S1 Diet, Immune and Infection

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DIET, IMMUNE AND INFECTION



References

1. Andrews JF and Griffiths RD, et al. Glutamine: essential for immune nutrition in the critical ill.

British Journal of Nutrition 2002 !": # $% & $!.2. Bar'ul A. (mmunonutrition comes of a)e *+ditorial. -rit -are ed 2000 2!:%: # !!/ & .

%. Bistrian BR, -linical as#ects of essential fatt acids meta'olism: Jonathan Rhoads lecture,J3+N 200% 2": 1! & 1".

/. -ollin D and Gi'son GR. 3ro'iotic, #re'iotic, and sn'iotics: a##roches for modulatin) themicro'ial ecolo) of the )ut. Am J -lin Nutr 1444 4: 102$ & 10"$

. Fenton and $il5erman +-. edical nutrition thera# for human immunodeficienc 5irus *6(7Disease in 8rause9s Food and Nutrition era# *ahan, ;8 and +scott<$tum# $ eds, 200!: #441 & 1020.

. Galla)her ;. he nutrients and their meta'olism. in 8rause9s Food and Nutrition era#*ahan, ;8 and +scott<$tum# $ eds, 200!: # /2 & 1/%.

". Grim'le G8 and =estwood >. Nucleotides as immunomodulator in clinical nutrition. -urr >#in-lin Nutr eta' -are 2001 /: "</

!. 6eim'ur)er D-. Nutritional su##ort: )eneral a##roch and com#lications in 6and'oo? of -linicalNutrition *6eim'ur)er D- and Ard JD, eds, 200: # 22 & 2!1.

4. ;ui?in), @- et al. he role of ar)inine in infection and se#sis. J3+N 200 24: $"0 & $ "/.

10. a))ini $, et al. $elected 5itamins and trace elements su##ort immune stren)thenin) e#ithelial'arriers and cellular and humoral immune res#onses. British Journal of Nutrition 200" 4!: #!24 & !%.



The role of nutrition in immune response

• Nutrition has essential role to maintain immune-competence

• Nutrition factor is required by all kinds of immune system, specific as

well as nonspecific

• Disruption of a balance between intake and requirement of energy

and nutrients → Malnutrition

↓ immune-competence ↓

↓

immune-compromised

Background



IMMUNITY

PHYSICAL BARRIERS:

SKIN MUCOSA, MUCOSA, MUCUS SECRETION

IMMUNE CELLSANTIBODIES

enetic

!geender

"itness

#moking#tress

$tc$tc

NUTRITION



NUTRITION

IMMUNITY

MACRO

NUTRITION

MICRO

NUTRITION

CARBOHYDRATE

PROTEIN

FAT

ITAMIN

MINERAL

PHYSICAL BARRIERS: SKIN MUCOSA, MUCOSA, MUCUS SECRETION

IMMUNE CELLS

ANTIBODIES

enetic !ge

ender "itness

#moking#tress

$tc

$tc



NUTRITION

IMMUNITY

MACRO

NUTRITION

MICRO

NUTRITION

CARBOHYDRATE

PROTEIN

FAT

ITAMIN

MINERAL

PHYSICAL BARRIERS: SKIN MUCOSA, MUCOSA, MUCUS SECRETION

IMMUNE CELLS

ANTIBODIES

NR(+N $A$



EE

(Basal metab/Activity/infection)

EI

(foods)

$nergy %alance & 'mmune Response ()*

1 Body !ei"#t

$ Body com%osition

Imm&ne system



• Act&al B! ' * Ideal B! → ↓ imm&ne com%etence

• Obesity → abno+malities of cell&la+ , #&mo+al

imm&nolo"ic com%onents

↓ - incidence of infection

• Ty%es of ene+"y so&+ces .

ENER!Y BALANCE AND IMMUNE



• Marasmic & +washiorkor ! clinical manifestation of seere .$M

• Disorder of immune system, including - !trophy of lymphoid tissues

- / lymphocyte concentrations

- // response of cellular & humoral immunity

• Disrupt integrity of epithelial cells → ↑ inasion of microorganism ↓

infection

/

0 acute phase response

0 actiation of immune system

/

0 micronutrients loss

/

0 Morbidity & mortality

PROTEIN ENER!Y MALNUTRITION



$ffects of .$M "irstly, studied in children

.$M 1 Dysregulation of immune response

'mmune response /

'mmune system needs %uilding substances

$nergy sources

other physiological

processes

2



NUTRIENT

TATU0

A2NUTRITION

↓ IUNIT3

IN4E5TION

/ food intake

Malabsorption

0 3atabolism &

4tili5ation ofnutrients by the

body

Released nutrients

"rom the storage

"or tissues synthesis &

growth

Disorders of immune

function

Disorders of body barrier that function as

Defense mechanism

(#ource %rown, 6778*



I6AIRE7 IUNIT3

8 5ell8mediated imm&nity

8 yc+obicidal activity of %#a"ocytes

8 5om%lement system

8 ec+eto+y antibodies8 Antibody affinity

- 9omitin" , malabso+%tion- N&t+ient losses in &+ine , feces

- e:&est+ation of n&t+ients

- Inc+eased catabolism

- 7ive+sion of n&t+ients

Unde+n&t+ition Infection

ain imm&nolo"ic deficits obse+ved in 6E and %at#o"enic mec#anisms

by ;#ic# infection can inc+ease n&t+itional deficiencies (o&+ces0 5#and+a< 1=>)



NUTRIENT

TATU0

A2NUTRITION

↓ IUNIT3

IN4E5TION

9



General Nutrition& +ner) ReCuirement and -om#osition

& 7itamins

& inerals $#ecific Nutrients (mmunonutrients

& Antioidants: A, -, +, -arotenoids, $elenium, Einc,

-o##er& Glutamine, ar)inine, nucleotide

& 3ro'iotics

NUTRITION THERAPY



(ndirect calorimetr +Cuations 6arris Benedict

& B++ * ,/" H 1%."= H .006 & ."A

& B++ *I .10 H 4.= H 1.!6 & /.!A

=ei)ht *= ?) 6ei)ht *6 cm A)e *a ears

+ner) )oals in refeedin) a h#ometa'olic star5ed #atient:

ENER!Y RE"UIREMENT FOR

MALNUTRITION PATIENTS

Days $nergy oal

) : 6 %$$ ; 7<=

8 : > %$$ ; )

> : ? %$$ ; )<) : )<>?@ %$$ ; 6

+cessi5el ra#id feedin) is ris?, 'ecause of h#o#hos#hatemia and heart failure.

Nutritional su##ort should 'e initiated cautiousl, to allow #atient ada#tation to new

ener) and )lucose load. a?in) u# to a wee? to reach to reach the final calorie )oal.

Ref =



Carbohydrate>55%

Protein15%

Fat<30%

5#oleste+ol0 '? m"/d

4ibe+0 $8? "/d

4A '@* total calo+ie

6U4A '1* total calo+ie

U4A ' 1* total calo+ie

RECOMMENDED NUTRIENT COMPOSITION

Ref ?



The sites of micronutrients on the immune

system

Ref )7



(mmune enhanced nutrition

(mmune 'oostin) nutrition

(mmune modulatin) nutrition

D#$%n%&%on

Nutrients or s#ecific food items which a'ilit tomodulation of immune sstem and the

conseCuences of acti5ation of the immune sstem

IMMUNONUTRITION

Ref 6



he term )i5en to descri'e s#ecial enteral

#arenteral feeds containin):

& Antioidants

& Glutamine

& Ar)inine

& >me)a<% fatt acids

& Nucleotides

& 3ro'iotics

IMMUNONUTRITION

Ref 6





Ma'nu&r%&%onMa'nu&r%&%on

Co()ro(%*# o$ %((un# *+*&#(Co()ro(%*# o$ %((un# *+*&#(

In$#c&%onIn$#c&%on

T# na&ur# o$ cr%&%ca''+ %'' )a&%#n&*-T# na&ur# o$ cr%&%ca''+ %'' )a&%#n&*-

cond%&%on*cond%&%on*

;en)th of (- and hos#ital sta

or'idit

ortalit

-osts of careRef 6



THE AIM OF IMMUNONUTRITION

to %+ese+ve o+ en#ance t#e imm&neto %+ese+ve o+ en#ance t#e imm&ne+es%onse in c+itically ill %atients+es%onse in c+itically ill %atients

to im%+ove o&tcome and +ed&ce t#eto im%+ove o&tcome and +ed&ce t#elen"t# of stay +e:&i+ed in #os%itallen"t# of stay +e:&i+ed in #os%ital

Ref 6



7itamin A is antioidant

• Aitamin ! regulates of : innate and cell mediated immunity

: Bumoral antibody response

• Aitamin ! deficiency : The integrity of mucosal epithelium is altered 0 susceptibility to

pathogens in eye, respiratory, 'T

: Diminished phagocytic and o;idatie burst actiity of macrophagesactiated during inflammation : ! reduced number and actiity of N+ cells : The increased production of 'C-)6 and pro-inflammatory TN"

ITAMIN A

Ref )7



7itamin A su##lementation:& K mor'idit and mortalit from acute measles in infants and

children, diarrhoea disease in #re<school children in de5elo#in)countries, acute res#irator infection, malaria, B- etc

& (ncreased delaed t#e h#ersensiti5it *D6 in infants whichma reflect of u#<re)ulation of lm#hocte function

& (m#ro5e anti'od to 5arious 5accines

ITAMIN A

Ref )7



7itamin - is antioidant

7itamin - is hi)hl concentrated in leu?octes and is used ra#idldurin) infection

7itamin - enhance neutro#hil chemotais.

7itamin - stimulate the immune sstem ' enhanchin) lm#hocte#roliferation in res#onse to infection increasin) cto?ine #roductionand snthesis of immuno)lo'ulins

7itamin - im#ro5e se5eral com#onents immune res#onse such asanti<micro'icidal and N8 cell acti5ities, lm#hocte #roliferation,

chemotais, and D6 res#onse. 7itamin - effecti5e in ameliorate sm#toms of u##er res#irator tract

infection.

ITAMIN C

Ref )7



ost cells of the immune sstem *monocte, macro#ha)es andthmus tissue ece#t B cells e#ress of si)nificant Cuantities of5itamin D rece#tors

7itamin D status influences the occurrence of h1<mediatedautoimmunit disease which is in accordance with the a'ilit of1,2*>62D% to inhi'it maturation of dendritic cells and down re)ulate#roduction of the immunostimulator (;<12, and the o'ser5edincrease in immunosu##resi5e (;<10

ITAMIN D

Ref )7



7itamin + is a #otent antioidant

7itamin + is stron) li#id solu'le antioidant which is a'le to enhancethe immune res#onse from free radicals and li#id #eroidation.

7itamin + increases lm#hocte #roliferation in res#onse to mito)ens,#roduction of (;<2, N8 cell ctotoic acti5it, and #ha)octic acti5it' al5eolar macro#ha)es, and causes an increased resistancea)ainst infectious a)ents.

7itamin + has #otential effect to im#ro5e the o5erall immuneres#onse, es#eciall in the elderl.

ITAMIN E

Ref )7



Folate status ma affect the immune sstem ' inhi'itin) the ca#acitof -D!H lm#hoctes cells to #roliferate in res#onse to mito)enacti5ation

Folate deficienc enhances carciono)enesis causes of increaseddama)e to DNA and altered methlation ca#acit.

Folate su##lementation of elderl im#ro5es o5erall immune function

' increase in N8 cell acti5it, #ro5idin) #rotection a)ainst infections.

FOLATE

Ref )7



B12 deficienc with im#airments in thmidine and #urinesnthesis and su'seCuentl in DNA and RNA snthesis,leadin) to alterations in immuno)lo'ulin secretion.

B12 deficienc showed a'normall in -D/H-D!H ratio andsu##ressed N8 cell effects.

(mmunocom#etent elderl with low 5itamin B12 serumconcentration, had an im#aired anti'od res#onse to#neumococcal #olsacharide 5accine

ITAMIN B./

Ref )7



$elenium is essential for o#timum immune res#onse and influencesthe innate and acCuired immune sstems

$elenium is an antioidant, #lain) a ?e role in the redo re)ulation

function throu)h )lutathione #eroidases that remo5e ecess of freeradicals.

he selenoenLme thioredoin reductase affects the redore)ulation of se5eral enLmes, transcri#tion factors and rece#tors.

$elenium deficienc decreases immuno)lo'ulin titres and s#ects ofcell<mediated immunit.

SELENIUM

Ref )7



Einc is essential for hi)hl #roliferatin) cells, es#eciall in the immunesstem and influences 'oth innate and acCuired immune functions.

Einc is in5ol5ed in the ctosolic defence as an antioidant.

Einc is an essential co factor for thmulin which modulates cto?ine

release and induces #roliferation. Einc su##orts a 61 res#onse.

Einc maintains s?in and mucosal mem'rane inte)rit.

Einc increases cellular com#onents of innate immunit, anti'od

res#onses and the num'er of ctotoic -D!H cells

0INC

Ref )7



-o##er status alters se5eral as#ects of neutro#hils,

monoctes and su#eroide dismutase.

=or?in) to)ether with catalase and )lutathione

#eroidase in the ctosolic antioidant defence

a)ainst R>$.

COPPER

Ref )7



(ron is essential for electron transfer reactions, )enere)ulation, 'indin) and trans#ort of o)en, and re)ulationof cell differentiation and cell )rowth.

(ron is in5ol5ed in the re)ulation of cto?ine #roduction andin the acti5ation of #rotein ?inase -

(ron is necessar for melo#eroidase acti5it which isin5ol5ed in the ?illin) #rocess of 'acteria ' neutro#hilsthrou)h the formation of hi)hl toic hdrol radicals.

IRON

Ref )7



3atho)ens such as infectious microor)anisms and

5iruses reCuire iron and other micronutrients for

re#lication and sur5i5al as well, it seems essential

to restrict of the infectin) microor)anism to iron, 'utto maintain a suita'le concentration of iron that the

host can mount an o#timum immune res#onse and

a5oid the #ossi'ilit of ecess amounts of iron which ma induce free radical mediated dama)e.

IRON

Ref )7



• C'A$ microbial which when administered

in adequate amounts confer a health

benefit on the host

"!E F GBE 677)

PROBIOTICS



#kin 6<H m6

Respiratory tract =7 m6

ut >77 m6

4rinary tract H m6

tonsils

thymus

lymph nodus

spleen

intestinal

lymphatic tissue

(.eyer-.laques*

appendi;

inquinal lymph nodes

bone marrow

Gut: the largest immunedefense

5RITERIA O4 6ROBIOTI5



!pathogen F non to;ic

3ontain a large number of

iable cells

%e capable of suriing and

metaboli5ing in the gut

Remain iable duringstorage and use

$;ert a beneficial effect on

the host

5RITERIA O4 6ROBIOTI5

Most probiotic strains are

commensal micro-organisms

without pathogenic actiity



!UT BARRIER DEFENSE MECHANISM

$;clusion of the antigen

$limination of the foreign antigen that hae penetrated the

mucosa

Regulating antigen specific immune response

Ref >



'mmunomodulatory effect

$limination of lactose intolerance

!nti-diarrhea

#uppressed Belicobacter pylori

.reention of cancer

Bypocholesterolemic

!ntio;idant

: 0 phagocytosis

: 0production of 'g!

: 0release of cytokines TN", 'C-? and 'C-)7

: 0human immune defense

: /manifested of atopic ec5eme in children

PROBIOTICS HEALTH BENEFIT

Ref >



ost a'undant free amino acid in: #lasma *M 20 of the total circulatin) free amino acid #ool

s?eletal muscle *M 0 of the total circulatin) free amino acid #ool

3rimaril snthesiLed in the s?eletal muscle

$u'strate for )luconeo)enesis and urea)enesis

3recursor for nucleotide and )lutathione

>idati5e fuel hi)h cell #roliferation rate in mucosa small intestine as

enterocte, colonocte and immune cells

Non essential in normal conditions

-onditionall essential durin) cata'olic state

!LUTAMINE

Ref )





-onditionall essential durin) cata'olic state

=ound healin) *snthesis of colla)en, G6

#)rades immune function

aintain the 'od9s nitro)en 'alance

3recursor of Nitric >ide, Glutamine

6ormone $ecretion Acti5it,

& Growth 6ormone, (nsulin, Gluca)on

AR!ININE

Ref I



EFFECT OF AR!ININE ON IMMUNE FUNCTIONS

$timulate the res#onse of monocte to anti)en

Reduce the destructions of lm#hocte O <hel#er odulate functions of cell lm#hoctes, macro#ha)es, and

neutro#hils

Ref I



PP immune functionimmune function

Booster neutro#hil acti5itBooster neutro#hil acti5it Distri'ution of lm#hocte throu)hout the 'odDistri'ution of lm#hocte throu)hout the 'od

Reducin) the 'od9s inflammator res#onse toReducin) the 'od9s inflammator res#onse to

trauma *K le5el of -R3, (;<, leu?otriene B/, 3AFtrauma *K le5el of -R3, (;<, leu?otriene B/, 3AF

OME!A 1 FATTY ACIDS

EFFECT OFEFFECT OF 22 11 IMMUNE FUNCTIONIMMUNE FUNCTION

Ref 8



maintainin) cellular inte)rit and function

stimulate natural ?iller cell acti5it a)aints tumourcells and 5irus infected cells

enhance the #roduction of re#air cells ?nown as

enteroctes, and also to #re5ent the loss of im#ortant'acteria in the )ut

NUCLEOTIDE

EFFECT OFEFFECT OF NUCLEOTIDENUCLEOTIDE ONON IMMUNE FUNCTIONIMMUNE FUNCTION

Ref J

% t i



E..ERT4N'#T'3

'N"$3T'EN

'MM4NE

3EM.REM'K$

%acteria

"ungi

.roto5oa

Airus

A2NUTRITION

HI INFECTION

9

3ro'lems in :

(n)estion

a'sor#tionDi)estion

eta'olism

use of nutrients

Diarrhea, 5omitin)

ala'sor#tion

Fe5er

=ei)ht loss

=astin)

+tc Ref H



Nutrition Management in B'A

3ro'lems in :

in)estion

a'sor#tion

Di)estion

eta'olism

use of nutrients

Diarrhea, 5omitin)

ala'sor#tion

Fe5er

=ei)ht loss

=astin)

+tc

General Nutrition

& AdeCuate ener) reCuirement and com#osition& icronutrients

& Fluids

$#ecific Nutrition

& Antioidants

& 3ro'iotics

& (mmunonutrition

Route: oral, enteral, #arenteral

Deli5er: small freCuent, nutrient<dense meals

A##etite stimulants, ana'olic thera#ies

Re)ular eercise and #hsical acti5itRef H



S1 Diet, Immune and Infection

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