Poor nutrition is costing Australians approximately 6 billion dollars annually. In USA and UK it will cost an proportionate increase. The three major causes of preventable death in Australia,UK and ,US are: Ischaemic Heart Disease 27.8 per cent Cancer 24.3 per cent Stroke 10.9 per cent,representing a total of 63 per cent. Nutritional factors play an important role in the causes of these three killer diseases1. 1. Australia. Health targets and implementation (Health for All) Committee. Health for all Australians: Introducing the Report of the Health Targets and implementation (Health for All) Committee. Canberra: AGPS, 1988; 2-4.
Over the past two decades there has been a virtual explosion in information in the medical and scientific literature relating nutrition to disease. Nutritional factors have been documented in the aetiology of most of our degenerative diseases including diabetes, arthritis, coronary artery disease, stroke, many cancers and neurodegenerative conditions including dementia. A change in diet and the appropriate use of nutrients reduce the risk of disease and are becoming increasingly important in the treatment of patients to either improve prognosis or achieve a state of well-being in serious disorders. 2. Brighthope I.E. "The role of nutritional medicine in general practice". Aust Fam Phys 1990;19(3)
Nutritional Medicine is the study of the interactions of nutritional factors with human physiology, biochemistry, pathology and anatomy and the clinical application of these interactions in the optimisation of health and the prevention and treatment of disease. Brighthope I E. "Nutrition Abstracts". J Aust Coll. Nutr. Med 1983-1998.
It is a system of therapeutics that favours dietary changes and the use of nutrient substances in appropriate doses to encourage physiological homeostasis.
Major factors to be considered in the evaluation of the
nutritional status of the patient are the quality and the quantity of food
eaten, the efficiency of its digestion, absorption and assimilation, and most
importantly, the biochemical uniqueness of the individual. Environmental and
genetic factors may influence these .
Nutrition In The Elderly This is also all connected with nutrition in the elderly.
Nutrition in the elderly is often severely compromised. Often they do not even
get the RDIs (Recommended daily allowance) of essential viamins and minerals and
certainly not the optimal amounts.The common vitamin and mineral deficiencies
occur in the elderly There is often deficiency in folate B12 and Vitamin
B6. Hypochlorhydria leads to mineral deficiency. As well as the
stomach the general function of other digestive organs such as the pancreas is
also reduced. Also the digestive lining not functioning as well as it used to,
leads to decreased absorption of minerals and vitamins. Many old age problems such as anorexia, fatigue
depression, weakened immune system and infections are the result of poor diets
and nutritional deficiencies ..Excess consumption of Simple sugars Saturated
fats refined foods and non nutrient calories need to be avoided. Also Sufficient
fluid and fiber are crucial. Elderly people require easy to digest well balanced
vitamin and mineral formulations.
Nutrition In The Elderly
This is also all connected with nutrition in the elderly. Nutrition in the elderly is often severely compromised. Often they do not even get the RDIs (Recommended daily allowance) of essential viamins and minerals and certainly not the optimal amounts.The common vitamin and mineral deficiencies occur in the elderly There is often deficiency in folate B12 and Vitamin B6.
Hypochlorhydria leads to mineral deficiency. As well as the stomach the general function of other digestive organs such as the pancreas is also reduced. Also the digestive lining not functioning as well as it used to, leads to decreased absorption of minerals and vitamins.
Many old age problems such as anorexia, fatigue depression, weakened immune system and infections are the result of poor diets and nutritional deficiencies ..Excess consumption of Simple sugars Saturated fats refined foods and non nutrient calories need to be avoided. Also Sufficient fluid and fiber are crucial. Elderly people require easy to digest well balanced vitamin and mineral formulations.
We can enhance immune
function in aging persons, in patients receiving cancer chemotherapy, and in
those with chronic viral or bacterial infections.
Molecular Immunology The immune system is the most diverse and widespread system in the body. The
cells are divided into two main groups defined by their place of maturation:
B-cells, or bursa/bone marrow derived, and T-cell, or thymus derived. B-cells are responsible for humoral immunity (e.g., formation of
specific antibodies), and T-cells are responsible for cell-mediated
immunity and the production of chemicals and messenger molecules that kill
the invading foreign materials. In the GI mucosa, for example, a thinning of the cells that line the gut (as
in colitis, for example) can result in leakage of toxins into the blood stream
(Hunter 1991; 1998). Any crossing of the barrier by what is considered foreign
by the immune system will result in activation of the system and the defense
forces will rally. The nonspecific immune mechanisms are particularly important early in
infection, because the antigen-specific response takes several days to develop,
but the nonspecific mechanisms continue to play a role in the immune response
until resolution of the infection and healing of tissue
damage. THE HARMFUL ROLE OF FREE RADICALS Immune cells are highly reactive metabolically, and they have a high
turnover. Proinflammatory cytokines will produce free radicals to kill foreign
cells in what is called an oxidative burst of activity (Goldsby et al. 2000).
Although free radicals kill foreign cells, they can also be deadly to our own
cells. Free radicals have been linked to immune system damage that accompanies
normal aging. A strong immune system is critical to the prevention of infection
by viruses, fungi, and bacteria. It is thought that cancer cells form regularly
and that a vigilant immune response is therefore required to kill or deactivate
these deformed cells before they become malignant tumors. The incidence of
cancer and new infectious diseases increases every year in the Developed World.
In addition, many dangerous bacteria have become resistant to the antibiotics
that once kept them in check. There is strong scientific
evidence showing that antioxidants and other natural therapies can play an
important role in maintaining and enhancing immune function. NUTRITIONAL IMMUNOLOGY Micronutrients are now known to play a key role in many of the metabolic
processes that promote survival from critical illnesses (Chandra 1983; Chandra
et al. 1986).
The immune system is the most diverse and widespread system in the body. The cells are divided into two main groups defined by their place of maturation: B-cells, or bursa/bone marrow derived, and T-cell, or thymus derived.
B-cells are responsible for humoral immunity (e.g., formation of specific antibodies), and T-cells are responsible for cell-mediated immunity and the production of chemicals and messenger molecules that kill the invading foreign materials.
In the GI mucosa, for example, a thinning of the cells that line the gut (as in colitis, for example) can result in leakage of toxins into the blood stream (Hunter 1991; 1998). Any crossing of the barrier by what is considered foreign by the immune system will result in activation of the system and the defense forces will rally.
The nonspecific immune mechanisms are particularly important early in infection, because the antigen-specific response takes several days to develop, but the nonspecific mechanisms continue to play a role in the immune response until resolution of the infection and healing of tissue damage.
THE HARMFUL ROLE OF FREE RADICALS
Immune cells are highly reactive metabolically, and they have a high turnover. Proinflammatory cytokines will produce free radicals to kill foreign cells in what is called an oxidative burst of activity (Goldsby et al. 2000). Although free radicals kill foreign cells, they can also be deadly to our own cells. Free radicals have been linked to immune system damage that accompanies normal aging. A strong immune system is critical to the prevention of infection by viruses, fungi, and bacteria. It is thought that cancer cells form regularly and that a vigilant immune response is therefore required to kill or deactivate these deformed cells before they become malignant tumors. The incidence of cancer and new infectious diseases increases every year in the Developed World. In addition, many dangerous bacteria have become resistant to the antibiotics that once kept them in check. There is strong scientific evidence showing that antioxidants and other natural therapies can play an important role in maintaining and enhancing immune function.
Micronutrients are now known to play a key role in many of the metabolic processes that promote survival from critical illnesses (Chandra 1983; Chandra et al. 1986).
THE ROLE OF VITAMINS
Vitamins are essential for oxidative phosphorylation (the energy generating pathway of the cell) and protection against oxidants. They also act as cofactors in many enzymatic reactions and as signal mechanisms to other cells
The most consistent nutrients linked to immune dysfunction have been low levels of vitamins A, C, E, and B6, copper, iron, and zinc (Johnson et al. 1992; Grimble 1997; Shankar et al. 1998; Ravaglia et al. 2000). Many of these nutrients are linked to deficiency in the Developed World
Kenneth H. Brown, a University of California at Davis nutrition professor, estimated that as much as half of the world population is at risk for zinc deficiency and 40% of children in low-income countries have stunted growth related to zinc deficiency
Chandra et al. (1983) have repeatedly demonstrated that groups such as atopic, formula-fed children, low-birth-weight infants, obese adolescents, malnourished hospitalized patients, and the elderly have not only increased immune dysfunction but also increased risk for infection and allergic disorders, such as eczema. Many of these studies have actually shown improvement of immune function when supplemented with appropriate nutrients and foods (Chandra 1999). Although actual protein malnutrition is rare in North America, we experience more undernutrition through overconsumption—of poor-quality food, namely, fat, sugar, and processed foodstuffs.
Another area where immunity suffers in western civilization is at the gut lining—. About 60% of the immune system cells are collected around the small intestine in areas known as Peyer’s patches or the GALT (gut associated lymphoid tissue). Any thinning of the gut lining, such as in lactose intolerance, food allergy, gluten sensitivity, ulcerative colitis, Crohn’s disease, antibiotic-induced colitis, yeast overgrowth, and so forth, will render the gut leaky. This leakiness allows incompletely digested food proteins, which are immune stimulating, to enter the blood stream.
From the above, it can be seen that a strong immune system is dependent on a good foundation of nutrition. There is no single nutrient that, by itself, will enhance immunity (Lesourd 1997; Scrimshaw et al. 1997). In fact, too much of one nutrient can do the opposite of what one might want and decrease immunity (Delafuente 1991). Thus, the descriptions that follow, where individual nutrients are identified as being important, should be taken in the context of "a chain is only as strong as its weakest link." (the various nutritional supplements work together in a synergic fashion)
Specifically vitamin A supports immunity by helping to maintain the integrity of the body’s mucosal surfaces (Villamor et al. 2000).
Beta-carotene has been shown to have a powerful effect in boosting natural killer (NK) cell activity in elderly men. (Santos et al. 1996).
Results show that long-term beta-carotene supplementation may be beneficial for immune viral and tumoral surveillance. .
A good study of the use of vitamin E to boost immune function appeared in 1997 (Meydani et al. 1997). when supplementation with vitamin E for people over 65 yrs for 4 months improved certain clinically relevant indices of cell-mediated immunity. Vitamin E is a powerful antioxidant and is also used as a preventitive for heart disease. It also impedes platelet clumping and anhances blood flow in this way.
Vitamin C (Ascorbic Acid)
High levels of vitamin C can protect levels of vitamin E in tissue and may contribute to the immune-enhancement of vitamin E (Niki 1987; Chan 1993; Stahl et al. 1997). Being an antioxidant, adequate vitamin C is an essential ingredient for "mopping up" the free radicals left behind after the immune system produces its oxidative burst killing activity.
A steady supply of vitamin C is vital to good health. Because the human body can neither manufacture nor store vitamin C, our requirements must be met from dietary sources, such as citrus fruit, vegetables, and supplements. Vitamin C’s antioxidant protection is especially important to healthy lungs. It also protets against heart disease enhancing the strength of the arterial walls and in large doses especially intrvenously has an overall revitalising effect on the body combating viral disease and reversing long term fatigue. As our population is very prone to stress, cardiovascular disease and cancer Vitamin C works synergistically with other nutritional supplements in contriubuting to the prevention of these diseases
Vitamin B6 (Pyridoxine)
Deficiencies are associated with marked immune depression. This vitamin has many functions throughout the human body in addition to its support of the immune system. Chandra et al. (1980, 1986) have reported that deficits of pyridoxine in addition to calories and zinc resulted in a significant lowering of serum thymic factor, a hormone involved in cell-mediated immunity. Vitamin B6, folic acid, Vitamin B 12 and Vitamin D are part of a group of vitaminsin the new science of nutrigenomics,Several molecular mechanisms that underpin the genomic machinery are sensitive to B vitamin status .B vitamins, particularly folate, may give considerable protection against serious diseases such as cancer, heart disease, and birth defects.The method of protection is by lowering homocysteine or through epigenetic mechanisms
It is now understood that trace elements are essential, not only for their direct antioxidant activity, but also for their role as cofactors for a number of antioxidant enzymes. Wound-healing and immune function are highly dependent on adequate levels of trace elements, as well as vitamin levels. Dietary supplements of (some) trace elements are crucial to compensate for mineral-depleted soils and the fact that much of the food we eat is grown on a substrate of artificial fertiliser cotaining only nitrogen, phosphorus and Sulphur
. Trace elements are very adversely affected by what are called heavy metals—typically aluminum, arsenic, cadmium, lead, and mercury. Zinc is particularly susceptible to the effects of cadmium, a ubiquitous heavy metal.
The trace element zinc has many roles in basic cellular function.It isn essential trace element occurring in the body in larger amounts than any other trace element except iron. It is involved with DNA and RNA synthesis and is a component of thespecial antioxidant enzyme superoxide disutase ( SOD ) and an important free radical scavenger. Zinc also functions as an antioxidant and stabilizes membranes. Zinc-deficient patients display reduced resistance to infection,. Zinc’s importance in many aspects of the immune system, from skin barrier to lymphocyte gene regulation, may be based on its importance in cellular function. Immune dysfunction and susceptibility to infection have been observed in zinc-deficient human subjects. (Prasad ‘s study 2000 demonstrates the crucial role of zinc in promoting specific immune responses.Zinc is not only seen to be an important regulator of immunity but has also been found clinically to be an excellent mineral to take in the event of viral illness, such as the common cold. a double-blind placebo-controlled trial published by Prasad (2000) was positive.The action of zinc ispotentiated by vitamin B6 which acts synergically with it.
Copper, Manganese, and Selenium
In addition to zinc--- copper, manganese, and selenium act as cofactors of antioxidant enzymes to protect against oxygen free radicals produced during oxidative stress (Leung 1998).Trace elements such as zinc,copper,and selenium have a multitude of positive effects on the immune system , in general defence and protection against major disorders such as cardiovascular disease and cancer.
Although all are essential, selenium is found to be most deficient in patients with liver disease ,cardiovascular disease ,cvancer and arthritis.
In recent years, the benefits of selenium have been recognized by researchers as an effective protector against certain cancers, such as breast, lung, liver, urogenital, colorectal, prostate, and ovarian cancer, by removing harmful lipids and hydroperoxides from the body. one study showed overall 37% ie prostate 63%,Colorectal 58% lung 46% !!!( JAMA Dec 1996 using 200mcg for 10 years)
In addition to being a regulator of enzyme reactions, selenium acts with vitamin E, and the two are intricately interwoven as antioxidants in the glutathione regeneration cycle.When levels are adequatwe it makes Vitamin E 50 times more active as an antioxidant. Cell-mediated immunity is impaired by this pair’s deficiency.Selenium is an essential component of the enzyme glutathione peroxidase which is important in the detoxification of lipid peroxides.
Copper deficiency impairs lymphocyte response to antigen stimulants and also impairs cell-mediated immunity. Copper is an important cofactor in many of the body’s enzyme reactions, including the antioxidant splitting enzyme superoxide dismutase. SOD is copper and zinc dependent and is present in the the mitochondria to mop up superoxide radicals.
Manganese is also involved in many antioxidant functions and is involved in a wide range of enzymes in the body including a form of superoxide dismutase which prevents oxidation in the mitochondria.. It is essential for the metabolism of amino acids,carbohydrates and the proper oxidative breakdown of fatty acids and the production of energy.
A number of studies have shown that the combination of zinc and selenium enhances immunity in the elderly. A pioneering study published in the Lancet (Chandra 1992) found that seniors taking modest doses of a multivitamin/multimineral supplement containing zinc and selenium showed a general reduction in infection and required antibiotics for significantly fewer days annually.
Probiotics are natural substances that can be taken by humans to enhance the bacterial flora of the intestinal tract. The better-known probiotic is Lactobacillus acidophilus that is found in live yogurt cultures and can be helpful in combating yeast and other organisms that should not be in the GI tract.
which produce ammonia and amines.
The reestablishment of normal enteric flora can be facilitated through
the use of fermented milk products which contain naturally occurring
lactic acid fermenting bacteria, or through the use of supplements
containing specific strains of lactobacillus organisms. Most lactobacilli
are capable of surviving the acid gastric environment. These organisms
adhere to specific receptors on the mucosal cells of the small and large
intestine, suppressing the attachment of other bacteria. They inhibit the
proliferation of less beneficial bacteria by creating an acid environment
through the production of acetic, formic and lactic acids. In hepatic
encephalopathy, the administration of lactobacilli alters bacterial flora
by lowering the number of gram-negative rods which produce ammonia and
Arunachalam et al. (2000) have found Bifidobacterium lactis (1.5 × 1011 units) in low-lactose milk consumption by healthy elderly subjects improves immune function after 6 weeks as measured by enhanced levels of alpha-interferon and phagocytic cell capacity. In general, probiotics are known for their ability to create a positive environment in the human GI tract for enhanced immunity, appropriate gut flora balance, and enhanced nutrient formation for enterocytes (cells of the intestinal wall) (Chiang et al. 2000; Gill et al. 2001a; 2001b).
The kind of fat that we eat will determine the balance of proinflammatory and anti-inflammatory hormones and messengers. In addition, the structure of all our cells will be determined by the amounts of saturated versus unsaturated fat in our diet.
The omega-3 series dietary fatty acids (polyunsaturated or PUFAs) are rapidly incorporated into cell membranes, and profoundly influence biological responses. These lipids influence membrane stability, membrane fluidity, cell mobility, the formation of receptors, binding of ligands to their receptors, activation of intracellular signaling pathways either directly or through the formation of eicosanoids, gene expression, and cell differentiation.( Ref --Life Extension Foundation )
The Omega-3 and Omega-6 Essential Fatty Acids are critical in the production of hormones called prostaglandins, which control inflammation, cell growth and differentiation, blood clotting, and key aspects of the immune system. Although the Western diet is plentiful in Saturated fats it is deficient in omega3 EFA.prostaglandins.
Saturated fatty acids produce hormones (prostaglandins) that promote inflammation, cell growth, and blood clotting. Omega-3 fatty acids produce hormones (prostaglandins) which are antinflammatory.Although it is most beneficial to consume these essential fats in a ratio of 2 omega-6 fatty acids to 1 omega-3 fatty acid (2:1 ratio) most Americans consume an estimated ratio of 20:1
This lack of imbalance is responsiblefor health problems involving virtually every organ in the body due also to cell membrabne weakness
In the metabolic pathways of omega 6 and omega 3 it is especially meat whichcontaining araachidonic acid leads to the production of series 2 pro inflammatory prostaglandins. It is these saturated fats that lead to the expression of inflammatory messengers, rigid cell walls, and fatty deposits in the arteries. We are commonly deficient in theEFA essential for the production of the antinflammatory prostaglandins ( Dr ED Siguel states at least 10% of the population is deficient)Diseases ssociated with this deficiency include cancer,cardiovascular disease.diabetic complications and inflammatory disorders such as arthritis,eczema and multiple sclerosis.
. In well-controlled clinical studies, consumption of omega-3 fatty acids has resulted in reduction of cardiovascular diseases including arrhythmias and hypertension, protection from renal disease, improvement in rheumatoid arthritis, improvement in inflammatory bowel diseases, reduced episodes of rejection, and protection from infection."
The conclusion is the need to eat less animal fat and more fish,nuts and seeds.
OTHER FACTORS -The Mind Body Connection
The key to healing is relationship. Being loved is about being seen and being able to express yourself in a situation where you can be heard. Carol Naiber an intuitive healer in North California explains that the perception of loneliness is a misperception because we are all connected and never really alone.
Thus these factorswhich influence immunity are indeed manifold. Chandra et al. (1991) have identified multiple factors that can predispose to immune dysfunction in the elderly—living alone, physical or mental disability, recent loss of spouse or significant other, use of multiple medications, poverty, and high alcohol consumption. The emotional and social factors are highly interwoven with the functioning of the immune system.. Social isolation doubles death rates. This was a study done in Scandinavia and the US on 35,000 people. Social relationships impact on our physiology. The most famous trials are the increased survival time in patients with breast cancer attending support groups (David Spiegel) and stress reduction techniques on healing malignant melanoma (Fauzey and Fauzey), reduction of heart disease with a comprehensive lifestyle program treating the mind and body (Dean Ornish).High levels of stress in animals and humans increase genetic damage. Social isolation, chronic life stress, personality factors, depression, anxiety and smoking are all independent factors for the risk of heart disease (Rozansky).eople who had a heart attack and did not have social support were three times more likely to die of heart disease in the next three months.Social support is a huge factor in the prevention of illness.
Candice Pert the famous research professor says that having loving relationships is how we evolved and EO Wilson, the biologist has talked about the biological basis of altruism. A study was done by James Billings on people who had been hospitalised for attempting suicide. A group of these were given psychotherapy and paradoxically the people in therapy were killing themselves at a substantially higher rate than the others. The reason was that the people needed to make contact with the therapist and have them respond in a nurturing and caring way. Instead, the therapist kept distance and therefore created this problem.
It does seem that having a relationship gives people the opportunity to grow and soothes and integrates their total system. Rachael Naomi Remen,( 1 ) Director for the Study of Health and Illness at Commonweal has said that intimacy heals suffering. She has said that we suffer not because we are in pain, the real suffering is that we feel we are in pain alone.
As little as six weeks in a loving supportive group can affect recurrence and death rates from cancer years later (Dean Ornish).
An important key here is that once the individual knows that their life matters to someone, it can’t be taken back. Once we know that our life is important and treasured and others feel this way about us, this has a huge affect on our survival.
Echinacea is also known as purple cornflower and is a member of the daisy family. Echinacea’s ability to fight cold viruses and respiratory infections has long been known. In vitro studies have shown that echinacea increases antibody production, reduces inflammation, and enables white blood cells to migrate to the infection site.
GRAPE SEED-SKIN EXTRACT
Pranthocyanidin bioflavenoids are powerful antioxidants and free radical scavengers ontained in foods such as avocado,straberries and bananas and also in grape seed extract and pine trees.They cross the blood brain barriert allowing them to act as antioxidants in the brain(Bagchi et al. 1998)..In vitro, grape seed-skin extract has been shown to have antioxidant action 50 times greater than vitamin E and 20 times greater than vitamin C (Bagchi et al. 1997).
Coenzyme Q10 (CoQ10) is an important antioxidant produced in the body and found in small amounts in some foods.It isessential for cellular energy production and is made lipid soluble by its side chain which enables it to access the inner mitochondrial membrane.Deficiency is common incardiac patients probably because the heaert is so metabolically active.It is very effective in treating people with advanced heart disease, congestive heart failure, angina, and arrhythmia.It is also of great value in treating hypertension( Ref Bioenergenics inclinical medicine Res Commun Pathol Pharmaccol 11:273, 1975)
It has been found to increase a number of immune parameters, including IgG, T4 cells, and the ratio of T4/T8 lymphocytes (Folkers et al. 1982, 1985, 1993).
Because of its immuno-stimulatory potential, CoQ10 has been used as an adjuvant therapy in patients with various types of cancer. CoQ10 has also shown promise in clinical trials on breast cancer patients in which tumor spread and mortality rate were significantly lowered with trial dosages (Lockwood et al. 1994a; 1994b; 1995). Austin (1997) has written an excellent review of the use of CoQ10 in the treatment of metastatic disease and has critically evaluated the papers by Lockwood et al. (Austin 1997). Although CoQ10 may show indirect anticancer activity through its effect(s) on the immune system, there is evidence to suggest that analogs of this compound are able to suppress cancer growth directly. Additional research is needed to determine long-term toxicity in cancer treatment.
Japanese studies show that regular physical activity may enhance NK cell activity (Shinkai et al. 1997). However, too much of a good thing may actually decrease immune effectiveness. A very low fat diet (less than 15%) coupled with a heavy exercise schedule has been shown to decrease immune efficacy (Venkatraman et al. 1996; Konig et al. 1997). Given the many other health benefits, regular, moderate exercise should be on everyone’s health agenda. There is research evidence that vitamin supplementation becomes increasingly important with exercise because physical activity raises oxygen demand, causing an increase in the formation of oxygen radical species. Many vitamins and cofactors are involved in energy metabolism and free-radical scavenging.
The immune system is the body’s protection against damage from invading bacteria, viruses, and cancers. In order for it to function properly, it must have the support of proper nutrition. Nutritional immunology is the field of study dealing with this support.
The task at present is to define biomarkers (immunologic indices) that can predict resistance to infection and other illnesses associated with poor immune function with reasonable accuracy. We do know that the older we get, and the poorer our diet, the more susceptible we are to infection, tumor, and immune dysfunction. Free radicals have been linked to the immune system damage that accompanies normal aging. Vitamins play a critical role along with trace elements in maintaining the human immune system. We have also mentioned herbs( echinacea and grape seed-skin extract). probiotics, and CoQ10. and esssential fatty acids.A good diet is essential for maximising immune response and wellness. Agood diet includes organic fruits, vegetables, and grains with cold-water fish and lean meats. We should have at least 5 to 6 fish dishes per week especially slmon, mackerel, tuna or sardines Diet and reduction of stress is the first priority.