Functional Nutritional Evaluation August 2, 2007
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1 NUTRITIONAL EVALUATION: Understanding Your Patients Nutrition & Supplement Needs Christian Renna, DO Director, LifeSpan Medicine Dallas, TX BRFSS, 1985 No Data <10% 10% 14% BRFSS, 1986 No Data <10% 10% 14% 1
2 BRFSS, 1987 (*BMI 30, or ~ 30 lbs. overweight for 5 4 person) No Data <10% 10% 14% BRFSS, 1988 No Data <10% 10% 14% BRFSS, 1989 No Data <10% 10% 14% 2
3 BRFSS, 1990 No Data <10% 10% 14% BRFSS, 1991 No Data <10% 10% 14% > 15% BRFSS, 1992 No Data <10% 10% 14% > 15% 3
4 BRFSS, 1993 No Data <10% 10% 14% > 15% BRFSS, 1994 No Data <10% 10% 14% > 15% BRFSS, 1995 No Data <10% 10% 14% > 15% 4
5 BRFSS, 1996 No Data <10% 10% 14% > 15% BRFSS, 1997 No Data <10% 10% 14% 15% 19% > 20% BRFSS, 1998 No Data <10% 10% 14% 15% 19% > 20% 5
6 BRFSS, 1999 No Data <10% 10% 14% 15% 19% > 20% BRFSS, 2000 No Data <10% 10% 14% 15% 19% > 20% BRFSS, 2001 No Data <10% 10% 14% 15% 19% 20% 24% 25% 6
7 BRFSS, 2002 No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2003 No Data <10% 10% 14% 15% 19% 20% 24% 25% BRFSS, 2004 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% 7
8 BRFSS, 2005 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% BRFSS, 2006 No Data <10% 10% 14% 15% 19% 20% 24% 25% 29% 30% Nutritional Evaluation or... What foods should I eat? What vitamins should I take? 8
9 Learning Objectives: Learn/ discuss tools to differentiate macronutrient needs Learn and implement tools to differentiate and determine micronutrient needs vitamins, minerals, and anti-oxidants. Understand laboratory assessments, both conventional and esoteric markers, to assess nutritional needs. Assessing Nutritional Status Epidemiology (NHANES) Clinical Experience Laboratory Measures Objective Data Motivational for Patients Individualized Treatment Facilitates Monitoring & Follow-up 9
10 Spot The Healthy Person Optimist Approach Fatalist Approach Eat right, exercise, die anyways. Bumper Sticker 10
11 Decreasing Nutrient Density foods (mainly vegetables) 13 nutrients measured 6 significantly low Biggest drop 37% Did not measure trace minerals! Davis DR, et al. J Am Coll Nutr 2004; 23: Decrease in Minerals Commonly eaten foods Vegetables 27 Fruits 17 Meats 10 Dairy 2 Fish no data Every mineral, except phosphorous in fruits and vegetables (fertilizer) and sodium in dairy decreased significantly Trace minerals worst Cu down 77% in vegetables 10% 0% -10% -20% -30% -40% -50% -60% -70% -80% Veg Frt Mt Dry Na K P Mg Ca Fe Cu Zn Thomas D. Nutr Health 2003;17: From the Farm to the Kitchen Table: A Review of the Nutrient Losses in Foods Ramberg J, McAnalley BH GlycoScience & Nutrition 2002 Vol. 3, No. 5 11
12 12
13 Biochemical Individuality Roger Williams first coined the term biochemical individuality in 1956 to explain genetic variability in disease susceptibility, nutrient needs, and drug responsiveness among otherwise seemingly healthy people Williams RJ. Biochemical Individuality: The Basis of the Genotropic Concept. New York, NY: John Wiley; Proteins: proteos = first, primary Proteins are the basic constituents of all living cells and hence of all living things 9/20 are essential amino acids that must be consumed in the diet or functional imbalances and disease will result 11/20 are non-essential or conditionallyessential and can be made by adding an amino group to an organic acid Assessing MacroNutrient Needs Protein/ Nitrogen Needs: Calculate Nitrogen Balance Serum Albumin Essential Amino Acids Plasma (fasting) Urine (24hr or FMV) 13
14 Amino Acid Inadequacies May Result From Restricted protein diet Insufficient stomach acid Inadequate gastric & pancreatic digestive enzymes (proteases) Increased loss due to stress acute stress increases protein breakdown by >20% Vitamin and mineral insufficiencies Brillon DJ, et al. Am J Physiol 1995, 268:E Essential Amino Acids At A Glance Arginine: urea cycle, nitric oxide, insulin Isoleucine: structural proteins Leucine: structural proteins, insulin release Lysine: structural protein building muscle Methionine: methylation and sulfation Phenylalanine: catecholamines, thyroxin Threonine: glycoproteins, malabsorption Tryptophan: serotonin, melatonin, NAD Valine: structural proteins Conditionally Essential Amino Acids Cysteine: glutathione, CoA, sulfation Histidine: histamine, hydrochloric acid Taurine: neurotransmitters, antioxidant, energy, bile, Magnesium Tyrosine: catecholamines, thyroxin Glutamine: Small intestine repair, stress response 14
15 Clinical Uses of BCAAs Wound and connective tissue repair (excellent post-surgery treatment) Diabetes and hyperglycemia (promotes insulin release from the pancreas) Builds muscle (with exercise) 43 Assessing MacroNutrient Needs Essential Fats: Found within cellular membranes prbcs (17 day average) Plasma (past 24 hours) Whole Blood (same as prbcs) Fatty acid imbalances significantly affect: cellular communication inflammatory disorders neuro-behavioral issues Maternal-fetal-infant development Laboratory Assessment of EFA Imbalances Measure Ω -6 fats vs. Ω -3 fats 3/6 Ratio = EPA/ Arachidonic Acid Omega-3 Index* = EPA + DHA [8-10] Biochemical individuality altered delta-6 desaturase activity micronutrient deficiencies (B 3, B 6, C, Zn, Mg) Saturated fats levels Trans-fatty acid levels * Harris WS et al. Prev Med 2004;39:
16 Fatty Acid Metabolic Pathways The Two Greatest Challenges Facing Medicine Today 1.Prevention: how do we prevent illness before it occurs and maintain health as long as possible 2.Personalization: how do we move beyond assembly line medicine and treat whole individuals 47?Questions?, 16
17 Biochemical Individuality Our analysis of metabolic disease that affects cofactor binding, particularly as a result of polymorphic mutations, may present a novel rationale for high-dose vitamin therapy, perhaps hundreds of times the normal dietary reference intake (DRI) in some cases... Feeding high doses of the vitamin raises the tissue cofactor concentrations and thereby increases the activity of the defective enzyme. Ames, BN et al. Am J Clin Nutr. 2002;75: You are here! 17
18 Assessing MicroNutrient Needs B-Vitamins Minerals Nutrient Toxic Anti-Oxidants Fat-soluble Water-soluble Vitamin D (not really a vitamin!) Assessing MicroNutrient Needs B-Vitamins Individual Bio-markers: MethylMalonic Acid [B12] Formiminoglutamic Acid [Folic Acid] Homocysteine [Methylation Cycle] Multiple markers Metabolomics Organic Acids Amino Acids Fatty Acids Assessing MicroNutrient Needs Metabolomics Organic & Amino Acids 18
19 Organic Acids for Cofactor Need B6 (Low): AKIV AKIC AKBM 4-HPPA homogentisic acid oxalic acid 5-HIAA (High): Orotic acid oxalic acid kynurenic acid B3 (Low): quinolinic acid orotic acid glutaric acid (High): AKIV AKIC AKBM AKAA orotic acid pyruvic acid B2 (Low): orotic acid MHPG VMA glutaric acid (High): succinic acid AKIV AKIC AKBM AKAA orotic acid pyruvic acid B1 (High): AKIV AKIC AKBM AKAA oxalic acid pyruvic acid Organic Acids for Cofactor Need Mg (Low): pyroglutamic acid glutaric acid (High): AKIV AKIC AKBM 3-HPA quinolinic acid AKAA orotic acid pyroglutamic acid pyruvic acid B12 (High): MMA 3-HPA Cu (Low): homogentisic ac (High): 4-HPPA MMA 3-HPAA Folic acid (High): FIGlu orotic acid Lipoic acid (Low): glutaric acid (High): AKIV AKIC AKBM AKAA pyruvic acid Vit C (Low): homogentisic acid (High): 2-HPAA Make everything as simple as possible, but not simpler. Albert Einstein 19
20 Assessing MicroNutrient Needs Metabolomics Organic & Amino Acids Assessing MicroNutrient Needs Anti-Oxidants Oxidative stress is linked to premature aging. Assess oxidative stress to evaluate the body s antioxidant reserve and oxidative injury. RESERVES: Glutathione (GSH) whole blood DAMAGE: Fats = Lipid Peroxides DNA = 8-OHdeoxyGuanosine Inflammation and oxidative stress are two sides of the same coin! Sed rate (ESR) & hs-crp Inflam-Aging 20
21 Effective Treatment Nutritional Anti-Oxidants (Vit A, C, E) Glutathione, alpha-lipoic Acid Plant-based Anti-Oxidants Resveratrol EpiGalloCatechinGallate (EGCG) Many, many, many others Mineral Co-Factors Amino Acid Balance and Protein Digestion Proper Methylation Function (B-Vitamins) Eat Your Vegetables! Vitamin D IT S NOT EVEN A VITAMIN, it is a STEROID HORMONE! produced in skin from sunlight consumed in the diet (fatty fish & milk) Insufficiency and deficiency common b/c: Malabsorption Decreased sun exposure Obesity decreases bio-availability Measured by serum [25(OH) Vitamin D] Vitamin D Deficiency = <32 ng/ml (80 nmol/l) Insufficiency = ng/ml ( nmol/l) Optimal = ng/ml ( nmol/l) Excessive = >100 ng/ml (250 nmol/l) 21
22 SO, Doctor... How does it really work in practice? Patient History Case Study 43 yo Female Increasing fatigue for past 11 years Meets CFIDS criteria; also Dx Depression No Meds Nutritional Supplements: Omega 3 fish oil, 3-4gm daily Other Supplements intermittently Initial testing: CBC & CMP = normal TSH = normal hs-crp < 1.0 Ht. = 5 2 Wt. = 127# BMI = 23.2 Results Overview 22
23 Supplement Schedule Antioxidants Functional Nutritional Evaluation Personalized Treatment Anti-Oxidants Evidence of borderline need for: Vitamin A/ 5,000 IU qd Vitamin E/ 200 IU qd 60mg qd Alpha-Lipoic 100mg qd Plant-based Anti-Oxidants Reflects overall need for anti-oxidant support via foods and plants 23
24 B Vitamins Functional Nutritional Evaluation Personalized Treatment B-Vitamins Borderline need for B-Vitamins 25mg qd 25mg qd 30mg qd B-12 AdenosylCobalamin 500mcg SL qd Folinic Acid 1200 mcg qd Minerals 24
25 Functional Nutritional Evaluation Personalized Treatment Minerals Add Zinc 20mg qd Add Magnesium 300mg BID Functional Nutritional Evaluation Personalized Treatment Bottom Line Whole foods diet with elimination/ challenge Improve digestion with Zinc & Pancreatic Enzymes Add Probiotics & fermented food to support gut Support energy production and Mitochondrial pathways with: Anti-Oxidants (Vitamins A&E, CoQ10, alpha Lipoic Acid) B-Vitamins (B 1, B 2, B 3, B 12, Folate) Minerals (Magnesium) Maintain Fish 3-4gm qd Vitamin D should be evaluated 25
26 Functional Nutritional Evaluation Personalized Treatment 3 months Fatigue much improved Diet improved and increased exercise tolerance Repeat NutrEval shows decreased need for: Anti-Oxidants (Vit A&E, CoQ10) B Vitamins (B 1, B 2, B 3, B 12, and Folate) Minerals (Mg, Zn) Continue same therapeutic approach at lower doses and follow-up with patient in 6-12 weeks X X X X X 26
27 X X X X Diagnosis = Fatigue & Depression Investigate Underlying Dysfunction Nutritional Decreased energy production (Krebs Cycle) B-Vitamin deficiencies Nutrient elements deficiencies Hormonal Abnormal Adrenal Function Abnormal Thyroid Function Gastrointestinal/ Immune Digestion/ Absorption Imbalance Inflammation/ Immune Dysregulation 27
28 FOOD AS MEDICINE It is very difficult to be simple enough to be good. Henry David Thoreau NUTRITIONAL EVALUATION: Understanding Your Patients Nutrition & Supplement Needs Christian Renna, DO Director, LifeSpan Medicine Dallas, TX 28
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