Changes

Chapters for further reading –

Chapters for further reading –

[[. Matrashiteeya Adhyaya]]

 

[[ Matrashiteeya Adhyaya]]

[[ Yajjah Purushiya Adhyaya]]

[[ Yajjah Purushiya Adhyaya]]

Complex network of signals has been involved in development of satiation and satiety. Satiation and satiety involves mechanism which exert their effect through physiological and/or psychological processes. Satiation can modulate the size of meals consumed, controls how much to consume. The physiological mechanism, as outlined by Benelam B. has been referred along with current knowledge which will help to explicit the concept and support to develop objective parameters to asses proper quantity of food (Ahara Matra) –

Complex network of signals has been involved in development of satiation and satiety. Satiation and satiety involves mechanism which exert their effect through physiological and/or psychological processes. Satiation can modulate the size of meals consumed, controls how much to consume. The physiological mechanism, as outlined by Benelam B. has been referred along with current knowledge which will help to explicit the concept and support to develop objective parameters to asses proper quantity of food (Ahara Matra) –

1. Sensory and cognitive factors – Sensory and cognitive factors affect intake of food predominantly. Foods sensory properties like taste, smell, texture, appearance, and food type to be consumed affect satiation in the initial period. These sensory specific properties of food are linked with the sensory specific satiety. Sørensen LB et al have reviewed the multiple aspects related to sensory perception of food and their role in appetite regulation. Sensory-specific satiety has an important influence on the amount of food eaten. Palatability of food greatly influences appetite and food intake. Increase in food variety observed rise in quantity of food and energy intake. This study also reviewed standard procedure to test sensory-specific satiety and identified flavor, texture and appearance-specific satieties.  

1. '''Sensory and cognitive factors''' :

 

Sensory and cognitive factors affect intake of food predominantly. Foods sensory properties like taste, smell, texture, appearance, and food type to be consumed affect satiation in the initial period. These sensory specific properties of food are linked with the sensory specific satiety. Sorensen LB et al have reviewed the multiple aspects related to sensory perception of food and their role in appetite regulation. Sensory-specific satiety has an important influence on the amount of food eaten. Palatability of food greatly influences appetite and food intake. Increase in food variety observed rise in quantity of food and energy intake. This study also reviewed standard procedure to test sensory-specific satiety and identified flavor, texture and appearance-specific satieties.  

Variety in food and pleasantness of food to sensory organs increase the intake of food. De Graaf C et al concluded that pleasantness of food affect satiation but do not have significant effect on satiety  . The sensory-specific satiety phenomenon has been explained by Rolls et al with reference to sight and test of food  . Study of Spetter M S et al shows that oral food ingestion evokes greater neural activation of brain signaling pathways specifically in the midbrain, amygdala, hypothalamus, and hippocampus area neural activity related to sensory-specific satiety.

Variety in food and pleasantness of food to sensory organs increase the intake of food. De Graaf C et al concluded that pleasantness of food affect satiation but do not have significant effect on satiety  . The sensory-specific satiety phenomenon has been explained by Rolls et al with reference to sight and test of food  . Study of Spetter M S et al shows that oral food ingestion evokes greater neural activation of brain signaling pathways specifically in the midbrain, amygdala, hypothalamus, and hippocampus area neural activity related to sensory-specific satiety.

2. Gastric mechanism of satiation-

2. '''Gastric mechanism of satiation:'''

a) Gastric distention- Stomach functions as key component in digestion. It acts as a reservoir of food. The reservoir capacity of the stomach allows it to increase its volume significantly. Its capacity limits the amount of food to be ingested. Stomach distention significantly controls the food intake and satiety.Geliebter A and team while assessing the changes in gastric capacity of obese patients determined the gastric capacity by oral insertion of a latex gastric balloon method .In other works also this is used as a tool to assess the gastric capacity.

a)'''Gastric distention'''- Stomach functions as key component in digestion. It acts as a reservoir of food. The reservoir capacity of the stomach allows it to increase its volume significantly. Its capacity limits the amount of food to be ingested. Stomach distention significantly controls the food intake and satiety.Geliebter A and team while assessing the changes in gastric capacity of obese patients determined the gastric capacity by oral insertion of a latex gastric balloon method .In other works also this is used as a tool to assess the gastric capacity.

b) Gastric and Intestinal Signals – In response to the food many gut peptides are secreted from enteroendocrine cells, which play essential role in regulating food. Steinert RE et al reveals that along with gastric distention, Gastric and intestinal signals (increased GLP-1 and PYY secretions and reduction in plasma ghrelin secretions) synergies to support satiation.

b)'''Gastric and Intestinal Signals''' – In response to the food many gut peptides are secreted from enteroendocrine cells, which play essential role in regulating food. Steinert RE et al reveals that along with gastric distention, Gastric and intestinal signals (increased GLP-1 and PYY secretions and reduction in plasma ghrelin secretions) synergies to support satiation.

Gut hormones such as cholecystokinin (CCK) and GLP-1, Oxyntomodulin (OXM), Peptide YY, Pancreatic polypeptide (PP) these are the important gut hormones involved in the mechanism of satiation, plays significant role in termination of meal. CCK is considered as potential biomarker for satiation  . Oxyntomodulin (OXM) delays gastric emptying and reduces gastric acid secretion, decrease food intake.  

Gut hormones such as cholecystokinin (CCK) and GLP-1, Oxyntomodulin (OXM), Peptide YY, Pancreatic polypeptide (PP) these are the important gut hormones involved in the mechanism of satiation, plays significant role in termination of meal. CCK is considered as potential biomarker for satiation  . Oxyntomodulin (OXM) delays gastric emptying and reduces gastric acid secretion, decrease food intake.  

Gut-Brain axis has bidirectional communication between central and enteric nervous system. It connects emotional and cognitive centers of brain to peripheral intestinal functions. By means of neural, endocrine, immune, and humoral links gut microbiota interact with GBA axis .Marilia Carabotti et al in there review article have explored these interactions, as well as the possible pathophysiological mechanisms involved. Microbiota-gut-brain axis monitors and integrates gut functions and links emotional and cognitive centers of the brain with peripheral intestinal functions. This complex network includes central nervous system (CNS), the autonomic nervous system (ANS), the enteric nervous system (ENS) and the hypothalamic pituitary adrenal (HPA) axis. Central nervous system communicates with enteric nervous system (ENS), intestinal muscle layers and gut mucosa through various afferent and efferent autonomic pathways. Gastrointestinal wall connect with CNS through enteric, spinal and vagal efferent pathways. Limbic system which includes Amygdala (AMG), hippocampus (HIPP), and hypothalamus (HYP): predominantly responsible for memory and emotional responses. Hypothalamic pituitary adrenal (HPA) axis which is a part of limbic system activates in response to emotional stress and releases corticotropin-releasing factor (CRF) from the hypothalamus. CRF further stimulates adrenocorticotropic hormone (ACTH) secretion from the pituitary gland, causing the secretion of cortisol (main Stress hormone) from the adrenal glands. This hormone affects brain functions. Brain through neural communication influences various intestinal cell targets. The Gut microbiota also influences these same cells.  Gut microbiota interact locally with intestinal cells and enteric nervous system (ENS), it also connect with central nervous system (CNS) through neuroendocrine and metabolic pathways .

Gut-Brain axis has bidirectional communication between central and enteric nervous system. It connects emotional and cognitive centers of brain to peripheral intestinal functions. By means of neural, endocrine, immune, and humoral links gut microbiota interact with GBA axis .Marilia Carabotti et al in there review article have explored these interactions, as well as the possible pathophysiological mechanisms involved. Microbiota-gut-brain axis monitors and integrates gut functions and links emotional and cognitive centers of the brain with peripheral intestinal functions. This complex network includes central nervous system (CNS), the autonomic nervous system (ANS), the enteric nervous system (ENS) and the hypothalamic pituitary adrenal (HPA) axis. Central nervous system communicates with enteric nervous system (ENS), intestinal muscle layers and gut mucosa through various afferent and efferent autonomic pathways. Gastrointestinal wall connect with CNS through enteric, spinal and vagal efferent pathways. Limbic system which includes Amygdala (AMG), hippocampus (HIPP), and hypothalamus (HYP): predominantly responsible for memory and emotional responses. Hypothalamic pituitary adrenal (HPA) axis which is a part of limbic system activates in response to emotional stress and releases corticotropin-releasing factor (CRF) from the hypothalamus. CRF further stimulates adrenocorticotropic hormone (ACTH) secretion from the pituitary gland, causing the secretion of cortisol (main Stress hormone) from the adrenal glands. This hormone affects brain functions. Brain through neural communication influences various intestinal cell targets. The Gut microbiota also influences these same cells.  Gut microbiota interact locally with intestinal cells and enteric nervous system (ENS), it also connect with central nervous system (CNS) through neuroendocrine and metabolic pathways .

 

 

Microbiome gut-brain axis structure

Microbiome gut-brain axis structure

Review article of Clair R. Martin et al states that Gut microbes communicate to the central nervous system through at least 3 parallel and interacting channels involving nervous, endocrine, and immune signaling mechanisms. Based on preclinical and clinical evidence from various studies, scholars have concluded that  brain by affecting community structure and functions of gut microbiota can modulate regional gut motility, intestinal transit and secretion, and gut permeability, and potentially through the luminal secretion of hormones that directly modulate microbial gene expression .  

Review article of Clair R. Martin et al states that Gut microbes communicate to the central nervous system through at least 3 parallel and interacting channels involving nervous, endocrine, and immune signaling mechanisms. Based on preclinical and clinical evidence from various studies, scholars have concluded that  brain by affecting community structure and functions of gut microbiota can modulate regional gut motility, intestinal transit and secretion, and gut permeability, and potentially through the luminal secretion of hormones that directly modulate microbial gene expression .  

 

'''Insufficient /Deficient Quantity of Food'''-  

 

Insufficient /Deficient Quantity of Food-  

Less quantity of food need be consider under two viewpoints: Total quantity of a meal (Sarvagraha matra)) and quantity of each food item of a meal (Parigraha matra). While serving different food articles in a meal (which is termed as parigraha matra) one must ascertain inclusion of all the six rasas (tastes) in required proportion. Nutritional requirement of body tissues will be fulfilled by inclusion of all the six rasas (tastes) in desired proportion (Principle of Shadrasa).  Biomedical fundamentals of nutrition, macronutrients and micronutrients need to be studied in correlation with Six Rasa principle to offer better nutritional solutions to the society.

Less quantity of food need be consider under two viewpoints: Total quantity of a meal (Sarvagraha matra)) and quantity of each food item of a meal (Parigraha matra). While serving different food articles in a meal (which is termed as parigraha matra) one must ascertain inclusion of all the six rasas (tastes) in required proportion. Nutritional requirement of body tissues will be fulfilled by inclusion of all the six rasas (tastes) in desired proportion (Principle of Shadrasa).  Biomedical fundamentals of nutrition, macronutrients and micronutrients need to be studied in correlation with Six Rasa principle to offer better nutritional solutions to the society.

   

   

Malnutrition generally implies undernutrition but also includes other deviations like energy undernutrition and over-nutrition. Malnutrition starts due to deficiencies of specific nutrients or from diets based on inadequate and or inappropriate combinations or proportions of foods. Undernutrition is caused primarily due to an inadequate intake of dietary energy. The impact of a deficient diet on an individual is mainly depending on age factor. Age reflects the condition of body tissues. Body tissues (dhatu) attain different stages form immature growing state of childhood, to the attainment of all the qualities and strength of body tissues in young age, which further slowly enters the state of depletion in old age. Nutritional requirement of body tissues differs according to age. Considering the age of a person, consequences arise due to inadequate diet is discussed under two categories- a) Childhood age  b) Adult age.

Malnutrition generally implies undernutrition but also includes other deviations like energy undernutrition and over-nutrition. Malnutrition starts due to deficiencies of specific nutrients or from diets based on inadequate and or inappropriate combinations or proportions of foods. Undernutrition is caused primarily due to an inadequate intake of dietary energy. The impact of a deficient diet on an individual is mainly depending on age factor. Age reflects the condition of body tissues. Body tissues (dhatu) attain different stages form immature growing state of childhood, to the attainment of all the qualities and strength of body tissues in young age, which further slowly enters the state of depletion in old age. Nutritional requirement of body tissues differs according to age. Considering the age of a person, consequences arise due to inadequate diet is discussed under two categories- a) Childhood age  b) Adult age.

World health organization explains the malnutrition phenomenon of childhood age under four categories: Stunting, Wasting and overweight and underweight   

World health organization explains the malnutrition phenomenon of childhood age under four categories: Stunting, Wasting and overweight and underweight   

    

    

1.Stunting (height-for-age below –2 SD) refers to a child who is too short for his or her age. It is the devastating result of poor nutrition during early childhood. These children fell to attain complete possible height. It also hampers cognitive development.

1.'''Stunting''' (height-for-age below –2 SD) refers to a child who is too short for his or her age. It is the devastating result of poor nutrition during early childhood. These children fell to attain complete possible height. It also hampers cognitive development.

 

2.'''Wasting''' (weight-for-height below –2SD) refers to a too thin child for his or her height. It results due to poor nutrient intake. Children suffering from wasting have weakened immunity, suffers long term developmental delay.

2.Wasting (weight-for-height below –2SD) refers to a too thin child for his or her height. It results due to poor nutrient intake. Children suffering from wasting have weakened immunity, suffers long term developmental delay.

3.'''Childhood overweight''' (weight-for-height above +2SD )and obesity are considered an emerging face of malnutrition, resulting in unhealthy, processed food. In later life this increases the risk for diet related non communicable diseases.

3.Childhood overweight (weight-for-height above +2SD )and obesity are considered an emerging face of malnutrition, resulting in unhealthy, processed food. In later life this increases the risk for diet related non communicable diseases.

4.'''Underweight'''- (refers weight-for-age below –2SD)  

4.Underweight- (refers weight-for-age below –2SD)

'''Determinants of under nutrition'''-  

Determinants of undernutrition-  Faustin Habyarimana found key determinants of malnutrition of children below five years of age: age, gender, birth weights, mother’s knowledge of nutrition, birth order, incidence of recent fever, multiple pregnancies, education level of the mother, age of the mother at childbirth, body mass index, prevalence of anemia, province, source of drinking water and wealth quintiles. A positive correlation between stunting and underweight and wasting and underweight was also found.

Faustin Habyarimana found key determinants of malnutrition of children below five years of age: age, gender, birth weights, mother’s knowledge of nutrition, birth order, incidence of recent fever, multiple pregnancies, education level of the mother, age of the mother at childbirth, body mass index, prevalence of anemia, province, source of drinking water and wealth quintiles. A positive correlation between stunting and underweight and wasting and underweight was also found.

'''Consequences of undernutrition:'''  The consequences of poor nutrition include impaired growth, poor cognitive and social development, poor school performance, increased risk of morbidity and mortality and reduced productivity later in life . Malnutrition in children’s by impacting cognitive functions, further impend individuals’ ability to lead productive lives and thus contribute to poverty.

'''Consequences of under-nutrition:'''  The consequences of poor nutrition include impaired growth, poor cognitive and social development, poor school performance, increased risk of morbidity and mortality and reduced productivity later in life . Malnutrition in children’s by impacting cognitive functions, further impend individuals’ ability to lead productive lives and thus contribute to poverty.

'''Undernutrition in adults-'''

'''Under-nutrition in adults-'''

Undernutrition in adults can be correlated with the etiopathogenesis of Karshya described in Ayurveda classics.  Undernourishment may be caused by the lack of one or more nutrients (under‐nutrition), or an excess of nutrients (over‐nutrition). Physiological changes associated with the process of ageing may further support malnutrition.

Under-nutrition in adults can be correlated with the etiopathogenesis of Karshya described in Ayurveda classics.  Undernourishment may be caused by the lack of one or more nutrients (under‐nutrition), or an excess of nutrients (over‐nutrition). Physiological changes associated with the process of ageing may further support malnutrition.

Determinants- Hickson M has Categorized the causes of malnutrition under three category as medical factos (like poor appetite, physical disability, endocrine disorders etc), lifestyle and social factors (lack of knowledge of nutrition, loneliness, povery etc.) and psychological factors .  Morley JE has enumerated the major causes of malnutrition as lack of food, paranoia, emotional factors (like depression), inappropriate dieting, anorexia, problem with feeding (tremors, dementia, functional impairment, and dysphagia), Enteral problems (e.g., gluten enteropathy), Wandering and other dementia related factors and malabsorption.

Determinants- Hickson M has Categorized the causes of malnutrition under three category as medical factos (like poor appetite, physical disability, endocrine disorders etc), lifestyle and social factors (lack of knowledge of nutrition, loneliness, povery etc.) and psychological factors .  Morley JE has enumerated the major causes of malnutrition as lack of food, paranoia, emotional factors (like depression), inappropriate dieting, anorexia, problem with feeding (tremors, dementia, functional impairment, and dysphagia), Enteral problems (e.g., gluten enteropathy), Wandering and other dementia related factors and malabsorption.

Old age persons are at high risk of developing protein-energy malnutrition. It affects health, congnitive and physical functions as well as quality of life. Study concludes that increasing age, unmarried/separated/divorced status, difficulties walking 100 m, climbing stairs and hospitalization, cognitive impairment or receiving social support are the major predictors of malnutrition.  

Old age persons are at high risk of developing protein-energy malnutrition. It affects health, cognitive and physical functions as well as quality of life. Study concludes that increasing age, unmarried/separated/divorced status, difficulties walking 100 m, climbing stairs and hospitalization, cognitive impairment or receiving social support are the major predictors of malnutrition.  

Shetty P has validated scoring systems such as MUST, which indicates patients at risk of malnutrition. BMI less than 18.5 kg/m2 is a sign of undernutrition. Laboratory investigations like hemoglobin or packed cell volume (indicators of anemia, hydration), blood urea (indicating hydration and  protein intake), C-reactive protein and ESR (inflammatory pathology), total lymphocyte count (for immune function) are also suggested to aid early diagnosis.Donini LM et al developed and validated a screening tool for the easy detection and reporting of both undernutrition and over-nutrition, two types of malnutrition . A systematic review to evaluate malnutrition biomarkers among older adults, concluded that BMI, hemoglobin, and total cholesterol are useful biomarkers of malnutrition in older adults.  

Shetty P has validated scoring systems such as MUST, which indicates patients at risk of malnutrition. BMI less than 18.5 kg/m2 is a sign of undernutrition. Laboratory investigations like hemoglobin or packed cell volume (indicators of anemia, hydration), blood urea (indicating hydration and  protein intake), C-reactive protein and ESR (inflammatory pathology), total lymphocyte count (for immune function) are also suggested to aid early diagnosis.Donini LM et al developed and validated a screening tool for the easy detection and reporting of both undernutrition and over-nutrition, two types of malnutrition. A systematic review to evaluate malnutrition biomarkers among older adults, concluded that BMI, hemoglobin, and total cholesterol are useful biomarkers of malnutrition in older adults.

Consequences : Malnutrition in adults is greatly associated with risk of sarcopenia, frailty, falls, dependence in activities, respiratory muscle wasting, effects musculoskeletal system,  experience metabolic changes in cellular electrolytes including calcium accumulation, reduced resistance to infection, poor functioning of excretory systems, longer hospital stay, poor response to other medical conditions. Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength and it is strictly correlated with physical disability, poor quality of life and death . Cachexia is a multifactorial syndrome with involuntary progressive weight loss as a result of reduction of skeletal muscle mass with or without depletion of adipose tissue . Frailty is a common clinical syndrome in older adults and is associated with poor health outcomes including falls, disability, hospitalization, decline in functions of various physiological systems and mortality.

'''Consequences''' : Malnutrition in adults is greatly associated with risk of sarcopenia, frailty, falls, dependence in activities, respiratory muscle wasting, effects musculoskeletal system,  experience metabolic changes in cellular electrolytes including calcium accumulation, reduced resistance to infection, poor functioning of excretory systems, longer hospital stay, poor response to other medical conditions. Sarcopenia is a syndrome characterized by progressive and generalized loss of skeletal muscle mass and strength and it is strictly correlated with physical disability, poor quality of life and death.Cachexia is a multifactorial syndrome with involuntary progressive weight loss as a result of reduction of skeletal muscle mass with or without depletion of adipose tissue.Frailty is a common clinical syndrome in older adults and is associated with poor health outcomes including falls, disability, hospitalization, decline in functions of various physiological systems and mortality.

'''Treatment strategies-'''  

'''Treatment strategies-'''  

Provide dietary solutions considering Guts changes of the elderly.  

Provide dietary solutions considering Guts changes of the elderly.  

Manipulation in energy / nutritive density of food .

Manipulation in energy / nutritive density of food.

 

Changes in hedonic pattern (taste, flavor, appearance) of foods.

Changes in hedonic pattern (taste, flavor, appearance) of foods.

Provide healthy environment to support emotional quotient.

Provide healthy environment to support emotional quotient.

Provide feeding assistance.

Provide feeding assistance.

Give motivation for physical activities .

 

Adopt interdisciplinary approach like inclusion of Yoga techniques to improve mental health .

Give motivation for physical activities.

 

Adopt interdisciplinary approach like inclusion of Yoga techniques to improve mental health.

'''Ama-'''  

'''Ama-'''  

===Abbreviations==

===Abbreviations==

*Cha.Sa. – Charak Samhita  

*Cha.Sa. – Charak Samhita