incidence data of Coeliac disease in the UK?
1 in 100 people
Incidence is increasing (possibly due to increase in processed foods)
Women have higher prevalence than men
What percentage of people with Coeliac disease or undiagnosed?
36% - roughly half a million according to Coeliac UK
PP- only 10-15% diagnosed
When is diagnosis of Coeliac disease typical?
8-12 months when babies are weaned
Third decade and beyond (particularly 4th and 5th according to Coeliac UK)
What is the worldwide incidence of Coeliac disease?
0.05-1.2%
In which ethnicities is Coeliac disease more prevalent?
Western Europe, US and Australasia and Jews (smaller genetic pool)
In which ethnicities is Coeliac disease less prevalent?
Africa, Far East and Caribbean
In which ethnicities is Coeliac disease increasing?
India, Middle East, Saharawui
What are the factors that lead to the development of Coeliac disease?
Genetic predisposition
Exposure to gluten proteins
&possible environmental trigger
Which genes are found to be linked to Coeliac disease?
HLA-DQ2 or DQ8 are found in 95% of patients with Coeliac disease
How do HLA-DQ2 and DQ8 contribute to Coeliac disease development?
Both of these genes code for receptors. These receptors bind to gliadin more tightly resulting in the increased activation of T lymphocytes and initiating an immune response.
Which other auto-immune conditions increase risk of Coeliac disease development?
Type 1 DM
Down Syndrome
Turners syndrome
Autoimmune thyroid disease
Dermatitis herpeitformis
Association of Coeliac disease in twins and first degree relative?
Monozygotic twins - 75%
First degree relative - 20%
What is dermatitis herpetiformis?
An auto-immune skin disease less common than Coeliac disease but is linked to it.
Only affects 1 in 3300 people
Can happen at any age but most commonly between 50 and 69
What are the typical symptoms of dermatitis herpetiformis?
Red, raised patches up to 1cm in diameter, often with blisters filled with watery fluid that burst with scratching
Severe itching and often stinging
This is accompanied with intestinal damage (can be asymptomatic)
Where does the patches of dermatitis herpetiformis usually occur?
Elbows, knees and buttocks usually symmetrical
What treatment is required for dermatitis herpetiformis?
Gluten free diet leads to an improvement in symptoms plus dapsone (antibiotic)
Explain the pathophysiology of Coeliac disease.
Often proteins are not completely broken down in the digestive system and they can be absorbed as small peptides.
Problematically however if gluten proteins are not fully digested their peptides can be immunogenic. Specifically in Coeliac disease the prolamines (alcohol soluble fractions of gluten) initiate the immune cascade.
The prolamines are absorbed in the small intestine and are presented to APCs in the lamina propria which then these immunogenic peptides are presented to T lymphocytes which initiate the immune response.
What are the different types of prolamines and where are they found?
Gliadins in wheat
Hordeins in barley
Secalins in rye
Avadins in oats (not everyone is intolerant to oats)
What are the main symptoms of Coeliac disease?
Fatty, bulky diarrhoea
Fatigue
Borborygmus (abnormal bowel sounds)
Abdominal pain
Weight loss
Failure to thrive
Abdominal distension
Flatulence
What are some of the uncommon symptoms of Coeliac disease?
Osteoporosis (can’t absorb calcium)
Abnormal liver function
Vomiting
Iron deficient anaemia
Neurological dysfunction
Constipation
Nausea
How do you diagnose Coeliac disease?
Symptoms
Restricted to the small bowel mucosa (differentiate from UC and Crohn’s disease)
Serological blood tests
Endoscopy
Macroscopic changes such as scalloping
Biopsy
What serological blood tests would you assess for diagnosis of Coeliac disease?
Tissue transglutaminase (tTG) antibodies
Endomysial antibodies
Total IgA antibodies if either of these negative but suspected disease
What are some of the complications of Coeliac disease?
Increased risk of malignancy (adenoma of GI tract) if untreated
Increased risk of miscarriage or congenital malformations
Malabsorption can lead to stunted growth and malnutrition if undiagnosed in childhood
What is the treatment for Coeliac disease?
Avoid wheat, gluten and barley
Including avoiding things manufactured from flours:
Chocolate
Beer
Cheese spreads
Gravy
Sausages
Canned foods
Soups
What percentage of patients do not adhere to a gluten free diet?
50-70% do not completely adhere later in life and there is non-compliance in children
What percentage of patients with Coeliac disease still experience symptoms even after cutting out gluten from the diet?
30%
What is the purpose of vitamins, mineral and electrolytes within the diet?
Co-factors for enzymes
What is the purpose of proteins, fats, carbohydrates and alcohol within the diet?
Major source of energy (alcohol less so)
Protein is also required for tissue and muscle growth and repair
What is the purpose of fibre in the diet?
Aids food GI transit but also is broken down in the large intestine releasing Vitamin K and short chain fatty acids
What are phytochemicals?
Plant chemicals which are biologically active and have benefit in the body.
What else may you find in the diet?
Methylxanthines
Vasoactive amines
Contaminants
Why do we need an optimal diet?
Prevent deficiency
Optimise body stores
Optimise biological/physiological function
Optimise a risk factors for some chronic disease (minimise risk factor)
Minimise incidence of disease
What does the Eatwell guide recommend about diet?
1/3 fruit and veg (and a variety of fruit and veg)
1/3+ starch based foods (wholegrain or high fibre)
Proteins - ideally lean meat and plant protein
Dairy or alternatives for Calcium and Vitamins
Small amounts of oils and spreads and limited cakes and biscuits
How much water should we drink a day?
6-8 glasses a day
Only 150mL maximum fruit juice
Explain the factors that influence nutrient requirements.
Age - nutrient requirements increase with age due to growth, decrease in elderly due to more sedentary lifestyle, decreased energy expenditure
Gender- men have more than women due to increased muscle mass
Physiological state- being pregnant increases nutrient requirements
Genotype- how we metabolism our nutrients can influence our requirements
Environmental factors- smoking alters anti-oxidant requirements
What are some of the food labelling that is used?
Guideline daily amounts
Traffic light scheme on the front of pack
Define Vitamins.
Organic substances that cannot be synthesised by the body so are derived from diet that are required for normal cell function, growth and development.
What can vitamins only be prescribed for?
The prevention and treatment of deficiencies and not as a supplement (would have to buy OTC)
What are the different classifications of Vitamins?
Fat and Water soluble vitamins
What are some examples of fat soluble vitamins?
Vitamin A, D, E and K
(These tend to have a long half life months apart from K 1 to 2 weeks)
What are some examples of water soluble vitamins?
B and C
Tend to have a short half life apart from B12 which is 3-6 years
How is minerals and trace elements differentiated and from vitamins?
They are inorganic compounds required by the body
Minerals you need more than 100mg a day but trace elements you need less than 100mg a day
What are some examples of trace elements and minerals?
Minerals: Calcium and Magnesium
Trace elements: Zinc and Iron
What are some of the functions of trace elements and minerals?
Maintain an osmotic gradient
Structurally such as bones and teeth
Biological fluids
Nerve and muscle function
For oxygen transport (iron)
Enzyme co-factors
Hormones (iodine)
Which water soluble vitamin is not absorbed passively?
Vitamin B12, requires an intrinsic factor for receptor mediated endocytosis in the terminal ileum
How are fat soluble vitamins absorbed?
Carried in micelles and absorbed passively with the end products of fat digestion
Why is calcium and iron absorption tightly regulated?
Iron: pro-oxidants and so can damage cells
Calcium is a second messenger so has to be regulated
What are the B vitamins involved in?
Energy metabolism
What are examples of antioxidants?
Vitamin C is the most potent antioxidant
Vitamin E is a lipophilic antioxidant
In addition to Vitamin A, Selenium and Zinc (incorporated into cellular antioxidants)
What are the functions of anti-oxidants?
They counteract free radicals but also have anti-inflammatory, anti-coagulation, anti-aging and anti-tumorigenic effects
Where is Omega 3 found and what are its claimed health benefits?
Found in fish oils - EPA, DHA
There are benefits for the skin, cholesterol levels (evidence is not as strong now) and inflammatory mediators (as they produce resolving lipid mediators, reducing inflammation) so anti-inflammatory
Also claim to have positive effects on the heart
What foods have Omega 3 added to it?
Columbus eggs
Fish fingers
Yoghurts
Cakes
What foods incorporate plants stanols or sterols?
Margarines
Mayonnaise
Vegetable oils
Yoghurts
Milk
Soy milk
Orange juice
Snack bars
What is the purpose of phytosterols?
Compete with cholesterol, causing a reduction in absorption of cholesterol.
2 grams daily, reduces LDL cholesterol
What are the benefits of probiotics?
They are live non-pathogenic micro-organisms, and when given in significant amounts can confer a health benefit to the host. Believed to have some benefit to GI diseases and immune diseases.
Where do probiotics accumulate?
They are resistant to acid digestion, some colonise in the gut.
What vitamins and minerals are needed to maintain good bone health?
Vitamin K, Vitamin D, Calcium and Magnesium, Phosphorous
Define what is meant by a functional food.
A food of beverage that contains an ingredient that has an additional health benefit beyond its usual nutritional value.
This health benefit either improves physical or mental performance or decreases disease risk.
What is meant by a nutraceutical?
Any substance that is a food or ingredient and provides medical or health benefits, including the prevention and treatment of disease
What is meant by a dietary supplement?
Concentrated source of nutrients or other substances with a nutritional or physiological function.
To maintain health or prevent deficiency
In what diseases are often associated with nutraceuticals or dietary supplements?
People often take nutraceuticals in the prevention and treatment of diseases including:
Cancer
CVD
Gout and arthritis
Osteoporosis
Neurological disorders
IBD and IBS
AMD
Respiratory disease
What health benefits may people take nutraceuticals for?
Aging
Well being
Gut function
Weight loss
Detoxification
Enhanced immunity
What are some of the ways functional foods have a dietary benefit? (or the ways their nutrients are added to the foods)
Either naturally nutrient rich or dense (lycopene in tomatoes)
Medicinal active (garlic)
The foods have been genetically modified (cows to produce low fat milk)
Or processed
How are functional foods processed to enhance their nutritional value?
Processed to either:
Increase the concentration of the active ingredient (adding B vitamins back into cereals)
Add a component that is not normally present (poly unsaturated fatty acids in eggs)
Eliminate or decrease a harmful component (low fat milk)
Replace a component with one with a known benefit (switching to plant cholesterol)
Increase bioavailability or stability (cooking tomatoes making the lycopene more bioavailable)
What is the cost associated with nutraceuticals?
$495 billion in 2021 mainly in Asia and the South Pacific
This is more than double the OTC and prescription cost combined
What is the breakdown of the nutraceutical market?
Dietary supplements
Herbal supplements - been reduced due to safety
Cosmeceuticals/nutricosmetics
Increase in functional foods
Increase in sports nutraceuticals
What are some of the reasons for taking nutraceuticals?
Prevent or treat disease (taking Calcium for prevention of Osteoporosis)
Healthy lifestyle and increased awareness
Media coverage
Increase in range and availability
Rising healthcare costs
Aging population
Growing fixation with beauty
What are the main types of supplements in the UK?
- Vitamins and minerals - multi-complex and single
- Selected vitamins and minerals with extra nutraceuticals
aimed at targeting disease/health benefit - Pick-me-ups
- Anti-oxidants
- Amino acids
- Fatty acids and oils
- Bioflavonoids and phytoestrogens
- Probiotics
- Weight loss
- Glucosamine, chondroitin sulphate
- Stimulants
How are targeted supplements advertised?
By population groups (menopause, children, vegetarians)
For disease prevention (Joint, Bone, Cardiovascular, Immune, Eye)
General wellbeing (Aging, Sleeping)
What are some examples of foods that have a CVD benefit over and above their nutritional value?
Fruit and veg
Garlic and onions
Low fat foods
Foods supplemented with sterols and stanols
Soy
Oats and other beta glucan products
Oily fish and food supplements with PUFA
Nuts
What is the cosmeceutical industry?
Prevent skin and hair aging
No evidence behind them
What are some examples of the beverages nutraceutical industry?
Smoothies with anti-oxidants
Teas - catechins, detox
Drinks with botanical extracts
Fruit and vegetables juices
Spring water based drinks
Stimulants
How does the cost range for the different types of nutraceuticals?
£1-4: single vitamins
£2-10: fatty acids and multivitamins for vegetarians
£8-20: multivitamins with extra compounds
£20-50: selected disease or health state targeted
Are nutraceuticals safe?
Most are relatively safe, but often have limited data behind them.
However sometimes they can cause adverse effects. People often feel more inclined to take them over pharmaceutical drugs as they appear more natural but often have limited beneficial effects.
What is some of the evidence based research for nutraceuticals?
Laboratory studies - in vitro and ex vivo effects on cell lines, cells and tissues
Animal studies
Observational studies
Prospective cohorts
RCT
Meta-analysis
Most useful are prospective cohorts of nutritional diets - follow people’s diet for years and seeing how disease develops within different diet
What factors influence the effects of nutraceuticals?
Genetic factors (how we metabolise the supplements)
Adverse effects
Nutrient interactions or with drugs
Bioavailability (lycopene increases with cooking)
Active form
Processing
Physiological state and behaviour of the individual
What are some of the causes of malnutrition?
Reduced food intake
Decreased absorption (Coeliac disease)
Decrease activity of co-factors which aid absorption such as intrinsic factor and Vitamin B12
Increased metabolism (Hyperthyroidism)
Underlying disease (Cancer)
What are the physical consequences of malnutrition?
Fatigue, malaise
Decreased immunity
Delayed wound healing
Decreased muscle strength and fatigue
Hypothermia
Reduced respiratory muscle function and cough pressure, increasing risk of chest infections
Immobility predisposing to venous thrombosis, embolism and pressure sores
Reduced final height in women leading to reduced pelvic size and small birth weight in infants
What are the psychological and behavioural consequences of malnutrition?
Depression
Anxiety
Reduced will to recover
Self-neglect
Poor bonding with mother and child
Reduced libido
What are the different types of malnutrition?
Protein energy malnutrition
- Deficiencies in any or all nutrients
Micronutrient deficiencies
- Deficiency of specific micronutrients
Describe the different types of protein energy malnutrition in children and how this can affect their appearance.
Protein energy malnutrition can either be short (acute) or long-term (chronic) .
Acute inadequate nutrition you will typically see rapid weight loss or failure to gain weight normally.
Chronic inadequate nutrition occurs when there is inadequate nutrition over a long time and will lead to shunted growth.
In a child that suffers with both, they will appear smaller and thinner
What does the World Hunger map 2021 inform regarding prevalence of malnutrition worldwide?
Up to 811 million people (which is 1 in 10) worldwide do not get enough to eat.
Regions in Central Africa particularly have over 35% of their populations are undernourished. Other areas include South and Eastern Africa (15-35%), the Middle East (mid range), islands in the Pacific - Australasia and lower levels in Central and South America.
What are some of the reasons for malnutrition in older adults, especially those institutionalised?
Suffer with both protein energy malnutrition and micronutrient deficiencies
Have a decreased GI function with reduced absorption or metabolism
Underlying disease and interaction with drugs
Reduced intake due to:
Dysphagia
Poor appetite
Poor mastication
Define cachexia.
It is the weakness and wasting (loss of weight and body mass) of the body due to chronic disease.
Known as disease related malnutrition.
What diseases may cachexia occur?
Cancer
Alzheimer’s
Hyperthyroidism
COPD
AIDS
IBD
Coeliac disease
Congestive heart failure
Cystic fibrosis
Severe schizophrenia
Drug addiction
What dietary advice or recommendations can be given to someone who is suffering with cachexia?
Food fortification to increase the energy denisty of a meal
Having smaller but more frequent meals and snacks
Using non prescribable or non-prescribable supplements
Supplements should be used in adjunct to dietary fortification and snacking
What are some examples of non-prescribable supplements?
Complan
Casilan and skimmed milk powder
Boost
Build up
What are some examples of milk tasting prescribable supplements?
Ensure Plus
Fortisip
Fortimel
Fresubin
Should be served chilled
Which other prescribable supplements are available?
Enlive (fruit juice)
Maxijul (glucose powder)
Pro-cal (fat and protein based)
Calogen (fat based liquid)
Forticreme (mousse)
What are the alternative feeding routes available?
Nasogastric and nasoenteric (short term feeding)
Gastrostomy (long term home feeding)
Jejunostomy (unlikely to resume full oral intake after abdominal surgery)
Parental nutrition (gut is not functioning anymore)
What are the advantages of nasogastric feeding?
Not invasive
Quick
Cheap
What are the disadvantages of nasogastric feeding?
Irritation
Risk of sinusitis, oesophagitis
Dysphagia
Risk of misplacement
Risk of reflux
Easy tube movement or removal
Regular tube replacement
X-ray confirmation
Stigmatising
What are the advantages of abdominal feeding tubes?
Less stigmatising
Less tube migration
Less tube removal
Less reflux
No nasal irritation
No dysphagia
No tube replacement
What are the disadvantages of abdominal feeding tubes?
Invasive
Sedation and antibiotics
Irritation at site
Leakage into the abdomen
Translocation of bowel
X-ray confirmation
Tube clogging
Hematomas causing bowel obstruction
When is nasogastric feeding required?
Short term feeding of less than 14 days
Unable to take any nutrition orally (such as stroke or upper GI surgery)
Or for use as additional nutrition to improve an inadequate intake (burns, cystic fibrosis)
What are examples of standard polymeric feeds and high energy feeds?
Standard polymeric (1kcal/mL) include Osmolite and Jevity (suitable for most feeding)
High energy (1.5 kcal/mL) feeds include Osmolite and Ensure plus, Jevity plus
When would you use higher energy feeds?
When the patient requires additional nutritional requirements or has volume restriction
What are the additional types of feed and give examples?
Fibre added (all the Jevity feed varieties)
Low sodium (Nutrison low sodium)
Low electrolyte, energy dense feed (Nepro)
Elemental/Peptide (Perative)
When would you recommend feeds with additional fibre intake?
For long-term feeding and in order to normalise the bowels
When would you recommend low sodium feeds?
In ascites or hypertension
When would you recommend low electrolyte or energy dense feeds?
In renal impairment or fluid restriction (CCF)
When would you recommend elemental/peptide feeds?
Malabsorption
Short bowel
Crohn’s
What are some of the common problems associated with alternative feeding routes?
Diarrhoea - temp of feed/ rate/ check date/ fibre
Constipation - fluid balance /fibre
Vomiting- rate of feed/ position of the patient/ infection
Blood tube - feed/ meds/ not flushed
What are some of the improved patient outcomes as a result of enteral feeding?
Shorter hospital stays
Lower mortality and hospital admissions
Improvement in immunity and fewer infections
Improved wound healing
Improved quality of life and well being
Improved liver function in liver disease
Improved clinical scores in CF and Crohn’s disease
Lower complication rate after surgery and liver disease
