疾病营养运动

疾病-运动-营养病例多数1岁左右/以下、散发、表现类似常见呼吸道、皮肤等感染性疾患脸胖、身上瘦，生长迟缓体检：浮肿喂养历史：化验：病例全身播散性出血点四肢严重有牙龈肿胀出血伤口不易愈合；在受压处出现瘀斑肌肉、关节内可有大量出血海地的孩子极度贫困环境年龄稍大，已停止母乳喂养饮食史体检化验病例常见食物维生素B1,B2含量(mg/100g)

名

称B1B2名

称B1B2籼稻米(糙)0.180.06芦柑0.020.03稻米(上白)0.090.05苹果0.020.2小麦粉(标准)0.280.08花生仁0.720.12小麦粉(富强)0.170.06葵花籽0.430.20燕麦片0.300.13猪肉(瘦)0.540.24小米0.330.10猪肝0.212.08黄豆0.410.20羊肉(瘦)0.150.16大白菜0.020.03牛乳0.030.14茴香0.090.80鸡蛋0.130.32病例美国叶酸面粉强化USFoodandDrugAdministrationregulationin1996requiringthatallflouranduncookedcereal-grainproductsintheUnitedStatesbefortifiedwithfolicacid(140g/100g)byJanuary1998(8).MandatoryfolicacidfortificationwasalsoimplementedinCanadain1998(9)andinChileasignificantreduction(15–50%)inNTDsintheUnitedStatesasignificant(60%)reductionintheincidenceofneuroblastoma(from1.57casesper10000birthsin1996to0.62casesper10000birthsafter1997,whenfolicacidfortificationoffoodbecamemandatoryinCanadaHowever,itisimpossibletodefinitelyattributethedecreaseintheincidenceofNTDsintheUnitedStatessolelytofortification(24)becauseNTDratesintheUnitedStates(andworldwide)weredecreasingevenbeforefortification

began,possiblyasaresultoffactorssuchasimprovednutritionorprenataldiagnosisandtermination.folicacidfortificationmaymasksymptomsofvitaminB-12deficiency,primarilyintheelderlypopulation,havebeenraisedchildrenwithacuteleukemiatreatedwithfolatesupplementationexperiencedanacceleratedprogressionofleukemiasomeEuropeancountrieswasevenlabeled

aspublichealthmalpracticeAmJClinNutr2004;80:1123–8结肠癌患病率NationwidefortificationofenricheduncookedcerealgrainswithfolicacidbeganintheUnitedStatesandCanadain1996and1997,respectively,andbecamemandatoryin1998.Therationalewastoreducethenumberofbirthscomplicatedbyneuraltubedefects.Concurrently,theUnitedStatesandCanadaexperiencedabruptreversalsofthedownwardtrendincolorectalcancer(CRC)incidencethatthetwocountrieshadenjoyedintheprecedingdecade:absoluteratesofCRCbegantoincreasein1996(UnitedStates)and1998(Canada),peakedin1998(UnitedStates)and2000(Canada),andhavecontinuedtoexceedthepre-1996/1997trendsby4to6additionalcasesper100,000individuals.CancerEpidemiolBiomarkersPrev2007;16(7):1325–9CancerEpidemiolBiomarkersPrev2007;16(7):1325–9癌变过程Clinicalcourseofepithelialtumorsovertime,fromtheintraepithelialneoplasiastagetometastases.Modi.edfromGoetal.(5).碘缺乏与碘盐强化政策严重的缺碘可引起成人的地方性粘液性水肿和婴儿的地方性呆小病。严重的母亲缺碘，阻止胎儿的生长和脑发育。地方性呆小病根据缺碘和遗传的相互作用可见两种形式中之一（神经性或粘液水肿性）鉴别：甲状腺激素合成中几种代谢性障碍能引起成人和婴儿的甲状腺功能减退。地方性缺碘仍然是甲状腺功能减退的主要原因。当碘化物摄入量大于每日需要量的20倍即每日2mg时即可发生慢性碘中毒。在某些地区，尤其在日本，居民每日摄入量多达50~80mg，引起血浆水平高。这些人当中的有些人发生甲状腺肿，但大多数甲状腺功能仍正常。有些人则发生粘液性水肿，而另一些人则反常地发生甲状腺功能亢进（Jod-Basedow现象）。甲状腺对碘的摄入增加可导致甲状腺激素合成的抑制（Wolff-Chaikoff效应），最终引起碘甲状腺肿或粘液性水肿。极高剂量的碘化物，似黄铜色的爱好可产生唾液分泌增加，胃部刺激和痤疮样皮肤损害克汀病；碘性甲亢碘强化盐……《中国碘盐风险评估2010》个体营养素需要量的差异个体营养需要量RNIEAR碘盐与甲状腺癌NEnglJMed2014;371:1765-1767韩国甲状腺癌患病率与死亡率：from1993to2011,theincidenceofthyroidcancerincreasedabout15-fold,fromlessthan5per100,000populationtoalmost70per100,000;thyroidcancermortalitywasnearlyaflatline—justabove0per100,000—androseverylittle.中国碘盐20-30mg/kg，每日300(200-400)μg85120600μg/d单纯性营养素缺乏VC与坏血病、叶酸与神经管畸形、pp与赖皮病、VD钙与佝偻病原发性供给不足：膳食供给绝对不足/生理需要相对增加继发于病理性吸收差、破坏多、利用障碍、丢失增加认知性营养素缺乏维生素缺乏病的原因食物结构：船员与坏血病、玉米与癞皮病、志愿军阴囊炎、巨幼红细胞贫血食品加工：大米反复淘洗与脚气病环境因素：日照与佝偻病生理病理条件：妊娠、先天性含硫氨基酸代谢障碍很多症状不特异，化验指标受条件限制，膳食、环境、病史综合考虑营养缺乏病的诊断和治疗缺蛋白质／热能

－缺B1－缺B2－缺pp－缺叶酸

－缺C－缺A－缺D－缺碘

－缺硒

－缺铁

－缺钙

－病史（疾病、环境）症状体征实验室…检查膳食史膳食调查食物品种食物摄入量营养素含量膳食评价代表性治疗反应骨质疏松造成骨小樑结构损伤Bonesinwhichtrabecularbonepredominatesareparticularlyvulnerabletoosteoporoticfracture.Becauseofthebones'largesurfaceareasrelativetotheirvolume,thinnedtrabeculaeareparticularlysubjecttoresorption.Shownisascanningelectronmicrographoftrabecularbonefromahealthywoman(topleft)andawomanwithosteoporosis(topright).Thetrabeculaeethinnerinosteoporosis,andeventuallyarelost,reducingbonestrength.Inadvancedosteoporosis,trabeculaemaybecompletelyresorbedsothatthecontinuityofthetrabecularlatticeislost(bottom).Lossofstrutsofthelatticedramaticallyreducesbonestrength.缺钙使然？若700／770／797，缺与不缺？膳食／身体缺？膳食1天／周／月／年缺，可造成身体缺？膳食／身体缺表现？800补钙的风险每日500mg钙补充剂以上，急性心血管事件增加30%。（RCT荟萃）——BMJ2010;29;341:c3691摄入钙主要来自于补充剂者心梗两倍于不补钙者（2.4万人11年队列）——Heart

2012;98:920-925每日补钙1000mg男性，对比不补钙者，心血管病死亡率增加20%（39万人12年队列）——JAMAInternMed2013;DOI:10.1001血钙水平与腹主动脉钙化程度相关（1471绝经后妇女1克/日补钙5年）——JBoneMinRes;25,2010,2777–2785USPSTF：补充VD和钙不能预防骨折，每天400iuVD和1000mg钙轻度增加肾结石风险——AnnInternMed2013

onlinefirst饮食中的钙不增加肾结石的风险，还具有保护作用；钙补充剂在一定条件下可能具有促进肾结石形成的作用，肾结石病史者特别要警惕。——IOM《DietaryReferenceIntakesforVitaminDandCalcium》2011

营养与慢病Whenrequirementsareestimatedtodecreaseriskofdisease,particularlychronicdisease,associationsmaynotbeeasilyidentifiedinshort-termstudies.Further,theAIsdevelopedinthisreportmaybeattheupperrangeofintakestypicallyfoundinnationwidesurveysifthecriterionorechoseninvolveschronicdisease.Theimplicationwouldbethatitmightbedesirabletoachieveanincreaseinthemeanintakeofthepopulationinordertolowerrisk.However,thequantitativeaspectisuncertainbecauseoftheapproximatenatureoftheAIandlimitationsoftheepidemiologicalandexperimentaldata.FNB：DietaryReferenceIntakes:ApplicationsinDietaryAssessment，ISBN:0-309-50254-3,2000如果每个人都每天少摄入40千卡热能估计有90%的人维持正常体重少吃一两口，多动15分1988-2000年的队列人群的证据:

◆体重正常成人在11年内成为超重者

90%的人年增加体重1.8公斤，折算成每天平均多摄入热能81千卡（男）和61千卡（女）

◆11年来维持正常体重者

90%的人年增加体重0.9公斤，折算成每天平均多摄入热能为35千卡（男）和30千卡（女）体力活动减少、能量摄入过多=能量正平衡每天能量正平衡25千卡能量（步行10分钟、半两多主食、半钱多植物油、三两个饺子）一年=9125千卡=1.2-1.3千克脂肪40年=50千克体重缺少运动和食物过量

可以使肥胖悄然而至肥胖=多吃？/少动？根据农业部的食物产量供给数据估计能量摄入的增加，并因此预测体重增加值，再与实际观察到的美国人体重变化，区分膳食和运动的贡献儿童体重增加与预测值相同，可以认为所增加的4kg都是饮食的贡献；成人比预测值少2.2kg，归因于运动量的增加，而所见增加的8.6kg都可归因于饮食AmJClinNutr2009;89:1723–8调定点稳态理论的质疑有人吃的少变胖，有人吃的多不胖？体重稳定期：几天/几周/几月，生命的某一阶段，吃动如何平衡？多动，吃的相对少，体重不增加或减少，导致能量平衡／负平衡？多吃，不爱动，体重增加，导致能量正平衡？ExercSportSciRev.

2010;3(3):114-121营养运动与癌症世界癌症研究基金会(WCRF)建议

每人每天600克蔬菜水果蔬菜B：口腔、咽、喉、食道、胃肿瘤C：鼻咽、肺、结直肠、卵巢、子宫内膜癌水果B：口腔、咽、喉、食道、肺、胃肿瘤C：鼻咽、胰腺、肝、结直肠癌心脏病中风

血压胆固醇肿瘤

肠息室

白内障和黄斑变性WhyDietaryCholesterolIsNoLongerEnemyNumberOne1.Thecholesterolmoleculeisuniquetotheanimalkingdom.Inhumans,cholesterolisprimarilyendogenousinorigin—thatis,manufacturedbyourbodies.Thereisalsoexogenouscholesterol,whichcomesfromfattyfoodsofanimalorigin.2.Thesecondconceptisthatofintestinalcholesterol,thecholesterolthatpassesintotheintestine.Someofitisreabsorbedandsomeiseliminatedinthefeces.Inintestinalcholesterol,adistinctionshouldthereforebemadebetweenthecholesterolmanufacturedinthebodyandexcretedinbile,anddietarycholesterol,whichcomesfromthefoodweeat.3.Thethirdconceptisthatofthelipoproteinsthattransportcholesterol.Wesimplisticallytalkaboutbadcholesterol,orlow-densitylipoprotein(LDL)cholesterol,becausetheselipoproteinsareatherogenic,andconverselyaboutgoodcholesterol,orhigh-densitylipoprotein(HDL)cholesterol,becausetheselipoproteinsprotectagainstatherosclerosis.Mostofthedebatesovercholesterolarisefromtheconfusionbetweenthesedifferentconcepts.Medscape.

Mar

19,

2015胆固醇代谢的平衡抑制胆固醇吸收的药物效果常常不突出，与自身代谢平衡的补偿调节的个体差异有关胆固醇吸收肝胆酸合成胆固醇合成肠道胆固醇粪胆固醇血胆固醇膳食胆固醇Whatistheimpactofdietarycholesteroloncardiovascular(CV)risk?First,byexaminingtheeffectofahigh-cholesteroldietonthelevelofoneofthemainCVriskfactors:LDLcholesterol.TheimpactofdietarycholesterolonLDLlevelsisvariable.Itdependsonboththeindividualandhisorherunderlyingdiet.Whileitmayhaveanimpact,weknowthatthemostimportantthingforreducingplasmaLDLlevelsistoreducesaturatedfatintakeinfavorofunsaturatedfats.Inthiscontext,reducingdietarycholesterolisnotuseless,butneitherisitthemostimportantthing.Andsecond,byexaminingtherelationshipbetweentheconsumptionofthefoodwiththehighestcholesterolcontent,eggs,andtheriskforcoronaryeventsorstroke.Forthis,weonlyhaveobservationalstudies,butoverall,eggsdonotpromotetheoccurrenceofCVdisease.Becareful,though,becauseaccordingtosomeofthemeta-analysesoftheseobservationalstudies,dietarycholesterolcouldhaveaharmfuleffect,specificallyinpeoplewithtype2diabetes,althoughthereasonforthisisnotreallyknown.Moreover,twostudiespublishedinlate2014concerningintestinalcholesterol:OnewasageneticstudythatfoundthattheCVriskwashigherinpeoplewhoabsorbedintestinalcholesterolespeciallywellbecauseofaspecificformoftheintestinalcholesteroltransporter.[2]TheotherwastheIMPROVE-ITstudy,whichshowedthattheriskforCVeventswasreducedbyinhibitingcholesterolabsorptionintheintestinewithezetimibe(Zetia®).[3]Itisimportanttounderstandthatthesetwostudiesmainlyconcernedtheabsorptionofendogenouscholesterol.Consequently,onecannotdrawanyconclusionsaboutdietarycholesterol,whichaccountsforonlyasmallportionofintestinalcholesterol.Medscape.

Mar

19,

2015不同膳食脂肪对血胆固醇的影响DietaryIntakesLDLmg(mmol/L)TC/HDLCCholesterol100mg

1.3(0.036)or()SatFats1%Calorieintake

1.2(0.032)0.002cis-Fats

0.7(0.019)0.025trans-Fats

1.4(0.04)0.022GinsbergHN,etal.ArteriosclerThromb1994;14:576–586RPMensink,etal.AmJClinNutr2003;77:1146–55食用油脂中的脂肪酸食用油饱和油酸亚油酸亚麻酸其他橄榄油1083*7花生油1941380.41葵花油1419635豆油16225273猪油434493黄油563241.34菜籽油13.358.8**MUFA糖消化吸收速度与血糖反应胰岛素抵抗血G胰岛素食物G食物脂肪血脂肪酸组织++––糖类的营养单糖和双糖：fructose,glucose,galactose

蔗糖

麦芽糖

乳糖寡（聚）糖：链长=3-10，（糊精）多（聚）糖：糖原、淀粉、膳食纤维GFLG糖消化吸收的生物学指征GlycemicIndex：葡萄糖吸收的速率复合膳食的血糖生成指数加权平均：GIc=GI1W1+GI2W2+GI3W3+GI4W4GIn:该食品的血糖生成指数，Wn:该食品的糖含量GlycemicLoad=GI糖含量食物中的糖类（g/100g）食物糖脂肪血糖指数血糖负荷白面包58.65.170±041米饭77.90.864±750可口可乐11058±56.4蔗糖100068±568牛奶3.43.227±40.92苹果13.20.238±25.0西瓜5.80.172±134.2香蕉220.252±411.4冰激凌17.35.361±710.6糖尿病营养治疗MedicalNutritionTherapy总热能精制糖/血糖指数脂肪供热比例蔬菜水果低血糖预防Medicalnutritiontherapyformsalargepartofthiseducation,andthereareanumberofgoals.Weightlossdoesnothavetobeoverwhelmingtoreducehyperglycemiaorothermacrovascularriskfactors.Areductionofabout5%to10%ofbodyweighthassubstantialmetabolicbenefits.Patientsarenotalwayshappywitha5%weightloss;theirgoalsaresometimesmorecosmeticorsocial.Butmetabolically,eventhatamountofweightlosswillbeverybeneficial.EvolutionsinInsulinTherapy:CurrentPerspectivesonTreatmentDesignRamachandiranCooppan,MD;PeterN.Weissman,MDReleaseDate:October8,2007糖尿病人应该根据临床治疗目的，接受个性化的医学营养治疗糖尿病人的MNT应由熟悉糖尿病治疗的注册营养师施行运动独立于药物的治疗作用运动的胰岛素样作用：血糖多数进入肌肉，转运、燃烧、储存肌肉体积、力量、血流量=储存、代谢糖的能力运动0月3月6月对照7.447.337.51有氧7.417.006.98肌力7.487.357.18两种7.466.996.56AnnInternMed.2007;147:357–369251例39-70岁病人分四组有氧：3天/周，75%最大心率，45分/天阻力：3天/周，7套器械锻炼，大负荷，8重复×3组有氧+阻力对照HbA1C有氧运动肌肉力量锻炼*用胰岛素、经常运动、病情和治疗方案近期变动者除外运动分类：按生理功能分类耐力（有氧）运动：运动中需要氧参与能量供给才能完成的运动。如步行、慢跑、蹬自行车等。抗阻力（无氧/肌肉力量）运动：对抗阻力的重复运动。如哑铃操、上楼。对抗阻力用力时主要依赖无氧供能，其中的间歇也含有氧供能的成分。关节功能锻炼：通过躯体或肢体的伸展、屈曲和旋转活动，锻炼关节的柔韧性和灵活性。运动

胰岛素样作用一次中等强度运动后糖耐量改善12小时开始，72小时后消失训练6个月后，停止运动几天，运动增加胰岛素敏感性的作用消失有益健康的身体活动量每周150分钟中等强度或75分钟大强度身体活动量=强度每次活动时间频度研究证据证明有益健康的最低活动量鼓励加倍最低活动量鼓励大强度Lackofphysicalactivitycausesnearly10%ofallprematuredeathsintheworld,primarilyduetocardiovasculardisease,type2diabetes,andbreastandcoloncancers.Physicalinactivityisresponsibleforanestimated5.3millionofthe57milliondeathsthatoccurredworldwidein2008andiscomparabletotheimpactofwell-knownchronicdiseaseriskfactorssuchassmokingandobesity.Incontrast,morethan1.3milliondeathsworldwidecouldbepreventedifmorepeoplegotthemendeddoseofthispowerfuldrugthatis150minutesaweekofmoderate-intensityphysicalactivity.Furthermore,ifwecouldeliminatephysicalinactivity,thelifeexpectancyoftheworld’spopulationwouldincreaseby0.68years.Lancet.2012:380:219-229不运动比肥胖更致命Freshevidencethatjustalittlebitofexercise,suchas20minuteswalkingaday,isextremelybeneficial—regardlessofwhetherpeopleareoverweight/obeseornot—hasemergedfromalargeEuropeanstudy.Infact,themostpronouncedreductioninprematuredeathriskwasobservedamongindividualswhowerenormalweight/abdominallyleanand"moderatelyinactive,"comparedwiththoseofthesamebuildwhowerecompletelyinactive,whichwasdefinedashavingasedentaryjobwithnoreportedrecreationalphysicalactivity.Lookingatthisanotherway,thestudy—inmorethan330,000menandwomen—showedthattwiceasmanyprematuredeathsmaybeattributabletolackofphysicalactivitycomparedwiththenumberofdeathsattributabletoobesity,theresearcherssay."Helpingpeopletoloseweightcanbearealchallenge,andwhileweshouldcontinuetoaimatreducingpopulationlevelsofobesity,public-healthinterventionsthatencouragepeopletomakesmallbutachievablechangesinphysicalactivitycanhavesignificanthealthbenefitsandmaybeeasiertoachieveandmaintain,"commentedDrNickWareham(MedicalResearchCouncilEpidemiologyUnit,UniversityofCambridge).IsEffectofPhysicalActivityIndependentofBMI,WaistCircumference?Intheirpaper,DrEkelundandcolleaguesnotethatphysicalinactivityhasconsistentlybeenassociatedwithanincreasedriskforall-causemortalityindependentofgeneraladiposityasdefinedbybodymassindex(BMI).Andpriorresearchthathasexaminedassociationsbetweenphysicalactivity,BMI,andmortalitysuggeststhatactivityprotectsagainstprematuredeathbutdoesnoteliminatetheincreasedriskassociatedwithhighBMI.Sotheysetouttoexaminetherelationshipbetweenphysicalactivityandall-causemortalityandtolookatwhetherBMIandwaistcircumferencemodifiedtheseassociationsinalargesampleof334,161menandwomenfollowedformorethan12ye