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FUNCTIONAL NUTRITON COURSE
Applying Functional Nutrition for Chronic Disease Prevention and Management:
Bridging Nutrition and Functional Medicine in 21st Century Health Care
Follow Up Webinar #3 y
January 20, 2011
Elizabeth Boham, MD, MS, RD
Common Conditions Managed Through Functional Nutrition: Osteoporosis and Food Allergies / Intolerances
Common Conditions Managed through Functional Nutrition
• January 6, 2011 5 pm PST ‐ Michael Stone
– Inflammatory and Respiratory Conditions and Depression/Anxiety
• January 14, 2011 5 pm PST ‐ Ruth DeBusk
– Hypertension and GERD
• January 20, 2011 5 pm PST ‐ Elizabeth Boham
– Osteoporosis & Food Allergies/Intolerances
• January 27, 2011 5 pm PST ‐ Mary Willis
– Overweight/Obesity and Dyslipidemia
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Elizabeth Boham, MD, MS, RD
Functional Nutrition Protocols
OSTEOPOROSIS
OSTEOPOROSIS
FOOD ALLERGIES/ SENSITIVITIES/ INTOLERANCES
Elizabeth W. Boham MD, MS, RD
ADIME
✔Assess
Diagnose
Intervene
Monitor &
Evaluate
The ABCDs
Of
Nutritional
Assessment
Anthropometric
Biomarkers & Labs
Clinical Indicators
Diet and Lifestyle Assessment
A
B
C
D
• Anthropometrics
OSTEOPOROSIS
– Loss of height
– % lean body mass and fat mass
• Biomarkers
– 25 OH Vit D
– Undercarboxylated osteocalcin
– Bone Resorption Assay
• Clinical Indicators
–
–
–
–
Nutrition focused physical exam
Kyphosis
Sarcopenia
Acid Blockers
A
Anthropometrics
• Diet Assessment
Diet Assessment
– Acidity vs alkalinity of diet
– Important bone nutrient intake
– History of restriction
A D I M E
Osteoporosis
Anthropometrics
BioMarkers & Labs
Clinical Indicators
Diet and Lifestyle Assessment
P O M F
B
Biomarkers & Labs
& Labs
Anthropometrics
BioMarkers & Labs
Clinical Indicators
Diet Assessment
A B
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V
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X
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A
T
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N
T
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POM FAB
Why Low Protein?
•
•
•
•
• Protein – Total Protein, albumin, prealbumin, amino acids ,
,p
,
• Oils
• Minerals
– RBC magnesium, ionized calcium, phosphorus • Fat Soluble Vitamins
Decreased intake
Maldigestion (achlorhydria low protease)
Maldigestion (achlorhydria, low protease)
Malabsorption
Increased use
A
D
I
M
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– Chronic infection – Toxin
– Excessive exercise
– 25 OH vitamin D, 1/25 diOH vitamin D, Vitamin K,
Undercarboxylated
y
osteocalcin
• Antioxidants
• B Vitamins
– MMA, homocyteine
A D I M E
Osteoporosis
Protein Digestion
Stomach
Pyloric valve
Enterocytes
Small Intestine
A
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Vitamin D Metabolism
A
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Vitamin D
Classification
Deficient
Insufficient
Sufficient
ng/dL vitamin D
<20 <30
30‐50
nmol/L vitamin D
<50
<75
75‐125
Optimal
50‐80
125‐200
A
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Holick, MF. Curr Diag Targets. Aug 27 2010.
Look at 1,25 diOH Vitamin D if…
Look at 1,25 diOH
Vitamin D if…
• Unable to increase 25 OH Vitamin D level
• Immune deficiency / autoimmune disorder / infection / cancer
Testing for Vitamin K Deficiency
• Plasma
Plasma vitamin K ‐
vitamin K phylloquinone< 1nmol / L phylloquinone< 1nmol / L
• Prothrombin time > 12 sec = vit K deficiency
• Undercarboxylated osteocalcin – functional marker > 20% total osteocalcin
– Vitamin K is required for carboxylation of osteocalcin so the osteocalcin can bind to calcium and deliver it into the bone
osteocalcin can bind to calcium and deliver it into the bone for bone formation
Booth SL. Nutr Rev. 1997 Jul;55(7):282‐4.
1:1 ratio of 1,25 diOH to 25 OH Vitamin D proposed
Biochem Pharmacol. 2010 January 1; 79(1): 1–9
A
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Optimal Amounts Depend on Physiological I
Need
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“Finally, our current findings in elderly women support the observation that vitamin K intakes greater than the
recommended dietary vitamin K AI l l
i dt
K AI levels are required to support maximal osteocalcin ‐
carboxylation. “
Booth et al. J Nutr 133 (8): 2565. (2003)
Other labs to consider…
• PTH, ionized calcium, phosphorus
p
p
• Celiac panel • hsCRP
• Thyroid panel, thyroid antibodies
• DHEA‐s
• Gonadal hormones
• Genetic testing – VDR, HLA DQ2/8, MTHFR
Osteoporosis
• Bone resorption assay –
pyridinium and py
deoxypyridinoline
• food allergy / sensitivity testing
• estrogen metabolism assay
• organic acids
organic acids
• stool test for infection and absorption
• heavy metal testing A D I M E
A
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Low vitamin D, low calcium from diet, renal insufficiency and possibly acidic diet, high phosphorus diet, high protein diet Secondary Hyperparathyroidism Osteoclasts break down bone to increase calcium in blood
C
Clinical Indicators
Hadley & Levine, 2006
Osteoporosis
A D I M E
Anthropometrics
BioMarkers & Labs
Clinical Indicators
Diet Assessment
SARCOPENIA AND OSTEOPOROSIS
SARCOPENIA
= Decrease in lean body mass seen with aging
•
•
•
•
Decreased metabolic rate
Increased risk of fractures / falls
Increased risk of fractures / falls
Increased morbidity
Loss of independence
• Assess activity / exercise • Assess nutritional status
Assess nutritional status
•
Osteoporosis
A D I M E
Genaro, Pde and Martin, LA. Effects of protein intake on bone and muscle mass in the elderly. Nut Rev. 2010 Oct;68(10):616‐23. Osteoporosis
A D I M E
Milk Intake and Risk of Hip Fracture in Men and Women: A Meta‐Analysis of Prospective Cohort Studies
• In summary, our results do not support an overall benefit of a higher milk intake in reducing the risk of hip fractures in adult women. D
Diet Assessment
Anthropometrics
BioMarkers & Labs
Clinical Indicators
Diet Assessment
•
Bischoff‐Ferrairi, Dawson‐Huges, etal. J Bone Miner Res. 2010 Oct 14.
ACID / BASE Balance of Diet
• Low grade metabolic acidosis
• Catabolic effect on bones
Lowered Bone Density
Decrease acid
dic foods
dic foods
Bone Resorption
Stimulated Increase fruits and veegetables
Acidic Foods
• Increase calcium in urine
Dawson‐Huges, B. etal. Treatment with potassium bicarbonate lowers calcium excretion and bone resorption in older men and women. J Clin Endorinol Metab. 2009 Jan:94(1): 96‐102. J Clin Endorinol Metab. 2009 Jan:94(1): 96‐102. IFM TOOLKIT
Food & Chemical Effects on Acid / Alkaline Body Chemical Balance
Most Alkaline
More Alkaline
Low Alkaline
Lowest Alkaline
Baking Soda
Spices/Cinnamon
Valerian
Licorice
•Black Cohash
Agave
•Herbs (most): Arnica,
Bergamot, Echinacea
Chrysanthemum,
Ephedra, Feverfew,
Goldenseal,
Lemongrass
Aloe Vera
Nettle
Angelica
White Willow Bark
Slippery Elm
Artemesia Annua
•Kambucha
•Green or Mu Tea
Molasses
Soy Sauce
Rice Syrup
Apple Cider Vinegar
•Sake
•Sucanat
•Umeboshi Vinegar
•Algae, Blue Green
•Algae
•Ghee (Clarified
Butter)
•Quail Egg
•Duck Egg
Sea Salt
Mineral Water
•Umeboshi Plum
Sulfite
Ginger Tea
Human Breast Milk
Food Category Lowest Acid
Spice/Herb
Preservative
Beverage
Fowl
Poppy Seed
Cashew
Chestnut
Pepper
Pumpkin Seed
Lentil
Brocoflower
•Seaweed
Noril|Kombu|Wakame|Hijiki
Onion/Miso
•Daikon/Taro Root
•Sea Vegetables (other)
Dandelion Greens
•Burdock/•Lotus Root
Sweet Potato/Yam
Lime
Nectarine
Persimmon
Raspberry
Watermelon
Tangerine
Pineapple
Kohlrabi
Parsnip/Taro
Garlic
Asparagus
Kale/Parsley
Endive/Arugula
Mustard Greens
Jerusalem Artichoke
Ginger Root
Broccoli
Grapefruit
Canteloupe
Honeydew
Citrus
Olive
•Dewberry
Loganberry
Mango
Primrose Oil
Sesame Seed
Cod Liver Oil
Almond
•Sprout
Potato/Bell Pepper
Mushroom/Fungi
Cauliflower
Cabbage
Rutabaga
•Salsify/Ginseng
Eggplant
Pumpkin
Collard Greens
Lemon
Pear
Avocado
Apple
Blackberry
Cherry
Peach
Papaya
Oat
'Grain Coffee'
•Quinoa
Wild Rice
•Amaranth
Japonica Rice
Avocado Oil
Seeds (most)
Coconut Oil
Olive/Macadamia Oil
Linseed/Flax Oil
Brussel Sprout
Beet
Chive/Cilantro
Celery/Scallion
Okra/Cucumber
Turnip Greens
Squash
Artichoke
Lettuce
Jicama
Orange
Apricot
Banana
Blueberry
Pineapple Juice
Raisin, Currant
Grape
Strawberry
More Acid
Most Acid
Vanilla
Stevia
Nutmeg
Pudding/Jam/Jelly
MSG
Kona Coffee
Benzoate
Alcohol
Black Tea
Aspartame
Coffee
Table Salt (NaCL)
Beer, 'Soda'
Yeast/Hops/Malt
Sugar/Cocoa
White/Acetic Vinegar
Antibiotics
Processed Cheese
Sweetner
Honey/MapleSyrup
Vinegar
Rice Vinegar
Therapeutic
Processed Dairy Cream/Butter
Cow/Human
Soy
Goat/Sheep
Egg
Meat
Game
Fish/Shell Fish
Grain
Cereal
Grass
Nut
Seed/Sprout
Oil
Bean
Vegetable
Legume
Pulse
Root
Citrus Fruit
•Therapeutic, gourmet, or exotic items
Prepared by Dr. Russell Jaffe, Fellow, Health Studies Collegium. Reprints available from Health Studies Collegium, 44621 Guilford Drive, #150,
Fruit
TM
Low Acid
Curry
Yogurt
Goat/Sheep Cheese
Chicken Egg
Gelatin/Organs
•Venison
Fish
Wild Duck
•Triticale
Millet
Kasha
Brown Rice
Pumpkin Seed Oil
Grape Seed Oil
Sunflower Oil
Pine Nut
Canola Oil
Spinach
Fava Bean
Kidney Bean
Black-eyed Pea
String/Wax Bean
Zucchini
Chutney
Rhubarb
Coconut
Guava
•Pickled Fruit
Dry Fruit
Fig
Persimmon Juice
•Cherimoya
Date
Balsamic Vinegar
Antihistamines
Cow Milk
Saccharin
Red Wine Vinegar
Psychotropics
•Casein, Milk
Protein,Cottage
Cheese
Aged Cheese
Soy Cheese
Goat Milk
New Cheese
Soy Milk
Ice Cream
Lamb/Mutton
Boar/Elk/•Game Meat
Mollusks
Shell Fish (Whole)
Goose/Turkey
Buckwheat
Wheat
•Spelt/Teff/Kamut
Farina/Semolina
White Rice
Pork/Veal
Bear
•Mussel/Squid
Beef
Chicken
Maize
Barley Groat
Corn
Rye
Oat Bran
Almond Oil
Sesame Oil
Safflower Oil
Tapioca
•Seitan or Tofu
Split Pea
Pinto Bean
White Bean
Navy/Red Bean
Aduki Bean
Lima or Mung Bean
Chard
Pistachio Seed
Chestnut Oil
Lard
Pecan
Palm Kernel Oil
Green Pea
Peanut
Snow Pea
Plum
Prune
Tomato
Cranberry
Pomegranate
Shell Fish (Processed)
•Lobster
Pheasant
Barley
Processed Flour
Cottonseed Oil/Meal
Hazelnut
Walnut
Brazil Nut
Fried Food
Soybean
Carob
Legumes (other)
Carrot
ChickPea/Garbanzo
The interaction between dietary protein and bone health.
Protein from vegetable, milk, and meat sources has each been (inconsistently) demonstrated to aid bone health. The relative superiority of one source over another, particularly in epidemiological studies, may relate more to other components of the diet such as calcium and fruit and ege ab es a e a o c a ac e s cs o e p o e
se
ee s o
vegetables rather than to characteristics of the protein itself. There is not enough evidence to suggest that one protein source (e.g., soy, milk protein) should be favored over another source.
Jesudason D, Clifton P. J Bone Miner Metab. 2010 Oct 26.
Italicized items are NOT recommended
Ashburn, VA 20147, 800-328-7372. Sources include USDA food data base (Rev 9 & 10), Food & Nutrition Encyclopedia; Nutrition Applied
Personally, by M. Walczak; Acid & Alkaline by H. Aihara. Food growth, transport, storage, processing, preparation, combination, & assimilation influence ef fect intensity. Thanks to Hank Liers for his original work. [Rev 4/09]
ADIME
Assess
Diagnose
Intervene
Monitor &
Evaluate
✔
DEXA scan
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Calcium‐ Rich Food Sources
• Green leafy vegetables: broccoli, collards, Chi
Chinese cabbage and kale. bb
dk l
• Low fat milk, cheese and yogurt
• Sardines, canned salmon
• Seaweed such as wakame, Kombu
• Sesame seeds and sesame seed butter(tahini) (
)
• Almonds, nuts and seeds in general
Osteoporosis
Vitamin D‐Rich Food Sources: • Best source is natural sunlight. Limit exposure t 10 15 i
to 10‐15 min most days to supply a good td
t
l
d
amount of Vitamin D to the body.
• Fish liver oils, such as cod liver oil
• Fatty fish species, such as herring, salmon, mackerel sardines and tuna
mackerel, sardines and tuna. • Mushrooms
• Dairy products and eggs
Osteoporosis
A D I M E
A D I M E
Other important nutrients for the bones!
•
•
•
•
Vitamin K2‐Rich Food Sources: Natto
Cheese and Butter from grass fed cattle
Cheese and Butter from grass fed cattle Greens – kale, collards, spinach, mustard greens •
•
•
•
•
Magnesium‐Rich Food Sources: Green vegetables
Halibut Almonds, cashews
Whole unrefined grains
•
•
•
•
•
•
Boron‐Rich Food Sources: Boron
Rich Food Sources:
Occurs naturally in various forms of fruits, vegetables and nuts. Raisins
Almonds Dates Prunes
Osteoporosis
A D I M E
Other Dietary Modifications
• Consider gluten free diet • Consider anti‐inflammatory diet
• Stop soda. •
Tucker KL, Morita K, etal. Colas, but not other carbonated beverages, are associated with low bone mineral density in older women: The Framingham Osteoporosis Study. Am J Clin Nutr. 2006 Oct;84(4):936‐42.
Osteoporosis
A D I M E
Exercise
30 minutes
SUPPLEMENTS
• High quality daily multivitamin with minerals. • Vitamin K. Vitamin K.
• Keep preformed vitamin A to 2000‐3000IU per day unless noted as deficiency then keep is <10,000 per day. • Calcium – 500mg of calcium citrate 1‐ 3 times per day. Look for a calcium supplement that provides magnesium in ratio of 2:1 with calcium. • Boron 1.5‐6mg per day. • Vitamin D generally, 1000‐10,000 IU per day (check 25OH vitamin D level Q3 months until you are comfortable with level).
Osteoporosis
A D I M E
BALANCE
Weight bearing
Strength training
Tai Chi
Dance
Yoga…
Rope Jumping
Osteoporosis
A D I M E
Osteoporosis
A D I M E
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DEFINITIONS
• A food allergy is defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food. It can be IgE or nonIgE mediated.
• Food Sensitivity is often used to describe a reaction to a food that is not IgE mediated. Ie IgG, IgM or IgA.
• Foods or food components that elicit reproducible adverse p
p
reactions but do not have established or likely immunologic mechanisms are not considered food allergens. Instead, these non‐immunologic adverse reactions are termed food intolerances.
Guidelines for the Diagnosis and Management of Food Allergy in the United States: Report of the NIAID‐Sponsored Expert Panel. The Journal of Allergy and Clinical Immunology. Dec 2010. 126(6): 51‐558.
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FOOD ALLERGIES/
SENSITIVITIES /
SENSITIVITIES / INTOLERANCES
ADIME
✔Assess
Diagnose
Intervene
Monitor &
Evaluate
The ABCDs of Nutritional Assessment
•
Anthropometrics
– Weight gain
•
Biomarkers/Labs
– IgE / IgG testing
– MRT / ALCAT testing
– Celiac testing
– Lactulose / mannitol test
– Stool testing to r/o infection
•
Clinical Indicators
– Rash
– Asthma
– Diarrhea
– Digestive Distress
– History of antibiotic use…
•
Diet Assessment
– Patterns in diet
– Childhood allergies
IgE •
•
•
•
•
•
•
•
1% adults and 6‐8% kids
Immediate response to foods
Systemic and intense
Anaphylaxis
Urticaria
Asthma
Di h
Diarrhea
Vomiting
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Mouthuy J, et al. Am. J. Respir. Crit. Care Med..2010; 181: A5623 Food Allergy / Sensitivity / Intolerance
IgE Testing
• Skin Prick Testing
• Serum IgE testing for foods
Sampson HA. J Allergy and Clinical Immunol Volume May 2001 107(5): 891‐896. Verstege A, et al. (2005), Clinical & Experimental Allergy, 35: 12201226
A D I M E
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Most Common IgE Allergies
Children
– Cow’s milk
– Egg
– Peanuts
– Tree Nuts
– Sesame Seeds
Adults
– Shellfish
– Fish
– Peanuts
– Tree Nuts
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IgG Testing
• Delayed Food Hypersensitivities
• Symptoms hours to days after exposure
S
t
h
t d
ft
• Food antigen is absorbed and the body makes IgG antibodies to that food
• No standardized testing
• False positives can be common
False positives can be common
• IgG vs. IgG4
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Nut in Clinical Practice, 2010;25:192‐198
Lymphocyte Response Testing
• Mediator Release Testing Mediator Release Testing – ie LEAP
• ALCAT
– Less research on this type of testing
Nut in Clinical Practice, 2010;25:192‐198
Mohammed A et al The Middle Eastern Journal of Family Medicine
Mohammed A, et al. The Middle Eastern Journal of Family Medicine. April 2009; 7 (3)
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IgG Symptoms
•
•
•
•
•
•
•
•
•
Fever
Fatigue
Joint Stiffness
Itching
Eczema
Hives
Bloating
Nausea
Abdominal Pain
ADIME
Assess
Diagnose
Intervene
Monitor &
Evaluate
✔
•
•
•
•
•
Cough
Asthma
Pain
Memory changes
Disturbed / Di
Disorganized thinking
i d hi ki
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The Five Rs
A properly functioning digestive system is critical to good health. In fact, problems with
the gastrointestinal (GI) tract can cause more than just stomach aches or diarrhea. GI
issues may underlie several other chronic health problems that seem unrelated to
digestive health including autoimmune diseases such as rheumatoid arthritis and type 1
diabetes, skin problems such as eczema and acne rosacea, and heart disease just to
name a few. So in the bigger picture, how can we deal with all that can go wrong
“down there”? In functional medicine we use a program that goes by the simple
acronym of the ‘5Rs’: remove, replace, reinoculate, repair and rebalance. When applied
to various chronic problems, the 5R program can cause dramatic improvement in
symptoms, and sometimes even complete resolution of the problem. The elements of
the 5R program are described briefly below.
✔
✔
✔
1. Remove
Remove stressors: get rid of things that negatively affect the environment of the GI
tract including allergic foods, parasites or other bad bugs such as bacteria or yeast.
This might involve using an allergy “elimination diet” to find out what foods are
causing GI symptoms or it may involve taking drugs or herbs to eradicate a
particular bug.
2. Replace
Replace digestive secretions: add back things like digestive enzymes, hydrochloric
acid and bile acids that are required for proper digestion and that may be
compromised by diet, drugs, diseases, aging, or other factors.
In the IFM Toolkit
The Five Rs
Remove
Replace
Reinoculate
l
Repair
Rebalance
3. Reinoculate
Help beneficial bacteria flourish by taking in probiotic foods or supplements that
contain the so-called “good” bacteria such as bifidobacteria and lactobacillus
species, and by consuming the high soluble fiber foods that good bugs like to eat,
called “prebiotics.”
4. Repair
Help the lining of the GI tract repair itself by supplying key nutrients that can often
be in short supply in a disease state, such as zinc, antioxidants (e.g. vitamins A, C,
and E), fish oil, and the amino acid glutamine.
5. Rebalance
Pay attention to lifestyle choices – sleep, exercise and stress can all affect the GI
tract.
Food Allergy / Sensitivity / Intolerance
A D I M E
Step 1 ‐ Remove
• Food ‐ Elimination diet
– 21 day comprehensive elimination diet
21 d
h i
li i ti di t
– Single food elimination
– Elimination diet based on food allergy / sensitivity testing
• Infections
– Bacterial
B
i l
– Parasite
– Yeast
55
Source: Vojdani, PhD
Food Allergy / Sensitivity / Intolerance
A D I M E
Step 2 ‐ Replace
The Comprehensive Elimination Diet
19 page document in 19
page document in
the IFM Toolkit
Hydrochloric Acid Digestive Enzymes
Bile Acids
Food Allergy / Sensitivity / Intolerance
A D I M E
Step 3 ‐ Reinoculate
Step 4 ‐ Repair
• Probiotics and Prebiotics– broad spectrum probiotic with 25 –
bi ti ith 25 200 billion active live 200 billi
ti li
cultures daily in divided doses.
• Saccromycies boulardii 2‐20 billion active live cultures per day in divided doses. • Rice based protein shake. Anti‐inflammatory medical food
medical food. • High quality daily multivitamin with minerals
• l‐glutamine – start with 1 gm and increase by 1 gram every week to 3‐4 grams three times per day. • Zinc 10‐75mg / day Zinc 10 75mg / day
• Vitamin A / Vitamin D
• EPA+DHA – 1‐3 gm / day. Food Allergy / Sensitivity / Intolerance
A D I M E
Food Allergy / Sensitivity / Intolerance
A D I M E
Step 5 ‐ Rebalance
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Food Allergy / Sensitivity / Intolerance
A D I M E
Upcoming Webinar
Thursday, 8p EST, 7p CST, 5p PST
 January 27 ‐ Mary Willis, RD
 Overweight/Obesity and Dyslipidemia
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