Better Health and Happiness                                       

What is better than a hearty laugh?                                                                                                          

• Hearty laughter is a wonderful stress reliever.
• Laughter increases blood flow to the brain, encourages deep breathing and takes your focus away from the source of your stress.
• Learn to take life less seriously and allow yourself to find the humor in every situation.
• Be a good friend and encourage others to lighten up!

A word about stress…
A little stress sharpens your senses and productivity, but too much can be harmful.

To prevent or cope with stress follow these tips:

• Express your feelings openly before stress builds up.
• Have realistic expectations of yourself and others.
• Accept that you cannot control every situation or decision.
• Get plenty of rest, exercise regularly, and eat a well balanced, low-fat, high-fiber diet.
• Make time for activities that help you relax, reading, listening to music or perhaps physical activity.
• Try to look for the best in yourself and others.
• Solve problems one step at a time.
• Learn to accept change and be flexible.
• When things get tense, close your eyes, relax your body, and breathe deeply several times. You will be surprised at how much this helps.

Signs of Stress and Signals to Seek Help:

• Difficulty sleeping or other changes in sleep habits.
• Chronic irritability or anxiety.
• Changes in eating habits.
• Increased use of alcohol, tobacco, or other drugs.
• Frequent illness, including headaches and stomachaches.
• Cold hands, rapid breathing and heartburn, achiness, and muscle tension.

COMPOUND LIPIDS

Phospholipids

Phospholipids contain phosphorus and a nitrogenous base
in addition to fatty acids and glycerol. Fats from plant and
animal foods contain phospholipids, but they are not required
in the diet because the body produces adequate amounts of
phospholipids. These substances cannot be absorbed intact;
they are broken down into their chemical components before
absorption. As a structural component of cell membranes,
tooth enamel, and dentin, they are the second most prevalent
form of fat in the body. As such, these substances are not
used for energy, even in a state of severe starvation. Although
the mechanism is not fully understood, phospholipids are
involved in the initiation of calcification and mineralization
in teeth and bones, and are present in higher amounts in the
enamel matrix of teeth than in dentin.
   Phospholipids are important in fat absorption and trans-
port of fats in the blood. Phospholipids can mix with either
fat-soluble or water-soluble ingredients and transport these
products across membrane barriers.
   Phospholipids include lecithin, cephalin, and sphingomy-
elins. Lecithin, the most widely distributed phospholipid, is
present in all cells. Lecithin supplements have been mar-
keted as reducing the risk of atherosclerosis. However, the
value of lecithin in this role is questionable because lecithin
is digested before it is absorbed. Cephalin is present in
thromboplastin, which is necessary for blood clotting.
Sphingomyelins are important constituents of brain tissue
and of the myelin sheath around nerve fibers. Phospholipids,
especially lecithin, are used as additives in commercial
products to prevent  fat and water components from
separating.

Lipoproteins

Lipoproteins are produced by the body to transport insolu-
ble fats in the blood. Lipoproteins are compound lipids com-
posed of triglycerides, phospholipids, and cholesterol
combined with protein. The liver and intestinal mucosa
produce lipoproteins. Four different types of lipoproteins are
present in the blood: high-density lipoproteins (HDLs), low-
density lipoproteins (LDLs), very-low-density lipoproteins
(VLDLs), and chylomicrons.
    The ratio of lipid to protein in lipoproteins varies widely;
these variations affect their density. Density increases as
lipids decrease and the protein increases. Lipoproteins can
be classified according to their density and composition, as
shown below. Phospholipids in lipoproteins are present
in approximately the same proportions in all individuals.
   HDLs, which are protective against the development of
heart disease, contain larger amounts of protein and less
lipid. LDL cholesterol typically constitutes 60% to 70% of
the total blood cholesterol. It is considered the main agent in
elevated serum cholesterol levels, or the “bad” cholesterol.
Serum HDL, LDL, and VLDL are important predictors of
heart disease.

Characteristics of lipoproteins  

CHOLESTEROL

Cholesterol is a fatlike, waxy substance classified as a sterol
(lipid) with a complex ring structure. Because the
body can produce all the cholesterol it needs, cholesterol
intake is not essential. Cholesterol has important functions
as a constituent of brain, nervous tissue, and bile salts; a
precursor of vitamin D and steroid hormones; and a struc-
tural component of cell membranes and teeth. Lipoproteins
transport cholesterol in the blood.

PHYSIOLOGICAL ROLES

ENERGY

Dietary fats are a concentrated source of energy, furnishing
9 kcal/g. Foods high in fats are generally referred to as
calorie-dense, which has its merits in some cases. Calorie-
dense foods are usually high in fats (or fat and sugar) and
low in vitamins and minerals and other nutrients. A charac-
teristic of calorie-dense foods is that less volume of food is
needed to furnish energy requirements. As an energy source,
fats are also referred to as protein-sparing because they
allow protein to be used for the important functions of build-
ing and repairing tissues.

SATIETY VALUE

Dietary fats are important for their satiety value. Fats con-
tribute to a feeling of fullness for a longer lime than carbo-
hydrates or protein because digestion of high-fat meals is
slower than other energy-containing nutrients. This fact has
given rise to such descriptions as “sticks to the ribs” in refer-
ence to rich meals. The higher the fat content of a meal, the
longer the food remains in the stomach. Nevertheless, about
95% of the ingested fats is absorbed. Soft fats that are liquids
at body temperature (e.g., margarine) are digested more
quickly than hard fats (e.g.. meat fats).

PALATABILITY

Fats contribute to palatability and flavor of foods. Their use
in cooking improves texture. A receptor has been identified
on the tongue that detects dietary fat, which may affect food
preferences. Preference for high-fat foods develops at an
early age and persists through adulthood.

COMPLEMENTARY RELATIONSHIPS

Fat-soluble vitamins and linoleic acid are generally found in
foods containing fat. The absorption of fat-soluble vitamins
is facilitated by the presence of fats in the gastrointestinal
tract.
   Linoleic acid, an omega-6 fatty acid with 18 carbon
atoms and two double bonds cannot be synthesized
by the body and must be supplied from dietary
sources. If linoleic acid is not furnished in the diet, signs of
deficiency, including growth retardation, skin lesions, and
reproductive failure, result. For this reason, linoleic acid is
anessential fatty acid (KFA).
   Arachidonic (18-carbon chain with four double bonds)
and linolenic (18-carbon chain with three double bonds)
acids are also considered EFAs, but healthy individuals
can produce them from sufficient quantities of linoleic
acid. Linolenic acid can he converted rapidly into omega-3
fatty acids in the body. The conversion of linolenic acid
to EPA and linoleic acid to arachidonic
acid is competitive because the process uses the same
enzyme. When intake of linoleic acid is substantially higher
than intake of linolenic acid, less EPA is available. Linolenic
acid may be a protective factor against coronary heart
disease.
   Omega-3 fatty acids are used to produce compounds
regulating blood pressure, clotting, immune responses, gas-
trointestinal secretions, and cardiovascular functions; they
also prevent heart arrhythmias and decrease triglyceride
levels. The presence of omega-3 fatty acids in the diet has
been linked to reduction or amelioration of several chronic
diseases, including atherosclerosis (a complex disease of
the arteries in which the interior lining of arteries becomes
roughened and clogged with fatty deposits that hinder blood
flow) and atherosclerotic plaque, rheumatoid arthritis, pso-
riasis, inflammatory and immune disorders, and serious eye
problems such as macular degeneration.
   Naturally occurring trans PUFAs, also called CLAs, in
foods have unique biological effects. Scientific studies in
animals have shown CLAs to decrease fat deposits; decrease
risk of different types of cancer and cardiovascular disease;
and improve bone health, insulin resistance, and immune
response. Human research on CLA is promising, but limited
at this time.

Dental Hygiene Considerations

• Lipids are an integral part of many foods and are important physiologically
• The primary form of fat in the body is triglyceride, not cholesterol

Nutritional Directions

• Frying foods at low temperatures causes the food to absorb excessive amounts of fats, whereas frying at very high temperatures results in decomposition of some fats, which can be irritating to the intestine and cause gastrointestinal discomfort after meals containing fried foods.
• The relatively small amounts of trans fatty acids that occur naturally in meat and milk products do not seem to be harmful.
• BHA and BHT are added to processed foods to retard or prevent spoilage.

to be continued…

Unsweetened coconut, mayonnaise, sour cream, blue
cheese salad dressing, almonds, pecans, olives, avocados,
and sausages—what do all these foods have in common?
More than 50% of the kilocalories in each of these food
items comes from fat, a vital nutrient in our diet.

   As shown below added fats and oils provide more
kilocalories in the average American’s diet than any other
food group. Examination of food supply trends in the United
States indicates an increase in added fat intake with a greater
portion of the fat coming from vegetable fats, whereas satu-
rated fat and cholesterol intake has decreased. Consumer
concerns about healthy food choices explain these changes.
Food manufacturers, producers, and grocers have responded by:
 (1) trimming fat from meats

 (2) providing leaner cuts of beef and pork

 (3) replacing tropical oils in processed foods

 (4) manufacturing foods containing less fat

In addition, consumers have:
 (5) increased their consumption of fish and poultry

 (6) substituted lower fat milk for whole milk

The fat content of very lean beef and pork cuts currently com-
pares favorably with a skinless chicken breast.

 CLASSIFICATION

Fats in the diet should actually be called lipids. Lipids
contain the same three elements as carbohydrates:

carbon

hydrogen

oxygen

Lipids contain less oxygen in proportion to hydrogen and carbon than
carbohydrates. Because of their structure, they provide more energy per
gram than either carbohydrates or proteins.

The two classes of water-insoluble substances are
(1) simple lipids or triglycerides, which occur in foods and in
    the body
(2) structural lipids, which are produced by
      the body for specific functions.
The structural component of lipids is fatty acids.
Triglycerides with at least one of the fatty acids
replaced with carbohydrate, phosphate, or nitrog-
enous compounds are called compound lipids. Dietary
lipids usable by the body include triglycerides, fatty acids,
phospholipids, and cholesterol. Lipoproteins are found
solely in the body.

Added fats and oils provide more calories per day
for the average American than any other food group in 2006.
(Data from the U.S. Department of Agriculture and Economic
Research Service.)

CHEMICAL STRUCTURE

Triglycerides are composed of fatty acids and glycerol, as
shown:

Monoglycerides = glycerol + one fatty acid
Diglycerides = glycerol + two tatty acids
Triglycerides = glycerol + three fatty acids

A fatty acid is a chain of carbon atoms attached to hydro-
gen atoms with an acid grouping on one end. Glycerol is the
alcohol portion of a triglyceride to which the fatty acids
attach. Triglycerides are the most common fat present in
animal or protein foods.Monoglycerides and
diglycerides are found in the small intestine and result from
the breakdown of triglycerides during digestion. Free
fatty acids, monoglycerides, and glycerol can cross cell
membranes.
   All three fatty acids attached to the triglyceride can be
different: they can be long, medium, or short, and saturated
or unsaturated. Medium-chain and short-chain fatty acids
are readily digested and absorbed, but most fats in foods
(especially vegetable fats) contain predominantly long-chain
fatty acids. Short-chain fatty acids contain less than six
carbon atoms, medium-chain fatty acids contain 6 to 10
carbon atoms, and long-chain fatty acids contain 12 or
more carbon atoms.

SATURATED FATTY ACIDS

Fatty acids are classified according to their degree of satura-
tion. Saturation of a fatty acid depends on the number of
hydrogen atoms attached to the carbon. Saturated fatty
acids (SFAs) contain only single bonds, with each carbon
atom having two hydrogen atoms attached to it.
Palmitic and stearic acids are the two most prevalent SFAs.
They are structural components of tooth enamel and
dentin.

MONOUNSATURATED FATTY ACIDS

When adjacent carbon atoms are joined by a double bond
because two hydrogen atoms are lacking, there is a gap
between the hydrogen atoms in the chain; the fatty acid is
unsaturated.Monounsaturated fatty acids (MUFAs)
contain only one double bond. The most abundant
MUFA is oleic acid. Oleic acid is also a structural
component of the tooth.

TRANS FATTY ACIDS

Hydrogenation is a commercial process in which vegetable
oil is converted to a solid margarine or shortening by adding
hydrogen to the oil. This process results in naturally unsatu-
rated vegetable oils being changed to an SFA by changing
unsaturated bonds to saturated bonds. Hydrogenation can be
controlled, so “tub” or “soft” margarine is “partially hydro-
genated.” or not completely saturated. The hydrogenation
process not only increases the proportion of SFAs, but also
the shape of the fatty acid. When the hydrogen atoms are
rotated so that they are on opposite sides of the bond, in the
“trans” position, the fatly acid is called atrans fatty acid.
Partial hydrogenation results in large numbers of
fatty acids having this altered shape. Foods with trans fatty
acids have a longer shelf life, and flavors are stable. The
most common trans fatty acid is elaidic acid, found in par-
tially hydrogenated vegetable oils, such as tub margarines
and cooking oils. A naturally occurring trans fatty acid with
double bonds on adjacent carbons is present in small amounts
in milk and meat of ruminants (cows, sheep, and deer).

POLYUNSATURATED FATTY ACIDS

When numerous carbons in a fatty acid are connected
by double bonds, the fatty acid is polyunsaturated. A
polyunsaturated fatty acid (PUFA) has two or more double
bonds. Linoleic, arachidonic, and a conjugated
linoleic acid are PUFAs. These PUFAs are omega-6 fatly
acids. They have their first double bond on the sixth carbon
from the omega (terminal) end; they are also referred to as
n-6 PUFAs.
   PUFAs naturally occur in what is called the “cis”
configuration (i.e., the carbon chain bends so that hydrogens
stick out on the same side of the molecule). These trans
PUFAs, called conjugated linoleic acid (CLA), have
naturally occurring double bonds on adjacent carbons.
CLAs are a derivative of linoleic acid and have different
physiological functions than commercially produced trans
fatty acids.
   Omega-3 fatty acids, or α -linolenic acids, make up
another class of PUFAs. These fatty acids are unique in that
the first double bond is located three carbon atoms from the
omega end of the molecule; hence they are called omega-3’s
or n-3’s. Omega-3 fatty acids include α-linolenic acid,
which has 18 carbon atoms and two double bonds,
eicosapentaenoic acid (EPA),  which has 20 carbon atoms
and five double bonds.

CHARACTERISTICS OF FATTY ACIDS

The carbon chain length and degree of saturation determine
various properties of fats, including their flavor and hardness
or melting point (the temperature at which a product
becomes a liquid). Most SFAs are solid at room temperature;
because most animal fats are predominately saturated fats,
they are solid at room temperature. Short-chain fatty acids
(12 carbon atoms or less), MUFAs, and PUFAs that are
liquid at room temperature are called oils. Milk fat contains
a large amount of short-chain SFAs.
   Fats with a high proportion of unsaturated fatty acids may
deteriorate or become rancid, resulting in unpleasant flavors
and odors. Fats become rancid when subject to high tem-
peratures and exposure to light, which cause oxidation and
decomposition of fats. The decomposition results in perox-
ides that may be toxic in large amounts. Vitamin E, a fat-
soluble vitamin, is an antioxidant and, to some degree,
protects the oil to which it is added; however, in doing so,
vitamin E is inactivated so that it cannot be used by the body.
Other antioxidants, such as butylated hydroxyanisole (BHA)
and butylated hydroxytoluene (BHT), are added to com-
mercially processed fats and oils to prevent their spoilage.

 

to be continued…

 

An upper limit for safe levels of protein intake has not been
determined. Most patients believe no upper limits for protein
exist. Americans frequently eat 150% to 200% of the RDA
for protein. Excessive protein intake can contribute to obesity
because any energy-providing nutrient consumed in excess
of physiological needs is converted to fat and stored.
   One concern regarding high protein intake is its effect on
calcium balance. The adequate intakes (AIs) established for
calcium in the United States are approximately double the
recommendations for most other nations. For many years,
general consensus in the medical community was that high
protein intake had a negative impact on calcium and bone
metabolism. Numerous studies contradict this theory,
however, and research generally indicates meat intake may
have a favorable impact on bone health if calcium intake is
adequate, at least in older men and women.
   When protein intake is excessive, fluid imbalances may
occur in all age groups, but especially in infants. Metabolism
of 100 kcal of protein requires 350 g of water compared with
50 g of water for a similar amount of carbohydrates or fats.
Water requirements are increased as well as the end products
of protein metabolism in the bloodstream.
   It is controversial whether the popular high-protein diets
are excessive in protein content. Regardless, this trend has
stimulated scientific research that has expanded the scien-
tific knowledge base in this realm. Higher protein diets are
beneficial for weight control by enhancing loss of body fat
with less muscle loss and improved control of blood glucose
levels. Dietary protein may aid in weight loss by increasing
satiation; increasing muscle mass, which burns more kilo-
calories and increases thermogenesis (production of body
heat); and decreasing energy efficiency. Protein intake
generally increases satiety to a greater extent than carbohy-
drate or fat and may facilitate a reduction in ad libitum (as
desired) energy consumption. Obtaining adequate protein,
or within the upper range of recommended amounts, is an
important dietary concern, especially for weight loss or
management or for physical activity.
   Clinicians are concerned about the long-term effects of a
high-protein diet, especially when the principal source of
Protein is red meat and regular dairy products because of
Their large cholesterol and saturated fat content. A study
Involving 29,000 postmenopausal women found subjects
Who reported the highest protein intakes from red meat and
Dairy products had approximately a 40% higher risk of dying
of heart disease than subjects with the lowest intake of these
foods. Although high protein intake is not associated with
kidney function decline in individuals with healthy kidneys,
protein intake three times the RDA can lead to kidney prob-
lems in people with mild kidney impairment. The American
Diabetes Association recommends limiting protein intake
to less than 20% of total kilocalories (100 g protein for a
2000-kcal diet).

Dental Hygiene Considerations

• Protein intake exceeding daily caloric needs results in additional fat stores and obesity.

 

Nutritional Directions

• Extremely high protein intake is especially undesirable in infants.
• Because proteins must be metabolized by the liver and filtered
  by the kidneys, excessive amounts (more than 200% of the RDA)
  result in additional work by or stress on these organs.

 

Vegetarianism 

 Despite the fact that protein is not limited in the U.S. food
supply, some people choose plant sources of protein for
health reasons or because of their philosophical, ecologi-
cal, or religious convictions. The large numbers of vegetar-
ian cookbooks and meatless “veggie” burgers and
sausage-style products would lead one to believe vegetari-
anism is a growing consumer movement. The Vegetarian
Resource Group indicates only 2% to 3% of the population
are true vegetarians; in 2006, 6.7% of adults said they never eat meat.
   Technically, the major types of vegetarian diets differ in
the types of foods included. In a lactovegetarian diet,
dairy products are consumed in addition to plant foods
(lacto– comes from the Latin word for milk, lactis). Meat,
poultry, fish, and eggs are excluded. Milk and cheese prod-
ucts, which complement plant foods and enhance the
amino acid content, are included. The ovolactovegetarian
diet is supplemented with milk, cheese, and eggs (ovo–
comes from the Latin word for egg, ovum). Only meat, poultry
and fish are excluded. If adequate quantities of eggs, milk,
and milk products are consumed, all nutrients
are likely to be provided in sufficient quantities. Strict
supervision is not warranted. The ovovegetarian diet con-
sists of foods from plants with the addition of eggs. Meat,
poultry, fish, and dairy products arc excluded. The vegan
(or strict vegetarian) diet is the strictest type and contains
only food from plants, including vegetables, fruits, and
grains. No foods of animal origin are allowed (e.g., meat,
milk, cheese, eggs, butter). Some “self-described” vegetar-
ians are not true vegetarians because they occasionally eat
fish and poultry. These people are known as “semi-
vegetarians” or flexitarians.
   Some groups, especially Seventh-Day Adventists, sup-
plement protein intake with many textured vegetable
protein (TVP) products. These meat substitutes are pro-
duced from vegetable proteins, usually soybeans. The
protein in TVP products is of good quality, but these prod-
ucts may have a high sodium content.
   EAAs can be provided by plants, but larger amounts of
these plant products must be consumed to match the protein
obtained from animal sources. EAAs present in low levels
in grains are abundant in other plants, such as legumes.
Beans are low in methionine and tryptophan, and corn is
low in lysine and threonine. When eaten together, as in
pinto beans and cornbread, they are said to be complemen-
tary foods, and less volume is required.
   Protein from a single source is seldom consumed alone.
Foods are usually combined without awareness they are
complementary to each other (e.g., beans are usually com-
bined with rice, bread, or crackers (wheat), or tortillas or
cornbread (corn)). When a combination of plant proteins
is eaten throughout the day, the amino acids provided by
each complement each other—that is, the deficiencies of
one are offset by the adequacies of another. Additionally,
small amounts of high-quality proteins can be combined
with plant foods, as in macaroni and cheese or cereal and
milk, to provide adequate amounts of EAAs. If caloric
requirements are met, protein requirements are met when
a variety of protein-containing foods are eaten throughout
the day. The foods providing complementary amino acids
do not have to be consumed at the same time.
   With some basic nutrition knowledge, vegetarian foods
can be selected that are healthy and nutritionally balanced.
The major difference is the protein source. The Vegetarian
Food Guide Pyramid and Vegetarian Food Guide Rainbow
are designed specifically to address the nutrient
inadequacies and reduced mineral bioavailability of vege-
tarian diets. Vegetarian diets generally result in lower
dietary intake of saturated fat and cholesterol, and high
levels of carbohydrate, fiber, magnesium, boron, folate,
and vitamins C and E. Key nutrients that may fall short
of the DRI in the vegetarian diet include zinc, calcium,
riboflavin, vitamins D and B12, and n-3 fatty acids.
Laboratory tests show reduced blood levels of vitamins B12
and D and the minerals calcium, zinc, and iron in vegetar-
ians. Commonly available fortified foods (i.e., fortified
breakfast cereals and nondairy soy milks) are emphasized
to ensure good sources of vitamins B12 and D and
calcium.
   By using a variety of principally unrefined foods, and enough
kilocalories to promote good health, protein quality and
quantity and other nutrients can be adequate for most individuals.
   Because of the difficulty of consuming adequate volumes
of food to meet kilocaloric requirements, the vegan diet is
not recommended for infants, children, or pregnant/lactat-
ing women. Breastfed infants of two vegan mothers in the
United Stales developed brain abnormalities as a result of
vitamin B12 deficiency.
   Much can be said of the healthy aspects of vegetarian
diets. Vegetarian diets can meet the DRIs as long as the
variety and amounts of foods are adequate. The fact that
vegetarian diets and lifestyles seems to be conducive to
good health is exemplified by vegetarians exhibiting better
weight control, improved gastrointestinal function, fewer
breast and colon cancers, better glucose control, a lower
incidence of gallstones, lower blood pressure, and a
decreased rate of coronary heart disease; they also live
longer. These advantages are not attributed solely to
avoidance of meal products, but benefits from additional
plant food selections. For instance, beans, legumes, and
whole-grain products help with blood glucose control;
plant foods are associated with a lower risk of cardiovas-
cular disease. People who have an interest in pursuing a
vegetarian diet should be encouraged to do so; all people
should have more meatless meals and to consume more
plant foods.

Although protein supplies in the United Stales are plentiful,
and drastic protein deficiency is uncommon, several groups
of individuals are susceptible to insufficient intakes:

(1)elderly individuals
(2) individuals with low income
(3)strict vegetarians
(4) individuals with a lack of education or who are unwilling to shop wisely
(5) patients who are chronically ill or hospitalized (e.g.. patients with AIDS,
      anorexia nervosa, or cancer)
Fewer than 10% of U.S. adults older than 70 years of age get
less than the recommended 0.8 g/kg body weight per day.
Consumption of protein by older Americans may be related to cost,
inability to prepare nutritious meals, depression, difficulty chewing,
or concerns about the fat and cholesterol content of meats.
Inadequate amounts of dietary protein contribute to sarcopenia.
   Certain physiological conditions and impaired digestion
or absorption cause excessive protein losses and may pre-
cipitate protein-energy malnutrition (PEM). Although
PEM is uncommon in the United States, given the above-
mentioned conditions, malnutrition is frequently unrecognized.
PEM is usually accompanied by other nutritional deficiencies.
Separating the effects of different nutrient defi-
ciencies by observing clinical symptoms is often difficult.
PEM affects the whole body, including even component of
the orofacial complex.
   The occurrence of PEM during critical developmental
stages, including the prenatal and postnatal periods, may
affect developing tissues and can lead to irreversible changes
affecting oral tissues. During tooth development, mild-
to-moderate protein deficiency results in smaller molars,
significantly delayed eruption, and retardation during devel-
opment of the mandible. Smaller salivary glands result in
diminished salivary flow; this saliva is different in its protein
composition and amylase and aminopeptidase activity, com-
promising the immune function of the saliva.
   Poor nutrition results in delayed eruption and delayed
exfoliation of deciduous teeth. In addition to the increased
rate of caries in malnourished children, the peak caries expe-
rience is delayed by approximately 2 years. The increased
caries rate may simply be related to the length of time a tooth
is in the oral cavity; if the delay in exfoliation is greater than
the delay in eruption, the tooth is in the mouth a longer time,
and it is exposed to caries-producing bacteria longer. Chil-
dren with malnutrition (e.g., in developing countries and in
many urban and rural areas in developed countries) have
different dietary habits overall and oral environments that
are not conducive to dental caries. However, the teeth in
these populations are highly susceptible to dental caries.
Increased caries susceptibility may be related to alterations
in structure of tooth crowns and diminished salivary flow,
or changes in saliva composition may be related to malnutri-
tion issues.   
   Epithelium, connective tissue, and bone also may be
poorly developed. An increase in acid solubility associated
with chemical alterations of the exposed enamel surface may
contribute to increased caries susceptibility.
   The periodontium includes the hard and soft tissues sur-
rounding and supporting the teeth: gingival, alveolar mucosa,
cementum, periodontal ligament, and alveolar bone. An
insufficient intake of protein results in negative nitrogen
balance depleting nitrogen reserves, reducing blood protein
levels, and decreasing resistance of the periodontium to
infections. In addition, the ability of the periodontium to
withstand the stress of injury or surgery is reduced, and
recovery periods are longer. In malnourished children,
secretory immunoglobulin A (sIgA) levels are depressed.
sIgA is the predominant immunoglobulin, or antibody, in
oral, nasal, intestinal, and other mucosal secretions, and
provides the first line of defense in the oral cavity. Low sIgA
levels in malnourished children probably play a role in their
increased susceptibility to mucosal infections.
   PEM may be a major reason for the increased incidence
of noma and necrotizing ulcerative gingivitis (NUG), con-
ditions that are clearly associated with depressed immune
responses caused by nutritional deficiencies, stress, and
infection. Noma is u severe gangrenous process usually
manifesting as a small ulcer on the gingiva that becomes necrotic
and spreads to produce extensive destruction of the lips, cheek,
and tissues covering the jaw. NUG is characterized by erythema
(marginated redness of the mucous membranes caused by inflammation)
and necrosis (degeneration and death of the cells) of the
interdental papillae. This painful gingivitis is generally
accompanied by a metallic taste and foul oral odor. Cratered
papillae often remain after treatment of the disease.
   A scenario in which NUG occasionally occurs is in
college students who are under a great deal of psychological
stress and have poor eating habits. It also can be observed
in individuals who live in developed countries and are
severely debilitated or immunocompromised (having an
immune response that has been weakened by a disease or
pharmacological agent), or in children 2 to 6 years old who
live in developing countries, are malnourished, and have
recently experienced a stressful event, such as a viral
disease.
   NUG is possibly precipitated by emotionally stressful
situations that affect eating patterns, leading to acute defi-
ciencies, and lowering the immune response to bacteria nor-
mally found in most oral cavities. Decreased host resistance
to infection may permit gingival lesions to spread rapidly
into adjacent tissues, producing extensive necrosis and
destruction of orofacial tissues, whereas in a healthy indi-
vidual, the lesion is limited to the gingiva alone. Wound
healing is also delayed.
   In other areas of the world, where quantities of high-
quality protein and kilocalories are insufficient, PEM is
commonly seen. Kwashiorkor develops when young chil-
dren receive adequate kilocalories, but not enough high-
quality protein. It usually appears after the child
has been weaned from breast milk. Marasmus occurs in
infants when protein and kilocalories are deficient in the
diet.
   Kwashiorkor and marasmus are very serious health prob-
lems that have received much attention by the United Nations
and the WHO. Incaparina, a food powder made from corn,
cottonseed, and sorghum with mineral and vitamin supple-
ments; skim milk powder; and the addition of lysine to
cereal products have been used to improve nutritional status
in developing countries. However, most of these efforts to
improve the status of nutrition worldwide have not been well
accepted for various reasons, and the protein-energy prob-
lems in the world still exist.

Nutritional Directions

• Suggestion Meals-on-Wheels or community senior centers for
  older people with an inadequate diet.
   
• Suggestion for supplementation of protein content of the diet by
  adding skim milk powder to milk, soups, or mashed potatoes
  (if the person is not lactose intolerant) and by adding cheese
  to foods.

Ovolactovegetarian menu       Protein content (g)

Breakfast
Oat bran bagel (1)	6.1
Whipped cream cheese (2 Tbsp)	0.7
Seedless raisins (1/4 c)	0.8
1% Low-fat milk (8oz)	9.9
Coffee (12 oz)	0
Morning snack
Fresh orange (1)	1.6
Lunch
Sandwich with:
Low-fat monterey jack cheese (1 oz)	7.6
Cherry tomatoes (5)	0.4
Thinly sliced cucumber	0.2
Sliced green bell peppers (1/4 c)	0.2
Whole wheat bread (2 slices)	6.0
Baby carrots (8)	0.5
Fresh apple (1)	0.5
Water (12 oz)	0
Afternoon snack
Diet carbonated beverage (12 oz)	0
Dry roasted peanuts (1/4 c)	6.0
Dinner
Vegetarian stew (1 c)	42.0
Brown rice (3/4 c)	3.0
Steamed broccoli spears (1 c)	3.2
Salad with garbanzo beans (l/4 c)	3.5
Low calorie salad dressing (2 Tbsp)	0.1
Whole wheat roll (1)	2.2
Soft margarine (1 Tbsp)	0
Fresh cantaloupe (1 c)	0
Iced tea, unsweetened (12 oz)	0
Evening snack
1% Low-fat milk (8 oz)	9.9
Cinnamon graham crackers (4)	3.1

Total                                            107.5

Sample menu                          Protein content (g)

Breakfast
Oat bran bagel (1)	6.1
Whipped cream cheese (2 Tbsp)	0.7
Seedless raisins (1/4 c)	0.8
1% Low-fat milk (8oz)	9.9
Coffee (12 oz)	0
Morning snack
Fresh orange (1)	1.6
Lunch
Sandwich with:
Tuna salad  (1/4 oz)	8.1
Tomato slices (2)	0.4
Thinly sliced cucumber	0.2
Sliced green bell peppers (1/4 c)	0.2
Whole wheat bread (2 slices)	6.0
Baby carrots (8)	0.5
Fresh apple (1)	0.5
Water (12 oz)	0
Afternoon snack
Diet carbonated beverage (12 oz)	0
Dry roasted peanuts (1/4 c)	6.0
Dinner
Lean roast beef (2 oz) Brown gravy (1/4 c)	21.42.2
Brown rice (3/4 c)	3.0
Steamed broccoli spears (1 c)	3.2
Melted reduced fat and sodium cheddar cheese  (l/4 c) Mixed green salad (1 ½ c)	6.0
Low calorie salad dressing (2 Tbsp)	0.1
Whole wheat roll (1)	2.2
Soft margarine (1 Tbsp)	0
Fresh cantaloupe (1 c)	0
Iced tea, unsweetened (12 oz)	0
Evening snack
1% Low-fat milk (8 oz)	9.9
Cinnamon graham crackers (4)	3 1

Total                                            92.6

  

 

Protein content of sample menu and modifications for ovolactovegetarian diet. (Nutrient data from U.S. Department of Agriculture, Agriculture Research Service. U.S Department of Agriculture, national Nutrient Database for Standard Reference, Release 20, 2008.

Nutritional Directions

• Increased muscular activity does not seem to elevate the
  protein requirement except for a small increase needed for
  muscle development during conditioning. Athletes may
  require 1.2 to 1.7 g of protein a day depending on the inten-
  sity of training. This should be determined by a registered
  dietitian specializing in sports nutrition.
• Protein requirements should be met by foods from several
  sources (even animal protein foods) because of other nutri-
  ents that accompany the protein. For example, pork is an
  excellent source of thiamin; red meats furnish a significant
  amount of iron. In contrast, too many egg yolks in the diet
  contribute excessive cholesterol.
• Animal sources of protein are generally the most expensive.
  When people have limited resources, they can: 
  (1) eat protein in adequate but not excessive amounts
  (2) use a variety of proteins of lower quality (which are less expensive)
  (3) purchase less expensive kinds of protein foods.
• The color of the eggshell is not related to its nutritional value.
  The breed of the hen determines the color.
• Reinforce the lack of benefit and possible danger of taking
  amino acid supplements if protein intake is adequate.