Natural Healthcare College

Naturopathic Nutritional Therapy

Diploma Course
Stage One

Module Two
Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One Module Two

Contents  Explore the roles of the liver,

gall-bladder and portal
Weight control – satiety and satiation circulation and explain the
Enzymes aetiology, signs and symptoms
Homeostasis of diseases associated with a
The small intestines toxic internal environment
Chemical breakdown of nutrients  Understand the influence of
Problems due to faulty chemical diet, lifestyle and environment
breakdown that may result in a toxic
Disorders of the small intestines internal environment and
Portal circulation identify individual situations
The liver where detoxification may be
Liver toxicity appropriate or contra-indicated
Substances that interfere with the liver  Identify the role of insulin and
Gall bladder glucagons in the control of
Disorders of the liver and gall bladder blood sugar
Pancreatic exocrine function  Explore the aetiology, signs
Disorders of the pancreas and symptoms of diseases
Pancreatic endocrine function associated with dietary
Blood sugar imbalances, insufficiencies or
Disorders associated with blood sugar excesses
Balancing blood sugar  Identify disorders associated
Bibliography and Citations with dietary imbalances and
suggest dietary modifications
 Develop the skill of using food
Learning Outcomes for Module
as therapy with regard to:
Two digestive system disorders,
blood sugar control, and
On completion of this module you will factors affecting food choice.
be able to:
 Describe factors affecting
satiety and satiation Reading for Module Two
 Provide knowledge of the
principles of nutrition and how  Optimum Nutrition Bible –
these can be put into practice Living Food (enzymes see
 Identify the component parts of Living Food chapter);
the small intestine and Improving your Digestion; From
pancreas and explain the Monkeys to Man; Food
digestive process through them Combining – Facts and
 Explain the role of enzymes Fallacies; Sugar - the Sweet
needed for the digestive Truth
process and evaluate the  Health Defence – Chapters:
functions they serve How you can avoid and treat
 Explore the aetiology, signs diabetes
and symptoms of diseases of  The New Vitamin Bible
the small intestine and  Digestive Wellness
pancreas that lead to a
 Anatomy & Physiology guide –
differential diagnosis
use for reference
 Explore sources, functions and
interactions of micro- and Optional reading
macronutrients and  Healing with Whole Foods by
phytonutrients, including their Paul Pitchford Published by
bioavailability, and signs and North Atlantic Books ISBN 1-
symptoms associated with 55643-221-6
deficiency and imbalance Additional reading and research is
Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
recommended using nutritional
journals e.g. Journal of the Institute of
Optimum Nutrition, and research
papers on line e.g.
http://www.pubmedcentral.nih.gov/
Study Guide
This is an assisted, self-study/distance
learning course. The information
contained in each Stage One module
should be considered to comprise
approximately one-third of the total
study time required – the other two-
thirds coming from self-study,
additional reading and research. As
such, each module, rather than
providing all the information needed,
gives an indication of where additional
learning is needed, so should be
considered as a study guideline. We
suggest you develop a Learning
Journal where you can file additional
study information.
Introduction
We began this course by looking at the
working of, and problems associated
with, the upper digestive tract, and one
of the macronutrients, namely
carbohydrates. Our logical
progression in Module Two takes us to
the small intestine and its associated
organs.
You are not expected to ‘learn by
heart’ all the information in this
module, or to become a walking
encyclopaedia. It is very important that
you gain a good working knowledge of
the structure and chemistry of the
digestive tract and its associated
organs, such as the liver. Beyond that,
you will need an understanding of their
pathological pathways to disease,
enabling you to make reference to
information in these modules when the
need arises.
A major topic in this module relates to
lactose intolerance. Many people self-
diagnose intolerance to lactose. As
© Jackie Day 2009 v2014
Module Two
you will learn, it is likely to be a
problem for some people, but many
individuals currently excluding lactose
from their diet, for other than ethical
reasons, may not need to do so. This
section is quite technical but worth
persevering with as a good
understanding will enable you to offer
effective advice.
Another major topic is blood sugar
(glucose) control. The need to
understand this subject cannot be
overstated. Elevated blood sugar has
now been demonstrated to be one of
the major factors contributing to
obesity, cardiovascular disease, type 2
diabetes, inflammatory conditions
throughout the body and contributing
to some forms of cancer [1] [2].
The World Health Organisation’s
Global Strategy on Diet, Physical
Activity and Health discusses factors
that increase the risks of non-
communicable disease as including:
elevated consumption of energy-
dense, nutrient-poor foods that are
high in fat, sugar and salt; reduced
levels of physical activity at home, at
school, at work and for recreation and
transport [3]. In this module you will
begin to learn how these factors link
together to create the devastating rise
in obesity and type 2 diabetes in the
western world. The number of adults
with diabetes in the world was 135
million in 1995 and is set to rise to 300
million by 2025, with the majority of
cases being type 2 (T2D). This
dramatic increase will have a major
impact on global health and health
care spending as individuals with T2D
have more than twice the risk of
premature death, heart disease and
stroke [4].
When you begin to give advice, you
may be surprised at how many people
say ‘I eat a healthy diet’. As you
already learnt in Module One, the
health of the body is entirely
dependent upon the food we eat so if
all these people are eating a ‘healthy
diet’ why are they not healthy?
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
There are misconceptions about which
foods are healthy. Governments in the
western world are encouraging
everyone to eat five pieces of fruits or
vegetables a day and to avoid fats [5].
This is supposed to reduce problems
such as heart disease, diabetes and
obesity. It certainly appears that many
people try to follow this advice but, in
spite of it, the incidence of those
disorders is increasing [6] [7, 8] .
Whilst plenty of fruit may be helpful in
some respects, it increases fibre in the
diet [9, 10], the acids in fruit may
aggravate inflammatory conditions [2]
[11]. Fruits and vegetables are
primarily carbohydrates, admittedly
complex carbohydrates – the ones we
should be eating – but the emphasis
on these foods does seem to be taking
many people down a one-sided route.
The buzz words these days are
‘healthy diet’, which many people
construe to simply mean eating as
much fruit and vegetables as possible.
Earlier generations used the
expression ‘balanced diet’, which
may be entirely different to ‘healthy
diet’. The ‘balance’ then was between
macronutrients i.e. carbohydrates,
proteins and fats.
Yet the problem goes back further than
that. In the time of Hippocrates, on the
Greek island of Cos, the human
digestive system was accustomed to
unrefined food and the most common
forms of medication were herbs and
spices. If we use herbs and spices
today instead of orthodox medicine will
sick people become healthy? If they
stop using refined foods will they
automatically become healthy? In the
intervening years between
Hippocrates and the 21st century, not
only has the type of food we eat
changed, in some cases out of all
recognition, but significantly, our
digestive systems have not had time to
evolve to handle the changes.
The key to the problem revolves
around a balanced diet. Not all fats are
bad and, in fact, some are deemed
© Jackie Day 2009 v2014
Module Two
‘essential’ for life, as you will learn in
subsequent modules. Without
adequate proteins the body lacks the
building blocks for cellular repair and
renewal. A one-sided carbohydrate
based diet, even if it does include all
those good pieces of fruits and
vegetables, is not a ‘healthy diet’ for
many people if it lacks proteins and
good fats. Part of your role as a
Nutrition Advisor will be to unravel the
puzzle as to what they are unwittingly
doing wrong. You can then point them
on the right road to long-term health.
We began the topic of carbohydrates
in the last module and you will find it
remains a major discussion area in
Module Two. Module Three will move
on to the next group of macronutrients.
Weight Control
Concerns about weight control and
obesity are prevalent in the western
world and as such many aspects of
this course will relate directly or
indirectly to this area of health. A good
starting point is an understanding of
how bodyweight is controlled. Satiation
and satiety are part of the body’s
system of appetite control [12].
Satiation is defined as the process
that leads to the termination of eating,
which may be accompanied by a
feeling of satisfaction. Satiety is
defined as a feeling of fullness that
persists after eating, potentially
suppressing further energy intake until
hunger returns. Satiation affects how
much is eaten at one sitting, whilst
satiety influences the length of time
until the next eating occasion, and
potentially how much is eaten then, so
both satiation and satiety play a role in
total energy intake[13].
Satiation and satiety develop at
different times during the process of
eating and drinking. Once food or drink
enter the stomach, gastric distension,
detected by ‘stretch receptors’ in the
stomach, plays a role in the
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
development of satiation. Satiation is
also stimulated as digestion continues
and nutrients are detected. As
nutrients are absorbed a number of
endocrine hormones are released from
the gut, acting on specific parts of the
brain to induce satiety. Production of
the hormone grehlin, which stimulates
the hypothalamus to increase appetite,
is suppressed.
Signals from gut hormones fluctuate
according to nutrient intake. Satiety is
also affected by other hormones, such
as leptin, which indicates the body’s
level of fat storage. Leptin is released
in proportion to the amount of adipose
tissue in the body and low levels
stimulate energy intake. Most obese
people have high levels of circulating
leptin, though in rare cases its
deficiency has been found to cause
obesity. It has been suggested that
leptin resistance develops when levels
are chronically high.
Satiety is generally proportional to the
amount of energy consumed but it is
important to understand whether, for a
given energy level, different foods
have the potential to increase or
decrease satiety. Fibre can promote
satiation by increasing chewing time
and bulk, and by prolonging nutrient
digestion. This effect is very much
dependent upon the amount and the
type of fibre; fibres such as found in
oats and psyllium husk appear to be
the most effective[14].
Whilst most liquids are less satiating
than food, others such as soup have
been found to be more satiating than
their equivalent solid foods. It has
been suggested that the mode of
drinking soup (drinking as opposed to
eating with a spoon) and the
perception of a liquid (to quench thirst
rather than a source of food) may be
important in determining the satiation
of liquids[15].
Some studies suggest that of the
macronutrients, protein is the most
satiating, whilst others have found little
difference when comparing their
© Jackie Day 2009 v2014
Module Two
energy density (in terms of kcal/g or
kJ/g) and diets with a lower energy
density are associated with lower body
weight[16]. Energy density can be
moderately reduced by fibre and
increased by fat. The energy density of
foods is strongly affected by their
water content. This means that foods
such as fruits and vegetables that are
naturally high in water, and those
cooked with water such as soups,
stews, rice or pasta are more satiating.
This theory was demonstrated
comparing a chicken casserole with a
soup that had the same ingredients
but added water[15].
Reducing the energy density of the
diet appears to be the most effective
strategy for enhancing satiety,
reducing energy intake and controlling
weight. This theory is in line with
recommendations to eat more fruit and
vegetables, include high fibre foods
and reduce fat intake. Due to various
factors, some people need to increase
their weight so increasing dietary
energy density can be helpful to
reduce satiety and allow more energy
to be consumed.
Psychological, lifestyle and varied
environmental factors influence eating
patterns. Many people continue to eat
despite their internal signals of
satiation and satiety telling them they
are full, whilst others may avoid eating
despite being hungry. Other relevant
factors to consider include:
 Portion size: most people eat
more when given a larger
portion.
 Variety: studies suggest the
greater the choice of foods
offered at a meal, the more
people will eat. ‘Sensory
specific satiety’ is the term
used to describe the
phenomenon where people tire
of eating the same food but
regain enthusiasm when
offered something different.
 Physical activity: in the short
term, the body’s stores of
energy can be used up without
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
a resulting loss of satiety.
 Distractions: people generally
eat more when distracted (e.g.
watching the television) than
when undistracted.
As you progress
through the
course, you will
learn a great deal
more on how to
help people with
problems related
to weight control
and obesity.
Enzymes
Enzymes are proteins that will trigger
and speed up chemical reactions,
known as metabolism. The body
completes around 200 million
reactions every day. A reaction that
takes a second under the influence of
its specific enzyme could take days
without it. Enzymes can be subdivided
into three main groups: digestive,
made by the digestive system to help
breakdown food; food enzymes in raw
foods; metabolic enzymes made by
cells for various functions. The body
produces enzymes for all its numerous
chemical processes; hormone
production, wound healing, immunity,
blood fluidity, the collection and
removal of toxins, and the digestion of
food are some of the tasks
accomplished by enzymes. Most
enzymatic processes take place within
cells; enzymes of the GI tract are the
exception, working on the exterior of
macronutrients.
Hydrolysis is the process by which
chemical digestion unites water with
small compounds to break their
chemically bonded chains into single
units that can be easily absorbed by
the body [17]. This mechanism is
dependent upon enzymes that speed
up the hydrolysis process. Each type
of food compound requires its
individual enzyme that attaches to the
food like a lock and key.
© Jackie Day 2009 v2014
Module Two
As mentioned in Module One, you can
recognise a name is an enzyme by the
suffix ‘ase’ (as in amylase), though
some will have the suffix ‘psin’ (as in
pepsin). The suffix attaches to the
name of the compound on which it
works e.g. lipase works on lipids.
The pH (acidity/alkalinity) level of
tissues and blood is one of the
homeostatic factors (see the following
section for a definition of homeostasis)
that influence the activity of enzymes –
too much acid will slow metabolism.
The acidity or alkalinity of the GI tract
controls protein metabolism; an
incorrect pH will change the shape of
the protein, rendering it incapable of
hydrolysis. A toxic digestive tract can
change the natural pH, adding to the
problems of digestion and absorption
that will create a vicious circle of
increased toxicity and inability to
digest and absorb efficiently. Amylase
in saliva works in a neutral to slightly
acidic pH, being the required medium
for carbohydrate hydrolysis. Pepsin in
the stomach is entirely dependent
upon an acidic pH. The hormone
gastrin and the vagus nerve trigger the
release of both pepsinogen and HCl
from the stomach lining when food is
ingested, enabling proteins to be
digested in the stomach [18].
The active forms of enzymes such as
pepsin are so powerful they could
destroy the surrounding tissues. To
avoid this, some enzymes are
secreted in an inactive form, called a
proenzyme, that requires a specific
chemical reaction to activate it e.g.
pepsinogen is the inactive form of
pepsin – the suffix ‘gen’ denoting the
name relates to a proenzyme.
All enzymatic processes are
dependent on high quality nutrients to
ensure maximum digestion and
absorption. Some enzymes will need a
separate chemical, a co-enzyme,
without which it would remain inactive.
Many such co-enzymes are derived
from B vitamins so a deficiency of
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these water soluble micronutrients will
have an impact on enzyme production
that affects all functions of the body.
Magnesium is a mineral that is
responsible for over two hundred
enzymatic processes. Zinc is needed
to make the proteases that break
down proteins and if zinc is deficient
proteins may not be broken down
thoroughly. Water is required for
enzyme activation so good hydration is
vital, as is stable body temperature.
To recap on Module One, you learnt
about the enzymes amylase and
proteases, the latter being the term for
enzymes involved in the digestion of
proteins, one of which is pepsin. As
food progresses through the digestive
tract it encounters trypsin and its
proenzyme trypsinogen, secreted by
the pancreas. You saw in Module One
how carbohydrates are broken down
and later you will learn how proteins
undergo the same process. Complex
chains of amino acids are held
together by peptide bonds. Each bond
needs a specific enzyme to break it
down into an individual peptide and
then the peptides are hydrolysed again
into an absorbable form of amino acid
that can be absorbed in the small
intestines. A complicated process!
Quick Quiz
What is the meaning of the suffixes
‘ase’, ‘psin’, ‘gen’?
Fats (lipids) are insoluble in water and
you will remember that hydrolysis
requires water. So now we need bile
salts and lecithin to emulsify the fats.
They achieve this by surrounding fatty
globules to form tiny micelles that
cover a suitably small area for
enzymes to work on. Lecithin is a
phospholipid used in cell
membranes. Bile salts are formed from
cholesterol in the liver. The chief fat-
digesting enzyme produced by the
pancreas is lipase, which hydrolyses
the fatty droplets into fatty acids,
glycerol and monoglycerides, i.e. the
main components of triglycerides.
© Jackie Day 2009 v2014
Module Two
In Module One you learnt that raw fruit
and vegetables contain sufficient
enzymes for their own digestion.
Processed foods contain mostly fats
and sugars, along with additives that
are not natural to the body and as
such the body does not have specific
enzymes to digest them. As long as
they are small enough, they can be
absorbed and hopefully detoxified
through the liver. Some however may
not be eliminated from the body and
may find their way into various tissues,
where they may trigger inflammatory
responses [19-21] .
The control of enzyme production is an
example of homoeostasis at work; as
enzymes are used up, more are
produced.
Homeostasis
Homeostasis is the key to well
functioning metabolism [22].The body
is a self-healing mechanism; in a
healthy state there is a constant
process for normalisation and health
promotion called homeostasis. The
homeostatic functions can become
overwhelmed if too many demands are
made of them due to a variety of
negative impacts such as nutritional
deficiencies, toxicity (either from
environmental pollution, food,
medication etc), stimulants, stress
overload, social pressures, low
immunity, chronic health problems,
poor posture, poor breathing patterns,
lack of sleep, lack of exercise etc. If
these impacts happen at a certain
point in time the adaptive homeostatic
mechanisms break down and illness
develops – this situation where
homeostasis is overwhelmed is called
heterostasis. The result is likely to be
immune system weakness and poor
cellular repair and renewal.
Allostasis describes what happens
when the brain, nervous and hormonal
systems over- or under-react to
whatever is happening to the
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individual. It involves the release of
excessive stress hormones, usually in
response to a state of chronic anxiety.
Such abnormal and excessive (or
deficient) allostatic responses are
accompanied by a range of hormonal
imbalances that can influence almost
any part of the body or its functions.
Understanding homeostasis and
allostasis helps us realise why
treatment protocols need to look
beyond the presenting symptoms and
focus instead on holistic and
constitutional approaches that focus
on the causes of ill health. To help
restore homeostasis the body may
need help in the form of treatment that
aims to remove as many as possible
of the negative factors, as well as
treating the symptoms to make sure
nothing further is being added to the
burden being borne by the defence
mechanisms. There is nothing wrong
with treating symptoms as long as the
underlying causes are also being
addressed, and as long as the
treatment being used is not creating
more problems than it is solving.
Genetic predispositions can be
determined via diagnostic techniques
such as Iridology, Traditional Chinese
Medicine and Ayurveda. They are
beyond the scope of this early stage of
training but are included as part of the
Clinical Practice level.
The end result of a catalogue of
stressors and the ultimate breakdown
of adaptive capabilities has been
described as ‘vertical ill-health’ with
symptoms such as chronic fatigue.
Holistic approaches aim to avoid
overload, modify the stressors,
improving coping abilities and use
specific and non-specific strategies.
Non-specific approaches such as
relaxation techniques and massage
are often more beneficial than specific
treatments that can make excessive
adaptation demands.
The Small Intestine
The intestines have two diametrically
© Jackie Day 2009 v2014
Module Two
opposing functions: to absorb as much
nutrition as possible from the diet, but
at the same time to protect the body
from any harmful substances ingested.
It has to distinguish the ‘good’ from the
‘bad’ and launch an appropriate
response in conjunction with the
immune system. This section of the
digestive tract is continuous with the
stomach at the pyloric sphincter and
leads into the large intestines at the
ileocaecal valve. It comprises three
sections – duodenum, jejunum and
ileum, and varies in length from
around 275-850cm in adults. The
breakdown of macronutrients into their
single elements is completed here,
preparing them for absorption into the
bloodstream and utilisation by tissues.
The major sites of absorption are:
 stomach: some drugs, water,
alcohol and some short-chain
fatty acids from butter and milk
fat
 duodenum: calcium, sodium,
iron, magnesium, vitamins,
sugars, proteins, fats and water
 jejunum: proteins and sugars
 ileum: bile salts, calcium and
vitamin B12
 colon: electrolytes[23] and
water. Electrolytes are minerals
in the blood and other body
fluids that carry an electric
charge, e.g. sodium ions
The intestines have a ribbed surface
covered with tiny projections called
villi, providing a huge area for the
uptake of absorbed nutrients into
blood and lymphatic vessels. The
surface of every villi is made up of a
layer of epithelial cells that form
microvilli. Broken down food particles
easily pass through microvilli into the
blood. Each villi has a central lymph
channel (lacteal) in addition to its
network of blood capillaries. Epithelial
cells on the surface of villi can be seen
by microscopy to have a surface
resembling a fine brush; intestinal
digestive enzymes are produced in
these brush border cells towards the
top of the villi. In enterocytes (cells) of
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
the walls of the villi, the digestion of
carbohydrates and fats is completed.
Monosaccharides pass into capillaries
in the villi, fatty components of food
are absorbed into the lymphatic
system via the lacteals. Lacteals are
so called because they absorb fats
into the lymphatic system. This milk-
like, fat- containing fluid, known as
chyle, is absorbed by lacteal
capillaries and ultimately transported
into the bloodstream via the thoracic
duct. Once food has been broken
down into small enough molecules, the
function of absorption becomes the
focus of activity in the GI tract.
The duodenum’s submucous layer
contains Brunner’s glands that
secrete protective mucus that prevents
damage by stomach acid. Because of
constant wear and tear on the inner
lining of the intestines, its cells are
replaced much faster than other cells
of the body, averaging 3 to 5 days.
Cells migrate upwards to form new
villi, replacing those at the tip that have
been worn away by digestive activity.
The innermost layer of the duodenum
secretes alkalising juices and some
enzymes. The two muscle layers relax
and contract to stimulate peristaltic
propulsion of chyme.
The jejunum is rich in blood vessels
through which nutrients enter the
blood stream. Veins carry blood to and
from the jejunum and to the mesentery
which is a fan-like structure attached
to the posterior abdominal wall,
supporting the jejunum and ileum.
Waste products are passed to the
large intestines. Blood vessels unite to
form the portal vein, which flows
directly to the liver, allowing food to be
processed in the liver before being
distributed back into the rest of the
bloodstream. If digestive chemistry is
inefficient and fermentation occurs,
waste products pass into the liver via
the same mechanism.
Just to the side of the duodenum are
the liver and pancreas; they secrete
important fluids into it via the common
bile duct. As the highly acidic chyme
© Jackie Day 2009 v2014
Module Two
enters the duodenum, the gall-bladder
contracts and ejects bile into the duct.
Throughout the intestines, lying below
the lamina propria, are a number of
lymphatic nodules, either isolated or in
groups. The largest group, the Peyer’s
Patches, are found mainly in the
ileum. They act as filtration systems,
directing microbes for assessment and
ultimate inactivation by macrophages.
The supply of antibodies from the
lymphatic system is a vital part of the
body’s defence network against
bacterial infection, both in the gut itself
and elsewhere e.g. infections that
cause fevers. Between 60-70% of the
body’s immune system is located in
the digestive tract. Billions of
protective bacteria live in the mouth,
oesophagus and small intestines and
even greater quantities in the large
intestine. The stomach, being highly
acidic, has fewer protective bacteria as
most micro-organisms cannot survive
in that environment [24].
Quick Quiz
What are the three sections of the
small intestines?
Chemical Breakdown of
Nutrients
The small intestine is the tissue where
the greatest volume of exchange
between the contents of the gut and
the mucosa and gut associated
lymphoid tissue (GALT) takes
place[25]. Nutrients extracted in the
small intestines include vitamins,
minerals, amino acids, sugars and
fatty acids – all essential for health. By
the time food reaches the end of the
small intestine, most nutrients have
been absorbed. Protein is broken
down into amino acids; complex
carbohydrates into simple sugars; fats
into fatty acids and glycerol. Every day
approximately 10 litres of digestive
juices, mainly from the pancreas, liver,
stomach and intestinal walls, pour into
the small intestines.
As you learned in Module One, the
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second phase of digestion, the gastric
phase, is controlled by the hormonal
secretion of gastrin. As all enzymes
and hormones are produced from
proteins, meals low in protein may fail
to trigger sufficient gastrin release and
subsequently parietal cells of the
stomach may not produce adequate
hydrochloric acid. Chyme passes
from the stomach by peristaltic action
to the duodenum. Adequate HCl in the
stomach will activate not only the
enzyme pepsin but will also trigger the
intestines and pancreas to secrete
enzymes, and the gall-bladder to
release bile into the intestines.
Pancreatic enzymes only work in an
alkaline environment and in the
normally highly acidic environment of
the stomach, plant enzymes may
become ineffective (enzymes in
supplements are enterically coated to
enable them to resist stomach acid
and pass into the intestines intact). As
soon as chyme reaches the duodenum
alkalising salts from bile, the
pancreas and the inner walls of the
duodenum begin to neutralise the
stomach acid. More digestive enzymes
are mixed into the digestive juices to
breakdown proteins, fats and
carbohydrates. The main enzymes are
amylases, which digest
carbohydrates; proteases for proteins;
lipases for fats. Food must be
acidified in order to trigger the
hormones secretin and
cholecystokinin (CCK), located in the
endocrine cells of the intestinal
mucosa. These hormones react in
response to food entering the small
intestine. By causing the
hepatopancreatic sphincter to relax,
they allow bile and pancreatic juices
into the duodenum to mix with the
incoming chyme. The sphincter
stimulates contraction of the gall-
bladder (the storage depot for bile)
and the action triggers the pancreas to
produce pancreatic juice. Secretion is
markedly increased after a high-fat
meal. Secretin and CCK also slow the
exit of chyme into the duodenum,
allowing more time for the bile and
pancreatic juices to mix with the
© Jackie Day 2009 v2014
Module Two
chyme. If the stomach is unable to
secrete sufficient HCl, the potentially
low production of digestive enzymes
may result in poor digestion and
malabsorption.
Bile, produced by the liver and stored
in the gall-bladder, emulsifies fatty
globules, converting them into droplets
so that the pancreatic enzyme lipase
can complete their conversion into
glycerol and fatty acids. Bile contains
the phospholipid lecithin, which
emulsifies large fatty particles, making
them smaller to provide a greater
surface area for lipase to work on. You
can see a similar process at work
every time you use washing up liquid
to remove fats from dishes.
The pancreatic enzyme amylase is
responsible for the breakdown of
starches (that were not affected by
salivary amylase) into sugars i.e.
monosaccharides (single sugar
molecules) and disaccharides
(maltose, lactose or sucrose). We
have already mentioned the pancreatic
enzyme trypsin which is responsible
for the breakdown of some
polypeptides to amino acids and some
to smaller polypeptides. Trypsin and
chymotrypsin are known as
proteolytic enzymes i.e. protein-
splitting enzymes that technically are
capable of digesting the pancreas. To
avoid that, trypsinogen and
chymotrypsinogen, inactive enzyme
precursors, need to come into contact
with enterokinase, an enzyme in the
microvilli, which converts them into the
active forms [26]. Various other
enzymes such as aminopeptidase,
an enzyme of the brush border of the
small intestine, will cleave (break
apart) a single amino acid from the
end of a peptide chain e.g. the amino
acid alanine. You will learn more
about amino acids later on.
Quick Quiz
Name the chemicals responsible for
the breakdown of nutrients in the small
intestine
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
Problems due to faulty chemical
breakdown of nutrients
The chemistry of the G.I. tract affects
the whole body by its balance of pH
(acidity and alkalinity), assimilation of
nutrients and elimination of waste.
Problems can begin with the stomach,
where inadequate HCl may result in
restricted secretions of other
chemicals. Incomplete breakdown of
food in the stomach results in chyme
becoming sticky and rather than
flowing through the intestines, it
adheres to the walls where it hardens
and putrefies.
Blood vessels radiate out from the
digestive tract, carrying nutrients and
influencing all cells via the circulatory,
lymphatic and nervous systems.
Toxins that result from the inadequate
breakdown of food can also pass into
the bloodstream via this same
network. This percolation of toxins is
known as dyscrasia. The liver is
capable of neutralising and detoxifying
intestinal putrefaction in order to limit
the entrance of poisons into the
bloodstream but if it is incapable of
sufficient detoxification to compensate
for the lack of enzymes, toxin
infiltration into cells can create wide-
ranging symptoms. Systemic disorders
such as migraine, arthritis, fatigue and
degenerative mental disorders can all
be attributable to a toxic digestive
system.
Dysbiosis (imbalance of friendly and
unfriendly gut flora) is a common
feature of dyscratic conditions. The
microflora of the duodenum and the
first section of the jejunum are mainly
lactobacilli (L. acidophilus and L.
bifidus) and streptococci, along with
smaller colonisations, including
escherichia coli (E.coli) and various
forms of yeast. In the latter section of
the jejunum and in the ileum, the
bacterial population takes on more
complex forms e.g. enterobacteria
and bifidobacteria [27].
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Module Two
Lack of HCl may lead to harmful
bacteria, viruses, parasites and yeasts
from food and the environment
passing into the intestines, rather than
being destroyed in the stomach. The
delicate balance of the gut flora begins
to be compromised, leading to
dysbiosis. As a result, the lining of the
digestive tract may be exposed to
chemicals, gases and acids produced
by excessive numbers of unfriendly
bacteria. Cells that line the walls are
weakened, widening the tiny gaps
between villi, allowing food particles
(allergens) and toxic waste to enter the
bloodstream. This intestinal
permeability is commonly referred to
as leaky gut [28]. At this stage many
people claim they are either allergic or
intolerant to certain foods. The body
launches an immune response,
activating detoxification pathways via
the liver, diverting energy and
antioxidants from other parts of the
body. Initial reactions may be mild but
left unchecked could lead to conditions
such as chronic fatigue, premature
ageing, headaches, migraines, joint
inflammation, skin problems, low
immunity. All this from low HCl.
Lactose intolerance, due to a lack of
the enzyme lactase, particularly if
combined with an acid/alkaline
imbalance at the start of the small
intestine, can allow lactic acid from the
intestines to rise up and leach into the
stomach, thereby reducing HCl and
causing increased fermentation.
The complex mechanism of the small
intestines can also be disrupted by
antibiotics, other drugs including anti-
inflammatories and pain relief
medication, a high intake of sugar,
alcohol, canned drinks, a high fat diet
(including fried foods) [29].
Chemicals, hormones etc
found in many foods can
additionally undermine
the digestive processes
and not least the
efficiency of the liver, which has to
break them down for removal from the
body [30].
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Food intolerances result from the
inadequate breakdown of their
proteins [31, 32]; improvement of the
digestive chemistry will frequently
resolve the problem. As a simple
example, if we consider a cheese
sandwich – in the stomach, bread
absorbs gastric juices, including
secreted enzymes – although
predominantly carbohydrate, bread
contains proteins such as gliadin. The
result is that it may leave little to break
down the protein (casein) in the
cheese. The resulting discomfort leads
the sufferer to assume intolerance,
either to dairy products, to wheat, or to
both!
Summary: You now understand that
most of the absorption of food
constituents takes place in the small
intestines; if there has been
inadequate chewing in the mouth or
you rush around while eating meals,
the result is likely to be partially
digested food that ferments, causing
bloating, pain and inflammation.
Additionally, if food has not been
adequately broken down and
absorbed effectively, you cannot derive
the benefit of its nutrients and will
technically become malnourished. So,
in spite of eating the best quality food,
you may experience hunger pangs
because your body is looking for
nutrients. Therefore, correcting poor
eating habits can reduce not only
these symptoms but also cravings.
The chemical breakdown of food
from the mouth to the small
intestine
On descending the gastro-intestinal
tract, there is an increase in both the
types of bacteria and the total number
of microbes. The tract becomes more
anaerobic (free of oxygen) as it
descends. Therefore, the types of
bacteria that can thrive in different
sections vary depending on oxygen
levels e.g. lactobacillus thrives higher
in the tract due to the higher
© Jackie Day 2009 v2014
Module Two
concentration of oxygen while
bifidobacteria thrive in low oxygen
concentrations. Secondly, as the
transit time decreases progressively
along the length of the tract, bacteria
have an increased contact time with
the gut and, therefore, a greater
chance to survive.
Amylase
(ptyalin)
HCL + Pepsin
Amylases
+ Bile
Proteases
Lipases
Quick quiz
Where in the digestive system do the
above chemical processes take place?
Both proteins and fats can be broken
down into amino acids and fatty acids
by lactobacilli bacteria. Lactose, the
sugar in milk, is broken down by
bacteria into glucose and galactose,
especially helpful for individuals who
are lactose intolerant and lack the
normal digestive enzyme for the job.
For digestion of lactose to be
enhanced, consumption of viable lactic
acid is essential. If the upper part of
the small intestine is adequately
colonised with lactobacilli, they should
be able to aid the digestion of dietary
lactose without the need for
supplements. This suggests that a
large percentage of lactose intolerant
individuals are either deficient in
lactose fermenting lactobacilli or their
activity is depressed. While some
individuals may be genuinely intolerant
to cows’ milk products, most people
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
with a ‘suspected intolerance’ may
simply have poor digestive chemistry
and an imbalance of bacteria. Further
information about lactose intolerance
will be found in the next section.
Research Topic
The body needs a balance of friendly
and unfriendly bacteria. This is a very
important issue that should be
thoroughly researched.
Disorders of the Small Intestine
When things go wrong in the gastro-
intestinal tract, it reflects as suboptimal
digestion and absorption of nutrients.
If the intestinal walls have become
encrusted with mucus, fats and chyme
due to inefficient breakdown of food,
the absorption of nutrients will be
impaired. Malabsorption syndromes
include Crohn’s Disease, an
Inflammatory bowel disease (IBD),
sometimes called ileitis. Inflammatory
bowel disease should not be confused
with Irritable bowel syndrome (IBS).
Crohn’s Disease may affect both the
small and the large intestines.
Because the symptoms of Crohn’s are
similar to other intestinal disorders,
such as irritable bowel syndrome and
ulcerative colitis, it can be difficult to
diagnose. This is a serious and difficult
condition that may have life-
threatening complications. As such it is
beyond the scope of a Nutrition
Advisor, needing the help of an
appropriately qualified practitioner.
Duodenal (Peptic) ulcers
Helicobacter pylori (H pylori) is
responsible for around 90% of
duodenal ulcers [33]. They can occur if
an H pylori infection is limited to the
upper part of the stomach. An infection
here results in excess stomach acid
being produced, which flows into the
duodenal area, increasing the risk of
an ulcer developing. The second most
common cause is non-steroidal anti-
inflammatory drugs (NSAIDs) such as
© Jackie Day 2009 v2014
Module Two
aspirin; if NSAIDs are taken over long
periods of time, they can damage the
protective mucus lining of the
stomach. Duodenal ulcers are often
associated with stress; if the pyloric
valve between the stomach and
duodenum has become tense, the
acidic stomach content can seep into
the duodenum, causing erosion.
Whatever the cause, the chief
symptom is burning pain due to the
erosion in the upper abdomen or lower
chest that feels like indigestion.
An endoscopy is often used to
diagnose a peptic ulcer, allowing the
inside of the stomach to be examined.
Both gastric (stomach) and duodenal
ulcers can be detected by this
procedure. Tests to diagnose H. pylori
are: a urea breath test; a stool antigen
test; a blood test for antibodies to H.
pylori bacteria; antibodies are proteins
that help fight infection and are
produced naturally in the blood.
Treatment for peptic ulcers focuses on
either reducing the amount of stomach
acid so that the ulcer has time to heal,
or treating the H pylori infection.
Proton pump inhibitors reduce the
amount of acid that is produced –
unlike antacids that neutralise the acid.
H2-receptor antagonists work by
reducing the amount of stomach acid,
thus making it less acidic. Processed
foods, spices, salt, fried food and
coffee should all be avoided. The aim
is for several small meals throughout
the day, rather than large ones that
strain the GI tract, including only a
small amount of less-dense protein,
e.g. fish, cottage cheese [34]. Further
information can be found on the
website:
http://www.nhs.uk/Conditions/Peptic-
ulcer/Pages/Introduction.aspx
Candida albicans
Under normal circumstances there is a
carefully controlled balance of yeasts
and bacteria within the gastrointestinal
tract. Approximately 500 different
species of micro-organisms, bacteria
and fungi, work to maintain health;
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they produce their own antibiotics,
thereby maintaining a healthy micro-
flora and avoiding the dominance of
any single organism [35].
Candida is yeast, a tiny single celled
organism that is a normal part of the
ecology of the skin, digestive tract and
vagina. It only becomes a problem
when an uncontrolled overgrowth
occurs as a result of disruption to the
body’s natural immunity and bacterial
balance. The term Candida usually
refers to Candida albicans, though
there are many more species of
Candida e.g. Candida glabrata, and
there are other strains of fungi e.g.
Aspergillus niger. When fungi
overgrow in the digestive tract, they
usually change their form from
harmless round cells into filament
shapes that provide the ability to
attach to the intestinal walls.
An important part of the immune
system is found within the gut. From
here white blood cells migrate to other
parts of the body. Any fungal
overgrowth within the intestines can,
therefore, affect this process and may
cause the immune system to react to
various foods. This irritation may also
cause the junctions between the gut
wall cells (villi) to become more
permeable, leading to Leaky Gut
Syndrome [36]. This enables
undigested food molecules to enter the
blood stream, with the potential to
trigger allergic reactions.
Several factors enable the proliferation
of Candida:
 Frequent use of steroidal
medication and antibiotics
depress levels of beneficial
bacteria
 Oral contraceptives induce
hormonal changes that can
increase Candida levels
 Diets high in simple
carbohydrates create a
constant food source that
enables Candida to grow and
proliferate
 A compromised immune
system allows opportunistic
© Jackie Day 2009 v2014
Module Two
organisms to flourish
 Endocrine gland imbalances
such as low thyroid and
adrenal function, possibly as a
result of stress and blood sugar
imbalances (see later sections
in this module), can support
Candida growth.
Common signs and symptoms of
Candidiasis (Candida overgrowth):
Oral or vaginal thrush
Heavy bloating, gas or flatulence –
particularly after eating sweet food or
fruit
Rectal itching
Depression and mood swings
Fatigue
Headaches
Skin complaints
Food allergies and intolerances
Fungal nail infections and Athletes foot
With so much publicity about Candida,
it is easy for people to think they ‘tick
all the boxes’ with regard to symptoms
but these symptoms can be caused by
other factors e.g. poor digestive
chemistry, lack of beneficial gut
bacteria , low secretory
immunoglobulin A (SIgA) – SIgA is
found in the lining of the gut where it
acts as one of the body’s first lines of
defence, being the only type of anti-
inflammatory immunoglobulin
produced [37]. SIgA [32] inhibits
adhesion by unwanted microbes, no
adhesion – no inflammation. High
levels of cortisol in response to stress
relate to low levels of SIgA, lowering
the mucosal output in the protective
layer of mucus in the gut wall. A SIgA
deficiency is associated with food
allergy/sensitivity, and its absence may
have immunomodulatory effects on
mood via food antigen stimulation. It is
particularly important in children prone
to gastrointestinal inflammation and
infection. Strains of probiotic bacteria,
including Lactobacillus rhamnosus,
have been identified as an inducer of
higher levels of SIgA.
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
Dealing with Candida
The approach used to be to promote a
highly restrictive anti-Candida diet.
Although this approach works, the
anti-Candia diet is very hard to follow
so compliance levels are low. The
approach now is to restrict primarily
simple carbohydrates and support the
digestive tract by including anti-fungal
agents and probiotic bacteria. [38-40]
As Candida feeds on sugars, the
removal of simple carbohydrates can
help reduce the number of cells but in
most cases would not stop the fungi’s
ability to cling to the intestinal walls.
When Candida is starved of these food
sources, the yeast is forced into its
cyst form and will use its fungal ability
to lay dormant; in this form it can
survive for years so that when food
sources are re-introduced, the yeast
spores will start to replicate again.
When conditions are favourable for
fungi, they can switch to protein
digestion, leaving an impossible
dietary challenge. It is, therefore,
better to maintain the Candida in a
weakened form, rather than forcing it
to lay dormant as this will enable anti-
microbial agents to work.
When a person has Candidiasis, if you
try to do too much too quickly, e.g.
changing the diet and adding anti-
fungals all at once, the toxic overload
created by the release of Candida into
the bloodstream can be overpowering
and more than the liver can easily
handle. This is often referred to as a
‘die off’ reaction.
Always start by looking at the diet.
Ideally:
 Reduce all highly processed
products and those made with
white/refined carbohydrates
e.g. biscuits, cakes or bread
products.
 Reduce all forms of sugar -
many manufactured products
contain sugar in one form or
another e.g. sweets, chocolate,
fizzy drinks, ice cream.
© Jackie Day 2009 v2014
Module Two
 Avoid sweet fruits and fruit
juices (vegetable juices are
OK) and restrict others to one
or two pieces daily. Appropriate
fruits would be: pears, apples,
lemons, oranges, grapefruit,
nectarines, pomegranates,
cherries, apricots.
 Eat unlimited amounts of
complex carbohydrate foods
and particularly those that are
helpful to the liver and rich in
antioxidants e.g. dark green
leafy vegetables such as
broccoli. Also, radishes,
cauliflower, carrots, peppers,
tomatoes, onions, garlic, leeks,
peas, sprouted beans.
 Eat regular amounts of good
quality protein foods such as
fish, poultry, eggs, pulses, nuts
and seeds.
 Combine proteins with
carbohydrates to slow the
release of sugar and help
balance blood sugar levels (a
later section of this module will
introduce you to the vital issue
of blood sugar balance).
 Although mushrooms are a
different type of fungus to
Candida, avoidance is
recommended as they may put
additional strain on an already
compromised digestive system.
The same applies to alcohol,
though theoretically a very
small amount of dry wine or
spirits may be tolerated.
 Drink 1.5-2 litres of water daily
to help maintain hydration and
to help flush out toxins.
 Some recommendations
include a short-term elimination
of dairy and wheat – again to
help reduce irritation to a
compromised digestive system.
Substitute with Rice, Almond or
Soya milk.
Garlic (Allium sativum)
has anti-fungal
properties. It is selective
in its inhibition of micro-
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
organisms and does not exert a
negative effect on beneficial probiotic
bacteria. It is effective against various
bacterial and fungal species [41, 42].
The chief components within olive oil
are oleic and palmitic acid. Oleic acid
has been shown to hinder proliferation
of Candida. Two teaspoons of Olive
oil, three times daily, has been found
to be helpful [43].
A number of potentially beneficial
nutraceuticals are available to help
eradicate the fungal overgrowth but at
this stage of training you should refer
to a qualified therapist for further
advice.
Coeliac Disease is caused by
intolerance to gluten, a protein found
in foods such as bread, pasta, cereals,
and biscuits. Some people with the
condition find that eating oats can also
trigger their symptoms. It is an
autoimmune condition in which any
time gluten is eaten the immune
system mistakes it for harmful
substances and produces antibodies
against it. When the antibodies attack
gluten, they can also damage the gut
lining causing inflammation. In coeliac
disease, the damage and inflammation
to the lining flattens the villi, reducing
their ability to aid digestion. As a result
the gut can no longer digest nutrients
efficiently and this can lead to
diarrhoea, malnutrition and weight
loss; in children, malnutrition can
caused stunted growth and delayed
development. A common symptom is a
clay-coloured, greasy stool due to the
inability to absorb fats in the small
intestine. The condition may cause the
spleen to work less effectively,
triggering vulnerability to infection [44].
The exact reason why coeliac disease
occurs is not fully understood and, in
some cases, it may not be possible to
identify a cause. It is possible to
develop intolerance to gluten at any
age, for no apparent reason. It can be
inherited and often runs in families and
in some cases may be brought on by
© Jackie Day 2009 v2014
Module Two
severe stress, although the reason for
this is unknown.
A blood test will check for certain
antibodies, though it is possible to
have coeliac disease and not have
these antibodies. Symptoms can
appear to be similar to those of other
digestive conditions, such as irritable
bowel syndrome (IBS), and Crohn's
disease. For this reason a gut biopsy
is usually only obtained after
antibodies have been detected.
Sufferers are allergic to gluten in all
forms, so they should avoid wheat,
oats, barley and rye. This can be
daunting but there are now a number
of gluten-free flours and products
available and a gluten-free diet will
normally bring speedy improvements.
However, even after years without
gluten, a small amount in the diet is
likely to provoke an adverse reaction.
There are also many basic foods that
are naturally free from gluten, such as
meat, vegetables, cheese, and rice.
Individuals with Coeliac disease are
more likely to also develop lactose
intolerance because the damage to
the digestive system, caused by
gluten, may also make it difficult to
digest lactose. More information about
Coeliac disease can be found at:
http://www.nhsdirect.nhs.uk/articles/art
icle.aspx?articleid=105
Lactose intolerance has been
mentioned above, in relation to
dysbiosis. The
disaccharide
lactose is found
only as a
storage
carbohydrate in
the seeds of a few plants, and in
mammalian milk and dairy products,
e.g. human, cow, ewe and goat, and is
hydrolysed by lactase in the small
intestine. Lactase is a digestive
enzyme required for the breakdown of
the milk sugar lactose. Lactase should
be produced in the small intestine,
however if little or no lactase is
produced or if production is impaired,
undigested lactose moves into the
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
colon where it is fermented and
hydrogen, carbon dioxide and organic
acids are produced, often resulting in
cramps, wind and diarrhoea.
There is 7.2 g/100 ml in mature human
milk, whereas cow’s milk has 4.7
g/100 ml [45]. The term lactose
sensitivity is preferred as it is
considered not everyone who is
sensitive to lactose will be intolerant as
everyone has their own threshold and
can tolerate some lactose. They may
tolerate up to 12g lactose if taken
spread throughout the day, e.g. with
breakfast and in drinks [46, 47].
The lactose hydrogen breath test is
currently considered to be the most
reliable test to measure lactose
maldigestion [48]. It usually involves
taking 50g lactose orally (equivalent to
that found in 1 litre of milk) and
measuring breath hydrogen levels
over the following 3-6 hours with > 20
p.p.m. above baseline indicating
lactose intolerance. The sensitivity
increases from 40-60% if results are
taken for 6 hours [49].
Within the first few months of life,
lactase activity starts to decrease. In
most mammals, it declines at variable
rates following weaning to
undetectable levels but in humans,
approximately 30% of the population
has continued lactase activity beyond
weaning and into varying stages of
adulthood [49]. Ethnic origin affects
the frequency of lactose intolerance; in
adults, white north Europeans, North
Americans and Australasians have the
lowest incidence ranging from 5% in a
British population to 17% in Finland
and northern France. In South
America, Africa and Asia, over 50% of
the population has lactase deficiency
and in some Asian countries this rate
is almost 100%. [49]. One problem is
that many non-white European ethnic
groups are adopting a Western style
diet, and many are unaware that
lactose is commonly added to many
foods, without adequate labelling. The
rate of loss of lactase activity also
© Jackie Day 2009 v2014
Module Two
varies according to ethnicity: Chinese
and Japanese lose 80-90% of lactase
activity within 3-4 years, the Jewish
race and Asians lose 60-70% over
several years, and in white Northern
Europeans it may take up to 18-20
years for lactase activity to reach its
lowest expression [49].
Lactic acid bacteria e.g. Lactobacillus,
Bifidobacterium, Staphylococcus,
Enterococcus, Streptococcus,
Leuconostoc and Pediococcus, have
the property of producing lactic acid
from sugars by a process called
fermentation [50]. In the process of
fermentation, microbial lactase present
in lactic acid bacteria initially breaks
down unabsorbed lactose by
hydrolysis to its component
monosaccharides, glucose and
galactose, which are then absorbed or
fermented. If lactose, or other
carbohydrate, is maldigested and
cannot be absorbed in the small
intestine, bacteria can metabolise
them to produce short chain fatty
acids; although these are normally
considered beneficial in the large
intestine, they increase osmolarity in
the small intestine and may result in
diarrhoea. The majority of unabsorbed
lactose finds its way to the large
intestine where it is hydrolysed by
bacterial beta-galactosidase present in
lactic acid bacteria to galactose and
glucose, which are then absorbed or
fermented. The gastrointestinal tract
is home to over 500 species of
bacteria that have complex nutritional
requirements for amino acids,
peptides, vitamins, minerals, fatty
acids and carbohydrates [51] [52].
More than 90% of the bacteria in the
large intestine are anaerobes (live
without oxygen); in low-oxygen the
biochemical metabolism of
monosaccharides produces gases
such as methane, carbon dioxide and
hydrogen, as well as various toxins
and alcohols. It is absorption of these
that cause symptoms of lactose
intolerance e.g. abdominal pain,
bloating, diarrhoea or nausea [49].
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
The ability of lactobacilli to convert
lactose to lactic acid is used in the
treatment of lactose intolerance.
Lactase activity is optimal at pH 6-8,
as in the small intestine, but in the
colon, where the pH drops to as low as
4, bacterial lactase activity is
decreased and lactose is more likely to
be left unfermented. In this case,
symptoms of lactose intolerance may
develop because of the increased
osmotic load. The variable ability of
the colonic microflora to ferment
lactose in people with intolerance may
explain why different subjects have
different levels of tolerance [53]. The
growth of lactic acid bacteria is
optimum at pH 5.5-5.8. Lactic acid, by
lowering the pH of the intestinal
environment to 4-5, inhibits the growth
of putrefactive organisms which
require a higher optimum pH of 6-7.
Some people may experience
constipation possibly as a
consequence of reduction in carbon
dioxide by certain bacterial strains in
response to methane production,
slowing gut transit [54, 55]. Or,
unabsorbed lactose passing through
the colon has a high osmotic load,
leading to increased water and
electrolytes in the lumen which,
together with acidification of the colon
contents, speeds transit time, resulting
in loose stools and diarrhoea [56].
Probiotics, defined as live micro-
organisms that when given in
adequate quantities will have a health
benefit on the host [57], have been
known to be in the diet since the early
20th century but it is only recently that
interest has grown in their health
benefits. In subjects with lactose
intolerance, probiotics reduce bloating
symptoms possibly as a consequence
of microbial lactase being present
within lactic acid bacteria in the
probiotics thus improving lactose
digestion [58]. For digestion of lactose
to be enhanced, consumption of viable
lactic acid is essential. If the upper part
of the small intestine is adequately
© Jackie Day 2009 v2014
Module Two
colonised with lactobacilli, they should
be able to aid the digestion of dietary
lactose without the need for
supplements. Prebiotics are defined
as nondigestible food ingredients that
have a beneficial effect through their
selective metabolism in the intestinal
tract [59]. Unhydrolysed lactose can
be considered to be a prebiotic and it
has been demonstrated that numbers
of lactic acid bacteria increase
following lactose ingestion [60].
Fermentation of milk improves
tolerance to lactose because of the
presence of lactic acid bacteria [50].
Yoghurt and some cottage cheeses
contain lactose but because part of it
has been converted to lactic acid,
these foods can often be tolerated by
lactose sensitive individuals. Natural,
aged cheese (such as Cheddar and
Swiss) can be digested by many
people with a lactose restriction.
During the cheese-making process,
most of the lactose is drained off with
the whey. The small amount that
remains in the curd is changed to
lactic acid during the ripening (ageing)
of the cheese. Only trace amounts of
lactose remain. Fresh, unripened
cheese (such as mozzarella, cream
cheese and ricotta) are not aged, and
only part of the lactose that remains in
the curd has a chance to convert to
lactic acid. This means that dairy foods
in the form of cheese and fermented
milk are established components of
the human diet and provide good
sources of protein and calcium and
often do not lead to symptoms of
lactose intolerance as part of a healthy
balanced diet.
In symptomatic patients, excluding
lactose may not eliminate symptoms,
probably because there is another
underlying cause, e.g. IBS [61]. Cow's
milk protein allergy is rare in adults; its
symptoms can be similar to those of
lactose intolerance [62] but may be
more severe with bloody diarrhoea
and symptoms may include muscle
and joint pain, headaches, dizziness,
lethargy, difficulty with short-term
memory, mouth ulcers, allergies
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
(eczema, pruritis, rhinitis, sinusitis and
asthma) cardiac arrhythmia, sore
throat, increased frequency of
micturition, acne, depression [63-65].
However, if a potential lactose
sensitivity/intolerance exists or
diagnostic investigations are
inconclusive, it may be
appropriate to exclude lactose
from the diet until symptoms resolve,
usually at least 4 weeks. Intolerance
should be confirmed with a lactose
challenge test (challenge tests will be
discussed in a later module). It is
important to ensure that during this
period there is still adequate intake of
calcium through other dietary sources.
Lactose should then be re-introduced
slowly, to tolerance levels; up to 240ml
milk (12g lactose) is usually tolerated.
Further re-introduction can help
decrease symptoms of intolerance [66]
suggesting that there may be
adaptation in the colonic microflora
whereby the lactose is behaving as a
prebiotic as mentioned above. This is
useful in our society where the
addition of lactose in food products is
increasing e.g. in bread, or to add
texture and bind water such as in
processed meats, chicken, sausages
and burgers. It may also be used in
the production of soft drinks and lager
beers and is a major component of
whey. Some foods can contain as
much, or even more, lactose than milk
itself, e.g. slimming products [67], and
lactose is the most common filler in
pharmaceuticals.
Food temperature, the presence of
cereals and other solids, energy
content and nutritional composition of
a meal can alter gastric emptying and
change intestinal transit time by
several hours. A longer exposure time
of lactose in the small intestine allows
increased
hydrolysis by
lactase and
helps to
reduce
symptoms of
lactose intolerance in some subjects
[68].
© Jackie Day 2009 v2014
Module Two
Some lactose intolerant people may
also be sensitive to sugars other than
lactose. Two saccharides found in
beets, green peas, chick peas,
molasses, lentils, cauliflower,
parsnips, kidney beans and baked
beans block a protein that absorbs
glucose and galactose from the small
intestine. As a result, these sugars end
up in the large intestine, where
bacteria generate hydrogen and other
gases and toxic metabolites
(secondary compounds), exacerbating
the symptoms of lactose sensitivity.
Some vegetables that contain these
saccharides, when eaten with lactose-
containing foods, will have a double
effect, worsening symptoms; dishes
combining them with high-starch food,
e.g. rice, can be a particular problem.
Turn to the Appendix for the lactose
content of milk and some dairy
products [69].
When the fat (cream) is skimmed off,
removing the saturated fat, the
resulting liquid is skimmed milk. Semi
skimmed is the most popular milk in
the UK with a fat content of 1.7%,
compared to 4% in whole milk and 0.1-
0.3% in skimmed milk. The process
also removes the fat soluble vitamins A
and D and leaves a higher proportion
of water soluble nutrients such as
calcium, which needs vitamin D for its
uptake. Research has found the
utilisation of calcium from milk is poor,
particularly when on a high protein diet
(milk provides protein). The lower level
of fat in skimmed milk reduces its
calorie (energy) content. For this
reason it is not recommended for
children under 5 years of age as they
need the energy for growth [70].
Cream contains the high calorie,
highly saturated fats, and vitamins A
and D plus whatever vitamin E
survives the process of pasturisation.
The conclusion from
research suggests
that while some
individuals may be
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
genuinely sensitive to lactose, many
people with a ‘suspected intolerance’
may simply have poor digestive
chemistry and an imbalance of
bacteria that can be corrected with
appropriate nutritional advice. People
react individually to various amounts of
lactose in their diet. Some experience
more discomfort from skimmed milk
than from whole milk. Strange as it
seems, sweetened milk beverages
such as chocolate milk may be better
tolerated since the added sugar may
slow down release of the lactose from
the stomach into the small intestine.
Butter is obtained by churning cream
or milk to break the emulsion and
separate the fat. The buttermilk is then
drained off and the remaining mass is
washed and usually salted; at this
stage it has a similar composition to
skimmed milk. Butter is a concentrated
form of saturated fats and contains
around the same proteins as found in
milk. (Buttermilk is the liquid that
remains from cream after it has been
used for making butter.) Although
butter is high in saturated fat, it is a
rich source of trace minerals, e.g.
selenium and iodine, vitamins A and D,
as well as butyric acid which is used
by the colon as an energy source[71] .
Butter may not be as bad as we have
been led to believe and in many
respects may be better than
margarines and spreads. It does
contain high levels of trans fats but
these are the type known as vaccenic
acid, which is more easily metabolised
than artificially manufactured trans fats
found in some spreads [72].
Enteritis, sometimes known as
traveller’s diarrhoea, is inflammation of
one or more sections of the small
intestine, usually caused by an
infectious organism such as E. coli,
Campylobacter, Salmonella, Shigella
or Staph aureus. Members of the
genus Campylobacter are now
recognised as the most common
cause of acute bacterial enteritis in the
UK, with Campylobacter jejuni being
© Jackie Day 2009 v2014
Module Two
the dominant species in human
infections [73]. The organisms cause
inflammation and swelling that may
lead to abdominal pain, cramping, lack
of appetite, diarrhoea that is sudden
and may include blood in stools, fever
and dehydration. The inflammation
can also involve the stomach
(gastritis) and large intestine (colitis).
Enteritis may also be a result of an
autoimmune condition, such as
Crohn’s disease, or certain drugs
including ibuprofen.
Risk factors include recent family
illness with intestinal symptoms such
as diarrhoea or vomiting, recent travel,
eating or drinking substances
contaminated with bacteria or viruses.
Viral diarrhoea is usually self-limiting
and is treated with rehydration.
Antibiotics may be needed when
bacterial causes are suspected, e.g.
food poisoning or recent travel. A
similar dietary approach as for
duodenal ulcers would be appropriate.
For more information see the website:
http://www.nlm.nih.gov/medlineplus/en
cy/article/000296.hhtm
Revision Exercise
Revision exercises are for your
personal use, to help you assess your
understanding and progress. Against
each category make appropriate notes
as to whether your understanding of
each topic at this stage is good, or
whether you need to revisit it.
Enzymes
Small intestine
HCl
Chemical
breakdown
Problems due
to faulty
breakdown
Disorders of
small intestine
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
If you are having problems, please
contact the College for help.
Portal Circulation
In the systemic circulation, venous
blood passes from tissues to the heart
by the most direct route. In the portal
circulation venous blood passes from
capillaries in the intestines, the spleen
and the pancreas directly to the liver,
passing through a second capillary
bed, the hepatic sinusoids. By this
mechanism, nutrients pass first to the
liver for processing before ultimately
entering the main systemic circulatory
system via the inferior vena cava.
The liver has the only vein of the body
that goes to an organ before returning
blood to the heart – the hepatic vein.
Research Project
Study the anatomy and physiology of
the liver in your text book so that you
understand its function.
Accessory Organs
All the body systems are linked to
digestion, starting with the body cells
which need nutrition. Nutrients are
carried by the circulatory system
where hormones from the endocrine
(glandular) system help metabolise the
food, the nervous system stimulates all
the organs by nerve impulses and the
muscular system contracts the
alimentary canal in peristalsis.
The major accessory organs of the
digestive system are the liver, gall-
bladder and pancreas. The liver is the
largest organ in the body. It is known
as the power house and is located
under the dome of the diaphragm. It is
brownish red in colour and if of normal
size cannot be felt through the
abdominal wall. It has a large right
lobe and smaller left lobe as well as
two other lesser lobes. The liver has a
double blood supply: the portal vein
and the hepatic artery. These two
vessels deliver about 1500ml of blood
to the liver every minute. The hepatic
© Jackie Day 2009 v2014
Module Two
artery carries oxygenated blood while
the portal system of veins carries
blood that is rich in the end products of
digestion, as well as other raw
materials required for metabolic
activities in the liver.
The gall bladder is a muscular sac that
serves as a storage pouch for bile that
is produced by the liver. It is positioned
behind the liver, at the base of the right
lobe.
The pancreas is situated behind the
stomach, between the duodenum and
the spleen. It produces pancreatic
juice rich in digestive enzymes.
The Liver
The liver is one of the most vital
organs and tends to be excessively
overworked. Blood is cleansed in the
liver and further cleansed and
oxygenated in the lungs. Toxic material
is concentrated and changed into bile
which acts as an inciter for the bowel’s
peristaltic actions, helping to promote
natural bowel movements. The liver
also aids in digestion by producing a
myriad of enzymes.
As stated in Module One the aim of
the digestive process is to reduce
‘alien’ foods to their original forms, i.e.
carbohydrates, proteins and fats. This
process is aided by the liver, which
either attaches other chemicals to the
broken down molecules it has received
or regroups them into complex
molecules that the body recognises as
‘friendly’. If the liver considers
substances to be toxic, they are
destroyed or neutralised and their end
products may be used to create
energy or excreted in the form of urea.
The action of the liver upon
carbohydrates and fats (lipids) is to
catabolise them, i.e. break them down
to release energy that will fuel the
mitochondria of cells. The liver’s
action on proteins is the reverse, i.e. to
anabolise them (build them up) and
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
combine them with other proteins to
form new tissues.
The liver is central to all aspects of life,
health and well-being. It weighs
around 1.3 kilograms, is the largest
organ in the body[74] and has a
remarkable ability to regenerate itself.
Only 10-20% of the liver is required to
sustain life [75]. It is the highly active
chemical brain of the body –
recycling, regenerating and
detoxifying. Its cells are equipped to
produce considerable amounts of
energy needed for the processing of
nutrients and to detoxify and cleanse.
The breakdown products of lipids, i.e.
glycerol and fatty acids, and glucose
from carbohydrates are used to create
the Citric acid cycle (also known as
Krebs cycle or Energy cycle ) in liver
cells to maintain this demand for
energy [76].
If the liver becomes congested or
various functions are inhibited,
numerous medical conditions can
develop. Few organs work as hard; it
is crucial for most metabolic functions
and is thought to carry out around 500
functions including the production of
bile, processing cholesterol, regulation
of the body’s energy supply and
hormone balance, storage of various
vitamins and minerals [74].
As the body’s major detoxifying organ,
the liver is challenged on a daily basis
by toxins entering the body via food,
the environment and endogenous
toxins produced by unfriendly bacteria.
A combination of appropriate diet,
healthy lifestyle and low toxin intake
will allow the liver to process wastes
faster than they can build up. Most of
us do not live in such a perfect world
so wastes back-up in the organ.
Bile production and blood filtration can
be considered as further mechanisms
by which the liver performs its primary
function of detoxification. The liver
produces approximately 600-1200ml
of bile daily [74] which serves as a
carrier of fat-soluble toxins to be
© Jackie Day 2009 v2014
Module Two
excreted via the intestines. The liver
filters about 1500ml of blood per
minute to remove bacteria and other
foreign matter before the blood is
returned to the general circulation [75].
The liver filters approximately 1500ml
of blood every minute to remove
bacteria, viruses, parasites, yeasts,
fungi, dead cells, tumour cells,
haemoglobin and other foreign matter
before the blood is returned to the
general circulation. Most chronic
health issues stem from toxin
absorption into the portal circulation,
causing a sluggish liver and resulting
in a variety of disorders. Chronic
fatigue, poor sleep patterns,
migraines, gastro-intestinal disorders,
blood sugar disorders, vitamin and/or
mineral deficiencies, muscle or joint
pain, depression, disturbed
metabolism of blood fats, immune
problems, asthma and eczema, can all
be related to metabolic poisoning from
dietary factors or environmental
pollutants such as household or
industrial chemicals, cigarette smoke
or air pollution, and the resultant poor
liver detoxification of them. The liver
releases enzymes to control histamine
balance and without them allergies
can develop such as hayfever.
Parkinson’s Disease patients have
been found to be unusually
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
susceptible to exogenous (external)
and endogenous (internal) toxins.
Tyramine, which is found in foods such
as chocolate and cheese, causes
headaches and migraines in some
people as the result of poor metabolic
processes in the liver.
The liver should be seen as central to
the accumulation of hormonal by-
product; if it cannot adequately
degrade and remove excess
hormones, problems such as PMS or
menopausal symptoms may result,
due to excess circulating hormones.
The following two paragraphs are
rather complex but they demonstrate
the inter-relationship between
hormone regulation and diet.
Sex hormone-binding globulin
(SHBG) is a glycoprotein produced in
hepatocytes, the brain, uterus,
placenta and vagina. Its role is to bind
to sex hormones, specifically
testosterone, dihydrotestosterone
and oestradiol (the major oestrogen
in humans). Other steroid hormones,
such as progesterone, cortisol and
other corticosteroids are bound by
corticosteroid-binding globulin (also
known as transcortin), which is
produced by the liver and is regulated
by oestrogens. SHBG levels are
delicately controlled and are thought to
be decreased by high levels of insulin,
and by insulin-like growth factor 1
(IGF-1), a polypeptide mainly secreted
by the liver as a result of stimulation by
growth hormone (GH). Other
research suggests it is the liver’s
production of fats that reduces SHBG
levels, rather than a direct effect of
insulin [77, 78].
If there is less SHBG protein more
testosterone and oestrogen will be
released throughout the body, which is
associated with an increased risk of
acne, infertility, polycystic ovaries, and
uterine cancer in overweight women.
Abnormal amounts of SHBG also
disturb the delicate balance between
oestrogen and testosterone, which is
associated with the development of
© Jackie Day 2009 v2014
Module Two
cardiovascular disease, especially in
women. A low-fat vegetarian diet has
been associated with: increased
serum sex-hormone binding globulin
concentration, reductions in body
weight (where needed), improvements
in symptoms and duration of
dysmenorrhea (period pain) and
premenstrual tension[79]. Accordingly
the bioavailability of SHBG, whether
as a result of excess insulin, or a high
fat diet, can be a significant factor in
PMS.
The liver produces cholesterol, which
is used to make hormones and help in
the building and repair of cells. A diet
high in saturated animal fats will
encourage the liver to produce greater
amounts of cholesterol to metabolise
it. Cholesterol is used in the
manufacture of bile, which breaks
down fats and removes them via the
gall bladder and intestines. Around
2000mg of cholesterol is produced
daily by the liver [80] for the formation
of hormones such as oestrogen,
testosterone and those produced by
the adrenal glands. It is an overload
from inappropriate dietary intake,
together with oxidative stress (more
oxidants/free radicals than
antioxidants), that causes problems
with blood cholesterol levels [81].
Phospholipids such as lecithin are able
to emulsify digested fats and
metabolise stored fats.
Bacteria from the intestines
continually pass through the gastro-
intestinal mucosa into the portal
circulation. However, if the phagocytic
properties of the Kupffer cells are
working efficiently to overcome micro-
organisms, only around 1 percent of
them will succeed in entering the
systemic circulation where they
challenge the body’s immune system,
clog up tissues and deprive the system
of vital nutrients.
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
Research Project
We have just used the word
‘phagocytic’, which relates to the noun
‘phagocyte’. Use your anatomy and
physiology textbook to look up the
meaning of phagocyte and also
macrophage.
Major functions of the liver are:
 The detoxification of harmful
substances such as alcohol
and drugs.
 Removal of nitrogen and amino
acids.
 Storage of vitamins A, B12, D,
E and K.
 Storage of glucose in the form
of glycogen which it converts
back to glucose when required
for energy by the body.
 Storage of iron from the
breakdown of red cells in the
spleen.
 The modification of fats so they
can be effectively used by body
cells.
 Production of heat – the body’s
radiator.
 Vitamin A and D production.
 The manufacture of heparin, a
substance which prevents
clotting of blood.
 The formation of albumin,
fibrinogen, and other blood
plasma proteins.
 The manufacture of bile.
 Converts stored saturated fat
into other fat products such as
cholesterol.
 The synthesis of urea, a waste
product of protein metabolism
-released into the blood stream
for extraction by the kidneys.
 Metabolism of protein.
Liver Toxicity
The liver is the primary detoxifying
organ in the body. Unless it functions
efficiently, good health is impossible. A
combination of good diet, healthy
lifestyle and low toxin intake allows the
liver to process wastes faster than
© Jackie Day 2009 v2014
Module Two
they build up. Over-indulgence in
processed food, alcohol, tobacco
smoke, chemicals used in food
production and environmental
pollutants frequently result in wastes
backing up into the liver itself.
Virtually all of us can expect to have
some degree of liver toxicity.
Regardless of how health conscious
an individual may be, because of the
wide range of toxins that surround us
in the atmosphere, the food we eat
and the water we drink, it is effectively
impossible to escape their damaging
effects. Added to which, a significant
number of toxins are produced
generated within the body as a result
of its metabolic processes. Whatever
poisonous substances enter the body
or are created within it during normal
metabolic processes, the liver is
responsible for their removal. Billions
of chemical reactions take place within
liver cells every minute so the liver can
easily become overloaded.
In recent times there has been an
enormous increase in artificial
molecules that end up in our bodies
from food, the environment,
recreational drugs or certain forms of
medication. Cumulatively they may
lead to an overburdened liver in some
individuals. Often these molecules
mimic natural ones sufficiently to be
broken down by part of the body’s
enzyme system. In other cases they
may interfere with normal processes. It
is the liver that primarily has the job of
disposing of these molecules [30].
The cumulative effect of constant
exposure to oxidants is toxic damage
to the liver cells. A highly toxic load of
the liver may manifest in certain
physical signs and symptoms. They
include:
Dark circles under the eyes
Foul smelling breath
White coating over the tongue when
you wake up
Pale or pasty-looking skin
Chronic indigestion
Intolerance to alcohol and/or
medications
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
Foul smelling stools
Chemical sensitivities
Chronic constipation
Chronic skin itching
Poor blood clotting, easy bruising
Persistent fatigue
The liver disposes of harmful
compounds through a complex system
of chemical reactions. The key to
success is a protein/enzyme, known
as glutathione. If the liver fails to
produce sufficient glutathione, or the
individual consumes substances that
can destroy it, exposure to toxic
chemicals can be
life-threatening.
Certain herbs and
spices dramatically
enhance glutathione
synthesis.
Rosemary, Fennel
and Oregano can all increase the
production level by up to 400%.
Coriander is another hepatic stimulant.
The likes of Sage, Rosemary,
Oregano, Bay, Cumin and Turmeric
are potent antioxidants [82-84].
Interferon is one of the antiviral
proteins produced by cells that have
been invaded. Interferons are released
by those cells, providing protection to
other cells liable to invasion by the
original virus and any other possible
hostile microbe. Additionally, Interferon
can modify various cell-regulating
mechanisms, can slow down tumour
growth and activate Natural Killer (NK)
cells and macrophages to improve
immune responses. The liver is central
for balanced interferon, storing it for
times of emergency. The treatment of
viral liver infections is dependent upon
the availability of interferon. Kupffer
cells within the liver are macrophages
that have adapted for specific
functions, scavenging worn-out red
blood cells, bacteria and toxic debris.
As such they are an integral part of the
body’s immune system.
The liver deals with toxins in varying
stages. Kupffer cells can remove
bacteria, worn out red blood cells, and
© Jackie Day 2009 v2014
Module Two
other particles from the bloodstream.
When overworked, Kupffer cells can
proliferate and cause enlargement of
the liver. Ingested vitamins and other
nutrients that are to be stored or
metabolised by the liver enter hepatic
cells. Dissolved toxins in the blood are
also absorbed into these cells, where
they are further detoxified by enzymes.
Phase I of detoxification employs P450
enzymes that neutralise some toxins
immediately. Others are converted to
water-soluble forms for excretion by
the kidneys, and the remainder are
partially processed and converted into
what are known as ‘intermediate
chemicals’ needing Phase II
compounds to complete their
destruction and elimination. If the liver
is over-run with toxicity, Phase I and II
enzymes can become less capable of
carrying out their normal processes.
Phase II combines toxic substances
with less toxic compounds and then
excretes them via the kidneys and
bowels [85, 86]. Successful completion
of Phase II requires an adequate
supply of antioxidants, which are
believed to bind to intermediary toxins
to allow their expulsion from the body.
Accordingly, a lack of antioxidants may
result in the reabsorption of toxins in
the body.
The production of bile from the liver is
vital to detoxification since the fluid
acts to remove fat-soluble toxins from
the blood. Low secretion of bile may
lead to a build up of cholesterol and
other fat-soluble toxins in the liver.
Bile, formed by hepatic cells
(hepatocytes), passes to the periphery
of the liver lobule, to join small bile
ducts that ultimately emerge to form
the right and left hepatic ducts, which
then merge to create the hepatic
duct. By this mechanism bile carries
broken down toxins into the intestines
for removal from the body. Because
the liver secretes bile into ducts, the
organ qualifies as an exocrine gland.
Bile salts (formed in the liver from
cholesterol) are the most essential
component of bile, aiding the
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
absorption of fats by reducing them to
small globules. The salts are then
reabsorbed in the ileum and about
80% are recycled in the liver to again
form part of bile. Bile also assists in
the absorption of fat-soluble vitamins
(A, D, E and K), helps to assimilate
calcium, and activates trypsin. It also
serves as a pathway for elimination of
breakdown products of aged red blood
cells (erythrocytes); bilirubin, a bile
pigment, is derived from the non-iron-
containing residue of haemoglobin
after it is separated from globin in the
spleen, liver and bone marrow. It is
transported to the liver, where it is
extracted from blood and excreted into
bile. Once passed to the intestines,
part of the bilirubin is converted into
sterocobilin and excreted in stools
(being responsible for the dark brown
colouring), some is excreted by the
kidneys as urobilinogin and the
remainder returns to the liver. From
the above it can be seen that the flow
of bile unburdens the liver.
Quick Quiz
Name the vitamins stored in the liver,
and the vitamins produced by the liver.
Detoxification
Good health is determined by a
number of factors, one of which is the
ability of the body to effectively remove
toxins. In order for the liver to function
efficiently, there must be good kidney
and bowel function. Toxic wastes may
accumulate in the body due to kidney
malfunction or constipation. Unless the
body’s eliminatory channels are
functioning efficiently, many people
experience ‘detoxifying symptoms’
such as headaches, digestive upsets,
nausea, and general malaise when
attempting a ‘crash’ detoxification
regimen. Failure to follow an orderly
process and beginning detoxification
processes prematurely can result in
people becoming unwell.
Perhaps one of the biggest mistakes
made is that people embark on a
detoxification process when they are
© Jackie Day 2009 v2014
Module Two
already unwell; ironically this is the
worst time because the body needs to
have sufficient reserves to draw on to
allow the liver to do its job properly.
Detoxification processes have a basic
requirement for energy (ATP) to
remove a toxicant; therefore, a body
with a low ‘vital force’ and low energy
could be further depleted by a
detoxification process. Accordingly,
establishing a healthier diet and
lifestyle must be the first approach,
and in many cases nothing more
demanding will need to follow. Failure
to follow this approach can overwhelm
the liver’s ability to process the toxic
substances that are to be eliminated –
some people wish they had never
started on a detoxification regimen.
In any detoxification programme water
is an essential requirement, aiming for
1.5-2 litres daily to help flush out
toxins. It should be remembered that
many factors can affect liver
metabolism. For example, Grapefruit
juice and the herb St John’s Wort
inhibit Cytochrome P450 activity. On
the other hand, cigarette smoke and
Brussels sprouts increases P450
activity [85].
There are many lipotrophic agents
(substances known to encourage the
expulsion of fat from the liver) that may
help to encourage detoxification.
 Choline is a water-soluble
essential nutrient that is usually
grouped with the B vitamins. A lack
of choline may cause stagnation of
fat in the liver and in turn may
hamper its capacity to break down
fat. A condition known as fatty liver
may develop as a result of choline
deficiency [87]. The human body
can only synthesize a small
amount of choline, so it is
important that the nutrient is
consumed through eating foods
such as liver, eggs, wheat germ,
milk, shrimp and salmon.
 Inositol works closely with choline
to assist in fat metabolism. It
occurs naturally in the body, but
can also be obtained in foods such
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
as wheat germ, soybeans, nuts,
whole grains and citrus fruits.
 Methionine is an amino acid that
assists in the breakdown of fats.
This may be due to methionine’s
ability to raise levels of another
amino acid, taurine, which is
known to stimulate bile flow [88].
Methionine’s antioxidant action
may also help protect the liver from
free radicals, the by-product of
normal detoxification processes.
Good levels of methionine can be
found in eggs, parmesan cheese,
seaweeds, and many nuts and
seeds.
 Glutathione [89, 90] is stored in
the liver. It is a powerful
antioxidant, helping to protect the
liver from free radicals. It helps
with compounds such as heavy
metals, solvents and pesticides,
binding to these fat-soluble toxins
to convert them into a water-
soluble form, which is important as
fat-soluble toxins are not easily
excreted from the body.
Detoxifying products are now
commonly available and research by
the Food Standards Agency claims
that many Nutritional Therapists offer
‘so called detox diets’ as a marketing
opportunity for additional treatments
and dietary supplements. The chief
scientist of the UK government's food
watchdog wrote [91]: "There's a lot of
nonsense talked about 'detoxing' and
most people seem to forget that we
are born with a built-in detox
mechanism. It's called the liver.”
The question is can the liver efficiently
undertake this role? We are exposed
to synthetic, often toxic chemicals on
an unprecedented scale. Industrial
chemicals and their pollutant run-offs
in our water, pesticides, additives in
food, heavy metals, residues from
drugs, and environmental hormones
are trapped within cells in greater
concentrations than at any other point
in history.
A highly processed food, a severely
© Jackie Day 2009 v2014
Module Two
unbalanced diet, or simply too much
food will overburden elimination
systems. Lack of exercise contributes
to toxicity. The body’s natural
cleansing cycle of oxygen and vital
nutrients depends upon exercise. A
stagnant system encourages toxic
build up. Not to mention prolonged
mental stress and negative emotions
that can create internal poisons
through chemical imbalances which
are toxic on their own. Every system of
the body is affected, from tissue
damage to sensory deterioration.
Efficient digestion is vital to ensure
food is either converted into nutrient
fluids for absorption into the body, or
flushed out as waste. When the
digestive process is incomplete or
inefficient, partially digested food
remains in the digestive tract,
becoming increasingly toxic. The
toxicity also blocks channels in the
body, further disrupting the flow of
digestion and leading to an escalating
cycle of toxin build-up. This toxic
waste is the breeding ground for
infections and disorders to take root
and flourish.
One of the most frequently
encountered bowel problems is
constipation. A constipated system is
one in which the transit time of toxic
waste is slow. The longer the transit
time, the longer the toxic waste matter
sits in the bowel, allowing it to putrefy,
ferment and possibly be reabsorbed.
Celebrity-endorsed
detox diets have
become popular but
they may be little more
than a ‘quick fix’. The
role of a Nutrition
Advisor is to encourage
people to adopt a lifelong approach to
helping the liver perform its
detoxification role and that includes
good nutrition, appropriate intake of
water, and regular exercise. In many
cases these simple steps should allow
the liver to detoxify adequately.
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
Quick Quiz
Name at least six physical signs that
suggest toxicity of the liver.
Substances that Interfere with
the Liver
Possible negative influences on liver
function include:
excessive alcohol, refined
sugar, caffeine, stress,
suppressed emotions,
steroid medication, antibiotics,
saturated fats and hydrogenated oils,
refined polyunsaturated fats, viral
and/or bacterial overload, exhaust
fumes, nitrates and nitrites,
formaldehyde, ethylene glycol,
pesticides, fungicides, herbicides,
recreational and medicinal drugs, birth
control pill, HRT, dioxins, tobacco
smoke, high protein diet, chemicals,
paint fumes, charcoaled food [85, 86].
Certain foods may aggravate an
irritated liver e.g. coffee, chocolate,
alcohol, animal fats, fried foods,
pulses, peanuts, cashews, fibrous
foods such as pears, sugar, white
flour, red meat, spices. Although garlic
is generally beneficial, it can aggravate
an irritated liver. Some vitamins can
overload an already compromised liver
and particular care may be needed if
supplementing fat-soluble vitamins.
A healthy liver needs fundamental
nutrients: vitamins, minerals,
antioxidants, sulphur, kale, cabbage,
sprouts, cruciferous vegetables, e.g.
cauliflower and broccoli. It also needs
a good pH (acidity and alkalinity)
balance; fresh fruit and vegetables are
alkalising, stress is acidic. Cleansing
foods include vegetables and juices,
particularly apple, artichoke, beetroot,
lemon. Extra virgin olive oil is a
cleanser and food for both the liver
and gall-bladder. Detoxification plans
frequently use hot water with a slice of
lemon at the start of the day. Fasting
gives the body a break from work.
Many people feel better after a fast – a
testimony to the fact that creating
energy is as much about improving the
© Jackie Day 2009 v2014
Module Two
body’s ability to detoxify as it is about
eating. If we go back to ‘ancient man’,
he did not eat as many meals or
snacks as we do – he had to forage for
his food, not turn to the kitchen
cupboard. As such, he gave his
digestive system and liver sufficiently
long breaks. It is a good idea to get
into the practice of giving the liver a
break of around twelve hours every
day by avoiding solid food during that
time and restricting fluid intake to
water, preferably with a slice of lemon;
for many people this will involve no
more than giving up snacks and drinks
during the evening. On a longer-term
basis, using a modified diet, low in
toxins and including key nutrients, can
give the liver a powerful boost.
The Gall-bladder
The gall-bladder is attached to the liver
by connective tissue and by
peritoneum that covers both organs.
The liver manufactures bile
continuously but the body may only
need it a few times a day. Bile from
the liver flows through the liver ducts
and then the two hepatic ducts collect
bile from the right and left liver lobes
merge to form the common hepatic
duct, from which the cystic duct
connects to the gall-bladder.
The cystic and hepatic ducts combine
to form the common bile duct, which
carries bile to the intestines. Near the
duodenum, a few centimetres from the
pylorus, it is joined by the pancreatic
duct. Both ducts empty into the
duodenum through an elevation in its
wall. The entry of the ducts is
surrounded by a sphincter that
controls the flow of bile and pancreatic
secretions. When the duodenum is
empty, the spiral valve holds bile in the
gall bladder.
When chyme, the mixture of gastric
juice and food, enters the duodenum,
the gall-bladder contracts, squeezing
the bile into the duct leading to the
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
duodenum.
The function of bile is to emulsify fats,
stimulate peristalsis and create
alkaline conditions in the small
intestine. When fats and acids enter
from the stomach cholecystokinin
(CCK) is produced by the duodenal
mucosa. CCK enters the venous
drainage of the duodenum and passes
to the gall-bladder, pancreas and the
sphincters of the bile ducts. It causes
the gall-bladder muscles to contract,
relaxes the sphincters and allows the
release of pancreatic secretions.
Bile acts as an inciter for the bowel’s
peristaltic actions, helping to promote
natural bowel movements; if bile is not
secreted properly constipation may
develop.
Quick Quiz
What are the main constituents of
bile?
Disorders of the Liver and Gall
Bladder
Cholecystitis is inflammation and
possible infection of the walls of the
gall-bladder. It is caused by blockage
of the cystic duct when the flow of bile
© Jackie Day 2009 v2014
Module Two
if blocked by a stone. The most
common symptom is indigestion,
especially after eating fatty foods.
Cirrhosis is the term applied to
chronic liver diseases, characterised
by destruction of cells and an
overgrowth of fibrous scar tissue. With
this condition the spleen is likely to be
enlarged due to obstruction of the
portal blood flow from the liver to the
spleen.
Gallstones (Cholelithiasis) are
formed by an over-concentration of
bile. A symptom is right-sided pain that
extends to the right scapula. The gall-
bladder not only stores bile but also
concentrates it by water absorption.
Gall stones form when withdrawal of
water from bile causes the solution to
become saturated with bile salts.
Stones may block the bile duct,
causing obstructive jaundice due to
bile accumulating in the blood stream
rather than passing into the
duodenum. The stones can be as
small as a grain of sand, or as large as
a golf ball. The gall-bladder can
develop just one large stone, or
hundreds of tiny ones, or a
combination. Stones are formed by
various substances: pure cholesterin;
calcium biliverdin; calcium bilirubin;
calcium carbonate. For further
information visit the website:
http://digestive.niddk.nih.gov/ddisease
s/pubs/gallstones/
.
These complex disorders must be
treated by an orthodox physician.
The Pancreas
Anatomically, the pancreas has two
functions i.e. it acts as both an
endocrine (ductless) and exocrine
(with duct) gland: the exocrine function
secreting digestive enzymes, while the
endocrine aspect secretes hormones
that are vital for blood sugar
metabolism. Most of the tissue is
exocrine, with what is known as a
‘compound acinar arrangement’.
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
Acinar means cells are formed like
grapes, releasing their secretions into
a microscopic duct within each unit.
Compound means the ducts have
branches that join to the main
pancreatic duct that extends through
the entire length of the gland.
Pancreatic Exocrine Function
The pancreas produces juice rich in
digestive enzymes. It is confined to its
own channels so the enzymes cannot
damage body tissues. If the ducts
become blocked the enzymes will
back up and the pancreas will be
damaged by its own juices. The
outcome of this can be fatal. (Gall
bladder disease may extend into the
pancreatic duct causing abnormal
activation of the pancreatic enzymes
causing the same result.)
The pancreatic duct, carrying
enzymes, combines with the common
bile duct where it opens into the
duodenum. Bile contains co-enzymes
that activate lipase. Bile salts help
lipase by emulsifying fats, reducing the
size of globules and increasing their
surface area so that they are easier to
break down.
After leaving the stomach, chyme is
mixed with alkalising juices to continue
the breakdown of carbohydrates and
proteins plus fats. The exocrine
pancreas produces four enzymes and
various salts. Trypsinogen and
chymotrypsinogen are precursors of
the protein-splitting enzymes, trypsin
and chymotrypsin. Amylase converts
starches into disaccharides and lipase
breaks down fats. The pancreas also
has the ability to produce rennin
should stomach production prove to be
inadequate.
The pancreas releases bicarbonates
to neutralise or reduce the acidity of
stomach secretions. Rotting protein
caused by stomach and pancreatic
inadequacies leads to overly acidic
blood that can result in inflammation
© Jackie Day 2009 v2014
Module Two
and irritations. Inadequate enzyme
secretions will generally lead to
prolonged transit time through the
remainder of the digestive tract.
Protein that has not been completely
broken down will putrefy – bad breath
is one of the more obvious symptoms.
Less obvious is the link between
rotting protein and systemic disorders;
blood becomes more acidic and in an
effort to alkalise itself, blood leaches
alkalising minerals from joints, tendons
and muscles. Therefore, arthritic and
rheumatic disorders and osteoporosis
can be entirely due to poor digestive
chemistry [92, 93].
Pancreatic insufficiency can cause
malabsorption of nutrients. Lipase
deficiency depresses the
emulsification of fats; low stomach
acidity inhibits lipase and precipitates
bile salts. Fatty, clay-coloured stools
are a symptom of improper fat
metabolism. An effective way to
correct the deficiency is to use a
supplement that will input the
necessary enzymes, as discussed in
the Nutritional Therapeutics level.
Disorders of the Pancreas
The flow of pancreatic juices can be
inhibited by a blockage in the bile duct
due to gall-stones. This potentially
serious condition could lead to
necrosis of the pancreatic cells.
Obstruction to the flow can also occur
when gastric juices and the contents of
the duodenum enter the pancreas as a
result of gall-stones, injury, gastritis,
pancreatic calculi, parasites or alcohol
induced cirrhosis of the liver and
pancreas.
Inflammation of the pancreas, leading
to overproduction of enzymes, may
result in pancreatitis. This condition
not only affects the pancreas itself but
also may extend into the bile ducts,
gall-bladder and duodenum. Acute
pancreatitis is characterised by
haemorrhage of the organ. It has
varying degrees of severity but can be
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
fatal. Chronic pancreatitis can develop
when a small stone obstructs the exit
from the pancreas but not the common
bile duct. This can have the effect of
enlarging the tissues, allowing the
otherwise inhibited duodenal content
to flow into the pancreas. Failure to
treat chronic pancreatitis can lead to a
cancerous condition. Pancreatitis is a
condition requiring orthodox medical
supervision.
Pancreatic calculi may form
secondary to inflammation from
inorganic calcium carbonate or
phosphate. Symptoms include pain
radiating into the left and right scapula,
vomiting, jaundice, hyperglycaemia,
fatty stools.
Disorders of the pancreas itself are
potentially life-threatening and must
be treated by an orthodox
physician.
Revision Exercise
Against each category make
appropriate notes as to whether your
understanding of each topic at this
stage is good, or whether you need to
revisit it.
The liver
Liver toxicity
Substances that
interfere
Disorders of liver,
gallbladder,pancreas
Pancreatic exocrine
If you are having problems, please
contact the College for help.
Pancreatic Endocrine Function
The portal circulation connects the
liver and the pancreas. The main inter-
relationship between the two organs
involves the pancreatic hormones,
which send messages to the liver to
release more or less glucose from
stored glycogen.
© Jackie Day 2009 v2014
Module Two
The pancreas produces insulin, the
major hormone secreted by the beta
cells of the Islets of Langerhans,
groups of cells that are scattered
throughout the pancreas. Insulin is the
hormone we associate with diabetes. It
is a huge protein molecule, containing
over 80 amino acids. It plays a key
role in the body’s regulation of
carbohydrate, fat and protein. The
islets also contain alpha cells that
produce another hormone, glucagon.
These hormones enter the
bloodstream in response to changes in
blood sugar levels and work to
balance levels, and together regulate
glucose homeostasis in the body.
Insulin secretion is stimulated by
raised blood glucose and gastro-
intestinal hormones, e.g. gastrin,
secretin and cholecystokinin. This
demonstrates how the digestive,
endocrine and circulatory systems all
work together. When blood sugar
levels rise after a meal, insulin is
released by the pancreas within a few
minutes. Insulin acts like a pump to
transport glucose into cells for energy
production. When absorbed nutrients,
especially glucose, are in excess of
immediate needs for energy
production, insulin promotes storage. It
reduces high plasma levels by
stimulating the uptake of glucose by
cells and increasing the conversion of
glucose to glycogen in hepatocytes.
Insulin also accelerates the uptake of
amino acids by cells and the synthesis
of protein and fatty acids. Its further
roles are to promote the storage of fat
in adipose tissues (body fat), prevent
the breakdown of protein and fat and
trigger the formation of new sugar from
protein. Glucagon has the opposite
effect, triggering the release of stored
glycogen from the liver and muscles
for conversion into glucose, to be used
for energy production.
Inadequate production of insulin can
lead to Diabetes Mellitus, where there
is excess sugar in the blood. With
insulin resistance or impaired glucose
tolerance, gastro-intestinal absorption
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
can overload the ability of other organs
to dispose of glucose, leading to
hyperglycaemia (high blood sugar).
High levels of insulin in the blood
encourage the conversion of
carbohydrates into body fat, while at
the same time inhibiting the
breakdown of stores of body fat into
glucose. Elevated insulin may be a
major source of oxidants. The eyes,
liver, kidneys, red blood cells, the brain
and the walls of the intestines allow
the free access of glucose, without
needing insulin, and are accordingly
vulnerable to damage by oxidative
stress caused by high blood sugar.
Somatostatin (GHRIH) produced by
the hypothalamus (part of the brain)
inhibits the secretion of both insulin
and glucagon.
Blood Sugar
After a meal, blood
glucose levels rise
to a maximum
within about 30
minutes and then
return slowly to
normal after 90–180 minutes. These
times vary according to the content of
the meal. The monosaccharide
glucose, as found in some fruits and in
some ‘diet foods’, is the most useful
carbohydrate to the typical human cell.
Glucose is able to move into the
internal environment without initially
being processed. Other important
monosaccharides, fructose and
galactose, are usually converted by
liver cells into glucose for use by other
cells of the body. This is particularly
significant for diabetics, who can
normally tolerate a certain amount of
fructose. Disaccharides, such as those
in refined sugar, must also be
chemically digested before they can
be absorbed. Cereal products cause a
faster rise in blood sugar levels than
beans and pulses [94]. A meal high in
glucose and sucrose will cause a more
rapid rise in blood sugar than one that
© Jackie Day 2009 v2014
Module Two
contains more fructose.
At some stage after eating a meal,
broken down carbohydrates in the
form of glucose will flood the
bloodstream, raising blood sugar
levels. This process has to be
controlled and that is the function of
the pancreas, via insulin, glucagon
and somatostatin. When nutrient-rich
blood passes through the pancreas, it
recognises a high sugar level and
releases insulin into the blood. When
insulin reaches the cells of the liver it
stimulates them to extract excess
glucose from the blood and convert it
into glycogen by a process known as
glycogenesis, i.e. the formation of
glycogen. If blood sugar levels fall
below normal, the pancreas will
release glucagons. This is done by
stimulating glycogenolysis in the liver
(lys meaning to break apart), i.e. the
breaking apart of stored glycogen into
glucose molecules. This entire process
is under the control of the autonomic
nervous system, aiming to supply the
steady supply of glucose needed to
provide energy to cells. This is the
homoeostatic control of blood sugar
levels [76].
It is not just pancreatic hormones that
are involved in blood sugar
metabolism. An adult human liver
stores around 160g glucose [76] and is
responsible for converting stored
glycogen and maltose into sugar,
making it effectively the most
important organ for regulating blood
sugar levels. If the liver is inefficient it
will not be able to store sugar and will
overload the bloodstream. If sugar
collects in the blood (due to liver
dysfunction, diminished receptor sites
or reduced insulin production) the
kidneys excrete the sugar in urine. As
blood sugar levels rise, the sugar
attaches itself to oxygen in the blood,
preventing blood entering cells. The
direct result can be eye, kidney,
circulatory and neural disorders.
The two sides of the autonomic
nervous system influence blood sugar
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
control: the sympathetic nervous
system triggers secretion of the
hormone adrenaline by the adrenal
glands, usually in response to the
‘flight or fight’ reaction. Adrenaline, in
turn, triggers the release of stored
glycogen to create energy [95] via the
pancreatic negative feedback system;
in this situation insulin production is
suspended and glucagon triggers the
release of glycogen stores in the liver
(glycogenolysis). When this ‘stress’
situation has passed, under the
influence of the parasympathetic
nervous system, insulin will promote
the storage of any excess plasma
glucose. However, when adrenaline is
discharged into the bloodstream too
frequently, the conversion of glycogen
to glucose may be impaired; this may
lead to cravings for sweet foods and/or
stimulating beverages.
If glucose levels drop below normal
(hypoglycaemia), adrenaline is
produced to inhibit a further drop in
glucose; it does this by triggering the
conversion of glycogen to glucose.
Prolonged high blood glucose levels
can lead to insulin resistance and
diabetes, due to a deterioration of an
overworked pancreas. The stress
source could be a high sugar diet
triggering first pancreatic and then
adrenal responses, or vice versa [96].
Either way, similar problems emerge.
The thyroid too plays a role in blood
sugar metabolism, dictating the
efficiency of liver function. An under-
active thyroid, or stress (which can
physically constrict the liver), can be at
the root of hypoglycaemia (low blood
sugar). Growth Hormone, produced
by the pituitary gland, creates energy
by mobilising fatty acids from adipose
tissues.
Constipation and a slow transit time
of food through the digestive tract,
allows toxic blood to reach the
pancreas. This escalates the death of
beta cells (insulin producing) and
lowers the compensatory functions of
the liver and kidneys in controlling
© Jackie Day 2009 v2014
Module Two
blood sugar
Disorders Associated with Blood
Sugar
Blood sugar (glucose) is used to
create energy throughout the body but
too much in the blood is dangerous. If
the individual’s metabolism is able to
handle carbohydrates, there is likely to
be little problem; the person is unlikely
to crave carbohydrates, the pancreas
will produce the normal amount of
insulin when he or she eats, and there
should be no weight gain (unless they
overeat). With a number of people the
tissues become resistant to insulin so
the pancreas has to make more of it to
bring blood sugar down [97]. The
result may be low blood sugar and
then urgent craving for carbohydrates
because more sugar is needed to
create energy. This characteristic roller
coaster between high and low blood
sugar is an increasing issue in the
western world. This is not just because
of energy issues but because
whenever insulin removes excess
sugar from the bloodstream, it turns it
into body fat, which can trigger health
problems, not least circulatory
disorders. Strange as it may seem,
obesity is one of the most common
disorders associated with malnutrition
(under nourishment) [98, 99].
As you learned in Module One,
unrefined carbohydrates provide the
body with valuable sources of vitamins
and minerals. When simple sugars are
eaten, the body’s carbohydrate need is
satisfied and hunger is eliminated but
these sugars, e.g. white flour, sugar
and processed foods that contain
these ingredients, are termed ‘empty
calories’, the refining process having
stripped them of many vital nutrients.
To process refined carbohydrates the
body uses up stores of vital vitamins
and minerals so by eating simple
carbohydrates on a regular basis the
body may technically be suffering from
malnutrition, though the person may
be obese. Being malnourished is
different from being underweight,
although the two often go hand in
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
hand. If an individual is not functioning
well, feeling below par, or suffering
from a variety of disorders that could
include hypertension and type 2
diabetes (see below), the cause may
be malnutrition. Excessive weight
(obesity), resulting from too great a
food intake, can be a form of
malnutrition, as is the excessive
consumption of any nutrient, whether
fat, sugar, mineral or vitamin, if it leads
to ill health. Overweight people may be
literally starving for the right foods and
nutrients to satisfy their hunger.
A number of terms are used to
describe symptoms and conditions
caused by an inability to adequately
transport blood glucose into cells to be
used for energy.
Hyperglycaemia is a medical situation
where there is too
much sugar in the
bloodstream.
Hypoglycaemia refers
to a medical situation
where there is
insufficient sugar in the bloodstream.
For type 1 diabetics, it occurs when
they have given themselves too much
insulin and need to eat or drink simple
sugars to raise their blood glucose
level.
Reactive Hypoglycaemia is a
common problem caused by an
excess intake of simple carbohydrates
and/or lack of proteins and good fats
to balance the carbohydrates. Highs
and lows of blood sugar will be
experienced, usually occurs two to
three hours after a high carbohydrate
meal, over-stimulating insulin release,
which triggers an adrenalin response.
Unless controlled, it can lead to Insulin
Resistance and type 2 diabetes.
Typical symptoms include fatigue,
mood swings, inability to cope with
stress, poor concentration and
memory [100].
Insulin Resistance (IR) is the term
used to describe the situation where
muscle, fat and liver cells do not use
© Jackie Day 2009 v2014
Module Two
insulin properly [97, 101] and is
characterised by a need for an
increased amount of insulin daily to
control hyperglycaemia and ketosis
(see below). The cause is associated
with decreased or ineffective glucose
transporter proteins with insulin-
sensitive cells or insulin-binding by
high levels of insulin antibodies.
Insulin receptors open the doors of the
mitochondria (the powerhouse of cells)
and allow glucose to enter and be
processed into ATP, the fuel that runs
the body [100]. The pancreas tries to
keep up the demand for insulin by
producing more but eventually it may
become exhausted and unable to
supply sufficient, resulting in excess
glucose building up in the blood. With
IR, the mitochondria no longer
recognise the ‘security pass’, and the
glucose is denied entrance. This could
be due to changes in the shape of the
insulin receptor, or to changes in the
way cells respond to insulin itself
[100]. Many people with IR have high
levels of blood glucose and high levels
of insulin circulating in their blood at
the same time. People with blood
glucose levels that are higher than
normal but not yet in the diabetic
range have “pre-diabetes.” Doctors
sometimes call this condition impaired
fasting glucose (IFG) or impaired
glucose tolerance (IGT), depending on
the test used to diagnose it. Pre-
diabetes is becoming more common.
About 40 percent of U.S. adults aged
40 to 74 (or 41 million people) had pre-
diabetes in 2000, whereas by 2007 the
number had risen to around 57 million
[102]. Studies have shown most
people with pre-diabetes go on to
develop type 2 diabetes within 10
years, unless they lose 5-7% of their
body weight by making changes in
their diet and level of physical activity.
People with pre-diabetes also have a
higher risk of heart disease [103]
[104]. Being obese or overweight
affects the way insulin works and extra
fat tissue can make tissues resistant to
the action of insulin, whereas exercise
helps insulin to work.
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
Many people with IR and high blood
glucose have excess weight around
the waist, high LDL (bad) blood
cholesterol levels, low HDL (good)
cholesterol levels, high levels of
triglycerides, and high blood pressure -
conditions that put the heart at risk [1,
105, 106]. Insulin is also the agent
that causes excess glucose to deposit
as belly fat [100]. Obesity can be one
sign of insulin resistance, but thin
people can have IR too. Insulin
resistance in some circumstances can
lead to osteoporosis as excess insulin
production impairs the synthesis of the
hormone DHEA (after the menopause
this is the only source of oestrogen),
which helps to prevent the breakdown
of bone. Raised insulin levels can be a
major source of free radicals
(oxidants) that increase the risk of
age-related disorders.
Metabolic Syndrome
The terms "metabolic syndrome," and
"syndrome X" are used to define a
‘clustering’ of several risk factors
associated with increased risk for the
development of cardiovascular
disease and type 2 diabetes [1, 105]
[103] [107]. These symptoms are:
obesity (particularly abdominal/central
obesity – see below), abnormal blood
lipids (dyslipidemia) with decreased
HDL cholesterol and raised
triglycerides, insulin resistance or
impaired glucose tolerance, and high
blood pressure (hypertension). The
syndrome may also be characterised
by the presence of microalbuminuria
(a marker for inflammation), where
protein is excreted in the urine, and
with abnormalities in blood clotting,
blood flow and blood vessel structure.
Disease risk is directly affected by
genetics, where certain individuals or
populations may be more likely to
develop the syndrome due to their
unique genetic make-up (e.g. Asian
and African-Caribbean
groups). There is a high
incidence in women with
polycystic ovary disease,
© Jackie Day 2009 v2014
Module Two
and in patients with schizophrenia and
non-alcoholic fatty liver disease.
Lifestyle factors such as diet and
exercise patterns are major influences.
Differences exist in the criteria used to
diagnose metabolic syndrome [1, 108].
The most frequent combinations of
symptoms are obesity with high blood
pressure or abnormal blood lipids but
features may also occur in individuals
with IR who have normal blood
glucose levels, and who may never
develop type 2 diabetes [103]. There is
debate regarding whether obesity or
insulin resistance is the cause of
metabolic syndrome or if they are
consequences of a more far-reaching
metabolic derangement. However,
metabolic syndrome is not observed in
the absence of insulin resistance,
while obesity is not present in many
individuals who present with metabolic
syndrome. A common factor relies on
waist circumference and blood
triglyceride level. This has been called
a ‘hypertriglyceridemic waist’ or apple-
shaped adiposity. For men this is
considered to be waist circumference
greater than 90cm and for women
greater than 85cm [19, 109].
Globally, the incidence of metabolic
syndrome is rising at an alarming rate.
In the US, it is estimated that 47
million residents have metabolic
syndrome, a figure which is expected
to increase in parallel with the rising
epidemic of obesity [110]. In the UK, it
has been suggested that as many as
25% of the population show clear
signs of the metabolic syndrome [111].
Implications of having the syndrome
are stark: a three-fold increase in risk
for coronary heart disease and stroke
compared to individuals with normal
glucose tolerance. In order to reduce
the incidence of this disease, and to
minimise costs to health services,
increasing emphasis must be placed
on disease prevention. Treatments for
metabolic syndrome may involve
pharmacological therapies, but also
diet and lifestyle changes.
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One Module Two

Central obesity, the "apple-shaped" that interventions on a sociopolitical

obesity commonly referred to as belly level are required to reduce
fat, is the accumulation of visceral fat development of metabolic syndrome in
(fat deposited between the internal populations [117].
organs in the torso) resulting in an
increase in waist size. Abdominal fat is Dietary advice is common to metabolic
especially active hormonally, secreting syndrome and central obesity:
a group of hormones called adipokines  Fresh fruit and vegetables (at
that may possibly impair glucose least 5 portions/day with more
tolerance. There is a strong correlation vegetables than fruit).
between central obesity,  Complex rather than simple
cardiovascular disease, hypertension, carbohydrates; wholegrain or
insulin resistance, type 2 diabetes, and high-fibre rather than refined
polycystic ovary syndrome (PCOS). carbohydrate [105].
Belly fat is a symptom of metabolic  Fats:
syndrome, and is an indicator used in o Reduction of dietary fat is
the diagnosis of the disorder [106] [1, traditional advice. However,
105]. The main causes of central "Low fat" is too simplistic
obesity are overeating and a and may even be
sedentary lifestyle. detrimental. The
composition of dietary fats
Various strategies have been is more important [21, 118].
proposed to prevent the development o Avoid trans-fats (often
of metabolic syndrome. Diet and labelled as 'hydrogenated'
exercise patterns are known to or 'partially hydrogenated'
influence disease risk and vegetable oils) found in
are a simple and effective many margarines and
way to tackle the spread of processed foods.
this disease. Lifestyle o Increase the proportion of
modification is considered to be monounsaturated fats (e.g.
a cornerstone of treatment for olive oil) Increase the
metabolic syndrome. Practical amount of omega-3
steps include a reduction in the polyunsaturated fatty acids
amount of carbohydrate, specifically - these are found in oily
fast digesting starches and sugars, fish, marine fish oils, nuts,
along with a healthy balanced diet rich linseed or flax oil, and
in fruit and vegetables and with green leafy vegetables
lower amounts of fat, sugar and salt [119, 120]. (SIGN
[112], and an increase in the levels of recommends "two portions
physical activity in our daily lives such of 140g fish, one of which
as walking 30 minutes every day [113]. should be fatty fish, per
Modern Western diets are very week" as being evidence-
different in composition to traditional based and consistent
human diets. Notably, they are high in advice [115]).
refined carbohydrates and refined o There is evidence the
vegetable oils; and low in omega-3
addition of nuts, such as
fatty acids, fresh fruit and vegetables.
almonds, in the diet is
All these have a role in obesity,
beneficial [121, 122].
adverse lipid profiles and metabolic
o A Mediterranean-style diet
syndrome [114, 115]. Many studies
support the value of a healthy lifestyle. encompasses these
However, one study stated that these recommendations and has
measures are effective in only a been found beneficial in
minority of people [116] and ‘The metabolic syndrome [123,
International Obesity Taskforce’ states 124].

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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
 Protein/carbohydrate ratio:
o The established view is that
complex carbohydrates
should form the major
proportion of calories in the
diet [1, 105]. More recently
there has been interest in
high protein/low
carbohydrate diets, both as
a method of weight loss
and to improve lipid or
glucose profile [125]. One
review proposes this type
of diet as the definitive
treatment of metabolic
syndrome [126].
Further information can be found:
http://www.patient.co.uk/showdoc/40002282/
and:
http://www.nutrition.org.uk/home.asp?
siteId=43&sectionId=729&subSectionId=327&p
arentSection=301&which
Type 1 Diabetes, also known as
juvenile onset diabetes because it
normally develops during childhood,
adolescence or early adulthood,
occurs when the pancreas is no longer
able to produce insulin. It is
considered to be an auto-immune
disease. Individuals with this disorder
are dependent upon insulin, hence its
former name – insulin dependent
diabetes mellitus. They must give
themselves insulin injections in order
to lower their blood sugar to the
desirable level of 70-110mg/100ml
(fasting) [127].
Type 2 Diabetes, also known as adult
onset diabetes because (until recent
years) it was typically found in middle-
aged and elderly people. Type 2
usually occurs when a person is
overweight and the body cannot
properly use the insulin that is
produced in the pancreas.
Unfortunately, due to ever increasing
poor dietary habits and obesity, type 2
is now being found in children and
adolescents. In most patients the
sequence of events is: insulin
resistance or impaired glucose
tolerance, progressive beta cell failure,
glucose toxicity. Individuals with insulin
resistance do not necessarily progress
© Jackie Day 2009 v2014
Module Two
to type 2, but without dietary
adjustments they typically continue to
be insulin resistant and glucose
intolerant. Type 2 diabetics usually
need oral medication that will help the
body use the insulin it has already
produced, in addition to dietary
adjustments. In the UK about 3 in 100
people aged over 40, and about 10 in
100 people aged over 65, have Type 2
diabetes. It often tends to run in
families. It is also more common in
South Asian and African-Caribbean
people (often developing before the
age of 40 in this group) [128].
Ketoacidosis occurs when there is
too much sugar in the bloodstream
due to a lack of insulin, often as a
result of a missed dose of medication.
While insulin’s main role is to lower
blood sugar, it also reduces the
burning of body fat. If insulin levels
drop significantly, the body will start
burning fat uncontrollably while blood
sugar levels rise. Diabetics cannot fully
metabolise fats and particles known as
ketones, or acetones, seep into the
blood. Without insulin they cannot be
stored so they continue to build up in
the blood, leading to ketoacidosis,
which makes cells over-acidic. When
the level becomes too high, ketones
are released into the urine, along with
large quantities of water and salt,
putting the body at serious risk of
dehydration. This is the body’s
alternative to insulin when trying to rid
itself of excess sugar. It is a serious
condition, requiring medical
intervention [129].
An interesting aspect of a diet high in
sugars of one form or another is that
sugar inhibits the enzymes needed by
the brain to form an essential fatty
acid, DHA. Insulin, produced in
response to sugar in the bloodstream,
affects the enzymes that convert
essential fats [130]. With too much
insulin the body converts the anti-
inflammatory gamma-linolenic acid
(GLA), as found in Evening Primrose
Oil, to pro-inflammatory arachadonic
acid (AA). With too much AA the body
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
is primed for inflammation. You will
learn about these and other fats in a
later module.
Polyuria describes the production of
excessive amounts of urine. Excretion
of urine is considered normal if it is
passed 4 to 6 times daily. Adults will
eliminate around 1500ml daily, less in
children. In normal circumstances,
fluid intake and output (urine and
perspiration) are interdependent,
maintaining a relatively constant fluid
balance. There is a difference between
frequency and an increase in urine
passed. An excess is known as
‘frequency’; it may be due to reduced
bladder capacity e.g. enlarged
prostate or irritation as in cystitis.
Increased output is often a symptom of
diabetes but to a lesser degree erratic
blood sugar levels can be involved. In
the latter case, dietary improvements
will often bring changes in urinary
output. Simple frequency may arise
from cold weather, nervous
excitement, early pregnancy, stones in
the kidney or bladder. Another factor
may be due to an over-acidic blood
pH. The urinary system will be covered
later in the course.
Type 3 diabetes
Historically, skeletal muscle, adipose
tissue and the liver were regarded as
key insulin target organs involved in
insulin-mediated regulation of
peripheral carbohydrate, lipid and
protein metabolism. The brain has now
been identified as an important target
for the action of insulin [131].
Alzheimer's disease was tentatively
dubbed "type 3 diabetes" in early 2005
when researchers learned that the
pancreas is not the only organ that
produces insulin. The brain also
produces insulin, and this brain insulin
is necessary for the survival of brain
cells.
In addition to its critical role as a
peripheral signal for energy balance,
central nervous system insulin
signalling is also involved in the
regulation of glucose metabolism.
© Jackie Day 2009 v2014
Module Two
Understanding of the role of insulin in
the brain has gradually expanded,
from initial conceptions of the brain as
insulin-insensitive to the identification
of insulin as a key component of
memory processes in the
hippocampus area of the brain [131].
A growing body of research is
highlighting the drastic effect diet plays
in brain health, such as significantly
raising the risk of cognitive
impairment. Among people aged 70 to
89, diet proved very influential in
contributing to the risk of mild cognitive
impairment, including problems with
memory, language, thinking and
judgment. The study revealed
carbohydrates and sugar to be the
biggest culprits, while protein and fats
were protective [132, 133]. Those with
the highest carbohydrate intake were
nearly twice as likely to develop mild
cognitive impairment as those with the
lowest intake of carbohydrates.
Faulty insulin (and leptin, another
hormone) signalling is an underlying
cause of insulin resistance, which, of
course, typically leads to type 2
diabetes. However, while insulin is
usually associated with its role in
keeping blood sugar levels in a healthy
range, it also plays a role in brain
health. When researchers disrupted
the proper signalling of insulin in the
brain, it resulted in dementia [132].
Blood Glucose Level Tests
High blood glucose may be a sign that
the body does not have enough insulin
or does not use it well. A fasting
measurement or oral glucose
tolerance test gives precise
information. An insulin measurement
helps determine whether a high blood
glucose reading is the result of
insufficient insulin or poor use of
insulin. Diabetes and pre-diabetes can
be detected with the following tests.
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
A fasting glucose test measures
blood glucose after an individual has
gone overnight without eating. This
test is most reliable when done in the
morning. Fasting glucose levels of 100
to 125 mg/100ml are above normal but
not high enough to be called diabetes.
This condition is called pre-diabetes or
impaired fasting glucose, and it
suggests a state of insulin resistance
for some time. IFG is considered a
pre-diabetic state [134].
A glucose tolerance test measures
blood glucose after an overnight fast
and 2 hours after drinking a sweet
liquid. Blood glucose levels will be
higher after drinking a sugar solution
but should still be below 140
mg/100ml. If blood glucose falls
between 140 and 199 mg/100ml two
hours after drinking the liquid, it
indicates glucose tolerance is above
normal but not high enough for
diabetes. This condition, also a form of
pre-diabetes, is called impaired
glucose tolerance (IGT) and, like IFG,
it points toward a history of insulin
resistance and a risk for developing
diabetes. A level of 200 or higher, if
confirmed, means diabetes is already
present.
Everyday Symptoms of Blood
Sugar Imbalance
There has been a lot of technical
information in the foregoing sections
relating to blood sugar imbalance that
can be used when needed for
reference. The everyday effects of this
imbalance are all around us and it is
likely to be one of the most common
problems a Nutrition Advisor may
encounter. You may recognise some, if
not all, of the following typical
symptoms in people you know.
 Fatigue to varying degrees is the
most common symptom; this may
range from gradually decreasing
energy levels to far more
significant fatigue that can be
debilitating and can prevent people
© Jackie Day 2009 v2014
Module Two
functioning effectively. As people
age they may feel it is normal for
their physical energy to decrease
but this should only be relevant to
a degree. Younger people are also
experiencing energy problems so it
would be unrealistic to blame
everything on age.
 Reduced energy is often
accompanied by muscular
weariness and a general feeling
that everything is an effort to do.
 Coupled with decreased physical
energy is often a decline in ‘mental
energy’. People may say they have
noticed their memory is
deteriorating and/or their ability to
concentrate is now poor.
 Inability to lose weight is often part
of the picture and people may
genuinely be trying hard to restrict
the ‘bad’ foods.
 The ability to cope with stress is
compromised.
 When the situation has become
well established people may feel
that things are getting ‘out of
control’.
Left unchecked for an extended
period, these symptoms may develop
into the typical pre-diabetic state
described earlier.
Balancing Blood Sugar
How is a blood sugar imbalance
caused? This scenario, with which by
now you should be familiar, is most
likely to be caused by an excess of
refined carbohydrates.
Carbohydrates are essential to
produce energy and to feed the brain.
Although all carbohydrates are
converted into sugar in the
bloodstream, they do so at different
speeds. They are ranked according to
their glycaemic index; those with a
high index number break down into
sugar rapidly, causing elevated insulin
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
levels and stimulating the conversion
of carbohydrates into body fat. We
were designed to eat carbohydrates
with a low index number, supplying a
trickle charge of sugar into the
bloodstream and brain. There are
some anomalies i.e. fruit juice has a
moderate GI rating but if the fruit is
predominantly glucose the digestive
system does not have to break it down
so it will be rapidly absorbed into the
bloodstream; even the conversion of
fructose to glucose is likely to be more
rapid in this form and, as with all
excess carbohydrates, can be stored
as fat in adipose tissue. Many people
use fruit juices to achieve their daily
quote of five pieces of fruit and
vegetables but there is evidence to
show that the increased consumption
of naturally sugar-rich (fructose) fruit
juices is contributing to obesity [11,
135].
It is thought that insulin resistance
worsens with the increased use of
saturated fats but improves with
increased unsaturated fats such as
omega-3 fatty acids from fish; the role
of other unsaturated fats is still
unclear. Recent research has
demonstrated that diets high in
monounsaturated fats (olive oil, nuts,
avocados etc) improve blood sugar
levels in both healthy people and
those with diabetes [123, 124].
Because it is
harder for the
stomach to break
down proteins and
fats than
carbohydrates, it is
thought a meal that contains all three
nutrients slows the conversion of
carbohydrates into blood sugar.
Protein stimulates the pancreas to
release glucagon, which encourages
the breakdown of stored fat. Fibre can
help improve insulin and glucose
responses in a similar manner to
protein. The topics of fibre, protein and
fats will be discussed in later modules.
Every meal or snack should provide
sustainable mental and physical
© Jackie Day 2009 v2014
Module Two
energy for at least 2 or 3 hours. Failure
to achieve that suggests the previous
meal did not provide a balance of
nutrients needed. A meal that is
appropriate for one person may be a
disaster for another – everyone needs
to find their own metabolically
appropriate balance of macronutrients.
Most people in the western world eat a
carbohydrate-heavy diet; even
complex carbohydrates are at some
stage converted into glucose so they
do not provide a balanced diet. This is
an important aspect for a Nutrition
Advisor to understand. It is never too
late to rectify a dietary imbalance.
The uptake of glucose into muscles is
dependent upon physical activity. A
brisk daily walk of around 30 minutes
would generally be sufficient, but
better still would be 2 or 3 walks of
around 15 minutes each [1, 116].
How to make effective changes
The level of carbohydrates each
individual can handle efficiently will
vary. Basically the diet should include
complex (unrefined) carbohydrates,
along with a balance of proteins and
essential fats. People who have
become accustomed to energy slumps
and carbohydrate cravings are
surprised to find they feel full for
longer, they start to lose cravings,
have more mental and physical energy
– basically, they feel much better
overall. Stimulants such as tea, coffee,
alcohol and cigarettes all trigger the
release of stores of sugar into the
bloodstream so advice should be to
gradually reduce dependence on
them, while at the same time phasing
in plenty of water. An abrupt removal
of stimulants, rather than phasing
them out, can lead to temporary
‘withdrawal symptoms’. An overall fluid
intake of 1.5-2 litres daily should be
recommended; excessive fluid intake
can disrupt electrolyte (mineral) levels
in the bloodstream, having potentially
serious health consequences that
could trigger inflammation in the brain
(hyponatraemia).
To improve symptoms associated
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
with blood sugar imbalance: aim to
eat more carbohydrates with a low
index and less with a high index, as
part of a balanced diet. You will notice
that the items of food with a low index
number are mostly unrefined, complex
carbohydrates. Different GI charts may
show slightly varied index numbers for
a particular food; the list found in the
Appendix gives an average figure for
some commonly eaten foods. An
extensive list can be found on
www.glycaemicindex.com
GI is an excellent tool in that it directs
people towards favourable food
choices and promotes an awareness
of the effects of carbohydrates on
blood sugar. Low GI diets have been
shown to lower the risk of diabetes
and heart disease [125, 126, 136,
137]. The GI system can be confusing
as some foods that are considered to
be healthy have a high GI number, as
for cooked carrots, which are higher
than chocolate! However, you have to
eat a lot of carrots for them to have the
same effect on blood sugar as a small
piece of chocolate would have. GI is a
measure of quality, telling whether the
carbohydrate in a food is fast or slow
releasing but it does not tell you what
the particular carbohydrate does to
your blood sugar. A GI food is affected
by many factors, such as the amount
of protein and fat included with it in the
meal, and the method of cooking.
The glycaemic load (GL) system
helps to solve some of the confusion.
It is calculated using the quantity of
carbohydrate in the food, along with its
quality. It is considered to be the best
way of gauging what a serving of food
does to blood sugar. For example, the
GI of watermelon is 72 so it is classed
as a high GI food but the GL of a
portion of watermelon, i.e. a large slice
of 120g contains very few
carbohydrates so when you calculate
the GL it has a very low score of
around 4. This means a normal portion
of watermelon will have little or no
effect on the level of sugar in the
blood. Low GL = 10 or less; medium
GL = 11-19; high GL = 20 plus. Many
© Jackie Day 2009 v2014
Module Two
people tend to have a high glycaemic
load of over 120 per day whereas
aiming for around 70-80 is a good
target. There are many reference
sources, e.g. the internet or books that
explain the GL system, along with
reference tables of GL values.
Although the GL system is more
accurate, it has been suggested that
many people find the GI system easier
to work with.
Studies have investigated the
relationship between dietary
carbohydrate, GI, GL and chronic
diseases. In a Meta-Analysis of
studies [138], significant positive
associations were found between GI
or GL and the risk of Type 2 Diabetes,
heart disease, gall bladder disease,
breast cancer and all diseases
combined. GI was shown to have a
more powerful effect than GL (more
positive associations and associations
of a greater magnitude). Irrespective of
carbohydrate intake, the GI of
contributing carbohydrate foods was
found to be important in determining
the risk of chronic lifestyle-related
diseases. In diabetes and heart
disease, the level of protection was
similar to that of whole grain and high
fibre intakes.
A study of randomised controlled trials
that tested whether cinnamon can help
to regulate blood sugar levels and
reduce diabetes risk found that
cinnamon reduced glycated
haemoglobin (HbA1c) and fasting
plasma glucose levels [139].
Social interaction at mealtimes has
been shown to influence blood sugar
levels. Researchers found that blood
sugar levels were lower when
individuals talked with others at
mealtimes [140].
Health Organization (WHO)
Global Strategy on Diet, Physical
Activity and Health
In the WHO section in Module One the
report quoted “Physical activity is a
fundamental means of improving the
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One
physical and mental health of
individuals.” It goes on to discuss
physical activity with regard to
Diabetes and Metabolic Syndrome:
“Risk factors for non-communicable
disease frequently coexist and
interact. As the general level of risk
factors rises, more people are put at
risk. Preventive strategies should
therefore aim at reducing risk
throughout the population. Such risk
reduction, even if modest, cumulatively
yields sustainable benefits, which
exceeds the impact of interventions
restricted to high-risk individuals.
Healthy diets and physical activity,
together with tobacco control,
constitute an effective strategy to
contain the mounting threat of non-
communicable diseases.”
Physical activity is a key determinant
of energy expenditure, and thus is
fundamental to energy balance and
weight control. Physical activity
reduces risk for cardiovascular
diseases and diabetes and has
substantial benefits for many
conditions, not only those associated
with obesity. The beneficial effects of
physical activity on metabolic
syndrome are mediated by
mechanisms beyond controlling
excess body weight. For example,
physical activity reduces blood
pressure, improves the level of high
density lipoprotein cholesterol,
improves control of blood glucose in
overweight people, even without
significant weight loss, and reduces
the risk for colon cancer and breast
cancer among women [141].
Physical activity and Diabetes
The number of adults with diabetes in
the world was 135 million in 1995 and
is set to rise to 300 million by
2025, with the majority of
cases being type 2 (T2D).
This dramatic increase
will have a major impact
on global health and
health care spending
© Jackie Day 2009 v2014
Module Two
as individuals with T2D have more
than twice the risk of premature death,
heart disease and stroke [4]. Physical
activity has been found to dramatically
reduce the risk of developing T2D, as
well as its associated morbidities [116].
Skeletal muscle plays a major role in
glucose homeostasis and insulin
resistance; the role of regular aerobic
exercise in improving glycaemic
control, plus the importance of
avoiding a sedentary lifestyle and low
physical fitness by individuals with
diabetes cannot be overstated [97]. A
2003 study indicated that
cardiovascular exercise was
therapeutic in approximately 31% of
cases. The most probable benefit was
to triglyceride levels, with 43%
showing improvement; but fasting
plasma glucose and insulin resistance
of 91% of test subjects did not improve
[97]. Many studies have supported the
value of increased physical activity
and restricted caloric intake, showing
that compared to sedentary
individuals, those who are regularly
physically active have been shown to
have lower blood pressure, better lipid
profiles (including particle size),
reduced visceral fat at a given weight,
lower markers of systemic
inflammation, better cardiac function,
healthier blood vessels and high heart
rate variability, all of which may be
relevant given the high CVD risk
conditions of diabetics.
Despite well-documented benefits of
regular physical activity, 31% of
individuals with T2D report no regular
activity and another 38% report less
than recommended levels [142]. Many
clinicians and therapists advise
patients with T2D to be physically
active, but this is often done solely in
the context of weight control; there is
value in encouraging people to be
active and fit, whether or not it helps
them lose weight. For the purpose of
general health, the goal should be at
least 30 minutes daily, five or more
days per week of moderate intensity
activity [143]. This activity can be
accumulated in bouts of 10 minutes or
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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One Module Two

more, which means that three 20

minute walks/day is all it takes to Blood sugar
produce important health benefits. disorders
Balancing blood
There is a common misconception that sugar
spot exercise (that is, exercising a If you are having problems, please
specific muscle or location of the body) contact the College for help
most effectively burns fat at the
desired location, but this is not the
case. Spot exercise is beneficial for Conclusion to Module Two
building specific muscles, but it has
little effect on fat in that area of the According to the WHO Strategy,
body, or on the body's distribution of factors that increase the risks of
body fat. The same thing applies to sit- non-communicable disease include
ups and other abdominal exercises in elevated consumption of energy-
relation to abdominal fat; they are dense, nutrient-poor foods that are
useful in building the abdominal high in sugar. The Strategy
muscles, but they have little effect on recommends individuals should aim to
the adipose tissue located there. achieve energy balance, a healthy
weight and limit energy intake from
For the purpose of weight loss, the sugars, while increasing consumption
combinations of exercise and reduced of legumes, whole grains and nuts.
energy (food) intake have been found The knowledge you have gained from
to be more effective than either alone. this module should become the
The combination of reducing daily foundation of your advice to help
energy intake by 500-1000 kcal, and a people achieve those ideals
minimum of 150 minutes per week
exercise, with the goal to increasing to
200-300 minutes, is considered a good
foundation for developing effective diet
and exercise-based weight loss
programmes [144]. For formerly obese
individuals who have lost at least 12kg
and kept it off for at least two years,
even more exercise is probably
required. These recommendations are
only a starting point and will need to
be tailored to meet an individual’s
specific needs. Encouraging
individuals with diabetes to be
physically active is one of the most
important services you can offer

Revision Exercise

Against each category make

appropriate notes as to whether your
understanding of each topic at this
stage is good, or whether you need to
revisit it.

Pancreatic
function
Blood sugar

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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One Module Two

Appendix

Lactose Content of Milk, Dairy Products and Some Manufactured Products

Skimmed milk 4.8 Semi-skimmed milk 4.7

Full fat milk 4.6 Dried skimmed milk 52.9*

Goat 4.4. Human 7.2

Sheep (Ewe) 5.1 Soya or Rice milk Lactose free

Butter
Trace Single cream 2.2

Double cream
1.7 Crème fraiche 2.1

Brie/camembert Trace Cheddar 0.1

Cheese spread, reduced fat 7.3 Cheese spread 4.4

Cottage cheese, reduced fat 3.3 Cottage cheese 3.1

Feta 1.4 Goats cheese 0.9

Mozzarella Trace Cream cheese Trace

Plain Yoghurt 4.7 Fruit Yoghurt 4.0

Ice cream dairy vanilla 5.2 Ice cream non dairy 4.8

* (when diluted equates to <5g/100ml)

Glycaemic Index of commonly eaten foods

Approx Approx.
GI No. GI No.
10 Green leafy vegetables; Fructose; grapefruit; peanuts; soya
mushrooms; onion; red pepper; 20 (cooked); lentils
tomato
30 All Bran; apple; beans (haricot or Apricot (dried); carrot (raw); fig (fresh);
French); chick peas; milk (semi- 35 ice cream; orange; pear; quinoa;
skimmed) yoghurt
40 Apple or orange juice (fresh); Bread (wholemeal); kiwi; rice (Basmati
grapes; kidney beans; rye bread 50 or brown); sweet potato; chocolate
60 Rice (white); pasta (white); Jam; banana; melon; raisins
shortbread biscuit 65
70 Cereals (sugared); chocolate bars Potato crisps; carrot (cooked)
(e.g. Mars); cola drinks; bread 80
(granary); noodles; potato (boiled);
sugar (saccharose); turnip
85 Corn flakes; baguette; rice cake Honey; potato (mashed)
90
95 Potato (chips); parsnips; Lucozade Glucose
100
105 Maltose (beer)

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Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One Module Two

Marking Criteria for Module Two Assignment

Please refer to the full marking criteria included in Module One.

Assignment for Module Two

Answers will, where appropriate, be expected to show evidence of research or

additional reading. Please keep your answers as closely as possible to the number of
words requested for each question – additional information that results from your
research will be useful to include in your Learning Journal for future reference.

Please leave a few lines of space between answers for your tutor to add any
observations.

1) What happens to food after it has left the stomach to the stage where it
leaves the small intestine. Describe the changes that take place as the
enzymes act upon the food types and in which part of the intestine this
process occurs. Approx 200 – 400 words.

2) Explain the association between the small intestines and the immune system.
Approx 100 words.

3) Explain the common causes of food intolerances. Approx 100 words.

4) Explain the causes of candidiasis. What advice would you give to sufferers?
Approx 100 words.

5) Explain how an apparent problem with the digestion of dairy products can in
some cases be overcome without the exclusion of cows’ milk from the diet.
Approx 120-150 words.

6) Explain the role of the liver with regard to a) Premenstrual and menopausal
symptoms, and b) excess cholesterol in the blood. Approx 150 words.

7) Explain the need for good kidney and bowel function to improve the liver’s
detoxification ability. Approx 100 words.

8) List the organs and glands directly involved in the regulation of blood sugar
levels and briefly explain their roles. Approx 150-200 words.

9) Describe the homoeostatic control of blood sugar. Approx 150 words.

10) Discuss the role of exercise in a therapeutic approach for type 2 diabetes.
Approx 100 words.

Essay: Please submit an essay, of approximately 1000 words length, on one of the
following topics. Your essay should demonstrate research on the subject. Show your
research sources in a Bibliography.

 Explain the progression to Metabolic Syndrome that results from

© Jackie Day 2009 v2014 Page 45

Natural Healthcare College Naturopathic Nutritional Therapy Diploma, Stage One Module Two

inappropriate diet and lifestyle. Include the likely sequence of progression that
may include Reactive Hypoglycaemia and Insulin Resistance.
Or
 Explain factors that may give rise to suspected Lactose Intolerance. Include
advice you would offer to help an individual cope with dairy products.

Please ensure your name, the course title and the module number appear on the first
page of your homework submission.

Please submit your coursework by e-mail, sending to:

coursework@naturalhealthcarecollege.com adding the following information into the
‘Subject line’ – course name/module number/your own name.

To: coursework@naturalhealthcarecollege.com

Subject: Stage One Module Two Joan Smith

Bibliography and Citations

Anatomy & Physiology. Gary A Thibodeau, Kevin Patton. Published by Mosby. ISBN 0-323-01628-6

Anatomy & Physiology in Health and Illness. Kathleen Wilson, Anne Waugh. Published by Churchill
Livingstone. ISBN 0 443 05156 9

Mosby’s Dictionary of Medicine, Nursing & Health Professions. Published by Mosby Elsevier. ISBN 0-
7234-3393-3

© Jackie Day 2009 v2014 Page 46