NutritionNutrition
A Radical Approach to HealthA Radical Approach to Health
Linda Diane FeldtLinda Diane Feldt
With credit toWith credit to
Coco Newton Coco Newton MPH, RD, CCNMPH, RD, CCNfor slides 4-10, 12-17, 19-20, 23-25, 30-36, 38-45, 49, 51for slides 4-10, 12-17, 19-20, 23-25, 30-36, 38-45, 49, 51
OutlineOutline
Food that promotes healthFood that promotes health Food that hurts usFood that hurts us Controversial dietsControversial diets Dietary related illnessesDietary related illnesses Organic and sustainableOrganic and sustainable The good newsThe good news
What food can do for usWhat food can do for us
Anti-inflammatoryAnti-inflammatory AntioxidantAntioxidant Cell repairCell repair Decrease insulin resistanceDecrease insulin resistance Hormonal balancingHormonal balancing EnergyEnergy
PhytonutrientsPhytonutrients
LignansLignansFlavonoidsFlavonoidsIsoflavonesIsoflavonesPolyphenolsPolyphenolsTerpenesTerpenesPlant sterolsPlant sterolsComplex phospholipidsComplex phospholipidsCarotenoidsCarotenoidsAmino acidsAmino acidsPeptidesPeptides
Most thoroughly studied foodsMost thoroughly studied foods:: Cruciferous vegetablesCruciferous vegetables SoySoy Green leafy veggies Green leafy veggies Red-orange fruits/veggiesRed-orange fruits/veggies CitrusCitrus GarlicGarlic
Free RadicalsFree Radicals
Free radicalsFree radicals are by-products of oxidation- the process by which body uses are by-products of oxidation- the process by which body uses OO22 to burn food as fuel, producing energy, and to destroy harmful chemicals. to burn food as fuel, producing energy, and to destroy harmful chemicals.
Excess free radicals produced by nuclear radiation, pollution, smoking, Excess free radicals produced by nuclear radiation, pollution, smoking, alcohol, sunburn, stressalcohol, sunburn, stress
The fires of oxidation can produce chemical “sparks” that fly off and start The fires of oxidation can produce chemical “sparks” that fly off and start fires where they aren’t wanted. Those “sparks” are fires where they aren’t wanted. Those “sparks” are free radicalsfree radicals..
Normally electrons spin in pairs in opposite directions at 186,000 miles/sec. Normally electrons spin in pairs in opposite directions at 186,000 miles/sec. Free radicalsFree radicals are unpaired electrons that “rip each other off” in chain rxn are unpaired electrons that “rip each other off” in chain rxn
Free radicalsFree radicals damage tissue, blood, bile, cells, and DNA damage tissue, blood, bile, cells, and DNA
AntioxidantsAntioxidants are protective enzymes and circulating chemicals that protect are protective enzymes and circulating chemicals that protect the body’s cells from harmful oxidation and the body’s cells from harmful oxidation and limit free radicallimit free radical damage.damage.
Top Dietary Sources of AntioxidantsTop Dietary Sources of Antioxidants
Foods generally rich in antioxidantsFoods generally rich in antioxidantsRedRed, , yellowyellow, and , and greengreen vegetables, raw nuts and seeds, legumes, vegetables, raw nuts and seeds, legumes, whole grains, garlic, shrimp, scallopswhole grains, garlic, shrimp, scallops
Foods rich in carotenoidsFoods rich in carotenoidsApricots, broccoli, cantaloupe, carrots, collards, dandelion greens, Apricots, broccoli, cantaloupe, carrots, collards, dandelion greens, kale red peppers, mustard greens, papaya, pumpkin, sea kale red peppers, mustard greens, papaya, pumpkin, sea vegetables, spinach, sweet potatoes, Swiss chard, tomatoes, winter vegetables, spinach, sweet potatoes, Swiss chard, tomatoes, winter squashsquash
Foods rich in bioflavanoidsFoods rich in bioflavanoidsBeets, black cherries, blackberries, blueberries, buckwheat, Beets, black cherries, blackberries, blueberries, buckwheat, cranberries, asparagus tips, green tea, purple corn, purple onion, cranberries, asparagus tips, green tea, purple corn, purple onion, radishes, raspberries, red cabbage, red grapes, rhubarb, sweet radishes, raspberries, red cabbage, red grapes, rhubarb, sweet potatoes, spices (ginger, parsley, rosemary, sage, thyme, turmeric)potatoes, spices (ginger, parsley, rosemary, sage, thyme, turmeric)
AntioxidantsAntioxidants
DIETARY SOURCES: vit E, vit C, vit A, carotene, related DIETARY SOURCES: vit E, vit C, vit A, carotene, related carotenoids, bioflavanoids, selenium, manganese, copper, zinc, carotenoids, bioflavanoids, selenium, manganese, copper, zinc, sulfursulfur
Inhibit free radicals directly by quenching “sparks”Inhibit free radicals directly by quenching “sparks”
Inhibit free radicals indirectly by activating liver detoxification Inhibit free radicals indirectly by activating liver detoxification enzymes (cytochrome Penzymes (cytochrome P450450 system) that convert them into less system) that convert them into less destructive compoundsdestructive compounds
Need balanced anti-oxidant defense system to protect Need balanced anti-oxidant defense system to protect mitochondria (energy center of cell)mitochondria (energy center of cell)
CarotenoidsCarotenoids
Carotenoids are fat soluble compounds Carotenoids are fat soluble compounds that provide the light that provide the light yellowyellow to deep to deep orangeorange colors to fruits and vegetables. colors to fruits and vegetables.
Beta-carotene, alpha-carotene, lutein, Beta-carotene, alpha-carotene, lutein, lycopene, xanthinslycopene, xanthins
Foods, not individual supplements, fight Foods, not individual supplements, fight cancer, macular degenerationcancer, macular degeneration
BioflavanoidsBioflavanoids
Bioflavanoids are potent antioxidants that provide the Bioflavanoids are potent antioxidants that provide the bright bright yellowyellow to deep to deep purplepurple colors to fruits and colors to fruits and vegetables, and spices.vegetables, and spices.
Quercitin, proanthocyanadins (grape seed extract, pine bark Quercitin, proanthocyanadins (grape seed extract, pine bark extract), epigallo-catechin galactate (DGCG) found in green teaextract), epigallo-catechin galactate (DGCG) found in green tea
Protect against cancer, heart disease, allergies, circulatory Protect against cancer, heart disease, allergies, circulatory disorders, inflammationdisorders, inflammation
Stimulate immunity by increasingStimulate immunity by increasing• NK cell activity NK cell activity • Interleukin 2 (T-cells, lymphocytes)Interleukin 2 (T-cells, lymphocytes)
Cruciferous VegetablesCruciferous Vegetables
Broccoli, cauliflower, brussels sprouts, bok choy, Broccoli, cauliflower, brussels sprouts, bok choy, and cabbage are potent cancer fighting foods:and cabbage are potent cancer fighting foods:
SulphoraphanesSulphoraphanes anti-oxidants that stimulate release of detoxification enzymes in anti-oxidants that stimulate release of detoxification enzymes in
liverliver may inhibit early tumor growthmay inhibit early tumor growth
Indole-3 CarbinolIndole-3 Carbinol supports detoxification of estrogens and xenoestrogens supports detoxification of estrogens and xenoestrogens
(pollutants that mimic estrogen activity in body) (pollutants that mimic estrogen activity in body) promotes formation of beneficial estrogen metabolite promotes formation of beneficial estrogen metabolite
(2 hydroxy estrone)(2 hydroxy estrone)
Healthy Eating PyramidHealthy Eating PyramidHarvard School of Public HealthHarvard School of Public Health
Carbs, fats, proteinsseparated by quality
Multi vitamin recommended
Option calcium supplement
Fatty AcidsFatty Acids Omega 9 fatty acidsOmega 9 fatty acids
Olive, canola (oleic acid)Olive, canola (oleic acid)
Omega 3 fatty acidsOmega 3 fatty acidsflax seeds, flax oil, fish oil ( alpha-linolenic acid, eicosapentanoic flax seeds, flax oil, fish oil ( alpha-linolenic acid, eicosapentanoic
acid)acid)
Omega 6 fatty acidsOmega 6 fatty acidscorn, safflower, sunflower, sesame (linoleic acid)corn, safflower, sunflower, sesame (linoleic acid)evening primrose oil, borage oil, black currant seed oil (gamma evening primrose oil, borage oil, black currant seed oil (gamma linolenic acid)linolenic acid)
Optimal Omega-3: Omega-6 Ratio is Optimal Omega-3: Omega-6 Ratio is 1:31:3SStandard tandard AAmerican merican DDiet iet (SAD)(SAD) is is 1:251:25
Omega 3 Fatty AcidsOmega 3 Fatty Acids
precursors of prostaglandinsprecursors of prostaglandins
Prostaglandins are chemical messengers in Prostaglandins are chemical messengers in every cell of the body, regulating the every cell of the body, regulating the rhythm and inflammatory process.rhythm and inflammatory process.
Omega 3 Fatty Acids Omega 3 Fatty Acids BenefitBenefit
Heart disease-Heart disease- homocysteine, VLDL, Apo B, increases HDL homocysteine, VLDL, Apo B, increases HDL
HypertensionHypertension- avg - avg of 3.5mm diastolic, 5.5 mm systolic of 3.5mm diastolic, 5.5 mm systolic
Cancer-Cancer- growth of precancerous cells, tumor initiation, tumor growth, enhances growth of precancerous cells, tumor initiation, tumor growth, enhances chemotherapychemotherapy
Brain-Brain- low omega-3 assoc. with ADD, depression, bipolar, schizophrenia, learning low omega-3 assoc. with ADD, depression, bipolar, schizophrenia, learning disorders, Alzheimer’s, disorders, Alzheimer’s,
Rheumatoid Arthritis-Rheumatoid Arthritis- inflammatory leukotrienes inflammatory leukotrienes
Digestion-Digestion- inflammatory leukotrienes (Crohn’s , Ulcerative Colitis) inflammatory leukotrienes (Crohn’s , Ulcerative Colitis)
Dysmenorrhea-Dysmenorrhea- pain after 2 months pain after 2 months
Diabetes-Diabetes- insulin resistance, obesity, triglycerides, blood glucose insulin resistance, obesity, triglycerides, blood glucose
NSAIDSNSAIDS
Blocks all prostaglandinsBlocks all prostaglandins, even the beneficial ones, , even the beneficial ones, thereby suppress body’s own anti-inflammatory thereby suppress body’s own anti-inflammatory responseresponse
Blocks intestinal lining repair (every 3-5 days)Blocks intestinal lining repair (every 3-5 days)
Causes intestinal permeability “Leaky Gut”Causes intestinal permeability “Leaky Gut”
Increases risk for stomach and duodenal ulcersIncreases risk for stomach and duodenal ulcers
Increases risk for dysbiosisIncreases risk for dysbiosis
For the love of chocolateFor the love of chocolate
Cocoa contains procyanidins and Cocoa contains procyanidins and phytosterolsphytosterols
total cholesterol, LDL cholesteroltotal cholesterol, LDL cholesterol high in Mg, Cu, Ca, P, Fe, Zn high in Mg, Cu, Ca, P, Fe, Zn (magnesium, copper, calcium, phosphorous, iron, zinc)(magnesium, copper, calcium, phosphorous, iron, zinc) Fatty acids oleic, stearic, palmitic pose no harm Fatty acids oleic, stearic, palmitic pose no harm
Nutritional CrisisNutritional Crisis
35 % of Americans are overweight35 % of Americans are overweight 26% of Americans are obese26% of Americans are obese
1990- 1990- 40%40% fat in diet fat in diet 2000- 2000- 34%34% fat in diet fat in diet
1960- 1960- 31003100 calories/day calories/day1990- 1990- 37003700 calories/day calories/day
68% of all deaths are associated 68% of all deaths are associated with imbalances in diet and with imbalances in diet and
nutritionnutrition1988 Surgeon Generals Report1988 Surgeon Generals Report
Diet changes in conjunction with physical activity and normal BMI
could reduce cancer incidence by 30–40%.
1997, The World Cancer Research Fund and the American Institute for Cancer Research report,
"Food, Nutrition and the Prevention of Cancer: A Global Perspective"
20% of deaths from heart disease could be avoided by reducing fats and increasing fruits, vegetables, breads, cereals, and legumes (dry beans and
peas).
The 1989 National Academy of Sciences report, Diet and Health: Implications for Reducing Chronic Disease Risk
USDA 1988-89 Americans USDA 1988-89 Americans each ate on average/yeareach ate on average/year
638 serv soda pop (ages 12-29)638 serv soda pop (ages 12-29)134 lbs. sugar134 lbs. sugar 90 lbs. fats-oils90 lbs. fats-oils 63 doz donuts63 doz donuts 82 lbs. cakes, cookies, candy82 lbs. cakes, cookies, candy 23 gallons ice cream23 gallons ice cream 15 lbs chips15 lbs chips2.65 gallons pure alcohol= 2.65 gallons pure alcohol=
50 gallons beer 50 gallons beer 20 gallons wine 20 gallons wine 4 gallons distilled liquor4 gallons distilled liquor
$$$$$$$$ spent on supplements spent on supplements
$1.7 billion/year on vitamins/minerals$1.7 billion/year on vitamins/minerals
$3.8 billion/year on herbs$3.8 billion/year on herbs
$33 billion/year on weight control products$33 billion/year on weight control products
Center for Disease Control and PreventionCenter for Disease Control and PreventionFDA Consumer ReportsFDA Consumer Reports
Illusion of the Perfect DietIllusion of the Perfect Dietone size does not fit allone size does not fit all
Blood typeBlood type Metabolic typeMetabolic type Raw foodsRaw foods VegetarianVegetarian VeganVegan Macrobiotic Macrobiotic High protein, low carbHigh protein, low carb Low fat, high carbLow fat, high carb USDA pyramidUSDA pyramid Asian pyramidAsian pyramid Harvard pyramidHarvard pyramid Etc……… Etc………
The Myth of FastingThe Myth of Fasting
The body does a good job of “purifying” every The body does a good job of “purifying” every dayday
The colon is a muscle that does not need to restThe colon is a muscle that does not need to rest ““set point” change is a real danger of fastingset point” change is a real danger of fasting There is no evidence for the claim that the colon There is no evidence for the claim that the colon
is caked with a rubbery residueis caked with a rubbery residue Healing systems that routinely require fasting Healing systems that routinely require fasting
and purifying are rarely evidence basedand purifying are rarely evidence based Fasting can affect adrenal function and other Fasting can affect adrenal function and other
systems, creating feelings of euphoria systems, creating feelings of euphoria
*Fasting for spiritual reasons has a different purpose and effect*
1987 National Academy of 1987 National Academy of Sciences ReportSciences Report
20,000 cases of cancer per year can be 20,000 cases of cancer per year can be linked to US pesticide uselinked to US pesticide use
The biggest dietary offenders are meats, The biggest dietary offenders are meats, dairy, and producedairy, and produce
Environmental Toxins in Food Environmental Toxins in Food
PesticidesPesticides HerbicidesHerbicides FungicidesFungicides RodenticidesRodenticides HormonesHormones AntibioticsAntibiotics
A Research News Release on A Research News Release on March 3, 2003March 3, 2003
Fruits and vegetables grown organically have Fruits and vegetables grown organically have significantly higher levels of cancer fighting anti-significantly higher levels of cancer fighting anti-oxidants than conventionally grown foods.oxidants than conventionally grown foods.
The research suggests that pesticides and The research suggests that pesticides and herbicides actually thwart the production of herbicides actually thwart the production of phenolics- chemicals that act as a plant’s natural phenolics- chemicals that act as a plant’s natural defense and are good for our healthdefense and are good for our health
Parkinson’s and FruitsParkinson’s and Fruits
Correlation between high fruit and fruit Correlation between high fruit and fruit juice intake and risk of Parkinson’s juice intake and risk of Parkinson’s diseasedisease
““We speculate that this increased risk may be We speculate that this increased risk may be due to plant borne toxins, pesticides, or due to plant borne toxins, pesticides, or herbicides, rather than the fruit itself.”herbicides, rather than the fruit itself.”
American Academy of Neurology Annual Meeting in Honolulu, March 29 – April 5, 2003American Academy of Neurology Annual Meeting in Honolulu, March 29 – April 5, 2003
Pesticides in Children’s DietsPesticides in Children’s DietsOrganic vs. ConventionalOrganic vs. Conventional
Children fed predominantly organic produce/juice had Children fed predominantly organic produce/juice had one-sixthone-sixth the level of pesticides compared to children fed the level of pesticides compared to children fed conventional produce/juice.conventional produce/juice.
EPA risk levels above for conventional and negligible for EPA risk levels above for conventional and negligible for organicorganic
Environmental Health Perspectives, March 2003Environmental Health Perspectives, March 2003Cynthia Curl, et al (University of Washington) “Organophosphorus pesticide Cynthia Curl, et al (University of Washington) “Organophosphorus pesticide exposure of urban and suburban preschool children with organic and exposure of urban and suburban preschool children with organic and conventional diets”conventional diets”
NIH National Children’s StudyNIH National Children’s Study
Examining the relationship between Examining the relationship between environmental exposures and health and environmental exposures and health and development by following more than 100,000 development by following more than 100,000 children from birth to 21yrschildren from birth to 21yrs
Hypothesis: pre-conceptual, prenatal, and/or Hypothesis: pre-conceptual, prenatal, and/or early childhood exposure to pesticides and other early childhood exposure to pesticides and other environmental contaminants increases neuro-environmental contaminants increases neuro-developmental disorders developmental disorders
““Well run organic farms often Well run organic farms often match conventional ones for match conventional ones for productivity, even beat them productivity, even beat them when water is scarce. when water is scarce. Creating a sustainable food Creating a sustainable food supply may well require supply may well require advanced technology as well advanced technology as well as ecological awareness. But as ecological awareness. But an organic ethic could be the an organic ethic could be the very key to our survival.”very key to our survival.”
Newsweek Sept. 30, 2002Newsweek Sept. 30, 2002
RDARDA = = RReally eally DDumb umb AAllowancesllowances
Based on the “normal” 70 kg man Based on the “normal” 70 kg man
a statistical construct, a mythical mana statistical construct, a mythical man
The mean requirement of a nutrient increased by 2 standard The mean requirement of a nutrient increased by 2 standard deviations deviations
Nutritional needs of “practically all healthy people”- no relevance to Nutritional needs of “practically all healthy people”- no relevance to individualindividual
Use Optimal Daily Intake: 10 – 100X RDAUse Optimal Daily Intake: 10 – 100X RDAHalf way between RDA and Upper Limit (UL)Half way between RDA and Upper Limit (UL)UL = highest level that poses no adverse effects in general populationUL = highest level that poses no adverse effects in general population
Stages of Nutrient DepletionStages of Nutrient Depletion
1.1. Dietary inadequacyDietary inadequacy2.2. Diminished tissue reservesDiminished tissue reserves3.3. Decreased body fluid levelsDecreased body fluid levels4.4. Decreased functional levels in tissuesDecreased functional levels in tissues5.5. Decreased activity of nutrient dependent enzymesDecreased activity of nutrient dependent enzymes6.6. Functional changeFunctional change7. Clinical symptoms7. Clinical symptoms8. Anatomical Signs8. Anatomical Signs9. DISEASE9. DISEASE
1 – 61 – 6 functional/nutritional medicine functional/nutritional medicine 7 – 97 – 9 conventional medicineconventional medicine
Surfing the Nutrition WEBSurfing the Nutrition WEBgastrointestinal gastrointestinal
Gut is the most important Gut is the most important gateway to your body’s gateway to your body’s health.health. Look here first! Look here first!
Protective barrierProtective barrier
60% of immune system 60% of immune system (GALT-gut associated (GALT-gut associated lymphatic tissue)lymphatic tissue)
Enteric nervous system- Enteric nervous system- our 2our 2ndnd brain brain
Surfing the WEB- G.I.Surfing the WEB- G.I.
Approx 26 feet longApprox 26 feet long 2 + lbs of bacteria 2 + lbs of bacteria
Normal g.i. tract 85-90% good, 10-15% badNormal g.i. tract 85-90% good, 10-15% bad
symbioticsymbiotic- acidophilus, bifidobacteria, eubacteria- acidophilus, bifidobacteria, eubacteria commensalscommensals- e.coli, streptococcus- e.coli, streptococcus villainsvillains- clostridium, salmonella, staphylococcus, - clostridium, salmonella, staphylococcus,
proteus, campylobacter, listeria, pseudomonas, proteus, campylobacter, listeria, pseudomonas, klebsiellaklebsiella
Too many villains cause Too many villains cause dysbiosis.dysbiosis.
Major Causes of DysbiosisMajor Causes of Dysbiosis
Poor dietPoor diet Poor nutritional statusPoor nutritional status Antibiotic/drug therapyAntibiotic/drug therapy Decreased immune statusDecreased immune status Decreased gut motilityDecreased gut motility MaldigestionMaldigestion Intestinal infectionIntestinal infection XenobioticsXenobiotics Increased intestinal pHIncreased intestinal pH
Major Effects of DysbiosisMajor Effects of Dysbiosis• Vitamin B vitamin deficiencyVitamin B vitamin deficiency• SteatorrheaSteatorrhea• Irritable bowel syndromeIrritable bowel syndrome• Inflammatory bowel diseaseInflammatory bowel disease• Auto-immune disordersAuto-immune disorders• ArthritisArthritis• Colon and breast cancerColon and breast cancer• PsoriasisPsoriasis• EczemaEczema
• Cystic acneCystic acne• Chronic fatigueChronic fatigue• Fibromyalgia Fibromyalgia • HeadachesHeadaches• Food allergiesFood allergies• Weight gainWeight gain• Candida albicansCandida albicans• Emotional Emotional • Elevated cholesterol Elevated cholesterol
““Leaky Gut” is to blameLeaky Gut” is to blame
““Leaky Gut”Leaky Gut”
Excess toxins pass through damaged intestinal wall to Excess toxins pass through damaged intestinal wall to blood stream and are carried to liverblood stream and are carried to liver
Liver must detoxify, yet is overworkedLiver must detoxify, yet is overworked
Liver has Liver has KupfferKupffer cells which transfers immunological cells which transfers immunological message from liver to rest of body that toxins are coming message from liver to rest of body that toxins are coming from gi tractfrom gi tract
““TOXIN ALERT”-TOXIN ALERT”- overactive immune system causes overactive immune system causes toxic response systemically (auto-immune, arthritis, etc.)toxic response systemically (auto-immune, arthritis, etc.)
Some Foods to Support G.I. Some Foods to Support G.I. HealthHealth
Rice carbohydrates and proteinRice carbohydrates and protein
Dietary fiber (best are rice bran and barley bran)Dietary fiber (best are rice bran and barley bran) Friendly bacteria ferment them to short chain fatty acids which nourish Friendly bacteria ferment them to short chain fatty acids which nourish
intestinal cells.intestinal cells.
Probiotics and prebiotics in foodsProbiotics and prebiotics in foods
For hypoallergenic and anti-inflammatory effect:For hypoallergenic and anti-inflammatory effect: Avoid gluten-containing flours, dairy, eggs, soy, peanuts, caffeine, sugar, Avoid gluten-containing flours, dairy, eggs, soy, peanuts, caffeine, sugar,
alcohol, shellfisalcohol, shellfis Include ample vegetables, fruitsInclude ample vegetables, fruits
Candida overgrowthCandida overgrowth
Popularized by “The Yeast Connection” by William Popularized by “The Yeast Connection” by William Crook, MD requires a strict elimination diet.Crook, MD requires a strict elimination diet.
An alternative is to crowd out candida by An alternative is to crowd out candida by encouraging healthy intestinal flora.encouraging healthy intestinal flora.
Tempeh, miso, pickles, yogurt, and other Tempeh, miso, pickles, yogurt, and other fermented products are used as well as fermented products are used as well as acidophilus and probioticsacidophilus and probiotics
Sinful Side of SugarSinful Side of Sugar
DM, CHD, cancer (breast and colon), DM, CHD, cancer (breast and colon), obesity, ADD, tooth decay, nutritional obesity, ADD, tooth decay, nutritional deficiencies, Candida albicansdeficiencies, Candida albicans
immune function, B vits, Cr, Cu, Mbimmune function, B vits, Cr, Cu, Mb
Caffeine and CoffeeCaffeine and Coffee
Toxins used in growing and processingToxins used in growing and processing Decaf worse- uses chemical solventsDecaf worse- uses chemical solvents Stress hormones- adrenalin, cortisolStress hormones- adrenalin, cortisol
Stress hormones make glucose availableStress hormones make glucose available Stress hormones inhibit fat burningStress hormones inhibit fat burning
Adrenal exhaustionAdrenal exhaustion B vitamin, calcium, magnesium, potassium, B vitamin, calcium, magnesium, potassium,
and zinc absorptionand zinc absorption Homocysteine Homocysteine plaque, clotting plaque, clotting blood pressureblood pressure