Nutrition is more than diet. Case management frequently requires preventive nutrition through dietary control and supplementation as an aid in preventing cellular malnourishment and enhancing recuperative powers. Proper nutritional considerations should therefore consider supplementation, dietetic regimens, balanced quantities of nutrients, adequate ingestion, digestion, absorption, as well as transportation to and utilization by the cells.


Perspective

The number of senior citizens in the United States is constantly changing. Currently, the number is about 16% of our nation's total population. There are about 25,500 nursing homes in the United States with about 1-1/2 million beds. This means that there are more nursing home beds than hospital beds. For these reasons, there is an ever-growing need for the chiropractor to familiarize himself with the inherent problems of the elderly, from both their biochemical and biomechanical aspects.

Nutritional deficiencies may result from inefficient distribution such as in circulatory impairments; accumulation of injurious metabolic debris as in azotemia or uric acid deposition; inadequate nutritional supply such as in dietary deficiencies; or ineffective cellular utilization of nutrients as in hypoinsulinism, asphyxia, and enzyme deficiencies. Thus, malnutrition may be endogenous as well as exogenous. Besides inadequate intake, the role the nervous system plays in maintaining homeostasis by integrating, coordinating, and quickening anabolic and catabolic activities (and their by-products and side effects) should be held foremost in clinical chiropractic.


Aging Theories

Several theories have been advanced about the aging process. One prominent theory proposes that aging occurs as the result of chromosomal abnormalities in somatic cells. An example of this would be nondisjunction, in which 47 chromosomes go into one of the daughter cells and 45 into the other, instead of the normal split in which 46 of them go into each of the daughter cells. Sometimes even larger chromosomal abnormalities occur. All this may prevent the synthesis of active enzymes and therefore be an important factor in the aging process.

Another widely recognized concept is that cross-linking between protein molecules is involved. This type reaction might lead to the formation of insoluble protein "sludge" in the cells and produce some phenomena of aging.

Both of the above theories can be linked by a third involving molecules with an odd number of electrons corresponding to an unsaturated valence. These free radicals produce a cross-linking between protein molecules as well as genetic mutations. Vitamins C and E, especially, have the power of destroying free radicals because they are chemical-reducing agents.

There are, of course, many other theories and even more questions to be answered such as, "Does aging in vitro bear any relationship to the aging of the whole organism?" "Do studies carried out in cell cultures have any relevance to aging in the whole animal?"


Changing Physiology in the Elderly

Despite the dispute about the exact process of aging, a picture of the altering general, neural, and digestive physiology of geriatric individuals can be observed.

General Changes.   The basic cellular metabolic rate has decreased, cellular division and growth are limited, and newly forming replacement cells are less efficient.

Neural Changes.   End-organs degenerate. Nerve cells die and are not replaced with new nerve tissue. Stronger stimuli are needed to elicit response, and reaction time is increased as the body ages. Response to sensory stimuli is slower and less accurate. Tactile receptions are less sensitive, so the older person doesn't perceive pain or injury with the same intensity as in youth. Injuries may go unnoticed or untreated because pain itself may not be recognized or reported.

Digestive-Process Changes.   There is a progressive reduction of the gastric juices in older persons. A high incidence of subnormal secretion of hydrochloric acid has been reported. The secretion of pancreatic enzymes, especially of the fat-converting enzyme lipase, and pepsin is also diminished.

The most generalized complaints in geriatrics are how easily the elderly tire and how little vitality they seem to have. Less sleep seems needed, yet frequent rest periods are necessary.

According to a U.S. National Health Survey, the following major conditions are listed in order of influence in the aged:

• Arthritis and rheumatism
  

• Deafness and other hearing impairments
  

• High systolic blood pressure
  

• Hypertension
  

• Heart conditions
  

• Asthma
  

• Hay fever
  

• Visual impairments
  

• Hernia
  

• Peptic ulcers
  

• Diabetes mellitus
  

• Chronic bronchitis
  

• Paralysis of the extremities and/or trunk.

It appears that there are many physiologic differences between the aged and youth. But when tests are performed at resting levels, these differences are modest. It is only when the individual is called on to act under stress that differences become apparent. Thus, it seems the aged's inability to respond to physiologic challenges that demonstrates deterioration in the body.


Systemic Changes

      The Cardiovascular System

The cardiovascular system is generally the first system examined in the aged. This is logical because heart failure is a common cause of death. There generally are five changes that take place:

• Resting heart rate declines at age 25--65.
  

• Resting total peripheral resistance increases as aging progresses.
  

• Resting systolic blood pressure increases after age 55.
  

• Resting diastolic pressure increases at age 25--35 but normally changes little after that.
  

• Resting cardiac index declines at the rate of 1% per year as the mature adult ages.

In the vascular system itself, arterial distensibility decreases with age. The large arteries dilate with age, pulse velocity increases with age, and impedance to left ventricular output increases after 60 years. The aortic arch and carotid baroreceptor reflexes become less sensitive with age.

Animal Research.   Laboratory studies of the hearts of rats show that duration of contraction, time to peak tension, and relaxation time at maximum tension are prolonged in trabeculae carinae (thick muscular bands attached to the inner walls of the ventricles) of aged rats. Inotropic responsiveness to catecholamines is decreased in the trabeculae carinae of aged rats. Hearts of old rats have reduced ability to respond to elevated arterial pressure by increasing the work of the heart.

Dietary Requirements

In 1950, 57,654,000 members of a total United States' population of 161,000,000 were over 40 years of age. In 1960, 64,000,000 of a total population of 174,000,000 were over 40 years of age. Now, looking backward from the 1990s, these figures look insignificant. Because of this, more and more chiropractic physicians are turning their attention to increasing their knowledge of the needs of senior citizens --realizing that during the years from 40 to 60 many aspects involving the future health of the aged are largely determined.

In the battle against many correctable conditions and needless disturbances of "old age," dietary guidance and supplementation afford a significant weapon in chiropractic care and can contribute substantially to making the years after 40 the best years for the doctors' patients.

It has been reported that 60% of the people in the United States change their eating habits after reaching the age of 40. Seven out of ten of these people do so at the advice of their physicians.

Clinical problems in dietetics can be divided into two basic considerations: undernutrition and overnutrition.

• Undernutrition is quite common among the elderly afflicted with chronic conditions, and it becomes a prophylactic and therapeutic project for the doctor of chiropractic when viewed clinically.
  
  

• Overnutrition, resulting in obesity, affects a much larger segment of the geriatric population and requires strict adherence to an approved regimen.

Although the basic requirements for satisfactory human nutrition are fundamentally similar throughout life, various described and yet to be described physiologic changes occurring with the passing years call for diet modification. Recognition of and adaptation to these factors can help retard the onset of aging symptoms and establish habit patterns that tend to enhance the pleasure of the prime of maturity.

If we recognize that growth and general health processes depend largely on the food ingested and assume this growth is counterbalanced by a destructive or aging process, then it is logical to consider nutrition as one of the more important factors in the prolongation of healthful life. Unquestionably, the nutrition of the aging person is of great importance both for his or her prospect of survival and for day-to-day comfort and activity. Although the elderly body requires the same basic nutrients as the younger person, it usually requires less quantity and higher quality.


Inadequacy of FDA Requirements

Reference to the Food and Drug Administration's (FDA) minimum daily nutritional requirements has been disconcerting and has resulted in physicians commonly referring to the recommended allowances projected by the National Research Council's Food and Nutrition Board. The reason for this is the FDA emphasis on the minimum daily requirements for an "average" person in which any amount less than this level produces demonstrable signs.

While an "average" person is commonly found in textbooks and statistical tables, rarely can one be found in a doctor's office. An "average" person is described as male or female, 25 years old, in perfect physical health, 154 lbs (men) and 128 lbs (women), living in a temperate climate under little or no stress, active physically, and neither sedentary nor engaged in strenuous manual labor.

It is obvious from a clinical viewpoint that FDA requirements (which are insisted to be obtained through a balanced diet of common foods) fail to consider prior nutritional losses in storage, cooking, and serving, nor do they provide for possible incomplete availability or absorption of nutrients and varying requirements in states of febrile illnesses, gastrointestinal disturbances, or hypermetabolic conditions where normal needs may be markedly increased or nutrient absorption impaired.


Chiropractic vs Allopathic Focus

While allopathic attention is rarely given to malnutrition until overt symptoms appear, the chiropractic approach is more concerned with preventive measures. This is undoubtedly due to the emphasis placed on nutrition in chiropractic colleges and state boards while it is rare to find formal nutritional curricula in a medical college.

With emphasis on prevention, doctors of chiropractic are directing increased attention of the influence of altered metabolism on nutritional requirements. It is not uncommon to find that the capacity of a tissue's recuperative powers is strongly influenced by nutritional states and that convalescence can be shortened by a definitive dietary and supplemental program.

Within clinical geriatrics, it must be recognized that proteins, vitamins, electrolytes, and vital fluids, salts, and trace elements may be lost in exudates and bleeding or by gastrointestinal or renal routes. Advisedly, therapy should consider the increased nitrogen losses accompanying severe disease or injury in previously well-nourished individuals as well as the increased metabolic demands resulting from disease or trauma and possible increased losses of nutrients or faulty use of metabolites. It is not uncommon to find diminished protein synthesis and reduced vitamin utilization following liver stress, systemic insults, infection, injury, or shock. Remember that malnutrition by itself can lead to disrupted metabolism, thus initiating a vicious cycle within nutritional requirements.


Overnutrition and Undernutrition

A prerequisite for geriatric dietary management is knowledge of the patient's food habits and nutritional status. Studies indicate a tendency to overnutrition and obesity and suggest that caloric restriction or increased activity, when feasible, should be important considerations. While obesity is usually a carry over from an earlier age, it may also be the result of a continual high-calorie diet and/or decreased caloric expenditure. An elderly person also has changes in body compartments that consist of increased muscle mass. These factors tend to contribute to obesity. The bottom-line consideration is that mortality rates for principal diseases among the overweight focus attention on the need for dietary management among the aged.

The two major physiologic changes witnessed clinically in obesity of the elderly are (1) reduction in the body's energy requirements and (2) a decrease in the quantity of digestive juices secreted with a resulting slowed response to food by the digestive tract. The latter situation may involve interference with normal nerve transmission and expression from specific subluxations and/or faulty torso/pelvic biomechanics.

The geriatric patient commonly presents with a body that is diminishing both in height and weight as well as energy expenditure. As caloric requirements are determined largely on expenditure, there is a corresponding decline in need. An individual at age 65 requires only 80% of the calories needed at the age of 25.


Principles of Sound Nutrition in the Aged

The geriatric patient is particularly susceptible to malnutrition and undernutrition. Physical factors such as poor-fitting dentures or loss of teeth often lead to preference of soft foods rich in carbohydrates but low in nutritional value. Limited budgets may prevent the purchase of optimum foods. Emotional states may affect the appetite. And because sight, taste, and smell are less acute in the senior citizen, food may lose much of its subjective appeal.

      Adapting to Adverse Chronic Conditions

About 65% of the population over the age of 45 suffer chronic disorders or diseases. Some of these tend to promote malnutrition by either restricting the choice of foods or by interfering with normal metabolism. Dulled appetites, dysentery, and other conditions may cause inefficient intestinal absorption resulting in inadequate tissue nutrition. In such cases, case management commonly includes food supplements that provide sufficient protein, vitamins, and minerals in an easily digestible form. Cereals, soups, and broths that are nourishing and easily prepared are also recommended, as are multivitamin preparations. When chewing or swallowing are a problem, blended foods are suggested. As an appetite stimulant and digestive relaxant, the moderate and judicious use of alcoholic beverages is often advised.

Although the principles of nutrition in the aged vary little from those of the general population, the aging process, being one of decreasing reserves, brings with it anatomical and physiologic changes that are modified by factors of disease, trauma, heritage, social adjustment, and economy.

• Temperature, pulse, fasting blood sugar, urea, calcium, and many other internal environmental constants are maintained at levels found in childhood or early maturity.

• When free of edema, elderly persons usually have about the same blood volume per unit of body weight as those in middle age.

• Acid-base balance does not change, even in men 90 years of age.

• On augmented protein intake, elderly people are just as able to retain nitrogen as the young.

Although the above examples of body constants tend to imply little functional changes, significant changes do take place in the aging process. The neurologic symptoms of nutritional deficiency are shown in Table 9.1.

Symptom                Possible  Deficiency Factor(s)                        
Depression             B-1, B-2, B-3 pantothenic acid.
Insomnia               B-3, B-6, folic acid, C, hypoglycemia, food allergies.
Irritability           B-1, B-3, potassium, magnesium, calcium, hypoglycemia, food allergy.
Knee reflex loss       B-1, B-12.
Memory loss            Choline, inositol, lecithin, B-6.
Motor weakness         B-1, potassium, calcium, magnesium, manganese.
Poor concentration     B-1, B-12, protein.
Sensory loss           B-1, potassium, calcium, magnesium, manganese.
Vibratory sense loss   B-1, B-12

      Cellular Considerations

Once growth has ceased, persistent degenerative changes occur that are exhibited by (1) cells losing their ability to exist, (2) alterations in cell membrane, and (3) the cell interior no longer maintaining certain concentrations. Cellular atrophy and degeneration, gradual tissue desiccation, slowing of cell division, cell growth, and tissue repair continue (often in the absence of any proved disease) until the cells are unable to maintain homeostatic mechanisms and death of the total organism follows.

Of particular concern are the anatomical changes at the cellular level that are reflected in functional disturbances, however subtle and subclinical. For example, although fasting blood sugar may be normal, intravenous glucose tolerance tests in the aged show that the postingestion glucose level tends to return to the resting level much slower. Thus, there is a distinct impairment of glucose tolerance in the senior citizen.

Although nitrogen retention may appear normal in those free of renal pathology, renal plasma flow, glomerular filtration rate, and maximal tubular excretory capacity gradually diminish with advancing age. Several studies show that with increasing age there is a progressive loss of ability of renal tubules to perform osmotic work.

      Metabolic Considerations

Other pertinent changes in geriatric function are noted in studies showing there is a gradual diminution of basal oxygen consumption or heat production per unit of surface area as age increases. In addition, aging is accompanied by progressive reduction of lean body mass, which represents an extensive loss of protein and is associated with tissue water depletion. Thus, deficient protein intake may be related to an increase in body fat.

In advancing years, enzymes in the gastrointestinal tract decrease and achlorhydria is common. This may interfere with digestion and absorption of protein. Liver function is altered, serum albumin decreases, and all globulin fractions increase in advancing years. These factors may reflect a deficiency of protein, a decrease in gonadal secretion, or a diminished rate of synthesis from decreasing liver function. Also in later years, there is a lowering of resting cardiac output.

      Serum Considerations

Late life shows the B-12 content of serum decreasing and B-12 absorption diminishing. Ascorbic acid and thiamin levels also tend to be lower in the elderly. Inadequate vitamin intake is a major factor; however, age does not seem an important factor in determining vitamin absorption.

      Socioeconomic Considerations

In considering the principles of sound nutrition in the aged, there are specific social and economic factors that should be weighed besides the functional change of anatomical structures. Habits, changes in daily routine, the retirement syndrome --all may be obstacles to good nutrition. And the aged do not tolerate well abrupt changes despite wise counsel. Experience has taught them what they can tolerate, and habit confines them to what advice they will follow. This topic will be continued later in this chapter.


Old-Age Causes and Effects

      Etiology

The so-called "normal" aging process makes the elder citizen's joints less flexible, decreases muscle-work capacity and strength, impairs coordination and the sense of balance, brings about mental changes, increases capillary fragility, and causes many other obvious or subtle changes in body structure and function. Nutrition supplementation is useful in such situations.

      Examples of Therapy Effects

The prolonged continuous oral administration of niacinamide (alone or in combination with other vitamins) can frequently effect remarkable changes in body function and structure of an aging population subsisting on a diet adequate in calories and protein. How do the vitamins, in general, act when used in large doses to effect beneficial changes in aging tissues? The consequences are:

• A direct effect on cellular metabolism, with improved tissue function resulting.

• An indirect effect based on the mass-action principle by reducing the rate of breakdown of certain important vitamin containing enzyme systems;

• An indirect effect based on the mass action outcome from the production of greater amounts of certain vitamin-containing enzyme systems, which in turn favor the creation of a more "youthful" function and structure of aging tissues.

It has been clearly demonstrated that vitamin-mineral supplementation can improve joint mobility, muscle-working capacity and strength, disequilibrium, capillary strength, and mental syndromes that are concomitants of aging. For example, 842 ambulatory patients, without exception, taking from 900 to 4,000 milligrams of niacinamide in divided doses per day had a clinically significant measurable improvement in joint mobility, regardless of age. This improvement was maintained for as long as treatment was administered. In capacity and strength, disequilibrium, and certain mental syndromes common to geriatric patients in about 70% of the patients during the vitamin therapy. When 1500-4000 milligrams of ascorbic acid (divided doses per day) were added to the niacinamide, there was significant improvement in the increased capillary fragility as long as the vitamin C was taken.

These and collateral studies indicate that the aging body can, under professionally supervised vitamin therapy, reconstitute some of its functions. Thus, observations suggest that many commonly accepted signs and symptoms of "old age" may be reversible to a much larger degree than once supposed.

      Longevity Patterns and Radiation Effects

Aside from some racial variations, longevity does not appear influenced by geography or socioeconomic factors. Once a person reaches adulthood, a pattern seems to take over that appears predetermined whether the person makes his home in a straw hut or plush surroundings. Reflection of this suggests to several microbiologists that some extraordinary force is being exerted on us and that this force is similar to cosmic radiation.

If this is true, it explains a great deal about how our cells become unable to handle nutrients extracted from the food we eat and, as a result, wither away. The idea that we may change the body's vulnerability to radiation by altering the food we eat may impress some as academic fantasy, but the fact is that we now know enough about intracellular function to suggest that one day this knowledge will have practical application.

Aging bodies appear to be influenced by an internal conflict between two factors acting on a third: (1) the intensity and duration of radiation-like effects, (2) the polyunsaturated lipids upon which they act, and (3) the vitamin E available to protect lipids from excessive destruction. While polyunsaturated fats offer hopeful dietary means of combating atherosclerosis, evidence reveals that these same fats might be a primary source of radicals within the cell that contribute it to age.

Radiant energy can penetrate the entire body and enter every cell. When radiation strikes a polyunsaturated lipid that is present as a nutrient, one of two things can happen. First, if enough vitamin E is present, the radiation will have little effect. However, if there is intracellular deficiency of vitamin E, the rays will strike a lipid molecule and dislodge a hydrogen atom, which typically initiates the peroxidation of polyunsaturated lipid.

Peroxidation involves the direct reaction of oxygen and lipid to form free radical intermediates that fly about in the cell with terrific force but without pattern to movement until they strike other molecules and cause damage. Lipid peroxidation is, therefore, widely regarded as the mainspring in the aging process. And it should be kept in mind that free radical damage isn't just an isolated incident; it occurs all the time in the body.

Such events take place at the most fundamental level of cellular physiology because they begin with molecular reactions involving vital cell constituents. As structural damage to cell parts increases, it is followed by malfunction of the chemical mechanism in the cell that controls normal physiology and disposes of its damaged parts. Thus the aging process.

Polyunsaturated lipids are necessary to meet the body's normal requirement for essential fatty acids. They supply the nutrients from which most of the membranous structures of the cells are constructed and are particularly useful in forming endoplasmic reticulum and mitochondria, which are the principal energy sources of the cell.

The polyunsaturates compose about 17% of the total lipids in the American diet. Because of the likely relationship of lipid intake to atherosclerosis, most nutritionists agree that we should eat more polyunsaturated fats, keeping in mind that an increase in polyunsaturates necessitates an increased need for vitamin E because this vitamin offers primary biochemical protection against the excessive oxidation of cellular lipids.

Pure proteins exposed to the bombardment of free radicals released by lipid peroxidation undergo cross-linking that caused them to polymerize and be transformed into entirely new proteins --the like of which nature never intended. The normal precision arrangement of cellular constituents and enzymes is deformed and biologic activity is grossly distorted or completely lost as a result. When lipid peroxidation occurs and mitochondria are attacked, they swell, disintegrate, and then dissolve. Because mitochondria are the power-houses of the cell, effective lipid peroxidation destroys the energy-generating apparatus of electron transport and phosphorylation.

Equally vulnerable are the lysosomes. These are small sacks that seem to have the normal obligation of digesting nutrients and dissolving of cellular waste products, which is accomplished by acidic hydrolytic enzymes. From what we know about radiobiology, the lethality of the lysosomal enzymes and their ability to compound the damage resulting from peroxidation set the patterns that we observe in gross pathology and impede the tissue catabolism associated with old age.


Major Biologic Antioxidants

Increasing attention is given to the role of biologic antioxidants in the search to slow the aging process. The animal body, with its polyunsaturated lipids and sulfhydryl enzymes, which seem defenseless against peroxidation, could not exist without the protection of major antioxidants. The three major antioxidants are (1) vitamin E, (2) lipid antioxidants, and (3) water-soluble antioxidants and free radical scavengers.

The controversy about the essentiality of vitamin E is obviously because critics are seeking evidence of gross pathology while it appears that vitamin E inadequacy is manifested in subtle and more diffuse ways, the most serious being the increased destruction of lipid peroxidation.

Vitamin C is another nutritional component that may be involved in aging because large amounts are needed in the diet owing to the vitamin's prominent role in enzymic functions (eg, in the hydroxylation of proline in collagen biosynthesis). Vitamin C also reacts with glutathione; and through antioxidant synergism, it markedly increases the effectiveness of the protective role of vitamin C itself. Its ability to act as a synergist to vitamin E and simultaneously behave as an aqueous free radical trap suggest that a nutritionally optimum amount of vitamin C is also important in slowing the process of cellular aging.

Selenium is another useful antioxidant because it acts in a manner quite similar to vitamin E and is both a lipid antioxidant and a water-soluble free radical scavenger. Besides selenium, combined glutathione, cysteine, and sulfhydryl proteins constitute a pool of reducing compounds that act as important aqueous antioxidants and free radical scavengers. They are maintained at physiologic levels by adequate protein intake and absorption and may be effective in slowing the aging process.


Dietary Management

In any nutritional management or dietary regimen, consideration should be given to what people like to eat as well as what they should eat. The prescribing doctor should be cognizant of and adapt his thinking to include known social, religious, racial, ethnic, and psychologic factors involved in individual life-styles.

Maintaining cellular homeostasis or biochemical equilibrium by supplying proper nutrients is the purpose of nutrition and a basis of good health. Yet, it has been said by a number of authorities that Americans are the most overfed and malnourished people in the world. Dietary management is often necessary to see that a patient's diet contains balanced meals composed of adequate proteins, carbohydrates, and fats and the micronutrients necessary for their proper metabolism.

The clinical fundamentals considered by those planning meals for the aged are:

1   . Protein, iron, and calcium are the elements most likely to be inadequate in spontaneously selected diets among the aged.

2.   Anemia is more significant in later than early years. In the presence of any circulatory handicap, the quality of the circulating medium assumes a role of major importance. Optimum hemoglobin concentration rather than an average concentration should be the objective.

3.   The importance of adequate fluid intake should not be forgotten.

4.   Aged persons are unique individuals, and personal variations increase with advancing years. Many variables such as digestive and circulatory efficiency, diet habits, dentures, etc, affect the prescription of a healthy diet in the elderly.

5.   Moderation is imperative. Excesses are as undesirable as deficiencies. Both may cause malnutrition. Older persons should eat small quantities frequently rather than a few large meals.

Life-Style and Nutrition in the Elderly

Only a small number of the elderly are institutionalized. The majority are either living alone, with a spouse, or residing with family or friends. These aged individuals must rely on themselves or the people they live with for their meals.

A pertinent survey was taken in Tennessee in 1973:

• More than half the group lived alone. Two-thirds rented, and 44% lived in apartments. All participants had food preparation facilities: 40% shopped once a week, 36% from two to four times a week.

• Money spent for food daily varied from $5.00 or less (9% of subjects) to a range of $5.00--$10.00 (48% of subjects). [Note that food prices have increased greatly since this study was made.]

• The participants were asked to evaluate their physical health through their own feelings, through what their physicians had told them, their dental condition, and whether they used any prescribed medication or took vitamin-mineral supplements.

• More than 50% of the males claimed to feel healthy. Only 30% of the females made the same claim. None of the black males felt overweight, but 10% of the black females wished to lose weight. In general, women complained of more ailments than men. Diabetes mellitus, heart disease, hypertension, and arthritis were the most common complaints. Only 10% of the total group were dentureless, with 16% complaining of chewing problems.

The survey asked participants about their diet over an entire week. This was then analyzed and compared to the seven essential nutrients: protein, calcium, iron, vitamins A and C, thiamine, and riboflavin. This, in turn, was compared against the Recommended Dietary Allowance (RDA) of the National Research Council, which was used as a guide and not as an absolute nutritional requirement. Of the entire group, 66% or more of each group was classified as "satisfactory."

• Protein.   More than 80% of males (black and white) and white females received satisfactory ratings. Only 70% of the black females received a similar score.

• Calcium.   Two-thirds of the participants were rated satisfactory, with slightly fewer black females so rated.

• Iron.   78% of all males were satisfactory, with 48% white and 37% black females receiving satisfactory iron.

• Vitamin A.   Total males received 46% satisfactory amounts. Only 43% of all females were rated satisfactory.

• Thiamin.   Greater than half the total were below satisfactory levels, with Blacks (males and females) being the lowest (33% and 23%, respectively).

• Riboflavin.   In general, this was the lowest rating for all groups (37% males and females).

• Vitamin C.   Except for Black males, all groups were rated at least two-thirds satisfactory. Black males received 57% satisfactory amounts.

One out of every 12 people in the United States is 65 years of age or over, and the aged and aging comprise from 60% to 77% of the average doctor's practice. The management of these patients requires not only for more years added to life but also for more vitality added to the years.

The level of nutrients stored in the body during youth and middle age may be insufficient in later years, thus bringing on the development of nutritional deficiencies in the aged. For example, stores of calcium and iron are particularly important: insufficient supplies in the body can initiate disorders such as osteoporosis and anemia.

Typical complaints of malnourished patients are listed in Table 9.2, and typical findings in malnourished patients are shown in Table 9.3.

Children

    Abnormal discharge of tears        Hyperkinesia
    Anorexia                           Pain on standing and sitting
    Aversion to normal play            Photophobia
    Backwardness in school             Poor posture
    Bloating                           Poor sleeping habits
    Chronic diarrhea                   Repeated respiratory infections
    Failure to gain weight steadily    Sores at angles of the mouth

Adults

    Abnormal discharge of tears        Lack of mental application
    Anorexia                           Lassitude
    Burning or prickling skin          Loss of strength
    Burning or twitching eyes          Loss of weight
    Chronic diarrhea                   Muscle and joint pains
    Chronic fatigue                    Muscle cramps and spasms
    Depression                         Nervousness
    Gaseous bloating                   Photophobia
    History of sore mouth or tongue    Sore and bleeding gums
    Irritability                       Sores at the corners of the mouth

Children

Abdominal distention                    Red tongue
Cheilosis                               Red, greasy nasal area
Corneal and conjunctival changes        Rib beading
Easily bruised skin                     Rough (toad-like) skin
Enlarged wrists                         Serious dental abnormalities
Lack of subcutaneous fat                Square head
Nasal blackheads and whiteheads         Tachycardia
Pallor                                  Thrush
Poor muscle tone Vincent's angina       Wrinkling of skin on stroking
Poor posture                                

Adults

Abnormal deep tendon reflexes (+/-)     Nasolabial sebaceous plugs
Anemia not responding to iron           Nonspecific vaginitis
Bilateral symmetrical dermatitis        Papillary atrophy of the tongue
Changes in tongue texture/color         Perineal dermatitis
Cheilosis                               Poor muscle tone
Conjunctival changes                    Purpura
Early fatigue of ocular accommoda-      Rachitic chest deformity
   tion                                 Scrotal or vulval dermatitis
Extremity muscle tenderness             Spongy and bleeding gums
Facial butterfly rash                   Stomatitis
Follicular hyperkeratosis of skin       Swollen and red lingual papillae
   especially at extensor surfaces      Thickening and pigmentation of
   of the extremities                     skin at pressure points
Glossitis                                 Vascularization of cornea
Hyperesthesia                           Vincent's angina
Loss of vibratory sensation

Basic Considerations

The most common deficiencies found in geriatrics are of vitamin C, vitamin B-12, folic acid, vitamin E, calcium, and iron. Folic acid deficiency appears to be the result of dark green vegetables not playing much of a role in the diet of the elderly. Many believe lack of calcium can result in or contribute to osteoporosis, which is more common in older women who were child bearing. It can also result in predisposition to fractures and spinal decalcification. The latter condition seems principally due to a lack of calcium, often for many years, as well as a lack of vitamin D and a hormonal imbalance. Dietary surveys show that the calcium intake of older people is lower than the RDA.

Attention should be given to developing inexpensive, nutrient-rich diets for the elderly. Vitamin and mineral supplements should be considered for those who are chronically malnourished or those having problems with absorption or storage. Aging in any species is a complex biologic process related to a reduction in the capacity for self-maintenance. Frequently in later life, the everyday repair of body cells is no longer as efficient; viz, there is a failure of cellular homeostasis.


Geriatrition: Nutritional Requirements of the Aged

A report from the National Institutes of Health states that nutritional problems exist in advantaged as well as disadvantaged elderly and that vitamin supplementation may be a reasonable means of overcoming such deficiencies.

      Mental Health

A study carried out at Duke University's Center for the Study of Aging concluded that half the psychiatric patients over the age of 65 had "borderline" or worse nutritional status in at least one major nutrient for the body and brain to function normally. According to Dr. Alan D. Whanger of Duke's Medical Center, "Studies reveal a substantial incidence of vitamin deficiencies, often multiple, in the elderly poor and ill." Less-severe deficiencies that might cause mild mental and physical problems were found extraordinarily difficult to diagnose.

At the Center, psychiatric patients are "almost routinely" treated with vitamin-mineral supplements. Up to 40% of the Center's elderly patients showed some nutritional deficiency, and fully half of a group of severely ill hospitalized psychiatric patients over age 65 had only borderline levels of some important nutrient. Marked mental improvement was noted when the patients were served better meals and received inexpensive food supplements.

      Physical Health

Several studies have shown that proper attention to the diet of the aged and aging can improve health and prevent emaciation commonly ascribed to the physiologic aging process but which results primarily from prolonged dietary defects.

The changes in the declining years are essentially degeneration, dehydration, and a wasting of tissue that is either not replaced or replaced with inferior tissue. Before this event, however, functional disturbances may have developed. In dealing with both changes, proper nutrition (a diet rich in protein, vitamins, and minerals) is of fundamental importance. Glandular and other secretions of the body may be reduced to the point of affecting digestion and the efficient utilization of food.

Caloric Considerations.   Both overweightness and underweightness should be avoided by the elderly. Statistical reports show that overweightness of 25% or more increases the mortality rate by 74% above the norm. Of the two, underweightness is to be preferred because obesity is more likely to be accompanied by diabetes, hypertension, and degenerative vascular disease. In planning a weight-reduction program for older people, the intake of fat and carbohydrate should be limited with no change (or an increase) in protein intake. Adequate nutrition must be assured, and it may be advisable to fortify the special diet with vitamin-mineral supplements.

Protein Considerations.   Fatigue, anemia, edema, senile pruritus, bed sores, chronic eczematous dermatoses, and lowered resistance may be related to protein deficiency. Protein is not stored, thus adequate daily consumption is necessary. Older people frequently have difficulty in increasing protein intake; and in such cases, amino-acid supplementation should be considered.

Vitamin-Mineral Considerations.   Deficiencies of vitamins A, C, B-complex, and E are particularly common among the elderly. Iron and calcium are likely the minerals most needed. Use of a multivitamin-mineral food supplement containing these factors and other essential nutrients offers deficiency prevention.

Digestion Considerations.   There is a progressive reduction of the gastric juices in older people. Subnormal secretion of hydrochloric acid has been reported in a significant segment of the aged from 23.9% to 65% --depending on age. Secretion of the pancreatic enzymes (especially the fat-converting enzyme, lipase) and pepsin is also diminished.

Nutritional Status of an Aged Population

Many sophisticated studies have been conducted on the nutritional status of senior citizens. Although it is difficult to generalize from such studies, some conclusions may have clinical importance:

1.   The intake of several nutrients was low for many of the subjects studied. This could be corrected by changes in diet and for some subjects by food supplements, mostly multivitamin preparations.

2.   It was found that nutrient intake is influenced by many social and economic factors and by the methods of food procurement, preparation, and storage.

3.   Nutritional status as measured by height, weight, radiographs of the brachium, bone density, and blood pressure was not correlated with nutrition intake. The subjects studied tended to be heavier than what is considered desirable.

4.   Many subjects had reduced their usual intake of milk, eggs, meat and fish, usually because of changed circumstances of living relating to aging.

There are over 40 million people in the United States who are dangerously overweight. These people are most likely to develop certain degenerative diseases and risk a shortened life span as a result. Two out of three individuals afflicted are over the age of 40. Some authorities say that nearly half the ordinary ailments that become clinically recognized arise from dietary indiscretions, notably from overindulgence.

Besides subjecting body organs to inordinate and unnecessary stress and strain, obesity is a definite hazard to individuals in the later years, particularly after the age of 50. For men 20% or more overweight, the mortality rate from diabetes is 133% greater; that from liver and GI disorders, 68%; that from cerebral hemorrhage, 53%; that from heart disease, 43%; and that from malignant neoplasms, 16%. For women, increases in mortality rates are respectively, 84%, 39%, 29%, 51%, and 13%. In addition, obese people are likely to have dyspnea on minor exertion, cardiac hypertrophy, hypertension, elevated serum cholesterol levels, and impaired carbohydrate tolerance leading to eventual diabetes mellitus and atherosclerosis.

Incidence

Obesity is an excess accumulation of fat that is said to exist when 20% or more of body weight is fatty tissue. In the aging, increased weight occurs at a time when activities are beginning to wane and food intake remains at the level of more active earlier years. This is primarily the age bracket of 40--59 years. Fortunately, few new cases of obesity arise after the age of 60. The typical obese subject gradually declines in weight during senescence. However, many senior citizens suffer from the manifold illnesses associated with being overweight.

Etiology

Causes of obesity include: (1) an age-linked decrease in resting metabolic weight, (2) a natural decrease in physical activity, (3) maintenance of previous dietary habits, (4) increased intake as an emotional escape mechanism, (5) excessive intake from familial habits, (6) hypothyroidism or adrenal cortical malfunction, the latter giving rise to central obesity, hypertension, low concentration of sodium in sweat, and in women, a history of menstrual irregularities. In addition, heredity can be an extenuating circumstance. Generally, obesity results from many factors that include an intake of calories greater than the output of energy.

Calories

With advancing years, body size diminishes both in height and weight, with a corresponding decline in energy expenditure. Because caloric requirements are determined primarily by these expenditures, there is a resulting decline in need. At age 65, a person requires only 80% of the calories necessary at age 25. For men 65 years old or over, 2400--2600 calories daily are recommended as compared with 2900--3200 for younger men. For women 65 and over, a 1600--1800 calorie daily diet is advocated as compared with 2100--2300 calories for earlier years. Studies suggest that the majority of the elderly has diets greatly exceeding their caloric requirements.

The metabolic energy needed by an adult is the amount necessary to maintain normal body weight. The easiest method of measuring caloric balance is the regular use of the bathroom scale. When intake equals output, weight remains constant. When intake exceeds output, fat will be deposited and weight will increase, and vice versa.

Treatment

Within the medical community, the use of metabolic stimulants (such as thyroid hormone), sedatives, tranquilizers, cathartics, and diuretics have often been used to extremes. The doctor of chiropractic should be aware of the signs and symptoms of such overutilization in patients previously or simultaneously under medical care and consider their effect within the prognosis. Conversely, some nutrients adversely affect certain medications. See Table 9.4.

Nutrient             Antagonistic to:               
C*                   Methyldopa, oral contraceptives
Calcium              Tetracyclines
E                    Oral coagulants
Folic acid           Anticonvulsants, fluorouracil, levodopa, methotrexate
Iron                 Tetracyclines
K                    Anticoagulants
Magnesium            Tetracyclines
Pyridoxine (B-6)     Levodopa, penicillamine
Zinc                 Tetracyclines
____________________________________________
* Greater than 1000 mg/day.

Obesity is a problem of considerable complexity and requires a certain rapport between doctor and patient if effective management is to be attained. Office counseling, planned dietetic therapy, and corrective adjustments, in combination, are the mainstays of treatment. Geriatric weight reduction may also require a qualitative change to assure adequate intake of protein, vitamins, and minerals.

Protein Concentrates in Weight Control

Three basic considerations should be given attention in weight reduction:

1.   A person will gain less weight if he eats several small meals rather than one or two large meals a day, provided the total calories are the same. For example, if a person takes 1500 calories spread over six meals, he will not gain as much weight as he would if he took the 1500 calories in three meals.

2.   It is better to eat more vegetable fat and less carbohydrate for the same caloric intake.

3.   It is better to increase protein intake. Protein has been found helpful in appetite satisfaction and contributes to the metabolism of fat.

Overview of Vitamin Function, Sources, Deficiency, and Toxicity

      Vitamin A

Function:   constituent of visual pigments and adrenocortical cells; maintenance of epithelial tissue, growth, reproduction, and resistance to infection; important to the integrity of bones, eyes (especially visual purple), skin, soft tissues, hair, and teeth.

Sources:   liver, meat, fish liver oils, eggs, fats, tomatoes, green and yellow fruits and vegetables, and dairy products. The provitamins (carotene) are found in yellow and green vegetables and in fruits.

Deficiency:   Manifestations include night blindness, xerophthalmia, allergies, itchy burning eyes, loss of smell, anorexia, dental caries, dry skin, and hyperkeratosis. Conditions such as hepatic cirrhosis may impair the ability to store vitamin A compounds. Diabetes and hypothyroidism may hamper ability to convert carotene. Absorption of vitamin A may be impaired by lack of dietary fat, inadequate bile secretion, gallbladder removal, overuse of laxatives (in particular, mineral oil), pancreatic insufficiency, the presence of sprue or ulcerative colitis, the use of antibiotics, and protein malnutrition. Resistance to infection is reduced.

Toxicity:   Large doses of carotene can result in yellowing of the skin. Extremely large doses of vitamin A, 20--30 times RDA, are definitely toxic; 100,000 units for 6 weeks result in severe hepatic fatty degeneration, skin lesions, bone decalcification, and increased intracranial pressure. The RDA is 5000 IU. The toxicity level is reported as 10 times or more over the RDA.

      Vitamin B-1 (Thiamine)

Function:   coenzyme for 24 carbohydrate enzyme systems; synthesis for 5-carbon sugars for deoxyribonucleic acid (DNA) and ribonucleic acid (RNA). Thiamine is an important ingredient for the integrity of the nervous system, ears, eyes, heart, and hair. It plays an important role in blood building, gastric hydrochloric acid production, learning capacity, maintenance of smooth muscle tone, energy, and growth.

Sources:   blackstrap molasses, wheat germ, brewer's yeast, red meat (especially organs), fish, poultry, whole grains, brown rice, nuts, sunflower seeds, and green vegetables.

Deficiency:   "dry" beriberi with ascending symmetric polyneuritis. Wernicke's disease generally represents deficiencies of multiple nutrients, but the ophthalmoplegia usually responds to thiamine. Deficiencies occur when thiamine requirements increase because of febrile conditions, malignant disease, high carbohydrate intake, or parenteral glucose. Diuretics tend to increase the rate of excretion of the vitamin. Deficiency symptoms also include digit numbness, dyspnea, substernal chest pains, digestive disturbances, fatigue, nervousness and irritability, hypersensitivity to noise, and anorexia.

Toxicity:   Toxicity level is unknown; very few toxic effects have been reported. Thiamine in 100 mg daily doses is partly excreted by the skin, imparting a yeasty odor that acts as a mosquito repellant. The RDA is 1.5 mg.

      Vitamin B-2 (Riboflavin)

Function:   flavoprotein enzymes; intracellular functions for protein, carbohydrate, and fat. Riboflavin is necessary for healthy eyes, nails, skin, hair, and soft tissues. It plays a role in antibody and red blood cell formation, cellular respiration, and the metabolism of carbohydrates, fats, and proteins.

Sources:   milk, eggs, and meat.

Deficiency:   marked by cheilosis, glossitis, seborrheic dermatitis of the nose and scrotum, cataracts, corneal neovascularization, itchy burning eyes, indigestion, and retarded growth. In elderly citizens, decreased tissue levels are found in some organs and altered intestinal flora. Requirements increase during tissue repair and testosterone therapy. A deficiency of this vitamin alone is unusual.

Toxicity:   Little toxicity effects have been reported. Riboflavin is often used in large amounts pharmacologically to reduce serum cholesterol. The RDA is 1.7 mg.

      Vitamin B-3 (Niacin, Niacinamide, Nicotinic Acid, Nicotinamide)

Function:   nicotinamide enzymes; release of energy from protein, carbohydrate, and fat. It is necessary for healthy nerve tissue, tongue, skin, soft tissues, and hair, and plays an important role in circulation, blood cholesterol level control, growth, gastric hydrochloric acid and sex hormone production, and the metabolism of carbohydrates, fats, and proteins.

Sources:   brewer's yeast, rhubarb, liver, lean meat, seafood, poultry, dairy products, peanuts and legumes. Dietary tryptophan can be converted into niacin.

Deficiency:   Dermatitis, diarrhea, and dementia are the "3 Ds" of the typical deficiency syndrome, along with pellagra, which are associated with diets consisting mainly of corn, malabsorption states, alcoholism, and food faddishness. Deficiency may be manifested only by intestinal hypermotility. Niacin levels in tissue are somewhat decreased in the elderly. Besides the deficiency signs described above, nervous disorders, canker sores, depression, halitosis, headaches, indigestion, insomnia, fatigue and weakness, anorexia, and nausea are commonly associated.

Toxicity:   The RDA is 18 mg. The toxic level (rare) is given as 5 grams or more daily, resulting in hypertension and liver damage.

      Vitamin B-6 (Pyridoxine)

Function:   amino acid metabolism; coenzymes for transaminases, decarboxylases, and for two enzyme systems involved in the metabolism of sulfur-containing amino acids. Pyridoxine is necessary for healthy blood, muscle, nerves, and skin. It plays an important role in antibody formation, gastric hydrochloric acid production, fat and protein utilization, and the maintenance of sodium/potassium balance in nerves. Sources:   blackstrap molasses, brewer's yeast, wheat germ, whole grains, desiccated beef liver, meat (especially organs), prunes, whole grains, brown rice, peas, root and green leafy vegetables. It is found in a large variety of foods.

Deficiency:   Because it is found in many sources, overt deficiency is rare. When it occurs, clinical symptoms resemble those of riboflavin and niacin deficiency. People with pyridoxine deficiency have frequent urinary tract infections. Common deficiency features include anemia, arthritis, weakness, infant convulsions, depression, dizziness, irritability, learning disabilities, acne, and hair loss.

Vitamin B metabolism is altered in the elderly, but the consequences are vague. Sluggish or deficient antibody formation has been reported. Deficiency is age-linked with gastric achlorhydria.

Toxicity:   50 mg per day for a year have been given without toxic effects reported. The RDA is 1.8 mg. The toxic level is given as 500 or more md daily.

      Vitamin B-12 (Cyanocobalamin)

Function:   intracellular coenzymes for red blood cell maturation and the synthesis of DNA; thus an important constituent in blood and nerves. It also plays an important role in cellular longevity and the metabolism of carbohydrates, fats, and proteins.

Sources:   "Cobalamin" is the generic term for several related compounds found almost entirely in animal products, especially liver, kidney, and oysters. It is produced in large quantities by some intestinal bacteria. Other sources are dairy products, fish, and eggs.

Deficiency:   Pernicious anemia is the classic deficiency. Some studies link low levels with psychiatric disorders in the elderly. Conflicting evidence suggests a decrease in serum B-12 levels in elderly people that could reflect impaired absorption owing to a decrease of an intrinsic factor (gastric atrophy) or abnormal bacterial growth in the small intestine. Poor or vegetarian diets may deplete vitamin B-12 stores. Achlorhydria is associated with poor absorption, and people having partial gastrectomies, ileal resections, blind loops, small-bowel diverticula, sprue, or other malabsorption syndromes are subject to vitamin B-12 and folacin deficiencies, as B-12 is absorbed by the terminal ileum. Deficiency symptoms are obscure such as in general weakness, nervousness, and walking and speaking difficulties.

Toxicity:   Little toxicity effects have been reported. When body stores are satisfied, excesses are excreted. The RDA is 3--6 micrograms.

      Folic Acid (Folacin)

Function:   coenzymes for synthesis of DNA, RNA, methionine, serine, and for utilization of histidine. It is an important ingredient for healthy red blood cell formation, gland function, and liver tissue. It plays a role in body growth, reproduction tissues, gastric hydrochloric acid production, and in the metabolism of protein.

Sources:   "Folacin" is the generic name for folic acid and related compounds originally designated as vitamins Bc, B-10, B-11, and M. It is found in liver and other organ meats, oysters, salmon, tuna, whole grains, brewer's yeast, milk products, dates, and green leafy vegetables.

Deficiency:   Megaloblastic anemia, glossitis, and diarrhea occur in severe deficiency states; sometimes digestive disturbances, premature graying of hair, and growth problems manifest. Vitamin B-12 and iron deficiencies interfere with the utilization of folacin. Depletion states occur frequently in the elderly and are probably largely attributable to inadequate dietary intake, destruction of folacin in cooking, and increased tissue demands.

Toxicity:   Toxicity is unknown. Folacin in doses of more than 0.1 mg per day or about 1.5 times RDA may prevent the development of pernicious anemia signs without preventing neurologic degeneration. Its use is thus occasionally dangerous, and larger doses are not recommended by several authorities. The RDA is 400 mcg.

      Pantothenic Acid

Function:   constituent of coenzyme-A; synthesis of amino acids, fats, sterols, porphyrins, and hormones; metabolism of protein, carbohydrate, and fat. Important factor in healthy adrenal glands, digestive tract, nerves, and skin. It serves an important role in antibody formation, growth stimulation, vitamin utilization, and in converting (energy) carbohydrates, fats, and proteins. Pantothenic acid prevents graying hair in rats but not reportedly in man.

Sources:   This coenzyme is widely distributed in most foodstuffs, and there is no known deficiency syndrome. Major sources are brewer's yeast, raw elderberries, wheat germ, liver and other organ meats, salmon, whole grains, mushrooms (cooked), and fresh orange juice.

Deficiency:   A deficiency syndrome is unreported except that for men deficient in both pantothenic acid and pyridoxine. Deficiency in either appears to produce sluggish antibody formation; for men deficient in both, antibody formation completely fails. Some authorities cite associated diarrhea, duodenal ulcers, eczema, hypoglycemia, renal dysfunction, hair loss, premature aging, cramps, restlessness, frequent respiratory infection, paresthesia, sore feet, and vomiting.

Toxicity:   nontoxic; excesses are removed in urine. The RDA is 10 mg.

      Biotin, Choline, and Inositol

Function:   The nutrient biotin acts as a coenzyme for fatty acid synthesis and is necessary for healthy muscle, skin, and hair. It also plays a role in cell growth, vitamin B utilization, and in the metabolism of carbohydrates, fats, and proteins. Choline aids the formation of collagen, metabolism of tyrosine, and regulation of the respiratory cycle of cells. It is necessary for healthy kidneys, liver, thymus gland, and hair. Inositol is an important factor in healthy nerve, heart, kidney, liver, muscle, and hair tissue. It serves an important role in retarding arteriosclerosis, checking blood cholesterol limits, lecithin formation, hair growth, and the metabolism of cholesterol and fats.

Sources:   brewer's yeast, wheat germ, whole grains, organ meats, nuts, vegetables, bean sprouts (esp. biotin), soybeans (esp. choline), and grapefruit (esp. inositol).

Deficiency:   officially undetermined in man. Several authorities list two or more of the following:

• Biotin --depression, gray-dry skin, fatigue, insomnia, and myalgia, anorexia.
  
  

• Choline --bleeding stomach ulcers, intolerance to fats, heart symptoms, high blood pressure, impaired liver and kidney function, and growth problems.
  
  

• Inositol --high blood-cholesterol level, eczema, constipation, visual disturbances, and hair loss.

Toxicity:   Normal or toxic levels have not been established. Typical recommendations of authorities are 300--500 mcg for biotin, 100--1000 mg for choline, and 100--1000 mg for inositol.

      Vitamin C (Ascorbic acid)

Function:   formation of collagen; metabolism of tyrosine; regulation of the respiratory cycle of cells. It is necessary for healthy adrenals, blood capillary walls, and the connective tissue of skin, ligaments, and bone. It serves an important role in tooth and bone formation, collagen production, iodine conservation, digestion, red blood cell development, burn and wound healing, resistance to infection, vitamin protection (oxidation), and diminishing the adverse effects of shock.

Sources:   found in fruits, vegetables, and liver. It is highly vulnerable to heat and processing.

Deficiency:   Marked deficiency damages most body tissues. The classic deficiency state is scurvy. Low vitamin C levels are likely to be found in the elderly or chronically ill people living alone. Levels in tissue, blood, and cerebrospinal fluid tend to decrease with age, and the ability of tissue to retain the vitamin may decline. Some studies show a relationship of smoking with low levels. The overt features usually associated with deficiency include anemia, capillary rupture, bleeding gums, nose bleeds, indigestion, and dental caries.

Toxicity:   Although excess vitamin C is readily excreted in urine, some studies report toxic effects at 4,000--15,000 mg levels. The RDA is 45 mg, but many authorities recommend 250--5,000 mg daily.

      Vitamin D

Function:   utilization of calcium and phosphorus; conversion to organic and inorganic phosphorus, and serves an important role in cardiopulmonary function, nervous system function, and normal blood clotting. Vitamin D is necessary for healthy bone, heart, nerve, skin, tooth, and thyroid gland tissue.

Sources:   There are several steroids with vitamin D activity found in milk, butter, egg yolk, and fish liver oils. Other major sources include bone meal, beef liver, salmon, and tuna. Provitamins in the skin are converted into active vitamins by ultraviolet light.

Deficiency:   Deficiency causes rickets in the young and osteomalacia in adults. Reliable information about vitamin D metabolism in the aged is meager, but large doses have an osteolytic effect. Adults who do not drink milk and are rarely exposed to sunlight are subject to deficiency. There is no official RDA, but an intake of 400 IU daily is generally recommended. Most reports state that this amount is adequate to prevent osteoporosis. Prior to radiographic signs of rickets or osteomalacia, burnings sensations in the mouth and throat, nervousness, insomnia, diarrhea, and myopia often manifest.

Toxicity:   Excessive intake of vitamin D, as once employed for treating arthritis, has caused hypercalcemia and metastatic calcification and even renal insufficiency from calcium deposits. Intakes above 2000 to 3000 units a day are not usually recommended, but supplements of the RDA dose of 400 units are considered safe by all authorities. The toxicity level is given as 25,000--50,000 IU for adults.

      Vitamin E

Function:   antioxidant; maintains structural integrity of cell membrane. Vitamin E serves as an aging retardant, anticlotting factor, blood cholesterol reducer, vessel wall strengthener, and lung protector against air pollution. It also plays a role in female fertility, male potency, and maintaining the integrity of healthy pituitary gland, muscle, nerve, and skin tissue.

Sources:   The richest sources of tocopherols comprising the vitamin E group are various vegetable oils, egg yolk, liver and other organs, fish, and milk. Other major sources are wheat germ, dark green vegetables, tomatoes, and peanuts.

Deficiency:   While relatively little is known about the role of vitamin E, there is sufficient evidence of its part as an antioxidant and the possibility of slowing the aging process. Increased amounts of dietary polyunsaturates increase the need for tocopherols. Absorption may be impaired by biliary and pancreatic disease and by the ingestion of mineral oil. Only in premature infants has a definite human deficiency syndrome been described. As explained earlier, most deficiencies offer an intracellular condition rather than a macroscopic picture. Several authorities report two or more of the following associated with deficiency: dry or falling hair, enlarged prostate gland, heart disease, gastrointestinal disease, impotency, sterility, miscarriage, and wasting.

Toxicity:   Reports conclude that vitamin E is not toxic at 800 units per kilogram of body weight for 5 months. The RDA is about 15 IU, but some authorities recommend 50--600 IU. The toxic point is vaguely given as 2,000--30,000 IU.

      Vitamin K

Function:   essential in blood coagulation; important to liver integrity. It is often used therapeutically in obstructive jaundice, and hemorrhagic states of the intestines or liver.

Sources:   Several analogues of the vitamin K group are found in all green leafy vegetables and are produced by intestinal bacteria. It occurs naturally in safflower oil, yogurt, cabbage juice, blackstrap molasses, oatmeal, alfalfa, and egg yolk.

Deficiency:   Deficiency causes a drop in the prothrombin level. Aging per se is not associated with a deficiency, but conditions predisposing to it are more common in the older age group: liver disease, biliary insufficiency, gallbladder removal, chronic use of antibiotics or salicylates, alterations of intestinal flora, uremia, and internal use of mineral oil. Ecchymosis of the forearms should alert one to a possible deficiency. Deficiency is also associated with diarrhea and an increased tendency to nosebleeds, hemorrhage, and miscarriage.

Toxicity:   One form of vitamin K, menadione, is toxic and is prohibited in over-the-counter supplements, whereas vitamin K from plants, phylloquinone, is not. Only microgram amounts are required by man, and any tendency toward clotting of the blood in the elderly is reason to avoid using vitamin K as a routine supplement. Human requirements have not been established, but some authorities recommend 300--500 mcg daily.

The major features of hypervitamin toxicosis are shown in Table 9.5.

NOTE: Table 9.5 is too complex for this format


Overview of Nutrient Sensitivity

Few people realize what they eat when they eat. While meat is the common source of protein, for example, it is commonly ingested with an array of antibiotics, artificial sex hormones, and a round of additives to preserve, age, cure, tenderize, color, flavor, season, and scent to satisfy producers' profit motives. Fruits and vegetables commonly contain a degree of pesticide residue.

      Food Supply Logistics

All natural foods contain the micronutrients necessary for their metabolism but seldom have their original spectrum of vitamins when they reach the table. While caloric values and the quantity and quality of protein, carbohydrate, and fat are relatively unchanged, at least six vitamins can be lost or partly destroyed by steaming, frying, boiling, roasting, processing, freezing, drying, storage, and/or irradiation. Essential elements are usually lost only through boiling. Industrialized food processing often results in deficiency in vitamins and elements necessary for metabolism. Thus dietary supplementation is the price we must pay for wide distribution of purified, stored, and processed foods. Without supplementation, we run the risk of unbalancing the diet in micronutrients.

It has been explained that at least seven vitamins are removed in typical processing from wheat to the extent of 50% to 86% of that of whole grain, and six essential trace elements are diminished to 40%--88%. Four are added to "enrich" flour. Only traces of elements remain in refined sugar and no vitamins. It is likely that many people have marginal intake of those vitamins and trace elements not replaced when they depend on refined carbohydrates for calories. Furthermore, the processing, canning, partitioning, storage, and cooking of foods necessary for widespread distribution in our society remove some trace elements and partly destroy some vitamins necessary for proper metabolism. Most of these trace elements are not replaced except by supplementation.

Raw unprocessed foods naturally contain the necessary micronutrients and trace elements necessary for their metabolism. It is unfortunate from a nutritional standpoint that almost all foods are cooked or superheated, refined, processed in many ways, preserved with additives, or irradiated --which have little effect on protein, carbohydrate, or fat content but adversely affect certain micronutrients and trace elements necessary for proper metabolism.

Those vitamins and minerals that are heat labile can be partly destroyed or volatilized. Particularly sensitive are thiamine, pyridoxal, pyridoxamine, ascorbic acid, pantothenic acid, folacin, and selenium.

The separation of food into its components can separate micronutrients necessary for metabolism. For example, when whole milk is separated into butter and skim milk, the butter contains substantial quantities of calcium and phosphorus, but much of the vitamin D necessary for its absorption remains in the skim milk.

Water soluble micronutrients can be partly removed from the food during boiling; thus, they remain in the water that is normally discarded. This loss is neither a small amount nor only a few nutrients.

Note the following water-soluble micronutrients:

    Ascorbic acid       Niacin                   

    Bioflavonoids       Pangamic acid            

    Biotin              Pantothenic              

    Choline             Para-aminobenzoic acid   

    Cobalamin           Pyridoxine               

    Copper              Riboflavin               

    Folic acid          Thiamine                 

    Inositol            Zinc                     

    Magnesium

Studies on the amounts of vitamin C, thiamine, riboflavin, and niacin in vegetables show that there are large losses after freezing or canning. As much as 62% of vitamin C can be lost by cooking or freezing. Storage for a year results in about 85% loss; canning produces about 90% loss. Half the B vitamins are lost in cooking frozen vegetables; up to 84% is lost in canning. Carotene is generally stable.

      Vitamin Specifics

Vitamin A.   Vitamin A is sensitive to irradiation. Its intake is weakened or rendered ineffective by alcohol, coffee, cortisone, mineral oil, excessive iron, and vitamin D deficiency.

B-Complex.   The natural effects of ingesting the B-complex group are partially or wholly nullified by alcohol, coffee, infection, overstress, sleeping pills, sulfa drugs, birth control pills, and sugar in large quantities.

• Thiamine (B-1). Thiamine is partly destroyed by blanching with sulfite, brine grading, dehydration, cooking, baking (bread), roasting (meat), evaporation (milk), and curing with nitrites and irradiation (meat). Antifactors are alcohol, coffee, raw clams, excessive sugar, tobacco, fever, prolonged stress, and surgery.
  
  

• Riboflavin (B-2). While water-soluble riboflavin is relatively stable in food processing, it is destroyed by light. Other antifactors are alcohol, coffee, tobacco, and an excessive sugar intake.
  
  

• Niacin (B-3). Niacin is generally stable in food processing as compared to riboflavin or thiamine. However, known antifactors are alcohol, coffee, antibiotics, corn, and excessive intake of sugar and starches.

• Pyridoxine (B-6). Pyridoxine is water soluble. In meat and vegetables, it is partly destroyed by cooking, irradiation, canning, and light. Other antifactors are alcohol, coffee, tobacco, birth control pills, and exposure to radiation.
  
  

• Cobalamin (B-12). Water soluble Vitamin B-12 is much stronger to the effects of food processing than other vitamins, but its function is greatly reduced when the use of alcohol, coffee, tobacco, and laxatives is associated.
  
  

• Pangamic Acid (B-15). Because pangamic acid is water soluble, circulating supplies are lost when alcohol, coffee, or other diuretics are used.
  
  

• Biotin. The effectiveness of water soluble biotin is greatly diminished when it is associated with the ingestion of alcohol, coffee, and raw egg white.
  
  

• Choline. The function of choline is reduced when large amounts of sugar are consumed. Because it is water soluble, alcohol, coffee, and other diuretics are antifactors.
  
  

• Folic Acid. Boiling for 5 minutes destroys the folacin (water soluble) of milk as do traces of copper (common in dairy equipment). Other antifactors are alcohol, coffee, tobacco, and prolonged stress.
  
  

• Inositol. Body supplies of water soluble inositol are diminished when alcohol, coffee, and other diuretics are used.
  
  

• Pantothenic Acid. Blanching partly degrades pantothenic acid. Other antifactors of this water-soluble vitamin are alcohol, coffee, and other diuretics.
  
  

• Para-aminobenzoic Acid (PABA). The effectiveness of PABA is destroyed in the presence of sulfa drugs. Body supplies of this water-soluble vitamin are lost when alcohol, coffee, or other diuretics are used.

Vitamin C.   Water-soluble vitamin C is unstable in storage, freezing, drying, heating, canning, cooking, blanching, dehydration, brine grading, and in the presence of alkalies, traces of copper, or oxygen. Antifactors include the presence of antibiotics, aspirin, and cortisone; states of high fever or prolonged stress; and the use of tobacco.

Vitamin D.   The most common antifactor of this fat-soluble vitamin is the ingestion of mineral oil as when habitually used as a bowel-lubricating cathartic.

Vitamin E (Tocopherol).   Fat-soluble vitamin E is degraded in storage whether cold, frozen, or at room temperature. Alphatocopheral is readily oxidized and deteriorates on exposure to light. Much of it is lost in processing, freezing, and storage; and it is rapidly decomposed by ultraviolet light or by traces of iron or lead. Other antifactors are birth control pills, chlorine (found in most municipal tap water), mineral oil, and rancid fats and oils.

Vitamin F (Unsaturated Fatty Acids).   This fat-soluble group is adversely affected only by radiation, especially x rays.

Vitamin K.   Aspirin, prolonged use of antibiotics or mineral oil, rancid fats, and x-radiation greatly diminish the effectiveness of menadione supplies in the body.

Vitamin P (Bioflavonoids).   The function of the water-soluble bioflavonoids is severely hampered by the antifactors to vitamin C.

      Mineral Specifics

Chromium, iodine, magnesium, and sulfur have no known antifactors. Copper is only adversely affected by a high intake of zinc; sodium, by a lack of chlorine and potassium.

Calcium.   Calcium stores are depleted when adequate exercise is diminished or in states of prolonged overstress.

Iron.   Coffee, tea, and excessive phosphorus or zinc intake diminishes iron reserves or utilization.

Manganese.   Excessive calcium or phosphorus intake are antifactors to manganese.

Phosphorus.   The major antifactors to phosphorus utilization are an excessive intake of aluminum, iron, magnesium, or white sugar.

Potassium. Potassium utilization is hampered by cortisone, excessive sugar or salt, and prolonged stress; and reserves are depleted by using laxatives, alcohol, coffee, and other diuretics.

Zinc.   The utilization of zinc is thwarted by alcohol, a high intake of calcium, and phosphorus deficiency.

Basic Mineral Requirements

Mineral requirements are not diminished with age. Iron and calcium are most apt to be deficient. An increasing incidence of achlorhydria is often associated with chronic iron-deficiency anemia The need for calcium appears to be greater in the aging person than in the mature adult. While it was once believed that low calcium intake resulted in the high incidence of osteoporosis and fractures in the elderly, osteoporosis is now believed to be the result of faulty metabolism of the protein-rich bone matrix rather than of calcium metabolism. While senior citizens tend to lose body calcium, this can be prevented with high intake of calcium-rich foods such as milk, cheese, ice cream, green vegetables, and legumes.

The Bulk Elements

The bulk elements make up 3.39% of body weight. In a 70-kg person, there are 18 grams of silicon, 20 of magnesium, 100 of chlorine, 110 of sodium, 140 of potassium, 160 of sulphur, 840 of phosphorus, and 1 kg of calcium.

      Potassium

Potassium is the most prevalent electrolyte in the cells, both of the blood and tissues in general, but particularly in the cells of cartilage and muscle. Studies reveal that potassium is essential for normal heart rhythm, other muscle contraction, normal nerve activity, glycogen formation, and normal pituitary function.

Potassium deficiencies are common after the use of ACTH, cortisone, and diuretics. Symptoms of potassium deficiency include malaise, muscular weakness, vague muscle and abdominal aches and pains, tachycardia, hypertension, rapid respiration, dry mouth, low gastric acidity, GI hypertoxicity, spastic sphincters, constipation, and dehydration.

      Sodium

An adequate intake of sodium is essential for the maintenance of osmotic equilibrium in body fluids. Strong homeostatic mechanisms in the kidney, colon, and sweat glands conserve sodium and magnesium when dietary deficiencies exist.

Except in severe renal disease, negative renal balances seldom occur. Elderly citizens on strict low sodium diets, however, may experience muscle cramps from sodium depletion after severe sweating.

Diuretics increase loss of sodium, potassium, and magnesium and can lead to insufficiency. It is well to remember that, clinically, the aged kidney is half a kidney; ie, half as active in electrolyte homeostasis as the young kidney.

      Other Bulk Elements

Adequate intake of magnesium and potassium are necessary for intracellular balance and energy exchange. Both magnesium and potassium are mainly intracellular cations, while sodium is largely extracellular in action. Magnesium serves as a cofactor for almost all enzymes concerned with phosphate energy exchanges. Under average conditions, there are ample magnesium, sulfur, chloride, potassium, and sodium in table foods and drinking water to meet body requirements adequately.

Osteoporosis

The cause of osteoporosis is not completely understood. It is more common in women than men, and more common in Caucasians than Blacks. Hip fracture in senior women with underlying osteoporosis is not uncommon. Treatment is slow and often discouraging, and it often includes increased intake of calcium and vitamin D.

Several factors appear to contribute to osteoporosis:

• Decreased parathyroid activity,
  

• Low calcium intake,
  

• Imbalance between bone resorption and bone synthesis induced by menopausal hormone imbalance
  

• Loss of calcium from bone as a result of inactivity,
  

• Low intake of vitamin D, and
  

• Low intake of bone hardening trace elements such as fluorine, strontium, vanadium, or molybdenum.

Osteomalacia (Adult Rickets)

This condition is rare in this country, but it is occasionally seen in patients who have low calcium intake, rarely are exposed to the sun, or have poor absorption rates. It is a deficiency disease resulting in inadequate vitamin D, phosphorus, and calcium. Treatment, naturally, is to correct the deficiency of these elements and vitamin.

Trace Elements

The ten trace elements essential for human metabolism are chromium, iron, cobalt, copper, zinc, selenium, molybdenum, fluorine, and iodine. At least five of these have been determined essential for mammalian life: zinc, copper, iron, manganese, and cobalt (B-12); and five have been determined essential for good health: selenium for reproduction, chromium for fat and glucose metabolism, and molybdenum and fluorine for bone and teeth hardness. Although all trace elements are toxic at high levels, only selenium (volatile) is toxic at low levels. All trace elements are found in plants in varying quantities, providing amounts necessary for metabolism.

While excesses are toxic, deficiencies produce disease in both animals and plants. Elements are more important in the biologic cycle than vitamins that are synthesized by bacteria or plants. Before trace elements can be food, they must first be in the soil, be present within a narrow range of concentration, and be absorbed within the body in fairly exact amounts.

Fortunately, excellent homeostatic mechanisms have evolved within mammals to prevent over accumulation and to conserve stores in cases of lack of supply. Over accumulation is often prevented by urinary excretion, intestinal rejection, and biliary excretion to maintain homeostasis. Elements absorbed from water and foods must equal losses in urine, feces, sweat, nails, hair, and skin. Relatively large amounts are lost in perspiration.

Just as processing, refining, and storage of natural carbohydrates result in vitamin loss, so do such actions result in losses of trace elements.

Heating, boiling, canning, and partitioning take their toll, often separating the trace elements that are necessary cofactors for many enzymes concerned with metabolism.

Principal Functions of the Essential Element

In regard to the bulk elements, calcium functions in body structure and activates a few enzymes. Sodium plays a role in extracellular electrolyte balance. Potassium functions as an intracellular cation in electrolyte balance and as an enzyme activator. Magnesium activates phosphate transferases and many decarboxylases, serves as an intracellular cation, and functions in the metabolism of fats, proteins, and carbohydrates.

Of the five trace elements essential for life, manganese activates the phosphate transferases and decarboxylases, acts as a cofactor of two flavin enzymes, and functions in the metabolism of protein. Iron activates oxidases, is a constituent of flavin and porphyrin enzymes, serves as an oxygen carrier, serves as a cofactor of three enzymes, and functions in the metabolism of fat, protein, and carbohydrate. Cobalt is a constituent of cobalamin and cobamide in four enzymes and serves in the maturation of red blood cells. Copper is a constituent of cytochrome oxidase and serves as a cofactor of three flavin and ten other enzymes. And zinc is a cofactor of eight enzymes, serves in protein synthesis, increases wound healing and vasodilation, and functions in the metabolism of bicarbonates, protein, lactic acid, and ethanol.

Of the five trace elements necessary for health, chromium serves in glucose and cholesterol homeostasis and in glucose and fat metabolism. Molybdenum is a constituent of aldehyde and xanthine oxidases (flavin enzymes). Fluorine functions in the structure of apatite and bone hardening. Iodine serves as a constituent of thyroxine. The function of selenium has not been officially determined except its role as an antioxidant.


Zinc Deficiency

The need for zinc is world wide and its deficiency is considered only secondary to nitrogen deficiency among soil fertility problems. Thirty-two states of the nation show zinc-deficient soils, being most prevalent in neutral to alkaline soils that contain lime, in acidic leached soils, and in very acidic peat soil. All soils are apt to produce zinc deficiency during periods of high production. The great use of commercial fertilizers since World War II has increased the deficiency.

      Function

Pancreatic juice and bile contain zinc. It is also part of several important enzymes and carbonic anhydrase, serves with the enzyme that converts carbon dioxide to carbonic acid in cells and plasma and releases carbonic acid in the lungs. Carboxypeptidase contains an atom of zinc per molecule and brings about certain types of protein digestion. Zinc is in pancreatic juices, in at least four dehydrogenases, and in alkaline phosphatase. It plays an important role in vitamin B-1, phosphorus, and protein metabolism. The highest concentrations of zinc are found in the sperm, prostate gland, skin, hair, nails, lens, retina, cornea and iris. It is also present in the liver, muscles, and bones.

Zinc is the most abundant intracellular element. Normally, 2.3 grams are in the body. Among the metals, only iron is present in greater amounts, but iron predominates in the circulating blood rather than in the tissues.

      Nutritional Concerns

All tissues contain some zinc. Zinc's relationships and interactions with other metabolic functions and substances appear to be manifold. As zinc and copper are biologic antagonists, plentiful copper (eg, from copper plumbing) seems to displace zinc in sites normally occupied by zinc rather than copper, and vice versa, thus possibly resulting in changes in enzyme activity to trigger various biochemical effects.

When calcium levels increase, there is a greater demand for zinc requirements. On the other hand, when zinc levels increase, there is a larger need for vitamin A.

      Sources

Major food sources of zinc are brewer's yeast, wheat germ, whole grains, bran, fish, oysters, liver, eggs, sunflower seeds, nuts, spinach, mushrooms, and sunflower and legume seeds. The lowest sources of zinc are in white sugar and citrus fruit.

      Deficiency

Zinc deficiency, as manifested by low plasma-zinc concentrations, has been found in human patients with the following status:

• Delayed sexual maturity

• Loss of taste and anorexia

• Fatigue

• Prostatic gland malfunction

• Reproductive organ growth and development

• Sterility

• Indolent ulcers of the legs

• Myocardial infarction

• Active TB

• Alcoholic cirrhosis of the liver and other hepatic disorders

• Pulmonary infections

• Indigestion

• Uremia

• Pregnancy

• Women taking oral contraceptives

It has been reported, but not firmly confirmed, that products made from soy may cause a zinc deficiency and atherosclerosis.

      Therapeutic Applications

Reports show zinc supplementation effective in posttrauma and postsurgical healing, alcoholism, hepatic cirrhosis, atherosclerosis (lessens cholesterol deposits), nonhereditary balding, infertility, and impotency.

Young individuals presenting severe malabsorption problems exhibit dwarfing and sexual underdevelopment. The primary low-zinc symptoms in geriatrics include poor healing rates, loss of taste and smell, and poor appetite --all which respond well to zinc therapy. Clinical abnormalities attributed to zinc metabolism bear witness to the likelihood of a larger population of subclinical zinc-deficient or marginally adequate people.

Role in Healing.   Studies at the University of Rochester indicate that during tissue healing, zinc moves into the wound site in elevated concentrations, yet moves out after healing. Postoperative ulcer patients excrete twice as much zinc in the urine as do nonoperative ulcer patients. Zinc requirements appear to rise sharply in trauma.

Oral zinc supplements have increased wound healing by 50% and have been found of value in cirrhosis. In partial arterial obstruction and Raynaud's disease, probably induced by cadmium, excess zinc appears to oppose the vasoconstriction beyond the obstruction; results are often dramatic. Zinc supplementation has been of value in major burns, serious intestinal fistula, pilonidal sinus (postoperative), dermatitis, disruption of estrous cycles, diabetes, and upper respiratory infections.

In cases of inoperable vascular disease, both Wright-Paterson Air Force Base and the University of Rochester have seen excellent results with zinc therapy. All patients showed improved exercise tolerance and leg warmth, and more than half regained peripheral pulses. The rationale of zinc therapy for vascular disease is based on studies showing body zinc levels are about 30% of normal in proved atherosclerosis. The existence of blood vessel conditions in zinc-deficiency patients such as aneurysms, occlusions, and stenosis has been verified by x-ray and surgical techniques. Correcting zinc deficiency has also improved mental processes.

Adjunctive Therapy in Rheumatoid Arthritis.   RA is characterized by swelling of the joints, severe pain, and crippling. More effective and safe therapy is desperately needed. A pilot study conducted by Peter A. Simkin, a rheumatologist at the University of Washington in Seattle, suggested that zinc supplements may alleviate many symptoms of rheumatoid arthritis and without adverse side effects.

Since 1971 there has been increasing evidence that rheumatoid arthritis patients have far less zinc in their blood than do healthy persons. These results suggest that a zinc deficiency in fluids surrounding joints may be a cause or a serious aggravator of the disease. So Simkin conducted a preliminary trial to see whether oral zinc supplements might help patients.

Zinc sulfate (220 milligrams three times daily) or placebo capsules were added to the existing therapy of 24 rheumatoid arthritis patients for 12 weeks. This double-blind trial was followed by an open 12-week period when all subjects took zinc. During the double blind phase, zinc treated patients fared better than controls with regard to joint swelling, morning stiffness, walking time, and the patient's impression of overall disease activity. The indices and joint tenderness also improved with zinc treatment in both groups of subjects during the second 12 week period. "These encouraging results," Simkin concludes in the September 11, 1976, issue of Lancet, "indicate that oral zinc sulfate deserves further study in patients with active rheumatoid arthritis."

Chromium Deficiency

Chromium deficiency, as determined by tissue analysis, is prevalent in the United States but few other countries. Deficiency is related to atherosclerosis and is characterized by deposition of lipid in the aorta, a rise in serum cholesterol, mild diabetes mellitus, and intolerance to glucose. When dark brown sugar was experimentally substituted for white sugar, the syndrome was prevented, and both blood glucose and cholesterol levels returned to normal. This syndrome is common in senior citizens. The chromium level appears to decline with age in tissue and is even found absent in many geriatric studies.

It is interesting that supplemental chromium seems to decrease a "craving for sweets" in overweight patients.

Iron Deficiency

It is unwise for senior citizens to take supplemental iron preparations and tonics without the advice of their doctor because they may mask an anemia resulting from chronic low-grade bleeding caused by gastrointestinal malignancy. Elderly men and postmenopausal women require little iron unless blood is chronically lost. Iron-enriched foods aid little, as about 80% of the added iron is not absorbed, being in the form of ferric orthophosphate.

Abnormal Trace Elements

Mercury.   Mercury is commonly found in fish from polluted waters. It is absorbed and deposited as methyl mercury in fat and nerve tissues. Symptoms of heavy metal toxicosis arise but are frequently misdiagnosed. Inorganic mercury, however, is rapidly excreted in urine if ingested.

Nickel.   While food nickel is undoubtedly harmless, nickel accumulations in the lungs from polluted air may be harmful. Nickel carbonyl is a known carcinogen. Large amounts of nickel are found in sweat if it's present in the system.

Lead.   While ingested lead paints are a problem in pediatrics, poisonous lead in geriatrics mainly comes from automobile exhaust fumes using leaded gasoline. It can be absorbed directly into the lungs or from the fumes contaminating food grown near a highway. Sweat contains large excretions of this lead.

Cadmium.   There is evidence that abnormal cadmium intake can result in arterial hypertension.

Tin.   Tin is slightly toxic. Large losses are evident in perspiration when circulating levels rise.

Water must be considered the most nutritional substance. All physiologic functions of life occur in a milieu of water, and the type of food ingested influences water requirements. For example, carbohydrate yields water when burned and therefore lessen water intake requirements. Fat, which does not yield water during its metabolism, increases requirements. Protein, on the other hand, produces urea, and each gram requires about 20 grams of water for its excretion. Thus, the need for water increases with increased protein intake.

Salt in food will also affect water requirements, as renal function (particularly its concentrating ability) has a conserving effect on the need for water. The salt content of food is not the only consideration. When chlorine is added to the municipal water supply or abundant in food intake, food sodium is readily converted to salt during the digestive process.

For any total kidney output, an adequate quantity of water is necessary. Water must be supplied in sufficient volume to provide for both perspiratory and urinary excretion of waste products. Water requirements increase during illness or after injury with increased nitrogen excretion. Fever increases requirements, as do large fluid losses from severe vomiting, diarrhea, heavy sweating, and the polyuria associated with uncontrolled diabetes.

In the aged, because of failing renal tubular work against osmolarity, the minimal excretory volume for concentrating power is higher than in a younger person. It is advisable to increase water intake when necessary so that the urine output is at least 1,500 cc per 24 hours.

Thirst in healthy individuals is usually sufficient to provide normal intake. However, in sick or injured persons and often in the obese, the desire for fluids may be weakened or depressed to such an extent that fluid intake becomes inadequate. In such cases, fluid requirements should be determined daily for each patient, recording intake and fluid losses through urinary excretion. A normal adult at rest and not sweating heavily requires about 1800--2500 ml of water per day, plus extra amounts for abnormal fluid losses from vomiting, diarrhea, polyuria, etc. Input is considered too low if urine output is under 500 ml per day in afebrile patients, less than 1000 ml per day in feverish patients, and/or if a 24-hour collection indicates a specific gravity of over 1.025, and/or if there is evidence of dehydration.

Media

As water per se may not be too well received in some situations, it is often wise to incorporate into the intake of water other forms of liquid such as mild tea or coffee, soups, broths, fruit juices, milkshakes, ginger ale, and sometimes even beer, wine, or other alcoholic beverages. Food with a high content of water should also be considered such as melons, celery, tomatoes, cabbage, and fresh fruits.

Beverage Alcohol

Moderate amounts of alcohol taken with or before meals or at bedtime are a solace to many elderly people and probably not harmful if taken in moderation and if adequate micronutrients are supplied. Water soluble vitamins and minerals must be provided as distilled liquors contain almost no essential micronutrients and fermented drinks are deficient. Alcohol is a strong diuretic.

Drinks containing alcohol provide a rapid source of energy. With regard to the metabolism of ethyl alcohol, it is converted to acetaldehyde in the liver by alcohol dehydrogenase, a zinc dependent enzyme. Acetaldehyde is then converted to acetylcoenzyme-A (containing pantothenic acid) that is metabolized, with almost no ethanol carbon incorporated into fat or glycogen.

Note: Although "calorie counters" show that alcoholic beverages have a high caloric content, such beverages by themselves do not increase body fat. The liver does not convert ethanol into fat. Assimilated alcohol is converted into energy that cannot be stored. However, if calorie-rich food is consumed with alcohol beverages, less energy is required by the food source and the result is greater storage.

Thymus Gland Supplements

Studies at the University of Texas showed that a key hormone produced by the thymus is directly related to the aging process. Blood levels of thymosin appear to decrease dramatically with age and are a major factor in the aging process by retarding the body's natural defense (immunological) system to combat disease. Thymosin levels decrease significantly between the ages of 25 to 45, and thymosin seems to be the controlling agent of that part of the immune system concerned with what is called "cell mediated immunity," the resistance to viral and fungal infections, organ transplants, and cancer.

The Texas study showed that patients with Hodgkin's disease, chronic leukemia, and cancer had low blood levels of thymosin and indicated thymosin's role in many autoimmune diseases where the body's defense system, specifically the white blood cells processed by the thymus gland, fails to recognize its own tissue and tries to destroy it as though the tissue were a foreign invader.

Pancreas Supplements

Pancreatic supplements are often found beneficial as enzyme aids. Several studies have found pancreatic enzymes beneficial in conditions associated with the elastic elements of connective tissue, poor fat absorption, cystic fibrosis, absorption of B-12, fat embolism, and low serum lipase levels. Studies at John Hopkins revealed marked stool improvement, and other researchers offer evidence that it is an aid in treating chronic pancreatitis, malabsorption syndromes, steatorrhea due to enzymatic insufficiency, pancreatic azotorrhea, reduced fecal fat and nitrogen losses, pancreatic fibrosis, and other digestive disturbances.

Duodenal Supplements

Studies of the use of natural raw duodenal substances suggest that these preparations are at least as good as the currently popular antacids and antispasmodics and have no toxic or side effects. A series of studies revealed that concentrates prepared from animal duodenum affected gastric secretions and motility and are useful in the treatment of peptic ulcers by neutralizing gastric acidity and increasing mucosal resistance to irritation. Relief is often prompt, with repair and healing demonstrable by radiography. When used in cases of duodenal ulcer, symptom recurrence has been greatly reduced even in patients showing a high-frequency of exacerbations. Duodenal supplements have also proven effective in cases of ulcerative colitis, nonspecific colitis, and nonspecific diarrhea. Not a drug, such preparations have no side effects; and patients report better appetite, weight gain, and vitality.

Liver Supplements

Uncooked liver supplementation has proved itself effective in chiropractic and medical communities for several years. Many years ago, about 6 ounces of raw liver taken orally was found to be a control of pernicious anemia. In more recent years, injected liver extract has been more acceptable. Although the Journal of the American Medical Association (92:1332, 94:1811) reported that raw liver could be used to control diabetes, little attention to the fact is made within medical circles "because taking 6 ounces of raw liver daily is unpalatable and the injection of insulin is simpler."

Supplement companies have now developed a process to convert raw wet glands into defatted, dehydrated powders without causing any change in their biologic value. All enzymes normally found in raw liver are present, and it has iron, vitamin B-complex, B-12, C, and all the unidentified nutritional factors existing in raw liver. Various studies indicate raw liver effective in the treatment of chronic lymphatic leukemia but not the acute form. Dramatic results are reported in the treatment of the rare disease amyloidosis.

Wheat Germ Oil

Dr. T. K. Cureton's "The Physiological Effects of Wheat Germ Oil on Humans in Exercise" (Thomas) lists 42 separate experiments on 894 persons. Cureton's results show statistically significant effects on several types of endurance performances, total body reaction times, precordial T waves of the EKG, brachial pulse waves, pulse rate tests, pre-ejection intervals, BMR, flicker fusion frequency, oxygen intake tests, and oxygen debt.

Improved physical fitness was attributed to wheat germ oil apart and separately from the effects of physical training. The positive effects of wheat germ oil appeared more apparent on the central nervous system than on metabolism, but there was some effect on the speed of recovery from oxygen debt. Studies also found quicker reaction time, reduced heart stress, and improved endurance and stamina in nonathletic senior citizens.

A "neuromuscular fraction" is contained within wheat germ oil that has the potential of stimulating the repair of neurons, even in the brain where such repair is supposed to be impossible. In studies of brain-injured children, the oil may offer an opportunity for greater response when used with B-complex, which is rich in inositol. One study holds promise for this fraction in many of the myoneuropathies such as cerebral palsy, multiple sclerosis, myasthenia gravis, amyotonia congenita, and rheumatism in geriatrics. In muscular dystrophy, both the progressive and the menopausal types, wheat germ oil has been significantly beneficial. The factor in wheat germ oil that is active for these diseases is not vitamin E. The same factor sharply stimulates the BMR in animals. In humans, dermatomyositis has also responded significantly.

Pollen Supplements in Prostate Disorders

According to a study reported in the Swedish Medical Journal (59:3296 1962), 90% of the patients suffering from prostate infections became symptom free after receiving pollen supplements. Both treated and placeboed patients received periodic digital massage to remove secretions that might be infected. however, only 50% of the placeboed patients showed improvement.

The major nutrient content of prostate fluid are albumin, lecithin, vitamins C and A, and unusually high concentrations of magnesium and zinc, among other substances. The chemical composition of pollen extract supplements contain many essential nutrients such as essential amino acids, water soluble vitamins, high concentrations of nucleic acid derivatives, and high concentrations of zinc for plant material.

Pollenization is the mechanism in flowering plants by which they are fertilized and made capable of producing seeds. The seeds, in turn, contain all the elements necessary to sustain new plant life. Many believe that pollens are helpful by their high concentration of zinc, which serves the needs of zinc hungry prostate cells. While it is unknown how zinc maintains prostate health, it is known that zinc deficiency leads to unhealthy changes in the size and structure of the prostate.

Vitamin E Ointment

Some studies indicate that vitamin E ointment has been beneficial in relieving the itching associated with striae gravidarum, pruritus ani, and irritation of keloids. Other studies report benefit in Peyronie's disease. And still other studies indicate the ointment beneficial in improving the circulation in limbs showing small areas of gangrene (eg, diabetics). The viable tissues just proximal to the dead cells can, by the usual process of capillary budding and phagocytosis of dead cells with liquefaction, separate necrotic from living tissue at the zone of separation. When the gangrenous patches detach themselves, healing of the raw subgangrenous areas can be accelerated by the local use of the ointment.

Wounds.   Studies in both this country and Canada show good use from topical vitamin E ointment in conjunction with oral administration whenever practical. Open wounds so handled, whether traumatic or ascribable to prolonged decubitus, heal faster with less scar tissue contraction, have a subcutaneous layer that is more pliable, and exhibit a less tender surface covering than do wounds treated in more conventional ways.

Burns.   The usefulness of alpha tocopherol ointment in burns, whether from heat or radiation, has also been demonstrated. In thermal burns, necrosis is limited if application is prompt. First-degree burns may disappear in 1 or 2 days with freedom from infection, toxemia, and contracture, and frequently make skin grafting unnecessary in deeper burns. The ointment appears to be just as effective in small household burns and sunburn.

Arthritis.   In joint conditions, studies have found that the alpha tocopherol in the ointment is absorbed by the tissues under the skin as far as the periosteum.

Musculoskeletal Complaints.   Cases of fibrositis, myositis, and even rheumatic arthritis have been reported indicating reduced swelling and pain in joints. It is often helpful when the ointment is rubbed on fingers showing rheumatoid arthritis, however, not all cases respond and evidence is limited.

Intercostal Neuralgia.   In intercostal conditions, ointment is usually applied on the skin over the nerve roots involved for 10 minutes, and then followed for another 10 minutes by heat. In lumbago and other spinal conditions, after corrective adjustments have been made, ointment applied to the area followed by mild superficial heat often results in dramatic results.

Idiopathic Costalgia.   It is not uncommon to find right-handed people complaining of left chest pain that is noncardiac in origin. Such pain is usually felt in the area of the 4th or 5th interspace, accompanied by tenderness on pressure between the ribs that may extend around to a point just lateral to the spinous process. This pain can closely simulate angina pectoris, since exertion and heavy breathing may irritate the lesion and produce pain. It can usually be differentiated from true angina as it begins with sitting in a very soft chair or from lying on an extremely soft mattress.

Trends

Arthritis, one of mankind's oldest afflictions, results in agony on movement or touch to over 12 million Americans, 80% of which are over 45 years of age. Following are some old statistics, but the point they make is valid today.

• In 1967, there was an estimated 11.5 million geriatric people tormented by arthritis and rheumatism, representing an increase of 14% from 1960. By 1970, the annual incidence of these crippling diseases was over 12 million. By 1975, the number approached 13 million geriatric age sufferers. The incidence is more than those with cancer, tuberculosis, and heart disease combined.
  
  

• The total forecasts, which are conservative, for geriatric patients receiving professional health care among all primary health providers may well exceed 12 million by 1985 and may approximate more than 30 million visits according to some estimates.
  
  

• A study conducted in 1960 suggested that one out of every 15 people suffered from arthritis; one out of six, in the over 45-age bracket. While only two cases per 100 appear in the population under 25, 28 cases per 100 arise in the population 75 or older.

Because of the influence of Medicaid and Medicare programs, these visitation projections are undoubtedly conservative as such programs will have greater effect on patients 45 and older, particularly those 65 and older. The older the patients, the more arthritic or rheumatic severity, and the more the need for professional attention.

Economic Considerations

Economically, arthritis is important for two reasons: the high incidence and disability, and the huge sums spent annually on care. Although arthritis is of long duration and shows a comparatively low death rate, the condition is prevalent throughout the population and occurs in every age bracket. Its incidence is twice as high in farmers as compared to other occupations.

From the viewpoint of our national economy, arthritis, especially rheumatoid arthritis, has a profound effect. At least three million of its victims are forced into less productive work each year. Arthritis and rheumatism accounts for approximately 238 million days of restricted activity per year in those who have spasmodic attacks. The average arthritic misses an average of 15 work days a year; with one-fourth or 60 million bed disability days.

Nutritional Considerations

      Vitamin B-6

Several reports conclude that massive and continuing doses of niacin have eased stiffening joints and strengthened weakening resulted in every case reporting increased flexibility of joints, with 70% reporting restored tone and strength in previously weakened muscles. The 70% group also reported great improvement in reduction of mental depression and dizziness. The exact mechanism of the activity of niacin and niacinamide in arthritic and rheumatic conditions is not completely understood, but it has been linked to reduction of blood cholesterol, niacin's ability to combine with glycine, and an improvement of intracellular oxidative respiration.

      The Biologically Active Isomers of Glycyrrhetic Acid

Research and clinical trials on substances derived from licorice in arthritis, GI conditions, respiratory conditions (eg, asthma), and a host of other conditions shows promising results. Licorice has long been used as a demulcent and sweetening agent. For years, it has been observed to have a value in the treatment of stomach ulcers and to have a deoxycortone-like action of value in treating Addison's disease.

An important constituent of licorice is glycyrrhizin, a glycoside the aglycone of which is glycyrrhetic acid. The structure shows some resemblance to cortisone. Glycyrrhetic acid has proved in experiments to have a distinct anti-inflammatory property without causing depletion of liver glycogen. Unlike hydrocortisone, prolonged administration of glycyrrhetic acid does not appear to cause adrenal atrophy.

      Vitamin B-6

Vitamin B-6 exists in nature in three forms: pyridoxine, pyridoxal, and pyridoxamine. It is believed that once taken into the body these three forms combine with phosphate to form a coenzyme known as pyridoxal phosphate, which speeds and stimulates necessary biochemical reactions in human metabolism.

In one classic study, pyridoxine was given orally, for the most part 50 mg once daily, to hundreds of patients with rheumatic complaints. Painful interphalangeal joints were relieved to some extent within 3 weeks and substantially improved at the conclusion of 6 weeks (the evaluation cut-off date).

In hands where there was no deformity, the relief of finger pain was more complete for both men and women. Heberden's nodes became less painful and often smaller. Finger edema was greatly reduced. Stiffness of fingers improved; fingers became more pliable both actively and passively. Coordination of finger movements improved. Grip strength improved to an exceptional degree. The so-called "trigger finger" locking of joints disappeared in several patients, and index-finger flexion was clearly relieved.

In addition, shoulder pain, either unilaterally or bilaterally, responded well. Elbow pains, hip pains, and nocturnal muscle cramps were relieved, as were knee pains. In addition, sleep improved. Paresthesia and nocturnal paralysis of the arms responded especially well. Sadly, rheumatoid arthritis was not improved by pyridoxine.

It is well to remember that B-6 is water soluble and destroyed by heat at 245*F. Thus, adequate supplies in food are greatly depleted by the time the vitamin source is ingested. Studies show that there is no reason to fear toxic accumulation of taking pyridoxine 50--100 mg daily for many years. It is likely that any ingested excess is excreted by the kidneys within 8 hours.

Over 60% of deaths in this country can be attributed to cardiovascular diseases, and this figure includes all deaths from disease, accidents, or felonious actions. The most common cardiovascular condition is atherosclerosis, which is associated with or attributed to elevated fats of lipoproteins in the blood such as cholesterol and triglycerides.

      Cholesterol vs Triglyceride Levels in the Blood

For many years, it was commonly thought that all atheroscleroses were associated with hypercholesterolemia. Current studies, however, conclude that this belief is in error because most related problems are associated with elevated triglyceride levels rather than those of cholesterol.

As explained previously, an overabundance of blood cholesterol is often associated with a deficiency in lecithin. In addition, it has been proved untrue that elevated blood cholesterol levels are associated solely with the intake of cholesterol-rich foods such as meat, eggs, and butter. It is now known that any foodstuff, especially carbohydrate, can be synthesized into cholesterol by faulty liver action.

In many cases, atherosclerosis has often been effectively controlled through chiropractic treatment and dietary management. Spinal involvement affecting the sympathetic nervous system, particularly nerve supplies to the thyroid gland, liver, and pancreas via the celiac ganglion are known factors associated with the cause of hyperlipoproteinemia. Naturally, objective controls are necessary. These are found in lipoprotein phenotyping, which offers a quick method of detection and classification.

      Typing

Lipoprotein phenotyping includes the measurement of the elevation of cholesterol, triglycerides, beta, prebeta, and chylomicron. It's accomplished by electrophoresis of lipoproteins into their major components. In the determination of the phenotype, a laboratory can supply the doctor with information of the percentage and elevation of the different lipoproteins in the blood sample and instruct the doctor in the proper procedures for preparing the blood specimen for phenotyping as well as patient instruction before sample withdrawal.

Note: The five types of hyperlipoproteinemia will be described later in this chapter under the topic Therapeutic Nutrition, Dietetic Modifications, Lipoprotein Modification.

It is only in the last 100--150 years that civilized society has radically changed its diet. Because of processing and packaging, many nutrients have been lost. Additives have been added as "fortifications," preservatives, or chemicals to enhance the food' s taste, appearance, or shelf life. But one loss that has not been adequately compensated is that of bulk. The typical American eats only a small portion of the bulk our forefathers did. Several conditions have been attributed to this dietary deficiency.

Constipation

In cultures where bulk has not been removed from the diet, the average passage time of the stool is 30 hours. In Western cultures, this time is increased to 80 hours. There is also a reduction in the daily weight of feces from 452 to 113 grams. Since a function of the large intestine is to remove water from feces, this seems only natural as a direct function of time. This of course, leads to the problem of constipation, which has been corrected in many instances by adding fiber to the diet.

Diverticular Disease

Diverticular disease is a common problem of the aged. In a random study, it was found that:

• No patients under the age of 40 years had diverticuli

• 18.5% between age 40 and 59 had diverticuli

• 29.2% between age 60 and 79 had diverticuli

• 42.0% of those 80 years of age or more had diverticuli.

It has long been the practice to restrict the fiber of patients with this problem in the hope the lack of fiber would reduce irritation of the diverticuli. But, in an international study, it was found that societies with high fiber in their diet, even when taking genetics into account, had consistently fewer cases of diverticulitis per population.

One theory that seems plausible is that diverticuli are formed when intestinal intralumen pressure is increased. This occurs when fiber is lacking in the diet and constipation occurs. As people age, the muscular layer of the colon decreases in tone and diverticuli may form because of the increased pressure. This would explain why there is a higher incidence of diverticuli with increasing age.

Carcinoma of the Colon

The incidence of colon cancer is several times higher in western nations than in underdeveloped countries. This difference cannot be attributed to racial or genetic causes. When people change residency and alter their diet from a high-fiber to a low-fiber intake the incidence of colon cancer increases. In comparison with studies in various Western countries, the only dietary correlation found of any significance was that of diet fiber.

There are three main theories to explain this effect:

1.   The first and simplest theory is that there are carcinogenic substances in certain foods (eg, simple sugar, refined cereals). The longer these substances remain in the intestine, the greater the chance of cancer.

2.   The second theory states that bacterial end-products of metabolism are carcinogenic. The more quickly these are removed, the less probability of intestinal cancer.

3.   The third theory states that bacterial by-products or bile acids in the intestines are carcinogenic. Fiber absorbs the bile acid like a blotter so the bacteria cannot get at it, and this helps speed it on its way. This hypothesis has been substantiated by using a species of clostridium and bile acids in vitro. Three of the four metabolites were shown to be carcinogenic, as is bile acid to a slight degree.

Micronutrient Influences on Neurophysiology

As a rule, appetite does not wane with diminishing mental activity. In fact, overnutrition is often the rule. The result is gastric distress, which, in turn, increases mental stress.

Mental health depends largely on proper nerve function, which has its own nutritional requirements --as do all tissues. But no other system seems more involved with all phases of nutrition than the nervous system. Just as nutritional factors are important in brain metabolism, malnutrition of the spinal cord and peripheral nervous system may be both a cause and an effect of deranged metabolism in other tissues.

The brain is only 2% of total body weight, yet its metabolism accounts for approximately 20%--25% of the total oxygen consumption in the body and for about 15%--25% of the resting cardiac output.

For some unknown reason, despite its extraordinary metabolic activity, the rate of entry of many substances from the blood into nerve tissue is much slower than in other tissues. It's a fact that changes in the concentration in the brain of any substance normally present affects mental function.

Vitamin A has numerous metabolic roles in the central and peripheral nervous systems. The B-complex vitamins are required in a variety of highly complicated enzyme systems that govern and control neural energy. Thiamin deficiency causes neurologic changes of polyneuritis, Wernicke's encephalopathy, Korsakow's syndrome, beriberi, and other neuropathies. The vital role of vitamin E as an antioxidant has been described earlier. Carbohydrate metabolism is highly essential as the principal source of glucose, which is so necessary in brain metabolism.

Niacin.   Niacin, but not niacinamide, leads to vasodilation, and deficiency leads to such conditions as the psychoses of pellagra and schizophrenia, periods of depression and apprehension, increased irritability, insomnia, headaches, dizziness, and weakness. Niacin is often recommended as a preventive for senile psychoses.

Folacin.   Folic acid plays an important role in the synthesis of purine and pyridoxamine compounds used in the formation of nucleoproteins and transmethylation processes. Folacin deficiency is often related to developmental anomalies in the brain such as hydrocephalus, severe mental retardation, and dilation of the lateral ventricles.

Vitamin B-12 and Folic Acid.   Cobalamin appears involved in the activities of folic acid coenzyme processes. B-12, like folic acid, is also involved in coenzyme form in the metabolism of purines and pyridoxamines and appears to play an integral part in the metabolism of nerve tissue. Folic acid and B-12, especially, are important to oxygen provision. Subacute combined degeneration of the cord is associated with B-12 deficiency.

Vitamin C.   Vitamin C seems to play an important role in mental health. Deficiency is noted in both depression and schizophrenia and can be found by low serum ascorbic acid concentrations. Some authorities relate this to high vitamin C utilization during these conditions rather than to low intake.

Amino Acids.   Protein provides the amino acids the brain needs for the synthesis of protein and phospholipids. It appears that many amino acids not deemed of vital importance to the body as a whole are required by the brain. These vital amino acids are obtainable only in appropriate quantities when the liver and kidney carry out their synthetic processes normally, thus the attention so often given to liver function in chiropractic care of mental health.

The amino acid glutamic acid is often used in the treatment of petit mal epilepsy. Excellent results have also been reported in cases of minor mental retardation and in situations where the goal is improvement in personality behavior and intelligence. Is one's I.Q. static? No, improvement in 5--20 I.Q. points have been reported from the use of glutamic acid supplementation.

In general, mental conditions usually associated with physical disease result from low concentrations in the brain of either one or more important nutrient. The most common offenders in deficiency states are thiamin, niacin, pyridoxine, B-12, biotin, and folic and ascorbic acids. Both behavior and mental function can be influenced by changes in concentration in the brain of any substance normally present --with glutamic acid, uric acid, and y-aminobutyric acid heading the list in importance.

It is well to recall that mental and behavioral symptoms are usually observed long before any overt physical symptoms appear of avitaminosis. This is likely because the brain is more sensitive to precise concentrations than are other tissues and organs.

Note: It has been reported that some people may show cerebrospinal concentrations grossly low in micronutrients, yet present normal concentrations in the blood and lymph, resulting in localized cerebral deficiency diseases.

In mental health, the minerals calcium, phosphorus, magnesium, and iron play the most important roles.

• Calcium is essential for proper control of nerve center excitability. Deficiency is associated with irritability and instability of the nervous system.
  
  

• Phosphorus, which is especially abundant in nerve tissue within phospholipids, serves in nerve tissue metabolism.
  
  

• Magnesium functions in nerve conduction and muscle activity. Adenosine triphosphate, which governs nerve impulse transmission, depends greatly on the presence of magnesium. A deficiency of magnesium is marked by hyperirritability such as seen in tremors and tics and by mental states of confusion and an increased tendency to fantasize.
  
  

• Iron deficiency anemia can lead to symptoms of apathy, lassitude, irritability and anxiety.

Osteoporosis

Patient's with osteoporosis are commonly seen in the chiropractor's office. One-third of women over 60 years, and many men, are plagued by this disorder. The age of onset seems to be lowering, and the disorder may be one of the more common problems of the future.

An osteoporotic patient is symptomatically with pain and disability resulting from fractures, generally of the femoral neck or one or more vertebra. The disorder is also characterized by bone loss and as such can be classified by degree. It may be graded via an x-ray film and the Singh Index. Singh's Trabecular Grading Patterns range from normal (Grade 7) to severe (Grade 1). Grades 1--3 are usually symptomatic, with Grade 4 marginal.

Remember that symptomatic and asymptomatic situations are not only the result of the amount of weakening but also the amount of stress placed on the bone. Morphologically, there is a decrease in the number of trabeculae in spongy bone and a tendency of cortical bone to become porotic. Stress on bone (eg, muscle contraction) tends to limit the extent of osteoporosis that occurs because activity increases normal calcification. It is the amount of trabeculation that determines what bones become porotic. The osteoblasts and osteoclasts that help form the trabeculae are the most sensitive to hormonal influences (eg, estrogen, parathyroid hormone, and calcitonin).


Other Bone Disorders

A distinction must be made between osteoporosis and osteomalacia. Osteoporosis is a result of insufficient calcium after the bone is formed. Osteomalacia is the result of a poor matrix. This may be caused by insufficient protein in the diet, not enough vitamin C (resulting in starved connective tissue), or some problem with the osteoblasts.

• Lack of exercise is one of the main contributing factors of osteoporosis. As the patient ages, there is a tendency to decrease physical activity. This adds to other inimical factors involved.
  
  

• Protein deficiency is not a major factor in the United States. Problems with calcium and phosphorus are by far more common in osteoporosis.
  
  

• Severe vitamin C deficiency, or scurvy, is a documented cause of osteoporosis. Except in rare instances of Blacks or Orientals who are shut-ins, it is an uncommon problem. Relatively small amounts of the vitamin will correct the problem, even in advanced circumstances.
  
  

• Abnormal absorption of vitamin D in cases of complete or partial gastrectomy is common. This results in steatorrhea and a dumping syndrome, causing vitamin D and calcium to be lost. These losses should be countered with dietary supplements. In addition, liver disease or substances such as phenobarbitone or diphosphonate may produce vitamin D metabolic abnormalities.

Calcium Shortage.   Calcium deficiency almost never results in rickets in this country. Assuming adequate vitamin D is present, enough calcium can be obtained from the diet and tap water to prevent this extreme situation. After analyzing many thousands of fecal and urinary excretion for calcium, the conclusion is that almost all citizens live most of their lives with a negative calcium balance. However, dietary insufficiency can be a contributing cause of osteoporosis in the elderly and younger age groups with a related absorption or metabolic problem.

Bone Density.   The concept has developed that bone density decreases with age. This may be generally true. But in longitudinal studies conducted over 11 years, a significant number of people did not demonstrate this. Presumably, these people had sufficient calcium in their diet. In those that consume high amounts of animal flesh, there is a general decrease in bone density. Vegetarians who eat eggs and milk but avoid meat (a high-phosphorus food) have greater bone density. Omnivores fall between. In populations where the calcium-to-phosphorus ratio is near 1:1, there is better bone density. In general, the amount of phosphorus-rich food and phosphorus-containing foods (eg, additives and soft prunes with orthophosphates for acidification) has increased more than 200% in the last 40 years.

Phosphorus.   Excessive phosphorus exaggerates bone loss in animals. In humans, it is almost impossible to increase the calcium-phosphorus ratio beyond 1:1 by diet alone. Dairy products have only a slightly greater ratio (processed cheeses have even less calcium) and vegetables (except for leafy types) are rich in phosphorus. Only a few more unusual foods such as sesame seeds, molasses, and seaweed have large amounts of calcium with little phosphorus.

Fluorides.   An excessive intake of fluoride can produce osteomalacia. Fluorides stimulate osteoblasts and result in new bone formation. But if insufficient calcium is present, it will be removed from existing bone and cause osteomalacia.

Fluoride Plus Calcium.   These minerals ingested together have experimentally prevented osteomalacia and decreased osteoporosis. It has been shown that 50 mg of sodium floride and 1 gram of calcium per day taken orally is an effective combination. In this study, vitamin D in units of 50,000 was also given twice a week. It is not known if this is the optimal dose for vitamin D. Radiographs showed coarsening of trabeculae and an increase in bone density. Only one case of exostosis (a possible side effect) was observed at the site of a bone biopsy. The two most frequent complaints were joint discomfort and gastric pain. Removal of the floride or reduction of the dose eliminated the former, and giving the floride during meals eliminated the latter complaint. The long-range effects of this type of treatment are not known. Excessive vitamin D is the most toxic vitamin.

It is not within the province of this chapter to consider diets for older citizens suffering from specific ailments. They are detailed in standard texts on clinical nutrition. However, the doctor should be impressed that it is not uncommon that the basic nutritional requirements of the patient may be inadvertently neglected when the physician and/or nutritionist focuses attention pointedly on a specific problem. Such "blinders" in rationale have resulted in the famous "Sippy" ulcer diet, which is moderately deficient calorically and supplies only half the adequate amount of protein.

In any special diet, the objective is to retard the progression of diet-induced chronic disease, to maintain normal weight, and to prevent dietary excesses or deficiencies. In general, the nonfebrile patient requires fewer carbohydrates, more protein, less fat, and sufficient vitamins, minerals, and trace elements to correct deficiencies and meet individual requirements.

There are many diet-induced chronic conditions discovered in clinical practice. Following are some common examples:

• Disorders of magnesium, calcium, and phosphate metabolism, which contribute to osteoporosis and result from chronic negative calcium balance. Such an imbalance may be the effect of physical inactivity, hormonal imbalance, and/or a nutritional disorder, or some combination of these.
  
  

• Disorders of folacin deficiency leading to megaloblastic anemia.
  
  

• Disorders of caloric overnutrition leading to obesity, which can result in diabetes mellitus, hypertension, hepatic cirrhosis, atherosclerosis, and gallstones. Such manifestations are feasibly the result of excess carbohydrates grossly deficient in necessary micronutrients over a long duration.
  
  

• Disorders of glucose and lipid metabolism leading to atherosclerosis. Rare is the American that is unaffected. The cause is undoubtedly from chromium and lecithin deficiency as a result of extensive use of refined sugars and flours, and of excessive animal fats.
  
  

• Disorders of the liver, especially cirrhosis, resulting from long-term overutilization of ethanol and refined carbohydrates, both of which are highly deficient in the essential micronutrients that prevent fatty degeneration.
  
  

• Disorders of vascular homeostasis leading to vasoconstriction, which results in local ischemia and arterial hypertension. This is probably caused in the most part by excess cadmium begging for dietary zinc.
  
  

• Disorders of inadequate renal function as a consequence of normal aging, degenerative vascular disease, or other kidney disease. This leads to demoted nitrogen and electrolyte tolerance.

Overview

Nutritional therapeutics is that treatment mode in patient management which tempers and enhances the patient's diet to meet the conditions imposed by the physiologic stress or abnormal tone of the illness. During almost any sickness, changes in nutrient intake, metabolism, and utilization affect nutrient requirements and status. It is obvious that the diet then must be modified to meet the body's needs and demands.

To approach diet therapy clinically, several problems must be isolated and goals defined. Priority needs must be recognized. The characteristics of the dietary modifications used in the treatment of various disorders must be known, taking into consideration individual errors in metabolism, allergy, lactose intolerance, malabsorption, chronic disease processes, and individual habits and life-style.


Goal of Diet Therapy

The central objective of nutritional therapeutics is to provide optimal nutritional needs of every patient. Such health-care service is primarily based on the normal diet of the patient with modifications to meet the needs of the patient as indicated by the specific pathophysiologic state of the patient. With a few intake starvation exceptions (eg, overt scurvy, pellagra, pernicious anemia), dietetic services are not provided as the major means of treatment. Rather, they are used in support of or in conjunction with other methods of treatment. Holistic therapy must consider neurologic insults that may adversely affect digestion, absorption, and assimilation.

There are several ways by which nutritional status is affected during illness, which may be considered as primary or secondary factors. For instance, if a patient cannot consume adequate food because of anorexia, vomiting, distress, poorly fitted dentures, sore mouth or throat, etc, then nutrient availability is jeopardized. This primary nutritional deficiency may result from a variety of causes such as effects of treatment, severe injury, or gastrointestinal and psychologic problems. The inability of the body to absorb and/or use nutrients is called a secondary nutritional deficiency. Secondary deficiencies occur particularly in problems such as the malabsorption syndrome, diarrhea, and various enzyme deficiencies. Secondary deficiencies also result from excessive excretion and/or nutrient catabolism. Underlying any of these malfunctions may be a subluxation complex. The modification of diet for therapeutic purposes during illness and convalescence is therefore an essential part of total patient care.

Nutritional support is often crucial for promoting rapid recovery and restoring normal body function. The need for nutrients is holistically increased during the stress of dysfunction or disease. In addition, an accompanying primary and/or secondary deficiency further predisposes a patient to dysfunction because of the deteriorated nutritional status. Thus, it is clinically important to counteract the condition and promote recovery processes by professionally guided nutritional support. To provide the patient with an optimal internal and external environment for recovery as rapid as possible is an essential part of total patient care.

      Office Records

A brief description of any diet or supplementation advised by the doctor should be recorded in the patient's office visit records. The diet may then be adjusted and modified according to patient needs and progress. Whether the formulation of the diet is made by the dietitian, the doctor, or on a printed form, the physician assumes ultimate responsibility for the diet order or prescription.

      Reference Sources

There are many diet manuals available that provide guidelines for routine and therapeutic diets used for various disorders. These manuals describe the rationale of the diet recommended, list foods allowed or not allowed, often provide a sample menu, and serve as a general reference for the physician prescribing the diet. However, all should be modified to meet the needs of the specific patient and circumstances at hand. Specific diets vary with the patient's condition, and personalization of the diet must be based on the patient's food habits, preferences, and the pathophysiology involved to assure patient adherence to accomplish the necessary objectives.


Goals of Nutritional Assessment

Nutritional evaluation is a complex, scientifically constructed procedure. It consists of many facets; eg, health history, family history, diet history, dietary evaluation, vitamin evaluation, mineral evaluation, dietary analysis, complete physical examination, anthropometry, activity profile, nutrition behavior profile, biomechanical evaluation, including blood and urine profiles, neurologic and orthopedic work-ups, and often radiography and other tests.


Dietetic Modifications

The patient's average diet must be modified in several aspects for therapeutic purposes such as in considerations of consistency, fiber, residue, flavor, mineral content, acid or alkaline ash, frequency, energy requirements, and possibly exclusions of specific foods, beverages, or unfavorable habits (eg, excessive use of tobacco, coffee, tea, "junk" foods). With many patients, vitamin and mineral supplementation may be necessary according to the adequacy of the diet and the needs of the patient for a particular malady.

It's important to keep in mind that the patient's typical diet and the majority of those printed in standard nontherapeutic references are not applicable in illness because the standards are derived from a healthy population rather than during illness that requires individualized dietary considerations.

      Consistency Modifications

Diets modified in consistency are usually prescribed in circumstances requiring foods that are easily digested, are free of chemical or mechanical irritants, and/or are easy to chew and swallow. Common examples are the liquid diet and soft diet. These diets are often used in conditions of vomiting, diarrhea, infections, and GI problems.

Liquid Diets.   A liquid diet consisting of broth, gelatin, weak tea, and some carbonated beverage as ginger ale can only be prescribed for a short time because it is nutritionally inadequate. However, with careful planning, a fluid diet can be used for a longer period by approximating nutritional requirements by including vegetable juices, purees, specially prepared liquid formulas (eg, Ensure Plus), and using supplementation.

Soft-Food Diets.   Soft foods are generally used for patients who have difficulty chewing or swallowing. This diet has a smooth consistency, is low in fiber, has a mild in flavor, and allows cooked vegetables, eggs, tender meats, and puddings. As with a liquid diet, it is used only for a short time. Ice cream and frozen yogurt may be helpful in some conditions (eg, peptic ulcers) but counterproductive in phlegm-producing illnesses.

Note: Transition from a liquid diet to a soft diet to a standard diet should be made slowly with monitored modifications.

      Gastrointestinal Adjustments

In frank disorders of the GI tract, modifications are made in accordance with lesion location such as (1) in the duodenum, stomach, or esophagus, or (2) disorders of the small or large intestine.

In disorders of the upper GI tract, diets are generally used that modify gastric motility or influence gastric acidity. Gastric motility is changed by increasing or decreasing the amount of fiber from indigestible plant carbohydrates. When GI irritation is a concern, a decrease in fiber is indicated. Typical high-fiber foods are salads, whole grains, bran, and raw vegetables.

Gastric acidity is influenced by dietary adjustments as in a peptic ulcer where the presence of digestive acids and enzymes may irritate a lesion. Protein foods buffer acidity, while fats inhibit gastric secretions and slow emptying time of the stomach. Thus, fat and meats are used in GI disorders where gastric acidity is a concern. On the other hand, coffee, tea, alcohol, and meat extracts generally stimulate acid flow, and should be avoided in conditions of abnormal gastric acidity.

Flavor modification, as in a bland diet, is often used to preclude gastric irritation and avoid stimulating acidic secretions. Fiber is usually, but not always, restricted in GI hyperacidity states.

In disorders of the small and large intestines, dietary modification is used to control residue content, especially if motility or rest of intestinal tissues is indicated. Note that fiber and residue are not synonymous terms. Fiber is indigestible carbohydrate from plant foods, especially the cell wall and other structural components of plant food. The term residue, a broader term, refers to the form of food when it reaches the large intestine or to the remaining contents after digestion. Roughage, an archaic word, refers to both fiber and residue.

All food has some degree of residue, but not necessarily fiber. For example, fat, milk, and dairy products have a moderate residue but are fiberless. Since all plant fiber is relatively indigestible, it is present in this form in the large intestine after digestion and has a high residue. Any inflammatory process of the intestine or colon would indicate a low-residue diet.

      Cardiorenal Modifications

Dietary management in disease of the heart or kidneys requires many considerations beyond the scope of this section. The two most important factors, however, are sodium and potassium restriction.

Sodium.   Sodium is abundant in many commercial foods. It is commonly restricted to control edema and other forms of water retention, particularly in hypertensive states or heart disorders. Normal intake of sodium is from 2000 to 7000 mg/day. Mild restriction would be from 2500 to 4500 mg/day, with severe restriction from 250 to 2500 mg/day. In sodium restricted diets, the use of table salt, cooking salt, and the sodium content of foods must be considered. A palatable salt substitute is of value. Commercial NoSalt, for example, is almost indistinguishable from common table salt and leaves no after-taste. Rarely is supplemental sodium required, even for athletes in hot weather (See Schafer RC: Chiropractic Management of Sports and Recreational Injuries, ed 2. Baltimore, Williams & Wilkins, 1986).

Potassium.   Potassium is widely distributed in foods. It is usually restricted in conditions of advanced diabetes mellitus and renal insufficiency. Normal intake is from 2000 to 6000 mg/day. Restricted levels are usually from 1500 to 2000 mg/day. Besides sodium and potassium, protein must be restricted in some kidney diseases (eg, glomerulonephritis). If a nonpotassium-saving diuretic is necessary in case management (eg, hypertension) potassium should be supplemented to avoid sodium-potassium imbalance. Severe imbalance will usually manifest as a heart attack.

      Genetic and Other Special Factors

Genetic defects producing errors of metabolism may require special management. The two most common conditions seen in practice are cystinuria and phenylketonuria:

Cystinuria.   In cystinuria, the transfer of the amino acid cystine across renal tubules is hindered. The result is the formation of stones. This genetic renal defect requires alkaline foods to alkalize the urine and reduce the tendency toward building renal calculi (nephrolithiasis). Increased water intake (especially distilled) is also commonly prescribed.

Phenylketonuria.   This disorder is characterized by a lack of enzymatic conversion of phenylalanine, an essential amino acid, to tryosine and an accumulation of deleterious by-products of phenylalanine that may cause brain damage.

Other conditions not necessarily inborn may require the restriction of certain foods such as in lactose intolerance, allergy, and sprue.

• Some patients may have an intolerance to milk because of a lack of the enzyme that hydrolyzes lactose to glucose and galactose. A soy milk or meat-base formula may be a necessary substitute for infants and children with this type of malabsorption syndrome.
  
  

• With some patients, such foods as eggs, milk, chocolate, malt, fruits, tomatoes, or nuts may cause an allergic reaction. Typical responses are diarrhea or a wet (vesicular) rash.
  
  

• The protein gluten is within rye, wheat, barley, and oats and is sometimes related to destruction of the intestinal mucosa, thereby reducing absorption (celiac disease). In this nontropical sprue, the appropriate grains must be eliminated from the diet until the condition is under control, if ever.

      Energy Modifications

Many disorders require modification of carbohydrate, protein, or fat intake as a major aspect of dietary management. In conditions of obesity, the reduction in total caloric intake is usually the primary consideration. The specific amount of total calories produced by fat depends on the specific condition of the patient. In situations of underweight and the catabolism of infection, intake of carbohydrate must be considered as well as that of protein and fat.

Modification of fat content (quantity and type) in the diet is often necessary in malabsorption problems, atherosclerosis, hyperlipoproteinemia, and with disturbances of the liver and gallbladder.

• Steatorrhea is the result of low bile production failing to aid absorption of the long-chain triglycerides, inducing fat in the stool.
  
  

• Considerable evidence links high fat consumption, especially that of the saturated fats, and increased blood levels of certain lipoproteins with coronary artery disease.
  
  

• Gallstones may hinder bile flow, which then impedes fat digestion. Both gallbladder and liver disease (eg, hepatitis) indicate liberal unrefined carbohydrates and protein ingestion and restricted fat intake.

Note: Some "diet specialists" fail to consider the caloric consumption in the metabolism of food. That is, the potential caloric content of a food is no more important than the number of calories necessary to metabolize it. Sugars and refined carbohydrates require proportionately few calories for their metabolism. Protein requires proportionally more. Fat is almost neutral.

      Lipoprotein Modification

The lipoproteins, which are produced in the intestinal wall and liver, are the primary means of transport for lipids. The major classes of lipoproteins and their lipid content are:

1. Chylomicrons (low density).   This class has the highest lipid content. The major lipid sources are dietary triglycerides with a small amount derived from protein.

2. Prebeta lipoprotein (very low density).   This class has a large lipid content that includes 20% cholesterol.

3. Beta lipoproteins (low density).   This class has less lipid content and two-thirds or more of total plasma cholesterol.

4. Alpha lipoproteins (high density).   This class represents the lowest total lipid of any lipoprotein and the highest protein content.

Several blood lipid abnormalities have been identified by paper electrophoresis, and these major classes serve as the basis for dietary modification:

Type 1 Hyperlipoproteinemia.   The blood picture shows increased chylomicrons due to elevated triglycerides. Dietary modifications include decreasing the level of dietary fat to 30 grams of saturated fats, or the use of polyunsaturated fats, and increased carbohydrates for energy requirements.

Type 2 Hyperlipoproteinemia.   The blood picture shows increased beta lipoproteins and increased cholesterol to 300--600 mg/100 ml. Dietary modifications include decreasing cholesterol intake and substituting polyunsaturated fats for saturated fats.

Type 3 Hyperlipoproteinemia.   The blood picture shows increased prebeta lipoproteins, increased beta lipoproteins, and increased cholesterol. Dietary modification is the same as for Type 2; viz, decreasing cholesterol and substituting polyunsaturated fats for saturated fats.

Type 4 Hyperlipoproteinemia.   The blood picture shows increased triglycerides, increased prebeta lipoproteins that are usually induced by carbohydrates and accompanying obesity, and normal or increased cholesterol. Dietary modifications include restricted carbohydrate and cholesterol intake and reduction in body weight.

Type 5 Hyperlipoproteinemia.   The blood picture shows increased chylomicrons, increased triglycerides, and increased prebeta lipoproteins accompanying obesity. Dietary modifications include restricted carbohydrate and fat intake and reduction in body weight.

The nutrition/infection interaction has important implications in infection morbidity and mortality, especially in the malnourished as seen in poverty areas, the disadvantaged elderly, and in hospitalized patients. The consequences of any infection will be more severe in the nutritionally compromised patient.


The Cyclic Relationship Between Nutrition and Infection

A deficient nutritional status enhances infectious disease, and, in turn, infection creates abnormal nutritional demands that further deplete nutritional reserves. In addition, the nutritional/infection interaction creates synergistic effects for the host that are significantly worse than would be anticipated from the combination of these two factors if each were acting separately.

In rare cases of highly severe malnutrition, the nutrition/infection interaction might produce an antagonistic relationship where the malnourished host provides such a poor environment that the infectious agent is unable to complete its life cycle. To break the cycle between malnutrition and infection, optimal nutritional status must first be achieved before infections can be effectively treated.

The infectious process may change the nutritional status of the host either directly or indirectly.

• Alteration of proteins, lipids, carbohydrates, vitamin metabolism, and mineral metabolism are examples of direct effects.
  
  

• Indirect effects of infection include such situations as decreased or altered food intake as in anorexia or a swollen throat making chewing and swallowing difficult.

Direct Effects of Infection and Infestation on the Nutritional Status

The word nutriture refers to the status of the body relative to its nutrition. During an infectious process, nutriture is altered in six ways:

1.   Protein digestion and absorption are decreased

2.   Protein catabolism is increased

3.   Plasma amino acid levels are altered

4.   Lipid and carbohydrate metabolism are altered

5.   Vitamin nutriture is altered

6.   Mineral stores are adversely affected

Nutritional status affects host resistance through specific (humoral and cellular immunity) and nonspecific immune mechanisms such as tissue integrity, phagocytic activity, and cell products (eg, interferon and properdin) that offer resistance against invading organisms and foreign substances.

Specific immunity is characterized by the host's ability to distinguish itself from the invading organism, producing a specific response that becomes imbedded within one's immunological memory. Antigens producing a specific immunologic response are by definition capable of reacting with antibodies composed of serum protein immunoglobulins produced in response to an antigen and can bind specifically with an antigen. The five classes of immunoglobulins are represented as IgG, IgA, IgD, IgM, and IgE.

• The humoral component of the immune response can be simply stated as follows:

  An antigen or foreign substance enters the body. It is seized and processed by a macrophage. The processed antigen may then be embraced by a B-lymphocyte (derived from gut-associated lymphoid tissue) that, upon proliferating, produces a line of lymphoid cells capable of synthesizing and secreting antibodies into the blood circulation that can combine with and destroy the antigen.

• The cellular component of the immune response can be simply stated as follows:

  A processed antigen is seized by a group of thymus-dependent lymphocytes (T-lymphocytes) that produce specific mediators, instead of secreting antibodies, which facilitate destruction of the antigen.

Trace elements should be considered from the position of various levels of intake:

• Low supply: a deficiency state does not permit normal function to be maintained for health.
  
  

• Moderate supply: At a dose somewhat higher than a deficiency state, trace elements function in the biologic system as necessary components of certain enzyme reactions or biologic complexes.
  
  

• High supply: At a dose higher than moderate, a trace element may have pharmacologically active properties (eg, zinc in wound healing) or it may interfere with the function of another trace element (eg, molybdenum interfering with copper metabolism).
  
  

• Excessive supply: Extremely high concentrations may produce toxic symptoms and possibly death.

The range of concentration between a trace element's essential and toxic character may be very large or very small (eg, fluorine). Toxic levels are often difficult to define because individual needs and tolerances vary considerably.


Internal and External Factors

Several endogenous factors may be involved that can lead to improper utilization of trace elements. There may be ingestion of a substance (eg, phytate, goitrogens, pica, certain drugs) that interfere with normal utilization. In malabsorption syndromes, a poorly functioning intestinal tract may be unable to absorb the trace element. The trace element may be ingested in a form in which the body cannot use the element. In protein malnourishment, necessary blood protein may be too deficient to transport the trace element. A genetic defect may be present that interferes with proper metabolism of the element.

Several exogenous factors may be involved that can lead to a state of deficiency or toxicity.

Deficiency States.   Specific individual needs (eg, pregnancy, periods of rapid growth) may require heightened amounts not usually required. Improper cooking procedure may cause trace minerals to be lost through boiling; or unsuitable cooking vessels may react with trace elements to render them unavailable. Due to depleted soil producing crop deficiency, the diet may lack sufficient quantity; or due to an unbalanced diet, available sources may not be ingested.

Human error can also account for toxic states from overingestion. Examples are contamination, deliberate (suicidal) overdose, over supplementation, food ingested grown on soils with toxic concentrations, or pollution during food preparation, processing, cooking, or storage.

Toxic States.   Infrequently, (1) a genetic defect in metabolism may permit an abundance of the element to accumulate in the body or (2) a disease process may cause tissue breakdown to such an extent that large amounts of the elements are released into the blood.

Trace Element Function, Deficiency, and Toxicity

The most common trace elements considered are iron, zinc, copper, iodine, fluorine, chromium, selenium, manganese, magnesium, sulphur, cobalt, and molybdenum.

      Iron

Iron is necessary for the transport and exchange of blood oxygen. It is an integral part of hemoglobin and myoglobin, and involved in oxidation reduction reactions for important enzymes. Therapeutic application is usually indicated in alcoholism, anemia, overstress, lowered resistance to disease, colitis, and menstrual problems. Primary natural sources are eggs, fish, organ meats (esp. liver), poultry, wheat germ, and blackstrap molasses. The RDA is 10 mg/day for males; 18 mg/daily for females.

Common Causes of Excessive Loss.   Blood loss from infection, bleeding ulcers, intestinal parasites, during peak periods of growth (adolescence, pregnancy, lactation), malignancy, and menstruation are common causes of adult iron deficiency. Iron deficiency in infants typically results in depleted stores from naturally excreting larger amounts than adults and hyperutilization during periods of rapid growth.

Clinical Features of Deficiency.   Deficiency symptoms and signs include anorexia, brittle nails, constipation, fatigue, depressed growth, breathing difficulties, pale skin and tongue, decreased resistance to infection, koilonychia, and listlessness. Blood signs include hypochromic anemia, high total iron-binding capacity, low serum iron, and low percent transferrin saturation.

Hemosiderosis.   As the body has a limited capacity to excrete iron, excessive amounts can accumulate in the body. This buildup (hemosiderosis) can be caused by excessive red blood cell destruction (eg, hemolytic anemia, infection), inability of the body to regulate iron balance, and iron overingestion. Hemosiderosis is often related to hepatic disease or chronic pancreatic disease. A potential feature is hemochromatosis, the bronzing pigmentation of skin from excessive body iron as seen in diabetes and hepatic cirrhosis. Toxic levels are given as intakes exceeding 100 mg daily.

      Zinc

Zinc is an important factor in many enzymes (eg, carbonic anhydrase, carboxypeptidase, several dehydrogenases) and plays a role in leukocyte function and insulin function and storage. Therapeutic application is usually indicated in alcoholism, prostate troubles, atherosclerosis, certain types of baldness, diabetes, internal and external wounds, cholesterol deposits, and infertility. Primary natural sources are brewer's yeast, liver, seafood, soybeans, spinach, mushrooms, and sunflower seeds. The RDA is 15 mg daily.

Common Causes of Deficiency.   Due to soil depletion, zinc deficiency is be coming quite widespread in the United States. Zinc content of food usually parallels protein content; thus patients on low-protein diets risk zinc deficiency. A diet high in grains may also result in zinc deficiency because the phytate in plant seeds binds zinc and other trace minerals to render them unavailable to the body. Serum zinc decreases in numerous bacterial and viral infections, in acute inflammatory diseases, in myocardial infarction, and following severe trauma. During pregnancy and rapid periods of growth, zinc may become depleted.

Clinical Features of Deficiency.   Deficiency symptoms and signs include anorexia, fatigue, loss of taste and smell sense, slow wound healing, growth retardation, delayed sexual maturity, delayed reproductive development and impaired function, possible sterility, and skin lesions. Blood signs include a lowered level of retinol-binding protein in the blood.

Toxic States.   Specifically defined syndromes of zinc toxicity have not yet been isolated, but it is known that heavy ingestion of zinc compounds can cause nausea, vomiting, fever, and diarrhea. An industrial hazard is "metal fume fever," resulting from excessive inhalation of zinc. It is characterized by fever, chills, pulmonary problems, and gastroenteritis. Zinc toxicity often results from storage of acidic foods in galvanized containers.

      Copper

Both copper and iron are essential for normal hemoglobin and red blood cell formation. Copper is also a necessary component of several key enzymes, most of which function as oxidases (eg, cytochrome, ceruloplasmin, dopamine B hydroxylase, and monamine oxidase). It serves a role in bone formation, hair and skin color, and healing processes. Therapeutic application is usually indicated in anemia and some types of baldness. Primary natural sources are legumes, nuts, organ meats, seafood, soybeans, raisins, molasses, and bone meal. The RDA is 2 mg daily.

Deficiency.   Because many foods contain copper and copper plumbing is common in the United States, deficiency is rare. Deficiency is seen in nephrosis with marked proteinuria, infants with diarrhea or malabsorption problems, kwashiorkor, and diets high in grains (phytate). Deficiency symptoms and signs as those of anemia, general weakness, impaired respiration, Menke's kinky hair syndrome, and skin sores.

Toxicity.   The two most common causes of copper toxicity are overingestion and Wilson's disease. Excessive ingestion leading to toxicity is usually the result of interaction between acidic liquids and copper cooking vessels or copper plumbing. An intentional dose (suicidal) of copper sulfate greater than 10 grams results in vomiting, gastritis, shock, liver necrosis, hemolysis, renal toxicity, coma, and death. Low molybdenum or sulphate levels encourage copper toxicity. The toxic level is at 40 or more mg/daily.

Wilson's disease, a genetic disorder, features deposits of excessive copper in various organs such as liver, brain, and kidneys. It is associated with low serum copper and ceruloplasmin, neurologic abnormalities, liver damage, renal dysfunction, and a corneal rusty-brown ring.

      Iodine

Iodine is an important part of thyroid hormones thyroxine and triiodothyronine that are necessary for proper growth and mental development, and involved in several metabolic activities, most of which concern the regulation of the cellular oxidation rates, and the metabolism of fat. Therapeutic application is usually indicated in atherosclerosis, hair problems, goiter, and hyperthyroidism. Primary natural sources are iodized salt, seafood, and kelp (tablets). The RDA is 130 mg daily.

Deficiency.   Iodized salt is usually the major dietary source of iodine in iodine deficient (goitrous) areas. Besides goiter, deficiency symptoms and signs include mental sluggishness, cold hands and feet, dry hair, obesity, irritability, nervousness, and cretinism.

Toxicity.   There is a large range of safety between amounts normally ingested and toxic levels (unknown). Prolonged doses of iodine markedly reduce the thyroid's ability to embrace iodine and can yield goiter as a result.

      Fluorine

Fluorine is used in the hydroxyapatite mineral of bones and teeth, offering a natural protection against caries and playing a role in the maintenance of normal bone structure. The RDA is undetermined.

Deficiency.   Inadequate intake is known to increase susceptibility to dental decay, reduce bone density, and contribute to osteoporosis.

Toxicity.   Excessive intake causes fluorosis, characterized by mottled tooth enamel and weakened bone crystal.

      Chromium

Chromium plays an important role in normal carbohydrate metabolism as part of the glucose tolerance factor (GTF), which combines with insulin to facilitate glucose uptake at the cellular level and resembles a hormone in its action. Chromium is believed to have a role in the reduction of elevated blood cholesterol and triglycerides. Some authorities believe it is helpful in the prevention of atherosclerosis. Therapeutic application is usually indicated in diabetes and hypoglycemia. Primary natural sources are brewer's yeast, clams, corn oil, and whole grains. The RDA is not stated.

Deficiency.   Deficiency is becoming quite widespread in the United States but how to cope with the problem is controversial (eg, adding it to municipal water supply). Serum concentrations decline in the elderly, in patients with diets high in refined sugar, and during pregnancy. Prolonged deficiency impairs glucose tolerance and contributes to both diabetes mellitus and atherosclerosis.

Toxicity.   Toxicity syndromes are undefined. Excessive amounts experimentally suggest liver damage, kidney damage, and growth depression.

      Selenium

Selenium is an important component of the enzyme glutathione peroxidase, which serves in normal peroxide metabolism to prevent the accumulation of free radicles that are destructive to the biological system. Some evidence indicates that selenium plays a role in inhibiting tumor formation and controlling alcoholic addiction. The RDA is undetermined.

Deficiency.   Selenium concentrations parallel dietary protein content, thus deficiencies are related to low-protein diets. Deficiency is commonly found in kwashiorkor.

Toxicity.   Toxicity syndromes have not been identified, but excessive amounts experimentally suggest anemia, bruxism, emaciation, heart atrophy, ataxia, and death from suffocation. Poisoning results from eating plants grown on toxic soils.

      Manganese

Manganese is a vital cofactor in the enzyme pyruvate carboxylase, which catalyzes the conversion of pyruvate into oxalacetate (an important intermediate in the Krebs cycle). Manganese is also a factor in glycoprotein and mucopolysaccharide synthesis. Therapeutic applications are beneficial in some cases of allergies, asthma, diabetes, and fatigue. Primary natural sources are bananas, bran, celery, cereals, egg yolks, green leafy vegetables, legumes, liver, nuts, pineapple, and whole grains. The RDA is not stated.

Deficiency.   Overt deficiencies of manganese are almost unknown in humans. Several authorities list ataxia, dizziness, tinnitus, and loss of hearing.

Toxicity.   Toxicity is extremely rare, and exact levels are not reported. Chronic inhalation by manganese miners causes a toxic condition characterized by permanent psychiatric and neurologic symptoms resembling parkinsonism; eg, ataxia, dizziness, tinnitus, and loss of hearing.

      Magnesium

Magnesium, not always considered a trace mineral, plays an important role in healthy arteries, bones, heart, muscle, nerves, and teeth. It aids in such body functions as the acid/alkaline balance, blood sugar metabolism, and the metabolism of calcium and vitamin C. Therapeutic applications are often beneficial in alcoholism, high cholesterol levels, depression, heart conditions, kidney stones, nervousness, prostate disorders, sensitivity to noise, stomach acidity, tooth decay, and obesity. Primary natural sources are bran, honey, green vegetables, nuts, seafood, bone meal, and kelp (tablets). The RDA is 350 mg daily.

Deficiency.   Deficiency symptoms and signs include confusion, nervousness, disorientation, easily aroused anger, rapid pulse, and tremors.

Toxicity.   The toxic level is given as intake of 30,000 mg or more daily. Features are not specific.

      Sulphur

Sulphur, not always considered a trace element, is an important component of hair, nails, nerves, and skin. It aids such body functions as collagen synthesis and tissue formation. Deficiency symptoms and toxic levels are unknown. Primary natural sources are bran, cheese, clams, eggs, nuts, fish, and wheat germ. The RDA is undetermined.

      Cobalt

Cobalt serves as a vital ingredient of vitamin B-12, necessary for normal erythropoiesis. In humans, deficiency is commonly associated with pernicious anemia. Symptoms and signs of toxicity are those of polycythemia. The RDA is unknown.

      Molybdenum

Molybdenum is a part of the enzyme xanthine oxidase, which catalyzes the formation of uric acid during the breakdown of purines. It is a component of liver aldehyde oxidase, which catalyzes the oxidation of aldehydes into carboxylic acid. The RDA is undetermined.

Deficiency.   Features of deficiency have not been defined.

Toxicity.   Toxicity is uncommon to humans. When present, it is involved in the ratio of molybdenum to copper. The higher the copper concentrations, the less toxic are the molybdenum concentrations. Copper deficient patients exhibit molybdenum toxicity at low levels.

Many toxicants occur naturally in food and are avoided through trial and error over the years. Polar bear liver, avoided by Eskimos, contains about ten times the amount of vitamin A as does beef or pork liver.

Natural foods contain a great variety of natural poisons. The simple potato contains at least 150 different chemical substances such as solanin, oxalate, arsenic, tannin, and nitrate. The average American consumes about 120 pounds of potatoes a year, which contain enough solanin (10,000 mg) to kill a horse if given in a single dose. A year's supply of lima beans (1.85 lbs) contains 40 mg of cyanide. Because we consume some toxic substances each day in the typical diet, the body's detoxification mechanisms must be efficient.

The toxic chemical substances commonly ingested may be classed into three major categories:

• Those that are added to food for purposes of marketability, preservation, restoration, enrichment, and fortification.
  
  

• Those that accompany ingested foods such as toxic substances transmitted through feed grains, various microbial toxins, metals, and radionuclide fallout.
  
  

• Those that occur naturally in foods and are potentially toxic if consumed in large quantities.

Toxic substances occurring naturally in foods may be classified as:

• Substances necessary in some amounts but are toxic in larger amounts such as certain minerals and vitamins A and D.
  
  

• Substances that interfere with vitamin or mineral utilization. These particularly affect individuals with borderline intakes of specific vitamins or minerals.
  
  

• Poisonous substances found in plants such as quick-acting mushrooms or slow-acting lathyrogens where an accumulation of toxicity builds up over a long period to produce harmful effects.
  
  

• Substances that are toxic only under special circumstances.

Mineral Antagonists

Common examples of specific antagonists that interfere with normal mineral utilization at some point in metabolism are goitrogens, oxalates, phytates, heavy metals, and other substances and actions.

      Goitrogens

Goitrogens are substances having antithyroid properties that interfere with iodine utilization and are probably the best known group of mineral antagonists. The most potent goitrogens are found in broccoli, Brussels sprouts, cabbage, kale, kohlrabi, rape, rutabaga, and turnips. Less potent sources are raw nuts and fruits, milk, raisins, lettuce, celery, radishes, and green pepper. Cooking has a strong tendency to destroy the goitrogenic quality of most plants.

      Oxalates

Oxalates interfere with calcium absorption. The most potent natural sources are such plants as beet tops, lamb's quarters, poke, purslane, rhubarb, spinach, and Swiss chard.

      Phytates

Phytates are substances having a high-binding quality for zinc, calcium, and other minerals. They also inhibit the intestinal absorption of divalent cations such as iron, calcium, and zinc. Phytates normally occur in wheat, sesame seed, and soybean. Leavening destroys much of the phytate in food.

      Heavy Metals

Toxic manifestations of heavy metals (eg, lead, mercury) may result from pica or environmental contamination. Because of the high affinity of their interactions, toxic effects usually involve the proteins of blood carriers and enzymes.

      Other Mineral Antagonistic Substances and Actions

• Calcium   lack of or excessive exercise
  
  

• Copper   high zinc intake
  
  

• Iron   coffee, excess phosphorus, tea, excessive zinc intake
  
  

• Manganese   excessive calcium and phosphorus intake
  
  

• Phosphorus   aluminum, iron, excessive magnesium, excessive intake of refined sugar products
  
  

• Potassium   alcohol, coffee, cortisone, diuretics, laxatives, excessive salt or sugar intake, overstress
  
  

• Sodium   lack of sodium or potassium
  
  

• Zinc   high intake of calcium or alcohol, lack of phosphorus

Vitamin Antagonists

      Major Vitamin Antifactors

Examples of antagonists interfering with vitamin absorption or enhancing the destruction of vitamins in the gut are citral, linetin, thiaminase, dicoumarin, avidin, and mineral oil.

• Citral.   Citral is a vitamin A antagonist that can cause eye disorders. Large consumption of orange peel such as in marmalade can lead to vitamin A deficiency.
  
  

• Linetin.   Linetin, a growth inhibitor, is a pyridoxine antagonist found in linseed meal.
  
  

• Thiaminase.   Thiaminase has a strong thiamin destroying characteristic. Sources with high concentrations of thiaminase are blackberries, black currants, Brussels sprouts, red beets, red cabbage, and raw seafood.
  
  

• Dicoumarin.   Dicoumarin is a vitamin D antagonist (used medically as an anticoagulant) found in sweet clover and some other plants.
  
  

• Avidin.   Avidin, known to bind biotin, is found in raw egg white.
  
  

• Mineral oil.   Mineral oil, often used as a laxative, interferes with the absorption of fat-soluble vitamins.

      Other Antagonistic Substances and Actions

• Vitamin A   alcohol, coffee, cortisone, excessive iron, and vitamin D deficiency
  
  

• B-complex   alcohol, birth control pills, coffee, infections, sleeping pills, overstress, excessive sugar intake, sulfa drugs; thiamine --alcohol, coffee, fever, raw clams, excessive sugar, stress, severe trauma, tobacco; riboflavin --alcohol, coffee, excessive sugar, tobacco; pyridoxine --alcohol, birth control pills, coffee, radiation exposure, tobacco; cobalamin --alcohol, coffee, laxatives, tobacco.
  
  

• Vitamin C   antibiotics, aspirin, cortisone, high fever, overstress, tobacco
  
  

• Vitamin D   mineral oil
  
  

• Vitamin E   birth control pills, chlorine, rancid fat and oils
  
  

• Vitamin F   radiation
  
  

• Vitamin K   aspirin, excessive antibiotics, radiation, rancid fats
  
  

• Vitamin P   antibiotics, aspirin, cortisone, high fever, overstress, tobacco
  
  

• Biotin   alcohol, coffee
  
  

• Choline   alcohol, coffee, excessive sugar
  
  

• Folic acid   alcohol, coffee, overstress, tobacco
  
  

• Inositol   alcohol, coffee
  
  

• Niacin   alcohol, antibiotics, coffee, corn, excessive sugars or starches
  
  

• Pantothenic acid   alcohol, coffee
  
  

• Para-aminobenzoic acid   alcohol, coffee, sulfa drugs
  
  

• Pangamic acid   alcohol, coffee

Substances Toxic Under Special Circumstances

Certain substances are toxic only under special circumstances such as those of genetic predisposition, sensitivity to a protein, or an interaction of food substances with certain drugs. Primary examples are monosodium glutamate, tyramine, and wheat gluten.

      Monosodium Glutamate

In patients with a particularly low threshold of sensitivity to monosodium glutamate, MSG causes the "Chinese Restaurant Syndrome." It is characterized by chest pain, flushing, burning sensations, visual changes, headache, and hypertension. Most of these clinical features are short term, but some patients develop permanent retinal damage.

      Tyramine

Tyramine is normally metabolized through action of the monoamine oxidase system. However, tyramine, formed by decarboxylation from tyrosine, is a potent vasopressor substance in the presence of monoamine oxidase inhibitors (a drug class). When a patient is taking the inhibitor, the tyramine from cheese, cheap wine, sherry, and beer can act on blood vessels to produce severe hypertension and possible death.

      Wheat Gluten

Wheat gluten, a wheat component, is safely consumed except in patients with celiac disease. Such people are hypersensitive to wheat gluten and do not absorb it.


Noxious Foreign Substances

Kuru, akee, and favism are also substances toxic under special circumstances, but it is highly doubtful whether their effects will be witnessed clinically in the United States. Kuru is a slow-acting virus that produces CNS changes caused by eating infected brains in cannibalistic populations. Akee is a fruit that is poisonous until ripe, which is eaten by the poor in Jamaica. Favism is an inherited metabolic disturbance that causes hemolytic anemia when sensitive individuals eat fava beans, most commonly used in Taiwan and the Mediterranean region.


Fungal Toxins

The most common toxins produced by fungi are ergotism, aflatoxins, and the toxins of mushrooms:

• Ergotism is produced by rust fungi that infect cereal grains. Alkaloid poisoning occurs from consuming large quantities of infected rye products and is characterized essentially by CNS and autonomic symptoms.
  
  

• Aflatoxins, from the mold Aspergillus, contaminate many foods, especially peanuts and grains. They produce enteritis, liver damage, and encourage hepatic carcinoma, along with other disorders.
  
  

• The toxins of mushrooms produce symptoms of vomiting, abdominal cramps, salivation, sweating, myositis, diarrhea, and collapse. There are two types in the United States; one where symptoms appear from 1 to 2 hours after ingestion, and another slow-acting type with a higher mortality where symptoms do not appear until 6--16 hours after ingestion.

Toxic Foods of Animal and Plant Origin

Toxic foods of animal origin are mainly of fish from tropical waters and shellfish. Eating large quantities of toxic animals, or animals who consume toxic plants, leads to a toxic condition not well understood.

Toxicity of plant origin is rarely seen in the United States and mention here is made only to be especially alert if a patient has recently been outside the country.

• Lathyrism, endemic in India and Africa, is a crippling disease of the spinal cord caused by a neurotoxin ingested by eating large quantities of lathyrus seeds.
  
  

• The palm-like tree Cycad, common in Guam, contains large amounts of toxic substances. Its nut flour, leaves, and husk can cause neurologic disturbances when eaten in large quantities.
  
  

• Ragort, which contains an alkaloid that damages the liver, is consumed in Jamaica, Africa, and parts of Asia as a tea and herbal remedy. Excessive consumption can lead to venous-occlusive hepatic disease resembling cirrhosis.

Parasite Infestation

Ingestion of parasite-infected animal products is also a source of food-borne poisoning. For example, an unsanitary water supply is associated with amoebic dysentery, and improperly cooked pork products and bear meat are a common source of trichinosis.


Microbial Food Poisoning

Besides inherent food-related toxins, ingested bacterial toxins can cause food poisoning. These bacteria usually enter the food supply under conditions of poor sanitation that encourages their culture in food media. In recent years, food vehicles are increasingly found in Chinese-type, Mexican-type, and Italian-type foods.

Homes and food-service establishments are the most common places where foods are mishandled to an extent to cause contamination. Food-processing establishments are rarely involved because of greater sanitation controls. But despite location, poor personal hygiene by infected workers is the most significant source of food-borne contamination.

      Staphylococcal Toxicosis

The most common form of food-borne poisoning in the United States is staphylococcal enterotoxicosis. The most likely source of the bacteria is partly cooked pork products such as ham, bacon, pressed meats, salami, sausages, etc. Holding the meats at room temperature for several hours during slicing, mixing, and other preparation encourages the growth of the contaminating staphylococci.

      Salmonella Poisoning

About 200 types of salmonella, which live in the human intestine, are pathogenic. Improper cleaning of the hands after use of the toilet is a common source of this feces-derived organism. Outbreaks tend to involve groups who have eaten infected food at the same picnic or restaurant. The primary sources of infection are unsanitary containers or food handlers, contaminated ingredients, inadequate protection of food, and insects. Meat and poultry are frequently the food vehicles for the bacteria.

While salmonella species are heat-labile, contamination of previously heated food readily overcomes this advantage. Typical symptoms are headache, abdominal cramps, nausea, vomiting, diarrhea, and fever. After ingestion, a latent period follows from several hours to 3 days that is followed by an acute attack in 1 or 2 days. It varies in severity and is rarely fatal.

      Botulism

The potent toxic substance in botulism is already preformed in the food supply by the bacterium. Its spores are particularly heat resistant and grow under anaerobic conditions in a medium with a pH of less than 4.1. The protective measure of boiling canned low-acid food for 15 minutes or more inactivates the toxin. Home-canned foods are suspicious of poor protective measures.

Ingestion of minute quantities can produce symptoms of headache, nausea, difficulty in swallowing and speaking, blindness, and ascending paralysis. The antitoxin is only effective when small quantities have been ingested.


Concepts About Toxic Substances in Food Supply

Much is left to be learned about the chemical substances in our food supply. The unknown toxicants of food are likely more dangerous than the known chemical additives and pesticides. The safety margins of food additives and pesticides are monitored much more closely than the chemicals occurring naturally in foods, yet the largest number of food-related disorders in humans is caused by naturally-occurring food components and microorganism toxins.

A chemical substance has the same action biologically whether it occurs in a food naturally or has been synthesized in a laboratory and put in food as an additive. Likewise, the same physiologic mechanisms that allow the body to metabolize natural toxicants safely also apply to foods that contain additives (natural or synthetic).

Because of stringent FDA guidelines, many chemical substances with adverse properties occurring naturally in food would never be allowed on the market as food additives today. For example, synthetic diethylstilbestrol (DES) was banned by the FDA because its carcinogenicity was quantified to be one case of cancer in the United States every 2,500 years. However, wheat germ, a substance many Americans consume, has 2,000 times the estrogenic potential of beef liver of cattle treated with DES.

Are "health foods" purely healthy? Although food has many potentially toxic substances, there is no evidence that a balanced diet consumed by a healthy person presents any hazard for several reasons.

• The body can tolerate small amounts of many substances at the same time, but only a minute quantity of any one substance. The total quantity of toxic substances is far less important than the quantity of each separate substance.
  
  

• With few exceptions, the natural toxic substances in most foods are continually being detoxified and not cumulative. When consumed in small quantities, the healthy individual can readily eliminate or metabolize most toxic substances in food compounds through biologic mechanisms.
  
  

• Because toxic concentrations of most food substances are quite low, a varied diet will offer the body an opportunity to detoxify the substances unless heavy reliance is made on one or only a few foods. Variety is the safeguard.

A survey conducted several years ago revealed that chiropractic is not being used nearly enough by the older patient. There are probably many reasons for this such as physical incapacity preventing their travel to chiropractic offices, disorders considered by the patient not to be amenable to chiropractic care, economic difficulties related to retirement and other financial hardship, poor appreciation or understanding of the chiropractic role, and possibly a failure of chiropractic to have demonstrated its effectiveness in caring for the aged. Whatever the reason, there is a distinct need for the chiropractic profession to develop a rational program for the elderly.

There are many complications in prescribing an adequate diet for older people that do not exist among the younger population. Such problems as economics, physical handicaps, health problems, ignorance, social and religious taboos, etc, must be understood or the best laid plans will suffer.

The need for optimum nutrition in the health of people has never received the level of importance that it deserves. Lengthy arguments could be developed to convince even the most doubting person satisfactorily that the health professions have and are continuing to fail the populace at large in this respect. It is necessary to incriminate chiropractic as well as other health professions in this area, although in all fairness, not to the same degree. There are, however, those in chiropractic who, for ideologic reasons, negate the entire field of nutrition as not within the scope of clinical chiropractic. A growing number of practitioners considers this unfortunate because for many sociologic, economic, humanitarian, moral, and professional reasons chiropractic should be the judge advocate of the healing power of nature --the Vix Medicatrix Naturae.

Chiropractic should and must become the defender of natural health-related processes that are beneficial to humanity. And of course, this includes much more than spinal adjusting and reflex technics acting on the nervous system, though the nervous system becomes the final pathway for beneficial effects to be realized.

In this context, several environmental problems are brought to mind that deserve our concern and support --air and water pollution, noise pollution, inadequate sewage control, poorly controlled additives to water, industrial safety standards, food processing, and questionable agricultural policies, to name a few. It is necessary that consideration be given to these today for the health and welfare of all tomorrow.

Following are five postulates that were emphasized by Dr. H. J. Vear in nutrition classes at Canadian Memorial Chiropractic College. While some may question the absolute validity of Dr. Vear's opinions, these postulates will serve to stimulate thought among the chiropractic profession in general:

• The removal of interference to the normal function of the nervous system is a basic premise of chiropractic principles. This removal is most commonly and easily accomplished by the practice of adjustment of the vertebral column.
  
  

• Normal function and repair of tissue depends on two fundamental needs: (1) proper and adequate control by the nervous system and (2) availability of essential nutrients for the metabolism and repair of used or altered cellular and tissue elements.
  
  

• The nervous system must possess a high level of biochemical integrity within itself to activate dependent tissues adequately and properly.
  
  

• Neural control depends on the ability of a nerve impulse to travel along a nerve axon and cross a synapse or neural end-plate. These latter areas must also possess biochemical integrity.
  
  

• Normal activity of the nervous system is a physiologic process that is part of the body's totality; the totality being the entire environment of the individual. The environment is all intrinsic or extrinsic activities influencing the biologic awareness of the individual and which, in part, consist of perfectly constituted food.

As can be gathered from these five statements, it is assumed that before a mechanical change in the spine can result in a visceral response, the nervous system has to enjoy a special type of integrity. Failing this, the clinical results of the mechanical change will be incomplete, temporary, or only reactive. Regardless, the desired result will not occur. It is the opinion of many that the older patient is a major victim of this problem. It is also speculated that the aging process is accelerated by this concept. Further, similar nutritional demands are placed on the aged as are for the developing young, although for different reasons.


Common Causes of Geriatric Nutritional Deficiency

The elderly patient must always be recognized as a less than flexible creature, conditioned in habit, opinionated according to moral, social, and educational codes, and resistant to change, particularly of self. If this were all, it would be bad enough, but, unfortunately, a host of other environmental and physiologic problems must be dealt with as well. To minimize the problem, we shall describe nutritional deficiency in the elderly under two major headings: (1) socioeconomic considerations, and (2) pathophysiologic considerations.

      Socioeconomic Considerations

This area is of particular importance in treating the elderly patient. It is significant to remember that our knowledge base of nutrition is relatively recent to scientific investigation and poorly understood by the average citizen -- and even more so by the senior citizen.

• Poverty.   Many people are just too poor to purchase enough food, let alone wholesome food. It has been claimed that some pensioners exist largely on dog and cat foods.
  
  

• Ignorance.   This is no respecter of social class. It is a problem of basic education and beyond the reach of the aged.
  
  

• Lack of incentive and isolation.   People living alone and particularly those suffering from chronic disease tend to eat food that needs little preparation. Isolation from the mainstream of life leads to poor eating habits, listlessness, apathy, and desolation.
  
  

• Food Taboos, Habits, and Fads.   Food taboos tend to be religiously based and although all taboos are not bad, many are without logical foundation. They are not a major problem in Western Society.
  
  

• Habits are linked to life-styles..   They continue after the ability to pay for them has left. A need to re-educate the patient about food substitutions exists. Fads are related to social trends, which are frequently short lived and ill conceived. Fads are closely related to food bias.
  
  

• Food Refinement, Storage, Precooking, and Other Preparation..   This entire area is too broad to deal with effectively in this chapter. It relates to nutrition education as much as to poverty and other reasons. The amount of money spent on advertising treated food products would best be put into the food products themselves. There is a phenomenal loss of nutrients in all convenience foods. The geriatric patient should always be encouraged to prepare meals from raw food items. It is not only less expensive but safer and more nutritious. In addition, the creative person will receive satisfaction from the personal involvement.

      Pathophysiologic Concerns

The effectiveness of the physiologic process declines with age, and the advent of disease increases. The transition from one to the other is subtle and often unexplained. That the older patient has more health problems than the younger individual is clearly established. The questions of concern here are twofold: first, what aberrant physiologic processes interfere with patient utilization of food; and secondly, what major disease states create special concerns for the chiropractor in treating the geriatric patient.

Aberrant Physiology.   A particular interest is a lack of gastric and intestinal enzymes to digest carbohydrates, fats, and proteins adequately. Reduced gastric acidity represents this aberration. The older patient is the most likely to have several teeth missing, have poorly fitting dentures, or have advanced dental problems. This problem cannot be ignored. Many instances of malnutrition can be traced to this mechanical problem.

Physical Activity.   Age also reduces activity primarily because of changing life style. The appetite is not stimulated and food intake tends to be reduced to less than adequate levels. Moderate activity should be encouraged.

Allergy.   Food allergies are common and often related to autonomic imbalance.

Anorexia.   Poor appetite is a frequent complaint in the elderly. Although often of organic origin, the most common causes are related to lonely living, listlessness, and boredom or depression related to a feeling of being unwanted. This problem is closely linked to socialization between people where food becomes the vehicle for social interchange, a substitute for love, and even an enhancer of the latter. Dysphagia should be considered in this context as well.

Neurogenic Factors.   These are of the utmost importance to the chiropractic physician. The lines between genetic-induced nutritional deficiency and neurogenic metabolic failure are not always clear. However, it is safe to say that in every failure of GI absorption there is a neurologic component. This is particularly obvious in old age. Every stage of digestion and assimilation is related to nerve activity. Awareness of the function of the autonomic nervous system in the digestion, absorption, and assimilation of food is the responsibility of every DC.

Pathologic States.   These states present such a broad area that only a cursory survey is possible under several headings. See Table 9.6.

Basic Process           Primary  Suspect Disorders                        
Decreased absorption    Congenital biliary atresia    Laxatives
                        Cystic fibrosis               Mineral oil
                        Dysentery                     Regional ileitis
                        Intestinal cancer             Ulcerative colitis
Decreased intake        Anorexia                      Mouth/neck trauma
                        Coma                          Oral/denture problems
                        Dysphagia                     Starvation
Increased loss          Alcoholism                    Polyuria (eg, diabetes)
                        Dialysis                      Sweating (chronic)
                        Diarrhea (chronic)            Tobacco
                        Hemorrhage                    Vomiting (chronic)
Increased utilization   Cancer                        Liver disease
                        Cardiac disease               Pregnancy
                        Diabetes                      Pulmonary disease
                        Hyperthyroidism               Pyrexia
                        Kidney disease

The pathologic state is of extreme importance in considering the nutritional requirements of the patient. It should also be recognized that there is a danger of conflict with the patient's medical practitioner if the DC attempts to overrule or change advice given by the MD. This points to the need for more interdisciplinary cooperation to prevent having the patient in the middle and being the eventual victim.

Chiropractors should, of necessity, become objectively alert to the inherent danger of iatrogenic disease. Chiropractic failures can be expected to be linked more and more with third-party prescribed drug use and the consequent inability of the nervous system to react.


Diagnosis of Geriatric Nutritional Problems and Corrective Procedures

Recognition of a nutritional problem in a busy practice is a diagnostic problem that is more frequently missed than recognized. The problem goes much deeper than this, however, in that far too many health practitioners have had little or no training in nutritional disorders, despite the fact that nutrition is one of the original fields of therapeutics.

Historically, it is reasonable to understand why nutrition has not gained general acceptance from the healing arts. Certainly the definitive deficiency syndromes such as scurvy, beriberi, and rickets are appreciated and cared for, but the more insidious subclinical nutritional disturbances that are increasing are being neglected by the vast majority of practitioners. Medical practitioners are using the tranquilizers and chiropractors the adjustment to resolve what in many instances are true deficiency states. These patients become the old chronics, the neurotics, the malcontents, and the failures.

Many chiropractors are practicing today who began their career before modern nutrition was reasonably accepted. In their battle to gain recognition for basic chiropractic principles, they had little time and no desire to promote other fields. Allopaths have traditionally rejected nutrition because it does not fit into their basic pharmaceutical philosophy. Also, 30 or more years ago, the food situation was not as critical as it is today. The average North American was still able to obtain good, wholesome, natural food so that nutritional problems were only common in large urban areas.

Since World War II, the progressive and insidious march of lower food qualities, refinement, soil deterioration, insecticides, pollution, and a host of other detrimental items has led to a serious reduction of value in food units compared to the same food unit 30 or more years ago. Suddenly, however, we find ourselves faced with a problem not well understood, not enough people experienced to handle the situation, and yet, a desperate need to do something.

As most DCs are aware, contemporary explorers in nutrition are looking into both homeopathy and the megavitamin field for dealing with conditions previously considered not amenable to any form of treatment. The trend will continue, and it is predicted that in time nutritional therapy, including scientific applications of herbology, will surpass the fondest hopes of its advocates.

There has been a great deal of mysticism in diagnosing nutritional problems, as well as many inconsistencies. Regardless, an attempt to give some guidance will be made in later sections of this chapter. It is suggested at the onset that all patients with other than traumatic problems should be considered as having a nutritional component to their problem as well as a neurologic element. This principle is particularly true for the elderly patient and refers back to the previous topic concerning socioeconomic concerns.

      Nutritional Interrogation

Nutritional assessment should be a part of the total health assessment of the patient. Although an interrogation technique must be developed to meet this need, the actual investigation becomes part of the systems review. Once a nutritional component is identified, it should be pursued just as a neurologic, musculoskeletal, or other component is stalked.

Identify the patient's chief complaints; then interrogate the patient in a system review with reference to these complaints. If a complaint is systemic, if the patient complains of many problems, or if the patient is obviously not at ease and symptoms are out of proportion to the complaint, then these other irregularities should be sought. Try to identify a nutritional component.

If the patient has a long history of illness that has not responded to conventional medical or chiropractic care, another search for a nutritional component should be made. The important thing is to be flexible enough to change the usual line of questioning. Again, experience suggests and reaffirms that a large percentage of elderly people has nutritional problems complicating their current problems.

      The Interviewing Approach

In questioning the patient in search of nutritional disturbances, it's necessary to follow a plan. Following is one approach.

Have the Patient Discuss the Typical Daily Diet. This may be accomplished by using a questionnaire or interrogation by a trained assistant. The patient should attempt to identify his intake of various food classes such as fruits, vegetables, meats, cereals, and dairy products. How many meals a day are eaten? Marital status and life-style are also important (see socioeconomic concerns), as is special inquiry into intake of refined carbohydrate. This includes all foods prepared with sugar and white flour. Explain to the patient what is meant by refined. Surprisingly, most people assume all sugar is natural.

Record medications and nutritional supplements used by the patient. Determine what specific foods the patient does not like, finds disagreeable, or avoids for whatever reason (eg, a loss of taste for meat). Seek signs of assimilation problems related to GI disease or abdominal surgery (gastrectomy, cholecystectomy, etc).

Look to the Whole Patient. At this point, the total experience of the doctor comes into play. In the course of consultation and examination, the doctor's awareness of the patient in nonchiropractic terms is necessary. The whole person is affected by his food, not just a part (eg, the spine).

One characteristic of the aging process is the progressive increase in clinical signs and symptoms. What starts as seemingly unrelated manifestations in early life becomes organized into complexes identified as a syndrome or disease in later life. The desirable point at which to interrupt the pattern is early during the amorphous period. Evidence suggests that the course of many degenerative diseases can be significantly altered by even minor changes in dietary habits.

Summary Points:   (1) Nutritional deficiency may alter the behavior of the patient. (2) Nutritional deficiencies usually occur in clusters (involving several nutrients). (3) A disease unrelated to nutrition can affect the nutriture of the patient. (4) Nutritional deficiency signs and symptoms are more frequently covert that overt. (5) Do not wait for obvious deficiencies to manifest themselves before becoming concerned. (6) Every patient deserves nutritional guidance to avoid malnutrition as a contributing factor in disease. Do not assume that the educated patient is well informed about proper nutrition.

      Food for Thought

The following two case histories from an article in Nutrition Today further emphasize the foregoing:

"Two cases with which we are acquainted come to mind. In both of these, well-trained physicians overlooked the possibility of nutritional disease that could easily have been treated. One case occurred under extraordinary circumstances; the other might have been encountered in any daily practice.

"The first example happened last summer when a well-known American adventurer and his wife, bound across the North Atlantic in their 40-foot yawl, sailed into port on the northern coast of Iceland, and the woman went to see a local doctor. She complained of tiredness and lassitude. Her shoes seemed too tight and her teeth ached. The physician apparently did not think women should be making such ocean passages, and quickly concluded there was nothing really wrong that couldn't be cured if she only would go home where housewives belong. While this advice might have seemed sensible, it was not very helpful. However, the sportswoman accepted the conclusion that she was not really sick and sailed on around the island to the capital, Reykjavik. By the time they got there, she was obviously quite ill. In fact, what alarmed her most was that her gums were bleeding. She immediately sought a dentist instead of a physician. The dentist took one look at her mouth and exclaimed, 'Scurvy!.' Two weeks ashore with plenty of fresh foods and fruit juices and she was cured.

"The setting of the second case is more prosaic. It might therefore be considered more pertinent to daily practice in the United States. A middle aged banker told his physician of vague, transient pain, especially in his extremities. He had lost weight; he was fatigued; he had frequent headaches. The only physical signs were a rash on his forearms, perifollicular hemorrhages, and ecchymoses over pressure areas. His teeth had been removed and his gums were unremarkable. Because of his complaints, the man had been referred to a surgeon, who found no reason for surgery; and then to a neurologist who, after a battery of tests, was just as perplexed about the illness as he had been before.

"Here was the man's history: His wife had died the year before. Now he lived alone. Her passing had been very difficult for the lonely man to accept, and he seemed to still suffer from grief when he first sought physicians' assistance. One of the doctors had written 'psychosomatic' on his record.

"Closer questioning about the man's diet revealed that, in his loneliness, he had subsisted on a glass of milk for breakfast, coffee at midmorning, a sandwich (usually a hamburger) for lunch, and for dinner a steak, preceded usually by two or more martinis. He disliked onions, considered potatoes 'fattening,' did not enjoy vegetables, and had no interest in fruits. When finally one of his doctors realized that here was an almost classic picture of scurvy, laboratory studies quickly confirmed the diagnosis.

"This patient was presented at the grand rounds of a famous medical school, and not a few of the attending physicians were surprised at the diagnosis. During the presentation they, like their colleagues who had actually seen the patient, paid little attention to the significant points in the man's dietary history. They had not even considered the possibility of nutritional disease. Rather, most physicians said later, they suspected a collagen vascular disease with a hemorrhagic diathesis. They were all misled by the fact that the man was a banker and 'bankers shouldn't have scurvy.'

"There is a lesson worth remembering in these two examples. We think physicians missed the diagnosis in both cases for one or more reasons: First, both these patients were very well off financially. Physicians, like most other people, think only the poor suffer nutritional disorders. Second, the doctors who saw the banker viewed him solely within the well-defined limitations of their own specialties. Third, overlooking malnutrition, and having confined their search to diseases they knew well, the physicians had neglected to see the patient as a whole."

The elderly patient, in an effort to offset loneliness, depression, and even his bitterness, may try to seek pleasures in other ways such as purchasing an expensive color television, liquor, tobacco, etc, all at the expense of the food budget with which these things compete. Thus, in dealing with the geriatric, it must be kept in mind that malnutrition is an integral part of today's environment.

The consultation and history are the first step in the four sequential paths to follow; the other three being physical examination, necessary laboratory procedures, and therapeutic trial. It is not always necessary that the entire diagnostic process be pursued if the information gathered points clearly to the problem.

Physical Signs of Nutritional Deficiency

The human body can react only in a limited number of ways to signs and symptoms produced by any given irritant. In other words, physical signs are not prima facie evidence that a deficiency exists or, for that matter, that a specific nutrient is absent. Any number of irritants may cause the same physical manifestation.

The World Health Organization has attempted to identify signs significantly associated with nutritional deficiency. Table 9.7 is the outcome of that attempt.

Eyes            Angular palpebritis              Corneal xerosis
                Bitot's spots                    Keratomalacia
                Conjunctival xerosis             Pale conjunctiva
Face            Diffuse pigmentatio              Nasolabial dyssebacia

                Moon-face

Glands          Parotid enlargement              Thyroid enlargement

Gums            Spongy bleeding gums            	

Hair            Dyspigmentation                  Lack of luster
                Easy pluckability                Straightness
                Flag sign                        Thinness and sparseness

Internal        Calf tenderness                  Mental confusion

Systems         Cardiac enlargement              Motor weakness
                Hepatomegaly                     Psychomotor changes
                Loss of ankle and knee jerks     Sensory loss
                Loss of position sense           Tachycardia
                Loss of vibratory sense

Lips            Angular scars                    Cheilosis
                Angular stomatitis

Muscular        Beading of ribs                  Frontal and parietal bossing0
and skeletal    Certain deformities of thorax    Knock-knees or bow legs
systems         Craniotabes                      Muscle wasting
                Diffuse or local skeletal        Musculoskeletal hemorrhages
                deformities                      Persistently open anterior
                fontanelle
                Epiphyseal enlargement (tender
                or painless)

Nails           Koilonychia

Skin            Flaky-paint dermatosis           Petechiae
                Follicular hypertosis            Scrotal and vulval dermatosis
                Pellagrous dermatosis            Xerosis

Subcutaneous    Amount of subcutaneous fat       Edema
tissue

Teeth           Mottled enamel

Tongue          Atrophic papillae                Magenta tongue
                Edema                            Scarlet or raw tongue

Laboratory Signs of Nutritional Deficiency

The laboratory adds the sophisticated element to the diagnostic process. A great deal of empiricism has been recorded in this area that has received questionable acceptance from the health community at large. Muscle testing as a basis for nutritional supplementation is one method in question. There may or may not be validity to this procedure once sufficient research has been made of the hypothesis. Meanwhile, it is wise to stay close to accepted procedures as a guide to diagnosis.

Standardized tests can be made to support a suspicion that a nutritional deficiency exists. The objectives are to decide if intake levels are satisfactory or if adequate absorption occurs. Most of these tests are not competently performed in the small practice unless the practitioner is specially trained and currently knowledgeable of acceptable laboratory procedures. A considerable investment in equipment is also necessary.

It is important to realize that no test is specific for a particular type of malnutrition. Blood and urine (infrequently feces or hair) offer the only suitable media for analyses and even these can be nondefinitive because the range of values for their constituents in healthy individuals varies widely. Variables are also introduced by the conditions of collection, storage, preparation, and technique of analysis. We also know that blood levels do not always parallel tissue levels.


      Blood and Serum Tests

The following tests are used to a greater or lesser degree to support a diagnosis of malnutrition. The glucose tolerance test is not listed, but it is of such importance that each practitioner should be fully familiar with its use and interpretation.

Red Blood Cell Count and Hematocrit. Macrocytosis may indicate lack of B-12, folate, and possibly vitamin E. Microcytosis may reflect a deficiency of iron or vitamin B-6.

Hemoglobin and Hematocrit.   Hypochromia may indicate an iron shortage.

Serum Iron.   Iron may decrease below 60 micrograms/100 ml serum after stores are depleted. Levels are high in liver disease and hemochromatosis, and low in anemia of infection (due to decrease in iron-binding capacity). The normal adult range is 50--175 mcg/dL.

Serum Iron-Binding Capacity (IBC).   Serum IBC is increased in iron deficiency unless protein synthesis is depressed. Normal IBC is 250--410 mcg/dL serum. It is decreased in saturation to less than 18% in iron deficiency (normal range is 20%--55%).

Serum Albumin.   Serum albumin is reduced if protein consumption and utilization are low or if there are abnormal exogenous losses, but it is not an early indicator of deficiency. Values below 3.5 g/100 ml serum are subnormal and indicate protein deficiency.

Serum Vitamin A.   Vitamin A values in serum are decreased if intake of green and yellow vegetables have been low, sources of preformed vitamin A have been inadequate, or a malabsorption state exists. Values below 20 micrograms/100 ml serum are low. A level below 10 micrograms/100 ml indicates severe depletion.

Serum Beta Carotene.   The significance here is similar to that of vitamin A. Inadequate intake of green and yellow vegetables are indicated by values in adults of less than 80 micrograms/100 ml serum. In deficiency states, this falls to 30 micrograms/100 ml. Values may be high in myxedema, hyperlipemia, and carotenemia.

Plasma Vitamin E.   Deficiency of vitamin E can result in creatinuria associated with plasma levels below 0.4 mg/100 ml. Low values are encountered in malabsorption states.

Serum Vitamin C.   Serum levels reflect current intake of vitamin C. Serum values below 0.3 mg/100 ml indicate far inadequate intake; values below 0.01 mg/ml are consistent with a diagnosis of scurvy.

Serum Vitamin B-12.   Serum B-12 values are decreased in pernicious anemia, malabsorption syndromes, and when intake is low (vegans). Normally, values are more than 70 millimicrograms/ml serum.

Serum Folic Acid.   Values of serum folic acid are decreased in malabsorption syndromes and dietary deficiency. Serum levels reflects recent intake. Levels below 7 millimicrograms/ml reflect subnormal intake; 3.0 millimicrograms or less, overt deficiency. Red cell folate decreases in prolonged deficiency.

Alkaline Phosphates.   Alkaline phosphatase values are elevated in rickets and osteomalacia. Values reflect osteoblastic activity, thus suggesting failure of bone calcification. Normal: 2--5 Bodansky units/100 ml.

      Excretory Tests

Creatinine.   The level of creatinine excretion is related to muscle mass. Consistency of excretion makes this a convenient reference unit for expression of urinary excretion values. The ratio of creatinine to centimeters of height may serve as an index of musculature. The creatinine/creatine ratio is useful in detecting vitamin E deficiency in which creatinuria occurs.

Iodine.   Excretion reflects intake. Values below 50 micrograms/g of creatinine suggest inadequate iodine intake.

N-Methylnicotinamide.   Excretion decreases when intake of niacin (and tryptophan) has been inadequate. Values of less than 1.6 mg/g creatinine are encountered in inadequately nourished subjects.

Riboflavin.   Excretion is decreased when intake of riboflavin is insufficient. Levels below 80 micrograms/g of creatinine in adults indicate low or deficient intake. In children under 6 years of age, levels below 300 micrograms/g of creatinine are subnormal.

Thiamine.   Excretion decreases rapidly with lowered intake. For adults, values below 66 micrograms/g of creatine indicate low or deficient intake; for children under 6 years of age, 120 micrograms/g of creatinine.

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