Nutrition

Health

"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity" "The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition"

GARLIC, ONION AND LEEKS

a. As we age we perceive bitterness less so babies like sweet things and will say "yuk" to bitter. b. Vegetables of the Allium family modulate liver and kidney detoxification enzyme processes i. Babies perceive bitter things as toxic c. Garlic, onions, leeks, scallions, shallots and chives d. Shallots (Moo-Seer in Persian cuisine) are easier to digest. Shallots are richer in flavonoids and phenols than other onions e. Sulfur compounds (allicins) are natural defenses; antibacterial and antifungal f. Allium vegetables support natural detoxification processes (reduce effects of neurotoxins)

CASE HISTORY #1 HEAD AND NECK CANCER

1. 58 year old male (self described as "athletic") Head and neck squamous cell carcinoma, HPV + 2. Chemotherapy: Taxotere, 5-FU, Cisplatin 3. Radiation - 36 treatments 4. Weight loss: 13 pounds in one week, 15 pounds by third week of combined treatment 5. Anthropometrics at Dx: Ht 5' 11" Weight 183 lbs; BMI 25.5 6. Symptoms: sore mouth, constipation, food "tastes bad" nausea, hiccups, weight loss

PRENATAL NUTRITION

1. Almost half of all pregnancies in US are unintended As a result the Centers for Disease Control and Prevention recommends: 2. Women of reproductive age should adopt healthy behaviors a. Take folic acid supplements b. Maintain a healthy diet and weight c. Be physically active regularly d. Quit tobacco use e. Abstain from alcohol and drugs 3. Most pregnancies are unplanned so important to eat right during that age cause it could happen

CONSTIPATION MANAGEMENT

1. American Cancer Society recommends Caregivers offer prune juice, hot lemon water, or tea to help stimulate bowel movements 2. Encourage extra fluids 3. Help keep a record of bowel movements 4. Offer high fiber foods such as whole grains, dried fruits, and bran 5. Talk with the doctor before using laxatives American Cancer Society, 2007

NUTRITION ASSESSMENT

1. Anthropometry 2. Height and weight (without shoes) have consistence in your institution 3. If waist circumference is more than 1/2 the height, the person is at risk for metabolic disease 4. BMI (Body Mass Index) Wt (kg)/ Ht (m2): App available from www.nhlbi.nih.gov a. Underweight: below 18.5 b. Normal: 18.5-24.9 c. Over: 25-29.9 d. Obesity: >30.0 5. Waist circumference 6. Ratio Height:Waist <0.5

NUTRITION AND BONE HEALTH

1. Bone is primarily composed of calcium 2. Bone health is determined by the dynamic state of bone building and bone break down by osteoblasts and osteoclasts. Women need to worry primarily about hip bone density 3. Ground substance of bone is also important and primarily composed of silicon salts 4. Calcium, magnesium, zinc, boron, manganese and strontium found in bone 5. Vitamin D regulates calcium uptake in GI tract and in bone 6. Vitamin K2 may play a role 7. pH (dietary acid/base balance more alkaline)

RISK FACTORS OF OBESITY AND OVERWEIGHT

1. Cigarette smoking 2. Hypertension 3. Cholesterol a. LDL b. HDL c. Triglycerides 4. Glucose (IFG) 5. Family history of premature 6. CHD 7. Age

CULTURAL FACTORS

1. Cultural and ethnic eating patterns vary widely a. International Food-based dietary guidelines at www.fao.org/nutrition/education/food-dietary- guidelines/home/en b. USDA National Agricultural Library c. Ethnic/Cultural Food Pyramids d. www.fnic.nal.usda.gov/dietary-guidance/past-food- pyramid-materials/ethniccultural-food-pyramids e. Power to Prevent: A family Lifestyle Approach to Diabetes Prevention for African-American Communities f. The Pima Indians: Pathfinders for Health g. NDEP (National Diabetes Education Program) materials in English and Spanish h. Within one country there are different patterns of eating, so learn about your patients patterns

REDUCE ADDED SUGARS

1. Cut down on regular sodas, energy drinks, sports drinks, fruit drinks (fruitades and fruit punch) a. Read labels - "added sugars" to be included (initially proposed to be enforced by 7/18 - now delayed). Help with flavor and shelf lifetime 2. Reduce intake of candy 3. Watch intake of cakes, cookies, brownies, pies, fruit cobblers and other desserts 4. Reduce intake of sweet rolls, pastries and doughnuts 5. Cut down on dairy desserts including ice cream and frozen yogurt NIH Dietary Guidelines for Americans 2015-2020

IF YOU ARE DEPRESSED

1. Depression can be crippling - ask for help if you find your mood is consistently preventing you from making self supportive actions 2. A hot beverage may be soothing 3. Starchy foods (oatmeal and raisin cookie with glass of warm milk) help tryptophan uptake by the brain

DIET PATTERNS D.A.S.H

1. Dietary Approaches to Stop Hypertension (DASH) rx a. Eating vegetables, fruits and whole grains b. Including fat-free or low-fat dairy products, fish, poultry, beans, nuts and vegetable oil c. Limiting foods that are high in saturated fat, such as fatty meats, full-fat dairy products, and tropical oils such as coconut, palm kernel, and palm oils d. Limiting sugar-sweetened beverages and sweets e. Sodium limited to 2,300 mg (1,500 mg lowers blood pressure even further) 2. Features a. Low in saturated and trans fat b. Rich in potassium, calcium, magnesium, fiber and protein c. Lower in sodium 3. Example of 2,000 calorie DASH diet: Grains 6-8 servings; meats, poultry and fish <6 ; vegetables 4-5; fruit 4-5; low fat or fat-free dairy products 2-3; fats and oils 2-3; nuts, seeds, dry beans, and peas 4-5; sweets <5

SCOFF - AN EATING DISORDER SCREENING QUESTIONNAIRE

1. Do you make yourself Sick because you feel uncomfortably full? 2. Do you worry that you have lost Control over how much you eat? 3. Have you recently lost more than One stone (14 lbs) in a 3- month period? 4. Do you believe yourself to be Fat when others say you are too thin? 5. Would you say that Food dominates your life? 6. 2 or more "yes" answers indicates likely to have an eating disorder 7. Ask about bulimia in a written form as part of a questionnaire, it will be easier to answer.

TO REDUCE ACID REFLUX AND GERD

1. Eat in a mindful manner to reduce stress 2. Reduce foods that cause acid backwash (reflux) which 3. irritates the lining of the esophagus a. Spicy foods b. Coffee c. Chocolate d. Hot temperature items e. Grapefruit f. Garlic or onion g. Peppermint h. Very fatty foods like a steak and cheese sandwich

TO REDUCE NAUSEA AND IMPROVE APPETITE

1. Eat small, easy to digest meals a. Plan ahead and keep ready to drink products available 2. Avoid unpleasant odors a. Prepare food in well ventilated areas 3. Ginger, Zingiber officinale may be helpful in reducing nausea a. Usual dosage is 250 - 1000 mg per day 4. Eat in a relaxed environment 5. Have food prepared in attractive and colorful way 6. Garnishes may be helpful like sprig of parsley or lemon wedge for added color and eye appeal

EATING PATTERNS: FROM DISORDERED EATING TO EATING DISORDERS

1. Eating disorder and disorders of eating are different 2. Feeding and Eating Disorders are characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychosocial functioning. Diagnostic criteria are provided for a. Pica b. Rumination Disorder c. Avoidant/Restrictive Food Intake Disorder d. Anorexia Nervosa e. Bulimia Nervosa f. Binge-Eating Disorder g. Other Specified Feeding or Eating Disorder h. Unspecified Feeding or Eating Disorder

REDUCE EXPOSURE TO HARMFUL BIOACTIVES CAUTION WITH PROCESSED MEATS

1. Eating processed meats often (more than once a week) increases the risk of colon cancer a. Processed meats include hot dogs, pepperoni sausage and other preserved meats; preservatives such as nitrites thought to be involved. b. HCA's (heterocyclic amines) are compounds that form on the surface of meat when cooked at a high temperature 2. Include vitamin C rich foods which inhibit nitrite formation 3. Marinade for 45 + minutes to reduce formation of HCA 4. Cook at a lower temperature most of the time

NUTRITION DURING PREGNANCY

1. Energy increased a. in 2nd trimester by 340 calories per day b. In 3rd trimester by 452 calories per day 2. Protein increased - 71 grams per day 3. Calcium RDA 1000 mg 4. Iron 27 mg 5. Folate 600 mcg

FOOD SOURCES OF CALCIUM

1. FISH: Salmon (canned), sardines (canned) 2. DAIRY: Yogurt, cheese, milk 3. LEGUMES: Tofu, soymilk 4. NUTS: Brazilnuts 5. SEEDS: Sunflower seeds 6. VEGETABLES: Collard greens, watercress, broccoli 7. GRAINS: Breakfast cereals (fortified), corn tortillas

INTERMITTENT FASTING

1. Fasting is voluntarily not eating food for varying lengths of time 2. Fasting is distinct from caloric restriction a. Intermittent fasting (IF) - alternate day or twice weekly b. Periodic fasting (PF) - lasting several days or longer every two or more weeks 3. Many religions include fasts a. Islam - fasting from dawn until dusk during Ramadan b. Christians, Jews, Buddhists and Hindus - designated days of the week or calendar year 4. Ask questions in a very respectful manor

US DIETARY GUIDELINES 2015-2020

1. Follow a healthy eating pattern across the lifespan. All food and beverage choices matter. Choose a healthy eating pattern at an appropriate calorie level to help achieve and maintain a healthy body weight, support nutrient adequacy, and reduce the risk of chronic disease. 2. Focus on variety, nutrient density, and amount. To meet nutrient needs within calorie limits, choose a variety of nutrient- dense foods across and within all food groups in recommended amounts. 3. Limit calories from added sugars and saturated fats and reduce sodium intake. Consume an eating pattern low in added sugars, saturated fats, and sodium. Cut back on foods and beverages higher in these components to amounts that fit within healthy eating patterns. 1. Shift to healthier food and beverage choices. Choose nutrient- dense foods and beverages across and within all food groups in place of less healthy choices. Consider cultural and personal preferences to make these shifts easier to accomplish and maintain. 2. Support healthy eating patterns for all. Everyone has a role in helping to create and support healthy eating patterns in multiple settings nationwide, from home to school to work to communities.

SUPPORT FOR HEALTHY DETOXIFICATION

1. Foods rich in organosulfur compounds support liver detoxification enzyme systems: a. Cysteine rich foods: i. Whey protein ii. Avocado iii. Dark rye (pumpernickel bread) iv. Spirulina and blue-green algae v. Seaweed 2. Vegetables from Allium and Cruciferous families 3. Asparagus 4. Artichoke hearts

HIGH WATER FOODS FOR HEALTH

1. Foods that contain natural water are more satisfying so you'll eat less calories. These are more perishable and less affordable 2. High water foods: Vegetables, Fresh Fruit and Beverages 3. Medium water foods: Meats, Eggs and Bananas We need about 3 liters of fluid a day a. 1 - 1.5 liters from water and beverages 4. Fatigue is one symptom of dehydration Ideal way to drink water is between rather than with meals 5. Press top of your hand - it should bounce back - if not you may be dehydrated 6. High water foods may provide more satiety

HEALTHY PEOPLE 2020

1. Healthy People is the National Health and Human Services science based focus for 10-year goals and objectives for health promotion and disease prevention 2. New focus area includes Genomics recognized as playing a role in 9 out of 10 leading causes of death including: a. Heart disease b. Cancer c. Stroke d. Diabetes e. Alzheimer's disease f. www.healthypeople.gov 3. My Family Health Portrait (good to know what conditions run in the family) a. An interactive tool from the Surgeon General with an option of sharing and reviewing with health care practitioners and family members b. https://familyhistory.hss.gov

BARRIERS TO EATING HEALTHILY

1. If you have little or no appetite 2. If you are nauseated 3. If you are constipated 4. If you have diarrhea 5. If you are depressed 6. If you are exhausted

TIPS FOR ADDING EXTRA PROTEIN

1. Include a protein smoothie in addition to your meals 2. Add milk, Greek style yogurt or whey protein (unflavored) to soups and use as a base for sauces 3. Keep hard boiled eggs in refrigerator and chop on top of salads or take peeled for quick snack 4. Use nut butters as spreads (almond butter or Nutella made with hazel nuts are good, nutrient dense ones) 5. Snack on low fat cottage cheese or string cheese 6. Add cubes of firm tofu or curd cheese to steamed or stir- fry vegetables

IRON: A KEY MINERAL FOR BLOOD HEALTH

1. Iron is essential for cell growth and differentiation 2. Iron delivers oxygen in the form of heme iron 3. Hemoglobin in red cells 4. Myoglobin in muscle 5. RDA for iron is 8 mg per day 6. RDA higher for menstruating women and during pregnancy 7. Tolerable Upper Limit (UL) is 45 mg per day 8. Supplemental iron is best absorbed as ferrous salts 9. Iron put used for nutrients in some cultures but can be too much

OTHER RELEVANT BIOMARKERS

1. Iron status a. Serum iron b. TSAT (serum iron/TIBC) c. Ferritin -- important test to occur once d. Hepcidin e. Don't have great zinc markers available 2. Chronic inflammation a. hs-CRP 3. Iodine sufficiency a. Urinary iodine concentration (UIC) b. Thyroglobulin

LEVELS OF OBESITY

1. Level I: BMI 30 - 34.9 2. Level II: BMI 35 - 39.9 3. Level III "extreme": BMI > 40 a. Resources for Weight-Control: Weight-control Information Network (WIN) at NIH National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK)

FOOD SOURCES OF MAGNESIUM

1. MEATS: Beef, dark meat poultry 2. FISH: Salmon, halibut 3. NUTS: Almonds, cashews, peanuts 4. SEEDS: Sunflower seeds, pumpkin seeds 5. GRAINS: Fortified breakfast cereals, oatmeal, brown rice 6. LEGUMES: Edamame, black beans 7. DAIRY: Yogurt 8. VEGETABLES: Spinach, broccoli, avocado

FOOD SOURCES OF ZINC

1. MEATS: Liver, lean meat, dark meat poultry, shellfish 2. FISH: Oysters and other shellfish 3. GRAINS: Fortified breakfast cereals, bran cereals, enriched breads, oatmeal 4. SEEDS: Sunflower seeds, pumpkin seeds 5. DAIRY: Yogurt NUTS: Pecans, walnuts

MAGNESIUM

1. Magnesium is a cofactor in more than 300 enzyme systems that regulate protein synthesis, muscle and nerve function, blood glucose control and blood pressure regulation 2. Magnesium is required for energy production, oxidative phosphorylation and glycolysis 3. Magnesium contributes to the structural development of bone 4. Magnesium is required for the synthesis of DNA, RNA, and glutathione 5. RDA for magnesium is 420 mg for men and 320 mg for women 6. Meta-analysis of prospective cohort studies detected a significant inverse association between magnesium intake and risk of type 2 diabetes 7. >400mg qday is a laxative

SUGAR

1. Many foods are naturally sweet and provide pleasure 2. Sugar and fat combined in an emulsion activate brain reward system 3. Naturally occurring sugars add pleasure to food 4. Added sugars particularly high fructose corn syrup have increased the sweetness of our diets since 1980's 5. Dietary Guidelines for Americans 2015-2020 recommend limiting added sugars to 10% of calories or 12 teaspoons (one soda contains 10 teaspoons) 6. 4.2 grams sugar per teaspoon (4 calories)

DIET PATTERNS, HEALTH AND TELOMERES

1. Mediterranean Diet (based diet of Crete prior to 1960) a. Vegetables, fruits, nuts, legumes, and grains (mainly unrefined); a high intake of olive oil but a low intake of saturated lipids, a moderately high intake of fish; a low intake of dairy products, meat, and poultry; and a regular but moderate intake of alcohol (specifically wine with meals) 2. Always go back to the source material of research to truly understand the diet 3. Alternate Mediterranean Diet (score 0-9 - 9 closest to MD) a. Vegetables (excluding potatoes), fruits, nuts, whole grains, legumes, fish, monounsaturated:saturated fatty acid ratio, red and processed meats, and moderate alcohol intake 4. Alternative Healthy Eating Index-2010 a. Foods and nutrients predictive of chronic disease risk 5. Telomere Length and Mediterranean Diet

NEW TERMINOLOGY FOR MICROBIOME ERA

1. Microbiome as an organ - human body as an ecosystem a. Gut microbiota b. Human Microbiome Therapeutics 2. Human gut ecosystem includes bacterial phyla: a. Bacteroidetes b. Firmicutes 3. Akkermansia genus a. Akkermansia Muciniphilia species 4. Crowd science project www.ubiome.com 5. Fecal Microbial Transplant (FMT) a. New therapy for treating refractory C. difficile infection

NUTRIENT AS MICRONUTRIENTS

1. Micronutrients are required in minute quantities for growth and healt 2. Micronutrients include vitamins, minerals and trace elements 3. Minerals: 22 essential 4. 7 required in 100 grams or more quantities per day 5. Calcium, magnesium, phosphorus, potassium, sodium, chloride and sulfur 6. Trace elements: required in amounts less than 100 grams a day 7. iron, copper, selenium, fluoride, iodine, chromium, zinc, manganese, molybdenum, cobalt, boron 8. Less studied minerals include silicon, lithium, vanadium and nickel 9. Vitamins: 13 - 9 water-soluble and 4 fat-soluble

RESEARCH-TESTED INTERVENTION PROGRAMS

1. New Moves school based physical education for adolescent girls a. www.newmovesonline.com/pdf/New_Moves.pdf 2. Strong Women-Healthy Hearts: for women aged 40 or older 12 weeks, 2 days a week, 1 hour physical activity class a. www.strongwomen.com 3. Promoting Healthy Living: Assessing More Effects: intervention program for firefighters including social-cognitive theory in 11 team sessions of 4 5minutes over one year a. www.phlameprogram.com 4. Body and Soul: program suitable for implementation in home and church settings for African American church members, aged 17-89 years. Program includes 3 nutrition activities designed to increase fruit and vegetable intake. "where faith and fitness meet" a. www.bodyandsoul.org

SUMMARY - what diet makes you feel best?

1. Nutrition is "the process of eating the right kind of food so you can grow properly and be healthy" 2. Patient assessment includes anthropometry, relevant biomarkers and knowledge of eating patterns and attitudes 3. Nutrition advice best integrates with lifestyle recommendations appropriate for budget and stage of life

OMEGA-3

1. Omega-3 fat (oil) is essential for health and has anti-inflammatory properties and supports nervous system health 2. Dietary sources: a. 18:3 (ALA )from plants (walnuts, chia, flax, etc.) b. 22:3 (EPA) and 24:3 (DHA) from fish, krill and algae c. EPA and DHA formed by enzymatic elongation of 18:3 3. Aim for ratio of omega6:3 of 4:1 4. Typical Western diet is about at least 15:1

DIARRHEA MANAGEMENT

1. Oral Rehydration Therapy (ORT) a. simple home made remedy i. 1 pinch salt (1.75 grams) in 2 1⁄2 Cups boiled water (should taste like tears) ii. Add 1 tablespoon sugar (20 grams) 2. CRAM (fortified cereal, rice, apple sauce, milk (or yogurt)) or BRAT for limited time to avoid zinc deficiency (banana, rice, apple sauce and toast)

PRACTICE POINTERS

1. Personalized responses to opiate pain medications; prevent constipation 2. Healthy ecology of colon involves appropriate dietary fiber as well as probiotic intake. Check intake of both is satisfactory 3. Evaluate serum Vitamin D status a. Ideal 50 - 90 nanograms per milliliter (from Nurse's Health Study nested study) 4. ICD-10 categories of malnutrition E40-E46

WHAT ARE PREBIOTICS?

1. Prebiotics are non-digestible food ingredients that beneficially affect the host by selectively stimulating the growth and/or activity of one or a limited number of bacteria in the colon, and thus improve host health a. Inulin and resistant starch 2. Selection of prebiotics should be by 3 criteria: a. 1) Be resistant to degradation by stomach acid, enzymes or hydrolysis b. 2) Fermented by intestinal microbes c. 3) Selectively stimulate growth and/or activity of beneficial microorganisms in the gut FOS and GOS are examples

LIFE CYCLE AND NUTRITION

1. Prenatal Nutrition 2. Lactation and Nutrition 3. Nutrition in Infancy, Childhood and Adolescence 4. Adult nutrition 5. Nutrition for Seniors a. Chronic conditions are more frequent in older population i. Cancer ii. Cardiovascular disease iii. Renal disease

Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016

1. Prevalence estimates reflect BRFSS methodological changes started in 2011. These estimates should not be compared to prevalence estimates before 2011. 2. *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) ≥ 30%. 3. Self-reported obesity in the Midwest and south 4. 1980s: high fructose corn syrup and introduction of AC (this is around the same time as the obesity epidemic) a. Body was working harder to regulate temp, but with AC body not working as hard

WHAT ARE PROBIOTICS?

1. Probiotics are living microorganisms which, when administered in adequate amounts, confer a health benefit on the host 2. Probiotics (Bios is Greek for "Life") opposite of antibiotics 3. Bifidobacterium and Lactobacillus genus a. New dietary supplements from this technology include specific strains of Bifidus Spp and/or Lactobacillus Spp, e.g. Activia® yogurt and supplements Align ® and Culturelle b. A good yogurt should contain 20 billion cfu (colony forming units) per 8 fl oz serving

NUTRITION AS MACRONUTRIENTS

1. Protein a. Based on your lean mass - most people need 60-80 grams a day b. Typical meal is usually about 25 grams c. Protein is found in fish, meat, poultry, Greek yogurt, cottage cheese, tofu, beans and grains like quinoa and wheat germ 2. Fats and oils: low fat diet is no longer important because you don't want to make them omega 3 or 6 deficient a. Omega-6:Omega-3 ratio ideally 4:1 b. Omega-9 in olive oil is beneficial for cardiovascular health c. Walnuts, olives, oily fish, grapeseed oil rich in omega-3 and GLA 3. Carbohydrates a. Complex not simple are ideal b. Beans, brown rice, 100% whole grain breads and pasta 4. To keep healthy cells healthy, protein is very important. Provides nutrients that contain nitrogen.

BIOMARKERS OF NUTRITIONAL RELEVANCE

1. Protein status a. Serum albumin b. Serum prealbumin c. Serum transferrin d. Serum Vitamin B12 (indicator of animal protein. If vegan need V12 supplement. Also people with PPI can also be B12 insufficient) 2. Calcium status a. Bone density (optimal is around 30 so when someone gets to menopause need to look at baseline so you can monitor going further) 3. Vitamin D status a. Serum 25 Hydroxy Vitamin D (25(OH)D)

CALCIUM

1. RDA for calcium is 1000 mg for men and women < age 70 for men and 51 for women; 1200 mg for 70 and older 2. Calcium needs are increased in postmenopausal women due to greater bone loss and reduced capacity to absorb dietary calcium 3. Women who exercise heavily, eat too little, or both 4. Those with lactose intolerance or who avoid dairy products such as vegans or ovo-vegetarians 5. Diets high in oxalic acid and phytic acid reduce calcium uptake Try to get calcium from diet

NUTRITION RESOURCES

1. Recommended textbooks a. Krause's Food, Nutrition & Diet Therapy, 14th edition b. Nutrition: Diagnosis-Related Care, 8th edition c. Nutrition in Clinical Practice, 3rd edition by David L Katz, MD, MPH 2. Recommended newsletters a. Nutrition Action (Center for Science in the Public Interest) b. Berkeley Wellness c. Nutrition Update (Harvard School of Public Health) 3. Recommended websites a. ClinCalc.com/Nutrition/Analysis b. Nutrition.org

SELENIUM

1. Selenium is a nutritionally essential trace mineral 2. Found in soil and converted in plants to organic forms associated with sulfur amino acids 3. Western US has a high selenium content of the soil 4. Richest dietary sources are Brazil nuts, meats, fish, eggs and cereals; Selenium is also found in cruciferous vegetables, garlic and mushrooms 5. Supplements are selenized yeast or selenomethionine (yeast grown in a selenium rich medium)

SODIUM AND SALT RECOMMENDATIONS

1. Shopping in the grocery store: shop around the outside of the store because all the sodium is in the middle of the store 2. Americans consume ~50% more sodium than most experts recommend 3. According to the CDC, 75% sodium in American diet comes from dining out, prepared foods and processed foods; 5% comes from home- cooking process; 6% from salt added at the table 4. FDA draft guidance for reducing salt in commercial and processed foods, June 2016 5. Goal of lowering average daily intake from 3,400 mg to 2,30o mg 6. Adults over 51 years, those of any age who are African American or have hypertension, diabetes, or chronic kidney disease should further reduce intake to 1,500 mg per day 7. Intakes below 1,300 mg for adults and 1,200 mg for seniors are not recommended

FOOD AND EATING PATTERNS: INDIVIDUALITY

1. Some people Eat to Live others Live to Eat (find out what people enjoy) 2. Some focus on a spiritual context of eating a. Obey rules such as Kosher, Halal meat, vegan, etc. b. Fast (no food or food restrictions) or eat symbolic foods 3. Some focus on physical aspects of food a. Body builders b. Those with digestive health challenges 4. Others focus on food and mood a. Memories linked to pleasure b. Foods and beverages for alertness c. Comfort foods

NUTRITION AND SENIORS

1. Special considerations 2. Osteopenia and osteoporosis (bone density and bone health) a. Assess Vitamin D status b. Supplement with bone health nutrients calcium, magnesium, zinc, boron and silica 3. Renal health a. Diet low in sodium, phosphorus and potassium 4. Oral health a. Diet choices may be restricted if oral health is poor 5. Depression and unintentional weight loss (mental health: pt comes in and they aren't doing everything they should be doing. If they are depressed they don't have the motivation to do it so need to address the mind, body and spirit). People feel a sense or quilt and shame which is counter productive 6. Monitor, evaluate and treat as appropriate

CARBOHYDRATES: SUGAR AND STARCH

1. Sugars are found alone or in the form of starch Refined wheat or corn flour are digested similarly to sugar - whole grains due to dietary fiber slow down absorption 2. Glycemic Index (GI) and Glycemic Load describes glucose absorption rates - dietary fiber is a "good carb" reducing GI and improving insulin sensitivity 3. Restrict added sugars to < 12 teaspoons or 50 grams 1 teaspoon sugar = 4.2 grams or 16 calories

ARE NON TASTERS MORE LIKELY TO BE OVERWEIGHT?

1. Taste perception may affect weight 2. 350 individuals divided into 4 groups by BMI a. A - underweight (16%) - b. B - normal (35%) c. C - overweight (28%) d. D - obese (21%) 3. Groups C and D (overweight and obese)- 81% and 82% non-tasters contrast with 28% non-tasters of PTC in Group B

ARE YOU A SUPERTASTER?

1. Taste sensitivity varies - 50-150 taste receptor cells in taste buds on fungiform papillae Supertasters have 100 times more taste receptors and are more sensitive to the 5 taste flavors Sweet, Sour, Salty, Bitter and Umami 2. Supertasters also have subtle differences in the CNS gustatory cortex and a heightened sense of smell 3. Bitter flavor PROP (6-n-propylthiouracil) and PTC phenylthiocarbamide (PTC) are detected by Supertasters 4. Some people avoid bitter vegetables like broccoli as a result 5. Try the taste papers - what do you taste? a. TAS2R38 codes for a taste receptor. Variants in this and other taste receptor genes affect your perception of bitter and other flavors

IF HEALTHY EATING BECOMES OBSESSIVE

1. The Bratman Test for Orthorexia 2. Do you spend more than 3 hours a day thinking about your diet? 3. Do you plan your meals several days ahead? 4. Is the nutritional value of your meal more important than the pleasure of eating it? 5. Has the quality of your life decreased as the quality of your diet has increased? 6. Have you become stricter with yourself lately? 7. Does your self-esteem get a boost from eating healthily? 8. Have you given up foods you used to enjoy in order to eat the 'right' foods 9. Does your diet make it difficult for you to eat out, distancing you from family and friends? 10. Do you feel guilty when you stray from your diet? 11. Do you feel at peace with yourself and in total control when you eat healthily? Yes to 4 or 5 of the above questions means it is time to relax more about food. Yes to all of them means a full-blown obsession with eating healthy food

Chronic disease prevention and health promotion

1. The Centers for Disease Control and Prevention chronic program notes 7 out of 10 deaths each year are due to chronic diseases a. Adopting positive health behaviors and accessing preventive health-care services can reduce morbidity and mortality 2. Surveillance of chronic diseases includes BRFSS (Behavioral Risk Factor Surveillance System) a telephone health survey system self-reported telephone interview a. Monitoring includes a cross-sectional, random-digit-dialed, state-based survey of >400,000 adults. Interviews completed annually 3 section BRFSS questionnaire; post 2011 both landline and cell phones used 3. Inform, inspire and uplift your patients. Want to encourage your patients.

CRUCIFEROUS (BRASSICA) VEGETABLES

1. The cabbage family have flowers in shape of cross (crucifers) hence the name 2. Brassica oleracea includes broccoli, cabbage and kale 3. Brassica napus includes mustard and rapeseed (Canola oil) 4. Radish, horseradish (wasabi) and watercress are also part of the Brassicaceae (Cruciferae) genus of plants 5. Watercress is especially healthful and has anticarcinogenic properties 6. Cabbage family vegetables support natural detoxification processes (reduce effects of neurotoxins) 7. Too much kale will inhibit thyroid because it's a goytrogen(?)

BIOACTIVES

1. Things that have activity in your body beyond making energy for your body 2. Each day we are exposed to some 23,000 bioactive compounds 3. Some are beneficial and some are not 4. Beneficial ones include botanicals and phytonutrients a. Lycopene in tomato, guava and pink grapefruit b. Alpha and beta glucans in mushrooms c. Sulfur and seleno- proteins in cruciferous and allium vegetables d. Curcumin

MANAGEMENT OF ALTERED PERCEPTIONS OF TASTE AND SMELL

1. To avoid food aversions caused by nausea and vomiting after chemotherapy, avoid food for one to two hours before and up to three hours after chemotherapy. In addition, avoiding favorite foods just before chemotherapy helps prevent aversions to those foods 2. Rinse with a salt and baking soda solution before meals to help neutralize bad tastes in the mouth (1⁄2 teaspoon of salt and 1⁄2 teaspoon of baking soda dissolved in 1 cup of warm water)

DIET PATTERNS

1. USDA Food Patterns and the Dietary Guidelines 2015-20201 describe food pattern goals for healthy eating 2. Energy levels (12 ranging from 1000 to 3000 calories) 3. Nutrient goals for 12 vitamins, 9 minerals and 8 macronutrients 4. Other Diet Patterns: 5. Vegetarian (ask patients what they mean by vegetarian—everyone has their own definition) a. Lacto-vegetarian includes cheese and dairy products b. Lacto-ovogetarian also includes eggs c. Semi-vegetarian includes chicken and fish but no red meat d. Vegan (total vegetarian) includes only foods from plants (fruits, vegetables, legumes, grains, seeds and nuts) 6. Macrobiotic a. 50% whole cereal grains (brown rice, millet, whole wheat, barley, corn, etc.) b. 25-35% Vegetables c. 5-10% Beans and sea vegetables d. 5-10% Soup e. Fish and seafood (optional)

VITAMIN D

1. Vitamin D is a fat soluble vitamin with hormone like properties 2. Vitamin D promotes calcium absorption and is important in bone health 3. Vitamin D is also important in immunity and plays a regulatory role in reducing inflammation 4. Vitamin D modulates genes encoding proteins that regulate cell proliferation, differentiation and apoptosis 5. Many cells have Vitamin D receptors (some also bind Vitamin A or other steroids along with Steroid Receptor Element (SRE) and zinc or boron). There is cross talk between Vitamin D Receptors (VDR) and PPAR signaling pathways 6. A blood test of 25-hydroxy Vitamin D is valuable at identifying those with high needs (<30 nmol/L or <12 ng/mL) 7. RDA is 600 IU and Tolerable Upper Limit (UL) 4,000 IU

VITAMIN K FOR BLOOD CLOTTING HEALTH

1. Vitamin K is a fat soluble vitamin 2. RDA is 75 mcg 3. 1 cup of a green leafy vegetable like Kale provides more than 100% RDA

CHILDREN'S ACTIVITY AND NUTRITION

1. We Can! Ways to Enhance Children's Activity & Nutrition (HHS) Resources for Parents and Community Members 2. Toni Yancey, PhD (1957-2013) Professor, UCLA Fielding School of Public Health www.instantrecess.com 10 minute activities Instant Recess breaks (on You Tube) a. Hip Hop b. New Orleans style 3. Let's Move www.letsmove.gov 4. America's Move to Raise A Healthier Generation of Kids Initiative launched by the First Lady Michelle Obama Toni Yancey served on the board of The Partnership for a Healthier America

PRACTICE POINTERS 2

1. Weight, especially lean mass, is an important indicator of overall health status during treatment 2. Improve digestive health with a soft diet 3. Consider digestive enzyme supplements 4. Maintain physical activity using core strength training (resistance bands for example), yoga, etc. for bone health 5. Integrate nutrition with other modalities to support quality of life

WITH FAT, IT'S ALL ABOUT INTAKE

1. What we eat (type of fat) is reflected in our body fat 2. Brain, retina and nervous tissue are about 1:1 omega-3 to omega-6. Most other tissues vary with diet 3. Range or grass fed animals have higher omega-3 in their fat than intensively farmed animals 4. Almost all animals are now "finished" by eating corn prior to slaughter which raises the arachidonic acid (omega-6) content of their fat 5. Ideal omega 6: omega 3 ratio is 4:1 - best achieved by increasing omega-3 and decreasing arachidonic acid

HEART DISEASE AND STROKE PREVENTION

1. What you can do to prevent heart disease and stroke: a. Eat a healthy diet b. Maintain a healthy weight c. Exercise regularly d. Don't smoke e. Limit alcohol use 2. If you have high cholesterol, high blood pressure, or diabetes, there are steps you can take to lower your risk of heart disease: a. Have your cholesterol checked b. Control blood pressure c. Manage your diabetes d. Take your medicine e. Talk with your health care team

ZINC AND ACCURATE DNA REPLICATION

1. Zinc plays an essential role in DNA synthesis and cell division. "Zinc fingers" are regulatory areas of the genome 2. Zinc is a cofactor in ~2,000 enzymes 3. DNA is crucial for healthy immune functioning and wound healing 4. RDA for zinc is 11 mg for men and 8 mg for women; Tolerable Upper Limit (UL) is 40 mg 5. Vegetarians and vegans require higher intakes of zinc as it is less bioavailable in a diet rich in legumes and whole grains 6. Prospective study of zinc intake suggests a reduction in risk of type 2 diabetes in women (Nurse' Health Study) 7. Too much zinc off sets ratio between zinc and copper

COLON - WHERE GUT MICROBIOTA THRIVE

1. ~60% immune cells line the gastrointestinal tract; organized lymphoid structures in small intestine (Peyer's Patches) 2. Gut microbiota estimated at 100,000 trillion bacteria -~500 species of bacteria or about 1.3:1 microbial to human cells 3. Other microbes include archaea, fungi, viruses and protozoa 4. Most bacterial cells in fecal specimens cannot be grown in culture 5. 16S-rRNA (ribosomal RNA) identification 6. Symbiotic relationship between gut bacteria and their host 7. In healthy adults, fecal composition is stable over time - microbial diversity between individuals is great. Each individual harbors a distinctive pattern set at birth and soon thereafter 8. The first two years of life program microbiota for the rest of your life. Probiotics can be helpful for some and not others

GLYCEMIC LOAD, BLOOD SUGAR AND FATIGUE

a. Eat small, frequent meals with sufficient protein b. Avoid sugar sweetened beverages without having a fiber rich snack at the same time (lowers glycemic load) c. Staying physical active improves mood and fatigue levels d. Protein, iron, zinc, B vitamins and Vitamin C all important for red cell production to minimize anemia, one cause of fatigue e. Drink organic green or black tea as a healthy stimulant i. some people are sensitive to caffeine and similar stimulants so avoid after 3 PM

FOODS TO PURCHASE ORGANIC "THE DIRTY DOZEN"

• Strawberries • Apples • Nectarines (imported) • Peaches • Celery • Grapes • Cherries • Spinach • Tomatoes • Cucumbers • Cherry • Tomatoes • Sweet bell peppers

BODY-MASS INDEX AND ALL-CAUSE MORTALITY

• Low BMI, low risk for mortality • High BMI, high risk for mortality • BMI is a J shaped curve so if weight too low then also at risk for mortality