1. Nutrition in Respiratory Health & Disease PCCHA 2014 Reaching New Heights in College Health October 14, 2014 C. Alan Titchenal, PhD, CNS Joannie Dobbs, PhD, CNS Human Nutrition, Food & Animal Sciences University of Hawaii at Manoa

2. Tiktaalik, Wikipedia Transition from Water to Air Required Substantial Adaptation Lungs: A delicate, and yet, robust interface with our dry external environment

3. What was needed for this transition? Moist tissue + Oxidative stress = Lungs

4. Essential Nutrients Provide energy Form body structures Regulate body processes Essential for life

5. The Nutrients Macronutrients Protein Carbohydrate Fat Water Vitamins Water Soluble B1, B2, Niacin, B6, Folate, B12 Biotin, Pantothenate, C, Choline Fat Soluble A, D, E, K Minerals (Ash) Major Minerals Calcium, Chloride Magnesium, Phosphorus Potassium, Sodium, Sulfur Trace Minerals Chromium, Cobalt, Copper, Fluoride, Iron, Iodine, Manganese, Molybdenum Selenium, Zinc Other Trace Minerals Appear to be essential: Arsenic, Boron, Nickel, Silicon Possibly essential: Cadmium, Lead, Lithium, Aluminium, Bromine, Rubidium, Vanadium Other Food Substances Caffeine Cholesterol Dietary Fiber Other Phytochemicals

6. Macronutrients Protein Carbohydrate Fat (omega-3 & 6 fatty acids) Water Vitamins Water Soluble B1, B2, Niacin, B6, Folate, B12 Biotin, Pantothenate, C, Choline Fat Soluble A, D, E, K Minerals (Ash) Major Minerals Calcium, Chloride Magnesium, Phosphorus Potassium, Sodium, Sulfur Trace Minerals Chromium, Cobalt, Copper, Fluoride, Iron, Iodine, Manganese, Molybdenum Selenium, Zinc Other Trace Minerals Appear to be essential: Arsenic, Boron, Nickel, Silicon Possibly essential: Cadmium, Lead, Lithium, Aluminium, Bromine, Rubidium, Vanadium Other Food Substances Caffeine Cholesterol Dietary Fiber Other Phytochemicals Nutrients with Special Importance for Lung Function

7. Water – circulation & normal cell hydration Protein – structure, immune function, hydration, etc Essential Fatty Acids – anti-inflammatory, etc. Vitamins – Many, many, many functions Minerals – Many, many, many functions Phytochemicals – ??? Nutrients Critical for Lung Integrity

8. Many Nutrients Have Been Potentially Implicated in Increased Susceptibility to Respiratory Diseases

9. Nutrient Functions Related to Lung Health Structure – Homeostasis cell turnover Tissue Lubrication Media for Gas / Nutrient Exchange (Blood) Anti-inflammatory Antioxidant

21. Overly Simplistic View of Nutrient Deficiency Symptoms

22. Malnutrition is Gradual

23. Food / Meal Form of Nutrient ↓ Digestion ↓ The Nutrient Journey From Food to Cells

24. Food / Meal Form of Nutrient ↓ Digestion ↓ Absorption The Nutrient Journey From Food to Cells

25. Food / Meal Form of Nutrient ↓ Digestion ↓ Absorption ↓ Transport ↓ Cellular Uptake The Nutrient Journey From Food to Cells

26. Food / Meal Form of Nutrient ↓ Digestion ↓ Absorption ↓ Transport ↓ Cellular Uptake ↓ Nutrient Function in Cell ↓ Storage → → → Mobilization ↺ The Nutrient Journey From Food to Cells

27. Food / Meal Form of Nutrient ↓ Digestion ↓ → Unabsorbed (fecal loss) Absorption ↓ Transport ↓ Cellular Uptake ↓ Nutrient Function in Cell ↓ Storage → → → Mobilization ↺ The Nutrient Journey From Food to Cells

28. Food / Meal Form of Nutrient ↓ Digestion ↓ → Unabsorbed (fecal loss) Absorption ↓ Transport ↓ Cellular Uptake ↓ Nutrient Function in Cell ↓ Storage → → Mobilization ↺ ↓ → Loss from Body (urine, feces, skin, etc.) The Nutrient Journey From Food to Cells

29. Nutrient Bioavailability The amount of an ingested nutrient that can be digested, absorbed, and assimilated. Amount consumed does NOT = amount absorbed into the body

30. Spinach does not equal Beef in terms of Iron Bioavailability

31. Bioavailability from Supplements is Complex

32. Food / Meal Form of Nutrient ↓ Digestion ↓ → Unabsorbed (fecal loss) Absorption ↓ Transport ↓ Cellular Uptake ↓ Nutrient Function in Cell ↓ Storage → → Mobilization ↺ ↓ → Loss from Body (urine, feces, skin, etc.) The Nutrient Journey From Food to Cells

33. Nutritional Status Reality Simplistic Realistic

34. Eating Styles of Potential Concern for Lung Health Weight Loss Eating Sustainably and/or Vegetarian Convenience (Fast or Take-out) Affordable Eater Paleo Meal Replacements

35. Eating Styles of Potential Concern for Lung Health AHA ACS ADA presently AND Autism Dietary Guidelines- My Plate Gluten Free Organic/Environmental Vegetarian “Healthy”

36. Eating Styles of Potential Concern for Lung Health Weight Loss Decreased Calories Decreased Variety Non-Fat Foods Decreased Animal Protein (except fish) Excess Fruit Meal Replacements Potential Issues Decreased energy intake and decreased food variety can decrease essential nutrient intake Skipping Breakfast  decreased protein and  decreased body hydration Increased caffeine intake  decreased body hydration? High intake of protein powders  redirects hydration to digestion and may decrease good iron sources

37. Questions to Identify Weight Loss Do you skip Breakfast? Do you use meal replacements? Have you eliminated foods from your diet? Do you count calories? What # do you aim to achieve? Are you consuming increased coffee or tea or energy drinks? Do you eat red meat or chicken thigh? Do you take a dietary supplement? What type?

38. Eating Styles of Potential Concern for Lung Health Eating Sustainably and/or Vegetarian Reduced or No Red Meat Organic No GMO No Pesticides “Clean” Potential Issues SHIFT IN NUTRIENT INTAKE Decreased nutrients for blood production (Iron, B12, protein etc.) Increased mineral inhibitors – polyphenols and fiber Excess water consumption w/ low sodium  hyponatremia tendency

39. Questions to Identify Sustainable and Vegetarian Eating What are your sources of protein, iron, B12? Do you count calories? What # do you aim to achieve? Do you salt your food? How much fluid do you drink? Do you take a dietary supplement? What type?

40. Take Home Messages About Eating Styles Too much of a “good thing” isn’t always good. –Too many foods considered “healthy” can cause imbalances in essential nutrients. Too much of a “good thing” can be harmful to critical functions needed for lung health. It takes months or years for most nutrient deficiencies to become clearly symptomatic.

41. Iron Deficiency is the most common micronutrient deficiency in the world and the U.S. Based on Our Analysis of National Health and Nutrition Examination Survey (NHANES) data, iron deficiency is greatly under-diagnosed.

42. Effect of Vegetarian Diet on Iron RDAs (For Adult Females and Males19 to 50 yrs of age) Iron RDA (mg/day) Omnivore Vegetarian* Females 18 33 Pregnant 27 49 Lactating 9 16 Males 8 14_____ * 1.8 times greater Source: Dietary Reference Intakes for Vitamin A, Vitamin K, Arsenic, Boron, Chromium, Copper, Iodine, Iron,.... Food & Nutrition Board, Institute of Medicine, National Academy of Sciences, National Academy Press, 2001.

43. Effects of Heavy Endurance Exercise on Iron Needs Potential Daily Iron Loss (mg/day) MaleFemale Sedentary 1 1.5 Athlete1.8 2.5 Difference0.8 1.0 ↑ Dietary Need*8 10 *Assumes 10% absorption efficiency

44. Based on Our Analysis of National Health and Nutrition Examination Survey (NHANES) data: Iron deficiency is greatly under-diagnosed

45. Brian Hill, MS Thesis, 2014

46. So what?  H&H is worse than flipping a coin  H&H, MCV, and RDW depends on age group – misses at least 1/3 http://www.doconomics.com/blog/wp-content/uploads/2012/03/coin-flip3-191x300.jpg http://www.doconomics.com/blog/wp-content/uploads/2012/03/coin-flip3-191x300.jpg 3-20-14

47. One Nutrient Deficiency Can Affect Other Seemingly Unrelated Health Problems

48. High Incidence of Vitamin D Deficiency May Be Due to Low Iron Status Vitamin D status is assessed by 25-OH Vitamin D The liver hydroxylase is iron-dependent. Iron deficiency is common and poorly diagnosed. Normalizing vitamin D status may require normal iron status.

49. Thyroid Function Is Affected by Iron Status Thyroid Hormone Synthesis Involves an Iron-Dependent Enzyme. Iron Deficiency Impairs Iodine Utilization for Thyroid Hormone Synthesis. People with Thyroid Problems Should Be Thoroughly Evaluated for Iron Status.

50. Carotenoid Craze Reflects Iron Deficiency Catabolism of carotenoids is iron-dependent Orange palms may indicate poor iron status

51. Fingernails – Window to Nutritional Health Status Zinc Deficiency Inadequate Protein / Hydration Iron Deficiency

52. Ferritin Levels of Clinical Significance Serum Ferritin (ng/mL) Cognitive achievement in school aged children and adolescents (Halterman et al., 2001) <12 Behavior performance in non-anemic infants (Oski et al, 1983) <12 Cognitive effects non-anemic girls (Bruner et al., 1996) ≤12 Thyroid function adolescent girls (Eftekhari et al., 2007) <12 Body temperature maintenance (Martinez-Torres et al., 1984) ≤15 Depression (Vahdat Shariatpanaahi, 2007) <15 Aerobic adaptation in non-anemic women (Brownlie et al., 2002) <16 Fatigue resistance in exercise non-anemic (Brutsaert et al., 2003) <20 ADHD in non-anemic children (Konofal et al, 2004) <30 Restless legs syndrome (Sun et al., 1998) ≤50 Unexplained fatigue in non-anemic women (Verdon et al., 2003) ≤50 Alopecia (Rushton, 1993, Rushton et al., 2002) ≤70

53. What About Supplements? Very Popular Better Choice

54. Sign up for daily tips with popular and scientific references. www.gotnutrients.net/

56. H N F A S Human Nutrition, Food & Animal Sciences This work is supported in part by USDA Smith Lever Funding for Project 289H

57. H N F A S Human Nutrition, Food & Animal Sciences Questions/Comments?