The Canadian College of Naturopathic Medicine

COURSE OUTLINE
2007

Course Clinical Nutrition- Year 2

Course Code NUT201Y
Location Lecture Theatre
Times Thurs 9:00am- 2:00pm
Instructor Dr. Philip Rouchotas BSc, MSc, ND
E-mail prouchotas@hotmail.com
Office Hours TBA
Office Location TBA

EVALUATION
Percent Test/ Due Date
Exam 1 20 Feb 8, 2007
Exam II 20 March 29, 2007
Final Exam 30 Final Exam Period, TBA
Assignment 30 Part I: Feb 15, 2007
Part II: April 12, 2007

Required Text:
None.

Suggested Texts:
• Shils ME et al. Modern Nutrition in Health and Disease 9th Edition. Lippincott
Williams and Wilkins. Baltimore. 1999.
• Bendich A and Deckelbaum RJ. Preventive Nutrition: The comprehensive guide
for health professionals. Humana Press. New Jersey, 2005.

Recommended Texts

NUTRITIONAL BIOCHEMISTRY
• Brody T. Nutritional Biochemistry, 2nd Edition. Academic Press. Berkeley
California. 1999.
• Groff JL et al. Advanced Nutrition and Human Metabolism 2nd Edition. West
Publishing Company. New York. 1995.
NATUROPATHIC CLINICAL NUTRITION
• Werbach MR. Textbook of Nutritional Medicine. Third Line Press, Inc.
California. 1999.
• Pizzorno JE and Murray MT. Textbook of Natural Medicine 2nd Edition. Churchill
Livingstone. Edinburgh. 1999.
• Marz RB. Medical Nutrition From Marz 2nd Edition.
• Murray MT. Encyclopedia of Nutritional Supplements. Prima Health. USA. 1996.

OTHER
• Medical Economics Company. PDR for Nutritional Supplement. Medical
Economics Company. New Jersey. 2001.
• Minister of Supply and Services Canada. Nutritional Recommendations. Report
of the scientific review committee. Canadian Government Publishing Center.
Ottawa. 1990.
• Czap K (Editor). Alternative Medicine Review Monographs- Volume 1. Thorne
Research Inc. USA. 2002.
• Zimmermann M. Burgerstein’s Handbook of Nutrition: Micronutrients in the
prevention and therapy of disease. Thieme. New York. 2001.
• Pharmacists Letter. Natural Medicines Comprehensive Database 3rd Edition.
Therapeutic Research Faculty. USA. 2000.

COURSE DESCRIPTION

Goal of this one semester course is to evaluate the existing evidence base
regarding the influence of lifestyle factors on the prevention and treatment of chronic
degenerative disease. The first half of the course is divided into three modules.
Module 1 establishes links to chronic degenerative disease incidence with respect
to each major “food group”. Two key features are highlighted: I) The magnitude of effect
of dietary habits on disease incidence. II) Misinterpretation of preliminary evidence
leading to search of “active constituents”, eventually culminating in reductionist adoption
of holistic principles. The ultimate goal is to establish evidence based guidelines of what
constitutes a truly health promoting diet.
Module 2 critically evaluates various popularized commercial diet plans. The
theme will be to adopt a “forest for the trees” view while examining each diet. Having
established sound dietary guidelines within module one, each commercial diet will be
examined to determine to what extent these guidelines are met by the diet in question.
The key principle will be to differentiate relevant clinical science from marketing
strategy. Does the diet in question impart efficacy through the proposed mechanism
claimed, or does the diet in question inadvertently increase a follower’s consumption of
dietary constituents clearly demonstrated to benefit health.
Module 3 combines the principles of the previous two modules in an examination
of specific body systems. Concept of “designer foods” will be explored. Application of
lifestyle modification in the promotion of heart health, bone health, and in the prevention
of cancer and diabetes will comprise the focus of the module.
Module 4 narrows the focus of investigation to examine selected topics of
importance in the understanding and implementation of practice in clinical nutrition.
Topics will comprise a combination of fundamental principles to the practice of clinical
nutrition, as well as media popularized concepts. The later will be covered in order to
provide students with a sound basis for counseling future patients on such matters.

LEARNING OBJECTIVES

• Provide students with an advanced level of understanding of the role of diet and
lifestyle factors in the prevention and treatment of chronic degenerative disease.
• Provide students with practical approaches to the application of diet and lifestyle
modifications in clinical practice.
• Enhance student’s ability to critically evaluate scientific evidence in the field of
nutrition.
• Create awareness of discrepancies between modern Naturopathic approaches to
nutritional intervention, relative to generally held view of the field of Nutritional
Science.

PEDAGOGY

An adult learning model will be used. The course will be lecture format, with
student interaction welcomed and encouraged.

EVALUATION

Exam I: 20% (9:00am- 10:00am)

(Thurs, Feb 8, 2007)

Exam II: 20% (9:00am- 10:00am)

(Thurs, March 29, 2007)

Assignment: 30%
(Part I: Feb 15, 2007; Part II: April 12, 2007)

Final Exam: 30%

(During Final Exam period, TBA)

EXAM FORMAT

The exams will be multiple choice format. They will not be cumulative. Exams I
and II will be held during class time. Final exams will be held during the final exam
schedule.
ASSIGNMENT

The goal of the assignment is to apply skills obtained in the critical evaluation of
scientific evidence during NUT201Y. Topics will be functional food/ nutraceutical
constituents, and their role in a particular disease process. In groups of no smaller than
10, students will sign up for a selected topic. The breadth of detail required for a given
assignment will depend on the size of the group. It will be expected that compiled
evidence will be presented in a manner which highlights the following:
• Methodology
Controls (Randomization, blinding, placebo, age, sex, other).
End point measure
Subject number
Duration of intervention
• Results
What was found.
Was statistical significance achieved.
Is this biologically relevant?

It is MANDATORY that students obtain instructor approval of the chosen topic

prior to completion of the project. Students must also submit a list of names and student
numbers for each group member.

ATTENDANCE/ PARTICIPATION
As per standard CCNM policy.
 NUT201Y
2006- TIMETABLE
WEEK DATE TOPIC
Week 1 Jan 11 Introduction to Year 2 clinical nutrition.
Fruit and vegetable consumption and the risk of chronic degenerative
disease.
Week 2 Jan 18 Dietary fat selection and risk of chronic degenerative disease.
Break- out Session A: Objective evaluation of possible supplemental
intervention.
Week 3 Jan 25 Fiber consumption and risk of chronic degenerative disease.
Protein requirements, influence of dietary restriction and other
lifestyle factors.
Break- out Session B: Objective evaluation of possible supplemental
intervention.
Week 4 Feb 1 Role of caloric balance in chronic degenerative disease.
Break- out Session C: Objective evaluation of possible supplemental
intervention.
Week 5 Feb 8 EXAM I
“Clinically relevant” diets.
Break- out Session D: Objective evaluation of possible supplemental
intervention.
Week 6 Feb 15 ASSIGNMENT PART I due.
“Clinically relevant” diets.
Break- out Session E: Objective evaluation of possible supplemental
intervention.
Feb 22 Reading Week
Week 7 Mar 1 Lifestyle factors in heart health. Strategies for intervention.
Week 8 Mar 8 Lifestyle factors in heart health. Strategies for intervention.
Break- out Session F: Case Management
Week 9 Mar Lifestyle factors in the prevention and treatment of diabetes. Strategies
15 for intervention.
Break- out Session G: Case Management
Week Mar Lifestyle factors in bone health. Strategies for intervention.
10 22 Break- out Session H: Case Management
Week Mar EXAM II
11 29 Lifestyle factors in the prevention and treatment of cancer. Strategies
for intervention.
Break- out Session I: Case Management
Week April Nutritional considerations in environmental medicine.
12 5 Break- out Session J: Case Management
Week April ASSIGNMENT Part II due.
13 12 Naturopathic tools for nutritional assessment.
Break- out Session K: Case Management
Week April Nutrition and athletic performance.
14 19 Break- out Session L: Case Management
COURSE OUTLINE

Week 1: Introduction to Year 2 clinical nutrition.

Objectives:
• Review course outline, rationale for course layout.
• Review the basis for the sequence of topics covered.
• Review introductory principles relating to the interpretation of scientific
evidence.
• Review mechanistic events responsible for initiation and progression of
chronic degenerative disease.

MODULE 1: Establishing Dietary Guidelines

Week 1: Fruit and vegetable consumption and the risk of chronic degenerative
disease (heart disease/ cancer).

Objectives:
•Review observational evidence (prospective cohort/ case control)
producing the phenomena.
• Establishing dose/ response relationship.
• Theoretical basis of mechanism: focus on essential antioxidant
nutrients.
• Understanding BIOMARKERS of fruit and vegetable intake.
• Intervention trials deducing the effects of essential antioxidant
nutrients on chronic degenerative disease.
• Understanding oxidant/ antioxidant interactions.
• To differentiate the antioxidant power of essential antioxidant
nutrients versus functional food/ nutraceutical constituents.
• Intervention trials examining the effects of supplemental essential
antioxidant nutrients, and supplemental functional food/
nutraceutical constituents, on biomarkers of heart disease/ cancer.
• Intervention trials of essential antioxidant nutrients: focus on
nutritional adequacy.
Required Reading: N/A

Study Questions:
• What magnitude of effect has been observed for the relationship
between fruit and vegetable consumption and the risk of chronic
degenerative disease?
 • Describe the relationship between dose of fruit and vegetable intake,
and response in disease incidence.
• Relate the concept of biomarker to possible misinterpretation of
observational evidence.
• Provide a mechanistic rationale for results of large scale intervention
trials with essential antioxidant constituents.
• Why do discrepancies exist among intervention trials of essential
antioxidant nutrients.

Week 2: Dietary fat selection and risk of chronic degenerative disease.

Objectives:
• Review of lipid chemistry
Saturated
Unsaturated (mono, poly) (W-3, W-6, W-9)
Trans fatty acids
Effects of heating an oil
• Observational evidence (prospective cohort/ case control)
regarding effects of saturated, W-3, W-6, and W-9 fatty acids and
risk of chronic degenerative disease.
• Mechanistic basis for observed phenomena.
• Intervention trials with oils: focus on fish oil.
Required Reading: N/A
Study Questions:
• What physiological sight provides the basis for the effects of dietary fats?
• Outline consequences of intake of saturated, trans, and heated fats.
• What effect do dietary fats have in the progression of chronic degenerative
disease?
• How do fish oils provide protection against heart disease?

Week 3: Fiber consumption and risk of chronic degenerative disease.

Objectives:
• Fiber defined. Soluble versus insoluble fibers.
•Observational evidence (prospective cohort/ case control) of fiber
intake and incidence of chronic degenerative disease.
• Proposed mechanism of action:
Hypocholesterolemic/ choleretic effects.
Focus on inositol hexaphosphate.
• Intervention trials with fiber:
Effects on markers of heart disease/ cancer.
• Effects on glucose management.
Required Readings: N/A
Study Questions:
 • What magnitude of effect has been observed for dietary fiber and
risk of chronic degenerative disease?
• Differentiate between mechanistic basis of fiber effects in heart
disease and cancer prevention.
• Outline basis of effect of fiber intake on glucose management.

Week 3: Protein requirements, influence of dietary restriction and other lifestyle

factors.

Objectives:
• Review of protein chemistry
Essentiality
Metabolism
Protein Energy Malnutrition
• Establishing adequacy of protein
General population versus athlete
Endurance athlete versus resistance training athlete
• Protein sources
• Achieving adequacy on unbalanced diets
Required Readings: N/A
Study Questions:
• What are the essential amino acids?
• What are the metabolic consequences of protein energy
malnutrition?
• What foods must vegetarians, and/ or vegans be sure to consume in
significant quantities to achieve protein adequacy.

Week 4: Role of caloric balance in chronic degenerative disease.

Objectives:
• RQ
• BMR, PMT, NEAT
• Calculations of daily energy requirements
• Consequences of caloric excess
Observational trials
Visceral adiposity
• Caloric restriction and exercise in the management of obesity
Mitochondrial density
• Energy partitioning, CHO versus lipid utilization
Required Reading: N/A
Study questions:
• Outline the one absolute law governing weight loss.
 • What are the effects of obesity on chronic degenerative diseases?
What has been observed regarding magnitude of this effect?
• What intensity and duration exercise would you recommend a
patient perform as part of a weight management protocol?

MODULE 2: CRITICAL EVALUATION OF COMMERCIAL DIET SYSTEMS

Weeks 5 & 6: “Clinically relevant” diets.

Objectives:
• Atkins/ zone
• Blood type
• Macrobiotic
• Feingold
Required Reading: N/A
Study Questions:
• Outline the aspects of each diet reviewed with respect to
knowledge of diet in prevention and treatment of chronic
degenerative disease.
• Outline potential therapeutic efficacy of each specific commercial
diet.

Week 5 & 6: “Clinically Relevant” Diets

Objectives:
•Vegetarian/ vegan
•Observational evidence (prospective cohort/ case control) relative
to chronic degenerative disease risk.
• Achieving nutritional adequacy
Protein
Vitamins
Minerals
• Intervention trials
Treatment of myocardial infarction
Required Reading: N/A
Study Questions:
• What are the most problematic nutrients for individuals following
vegetarian and/ or vegan diets to obtain in adequate amounts?
• What key factor must be considered when examining observational
evidence of vegetarian diet and incidence of chronic degenerative
disease?
• What are some potentially therapeutic applications of a vegetarian
diet?
Week 5 & 6: “Clinically Relevant” Diets

Objectives:
•Cleansing
“Forrest for the trees”
Commercially popularized cleanses
Master cleanse
Red Rose cleanse
Ultraclear
• Elimination diet
Suggested indications
Prescription strategy
The phenomena (intervention trials)
Common food allergens- basis for observed effects
Required Reading: N/A
Study Questions:
• What are the two general disease categories from which clinical
efficacy can be expected from intervention with an elimination
diet?
• What are common features shared by all commercialized cleansing
systems? What implications do these common features pose to
interpretation of mechanistic basis of therapeutic cleansing?

MODULE 3: APPLYING LIFESTYLE MODIFICATION TO THE PREVENTION

AND TREATMENT OF CHRONIC DEGENERATIVE DISEASE

Weeks 7 & 8: Lifestyle in heart health; Strategies for intervention.

Objectives:
• Response to injury hypothesis of atherosclerosis
• Hypertension
• Hyperlipidemia
• Hyperhomocysteinemia
• Newly emerging risk factors
W-3 score
C-reactive protein
Fibrinogen
Total cholesterol: HDL ratio
Required Reading: N/A
Study Questions:
• Outline the magnitude of effect for lifestyle modification in the
treatment of targets of heart disease management.
• On what basis is dose calculated for the use of functional food/
nutraceutical constituents in the treatment of heart disease risk
markers? In the management of heart disease?
 • Compare newly emerging objective risk markers of heart disease
to allopathic risk markers of choice.

Week 9: Lifestyle factors in the prevention and treatment of diabetes;

Strategies for intervention.
Objectives:
•
Epidemiology
Predictors of diabetes risk
Morbidity/ mortality associated with disease risk
• Diet/ lifestyle factors in the management of diabetes
Focus on caloric restriction + exercise as intervention for
treatment.
• Diabetes prevention and treatment: Materia Medica of
supplemental intervention:
IP6, chromium, fiber…
Required Reading: N/A

Week 10: Lifestyle factors in bone health. Strategies for intervention.

Objectives:
•Epidemiology
Calcium intake as a predictor of osteoporosis risk
• Factors effecting calcium balance
Protein
Caffeine
Carbonated beverages
• Osteoporosis prevention and treatment
Concept of peak bone mass
Calcium/ Vitamin D status
Other important minerals (Mg, P, K, boron)
Weight bearing activity
• Dietary intervention: Alkalinizing the diet
Required Reading: N/A
Study Questions:
• What key feature of observational evidence is highlighted by
examining the role of calcium intake and the risk of osteoporosis?
• What are the effects of specific reviewed dietary constituents on
calcium balance?
• What lifestyle factors appear to be most closely linked to achieving
peak bone mass?
 • What are the physiological implications of an alkalinizing diet
relative to calcium pharmacokinetics?

Week 11: Lifestyle factors in the prevention and treatment of

cancer; Strategies for intervention.
Objectives:
•
Epidemiology
Predictors of diabetes risk
Morbidity/ mortality associated with disease risk
• Diet/ lifestyle factors in the management of cancer
Using diet to manage adverse reactions of conventional
therapies, managing underlying malnutrition afflicting large
numbers of members of this population.
• Cancer prevention and treatment: Materia Medica of supplemental
intervention:
IP6, modified citrus pectin, high dose vitamin C (oral and
intravenous), leatril, turmeric…
Required Reading: N/A

MODULE 4: SELECT TOPICS IN CLINICAL NUTRITION

Week 12: Nutritional considerations in environmental medicine.

Objectives:
•
Assessing the meaning of the term organic. Exploring regulatory
status of organic produce production in Canada. Evidence base for
recommending organic produce.
• Chronic low- dose administration of antibiotics to livestock;
implications for human health.
• Heavy metal toxicity; assessment, clinical implications, and
treatment.
Required Reading: N/A

Week 13: Naturopathic tools for nutritional assessment.

Objectives:
•
Explore various objective tests commonly used by naturopathic
doctors for the evaluation of nutritional status:
Complete Digestive Stool Analysis, Fantus test,
Cytochrome P450 phase I and II, Hair analysis, Gastro test,
Intestinal permeability, saliva testing, food allergy testing,
zinc tally test, live cell microscopy, Vega testing…
Required Reading: N/A

Week 14: Nutrition and athletic performance.

Objectives:
•Training technique aimed at improving athletic performance. Mass
gain versus aerobic conditioning… Basis for manipulating training
regime will be explored.
• Materia Medica of supplemental intervention aimed at improving
athletic performance:
Weight loss aids (CLA, green tea, HCA, L-carnitine…)
Ergogenic aids (caffeine, creatine…)
Required Reading: N/A