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Seminar Pre-Reading

A Workshop in Clinical Nutrition

INTRODUCTION

Why Nutritional Medicine?

Over 60% of all deaths in Australia result from nutrition related disorders - namely cardiovascular diseases, diabetes and cancer. Improper diet, cigarette smoking, inadequate nutrition, obesity, stress, insufficient physical exercise, environmental toxin exposure, alcohol and drug abuse have been identified by modern research as specific risk factors related to disease incidence and outcome. Modification of these specific risk factors has been shown to reduce disease occurrence and improve clinical outcomes and, as such, is of increasing importance to the provision of comprehensive medical care.
A study into morbidity in family medicine (van Weel, 1997)3 reported that the most common (chronic) diseases in family practice were a mixture of diseases of organ and body systems : hypertension, obesity, cardiovascular disease, chronic arthritis, asthma, chronic obstructive pulmonary disease, eczema and diabetes mellitus .
"The survey supports the importance of nutrition-related interventions in family practice. Nutritional intervention techniques that can be applied in the personal care patients, in the context of their family life, should be developed."
Van Weel C. J Clin Nutr, 1997; 65:6 Suppl
The general practitioner is ideally situated to play a primary role in this process for several reasons :

    1. about 80% of the Australian population visit a medical practitioner within any one year
    2. studies indicate that patients are more likely to modify their health risk behaviours or engage in healthier behaviours if advised by their doctor
    3. GPs possess the basic biochemical/physiological knowledge to understand the molecular biology of nutrition-related disease and
    4. GPs possess the clinical skills of diagnosis & patient management which are of prime importance to achieving a successful outcome

" The close link between food and nutrient intake and health makes nutritional assessment and diagnosis an integral part of clinical medicine. Many common problems, such as obesity, non-insulin dependent diabetes and ischaemic heart disease, are amenable to dietary intervention and the general practitioner is ideally situated to apply an integrated approach.

Nutritional fluency is a prerequisite for the treating clinician.

It is the ability to apply scientific principles to dietary intervention, taking account of specific individual requirements and translating these into an adequate diet. To do this it is necessary to have a working knowledge of principles, and broad concepts of daily nutrient and energy requirements. The ability to elicit a meaningful food history is also a valuable technique, as any dietary advice must be based primarily on food that is readily available and tolerated by the patient."

(Marks & Wahlqvist, Modern Medicine, 1991).

However - though the Australian community has become increasingly health and nutrition conscious, the lack of undergraduate and postgraduate training in nutrition for medical students and graduates prevents the GP from fulfilling this primary role.
A 1988 survey of 150 GPs found that 2/3 rarely gave advice about nutrition to their patients though 82% wanted to know more about nutrition and 93% reported there should be more emphasis on nutrition in undergraduate and postgraduate education.(Porteous 1988 - Preliminary Report of the Canberra Nutrition Survey)5
The majority of GPs agree that nutrition is a major factor with regard to maintenance of long-term health and prevention of disease but the extent of nutrition counseling by GPs is considerably less than might be expected from the strength of their statements about the importance of nutrition and long term health. Obstacles to nutrition counseling are lack of time, lack of confidence and inadequate nutrition knowledge.2
GPs express interest in learning more about nutrition …. but there is still little coherent teaching on the subject, specifically tailored for GPs"

Dr. A. Helman, Am J Clin Nutr, 1997;65 6(Suppl) 2
A recent questionnaire asking GPs what specific nutritional topics they would like to know more about was sent out by the Brisbane North Division of General Practice. Sixty-seven responses out of 240 (27.9%) were returned and revealed an interest in further nutritional education as follows. :
General Practitioner Response to Nutrition Education -Several studies show that :

    • the GP is in a unique position to initiate and supervise nutritional intervention programs, tailored to individual patient requirements and integrated with ongoing medical management (van Weel, 1997; Wahlqvist, 1998; Wieseman, 1997)3,4,6.
    • The majority of family practitioners now regard complementary nutrition and diet therapy as "legitimate medical practices" (Baltimore, 1995)11 and many GPs are actively seeking to incorporate nutritional therapy into family practice (Widhalm et al, 1997; Michener, 1997; Bratland, 1997)12,13,14 and
    • Provision of nutrition education programs for GPs have resulted in an improved level of nutrition counseling by family medicine doctors - a family practice residency program which included a module of nutrition education showed increased nutritional knowledge in the participating family practitioners and a greater level of application of nutritional therapy in clinical medical practice (Lazarus, 1997)10.

Most primary care physicians seek nutritional advice from dietitians but report a preference for gaining nutritional information from postgraduate nutrition conferences and scientific journals, which are seen as being highly effective and more clinically applicable (Hiddink et al. 1997)15. Whilst, Helman2 reports that recent nutrition education initiatives have generated renewed interest and involvement by GPs in nutrition in medical practice. He further reports that development of a core curriculum by the RACGP for GP trainees will include a nutrition component and comments on the development of a nutrition practice assessment program for vocationally-registered GPs.
Community Demand and Use of Nutrition Medicine -
Modern Australian society has become increasingly interested in the application of nutrition in both disease prevention and for treatment of illness. Today’s patients expect competent nutrition guidance from their family medical practitioners, who are in a unique position to implement effective nutritional interventions (Hiddinck et al, 1997) 7. Unfortunately, due to lack of undergraduate and postgraduate nutrition education in medical curricula (Helman, 1997; Wahlqvist & Kouris-Blazos, 1998) 2,4, the majority of GPs are unable to satisfy to the persistent demand for nutritional medicine (Lupo, 1997) 8, forfeiting the arena to non-medical practitioners, dietitians and a variety of "alternative medicine" practitioners.
Recent studies in Australia and overseas show that the majority of today’s community attend non-medical, alternative health practitioners for ongoing treatment of their health problems (Elder et al, 1997)9 and the GPs’ role has been steadily eroded by the growing numbers of alternative health practitioners. The public has increasingly turned to the use of non-medical practitioners for help in dealing with their health problems, with approximately 50% of the population now utilising some form of Complementary Medicine therapy - often without the knowledge of their GP.
"A South Australian survey of 3000 people aged 15 years or older found that 48.5% used at least one non-medically prescribed alternative medication annually …. And 20.3% of those in the survey had visited at least one alternative practitioner during the year." and "fewer than 50% of both our study population and parents of children with cancer had informed their doctors of their use of alternative therapies"

Prof. G. Shenfield. Editorial. MJA. 1997 (166):516-7

Today’s GP needs to reclaim the skills, ability and confidence to manage patients’ nutritional health problems in a comprehensive and integrated manner, consistent with the current evidence of medical & nutritional research.
This workshop will challenge your beliefs, attitudes, knowledge and training.
It is designed to introduce you to the concepts and process of nutritional assessment and therapy in modern medical practice. It will provide a core knowledge of basic nutrition science, integrated with nutrition research and other biomedical sciences, which will enhance your knowledge and skills in the clinical application of nutrition assessment, diagnosis and therapy.
At the conclusion of this workshop, you will, hopefully, have developed a positive scientific and professional attitude in the management of nutrition problems in future clinical practice.
We hope you find this Nutrition Medicine program informative and enjoyable and a powerful source of motivation for your continuing interest in this dynamic area of clinical practice.
"Good nutrition leads to health and resistance to disease; poor nutrition leads to ill-health and susceptibility to many diseases."16

Nutrition - Chapter 10.3. Oxford Textbook of Medicine. Third Edition
References:
1.. Marks & Wahlqvist. Modern Medicine. 1991
2.. Nutrition and general practice: an Australian perspective. Helman A. Am J Clin Nutr, 1997;65 6(Suppl):1939S-42S.
3.. Morbidity in family medicine: the potential for individual nutritional counseling, an analysis from the Nijmegen Continuous Morbidity Registration.
Van Weel C, Am J Clin Nutr, 1997; 65:6 Suppl 1928S-32S.
4.. Introduction to the Nutrition Unit, Medical Curriculum, Monash University. Professor Mark Wahlqvist and A. Kouris-Blazos, 1998.
5.. Preliminary Report of the Canberra Nutrition Survey, Porteous J, 1988.
6.. Nutritional counseling in German general practices: a holistic approach. Wiesemann A. Am J Clin Nutr, 1997; 65:6 Suppl 1957S-62S.
7.. Consumers expectations about nutrition guidance: the importance of primary care physicians. Hiddink GJ et al, Am J Clin Nutr, 1997;65
6(Supp):1974S-79S.
8.. Nutrition in general practice in Italy. Lupo A, Am J Clin Nutr, 1997; 65:6 Suppl 1963S-66S.
9.. Use of alternative health care by family practitioners. Elder NC et al. Arch Fam Med, 1997, Mar-Apr 6(2):181-4.
10.. Nutrition practices of family physicians after education by a physician nutrition specialist. Lazarus K, Am J Clin Nutr, 1997;65 6(Suppl):2007S-
9S.
11.. Physicians attitudes toward complementary or alternative medicine: a regional survey. Berman BM, Singh BK et al, J Am Board Fam Pract, 1995
Sep-Oct;8:5 361-6.
12.. Medical education in nutrition in Europe. Workshop. Widhalm K et al. Ann Nutr Metab, 1997;41:1 66-68.
13.. Nutrition, education, and family physicians [editorial; comment]. Michener JL. Arch Fam Med 1997 Mar-Apr 6:2 146-7
14.. Handling nutritional advice in general practice in Norway. Bratland SZ. Am J Clin Nutr, 1997;65 6(Suppl):1953S-56S.
15.. Information sources and strategies of nutrition guidance used by primary care physicians. Hiddink GJ et al. Am J Clin Nutr. 1996;65(Suppl):1996S-2003S.
16.. Nutrition. Chpt 10.3. Oxford Textbook of Medicine. Third Edition.
NUTRITION IN MODERN AUSTRALIA - the lucky country ?
First - the obvious.
In the affluent society of modern Australia, doctors learn that malnutrition is extremely rare and of no major significance - BUT - frank protein-calorie malnutrition and vitamin deficiency states are not uncommonly found in specific sub-populations within the general community: the home-bound elderly, homeless children, Aboriginal rural communities, anorexic women, ethnic minority groups, drug addicts and those living in poverty -

    • scurvy and rickets are not uncommon in ethnic children in Melbourne;
    • a 4-yr old Aboriginal presents with acute bacterial infection, the 5th time in 4 months, and is given another course or two of antibiotics - the immunodeficiency due to Vit A & zinc deficiency is neither recognised nor treated;
    • throughout Australia, in all strata of society, young women with anorexia are overtly malnourished but what does one do with them?;
    • frank malnutrition in the 73-yr old arthritic widower goes unrecognised by GP &
      specialist alike;
    • the 68-yr old woman, severely depressed, is rendered "mindless" with increasingly potent psychotropic cocktails and, finally, institutionalised ECT, whilst the psychiatrist remains ignorant of the Type II nutrient deficiency state causing her depression;
    • whilst the "street child" with protein & zinc deficiency probably never even gets seen by a doctor.
      Do you see these types of patients in your practice?
      Do you recognise any of them - can you recognise them?
      They’re out there, in your community, waiting for you to diagnose and treat them properly -

In fact, medical practitioners’ knowledge of and attention paid to nutrition is so deficient that 30-40% of people hospitalised for illness or major surgery are discharged from hospital with frank evidence of malnutrition and an increased rate of complications and impaired recovery -

"malnutrition remains a largely unrecognised problem in hospital and highlights the need for education on clinical nutrition"

(McWhirter & Pennington, BMJ 1994;308:945-8

This is the challenge of Nutrition Medicine!

"Argh, not meat & salad sandwiches again, rabbit food. Hey guys, I’m going to the shop, anyone want anything….. Ahh, that’s better." - voiceover-

" Big Ben’s meat pies. Give him a man’s meal!" (TV advert, 1998).

"What you need to do is eat lots of hamburgers, bread and pasta" - (Brisbane physician to underweight patient with chronic diarrhoea of 12 years duration due to unrecognised gluten intolerance, 1998).

Second - the not-so-obvious
The majority of doctors are taught and believe that vitamin and mineral intake at or about the level of the RDI (Recommended Daily Intake), as set by the NHMRC of Australia, is perfectly adequate for the continued good health of the community. Greater intake levels than this are at best useless and at worst downright harmful. In Australia, we are told, because of our wonderful food supply, all one has to do is to maintain an adequate and varied diet and all nutrients will be supplied as advocated by the RDI. So learning about diet and nutrition is not really important to clinical medical practice - besides how much nutritional advice can one give in 6-10 minutes?The problem is that people, being people and usually hurried and hassled by modern life, much prefer to "grab something on the run" - the age of the takeaway has arrived. Now takeaways are meant to be fast, convenient, economical and quick to eat and someone in a hurry doesn’t buy a takeaway salad, it takes too much time to eat a salad (all that chewing, you know), so they grab a sandwich, or a burger or chicken’chips or just chips or skip the meal altogether, besides you can always grab a chocolate bar or can of coke - and this happens 4-5 times a week, it becomes a lifestyle habit. Of course, this leads to inadequate vitamin & mineral intake PLUS excessive fat & sugar consumption, but hey! What’s the problem? Still getting plenty of food, definitely not malnourished, besides even busy doctors eat like this, so it must be OK.
Hence, it comes as no surprise to learn that nutritional surveys invariably show that substantial sections of the population have nutrient intakes that fall below the RDI for one or more specific nutrients.
Australia’s own recently established National Nutrition Survey 1995-96 in its first report (Australian Bureau of Statistics) reveals the following disturbing findings:

    • average calcium intake was less than the RDI in adolescent boys (12 to 15 years) and females in most age groups
    • average folate intake in women aged 19 to 44 years was only 50% of that required to reduce the risk of neural tube defects in babies
    • iron intake - below the RDI in 25% of adolescent girls & young women
    • zinc intake - well-below the RDI in 50% of women and 10% men above age 19 years
    • magnesium intake - below the RDI in 25% of women aged 19 years & above
    • phosphorus intake - below the RDI in 20% of women over the age of 19 years
    • Vit A intake - below the RDI in 25% of persons above the age of 19 years

In addition to these micronutrient intake deficits, assessment of macronutrient intake revealed:

    • fruit & vegetable consumption was below recommended levels in 35% of adults and 65% of adolescents
    • dietary fibre intake was below recommended levels in 50% of women and 25% of men over the age of 19 years
    • 65% of adults consumed less than recommended levels of seafood oils
    • in adults, beverages (non-alcoholic and alcoholic) accounted for over 60 per cent of total food and beverage energy intake - i.e., alcohol and sugar accounted for over 50% of dietary energy

Excess Consumption - Substantial sections of the community in Australia also consume excessive levels of saturated fats, trans-fatty acids, and simple & refined sugars - (45% of daily carbohydrate intake was in the form of sugars). These "anti-nutritional factors" have been repeatedly linked to the development of chronic disease such as coronary heart disease, obesity, hyperinsulinism, diabetes, hypertension and cancer.
The result of this overconsumption is that:

    • 75 per cent of males aged 45 to 64 years are overweight or obese (BMI > 25)
    • 25 per cent of males and females aged 45 to 64 are obese (BMI > 30)
    • Only 40 per cent of the Australian population aged 19 and over had an acceptable weight for their height (BMI between 20 - 25)

Comparison of the waist:hip ratios of the adult population indicates a high proportion of the Australian community may have already developed insulin resistance and a high risk of progressive development of Syndrome X & Diabetes:
In the accompanying diagram, we see that the Waist:Hip ratio (W:H) exceeds the recommended maximum ratio in:

  • 45% males aged 25-44yrs
  • 78% males above age 45 yrs
  • 22% females aged 25-44 yrs
  • 48% females aged 45-64 yrs and
  • 67% females above 65 yrs of age 

Image5.gif

Approximately 36% of female adults and 55% of male adults exhibit increased W:H ratio (upper abdominal obesity), with the proportion increasing with advancing age. Upper abdominal obesity is the hallmark of insulin resistance, a major progenitor of cardiovascular disease, hypertension and diabetes. So it is perhaps not surprising that this survey also revealed a correspondingly high incidence of hypertension in the community - 21% of females and 25% of males aged 45-64 years and 50% of both females and males over the age of 65 years. "Hyperinsulinaemia, occurring as the direct result of insulin resistance in the presence of a high carbohydrate diet, can produce alterations in metabolic function ranging from hormonal imbalances to hypertension, hyperlipidaemia and alterations in the inflammatory cascade. The combined effect of high insulin and high intracellular glucose promotes advanced glycosylation end products (AGEs) and generates increased reactive oxygen intermediates (free radicals). This process results in progressive tissue oxidative damage and depletion of antioxidant levels, with accelerated biological aging, loss of organ reserve and development of chronic disease." (Dr. D. Jones, MD,1998) These survey findings mean that every second or third adult seen in your practice is likely to have a disease process, either overt or covert, that is directly related to their dietary and nutrient intake. The GP is, therefore, ideally situated to detect and treat these patients but can only do so if he/she knows what to look for (diagnosis) and how to treat the problem - this is why Nutrition Medicine is important to GPs and nutritional fluency must be a prerequisite for the treating clinician.
YOU can make a difference to your patients’ current and future health - set them on the road to good health and encourage them along this path OR leave it to the dietitian or naturopath down the road.
Nutrition - Dietary Guidelines and Recommended Dietary Intakes vs Optimal Intake
The Nutrition Survey results indicate that significant sections of the community fail to consume the RDI for at least one nutrient and overconsume with regards to energy and "anti-nutritional" factors, resulting in a high-level of nutrition-related "chronic disease" in our society. For these sections of the community we could say that the good nutrition message is not getting through &/or their economic situation restricts their dietary choices. However, even in those sections of the community who do indeed regulate their nutritional intake in accordance with the Australian Dietary Guidelines, there yet remains a high degree of chronic disease. WHY? Are the guidelines wrong or incomplete ? Like many things in medicine, there is no clear, definitive answer - the answer is both YES and NO !
First, let’s look at the Recommended Dietary Intakes for Australians.
A Working Party of the Nutrition Standing Committee on Recommended Dietary Intakes and Standards for Nutritional Assessment was established by the National Health and Medical Research Council (NHMRC) in 1980 for the purpose of revising the 1970 Australian Dietary Allowances, which had primarily been based on FAO/WHO expert committee reports. This Working Party developed or revised recommendations for energy intake and for 20 specific nutrients as applicable to specific age/gender groups (see accompanying tables). No recommendation was devised for the fat-soluble vitamin D, on the grounds that the status of this nutrient in the Australian population is determined by the exposure to sunlight rather than the vitamin D level in the diet - (NB: physiologically, however, Vit D requires conversion to its activated form and the final activation phase, which takes place in the kidney, is hormone dependent)
Definition
The NHMRC has defined Recommended Dietary Intakes (RDIs) as the levels of intake of essential nutrients considered, in the judgment of the Council, on the basis of available scientific knowledge, to be adequate to meet the known nutrient needs of practically all healthy people. The RDIs are derived from estimates of the requirements of each age/sex category and incorporate generous factors to accommodate variations in absorption and metabolism. They therefore apply to group needs. The RDIs exceed the actual nutrient requirements of practically all healthy persons and are not synonymous with individual requirements.
Purposes and potential uses of RDIs
The NHMRC has defined the purposes and uses of RDIs as follows:

"The tables of dietary recommendations for nutrients for use in Australia are intended as a guide for compiling diets from basic foods. When a diet is designed to contain the nutrients listed, it is likely to contain all other dietary factors necessary for health, but which have not been listed.

The understanding of the many aspects of good nutrition is by no means complete, but it is known that fundamental defects in the overall pattern of a diet cannot be corrected with vitamin/mineral supplements. A varied diet providing an adequate amount of each essential nutrient from basic foods should be planned for optimal health."

The NHMRC further states that the RDIs may be used:

  • As a guide to planning menus for individuals and groups;
  • For a first assessment of the adequacy of a group or individual
    (the use in this respect is limited because of the 'wide margin of safety' incorporated into values for some nutrients, variations in the needs of individuals, and the need to consider social factors);
  • As the denominator for nutrition labelling
  • As the reference for monitoring availability of nutrients in the national food supply; and
  • As a guide in planning diets for specific therapeutic purposes (although the recommendations are designed for normal healthy people).

(Recommended dietary intakes for use in Australia. National Health and Medical Research Council. Canberra: Australian Government Publishing Service, 1991)

Next - the Dietary Guidelines -
The NHMRC has also established a set of dietary guidelines to guide the community towards healthy eating patterns and increase the probability of achieving adequate consumption of nutrients, reduce the intake of "anti-nutritional" factors and minimise the risk of diet-related disease.

Dietary guidelines for Australians

(NHMRC, 1994)

Dietary guidelines for children and adolescents

(NHMRC, 1995)

Enjoy a wide variety of nutritious foods

1. Encourage and support breastfeeding

2. Eat plenty of breads and cereals (preferably wholegrain), vegetables (including legumes) and fruits

2. Children need appropriate food and physical activity to grow and develop normally. Growth should be checked regularly

3. Eat a diet low in fat and, in particular low in saturated fat

3. Enjoy a wide variety of nutritious foods

4. Maintain a healthy body weight by balancing physical activity & food intake

4. Eat plenty of breads and cereals, vegetables (including legumes) & fruits

5. If you drink alcohol, limit your intake

5. Low fat diets are not suitable for young children. for older children, a diet low in fat and in particular, low in saturated fat, is appropriate

6. Eat only a moderate amount of sugars and foods containing added sugars

6. Encourage water as a drink. Alcohol is not recommended for children

7. Choose low salt foods and use salt sparingly

7. Eat only moderate amounts of sugars and foods containing sugars

8. Encourage and support breastfeeding

8. Choose low salt foods

Guidelines for specific nutrients

Guidelines for specific nutrients

9. Eat foods containing calcium. This is particularly important for girls & women

9. Eat foods containing calcium

10. Eat foods containing iron. This is particularly important for girls, women, vegetarians and athletes.

10. Eat foods containing iron


 The Dietary Guidelines provide advice to the general population about healthy food choices, so that their usual diet contributes to a healthy life-style and is consistent with minimal risk for the development of diet-related disorders. The guidelines represent the best consensus of scientific knowledge and public health advice currently available. They recognise the modern nutrition problems related to excess intakes of various nutrients and associated with various disease states. The first guideline is in effect an umbrella statement. All subsequent guidelines describe different facets of variety in the diet. Whilst clearly providing a basis for counselling on healthy eating, they are broad and they still need to be interpreted, in a practical sense, for the individual patient. In short, these are guidelines for healthy eating, and they require supporting educational programs and food assessment tools in order to achieve their aims. They apply to the total diet, and it is not appropriate to use them to assess 'healthiness' of individual food items. They are designed for consideration as a coherent set of advice or information, and individual guidelines cannot be considered in isolation.
Use: Overall counselling on a diet, once as assessment has been made
Guidelines for change in a person's eating habits.
The Dietary Guidelines are further expanded by recommending that diets conform to the 12345+ eating plan, as exemplified by the recently designed Food Pyramid.Before the formulation of these dietary guidelines in the 1980s, the 5 Food Goups had historically been the mainstay of dietary advice. They were developed because of a variety of concerns, such as wartime, economic difficulty and famine, to ensure that in such times a population was adequately and nutritionally fed. They were principally concerned with the adequacy of the diet and its relationship to deficiency states (e.g vitamin A deficiency, anaemia), not with excesses (e.g fat) or deficits (e.g carbohydrate, fibre) and their relationship to chronic diseases (e.g heart disease, obesity, colon cancer). They used an adequacy or minimal requirement approach rather than a total diet concept. However, this 5 Food Groups food selection guide is no longer favoured as it does not address the problems of macronutrient excesses (fat, protein, energy, refined carbohydrates, ethanol) and macronutrient inadequacies (complex carbohydrates, fibre). Also, the 5 Food Groups are not relevant to the food habits of many different cultures and because they are essentially nutrient based, fail to encourage consumption of a variety of foods & food components now known to be beneficial to health (e.g fish & protection against heart disease, lycopene and phytoestrogens (in tomatoes & legumes) and protection against cancer and heart disease).In the early 1980s, the Healthy Eating Pyramid (formerly called Healthy Diet Pyramid) of the Australian Nutrition Foundation came into use. The Healthy Eating Pyramid is essentially a qualitative food guide which addresses the issue of dietary balance of the total diet through the use of descriptive terms such as "eat more", "eat moderately" and "eat less" in relation to various food groups and the Dietary Guidelines. Although some attempts have been made to quantify the Healthy Eating Pyramid, thus resulting in many different versions of the original Australian Nutrition Foundation version, this was generally done without any nutritional assessment being made of the resultant recommendations. In 1990, the CSIRO developed the 12345+ Food Pyramid (Baghurst et al., 1990), a quantified and nutritionally assessed food guidance system aimed at achieving the current recommended dietary intakes (RDIs) for vitamins, minerals, energy, fibre and macronutrients by different age groups with varying activity levels. The basic plan provides 5500 kJ (1300 kcal), 18% energy as protein, 50% carbohydrates (30% complex, 20% refined), 30% fat, 35g fibre, 100mg cholesterol and achieves 70% of the Recommended Dietary Intakes (RDIs) for all vitamins and minerals. This plan is also in line with the dietary guidelines. Although the basic 12345+ plan provides about 1300 kcal or 5500 kJ per day; most people will need more kilojoules than this - extra energy needs should be met by increasing servings from breads and cereals category. The major difference between the 12345+ plan and the 5 Food Groups system used previously in Australia lies in the reduced amounts recommended for meat and increased recommendations for dairy, fruits, vegetables and cereals. Since this food plan is essentially nutrient based it encourages regular consumption of small quantities of red meat in order to achieve the RDI for iron and zinc. In contrast, food guidance systems that are epidemiologically food based tend to advise occasional consumption of red meat and increased consumption of fish . Food guidance systems developed in the future will need to address such conflicting messages. In contrast to the 5 Food Groups, the food group "fats" is not specifically mentioned in the 12345+ food plan. This is because an allowance is made for 6 grams of poly or monounsaturated fat spread for each slice of bread eaten. If individuals do not wish to use this fat allowance, then a similar amount of fats or oils could be used in cooking or as dressings to ensure adequate essential fatty acid intake. Also, a novel feature of this food plan is that it addresses "indulgences" i.e the foods or drinks available to the public which, in many cases, are of relatively limited nutrient value but which form an integral part of the western dietary culture. The 12345+ food plan has enough leeway in the balance of macronutrients to allow for daily consumption of up to 2 "indulgences" e.g alcohol, soft drinks, pastries, pies, confectionary, nuts, sweet biscuits, cake, icecream. Each of these foods provides about 630kJ (150 kcal) and it takes only a tiny amount of crisps, cakes, pastries or alcohol to exceed your total energy intake. While no food is excluded, these foods should be restricted as they are high in fats, sugar or salt; they should be avoided if trying to lose weight. Hunger should be satisfied with more cereals and fruits. If the patient has developed a vitamin or nutrient deficiency or is at risk of developing such a deficiency, the patient should be encouraged to include foods which are good sources of these nutrients by referring to Food Facts (Briggs & Wahlqvist, 1984).
Limitations of the Dietary guidelines & RDIs -
Limitations Of Recommended Dietary Intakes

  1. Individuals have widely varying nutrient requirements - both from person-to-person and   from day-to-day. RDIs should be used with caution in assessing an individual's diet.
    There needs to be corroborating evidence (e.g biochemical measures) before a person's diet can be declared to be inadequate on the basis of a comparison with the RDIs alone.
    The likelihood of an inadequate diet increases with the extent to which intake is below the RDI.
  2. The RDIs do not allow for illness, medications or the effects of major life stresses, smoking and alcohol abuse.
  3. They assume a certain nutritive quality, biological value or availability of the various nutrients.
  4. They assume adequate intakes of other major nutrients and energy and do not allow for interactions between nutrients.
  5. They do not allow for adaptation to high or low intakes of some nutrients (e.g iron, calcium, energy) for the individual.
  6. They generally do not indicate toxic levels of intakes.
  7. They do not cover the proportional distribution of energy between carbohydrates, fats and proteins - nor do they address the minor vitamins and trace elements (it is assumed that if the intake of the main nutrients is adequate, then the requirements for others will automatically be covered).
    Nutrition Unit, Faculty of Medicine, Monash University, 1997.

So, given the limitations of the RDIs, which fail to encompass the nutritional needs of an individual’s unique gene-dependent metabolism and exposure to life’s stressors, it is understandable that a nutritional-related disease process is able to develop.

RDIs are the amounts of essential nutrients that are considered adequate to meet the nutritional requirements of healthy people. The RDIs are designed to easily prevent classical nutritional deficiency diseases, such as scurvy, beri-beri, pellagra, rickets and anaemia. Indeed, there is a wide margin of safety. However, they do not address the extra nutrient needs of persons with certain chronic ailments, who smoke, or who are on drug medication. New research suggests a greater role for vitamins (and minerals) in the prevention or slowing down of many diseases such as heart disease, cancer, cataracts, osteoporosis and birth defects. The total effects of vitamins on the body are still not fully known or understood. Further, there is increasing scientific evidence to suggest that higher levels of certain vitamins (e.g antioxidants vitamin C, E, and beta-carotene) may be necessary for optimal health, and may provide extra protection against cancer, heart disease and other diseases. In time, the concept of RDI may well be broadened to include a second set of much higher vitamin levels that optimise their disease-preventing properties. From the medical practitioner's point of view, it is particularly important to remember that RDIs are for healthy people. In illness the requirements for many nutrients are altered. For example, with stress, trauma or surgery, the requirement for vitamin C may be more than 8 times the RDI for healthy adults; zinc requirements increase for wound healing.

Nutrition Unit, Faculty of Medicine, Monash University, 1998

  The New Paradigm - Optimal Nutrient Intake & Biochemical IndividualityThe major failing of the current Dietary Guidelines and RDIs is that they do not to allow for the wide variation in nutrient requirements and metabolism that exist between individuals. Research studies have shown that tissue utilisation (and hence requirements) for specific nutrients can vary by an 8-fold factor between individuals (because of genetic polymorphism) as well as within any one individual depending on hormone activity, exposure to endogenous & exogenous toxins and environmental stressors. Because of this and fueled by modern research findings of improved cellular & organ function in the presence of tissue nutrient saturation, a new nutritional paradigm is gaining wide acceptance amongst clinically-oriented health practitioners - the twin concepts of "optimal nutrient intake" and "biochemical individuality". Nutrient intake needs to be equated to the optimal intake required to maintain tissue nutrient saturation within the individual according to the unique metabolic needs and environmental stresses of that individual. Now, it must be remembered that optimal means exactly that - not too little AND not too much - and applies to all nutrients, macro-nutrients (such as protein, fibre, fats & carbohydrates) and micro-nutrients (such as vitamins, minerals and phytochemicals). Nutrient intake should, advisably, be first derived from the diet, as much as possible, and only where optimal requirements cannot be met from dietary sources, additional supplementation prescribed. In practice, this means that the prescribing doctor must learn how to formulate a good diet plan to optimise food-derived nutrients and minimise "anti-nutritional" factors PLUS know how to detect the subtle indications of sub-optimal nutrient intake so as to determine what level of which supplements are required. This requires the practitioner to:

    • revamp all that forgotten physiology & biochemistry learned in medical school - you have to learn to think your way through clinical problems
    • pay close attention to the clinical symptomatology of the patient - each clinical symptom tells you what is going on in specific organ systems
    • learn to use clinical assessment tools - preferably quantitative tools that allow you to track the patients progress - or lack of it!
    • utilise pathology testing as required - you need all the help you can get
    • maintain and continually refresh his/her knowledge base - medical, nutritional, physiological and biochemical
    • have the courage to perform clinical trials as required - when no pathology test or other form of testing is available, you may have to trial different therapeutic agents - this is now called the N-1 Clinical Trial & is being advocated by researchers in General Practice.

  "The basis for many nutritional diseases is multifactorial and involves the cultural aspects of food preparation and social and economic influences, all of which may contribute to an inappropriate diet."
"Modern nutrition, however, has now to be understood as the study of a complex metabolic system whereby the body processes not only the nutrients from food but also those many bioactive molecules found in the diet which inhibit or modulate the body’s response to such nutrients."
"Thus to understand the nutritional basis of a patient’s disease requires a knowledge of physiological biochemistry and some molecular biology, as well as a perspective of what the patient had actually been eating."

Nutrition - Chapter 10. Oxford Textbook of Medicine. Third Edition.

The Nutrition Medicine Approach - "Functional Medicine" -
Whilst the symptom-treatment approach of modern medicine is generally effective in many acute illnesses, it fails to deliver effective recovery from chronic disorders such as heart disease, diabetes, arthritis, asthma, eczema, inflammatory bowel disease, autoimmune disease, mental disorders etc. This is unsurprising, in that medicine remains focused on a pharmaceutical drug approach which, at best, has little ability to enhance tissue repair & regeneration or, at worst, engenders a toxic effect in tissues and organs already metabolically stressed & diseased.

"Medicine should pursue the study of disturbed function and its multifactorial pathogenesis rather than search for unitary causes and magic bullets"

Ackernecht EH. A Short History of Medicine. Baltimore. 1982.

However, with the progressive advance in understanding of the molecular mechanisms of disease-causation, it is now apparent that similar molecular mechanisms act as the basic causal factors in the development of most, if not all, apparently dissimilar illnesses. These common molecular disease mechanisms are triggered or enhanced by multiple nutritional and environmental factors whilst the individual‘s susceptibility to these factors is dependent on his/her unique genotype. The good news, from the practising clinician’s perspective, is that the corollary also applies - i.e., these pathogenic molecular mechanisms can be beneficially modulated by therapeutic programs designed to correct and optimise the metabolic disturbances induced by the nutritional and environmental factors fueling the disease process.The nutritionally-oriented physician therefore needs to assess a multitude of factors which can impact negatively on the disease process - antecedent factors which enhance susceptibility to disease, trigger factors which tip the biologic balance into disease and mediators which maintain the disease process.

Antecedents

Trigger Factors

Mediators

Congenital

Trauma

Hormones

Dietary

Microbial

Ions -

Environmental

Antigens

Eicosanoid metabolites

Occupational

Allergens

Reactive Oxygen Species

Habitual

Environmental toxins

Tissue Metabolites

Learned

Drugs/Medications

Neurotransmitters

Traumatic

Radiation

Thoughts & Beliefs

Disease-induced

Social stress

Social Reinforcement

Drug-induced

 

Classical Conditioning

Mediators are the key factors which impair biological functioning at the cellular level. Uncontrolled release of these mediators can be activated by a wide variety of trigger agents, both exogenous and endogenous. For instance, excessive genesis of Reactive Oxygen Species (ROS), also called free radicals, may result in damage to mitochondrial DNA, enzymes and membranes, leading to impaired mitochondrial function & ATP generation or may damage cell membranes resulting in impaired hormone receptor function, nutrient transport and ion-channel dysfunction. Many chronic degenerative diseases are causally related to excessive free radical damage and symptoms respond, at least partially, to appropriate antioxidant supplementation.Nutrition-oriented practitioners generally seek to answer 3 major questions concerning a patient with chronic illness :

    • what mediators are active in this patient
    • what triggers are activating the mediators
    • what personal & familial features are present to permit / determine the development of this illness

Whereas conventional medicine views illness as something that just happens to an individual, the nutritional practitioner considers illness as a series of dynamic interactions amongst energy-driven, energy-sensitive body systems and their wider environments. Fundamental to this view is the deep awareness of the web-like interactions amongst all organ systems and the body-mind, such that dysfunction or metabolic stress within any one system or segment results in production, secretion and transport of chemical mediators throughout the whole organism, resulting in altered metabolism and symptoms of illness and dysfunction in apparently widely-disparate tissues and organs. In this sense, illness is a dysfunction of cellular and tissue metabolism resulting in loss of metabolic flexibility and organ reserve.Thus, the medical paradigm shifts to that of holistic medicine - and "patient-centred" diagnosis and treatment become the cornerstone of medical care. Using the patient as the point of reference, the nutrition medicine practitioner seeks to determine what factors have reduced metabolic flexibility, compromised organ reserve and impaired body function. The practitioner then works to reduce or eliminate the destructive endogenous &/or exogenous factors via therapies that restore, repair and rebuild organ reserve. The advantage of this approach is that the practitioner is able to focus more on understanding and correcting the physiological disturbance of illness, whilst supporting a failing metabolic system with appropriate pharmacotherapy if required, rather than merely suppressing the signs and symptoms of disease. In practical terms, this means that the doctor’s responsibility, the "duty of care" to the patient with hypertension, for instance, does NOT cease with the control of blood pressure (by using the latest and expensive ACE inhibitor) BUT extends into the realm of defining and correcting the metabolic disturbances that resulted in development of hypertension in the first place."People do not get sick from diseases, but rather diseases reflect a disruption in the dynamic balance between themselves and their environment."

Nutrition and Genetic Susceptibility to Common Diseases.

Motulsky AG. Am J Clin Nutr. 1992 (5S)

This is the challenge AND the satisfaction of Nutrition Medicine

Clinical Categories -From a clinical perspective, there are several major categories of dysfunction which contribute to most chronic or recurrent disease processes and correction of these dysfunctional processes usually results in restoration of cellular and tissue function, enhanced organ function and increased organ reserve. These clinical categories are:

    1. Nutritional Imbalances
    2. Immunological Imbalance & Inflammation
    3. Gastro-Intestinal Imbalance
    4. Imbalance of Metabolic Detoxification
    5. Oxidative Stress and Free Radical Pathology
    6. Neuroendocrine Imbalance
    7. Psycho-neuro-immunology Imbalance

These common categories of disease-causing mechanisms should be catered for in formulating a treatment protocol for the majority of disease conditions. But, it must be remembered that these categories are, of course, simply facets of the intimately-connected and indissoluble web of interactive molecular biochemical disturbances which characterise all disease processes. However, separating them out into specific categories, enables the physician to rethink and reprocess his/her assumptions about disease and plan effective and comprehensive treatment protocols.
Nutritional Imbalance - nutrient deficit -Nutritional medicine has its antecedents in the "nutrient deficiency" model, characterised by the symptomatology of classical nutrient-deficiency disease, such as scurvy or beri-beri, in which an absolute tissue deficiency of a specific nutrient was identifiable and corrected by supplementation of that specific nutrient. Much of the clinical presentation of this type of disease process was elucidated by controlled induction of specific nutrient deficiency within an experimental population sample, often prisoners, with the end-point defined by the development of specific, recognizable and reproducible clinical signs and symptoms. Whilst this form of nutrient deficiency still occurs commonly within identifiable sections of the our community (as well as in underdeveloped countries subject to poverty, famine and war), it is relatively uncommon in the community as a whole. In modern Australia, more subtle disturbances of nutrient balance and biochemical dysfunction predominate and create muted but widespread disharmony and progressive havoc within the metabolic web.For instance, it is now known that down-regulation of homocysteine-methionine metabolism, leads to tissue toxic levels of homocysteine which can cause cellular DNA transcription errors and result in a variety of apparently unrelated illnesses :

    1. neural tube defect in developing foetuses,
    2. neoplastic change in the bronchial cells of smokers,
    3. cervical dysplasia with progression to carcinoma-in-situ in young women
    4. atheromatous change in the coronary and cerebral arteries of the middle-aged and
    5. neuronal degeneration leading to cognitive impairment in the aged

Regulation of tissue homocysteine levels is dependent on maintenance of tissue folic acid activity, which regulates conversion of homocysteine to methionine, plus the synergistic activity of a variety of nutrients (Vitamin B6, Vitamin B12, Vitamin C and trimethylglycine/betaine) which modulate the degradative biochemical pathways involved in homocysteine regulation and the pathways required for conversion of dietary folate into its biologically active metabolite, tetrahydrofolinic acid. It is now known that inadequate tissue folate activity occurs commonly, despite normal blood and red-cell folic acid levels, resulting in toxic accumulation of homocysteine and chronic disease.
"The most remarkable aspects of this story of nutrient insufficiency are the subtleties of mild forms of homocystemia. This condition can go unrecognized for decades, while neurological and cardiovascular functions significantly decline."
Dr. David Jones. MD. 5th International Symposium of Functional Medicine, May 1998.
Similar complex interrelationships also exists for other nutrients, especially such pivotal nutrients as Vit C, Vit E, Vit B6 & B3. Synergistic activity between vitamins themselves and between vitamins and minerals has been well established in the research literature and adequate tissue saturation of all synergistic nutrients is an absolute requirement for optimal cellular and tissue function.
"In order for antioxidant nutrients to successfully recycle between oxidized and reduced forms and for redox potential to be maintained, an additional number of nutrients are required. For Vit E recycling, for example, vitamin C, vitamin B3 and carotenoids are required. For vitamin C recycling, vitamin E, flavonoids and glutathione are required. For glutathione recycling, vitamin C, selenium and lipoic acid are required. Itamin B3 is also required for continued recycling of lipoic acid between its oxidized (lipoate) and reduced (dihydrolipoate) forms."

Dr. Buck Levin, MD. Nutritional Management of Inflammatory Disorders.

Clinical Companion Series. 1998. Health Comm Inc.Imunological Imbalance and Inflammation -

Within recent years, the mechanisms and interactions between immune system function and inflammation have been more clearly delineated and the complex interaction of triggers and mediators that result in the inflammatory process have been greatly unwoven. It is now known that inflammation represents an alteration in cellular physiology that influences the homeodynamic function many organ systems: the musculoskeletal, cardiovascular, nervous, gastrointestinal, hepatic, immune, genitourinary and endocrine systems.
There are 3 basic events underlying inflammation: a) increased blood flow to the damaged area b) increased capillary permeability to permit enhanced access of immune-mediating molecules and cells and c) increased delivery of leucocytes to the injured area.
A variety of stimuli, such as trauma, ischaemia, toxins, allergens, microbial by-products and stress can trigger the release of pro-inflammatory cytokines from tissue macrophages and CD4 T-lymphocytes and thus initiate the inflammation process.
Though inflammation initially benefits tissue function in the injured area by enhancing immune surveillance, microbiocidal activity and recycling of damaged tissues, there is a shift in physiological status to a pro-inflammatory state, in which chemical mediators conveyed systemically throughout the body induce an "alarm reaction" in all body systems. This "systems alert" state results in increased production of reactive oxygen species and tissue damage, sets up a positive feedback mechanism in the immune system throughout the body and causes cytokine-induced tissue catabolism. In chronic inflammatory illness, or even severe acute inflammation, cytokine-induced catabolism increases nutrient requirements by 200 - 400 percent, a level that cannot be met by diet or from tissue stores.Induction of the pro-inflammatory state is dependent on a variety of nutrient balances which directly impact upon tissue macrophage and T-lymphocyte activity. For instance, it has been established that one of the most critical nutrient balances affecting inflammatory potential is the tissue ratio of the fatty acids - saturated fatty acids vs unsaturated fatty acids AND the ratio of W -6- polyunsaturated fatty acids vs W -3 polyunsaturated fatty acids vs W -9-monounsaturated fatty acids. A shift of the ratio to the right in these balances results in increased activation of tissue macrophages and CD4 T-lymphocytes, with augmented production and release of pro-inflammatory cytokines. Dietary fatty acid modulates actions of nucleotides on humoral immune responses.

Jyonouchi H et al. Nutrition, 1995 Sep-Oct, 11:5. (Dept of Pediatrics, University of Minnesota)

"Animal and human studies have shown that production of cytokines can be reduced by long-chain (n-3) polyunsaturated fatty acids (PUFA). This, in turn, results in reduction of the severity of certain autoimmune, inflammatory, and atherosclerotic diseases and reduces cytokine-induced anorexia."

Effect of (n-3) polyunsaturated fatty acids on cytokine production and their biologic function. Meydani SN; Nutrition, 1996 Jan, 12:1 (Nutritional Immunology Laboratory, Tufts University)

"Dietary supplementation with fish oil can inhibit the expression of surface molecules involved in the function of human antigen-presenting cells, a potential mechanism by which n-3 fatty acids may suppress cell-mediated immune responses."

Hughes DA et al. Am J Clin Nutr, 1996 Feb, 63:2

(Dept of Nutrition, Diet and Health, Institute of Food Research, Norfolk, UK.)
The deleterious effects of prolonged or uncontrolled inflammation are enhanced by inadequate tissue antioxidant status. In the presence of sub-optimal antioxidant capacity, inflammatory cytokines with nitric oxide genesis inevitably results in secondary generation of highly-damaging free radical species such as peroxynitrite, which cause severe cellular damage, resulting in pathological changes typical of chronic inflammatory disorders. Balanced antioxidant supplementation substantially reduces genesis of reactive oxygen species, enhances free radical scavenging and attenuates tissue damage.
Impaired immunocompetence -
In contrast to problems of immune system hyperreactivity, many patients, especially the elderly and young, suffer from problems of impaired immune function. These patients fail to mount a strong integrated immune response to microbial invasion and are subject to recurrent bacterial and viral infections. In these patients, assiduous assessment of nutritional status usually reveals some degree of nutrient inadequacy, usually of multiple nutrients (e.g., Vitamin C, Vitamin B6 & zinc). Commonly, some other form of physiological dysfunction is also present, e.g., immunological reaction to cows’ milk protein or gluten, and is compromising gastrointestinal function and nutrient uptake. Use of balanced "low-allergy" diets with digestive support and appropriate nutrient supplementation can return these patients to a state of immunocompetence. Even in elderly institutionalised patients, adequate nutrient supplementation has been shown to upregulate immune system function and results in decreased morbidity and death.
"Nutrition and nutritional status can have profound effects on immune functions, resistance to infection and autoimmunity in man and other animals. Nutrients enhance or depress immune function depending on the nutrient and level of its intake…. "Understanding the molecular and cellular immunological mechanisms involved in nutrient-immune interactions will increase our applications for nutrition of the immune system in health and in disease."

Dr. LS Harbige. Nutr Health, 1996, 10:4, 285-312

United Medical School of Guy's and St. Thomas's Hospital. London, UK.

Gastrointestinal Dysfunction -
Gastrointestinal dysfunction is possibly the most significant functional entity that impacts upon general health and nutritional disturbance. Nothing is more intimate in the interface between individuals and their environment than the process of introducing food substances into the GI tract and hoping for a sustaining relationship. GI tract disturbances may affect in health in several functional areas:

    • Inadequate digestive capacity in the stomach and pancreas
    • increased bowel permeability resulting in enhanced macromolecular absorption
    • increased activation of gut-associated lymphoid tissue (GALT) leading to immune system disturbance
    • intestinal dysbiosis leading to excessive absorption of bacterial endotoxins or presentation of bacterial antigens to the mucosal tissue macrophages & CD-4 cells
    • excessive mycelial candida growth occurring secondary to loss of regulatory control by the normal bowel flora
    • production and absorption of psychoactive amines and/or atypical neuroendocrine responses to physiological stimuli

The "gut-brain" connection has been consistently verified in the scientific literature and a strong relationship between brain function and the production of psychoactive-amines from dysbiotic microbiota of the GI tract has been defined. The byproducts of intestinal microbial metabolism has been associated with altered behaviour in children with autism and adults with schizophrenia, and the neurological sequelae of immunological reactions to food allergens confirmed.

"Keeping food and the fecal stream separate from the blood stream, but available for nutrient supply, is the key."

Dr. Sidney Baker. MD. in Detoxification and Healing. Keats Publishing. 1987

"Allergists, GI specialists and psychiatrists have found that certain types of food, impaired digestion and faulty absorption or ingestion of vitamins and minerals affect the function of the nervous system, including the brain."

Elaine Gottschall. MD. PhD. in Food and the Gut Reaction. Chpt 7

A number of seemingly unrelated clinical syndromes have been associated with alteration of intestinal permeability and immune-mediated pathology: Crohn’s disease, ankylosing spondylitis, Reiter’s syndrome, inflammatory joint disease, dermatitis herpetiformis, chronic dermatologic disorders and schizoaffective disorders. Each of these clinical conditions is apparently associated with a combination of GI tract disturbances: food antigen exposure, asthma 7 eczema, altered GI tract flora, abnormal GI tract fermentation and/or altered GI/liver detoxification function. Modifying the intestinal environment to reduce activation of gut-associated lymphoid tissue (GALT) has a significant impact on immune-mediated disease and chronic inflammatory disease. Removing foods and food-related trigger factors that activate the GALT can lower the systemic mediators of inflammation such as pro-inflammatory cytokines and eicosanoids and reduce, possibly eliminate, disease activity. A specific bio-therapeutic clinical protocol, the 4R Program, has been developed to modulate the GI tract environment. It has become the conceptual blueprint for normalisation of the GI tract function through nutritional support and related modalities and derives its name from the 4 steps of the program:
The 4-R Program -

    1. Remove - refers to elimination of food allergens and chemical factors affecting GI digestive capacity and mucosal permeability PLUS elimination of pathogenic microflora and parasites
    2. Replace - refers to the replacement of digestive factors and/or enzymes whose intrinsic, functional secretion may be limited or inadequate
    3. Reinoculate - refers to the reintroduction of desirable probiotic GI organisms such that a more beneficial microflora population can develop
    4. Repair - refers to the provision of specific nutrients shown to advance mucosal repair and regeneration

Dr. J Bland. Applying New Essentials in Nutritional Medicine:

HealthComm Seminar Series. 1995

 Imbalance of Metabolic Detoxification -
Primary metabolic detoxification occurs in the liver and involves chemical modification of bioactive molecules and toxic chemicals by the hepatocytes so they can be excreted. Usually, this process involves bio-transformation of these molecules from less-polar, lipid-soluble substances into more-polar, water-soluble molecules. Impaired hepatic capacity to perform this task diminishes protection against the negative impact of xenobiotics and toxins on cellular biochemistry and may lead to a slowly progressive systemic toxicity state and neuroendocrine dysfunction.
Detoxification generally occurs in a two-phase process:

    1. Phase I involves the polymorphic cytochrome P450 enzyme system in which bioactive molecules are oxidised into highly reactive metabolites suitable for excretion or further processing by conjugation with a variety of chemicals
    2. Phase II involves specific biochemical conjugation enzymes which transform the reactive metabolites of Phase I oxidation into new, non-reactive and more soluble compounds by bonding them to specific neutralising agents such as sulphur, glucuronic acid, glycine etc. These new molecules are the then excreted via the biliary system and GI tract or via the renal system, with some excretion also occurring via the lungs and skin.

Dr. J Bland. Fundamentals of Functional Medicine:

4th International Symposium on Functional Medicine. 1997

The hepatic detoxification systems are highly complex, show a great amount of individual variability, are an expression of that individual’s unique genotype and respond sensitively to environment and lifestyle. In apparently healthy individuals, hepatic detoxification enzyme efficacy is known to vary widely, by a factor of four- to seven-fold, indicative of the degree of genetic polymorphism involved in enzyme synthesis. Whilst, in patients with Parkinson’s and Alzheimer’s disease, studies reveal the occurrence of several genetically-impaired detoxification pathways, resulting in high susceptibility to the neurotoxic effects of certain chemicals derived from the diet, medications, bacterial metabolites (absorbed from the GI tract) or environmental toxins such as volatile chemicals from commercial solvents and petroleum by-products.

"The interplay between a patient’s predisposition and increased exposure to neurotoxins inadequately detoxified can combine to create damage to specific regions of the brain. Often biochemical dysfunction accrues slowly over many years with progression to the tissue destruction that may later be identified as a specific neurological disease."

Dr. J Bland. New Perspectives in Nutritional Therapies: Functional Neurology.

HealthComm Seminar Series. 199

In chronically ill patients, hepatic detoxification is also often compromised because of low enzyme efficacy related to polymorphic gene expression and further compromised by increased detoxification demand and oxidative stress imposed by GI tract dysfunction with increased GI mucosal permeability and immune system hyperactivation.
"Patients with GI dysbiosis, impaired gastric mucin formation secondary to defective sulfation and decreased GI mucosal integrity have greater hepatic toxin loads from gut-derived toxins. This situation can both impair or deplete nutrient-dependent detoxification mechanisms and stimulate the hepatic immunological cascades initiated by liver Kupffer cell activation. This results in increased oxidant stress and further hepatic compromise or injury. Thus, exotoxins can induce an immunological response that then produces immune-activating substances or endotoxins."

Dr. J Bland. New Perspectives in Nutritional Therapies:

Nutritional Modulation of the Detox Process. HealthComm Seminar Series. 1996

Up-regulation of hepatic detoxification enzyme activity and improved clearance of toxic metabolites can be achieved by specific nutrition-oriented therapy and results in improved systemic function, reduced symptom expression and improved health and lifestyle - i.e., chronically ill patients actually get well, get fitter, get stronger and get productive again. Nutritional support of Phase I oxidase enzyme activity (CYP-450) includes optimising intake of the necessary cofactors, Vitamins B2, B3, B6, B12 and folic acid together with zinc and magnesium. Antioxidant support with ascorbate, carotenoids, selenium, CoQ10 and thiol compounds found in garlic, onion, cruciferous vegetables, flavonoids and anthocyanidins is also a useful adjunct to enhancing CYP-450 activity. Up-regulation of Phase II conjugation systems can be achieved with supplementation of the specific conjugation compound(s) identified by appropriate investigation. For instance, sulphur conjugation responds to supplements of sulphur containing compounds such as methionine, cysteine and taurine and, similarly, supplementation with glycine, arginine, glucuronic acid, glutathione and ornithine may be required in specific individuals.In some patients, Phase I activity is desynchronised from Phase II activity resulting in high-level production of highly-reactive oxidised metabolites which outstrips the neutralising capacity of the Phase II system. These patients exhibit strong reactivity to a wide-range of environmental chemicals and medications and require heavy antioxidant and Phase II support whilst avoiding interventions that upregulate Phase I activity.
Oxidative Stress - free radical pathlogy -
Oxidative/reductive chemical processes occur throughout the body and are vital to life in that they allow metabolic reactions to proceed and inflammation processes to transpire and provide the major biocidal mechanism of the leucocyte defence system. However, the by-products of these metabolic processes are highly unstable molecules called reactive oxygen species or free radicals which have a potent ability to react with surrounding molecules and molecular structures, leading to bio-functional and structural changes in the affected cells and tissues - Oxidative Stress. The vast majority of free radicals are produced within the cell mitochondria where their reactive potential is controlled by intra-mitochondrial absorbents such as Coenzyme Q-10 and guided along the electron-transport chain, generating the formation of ATP. Generally, free radicals which escape from this system are further controlled and their damage capability neutralised by the activity of specific intra- and extra-cellular molecules and enzymes, called antioxidants.
The major anti-oxidants are:

    • enzymes - glutathione peroxidase, superoxide dismutase I & II, catalase
    • nutrients - ascorbic acid, Vitamin D & E, carotenoids, sulphated amino acids
    • phytonutrients - bioflavonoids, catechins, anthocyanidins
    • biological molecules - Coenzyme Q-10, glutathione, uric acid, lipoic acid, ferritin and caeruloplasmin
    • many herbal medications also exhibit strong antioxidant activity which may partly account for their therapeutic benefits - silymarin, green tea, gingko biloba, dandelion and ginseng are just a few of the herbal preparations with proven therapeutic effect

If antioxidant capacity is insufficient to cope with free radical genesis, the unquenched radicals react with surrounding molecules, producing reactive oxygen intermediates with resultant molecular and cell membrane damage. If these processes occur in critical areas of the body (e.g., mitochondria, neurons, coronary arteries) and with sufficient magnitude substantial morbidity and even mortality can result. In Australia, a common cause of excessive free radical genesis and oxidative pathology is the ongoing process of protein-glycolysation, occurring as a result of the aging process, which is itself accelerated by insulin resistance and hyperinsulinaemia. Other environmental factors which commonly contribute to substantial oxidative stress are cigarette smoking; excess consumption of alcohol, saturated fats and trans-fatty acids; atmospheric pollution and chronic drug ingestion.
The increase in oxidative stress as a consequence of the production and accumulation of advanced glycosylation endproducts (AGEs) is a hallmark of biological aging and loss of organ reserve.

Dr. D. Jones. MD. 1998. The ABCs of Functional/Dysfunctional Processes.

Fifth International Symposium on Functional Medicine.

Oxidative stress with subsequent lipid peroxidation and protein-glycosylation should be suspected in all patients presenting with chronic inflammatory disease, obesity (particularly if waist:hip ratio is increased), hyperlipidaemia, cardiovascular disease, glucose intolerance and diabetes, smokers and high alcohol consumption. The diet of these patients needs to be evaluated for high-level consumption of saturated fats and trans-fatty acids (margarine, processed foods and takeaway foods) and for low-level consumption of fruit and vegetables. The degree of oxidative stress and protein glycolysation can be grossly evaluated by measurement of C-reactive protein, fructosamine and haemogobin A1c. More specific assessment can be obtained by measurement of plasma or urinary levels of specific lipid peroxidation end-products (such as malondialdehyde and conjugated dienes) and reduced GTH. Appraisal of serum insulin levels during a Glucose Tolerance Test is useful in assessment of hyperinsulinaemia, whilst serial analysis of body composition provides information on the body’s catabolic/anabolic balance at time of diagnosis and in response to treatment.
Neuro-Endocrine Imbalance -
Development of endocrine imbalance may occur because of a combination of factors :

    • impaired hormone synthesis related to nutrient insufficiency -
    • under-activity of hypothalamic neurotransmitter serotonin & dopamine receptors, either as a function of the genotype and/or secondary to oxidative stress or immunological damage
    • interference in synthesis and release of regulatory factors related to xenobiotic agents and gut-derived toxins
    • inhibition of synthetic enzyme activity related to hyperinsulinaemia induced by insulin-resistance and/or environmental toxins and drugs
    • down-regulation of hormone receptors related to environmental oestrogen-like chemicals (hormone disruptors)
    • disturbance in hormone detoxification and excretion related to impaired hepatic detoxification and bowel dysbiosis

For instance, impaired androgen balance with loss of libido, low free-testosterone, hypogonadism, impotence and reduced sperm production has been identified in males in a variety of situations:

    • exposure to oestrogen-like chemicals in the embalming cream used by morticians, resulting in inhibition of hypothalamic and pituitary feedback systems and
    • recurrent high-dose exposure to ketoconazole prescribed for resistant fungal infections and resulting in inhibition of both testicular and adrenal androgen synthesis
    • heavy smoking and alcohol consumption resulting in impaired hepatic clearance of hormone metabolites and disruption of hormone regulatory pathways
    • cadmium toxicity resulting in selectively impaired androgen synthesis

In women, development of breast cancer has been linked to hyperoestrogenic stimulation of vulnerable breast tissue receptors (dependent on gene expression). Plasma and urinary oestrogen levels have been shown to decrease, coincident with an increase in faecal oestrogen excretion, in the presence of high dietary fibre. Studies indicate that high dietary intake of soluble fibre promotes and stabilises GI tract microflora whereas low dietary fibre intake results in GI tract dysbiosis. Dysbiotic microflora in the GI tract enhance deconjugation of conjugated-oestrogen metabolites (which have been excreted into the bile via the liver) resulting in re-circulation of active oestrogen metabolites through the entero-hepatic circulation with increased oestrogenic levels in the systemic circulation and increased oxidative stress on systemic tissues. This process explains the protective role of dietary fibre against development of breast cancer, documented in multiple epidemiological studies, and again exemplifies the interactive, web-like connections between nutrition-related biological processes and disease.Similar interactive nutrition-related processes have been defined in other endocrine disorders, such as Graves disease, thyroiditis & hypothyroidism, thymic deficiency and development of autoimmune disease, menstrual disturbances and PMT and, of course, insulin-resistance and diabetes.
Summary -
Individually-based patient assessment and treatment from a nutrition-oriented perspective enables the practitioner to define the basic physiological disturbances present and, with appropriate nutritional interventions, ameliorate the disease process, restore function and regenerate the damaged organs. In the best possible scenario, the forewarned and alert physician can define physiological dysfunction at a pre-morbid stage and, by appropriate early intervention, avert the onset of disease. If illness is a signal to change, then it is the family doctor, the GP, who must help patients to find purposeful and efficacious processes to change. During this workshop, we will explore the functional or dysfunctional mechanisms that underlie the multitude of diseases we have studied so assiduously in the past. We will show you how to separate any disease state into separate categories of physiological disturbance, to enable you to think comprehensively and coherently about the disease processe. And, we will also demonstrate clinical protocols you can use to assess, treat and monitor patients with confidence and efficacy, utilising integrated nutrition-oriented programs.

We trust you will enjoy the challenge of this workshop.