Understanding inflammation what does it mean to surgeons Stig Bengmark MD PhD University College UCL

1
Understanding inflammation what
does it mean to surgeons Stig Bengmark MD
PhDUniversity College - UCL, London University,
London, UK

• ESSR, Nimes, France
• May 20-23 2009
• Free and open access!
• 
  

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• A global epidemic of acute and chronic diseases
  
• increasing
• surgery-induced and ICU morbidity?

3
TSUNAMI OF CHRONIC DISEASES (ChDs)World Health
Organization Process for a global strategy on
diet, physical activity and health, Geneva 2003

• 46 of global disease burden
• 59 of global mortality
• 35 million die each year on earth in chronic
  diseases
• and it increases every year

4
EPIDEMIC OF ICU SEPSIS

• 751000 treated annually in the USA (300 mill
  inhabitants) in severe sepsis
• 215 000 deaths
• Increases by 15 per decade
• 10th commonest cause of death Angus DC, Wax RS
  (2001) Crit Care Med 200129109

5
NOSOCOMIAL INFECTIONS- a persistant threat
Liver transplant 50 Stem cell
transplant 50 Liver resection
33Gastric surgery 21Bowel
surgery 19Neurosurgery
18Coronary by-pass 11
Schwartz NN Proc Natl Acad Sci USA,
1994912420-2427Mora NP et al Transpl Proc
1991231528-1530
6
WHY? WHY? WHY? WHY?

• Associated to
• Hospital?
• Surgeon?
• Patient?

7
LESSONS FROM JAPAN
8
MORTALITY per 100 000 inhab. 1995Willcox CF et
al Ann. N.Y. Acad. Sci. 20071114 434455
9
DISESEASE GENETICS

• Studies in Japanese monocygotic twins one
  migrating to USA (Hawaij), one remaning in Japan
  taught us that
  lifestyle is more important than
  genetic predisposition
• healthy lifestyle can prevent disease and
  premature aging

10
THE JAPANESE EXPERIENCEThe age-adjusted death
rate in Prostatic Cancer rose
in 50 years (1948 98) in Japan25-fold
Parallel to increases in intake of egg 7 X
meat 9 X dairy 20 X Ganmaa D et al. Int J
Cancer 200298262-267
11
PROSTATIC CANCER INFLUENCE OF FOODSNegative
Positive

• Restriction in energy intake
• Low-fat diet
• Fish, Marine fish oils-omega-3
• Vitamin D - diet and sunlight
• Fruits vegetables
  tomatoes, onions and garlic, cruciferous
  vegetables, hot chili peppers, turmeric, berries
  ex. pomegranate, red wine, grape seed, hops
  extracts, brazil nuts, mushrooms tea (green
  black)

• Excess energy intake
• High intake of dairy foods
• Meat intake (red meat)
• Processed/ overheated foods
• High sugar intake
• High-fat intake
• Animal fat, saturated fat, trans-fatty acids
• N-6 fatty acids

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MALNUTRITION

• A new definition!

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PREDICTION OF OUTCOME OF MAJOR SURGERY

• The odds ratio for morbidity between well
  nourished and malnourished patients is
• 2.30 (CI 1.43-3.71) - Maastricht Index
• 2.81 (CI 0.79-9.95) - Mini Nutritional
  Assessment
• 3.09 (CI 1.96-4.88) - Subjective Global
  Assessment
• 3.47 (CI 2.12-5.68) - Nutritional Risk Index
• Kuzu MA et al. World J Surg 200630378-390

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CONSEQUENCE OF MALNUTRITION

• than doubles complication rate
• App 50 increase in
• length of hospital stay
• ICU stay
• hospital costs
  Chima CS et al J Am Diet
  Assoc. 1997 Sep97975-978

15
INCIDENCE OF MALNUTRITION

• 34 of hospital patients malnourished (P 0.05)
• Have in average two chronic diseases
  van Bokhorst-de
  van der Schueren MA et al.
  Eur J Clin Nutr
  2005591129-1135

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A NEW HYPOTHESIS
17
A MOTHER OF DISEASE
Bengmark S. J Clin Nutr
2004231256-1266
18
HYPOTHESIS!

• A discrete chronic, oxidative stress-induced
  inflammation precedes paves the way for disease
• - especially for surgical complications

19

• the challenge in critical illness is less the
  infection than the exuberant inflammatory
  response
  Taneja et al Crit Care Med
  20043214601469

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SYSTEMIC INFLAMMATION

• Persons with yet no obvious disease,
  who
  demonstrate higher levels of inflammatory
  markers/s
• C-reactive protein, fibrinogen, factor VIII
  activity, interleukin-6 and TNF-a etc.
• are candidates to develop chronic diseases
  complications to disease
• Finch CE, Crimmins EM Science 2004 30517361739

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DECLINE IN INNATE IMMUNITY

• - Number/function of monocytes/macrophages
• - Expression of Toll-like receptors
• - Production of various cytokines
• - Respiratory burst
• - Reactive nitrogen intermediate production
• - Ability to destroy pathogens
• Dendritic cells are less efficient to activate T
  and B cells
• NK cells show decreased ability of killing tumor
  cells

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IMMUNE DEFICIENCIES

• Under-nourished patients with colorectal cancer
  demonstrate impaired immuno-reactivity
• Preoperatively high levels of IL-1 receptor
  antagonist (IL-1Ra)
• Postoperatively Exaggerated IL-6 increase
• increased postoperative loss of body weight
  
  Miki
  C et al Crit Care Med 200533177-80

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IN FOCUS

• Gastrointestinal tract!
• Respiratory tract!

24
THE IMMUNE SYSTEMBrandtzaeg, P et al
Gastroenterlogy 1989971562-1584
25
AGING ORGAN FUNCTION After Hertoghe T Ann NY
Acad Scien 20051017448-465
26
SINGLE ORGAN FAILURE

• Example severe acute pancreatitis
• Lungs 81 - 91
• Kidneys 4.5 - 5
• Coagulation 4.5 - 14
• McKay CJ, Buter A 20033111-114
• Johnson CD, Abu-Hilal M Gut 2004531340 -1344

27
SMOKING WITH THE STOMACH

• Proinflammatory, often cured, foods (bacon,
  sausage, ham) induce inflammation
• FEV1 reduced when eating cured meats
• 3 to 4 times/mo 11.5 ml
• 5 to 13 times/mo 42.0 ml
• 14 or more times/mo 110 ml
• Jiang R et al Am J Respir Crit Care Med
  2007175798804

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COPD ANTIOXIDANT INTAKETabak C et al Am J
Respir Crit Care Med 2001 1646164

• Study of 13,651 adults of which 16 reported
  COPD
• Intake of solid fruits esp. catechin
  (tea apple) increases
• FEV1 130 ml
• reduces of four main COPD symptoms chronic
  cough, phlegm, breathlessness (p

29
PREOPERATIVE LEVEL OF INFLAMMATION

• regulates postoperative
• immunoparesis

30
ACUTE PHASE RESPONSE

• Rise in cytokines and coagulation factors within
  seconds
• Rise in acute phase reactants with hours
• Disappearance of protective flora 6-8 hrs
• Overgrowth with PPMs after 10-12 hrs and
• TRANSLOCATION

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APR Immunoparesis

• The height of acute phase response in the early
  nervous (inflammatory) phase is
  strongly
  associated with the depth of immunoparesis in the
  subsequent so called immune phase.

32
NARROW THERAPEUTIC WINDOW(24-36hrs) if to
prevent/reduce

• Impaired innate immunity
• Intestinal translocation
• Reduced intestinal motility
• Reduced preventive flora
• Overgrowth of PPMs
• INCREASED MORBIDITY

33
CYTOKINE REACTION IN LIVER TRANSPLANTATION

• than sixfold increase in TNF-alpha and IL-6 at
  the end of the operation indicated that the
  patients would
  develope infections
  Sautner T et al Eur J
  Surg 199516197-101

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INFLAMMATION BALANCE 2 mill
different molecules in absolute
balance homeostasis -
Cannon WB The autonomic nervous system an
interpretention Lancet 19301 1109
35
DISEASE AGING

• Common features Increased oxidative stress
  Limited cell repair
  Poor gene polymorphism Activated
  dead gene programs
  Telomere shortening Impaired circadian cycles
  Reduced synchronization Hormone
  deficiencies

• Common etiology Nutritional Dietary
  Behavioral Lifestyle
  Environmental - illumination
  - indoor pollutants - outdoor
  pollutants - dietary
  pollutants

36
MAJOR INFLUENCES

• Latitude
• Lifestyle

37
VITAMIN D-DEFICIENCY DISEASETouhimaa P
Nutrition Reviews 200866,suppl 2S147S152
38
VITAMIN D BREAST CANCERMohr SB et al Breast J
200814255-60
39
VITAMIN D/s, LATITUDE incidence of
CHDZittermann A et al.
Br J Nutr 200594483-492
40
VITAMIN D TREATMENT

• Supplementation of vitamin D
• suppresses expression of TLR2 , TLR4 protein and
  mRNA in human monocytes
  Sadeghi K et al Eur J Immunol 2006
  36 361370
• prevents coagulation disturbances (LPS-induced
  DIC)
  Asakura H
  et al Thromb Haemost 2001 85 287290
• maintains normal platelet count in exp sepsis
  (CLP)
  Möller
  S et al Int J Med Sci 2007 4190-195

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VITAMIN D INFECTION
42
VITAMIN D DEFICIENCY IN SURGERY

• 85 of hip or knee replacement patients
  Breijawi N et al Eur Surg Res 200942110
• 77 of chronic pancreatitis patients
  Dujsikova H et al Pancreatology
  20088583586
• 57 bariatric surgery patients (79 in Blacks
  and Hispanics)
  Gemmel K et
  al Surg Obes Rel Dis 2009,5, 5459
• 67 of renal transplantation patients
  Ducloux D et al
  Transplantation 200885 17551759
• 95 of Afro-American renal transplant patients
  
  Tripathy SS et al Transplantation
  200885 767770

43
VITAMIN D CARDIAC TRANSPLANTATION

• Low preoperative vitamin D concentrations (1753
  pg/mL) more often seen in non-survivors (58)
  than in survivors (37) (p0.046)
• Non-survivors have higher serum concentrations of
  inflammation markers hsCRP and TNF-alpha
• Zittermann A et al. Transplantation
  200987118124

44
VITAMIN D IN CARDIAC TRANSPLANT PATIENTS
CUMULATIVE 1 YR MORTALITY Zitterman A et
alTransplantation 200987118124
45
VITAMIN D DEFICIENCY COSTSGant WB et al Prog
Biophys Mol Biol 2009, E-pub

• 36 of direct
• 28 of indirect Health Costs associated with
  vitamin D deficiency
• Cardiovascular 13.5 7.5
• Infections incl influenza 7 6.5
• Type 2 diabetes 7 2.4
• Cancer 6.4 9.6
• Osteoporosis 1.5 0.5
• Multiple sclerosis 1 0.2

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SUBSTITUTING VITAMIN DGant WB et al Prog Biophys
Mol Biol 2009, E-pub

• to all European to 40 ng/mL can reduce
  the direct economic burden of disease by 11.4,
  or EUR 105,000 000 000
• the indirect economic burden of disease by 6.4
  or EUR 82,000 000 000
• the total reduction in economic burden of disease
  by 17.7, or
• EUR 187,000 000 000

47
MAJOR INFLUENCES

• Latitude
• Lifestyle

48
DIET AND BREAST CANCERCarroll KK Cancer Res
1975353374-3383
49
DESTABILIZING FACTORS

• Mental and physical stress
• Excess of refined foods fats, sugars,
  dysfunctioning peptides (AGEs ALEs),
  hormones, chemicals (pharma)
  -
  increase prooxidant actions
  - stimulate overexpression of NF-?B,
  COX-2, LOX and iNOS
  
  - destabilize the immune system
  - reduce flora
  -
  decrease resistance to disease

50
PROMOTORS OF INFLAMMATION

• DYSFUNCTIONING PROTEINS
• Advanced Glycation End products (AGEs)
• Advanced Lipoxidation End Products (ALEs)

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AGEs ALEs AMPLIFIERS OF INFLAMMATIONBengmark
S JPEN 200731430-440
52
Louis Camille Maillard
Febr 4 1878 May 2 1936

• Undertook in 1912 studies of the reaction between
  amino acids and sugars, which lead to the
  discovery of the Maillard reaction.
• Suggested this reaction to be the cause of
  chronic (renal) disease
• Recognized by several awards including the the
  French Academy of Medicine award in1914.

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AGEs ALEs IN TISSUES

• Glycated proteins produce app 50 X more free
  radicals than non-glycated
• - accumulate in tissues (amyloid)
  - make the body auto-fluorensing
• reduce antioxidant defense
• impair DNA repair mechanisms
• weaken immune system
• induce inflammation
• facilitate development of disease and
  complications
  
  Thorpe SR, Baynes JW Amino Acids 200325275-281

54
AGEs INFLAMMATIONBohlender JM Am J Physiol
Renal Physiol 2005289F645-659
55
AGEs ALEs ASSOCIATED DISEASES

• Cataract
• Glaucoma
• Macula degeneration
• Diabetes
• Hormone deficiencies
• Polycystic Ovary Syndrome
• Liver cirrhosis
• Chronic pulmonary disorders
• Rheumatoid diseases
• Fibromyalogia
• Ruptured Achilles tendon
• Osteoporosis
• Nephropathies
• Paradontosis

• Aging
• Allergy
• Autoimmune diseases
• Alzheimers disease
• Parkinsons disease
• Amyotrophic lateral sclerosis
• Huntingtons disease
• Stroke
• Familial amyloidotic polyneuropathy
• Creutsfeldt-Jakob disease
• Downs syndrome
• Atherosclerosis
• Cardiovacular disease

56
SOURCES OF AGEsVlassera H Ann N Y Acad Sci
20051043452-460
57
AGEs/ALEs IN FOODS

• HEATED DAIRY powdered milk (ice cream, baby
  clinical nutrition formulas) cheese, espec when
  heated (pizza, tacos, nachos, brown cheeses)
• HEATED GRAIN PRODUCTS Bread esp. toasted bread,
  bread crusts crisp breads
• HEATED MEAT, POULTRY, FISH increases app 10
  times between boiling and oven frying
• - Boiling 1000 kU/serving
• - Oven frying 9000 kU/serving
  
  Goldberg T et al. J Am Diet Assoc
  20041041287-1291
• Food powders ( milk. egg yolk, lecithin)
• Coffee, hard-cured teas, Cola drinks
• Roasted and salted vegetables (peanuts)
• Dark and sugar-rich alcoholic beverages, broth,
• Chinese soy, balsamic vinegars etc

58
DAIRY-INDUCED INFLAMMATION

• Dietary proteins of cows milk induce
  inflammation
• release inflammatory mediators
• increase intestinal permeability
• induce leakage of albumin/hyaluronan
  Jalonen T J Allerg Clin Immunol
  199188737, Isolauri E Gastroenterology
  19931051643, Bengtsson U et al. J Clin Exp
  Allerg 199626197, Allerg Clin Immunol
  1997100216

59
METABOLIC SYNDROME IN COWS

• Modern cow feeds are rich in starch
  carbohydrates (corn, maize grains, barley,
  molasses and dextrose)
• induce also in cows
  Insulin
  resistance
• Insulin-resistance observed in calves fed an
  intensive milk- and lactose diet
  Hostettler-Allen
  RL et al J Anim Sci 199472160-173

60

• AGEs IN VARIOUS MILK PRODUCTS
• Baptista J, Carvalho R
  
  Food Res Int
  200437739-747

61
COLA C0NSUMPTION BONE DENSITYTucker K et al Am
J Clin Nutr 200684936-942
62
ENVIRONMENTAL ENDOCRINE DISRUPTORS

• Up to 80 of milk comes from pregnant cows
  
  contains significant amounts of
  
  Pituitary hormones PRL, GH, TSH, FSH, LH,
  ACTH
  Steroid
  hormones estrogen, progesterone, testosterone etc
  
  Hypothalamic hormones TRH,
  LHRH, GnRH, GRH
  Gastrointestinal peptides
  Halogenated
  aromatic hydrocarbones
  Advanced glycation lipoxidation end
  products (AGEs/ALEs)

63
ESTROGENS IN MILK Malekinejad H et al J Agric
Food Chem 200654 9785-9791

• Dramatic increase in hormone-dependent cancers
  observed (testicular, breast, prostate, ovarian,
  and corpus uteri, and large bowel)
• 60-80 of human estrogen intake originates from
  dairy foods
• The average daily intake of dairy estrogens is
  372 ng dramatically more than
  currently recognized.

64
FREE ESTROGENS IN DAIRY (pg/g) E1
E2 - 17ß E3

• Whole milk 3.7 6.4 9.0 Skimmed milk
  20.2 3.4 8.2 Whey
  3.6 1.5 3.0 Cottage cheese 34.9 10.8
  6.1 Butter 539.4 82.3 86.8
• Wolford ST, Argoudelis CJ
  J Dairy Science
  1979621458-1463

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PN INFECTION

• A significant increase in mortality (63 vs 26)
• in patients with burns, fed with
  parenteral nutrition
  
• Herndon DN et al . J Burn Care Rehabil
  198910309313

66
EN INFECTION

• Increase in bacterial translocation in mice fed
  Vivonex (53), Criticare (67), or Ensure (60)
  vs chow-fed (p
• All three diets induce loss of jejunal and ileal
  mucosal protein content, intestinal microbial
  overgrowth translocation
• Haskel Y et al Crit Care Med 199422108-113

67
ANTIBIOTICS INNATE IMMUNITY

• Chemicals incl antibiotics suppress
  -
  Lymphocyte proliferation
  - Macrophage functions such as
  chemiluminescence response, chemotactic motility,
  bactericidal
• cytostatic ability
  Roszkowski K et al.
  Zeitschr Bakteriol Hyg 1988270270-279
  Pulverer G et al. Zentralbl Bakteriol
  1990272467-476

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REDUCE INFLAMMATION!

• especially
• preoperatively!

69
TAMING INFLAMMATION

• Cox-2 inhibitors
• Rao P, Knaus EE. J Pharm Pharm Sci
  20081181s-110s
• Vitamin D
• Adorini L, Penna G. Handb Exp Pharmacol
  2009188251-273A
• Omega-3
• Calder PC Proc Nutr Soc 200665264-277
• Minerals (zinc, selenium etc)
• Ferencík M, Ebringer L. Folia Microbiol
  200348417-426
• Polyphenol antioxidants
• Bengmark S JPEN J Parenter Enteral Nutr
  20063045-51
• Plant fibres
• Xu D et al JPEN 19982237-41
• Pre-, pro- synbiotics
• Bengmark S Anaesthesiology Clinics of North
  America 200624299-323

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ABDOMINAL ADHESIONS COX-2 INHIBITIONGreene AK
et al Ann Surg 2005242140-146
71
COX-2 INHIBITORS
72
IMMUNONUTRITION IN SURGERY

• 1 lit/d immuno-supportive nutrition (Impact) in
  elective major abdom. surgery patients
• 5 days preop 7 days postop
• Only postop 7 days
  TNF-alpha (postop days 1 and 3) CRP (postop day
  7) were significantly lower in the
  preop postop treated (p
• The length of IMU/ICU stay , hosp stay
  infect rate
• PREPOSTOP 1.9 1.3 days 19.7 2.3 days
  2/14 (14)
• ONLY POSTOP 5.9 0.8 days 29.1 3.6 days
  10/15 (67)
• Giger U et al Ann Surg Oncol 2007142798-2806

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IMMUNO-NUTRITION FORMULAS
74
IMMUNO-NUTRITION INFLAMMATION

• Compared immunomodulatory nutrition (Stresson)
  to standard nutrition (Nutrison) in malnourished
  patients after pancreatduodenectomy.
• Standard nutrition lead to significant elevations
  of PRO-INFLAMMATORY cytokines
• TNF-alpha day 3 (P0.006), day 7 (P
• IL-1beta day 7 (P
• Immunomodulatory nutrition lead to significant
  elevations in ANTI-INFLAMMATORY cytokines
• IL-8 day 1 (P0.011) days 3, 7, 10, 14
  (P
  IL-1ra/s day 7 (P(P0.017)
• Slotwinski R et al. JOP. J Pancreas 2007
  8759-769

75
SUPPLEMENTATION OF FOOD-DERIVED IMMUNO-NUTRIENTS
76
BIOLOGICAL REDUCTION Examples
bioflavonoids, polyphenols etc

• isothiocyanates in cruciferous vegetables,
  anthocyanins and hydroxycinnamic acids in
  cherries, epigallocatechin-3-gallate (EGCG) in
  green tee, chlorogenic acid and caffeic acid in
  fresh coffee beans and also fresh tobacco leaves,
  capsaicin in hot chili peppers, chalcones in
  apples, euginol in cloves, gallic acid in
  rhubarb, hisperitin in citrus fruits, naringenin
  in citrus fruits, kaempferol in white cabbage,
  myricetin in berries, rutin and quercetin in
  apples and onions, resveratrol and other
  procyanidin dimers in red wine and virgin
  peanuts, various curcumenoids, the main yellow
  pigments in turmeric curry foods, and daidzein
  and genistein from the soy bean

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NUTRIENTS IN NUTS Ros E J Am Clin Nutr 2009
E-pub
78
TURMERIC - Curcumin
79
A SHIELD AGAINST ACUTE AND CHRONIC DISEASE
Bengmark S JPEN J Parenter Enteral Nutr.
20063045-51
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CURCUMIN-REDUCED SEPSIS

• Curcumin attenuates endotoxin-induced
  coagulopathy prevents disseminated
  intravascular coagulation (DIC)
• Chen HW et al J Endotoxin Res 20071315-23
• Curcumin pretreatment (3 d) before cecal ligation
  and puncture
• prevents cellular alterations in macrophages
• decreases expression of TNF-a,
• - down-regulates PPAR-? in organs (liver)
• - reduces tissue injury and mortality
• Siddiqui AM et al Crit Care Med 2006 341874-1882

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PRE-, PRO-, SYNBIOTICS
83
BIOECOLOGICAL CONTROLBengmark S Anesthesiol
Clin N Amer 200624 299-323
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ROLE OF FLORA/PROBIOTICS

• - Modulates the innate and adaptive immune
  defence mechanisms
• - Synthesizes releases numerous nutrient
  antioxidants, growth-, coagulation and other
  factors
• - Controls GI motility
• - Reduces potentially pathogenic micro-
  organisms/PPMs
• - Reduces/eliminates the content of various
  toxins, mutagens, carcinogens
• - Promotes apoptosis

86
LACTOBACILLUS CONSUMPTION

• Improves specific immune functions
• Increases natural killer cell activity
• Takeda K, Okumura K. J Nutr 2007 137791S793S
• Increases phagocytic activity of PBMCs
  Gill HS et al. Am J
  Clin Nutr 2001 74833839.
• Reduces the incidence of winter infections
• Turchet P, et al. J Nutr Health Aging
  200377577
• Decreases the level by macrophages of TNFa
  Matsumoto M, Benno Y. Biosci Biotechnol Biochem
  2006 7012871292

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REDUCED INFECTION RATE

• Ex. pancreatdoudenectomy Probiotic treatment
  (lactic acid bacteria) from 53 23 (P
  0.02)Nomura T et al Hepatogastroenterol
  200754661-663synbiotic treatment (lactic
  acid bacteria fibres)from 40 12.5 (P
  0.05) Rayes N et al Ann Surg 200724636-41

88
SYNBIOTIC 2000 IN PANCREATECTOMY Rayes N et al.
Ann Surg 200724636-41

• Synbiotic 2000 Only fibers
• Enterobacter cloacae 2
  8
• Enterococcus faecalis/faecium 1 7
• Escherichia coli 0
  7
• Klebsiella pneumoniae 2
  2
• Proteus mirabilis 1
  1
• Staphylococcus aureus 0
  2 Total
  6 27

89
SYNBIOTIC 2000 IN LIVER TRANSPLANTATION

• 50 to 85 of transplant patients develop
  nosocomial infections within 30 days.
• Synbiotic 2000 or Only fibres daily
  from the day before
  surgery
  during 14 postop days
• 30 day-infection rate
• Synbiotic 2000 1/33 - 3
• Only fibres 17/33 - 51
• Rayes N et al. Am J Transplant 20055125-131

90
SYNBIOTIC 2000 IN LIVER TRANSPLANTATION

• Isolated bacteria Synbiotic Fibres only
  
• Enterococcus faecalis 1
  11
• Escherichia coli 0 3
• Enterobacter cloacae 0
  2
• Pseudomonas aeruginosa 0 2
• Staphylococcus aureus 0 1
• (total
  1) (total 18)
  Rayes N et al. Am J
  Transplant 20055125-131

91
LESSONS TO LEARN?
92
EASE INFLAMMATION

• E ELIMINATE/MINIMIZE intake of proinflammatory
  nutrients pharmaA ADD physical exercise
  stress control to the extent possibleS
  SUPPLEMENT anti-inflammatory nutrients
  omega-3, various B D vitamins, zinc
  polyphenols E EAT/FEED non-processed fresh
  fruit and vegetable juices - gaspacho

93
I AVOID/REDUCE FOODS

• hormone-rich (dairy)
• cured (ex. peanuts, bacon, sausages)
• heated to 100 C, and not for 2-3 min
• calorie-condensed (animal fat, sugars)
• containing fructose concentrates
• high fructose corn syrup (HFCS), modified corn
  starch, E1442(carbonated drinks)
• made from concentrates (ex. fruit juices)
• dehydrogenated/partly dehydrogenated
• directly/indirectly involving GMOs

94
LESSON FROM FRANCE?
95
Pierre Mendès France premier minister of France
1954 - 1955

• proclaimed milk - not wine - as the right
  beverage for the French people

96
France a micro-globe

• Great differences
• in pattern of chronic diseases between
• Northern
• milk and bear-drinking
• and
• Southern wine-drinking
• France

97
A NEW TIME!

• New challenges!

98
The sickest patient, the
critically ill often elderly patient Is in
constant mental physical stressCannot
exerciseReceives the worst food

• THE DILEMMA!

99
Our goal must be to provide the pleasure
benefit of eating also to the very sick
Enjoying French? cuisine Bernard Launois,
Professor of Surgery, Rennes, Fr  Président de
l'Académie nationale de chirurgie   l'un des
pionniers de la greffe d'organes   la première
greffe du foie au CHU Rennes
21 Avril 1978
100
FUTURE NUTRITION OF THE SICK PATIENT?Hospital-pro
duced absolutely fresh!
101
THANK YOU!s.bengmark_at_ucl.ac.uk