Table Of ContentP N
REVENTIVE UTRITION
Fourth Edition
Nutrition and Health
Adrianne Bendich, PhD, FACN, Series Editor
Forfurthervolumes:
http://www.springer.com/series/7659
P
REVENTIVE
N
UTRITION
The Comprehensive Guide
for Health Professionals
Fourth Edition
Edited by
Adrianne Bendich, p .d., facn
h
GlaxoSmithKline Consumer Healthcare,
Parsippany, NJ
and
Richard J. Deckelbaum, md,
frcp(c)
Columbia University, Institute of Human Nutrition,
New York, NY
Foreword by
Alfred Sommer, md, mhs
Johns Hopkins Bloomberg School of Public Health,
Johns Hopkins University,
Baltimore, MD
Editors
AdrianneBendich RichardJ.Deckelbaum
GlaxoSmithKlineConsumerHealthcare InstituteofHumanNutrition
1500LittletonRoad ColumbiaUniversity
630West168thSt.
Parsippany,NJ07054
NewYork,NY10032
USA
BHN7-702
[email protected] USA
[email protected]
ISBN978-1-60327-541-5 e-ISBN978-1-60327-542-2
DOI10.1007/978-1-60327-542-2
LibraryofCongressControlNumber:2009934689
©HumanaPress,apartofSpringerScience+BusinessMedia,LLC1997,2001,2005,2010
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Dedication
ABdedicatesthisvolumetohercoresupportteamwithdeepestgratitude:David,Debbie,Debra,
Elaine,Harriet,Jacob,John,Jorden,Oscar,Rebecca,andTyler.
RJDdedicatesthisvolumetoallhisstudents,fellows,andcolleagueswhohavehelpedhim
understandtheinterdisciplinaryrequirementsfortranslatingbasicnutritionscienceintopolicy,
actions,andprograms.
v
Series Editor Introduction
The Nutrition and Health Series of books has, as an overriding mission, to provide health profes-
sionalswithtextsthatareconsideredessentialbecauseeachincludes(1)asynthesisofthestateofthe
science;(2)timely,in-depthreviewsbytheleadingresearchersintheirrespectivefields;(3)extensive,
up-to-datefullyannotatedreferencelists;(4)adetailedindex;(5)relevanttablesandfigures;(6)iden-
tification of paradigm shifts and the consequences; (7) virtually no overlap of information between
chapters,buttargeted,inter-chapterreferrals;(8)suggestionsofareasforfutureresearch;and(9)bal-
anced, data-driven answers to patient/health professionals’ questions that are based upon the totality
ofevidenceratherthanthefindingsofanysinglestudy.
The goal of the Series is to develop volumes that are adopted as the standard text in each area of
nutritionalsciencesthatthevolumereviews.EvidenceofthesuccessoftheSeriesisthepublicationof
second,third,andevenfourtheditionsofmorethanhalfofthevolumespublishedsincetheNutrition
and Health Series was initiated in 1997. The series volumes that are considered for subsequent edi-
tionshaveclearlydemonstratedtheirvaluetohealthprofessionals.Neweditionsprovidereaderswith
updatedinformationaswellasnewchaptersthatcontainrelevantup-to-dateinformation.Eacheditor
of new and updated volumes has the potential to examine a chosen area with a broad perspective,
both in subject matter and in the choice of chapter authors. The international perspective, especially
withregardtopublichealthinitiatives,isemphasizedwhereappropriate.Theeditors,whosetrainings
are both research and practice oriented, have the opportunity to develop a primary objective for their
book, define the scope and focus, and then invite the leading authorities from around the world to be
part of their initiative. The authors are encouraged to provide an overview of the field, discuss their
ownresearch,andrelatetheresearchfindingstopotentialhumanhealthconsequences.Becauseeach
book is developed de novo, the chapters are coordinated so that the resulting volume imparts greater
knowledgethanthesumoftheinformationcontainedintheindividualchapters.
Preventive Nutrition: Fourth edition is very special for me and my coeditor, Dr. Richard
Deckelbaum.Eachofthevolumes’TableofContentsisincludedintheAppendixastherehavebeen
manycontributorstothepriorvolumes,andwehaveaddednewtopicsastheseemergewithfindings
thatarerelevanttohealthprovidersandtheirpatients,clients,and/orfamilymembers.Theoverarching
goal of the volumes is to provide readers with the most up-to-date and comprehensive review of the
stateofthescienceineachchapterandthentointegratetheinformationsothatthesynergiesbetween
chaptersarevisible.Theoverridingdriverforthetimingofthefourtheditionwasthepublishingofthe
resultsfromtheWomen’sHealthInitiative(WHI),thelargestplacebo-controlledinterventionstudyin
postmenopausalwomeneverundertaken.Twochaptersinthisvolumereviewthefindings.Thedietary
modification component of WHI examined outcomes for coronary heart disease and breast and col-
orectal cancer and the calcium and vitamin D arm looked at osteoporotic fracture risk and colorectal
cancer risk. In addition to the WHI results, there are several new chapters that expand the scope of
thevolume,includingachapteronhumandeficiencyvirus(HIV)infectionandhowthisaffectsnutri-
tional status; a chapter on econutrition, two on cancers of the female and male reproductive systems;
two new chapters examine the role of micronutrients and brain functions such as cognitive functions
anddementiaandanotheronpsychiatricconditions.Therearefournewchaptersintheareasofobesity
anddiabetes;anewchapterongastricacidlevels,treatments,andnutritionalconsequences;achapter
vii
viii SeriesEditorIntroduction
describingtheroleofthefoodindustryinpreventivenutrition,andafinalchapterforpracticinghealth
providersconcerningwaystosupportpatientsinmakingpermanent,beneficialchangesintheirdiets.
ThefirstchapterinthesectiononGlobalIssuesbeginswiththethoughtfulsynthesisbyDr.Walter
Willett ofwellover100epidemiologicalandinterventionstudiesthatprovidethebasisforapositive
public health perspective on the importance of preventive nutrition strategies. The following chapter
attempts to estimate the value, in dollars and cents, of currently accepted preventive nutrition strate-
gies. Econutrition, a new chapter, is relevant to determining how food intakes can be improved in
developing nations where food insecurity and undernutrition remain critical issues. Although it is
difficulttodevelopandconductstudiesontheeffectsofagrodiversityprograms,theauthorshavetab-
ulatedtheresultsofinterventionsaroundtheglobeandthetotalityoftheevidencepointstothevalue
of these programs for the health of the communities. Econutrition is equally relevant in developed
nations as fuel costs increase, food security issues become more prevalent, and the concept of con-
suming locally grown produce and locally manufactured foods is being embraced. The final chapter
inthissectionprovidesanin-depthexaminationofthepotentialeffectsofdrugsonnutritionalstatus,
includingabsorption,metabolism,andexcretionofbothmacro-andmicronutrients.Thisencyclopedic
chapter,withmorethan300references,containsnumeroustableswithpracticallistingsofinteractions
between drugs and food intake and disposition, drugs that affect body weight, drug-induced changes
in blood glucose levels, drugs that alter specific vitamin levels and those that alter macro and trace
mineralstatus.
ThesecondsectionexaminestheimportanceofPreventiveNutritiontoprimaryandsecondarycan-
cer prevention. The chapter on diet and childhood cancers updates the findings from the first edition
andconcludesthatthisarearemainsonewherethedatafromsurveystudiesaresuggestive,butnotas
yetconclusiveconcerningthebenefitofmultivitaminuseduringpregnancyandreducedriskoftwoof
themajorchildhoodcancers,leukemia,andbraintumors.Thereisaninsightfulevaluationofthedif-
ferencesbetweenthetimingofcancerdevelopmentinchildhood,especiallyyoungchildhoodcancers
versus adult cancer development. Virtually all the epidemiological studies of maternal diet, supple-
ment use, and major childhood cancers have been tabulated for the reader. Gastric and esophageal
cancers are closely related to lifestyle factors, including alcohol and tobacco use; chronic consump-
tionofveryhotliquids;salted,pickled,andsmokedfoods;andobesity.ThelinkbetweenHelicobacter
pylori infection, lifestyle factors and diet, and development of gastric and esophageal cancers is dis-
cussedindepth;treatmentguidelinesforH.pyloriareincluded.Eventhoughgastriccancerincidence
has fallen in the last 30 years, esophageal cancer and precancerous lesions have increased, and the
studies of dietary factors that may reduce the risk of these cancers are outlined in informative tables,
and the chapter includes over 200 references. The next two chapters review the major cancers of the
femaleandmalereproductiveorgans.Breastcanceristhemostcommoncancerinwomenworldwide.
As with all adult cancers, the incidence of breast and ovarian cancer increases with age. The chap-
ter reviews the genetics, lifestyle factors, obesity and importance of exercise, female hormone status,
otherhormonalconsiderationsincludinginsulinlevels,anddietarycomponentsincludingthosefound
in fruits and vegetables and phytoestrogens. Prostate cancer is among the most prevalent cancers in
men, and the incidence appears to be directly related to environmental factors as there is a 60-fold
difference in prostate cancer rates between black men in the United States and Japanese and Chinese
menintheirnativecountries.Theincidenceincreaseswithageandprostatecancerisacommoncause
ofdeathindevelopednations.Manydietarycomponentshavebeenassociatedwithdecreasedriskof
prostate cancer, including tomatoes and carotenoids in tomatoes, vitamin E, and selenium, yet inter-
ventiontrialshavenotshowndecreasedriskwhenthesenutrientshavebeenprovidedassupplements.
The chapter includes in-depth discussion of these nutrients as well as dietary fats, soy and phytoe-
strogens,dairyproducts,vitaminDandcalcium,cruciferousvegetables,andzincwithrespecttoboth
SeriesEditorIntroduction ix
surveydataandinterventionstudyfindings.Thelastchapterinthissectionreviewstheuseofdietary
supplements and their association with reduction in certain cancer risks as well as the increased risk
seen with beta-carotene supplementation in cigarette smokers. Supplements reviewed include beta-
carotene, vitamins C and E, selenium, calcium and folic acid, as well as multivitamins. The chapter
providesthereaderwithcriticalinformationaboutthedifficultiesincollectinginformationaboutuse
ofdietarysupplements,thetimingoftheiruse,andthemotivationforusebeforeorafterdiagnosisof
cancer.
Cardiovascularandcerebrovasculardiseasesarethefocusofthethirdsection.Long-chainomega-3
fatty acids (LC PUFA) have been associated with reduced risk of CVD in survey studies for the past
50years,andthepotentialmechanismsforreductioninriskcontinuetobeelucidated,butincludeanti-
inflammatory,antiarrhythmicandantiproliferativeactionsatthecellularlevelandbeneficialalterations
in lipid profiles, especially triglycerides. This chapter contains a detailed description of the effects of
LCPUFAonlipids,lipoproteins,triglycerides,apolipoproteinlevels,turnover,andmetabolism.New
dataontheroleofLCPUFAindiabeticsarealsoincluded.LCPUFAareexamplesof“goodfats.”The
nextchapterdescribestheadverseeffectstothecardiovascularsystemcausedbytransfats,examples
of “bad fats.” The majority of trans fats are found in foods that contained hydrogenated oils or con-
tainedfatsthatwentthroughotherproductionprocessesthatresultedintheirformation.Theconcen-
trationoftransfatsinprocessedfoodsintheUnitedStatesandEuropehassignificantlydecreasedover
the past few years. Nevertheless, trans fats are still part of the diets, as these are formed when foods
are fried or when hydrogenated margarines are used in baked goods or in other foods. The adverse
effectsmaylastovermanyyears.Theeffectsoftransfatsonlipidmetabolism,lipoproteinoxidation,
platelet aggregation, inflammatory actions, endothelial function are discussed, and excellent figures
areincludedtohelpthereaderunderstandthecomplexitiesoftransfatmetabolism.Thenextchapter
comprehensively reviews the areas of antioxidants and B vitamins and atherosclerosis. Atherosclero-
sis is the major cause of cardiovascular disease (CVD) and oxidative damage and inflammation of
the arteries are the primary mechanisms of action. Both the survey studies and the intervention data
fromprimaryaswellassecondarypreventionstudiesarereviewedfordietaryaswellassupplemental
intakesofvitaminsEandC,beta-carotene,andBvitamins.Arterialimagingtrialsusingangiography
andultrasoundinsupplementedpatientsareincluded,andthenewareaofnutragenomicsisdiscussed.
There is also a complete listing of the ongoing trials with antioxidants and/or B vitamins, and four
comprehensive tables of all the past trials are provided for the reader. The final chapter examines the
roles of the B vitamins in the prevention of cognitive decline and vascular dementia. Of note, stroke
mortalityhasdeclinedsignificantlyintheUnitedStatesandCanadapostmandatoryfolatefortification.
B vitamins are required for DNA synthesis,neurotransmitter metabolism andmaintenance of normal
homocysteine levels. Higher than normal homocysteine levels may damage brain tissues including
the vasculature. The chapter includes an extensive review of the functions of folate, vitamins B6 and
B12 and discusses the clinical study results that suggest that B vitamin status may affect age-related
cognitivedeclines.
Obesity is the major risk factor for type 2 diabetes and increases the risk of CVD, some cancers,
arthritis,andmanyotherchronicconditions.Oneofthecriticalfactorsthatledtothedevelopmentof
thefourtheditionofPreventiveNutritionwastheconclusionoftheWomen’sHealthInitiative(WHI)
that included the major clinical study of the potential for reduction in fat intake to reduce CVD risk
andriskofcancerofthecolonandbreast.Althoughthiswasnotplannedasanobesitystudy,74%of
women in the study were overweight (36%) or obese (38%). About 34% of the women self-reported
that they had metabolic syndrome yet only about 4% were using pills or other medications to treat
diabetes. All five chapters in this section on obesity and diabetes are new. The chapter that describes
the WHI study and its findings was written by investigators who were part of the study and thus this
x SeriesEditorIntroduction
important chapter provides insights into the difficulties in enrolling subjects and maintaining their
enthusiasmforabout9years.Thefiguresandtablesincludedinthechapterareexcellentresourcesfor
anyone who wants to know more about this landmark study, and the chapter serves as an important
introduction to the next four chapters that deal in depth with diabetes and obesity. The next chapter
includes a detailed description of the development of diabetes and provides the health professional
with an overview of carbohydrate metabolism, insulin resistance, the guidelines for the diagnosis of
prediabetes,metabolicsyndromeandtype2diabetesaswellasnutritionalstrategiesforthetreatment
ofprediabeticstatesandpreventionofdiabetes.
Thereisacriticalreviewofthefindingsfromhighfatversuslowfat,highcarbohydratedietstudies;
pharmacologicalstudies;studieswherethetypesoffatsarealtered;andstudieswherethetypesofcar-
bohydratesarealtered.Geneticsisalsodiscussedandanimportantdiscussionofgene–environmental
interactionsisincluded.Type2diabetesincidenceincreaseswithageasindicatedbythefactthatmore
than 40% of those with diabetes are over 65 years and over 15% are over age 75. Moreover, the risk
of co-morbidities associated with diabetes including diabetic retinopathy, peripheral vascular disease
and CVD, and renal failure increases with age. The chapter provides guidelines for dietary intakes
to help control insulin levels as well as information about medication use, special nutrition inter-
ventions, hypoglycemia, and depression. The next two chapters are new to the volume and include
the latest data on the biology of obesity and a chapter that describes the growing problem of obe-
sity in developing nations and potential ways to address the problem. Obesity is now considered a
disease that includes a chronic state of inflammation, and adipose tissue is the site of synthesis of
numerous cytokines (adipokines) that are pro-inflammatory. There is an in-depth chapter that thor-
oughlydescribesthesignificantinteractionsbetweenwhiteadiposetissueadipokines(includingleptin,
adiponectin,resistin,visfatin,andadipsin)andtheimmunecellsandcytokines(includinginterleukin-
6 and tumor necrosis factor) involved in the inflammatory process. Consequences of this interaction
include an inflammation-mediated dysregulation of insulin synthesis, insulin resistance, and type 2
diabetesultimately.Thenextchaptercontainsanin-depthdiscussionoftheinteractionsbetweentran-
sitionsin dietsandfoodavailability, workenvironments,political priorities, andtheeffectsonhealth
outcomes in developing countries. The chapter reviews the consequences of national initiatives that
have worked in the past to reduce obesity, and consequent cardiovascular disease risk by altering the
typesoffatsthatareconsumedthroughtaxationandothergovernmentprograms.Focusisplacedupon
thepotentialfortheeducationalandthemedicalcommunities’guidanceforthepoliticalleadershipin
thetransitiontomorehealthydietsandlifestyles.
The fifth section examines strategies for prevention of major disabilities, including osteoporosis,
gastric acid dysfunction, age-related eye diseases, and nutritionally related immune depression in the
elderlyandinotherat-riskgroups.TheeffectsofcalciumandvitaminDsupplementationonfracture
risk in the WHI trial are reviewed as are new clinical and epidemiological studies linking vitamin
D to bone and other functional outcomes. Nutrients examined include calcium, vitamin D, protein,
phosphorous, magnesium, vitamin K, trace minerals, as well as overall diet. Requirements for the
nutrientsthroughoutthelifecycleareincluded.ThelimitedpositivefindingsfromtheWHIareplaced
in perspective, and valuable discussions of drug-induced risk factors for fracture that impact nutrient
status are also included. The next chapter looks at the role of the stomach, gastric acid secretions,
and the effects of reduced acid secretion on absorption of essential nutrients. This is an important
new chapter as millions of adults and children are treated for acid reflux problems, and the condition
as well as the treatments can alter bioavailability of certain nutrients. Recent epidemiological studies
haveshownanassociationbetweentreatmentofgastricacidrefluxdisease(GERD)withgastricacid
suppressive drugs and altered nutritional status that may be related to increased risk of fractures and
infections.
