Zaporizhia State Medical University, Zaporіzhіа, Ukraine
SUMMARY. Three quarters of the population suffer from alimentary diseases. Dietology is an integral part of the treatment process. It significantly improves the effectiveness of treatment in the public health system. The dominant feature of it is the creation of the design of health programs for the sick person.
Purpose of the Study. Substantiation of innovative alimentary technologies of dietary support in the system of public health.
Materials and Methods of Research. The materials of the official reports of the Ministry of Health of Ukraine and UNAIDS about the state of health of the population for 2014-2016 are analyzed. Medical and statistical method and the method of system analysis were used.
Results of the Study and Discussion. The current state of Ukrainian community population health is characterized by crisis phenomena. The age-standardized mortality from non-infectious diseases is significantly higher than in the European Region and the World as a whole. Especially high mortality is in men. The transformation of the age structure of the population makes the «crisis of aging» closer. Specific features of morbidity include high levels of primary morbidity of the working age population and a significant accumulation of chronic pathology in old age. This fact determines the increase of the volume of medical services and the widespread use of innovative alimentary technologies, which serve as a necessary background for therapeutic agents.
Conclusions. Public health of the population of Ukraine is characterized by high mortality from non-infectious diseases, marked demographic aging, high level of primary morbidity of the working age population, polymorbidity in older age. Due to critical phenomena in the state of public health of the population, the volume of necessary assistance substantially increases and requires the intensive application of innovative nutritional technologies. Promising alimentary technologies are metabolic therapy, nutritional support and dietary support of the treatment process.
Key Words: alimentary technologies, innovation, health, nutrition.
Contemporary understanding of a healthy diet is based on the law of optimal nutrition, which implies a balance between dietary energy values and energy expenditures and physiologically appropriate ratios of dietary chemical composition. Three-quarters of the global population have alimentary-dependent diseases triggered and maintained by improper nutrition. The concept of customization of standard diet therapy for the non-infectious disease is based on the pathogenesis of various hormonal, immunological and antioxidant status disorders. This is why alimentary technologies are viewed as an integral part of medical treatment. Clinical nutrition is a mandatory therapeutic factor in chronic disease or in cases of exacerbations of the disease. It is intended to target clinical manifestations of the disease, impaired regulatory systems and metabolic disorders [1, 2].
Clinical nutrition is an integral constituent of multi-modality treatment. Using specialized sets of food products, methods of cooking and dietary patterns have positive effects on fundamental pathogenetic mechanisms of the disease and recover the impaired metabolic conveyor. In other words, by changing dietary patterns it is possible to meet the nutrient needs of the sick person with due regard for pathogenesis, clinical presentation and current stage of his/her disease as well as individual metabolic profile. It is quite important that alimentary technologies serve as an essential background for the use of therapeutic combinations. A correctly organized clinical nutrition is the most organic and natural method for treatment and rehabilitation in dysfunctional disorders [1, 3].
Objective of the study. Providing a rationale for innovative alimentary technologies of dietary support as part of the public health system.
Materials and methods of the study. The study has reviewed official reports by the MoH of Ukraine and UNAIDS concerning the population health from 2014 to 2016 [7-9]. This study used a medical statistical method and a system analysis method. Statistical processing of data was carried out using parametric and nonparametric statistics (with Descriptive Statistics capability of the Statistica 6.0 software package).
Results and discussion. Analysis of primary population morbidity has shown it to be virtually stable in 2014–2016 (see Table).
Table
Changes of primary morbidity with time and the prevalence of the disease among the population of Ukraine, cases/100,000 residents
Throughout this period, the highest rates of primary morbidity were seen in the employable population (54.118.2 to 55.919.2 cases/100,000 residents). There was a small upward trend in the latter period. The prevalence of the disease in the employable population was characterized by a more pronounced trend. Thus, annual growth rates in the population of working age were 1.2 %. Age-wise, higher prevalence of the disease is seen in the elderly population (an 81.8 % to 88.0 % difference); that is, chronic disease accumulates with age. Taking into consideration the decrease in professional and physical activity, these facts suggest the trend towards health deterioration with age. An increase in polymorbidity should also be pointed out in older age persons. Each person has 2.5 chronic morbidities on average. Indices of mortality are another confirmation of adverse trends in national healthcare. Both in Ukraine and in the European region, age-standardized overall mortality was higher due to infectious disease. However, the respective levels in Ukraine were higher (by 881 cases/100,000 (р < 0.05), a 1.5-fold difference compared to the European region. That said, non-infectious mortality in Ukraine was significantly higher compared to the European region and to the world as a whole. In particular, the standardized four-disease mortality rate (due to cardiovascular, cancer, diabetes and chronic respiratory disease) in Ukraine exceed the European average by 262.9 cases/100,000 (р < 0.05). It should be noted that young males (30 to 44 years of age) die 6 times more often than their EU peers do; in other words, people often die at a substantially younger age.The transformation of the age structure of the population documented in recent years can be referred to as the ageing crisis. Ukrainian population is one of the world’s 30 oldest. Thus, 22.1 % of the country’s population is beyond employable age; according to UN ageing scale, this translates into a very old population [9, 10]. The specific characteristic of Ukraine is that by the time of reaching an advanced age, the majority of the population acquires a number of various medical conditions and accumulates chronic disease. This means increasing volumes of healthcare demands.Thus, the crisis of population health highlights priorities for improved organization of health coverage, including implementation of alimentary technologies. Healthcare utilization is known to escalate with increasing multi-morbidity conditions and functional limitations. Such services are in the greatest demand by people with chronic conditions and functional limitations [5, 10, 11].Innovative alimentary technologies are one of the most important therapeutic and rehabilitative interventions aimed at restoration, preservation and strengthening of health. Global experience testifies that metabolic therapy, nutritional support and dietary support of treatment are the most promising interventions [4, 5, 9, 10]. The only way to achieve significant progress in public healthcare is to substantiate and to implement innovation programs.On the one hand, the patterns found during the study characterize population health; on the other hand, they highlight the priorities in the organization of medical services. The specific characteristic of Ukraine is that its population acquires a number of various diseases much earlier. As part of the therapeutic process, alimentary technologies allow reducing the doses and the duration of synthetic pharmaceuticals, reduce the risk of polypharmacy when using combinations of several synthetic pharmaceuticals and minimize the negative consequences of drug therapy. They also increase the adequacy of customized optimization of diets and enhance therapeutic effects.
The main principles of innovative alimentary technologies include the following: food processing/cooking and dietary pattern should be adequate for: the metabolic conveyor; food technology, chemical composition and energy value of diet appropriate for the specific characteristics of pathogenesis of the disease; individualized adjustment of chemical composition and energy value of the diet; enrichment of the diet with essential nutritive factors; dietetic coaching and gradual approximation of the patient’s diet to the diet of a healthy individual; taking into consideration drug and food interactions; wide use of composite and vitamin-protein-mineral complexes when cooking food; restricting the use of mixtures where clinical effects are unknown.
The principle of metabolism-adequate organization of nutrition is implemented by taking into account the specific features of absorption and digestion of food in the GI tract, the transport of nutrients to the cell, biochemical conversions of nutrients into intracellular structures and elimination of metabolic products from the body. The principle of adaptation of nutrition to the pathogenesis of the disease is implemented by taking into consideration local effects of food (chemical, mechanical, thermal, etc.) in a setting of different pathogenesis, as well as the specific features of general effect in the affected organ. The principle of customized (individualized) nutrition is implemented according to the nature of the underlying disease and/or comorbidities, specific features of clinical course and stage of the disease, tolerability of specific food products, gender, age and body weight, as well as the condition of the mastication apparatus. The principle of enrichment of diet with the essential nutritive factors is implemented by the additional use of essential amino acids, vitamins, dietary fibre, adsorbents, polyunsaturated fatty acids and essential biological micro- and macroelements. Implementation of the principle of interaction of food with the pharmaceutical agents is performed by taking into consideration the assimilation of pharmaceutical drugs depending on nutritional patterns, the risk of alimentary deficiency secondary to pharmaceutical treatments, metabolic impacts of pharmaceutical drugs and potentiation of pharmacological effects by consumption of specific foods.
Personalized alimentary technologies employed in various abnormal conditions are based on the assessment of individual needs of the patient taking into consideration the specific features of pathogenesis, the course of the disease, patient’s metabolism and prognostic risks of deterioration of disease and disorders of the metabolic conveyor.
The algorithm to provide rationales for personalized diets within innovative technologies involves the following: assessment of metabolism and genetic risk for potential metabolic disorders and disease, establishing the pattern of the course of disease and taking into consideration the alimentary preferences used as the basis to modify diet; all of the above are used to modify the technology of food processing/ cooking and the dietary pattern in general.
A principal specific feature of metabolic therapy is precise targeting of a certain organ or a body system. It involves the use of special diets, as well as dietary supplements, enzymes and other modalities for detoxification of the body and boosting its immunobiological resistance. Metabolic therapy is based on fundamental physiological processes and is determined by molecular mechanisms underlying the development of abnormal conditions. The determinants of metabolic therapy include the type of the underlying abnormal process, the status of blood vessels, lymphatics and nerve fibres, as well as the specific features of responses of the patient’s body to environmental factors. By its influence on endogenous metabolic regulators (autocrine, paracrine, endocrine and neurotransmitter regulators), metabolic therapy is aimed at maintaining the system responsible for hydrophilization of metabolites and for the elimination of hydrophobic molecules. Nutrients are used as agents for enteric correction of the body. The choice of nutrients is informed by the need to eliminate deficiencies of vitamins, minerals and essential microelements; to customize nutrition based on gender, age, physical activity and biochemical constitution, as well as by the need to improve common abnormal conditions, such as obesity, atherosclerosis, immunodeficiency etc.
The principal method of metabolic therapy is the consumption of raw or minimally cooked food products and vitamins. Customized and optimal corrective nutrient metabolic programs include diets, which are rational in terms of their nutrient composition and are appended by functional foodstuffs, nutraceuticals and pharmaconutrients. The constituents of metabolic therapy include detoxification therapy (using various adsorbents to neutralize and eliminate metabolites, xenobiotics, endotoxicants), reducing therapy (supplementation of deficient essential nutrients with enzymatic cofactor functions to restore their functional activity and to optimize immunological and neuroendocrine regulatory mechanisms) and additive therapy (replenishing deficient substances due to inhibited metabolism of amino acids, enzymes, polyunsaturated fatty acids, pro- and prebiotics for recovery of normal metabolism and optimal functioning of the body).
The main principles of metabolic therapy include consistent physiological action aimed at restoring the impaired functions of several organs and systems; detoxification effect, reducing the effect and additive metabolic effect; promoting achievement and maintenance of health improvement effects; public health/hygienic and epidemiological safety.
Nutritional support is an important intervention of the public health system (see Fig. 1).
Fig. 1. Nutritional support within the system of clinical nutrition.
Nutritional support is an aggregate of diagnostic and therapeutic measures aimed at detection and correction of disorders of nutritional status using the methods of nutrition therapy. The fundamental principles of nutritional support include timeliness, adequacy and optimal stabilization of nutritional status. The principal building blocks of nutritional support include determinants of the alimentary status and visceral protein pool, nutrient needs, monitoring of the efficacy of recommended treatments and evaluation of metabolism. The main criteria of alimentary status include somatic protein pool, shoulder circumference and the thickness of cutaneous fat fold. A more precise assessment of alimentary status is provided by the visceral protein pool (total protein, albumin, transferrin and nitrogen balance).
A priority step of nutritional support is to assess the patient’s nutrient needs and the calorific value of his/her diet. Monitoring the efficacy of nutritional support is performed using the patient’s body mass index and clinical manifestations of deficiency or excess of nutrients. The decisive criteria for adequacy of nutritional support for patients with diseases or with morphofunctional health problems include the status of different types of metabolism.
When prioritizing nutrients as part of innovative alimentary technologies, the preferred nutrients include those that enhance host defensive functions (e.g. hematopoietic stimulants, immunological stimulants and lipotropic substances). For the purpose of binding and elimination of toxic substances and enhancing the detoxification capacity of the liver, it is recommended to use dietary fibre (pectins, phytates/phytic acids, sulphur-containing amino acids, alginates) and minerals, which competitively inhibit radionuclide absorption (Са, Р, Мg, Ва, К). In order to inhibit free radical and peroxidation processes in the body, amino acids, vitamins and bioelements are used.
Dietary support as part of clinical nutrition includes the following five blocks: “Pathogenetic system of diets”, “Food ingredients”, “Special support for critical clinical conditions”, “Recovery of normal function of the metabolic conveyor” and “Recovery of normal function of endogenous ecology” (Fig. 2).
The pathogenetic system of diets includes basic variants of a standard diet, diets with protection against mechanical or chemical factors, low- or high-protein diets and low-calorie diets. The main constituents of dietary support include nutraceuticals and parapharmaceuticals. Nutraceuticals include natural components of food, which allow adjusting the patient’s diet in alimentary-dependent disease. These include provitamins, vitamins, polyunsaturated fatty acids, biomicro- and macroelements, dietary fibre, individual amino acids and parapharmaceuticals.
Fig. 2. Dietary support as part of the system of multi-modality treatment of patients.
At the stage of convalescence after critical clinical conditions, special support is used, i.e. enteral and parenteral nutrition. In enteral nutrition, the nutrients are administered orally or via a gastric/intestinal tube. The main objectives of the parenteral nutrition are restoring and maintaining fluid and electrolyte or acid-base balance and supply of structural and energetic substances and vitamins. Depending on the clinical condition of the patient, parenteral nutrition is classified as complete, partial, basic, tube-dependent and complete surgical. Decisions are informed by clinical indications, access options, dietary patterns, solutions and materials for monitoring and the limits of maximum administration volumes.
Recovery of normal function of the metabolic conveyor by alimentary substances includes enteric sorption of endogenous toxins in disease, detoxification of hydrophobic xenobiotics, stimulation of draining and excretory system, elimination of metabolic products, enhancing the digestive capacity of the GI tract, improving trophic and oxygen consumption, stimulation of endocrine cell function and the anti-inflammatory, ulcer-healing, anti-carcinogenic, mucotropic and antihelminthic effects.
Recovery of normal function of endogenous ecology system involves augmentation of biological benefits in the host, such as synthesis of vitamins and proteins, preventing the reproduction of pathogens, stimulation of digestion, absorption and immune response as well as inactivation of toxins. In addition to that, an important role of endogenous ecology is the prevention of disease and elimination of adverse functions, such as catabolic disintegration of proteins and synthesis of carcinogens or toxins.
The algorithm for justification of dietary support is as follows: analysis of actual diet --> detection of deficient --> supply of nutrients (animal proteins, polyunsaturated fatty acids, vitamins, minerals, biomicroelements, dietary fibre) or their excessive supply or suboptimal ratios (proteins, fats, carbohydrates, amino acids, polyunsaturated: monounsaturated fatty acids, minerals [Са : Р; Са : Мg], etc.) --> assessment of nutritional status --> correction of diet.
Therefore, the crisis developments in the health of the population of Ukraine stipulate the expected high volumes of care. The aforementioned, in its turn, calls for a wide application of innovative alimentary technologies as part of multi-modality treatment for non-infectious diseases.
Conclusions
- The population health in Ukraine is characterized by high non-infectious mortality, pronounced demographic ageing, high levels of primary morbidity in the employable population and polymorbidity at an older age.
- Due to critical phenomena in the condition of public health of the population, the volume of required interventions is markedly increasing and requires an intensive use of innovative alimentary technologies.
- Promising alimentary technologies may include metabolic therapy, nutritional support and dietary support of direct care.
Prospects of further research
The prospects of further research are associated with health-preserving innovative alimentary technologies on the pre-nosological basis.
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