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Nutritional engineering: From basic science to clinical practice
NUTRITION RESEARCH, Vol. 6, pp. 1243-1246, 1986 0271-5317/86 $3.00 + .00 Printed in the USA. Copyright (c) 1986 Pergamon Journals Ltd. All rights reserved. Editorial Commentary
NUTRITIONAL ENGINEERING: FROM BASIC SCIENCE TO CLINICAL PRACTICE Ranjit Kumar Chandra, M.D., F.R.C.P.(C), Janeway Child Health Centre St. John's, Newfoundland AIA IR8, Canada
At the turn of the 19th century, both doctors and patients were preoccupied with the role of diet in the management of illness. After a lag period of seven decades, we are witnessing a resurgence of interest in the nutritional regulation of disease. On a global scale, the enormous burden of suffering caused by protein-energy malnutrition and deficiencies of iron, vitaminLA and other nutrients has been brought to our attention by the visual and printed media. In spite of spectacular advances in genetic manipulation of agricultural production, mechanical tools, and fertilizers, the apparition of world hunger is most unlikely to disappear by the year 2000, the deadline proclaimed by international bodies for the achievement of rhealth for all.' In industrialized countries also, nutritional disorders occur frequently. These include deficiency states as well as obesity. It is clear that nutritional factors are important elements in the pathogenesis and progression of many diseases, including heart disease, hypertension, stroke, diabetes mellitus, cancer, infection, and allergy. Belatedly, clinicians are awakening to the concept of Nutritional Engineering, the use of nutritional support in the prevention a~d management of a variety of illnesses. Several nutrition surveys in the United States of America, Canada, and other countries, have demonstrated that nutritional deficiencies are not rare in affluent countries (1,2). Eating habits are ingrained in societies and families and despite the availability of food, Customary practices and deliberate deviations of dietary intake can result in subclinical, and rarely even obvious, deficiencies. Recent attempts to examine current eating habits and their significance for human health (3) are important first steps to appropriate interventions in terms of nutrition policy, education, and supplementation programs. In the hospital setting, there is growing awareness of the frequent presence of malnutrition among medical and surgical patients of all age groups, particularly the elderly(4). Among others, patients with inflammatory bowel disease, chronic malabsorption syndromes, malignancies, chronic renal disease, metabolic disorders, and cardiovascular disease, require careful nutritional assessment and m a y b e expected to benefit from appropriate nutritional and metabolic support(4,5). Host immunity and virulence of organisms are the two major determinants of infectious illness and its outcome. Nutrition is
1243
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established as an important factor that impinges on immunity and risk of infection (6,7). This is true both for protein-energy malnutrition and deficiencies of single nutrients, such as vitamins A, C, B6, folic acid, zinc, iron, copper, and selenium (8,9). Nutritional regulation of im~unocompetence has found application in the management and monitoring of several clinical states, including Crohn's disease, cancer, burn injury, and physical trauma(10). The proceedings of a recent symposium on this topic are summarized elsewhere in this issue. After the control of communicable diseases, genetic metabolic disorders and allergic disease are the major causes of morbidity and mortality in industrialized countries. There is a clear role for nutritional manipulation in the prevention ofdisability that results from inability to metabolize certain dietary constituents. Among others, patients with phenylketonuria, galactosemia, homocystinuria, glycogen storage disease, require careful monitoring and dietary therapy (11,12). Food allergy can produce a spectrum of clinical manifestations, from acute anaphylaxis to eczema and asthma to chronic arthralgia and migraine(13,14). A variety of dietary protein antigens are recognized inducers of food allergy. In patients with confirmed diagnosis, appropriate elimination diets are useful (15). Breast feeding and the use of protein hydrolysate formula reduce the incidence of atopic eczema among infants at high risk because of hereditary predisposition (16). The connection between diet and diabetes has been known for centuries. In spite of rapid advances in endocrinology and the availability of human insulin, nutritional management remains a key peg in the control of hyperglycemia and its complications (17). Total energy intake and balance are important determinants of obesity, and overweight correlates significantly with the occurrence of non-insulin dependent Type II diabetes mellitus. Nutrition and cardiovascular disease (atherosclerosis, myocardial infarction, hypertension, cerebrovascular disease) are the topic of intense debate, particular the role of dietary fat in the prevention and management of hyperlipidemia associated with heart disease. A prudent diet with less than 30% calories as fat, an increase in consumption of polyunsaturated fat, and moderately large intake of ~3 fatty acids, has been advocated and may be useful (18). The scientific evidence for benefit derived from fish (19) has found application in changing eating habits in North America where consumption of fish has increased at the expense of beef and other red meats. It should be pointed out that the initial insult to vascular intima may occur during childhood and thus good eating habits must be initiated during early life for maximum benefit in the prevention of degenerative disease in adults (20-22). Other common diseases in which preventive and therapeutic nutrition hold promise are cancer(23), goitre, renal failure, dental caries, and trauma. Changes in population dynamics and the progressive increase in the number of elderly individuals have forced attention on the role of nutrition in aging and health (23,24). The frequent occurrence of nutritional deficiencies in this segment of the community may be causally related to the high rate of illness seen in old age and could contribute to premature death. The decline in physiological functions is not invariable and as many
EDITORIAL
1245
as one-third of individuals above the age of 60 years demonstrate preservation of responses at levels seen in younger age groups. Thus we must consider the possibility that diet and nutrition, as also other environmental factors, contribute to the changes of senescence that are conventionally attributed to the aging process. This is an important concept because it raises the feasibility of taking preventive measures that may impact on health and illness in old age. The crucial role of diet and nutrition in the genesis and maintenance of a variety of clinical disorders cannot be denied. The scientific basis for this concept is established. In the array of armaments available to the physician and other health professionals for the prevention and management of common and rare diseases, nutrition must be given a prominent place by the side of other therapeutic strategies such as drugs, surgery, and physiotherapy. The time for nutritional engineering is here and now! I. National Center for Health Statistics. National Health and Nutrition Examination Surveys I and II. Department of Health and Human Services, Washington DC, 1972, 1982. 2. Bureau of Nutritional Sciences, Department of National Health and Welfare. Nutrition Canada. Ottawa, Health and Welfare, 1973. 3. Food and Nutrition Board. What is America Eating? Washington DC, National Academy Press, 1986. 4. Bernard MA, Jacobs DO, Rombeau JL. Nutritional and Metabolic Support of Hospitalized Patients. Toronto: Saunders, 1986. 5. Winters RW, Greene HL. Nutritional Support of the Seriously IIi Patient. Orlando, Academic Press, 1983. 5a. Rombeau JL, Caldwell MD. Enteral and tube feeding. Toronto, Saunders, 1 9 8 4 . 5b.Lebenthal E, ed. Total parenteral nutrition. New York, Alan R Liss, 1986. 6. Chandra RK. Immunocompetence in undernutrition. J Pediatr 1972; 81:1194-1200. See also Citation Classic| Current Contents, 1987 (in press) 7. Chandra RK. Nutrition, immunity, and infection. Present knowledge and future directions. Lancet 1983; i:688-691. 8. Beisel WR. Single nutrients and immunity. Am J Clin Nutr 1982; 35:417-468. 9. Chandra RK, ed. Nutrition and Immunology. New York: Alan R Liss, 1987 (in press) 10.Chandra RK, Newberne PM. Nutrition, Immunity and Infections. Mechanisms of Interactions. New York, Plenum, 1977.
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ii. Palmer S, Zeman FJ. Inborn errors of metabolism. In: Zeman FJ, ed. Clinical Nutrition and Dietetics. Lexington, Collamore Press, 1983: 383-440. 12. Winick M, ed. Nutritional Management of Genetic Disorders. New York, Wiley, 1979. 13. Jelliffe EFP, Jelliffe DB, ed. Adverse Effects of Foods. New York, Plenum, 1982. 14. Chandra RK, ed. Food Allergy. St. John's, Nutrition Research Education Foundation, 1987 (in press) 15. Collins-Williams C, Levy LD. Allergy to foods other than milk. In: Chandra RK, ed. Food Intolerance. New York, Elsevier, 1984: 137-186. 16. Burr M. Does infant feeding affect the risk of allergy? Arch Dis Childh 1983; 58:561-565. 17. Jovanovic L, Peterson CM, eds. Nutrition and Diabetes. New York, Alan R Liss, 1985. 18. Carol RE, Olson RE, Stare FJ, Whelan EM. Diet modification: Can it reduce the risk of heart disease? In Ellenbogen L, ed. Controversies in Nutrition. New York, Alan R Liss, 1981: 53-62. 19. Lands WEM. Fish and Human Health. Orlando, Academic Press, 1986. 20. Widhalm K, Naito HK. Detection and Treatment of Lipid and Lipoprotein Disorders of Childhood. New York, 1984. 21. Falkner F, ed. Prevention in Childhood of Health Problems in Adult Life. Geneva, World Health Organization, 1980. 22. Chandra RK, ed. Childhood Antecedents of Adult Disease. Montreal, Ross Laboratories, 1982. 23. Chandra RK, ed. Nutrition, Immunity, and Illness in the Elderly. New York, Pergamon Press, 1985. 24. Young EA, ed. Nutrition, Aging and Health. New York: Alan R Liss, 1986.
NUTRITIONAL ENGINEERING: FROM BASIC SCIENCE TO CLINICAL PRACTICE Ranjit Kumar Chandra, M.D., F.R.C.P.(C), Janeway Child Health Centre St. John's, Newfoundland AIA IR8, Canada
At the turn of the 19th century, both doctors and patients were preoccupied with the role of diet in the management of illness. After a lag period of seven decades, we are witnessing a resurgence of interest in the nutritional regulation of disease. On a global scale, the enormous burden of suffering caused by protein-energy malnutrition and deficiencies of iron, vitaminLA and other nutrients has been brought to our attention by the visual and printed media. In spite of spectacular advances in genetic manipulation of agricultural production, mechanical tools, and fertilizers, the apparition of world hunger is most unlikely to disappear by the year 2000, the deadline proclaimed by international bodies for the achievement of rhealth for all.' In industrialized countries also, nutritional disorders occur frequently. These include deficiency states as well as obesity. It is clear that nutritional factors are important elements in the pathogenesis and progression of many diseases, including heart disease, hypertension, stroke, diabetes mellitus, cancer, infection, and allergy. Belatedly, clinicians are awakening to the concept of Nutritional Engineering, the use of nutritional support in the prevention a~d management of a variety of illnesses. Several nutrition surveys in the United States of America, Canada, and other countries, have demonstrated that nutritional deficiencies are not rare in affluent countries (1,2). Eating habits are ingrained in societies and families and despite the availability of food, Customary practices and deliberate deviations of dietary intake can result in subclinical, and rarely even obvious, deficiencies. Recent attempts to examine current eating habits and their significance for human health (3) are important first steps to appropriate interventions in terms of nutrition policy, education, and supplementation programs. In the hospital setting, there is growing awareness of the frequent presence of malnutrition among medical and surgical patients of all age groups, particularly the elderly(4). Among others, patients with inflammatory bowel disease, chronic malabsorption syndromes, malignancies, chronic renal disease, metabolic disorders, and cardiovascular disease, require careful nutritional assessment and m a y b e expected to benefit from appropriate nutritional and metabolic support(4,5). Host immunity and virulence of organisms are the two major determinants of infectious illness and its outcome. Nutrition is
1243
1244
EDITORIAL
established as an important factor that impinges on immunity and risk of infection (6,7). This is true both for protein-energy malnutrition and deficiencies of single nutrients, such as vitamins A, C, B6, folic acid, zinc, iron, copper, and selenium (8,9). Nutritional regulation of im~unocompetence has found application in the management and monitoring of several clinical states, including Crohn's disease, cancer, burn injury, and physical trauma(10). The proceedings of a recent symposium on this topic are summarized elsewhere in this issue. After the control of communicable diseases, genetic metabolic disorders and allergic disease are the major causes of morbidity and mortality in industrialized countries. There is a clear role for nutritional manipulation in the prevention ofdisability that results from inability to metabolize certain dietary constituents. Among others, patients with phenylketonuria, galactosemia, homocystinuria, glycogen storage disease, require careful monitoring and dietary therapy (11,12). Food allergy can produce a spectrum of clinical manifestations, from acute anaphylaxis to eczema and asthma to chronic arthralgia and migraine(13,14). A variety of dietary protein antigens are recognized inducers of food allergy. In patients with confirmed diagnosis, appropriate elimination diets are useful (15). Breast feeding and the use of protein hydrolysate formula reduce the incidence of atopic eczema among infants at high risk because of hereditary predisposition (16). The connection between diet and diabetes has been known for centuries. In spite of rapid advances in endocrinology and the availability of human insulin, nutritional management remains a key peg in the control of hyperglycemia and its complications (17). Total energy intake and balance are important determinants of obesity, and overweight correlates significantly with the occurrence of non-insulin dependent Type II diabetes mellitus. Nutrition and cardiovascular disease (atherosclerosis, myocardial infarction, hypertension, cerebrovascular disease) are the topic of intense debate, particular the role of dietary fat in the prevention and management of hyperlipidemia associated with heart disease. A prudent diet with less than 30% calories as fat, an increase in consumption of polyunsaturated fat, and moderately large intake of ~3 fatty acids, has been advocated and may be useful (18). The scientific evidence for benefit derived from fish (19) has found application in changing eating habits in North America where consumption of fish has increased at the expense of beef and other red meats. It should be pointed out that the initial insult to vascular intima may occur during childhood and thus good eating habits must be initiated during early life for maximum benefit in the prevention of degenerative disease in adults (20-22). Other common diseases in which preventive and therapeutic nutrition hold promise are cancer(23), goitre, renal failure, dental caries, and trauma. Changes in population dynamics and the progressive increase in the number of elderly individuals have forced attention on the role of nutrition in aging and health (23,24). The frequent occurrence of nutritional deficiencies in this segment of the community may be causally related to the high rate of illness seen in old age and could contribute to premature death. The decline in physiological functions is not invariable and as many
EDITORIAL
1245
as one-third of individuals above the age of 60 years demonstrate preservation of responses at levels seen in younger age groups. Thus we must consider the possibility that diet and nutrition, as also other environmental factors, contribute to the changes of senescence that are conventionally attributed to the aging process. This is an important concept because it raises the feasibility of taking preventive measures that may impact on health and illness in old age. The crucial role of diet and nutrition in the genesis and maintenance of a variety of clinical disorders cannot be denied. The scientific basis for this concept is established. In the array of armaments available to the physician and other health professionals for the prevention and management of common and rare diseases, nutrition must be given a prominent place by the side of other therapeutic strategies such as drugs, surgery, and physiotherapy. The time for nutritional engineering is here and now! I. National Center for Health Statistics. National Health and Nutrition Examination Surveys I and II. Department of Health and Human Services, Washington DC, 1972, 1982. 2. Bureau of Nutritional Sciences, Department of National Health and Welfare. Nutrition Canada. Ottawa, Health and Welfare, 1973. 3. Food and Nutrition Board. What is America Eating? Washington DC, National Academy Press, 1986. 4. Bernard MA, Jacobs DO, Rombeau JL. Nutritional and Metabolic Support of Hospitalized Patients. Toronto: Saunders, 1986. 5. Winters RW, Greene HL. Nutritional Support of the Seriously IIi Patient. Orlando, Academic Press, 1983. 5a. Rombeau JL, Caldwell MD. Enteral and tube feeding. Toronto, Saunders, 1 9 8 4 . 5b.Lebenthal E, ed. Total parenteral nutrition. New York, Alan R Liss, 1986. 6. Chandra RK. Immunocompetence in undernutrition. J Pediatr 1972; 81:1194-1200. See also Citation Classic| Current Contents, 1987 (in press) 7. Chandra RK. Nutrition, immunity, and infection. Present knowledge and future directions. Lancet 1983; i:688-691. 8. Beisel WR. Single nutrients and immunity. Am J Clin Nutr 1982; 35:417-468. 9. Chandra RK, ed. Nutrition and Immunology. New York: Alan R Liss, 1987 (in press) 10.Chandra RK, Newberne PM. Nutrition, Immunity and Infections. Mechanisms of Interactions. New York, Plenum, 1977.
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ii. Palmer S, Zeman FJ. Inborn errors of metabolism. In: Zeman FJ, ed. Clinical Nutrition and Dietetics. Lexington, Collamore Press, 1983: 383-440. 12. Winick M, ed. Nutritional Management of Genetic Disorders. New York, Wiley, 1979. 13. Jelliffe EFP, Jelliffe DB, ed. Adverse Effects of Foods. New York, Plenum, 1982. 14. Chandra RK, ed. Food Allergy. St. John's, Nutrition Research Education Foundation, 1987 (in press) 15. Collins-Williams C, Levy LD. Allergy to foods other than milk. In: Chandra RK, ed. Food Intolerance. New York, Elsevier, 1984: 137-186. 16. Burr M. Does infant feeding affect the risk of allergy? Arch Dis Childh 1983; 58:561-565. 17. Jovanovic L, Peterson CM, eds. Nutrition and Diabetes. New York, Alan R Liss, 1985. 18. Carol RE, Olson RE, Stare FJ, Whelan EM. Diet modification: Can it reduce the risk of heart disease? In Ellenbogen L, ed. Controversies in Nutrition. New York, Alan R Liss, 1981: 53-62. 19. Lands WEM. Fish and Human Health. Orlando, Academic Press, 1986. 20. Widhalm K, Naito HK. Detection and Treatment of Lipid and Lipoprotein Disorders of Childhood. New York, 1984. 21. Falkner F, ed. Prevention in Childhood of Health Problems in Adult Life. Geneva, World Health Organization, 1980. 22. Chandra RK, ed. Childhood Antecedents of Adult Disease. Montreal, Ross Laboratories, 1982. 23. Chandra RK, ed. Nutrition, Immunity, and Illness in the Elderly. New York, Pergamon Press, 1985. 24. Young EA, ed. Nutrition, Aging and Health. New York: Alan R Liss, 1986.