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AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS and Roger Williams Ph.D. Dr. Pauling, Nobel Prize winner for Chemistry in 1954 and Peace in 1962, was already teaching about the importance of nutrients in modulating physiological processes at the biomolecular level. Roger Williams, Ph.D is credited with developing the concept of biochemical individuality and has been described as having ‚contributed to the evolution of the understanding of the molecular origin of disease‛ (1). The catalyst for the development of present-day nutritional genomics has been the Human Genome Project, a multinational undertaking that began in 1990. While there were a number of goals, the primary goal was to identify the nucleotide sequence of the human DNA. However, the specific goals have changed over time since the Human Genome Project was completed in 2003, earlier than expected. Current research is focused on identifying the total number of genes, their chromosomal location, and their function (2). Why is this important to the dietitian? One reason may be because the impact of the Human Genome Project has created new information that is expected to alter the approach to risk assessment of nutritional issues. However, the dietitian’s evolving role in the application of nutritional genomics to clinical practice will require a deepened understanding of genomics, gene-diet interactions and its applications to clinical nutrition practice to occur effectively (3). Fogg-Johnson and Kaput explain that some of the new information of the Human Genome Project is surfacing in areas that are not totally predictable. Through the Human Genome Project, it has been discovered that individual gene variations exist and are referred to as single nucleotide polymorphisms (SNPs, pronounced ‚snips‛). These SNPs result in differential response to environmental factors, such as diet. The science of how naturally occurring chemicals in foods alter expression of genetic information at the molecular level and how this effects the individual phenotype is the essence of what nutritional genomics scientists seek to uncover (4). As investigators learn how different individuals metabolize substances based on genetic uniqueness, there is an increasing awareness of the important roles specific nutrients can play in modifying the expression 86 2012 of metabolic patterns in the individual. Diet, lifestyle, and environment have significant influence on the way an individual can metabolize specific substances based upon his or her genetic uniqueness. These discoveries have opened the door for the future of molecular medicine and the development of a personalized medicine that recognizes aspects of diet, lifestyle, and environment and their roles in individual disease causation and the design of specific intervention programs. The takeaway from these concepts is that one size does not fit all. Diet and nutritional intervention must be personalized to the genetic characteristics of the individual. Gastrointestinal health is particularly important to achieving optimal nutrition and affords several examples of how diet and genes interface and how the field of nutritional genomics can assist the registered dietitian (R.D.) in maximizing nutrition care interventions for the individual. The Healthy Gut The gastrointestinal (GI) tract is the second largest body surface area. The condition of this organ and the maintenance of its uniquely balanced microflora is essential to optimal health (5). The healthy intestinal wall is coated with hundreds of different species of microorganisms, both beneficial and pathogenic bacteria numbering in the trillions (5). This rich protective coating of microorganisms acts in concert with the physical barrier provided by the cells lining the intestinal tract and other factors to provide the body with important filter-like protection. So, in addition to digesting, absorbing and eliminating food substances and nutrients, the normal GI tract functions as a critical semi-permeable (selective) barrier between the internal and external environment. This prevents toxic, antigenic or pathogenic molecules or microorganisms from entering the bloodstream (6). Ultimately, the importance of the intestinal microflora and, more specifically, its composition, in physiological and pathophysiological processes in the human GI is becoming more evident (6). Inflammatory Bowel Disease Inflammatory bowel disease (IBD) is a critical and chronic disorder of the intestines. Generally, its complications can be severe, widespread and very
AAPI’S NUTRITION GUIDE TO OPTIMAL HEALTH: USING PRINCIPLES OF FUNCTIONAL MEDICINE AND NUTRITIONAL GENOMICS painful. Crohn's disease (CD) and ulcerative colitis (UC) are two forms of inflammatory bowel disease (IBD). As researchers try to understand the long unknown etiology of CD, there does not appear to be one precise cause of CD. However, it is clear that CD is relapsing in nature and it affects all layers of the intestines from mouth to anus. In comparison, UC is generally limited to the large bowel and does not necessarily affect all layers of the intestine The anatomical location and behavior of CD can change over time. At diagnosis, the disease is located in the terminal ileum in 47%, the colon in 28%, the ileocolon in 21% and the upper GI tract in 3% of cases, respectively (7,8). ‚Patches‛ of asymmetrical intestinal inflammation and ulceration are seen in CD, interspersed between areas of healthy tissue (9). The inflammation and ulceration can potentially extend deeply into the intestinal wall, forming granulomatous lesions. The clinical presentation of patients diagnosed with CD is largely dependent on disease location. It can include some or all of the following symptoms: frequent diarrhea; lower right quadrant abdominal pain appearing soon after meals; bowel obstruction; fatigue; weight loss; low appetite; fever; stomatitis; passage of blood, mucus or both; and perianal fistulae or fissures. 87 2012 Some patients also present with arthritis and erythema nodosum lesions on the extremities. Failure to thrive is observed in 75% of pediatric CD patients (10). Approximately 10-15% of patients with disease confined to the colon and rectum present with ‚indeterminate colitis‛, in which the clinician is unable to definitively distinguish between ulcerative colitis and Crohn's disease (9). In such cases, blood tests that detect autoantibodies for "perinuclear anti-neutrophil antibody" (pANCA) and "anti-Saccharomyces cerevisiae antibody" (ASCA) are used to assist with a differential diagnosis (9). Frequently, those with UC present with the pANCA blood antibodies, while those with CD present with the ASCA antibodies. Although not every individual with UC and CD fits ‚neatly‛ into this profile, this approach is often helpful in distinguishing the two types of IBD (9). In 1932, a group of three scientists, Ginzburg, Oppenheimer and Dr. Burrill B. Crohn, published a paper describing the features of an inflammatory bowel disease that was ultimately named Crohn’s disease in honor of Dr. Crohn (9). Several categories of CD have been described, defined by the portion of the digestive tract involved and the presenting symptomatology (Table 1). Table 1. Subcategories and Symptoms of Crohn's Disease (9) SUBCATEGORY AREAS AFFECTED Crohn's (Granulomatous) Colitis Affects the colon only. Symptoms include diarrhea, rectal bleeding, and disease around the anus (abscess, fistulas, ulcers). Skin lesions and joint pains are more common in this form of Crohn's than in others. Gastroduodenal Crohn's Disease Affects the stomach and duodenum. Symptoms include loss of appetite, weight loss, and nausea. Vomiting may indicate that narrowed segments of the bowel are obstructed. Ileitis Affects the ileum. Symptoms same as ileocolitis. Complications may include fistulas or inflammatory abscess in right lower quadrant of abdomen. Ileocolitis The most common form of CD, affecting the ileum and colon. Symptoms include diarrhea and cramping or pain in the right lower part or middle of the abdomen. Often accompanied by significant weight loss. Jejunoileitis Produces patchy areas of inflammation in the jejunum. Symptoms include abdominal pain
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