Nutrient and

immune
Dr. dr. Joko Wahyu Wibowo, MKes
Bag. Gizi FK Unissula
 Macro-nutrient Deficiencies
Macronutrient deficiencies diseases in chlidren often
result from a lack of protein

Kwashiorkor is a specific wasting away

often occurring in infants at weaning. It
results from a lack of protein in the diet

Marasmus is a wasting away of the body tissues

from the lack of calories as well as protein in Kwashiorkor
the diet. The child is fretful rather than
apathetic and is skinny rather than swollen with
edema.

Marasmus

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Five Stages of Immune Response
1. Macrophages identify the invaders

2. Helper T cell calls for help.

3. B cell tags the invaders with antibodies

4. Killer T cells destroy the invader.

5. Memory T and B cells remember

the invaders
 What are free radicals
and how do they weaken
the immune system?

An atom or group of atoms with at least one

unpaired electron; in the body it is usually an
oxygen molecule that has lost an electron and will
stabilize itself by stealing an electron from a
nearby molecule.
Three ways free radicals weaken the
immune system
1. All of the immune cells are
damaged by free radicals as they
loose electrons to the free
radicals.
2. Free radicals knock out
communication between immune
cells affecting proper operation
of the immune cells during the
five stage response.
3. Free radicals cause an over production of nitric
oxide in the macrophage damaging the macrophage
thereby impairing its ability to fight off invaders.
Antioxidants to the Rescue!
1.An antioxidant is a molecule
capable of slowing or preventing the
oxidation of other molecules.

2. Oxidation is a chemical
reaction that transfers electrons
from a substance to an oxidizing
agent.

3. Oxidation reactions can produce free radicals,

which start chain reactions that damage cells.
Vitamin D Functions
• Vitamin D is an important regulator of
calcium metabolism.
• It is involved in the uptake of calcium and
phosphate ions from food into the body.
• It is necessary for the proper formation of
bone structures and teeth.

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Background
• Exposure to sunlight was historically known to cure
tuberculosis
• Sunlight stimulates the synthesis of vitamin D
• Vitamin D stimulates the production of cathelicidin anti-
microbial peptide (CAMP) to help fight infections
Background continued
Vitamin D Signaling Pathway
Pathogen invades cell

Toll-like receptor signaling activated

Increased expression of VDR and CYP27B1 genes

Activated vitamin D binds to VDR

Vitamin D and VDR go to the nucleus and binds

to the vitamin D response element (VDRE)

Production of CAMP increases to fight

microbes
Vitamin D binds to a “vitamin D binding protein” (VDP) for transport to target
organs.

Vitamin D is not active itself (it’s a prohormone); it is modified to yield

biologically active forms, such as calcitriol.

Calcitriol (derived from vitamin D) is a transcription factor, influencing

expression of proteins involved in calcium absorption and transport.

Vitamin D is also important for immune system function.

Deficiency causes rickets, bone loss.

Calcitriol, from
vitamin D.
Vitamin D production requires UV light (sunlight).
Sometime after humans migrated north out of Africa about
50,000 years ago, mutations appeared that reduced
melanin (pigment) production in the skin, permitting vitamin
D production with less sunlight.

Disadvantages of less melanin production are skin that is

easily damaged by the sun, skin cancer risk, and loss of
folic acid due to UV damage.

The melanin-reducing mutations helped early humans make

vitamin D in northern europe in winter.
Vitamin D Functions
• Many uses in the body
• Promotes absorption of calcium from the small intestine
• Maintain blood levels of calcium and phosphate for bone formation,
mineralization, growth, and repair
• Improves muscle strength and immune function
• Reduces inflammation
Noncalcemic Functions of
1,25-dihydroxyvitamin D

Cytokines

Adaptive
Innate
Immune modulation
 System and Tissue Distribution of Nuclear
Vitamin D Receptors (VDR)
System Tissue

Immune Thymus, bone marrow, macrophages, B cells, T cells

Gastrointestinal Esophagus, stomach, small intestine, colon, rectum
Cardiovascular Endothelial cells, smooth muscle cells, myocytes
Respiratory Lung alveolar cells
Hepatic Liver parenchyma cells
Renal Proximal and distal tubules, collecting duct
Endocrine Parathyroid, thyroid, pancreatic beta cells
Exocrine Parotid gland, sebaceous gland
CNS Brain neurons, astrocytes, microglia
Epidermis/appendage Skin, breast, hair follicles
Musculoskeletal Osteoblasts, osteocytes, chondrocytes, striated muscle
Connective Tissue Fibroblasts, stroma
Reproductive Testis, ovary, placenta, uterus, endometrium, yolk sac
Thus we can boost the immune
system through nutrition!
1. Vitamin C prevents the
production of free radicals
and reduces DNA damage in
immune cells.

2. Some sources of vitamin C

include berries, cantaloupe, kiwi,
red, green, or yellow peppers,
sweet potatoes, tomatoes,
broccoli, brussels sprouts, and
cauliflower.
 Boosting the Immune System
Through Nutrition
1. Vitamin E is a powerful fat-
soluble antioxidant. It protects
cellular membranes of the immune
system and other cells by trapping
free radicals and enhances the
effectiveness of white blood cells.

2. Some sources of vitamin E include mustard and

turnip greens, nuts, spinach, broccoli, carrots,
sunflower seeds, mangoes, papaya, and pumpkin.
 Boosting the Immune System
Through Nutrition
Vitamins B6 and B12
indirectly contribute to
antioxidant defenses having
considerable influence on
the immune system. A
deficiency of these vitamins
will create abnormalities in
the immune system.

Some B6 sources include tuna, banana, chicken,

turkey, salmon, cod, and snapper.
Some B12 sources include salmon, shrimp, scallops,
halibut, lamb, and snapper.
 Boosting the Immune Through
Nutrition
Metallic micronutrients such as copper,
zinc, and selenium reduce oxidative
stress due to free radicals and increase
production and activity of WBC’s.
Deficiencies in children have been linked
to immune deficiency and infection.
Copper sources include beef, beans, potato,
cooked Shitake mushrooms
Zinc sources include beef, turkey, chicken, milk,
cheese, peanuts, beans, whole wheat bread.
Selenium sources include garlic, snapper, halibut,
salmon, shrimp, and turkey.
 What About Probiotics ?

Intestinal tract relies on live

bacteria to help support a
robust intestinal immune
system.

Some sources of probiotics include yogurt, aged

cheese, and buttermilk that includes lactobacillus
which stimulates natural immunity by improving
phagocytic and natural killer immune cell activity.
Additional sources are pickles, sauerkraut, and sour
dough bread.
Antioxidant flavonoids
• The antioxidant effect of flavonoids can
reside both in their radical-scavenging
activity or in their metal-chelating
properties, of which the former may
dominate
• As antioxidants, flavonoids are by
definition capable of electron-transfer
reactions.
Practices which will enhance the success
of foodbased approaches
• To achieve dietary adequacy of vitamin A,
vitamin C, folate, iron, and zinc by using
food-based approaches, food preparation
and dietary practices mustbe considered.
• it is important to recommend that
vegetables richin vitamin C, folate, and
other water-soluble or heat-labile vitamins
are minimally cooked in small amounts of
water
How Can Fatty Acids Modulate the Immune
System
• Why do we need immune modulation in the first
place?
• Answer: Similar to avoid excessive, chronic
inflammation which leads to tissue destruction.
• FAs such as DHA and EPA can reduce production
of inflammatory cytokines (IL-6, IL-12, IL-23)
• FAs can increase phagocytic activity
• FAs can decrease lymphocytic proliferation
• FAs can influence immune cell migration
Alpha-linolenic Acid
• Humans can synthesize other omega-3 fatty acids from ALA:

• Eicosapentaenoic acid (EPA): 20:5n-3

• Docosahexaenoic acid (DHA): 22:6n-3

PBRC 2005
• These two are usually referred to as marine-derived
omega-3 fatty acids because they are abundant in
certain species of fish

• Whereas, ALA is considered a plant-derived omega-3 fatty acid

Infeksi HIV
• Gangguan absorbsi zat gizi
• Perubahan metabolisme
• Penurunan asupan makanan
• Nutrisi buruk menyebabkan peningkatan infeksi oportunistik
• Menurunkan efikasi obat
• Meningkatkan progresifitas penyakit
Malnutisi pada odha
• Sebagian besar ODHA mengalami malnutrisi
• Terjadi wasting syndrome
• Kehilangan BB > 10 % ; IMT < 20 kg/m2 dibandingkan saat
pertama kali
• Kehilangan berat badan > 5 % dalam 6 bulan
• Berhubungan dengan infeksi oportunistik
• IMT tinggi lebih lambat penurunan CD4
Penatalaksanaan diet
• Tidak berpantang makanan apapun
• Sebaiknya makanan dimasak sendiri
• Hangat : soto, bakso, nasi goreng
• Hindari : sambal, acar  diragukan kebersihannya
• Sayur dalam bentuk matang, hindari lalapan
• Bila mual : porsi kecil tapi sering ( 5-6 x)
• Suplementasi vitamin : B12, asam folat, thiamin, Zn, selenium,
kalsium, magnesium,vitamin A/ D
• Olah raga : latihan beban untuk mempertahankan masa otot
Body composition changes in
clients with HIV/AIDS
• Wasting Syndrome
• Fat redistribution syndrome
• Elevated Cholesterol levels
• Elevated Triglycerides levels
• Elevated blood sugars levels
Nutritional recommendations for
combating body composition
changes
• High protein diet will help the client fight wasting syndrome.
• Low saturated fat diet will help keep cholesterol level down.
• A diet high in grains and low in sugar will help the client
maintain adequate sugar and triglyceride levels.
• In addition to a heart healthy diet, 1 or 2 multivitamins and
minerals should be taken to insure that micronutrient needs
are met.
Vitamin A Deficiency
• Without vitamin A, mucus forming cells deteriorate and no
longer synthesize mucus.
• Contributes to poor health of cells in general, which increases
risk of infection in the oral cavity.
• Reduces activity of certain immune cells.
• Vitamin A deficient individuals are at a great risk for infection.
Vitamin A Food Sources
• Recommend foods such as yellow/orange vegetables and
fruits, green leafy vegetables, and dairy.
• Additional recommendations could include organ meats.
Vitamin B6 Functions
• Coenzymes in metabolizing protein
• Converts tryptophan to niacin
• Involved in synthesis of hemoglobin and fatty acids
• Production of energy from glycogen
• Helps proper function of the nervous system
Vitamin B6 Deficiency
Symptoms in the Oral Cavity
• Glossitis
• Pain in the tongue
 Feels as if tongue is scalded
• Edema
• Papillary changes
• Smooth, purple tongue
Vitamin B6 Deficiency
• Deficiency results in overall risk for opportunistic infections,
due to its role in immune function.
• HIV/AIDS clients, even with proper RDA, tend to be deficient in
B6; supplementation may be indicated to decrease risk of
infection.
• Recommend foods such as poultry, fish, whole grains.
Vitamin B12 Functions
• Coenzyme involved in folate metabolism
• Nucleic acid synthesis
• Involved in production of red blood cells
• Synthesis of myelin
• Catabolizes some amino and fatty acids
Vitamin B12 Deficiency
• Burning/itching of the tongue
• Red, smooth, shiny tongue
• Absence of papilla on tongue
• Painful lesions on buccal, pharyngeal mucosa and ventral
surface of tongue
• Pale, yellow mucosa
Vitamin B12 Deficiency
• HIV/AIDS Clients:
 Deficiency due to malabsorption
•Poor diet
•Bacteria overgrowth along digestive
tract
•Lowered GI function
Vitamin B12 Deficiency
• If diet cannot provide, recommend
supplementing.
• Too much Vitamin C will interfere with
absorption of B12.
• HIV/AIDS clients with B12 deficiencies
were shown to progress to advanced
disease twice as quickly as those without
deficiencies.
• Recommend foods such as beef liver,
lean beef, shrimp, protein fortified milk,
whole eggs, chicken breast and cheddar
cheese
Vitamin C Functions
• Significant in collagen formation

• Necessary for the use of proline and lysine in collagen

formation.

• Increases iron absorption. Vitamin C eaten with iron can

double iron absorption.
Folate Functions
• Involved in RNA and DNA synthesis
• Coenzyme
• Helps to maintain red blood cells
• RDA: 200mcg/d males, 180mcg/d females
Folate Deficiency:
Oral Symptoms
• Glossitis
• Chronic Periodontitis
• Loosening of the teeth
• Deficiency impairs immune response
 Oral cavity more prone to infections,
such as candidiasis
• Vitamin C helps with absorption of folate
Zinc Functions
• Cell growth/maturity
• Immune response
• Taste/appetite
• Collagen synthesis
• Bone formation
• RDA: 15mg/d males, 12mg/d females
Zinc Deficiency:
• Changes in tongue epithelium
• Flattened filiform papillae
• Loss of taste, appetite
• Impaired wound healing
• HIV/AIDS clients suffer from diarrhea and malabsorption, thus
zinc deficiency
• Supplementation indicated
Protein Functions
• Maintenance and growth (if protein is low, degeneration of
connective tissue including periodontium).
• Provides for enzyme and antibodies and their respective
functions.
• Supplies amino acids which are building blocks for tissue
synthesis.
• Participates in RBC production.
• When infection is present, body’s protein needs are doubled.
Protein Deficiencies
• Protein malnutrition and resulting loss of energy are the most
frequent condition reported with HIV/AIDS.

• Presents as a client with a low body weight and a general lack

of energy, protein and other nutrients, and a small muscle
mass