Nutritional and Clinical Management of Chronic Conditions and Diseases PDF

Preface

Nutritional status is now recognized as a major determinant in health and disease. The course of virtually all chronic diseases is affected by the nutritional status of the ill person, and treatment and outcome of a disease can be markedly improved if the patient complies with recommended diet changes. This book and its predecessor, Nutritional Aspects and Clinical Management of Chronic Disorders and Diseases (CRC Press, 2003) are intended to help clinicians integrate nutritional management into overall clinical management. Whereas the earlier book deals largely with diseases of major organs, the current book discusses broader topics, such as obesity, pregnancy, and errors of metabolism, as well as diseases of organs not previously covered, the skin, and the oral cavity.

The first chapter, "Childhood Obesity," by Peebles and Hammer, deals with what is fast becoming a major public health issue in the United States and other developed countries. After introductory statistics that call attention to the fact that nearly half of U.S. children and youth aged 6 to 19 years are overweight, the authors discuss measures for determining adiposity; review critical growth periods; define and indicate the importance of the glycemic index; and then describe the effects of decreased physical activity, genetics, family, social situation, and hormonal factors. After discussing the relationship of obesity to specific diseases and conditions, including hypertension and sleep apnea, the authors proceed to a discussion of treatment, emphasizing the need for exercise, and review the various dietary and medical approaches to effective weight loss and maintenance of the loss. This chapter, similar to all that follow, has an extensive list of bibliographic references.

Keith and Rowell, in the second chapter, deal with weight control in the adult. They too begin by emphasizing that in the past generation or so obesity has become an epidemic in both the developed and developing worlds, due in part to the ready availability of high-energy foods and the marked increase in sedentary living. Keith and Rowell recognize that proper weight control depends on a realistic definition of what constitutes success. They then discuss the genetics of obesity, pointing out that genetic influences, while important, do not account for 60% of weight variance. Indeed, genetic influences alone cannot account for the dramatic increase in weight, with decrease in physical activity, consumption of energy-dense food, increased stress levels, and sleep disturbances contributing significantly to energy balance. An important part of the chapter describes the approach to the overweight patient, including the use of the tools WAVE and REAP, which are defined and explained in tables that describe how to use them, depending on the amount of time available to the clinician. The chapter summarizes pharmacologic advances that may help control obesity and concludes with an outlook to future advances.

In the third chapter, Sharma, Calleo-Cross, and Aronne discuss in detail the indication for bariatric surgery in very obese adults who have not responded to the kind of medical intervention described in the preceding chapter. These authors point out that the burden placed on patients and society by severe obesity makes surgery a viable option, provided the surgeon selects the patients with great care. Gastric bypass surgery can make patients euglycemic long before they attain their ultimate, typically very profound weight loss. It can also improve cardiovascular status, respiratory insufficiency, and the sleep apnea syndrome. The chapter discusses contraindications to surgery, details preoperative screening, and describes the various operative procedures, including the Roux-en-Y bypass, the vertical banded gastroplasty, laparoscopic adjustable gastric banding, and the biliopancreatic diversion with duodenal switch.

The elderly constitute an increasing proportion of the population, and their nutritional management is an important part of their care, particularly since practices appropriate to the middle-aged adult may be inappropriate for the elderly. A striking example cited by Young and Apovian in Chapter 4 is the observation that some obesity in the elderly may in fact be protective and that excessive thinness may be undesirable for the very old. The chapter describes the physiologic changes that occur with aging and what they mean for nutrition of the elderly in terms of a modified food guide. It then proceeds to screening and assessment, evaluates overand undernutrition in this population, and discusses in some detail the sarcopenia of aging. Even though nutritional approaches are important in the attempt to overcome the frailty and muscle loss so typical of the elderly in assisted living and nursing facilities, Young and Apovian emphasize that the as yet best approach to sarcopenia is resistance training.

Food allergy, a topic of interest to otherwise healthy individuals, is a condition that can lead to severe allergic reactions, even anaphylactic death. In the fifth chapter, Abba Terr discusses the normal immune response, allergic responses, and mechanisms of allergy. He describes the three types of reactions, based on the particular immune pathway involved in the disease, and enumerates and details the various allergic diseases and their clinical manifestations. Terr then discusses nonallergic immunologic diseases associated with food intolerance, such as celiac sprue, nonimmunological reactions to foods, and reactions to food additives. An extensive section of the chapter deals with diagnosis and treatment. While the only sure way to overcome food allergy is to eliminate the responsible food allergen, other methods of treatment are available, such as immunotherapy. Terr also calls attention to controversial practices and inappropriate diagnostic procedures, as well as unproven therapies, thereby strengthening the informed clinician's hand.

In Chapter 6, Brenner and Bhatia deal with nutritional management of pregnancy and lactation. Starting with recommendations for women of all childbearing ages, they tabulate recommended dietary allowances, adequate intakes, and calorie requirements with respect to body index and deal with specific nutrients, such as folic acid, calcium, and iron. They then outline specific recommendations for the pregnant woman, including a discussion of weight gain, specific nutrients, and dietary environmental hazards, such as mercury. The second half of the chapter deals with the management of lactation. Lactating mothers' concerns regarding quality and volume of milk are discussed, as is the topic of weight loss during the lactation period and the effects of alcohol, caffeine, and peanut consumption.

For appropriate nutritional advice to become an integral part of clinical management, the advice must be repeated often, in different ways, and adherence to the recommended dietary pattern must be monitored. This is another way of stating the need for persistent behavior change. In Chapter 7, Fleming, Curtin, and Bandini address this general topic, outlining the way behavior change can be altered and retained. In their introduction, the authors point out that nutritional adherence to a particular regimen not only demands personal commitment by the patient and family, but is also greatly influenced by the environment and its "pull." For example, weight control is more difficult when a person is surrounded by the ready availability of energy-dense foods. The authors then discuss the three basic psychological theories - applied behavior analysis, social cognitive theory, and the transtheoretical model - that govern behavioral interventions. This is followed by detailed descriptions of how advice, counseling, and education can reinforce a patient's change in behavior. A section on comprehensive intervention programs is followed by a practical model for promoting patient adherence, which is also outlined in a table. The chapter concludes with suggestions for future research.

In Chapter 8, Kimberlee and Reuben Matalon discuss inborn errors of metabolism, with phenylketonuria (PKU) the classic example of a genetic disease that can be treated by dietary intervention. They review the disease, discuss NIH treatment guidelines, and refer to the response to tetrahydrobiopterin (BH 4 ). The chapter then discusses maternal PKU, galactosemia (where lactose restriction can lead to dramatic improvement), biotinidase deficiency, isovaleric academia, maple syrup urine disease, and urea cycle defects.

In a compact chapter, R.K. Chandra discusses the relationship between malnutrition and the immune system. Malnutrition has long been known to aggravate the risk of infection, but nutrient excess can also impair the immune response. Impaired immune response is in fact the key pathogenic factor in the interaction between malnutrition and infection. Although nutrition plays an important role in the development and maintenance of immunity at all ages, Chandra discusses persons of three periods of life in detail: low birth weight infants, adolescents, and the elderly. He cites a number of diseases where nutrition plays an important role in enhancing immunity, including AIDS, the human immunodeficiency virus infection, a disease that has spread over the globe in but two decades. The chapter concludes with advice for the treating physician, with special reference to children and the elderly.

By now dental caries and periodontal disease are recognized to be chronic infections of the oral cavity that are markedly influenced by diet. In Chapter 10, Tanzer and Livingston consider diet and nutrition as they affect oral mucosal disease, gingival/periodontal disease, and dental caries. They also explore the consequences of tooth loss and review gaps in overall knowledge concerning the management of patients with nutritional problems. A notable aspect of the chapter is the detailed discussion of dental caries, a disease that arises as a result of infection, largely by Streptococcus mutans, provided the host consumes a diet high in fermentable carbohydrates. Caries may therefore be termed an opportunistic infection. Various strategies to inhibit caries are discussed, including the use of nonfermentable carbohydrates like xylitol. The chapter concludes by calling attention to the needs of special patients, including those who have Sjögren's syndrome or gallbladder disease or who are edentulous.

In Chapter 11, McCusker, Marcy, Rothe, and Grant-Kels treat the relationship between skin and nutrition. Dermatitis herpetiformis and its relationship to gluten, acrodermatitis enterohepatica and its relationship to zinc, and erythropoietic porphyria and beta-carotene are dealt with first, as diseases with a known, nutrition- related epidemiology. Yet, the epidemiology of the most common skin disorder in the United States, acne vulgaris, is not fully known. The role of sugar in acne vulgaris has long been discussed, and the authors cite new evidence of a potential glycemic role, but their discussion of the nutritional aspects of this disease is much broader, including the role of macro- and micronutrients. Other skin diseases that receive detailed and extensive discussion are acne rosacea, acne dermatitis, psoriasis, melanoma, and nonmelanoma skin cancer. Treatment for each of these diseases is detailed in an extensive table that lists topical and oral agents, light and nutritional therapy, structure and function of a given agent, and comments thereon. Proper function of the esophagus, stomach, and pancreas is clearly essential for food intake and adequate nutrition. For this reason, the prognosis for persons with upper gastrointestinal cancer is poor, and nutrition support for these patients assumes major importance in their care. In Chapter 12, Ferrone and Scolapio describe dietary issues that are linked to cancer incidence, such as the consumption of foods that contain N-nitroso compounds and the chewing of betel nuts, a widespread custom in India and other Asian countries. Almost three-quarters of people with esophageal cancer have dysphagia. The authors describe various procedures to minimize this condition, with emphasis on a properly designed nutritional regimen. Although the incidence of gastric cancer has declined in the United States, its fatality rate is very high, and there is much interest in exploring ways to improve treatment by adjuvant or neoadjuvant therapy. Diet may play a role in the risk for gastric cancer, and nutritional management of the gastric cancer patient is essential. Similarly, nutritional management of the pancreatic cancer patient following a Whipple procedure (pancreaticoduodenectomy) is essential and can help the patient lead a near-normal life after surgery. In patients with advanced pancreatic cancer, various dietary approaches have been explored, but data are insufficient for firm recommendations.

The last chapter, by Frankenfield and Smith, deals with the nutritional management of body wasting that occurs as a result of disease, a condition known as cachexia. Although there is commonality between simple malnutrition and cachexia, the latter is driven by an inflammatory response. In malnutrition the body adapts by sparing body protein, but this is not true in cachexia. The authors describe the inflammatory response in detail and then proceed to discuss monitoring and treatment of the condition. Ideally treatment includes controlling the infection or healing the injury. This may not be possible in chronic illness, but a balance of n-6 and n-3 fatty acids, with a ratio of between 2:1 and 4:1 in n-6 to n-3 fatty acids, appears to be a promising nutritional agent that promotes an anti-inflammatory milieu. This can be achieved by dietary means, albeit with difficulty. Yet, as Frankenfield and Smith point out, the dietary approach here may be more desirable than using pharmaceuticals to inhibit enzyme activity.

It is reassuring that nutritional recommendations in the various chapters, even though they treat different diseases and conditions, are essentially similar: Eat moderately but with variety, make vegetables and fruit an important part of your diet, be sure to consume appropriate amounts of micronutrients, have a low fat intake, but make sure the diet includes certain fatty acids. Clearly, then, nutrition has become important in all aspects of life.

My thanks to the contributors for sharing their clinical knowledge and their willingness, even insistence, on making nutritional management an integral part of patient management. I also thank CRC Press/Taylor and Francis for their support in making this book a reality.