Index

Introduction……………………………………………………………....3 STEP 1. Establish the Oxidative Stress (OS) Status of the patient……4 STEP 2. A different proposal for each OS status…………………..…..5 STEP 3. General advices…………..……………………………………..9

2 INTRODUCTION Free radicals induce oxidative stress, which is balanced by the body's endogenous antioxidant systems with an input from co-factors and by the ingestion of exogenous antioxidants. If the generation of free radicals exceeds the protective effects of antioxidants, and some co-factors, this can cause oxidative damage which accumulates during the life cycle, and has been implicated in aging, and age dependent diseases such as cardiovascular disease, cancer, neurodegenerative disorders, and other chronic conditions Concerning antioxidant supplementation and OS the following issues need to be addressed : 1) further assessment of oxidative mechanisms targeted to the aging process physiopathology, 2) easy and precise dedicated instruments of reliable markers of oxidative damage and antioxidant status, 3)choice of therapeutic schedules of antioxidant supplementation to beneficial, 4) more knowledge of the antioxidant molecules which in several conditions may act as pro- oxidants. Accordingly Callegari S.p.A., has invested it’s resources in developing a reliable and easy to handle Point of Care Instrument for an accurate assessment of both free radicals and the antioxidant blood pool, related to illnesses, drugs or nutraceutical administration. In fact, oxidative stress detection allows the development of intervention strategies which can contribute to delay the progression of a condition/disease as well as to ameliorate the outcome and then to enhance the quality of life. Therefore, oxidative stress emerges as a novel health risk factor –particularly if prolonged and associated with other well known risk factors, such as blood hypertension, high lipid profiles, hyperglycaemia, overweight, and smoking. Measuring the level of free radicals in your body (testing the FORT assay) and your antioxidant defence (testing the FORD assay) is a way of preventing the damages associated to oxidative stress and in the case of high values intervening to reduce damages which may be caused. But how should you do it1?

1 The information is based on advice from experts in the fields, many years of experience in OS testing and scientific literature. The information is not intended to replace the advise of a licensed health care professional. Callegari does not recommend changing any current medication or starting/adding any new therapies without consulting a fully qualified medical professional. 3

STEP 1. Establish the Oxidative Stress (OS) Status of the patient The first and most essential step is to establish the global OS state of the individual. This requires testing both the free radical action and the antioxidant defences of a patient. Once the FORT and the FORD have been obtained, the individual OS level is established allowing assessment of the health of the patient and the most appropriate course of action for that patient. The table below is of use to interpret the OS states of individuals based on both the FORT and FORD results. Five major conditions have been depicted.

4 STEP 2. A different proposal for each OS status

Please see notes below.

1 WHO guidelines recommend a minimum of 400g daily that is approx 5 servings. Otherwise, it may be difficult to get all of the vitamins and minerals the body needs. Also, if you eat only one or two times a day, you may be limiting the number and variety of servings you eat from the various food groups. In these cases a supplementation should be advised. 1 You could adopt some of the following healthy habits: add some fruit to your breakfast cereals; grab pieces of fruit or raw vegetables as snacks; eat fruit for dessert; eat a big salad as lunch. 1 It should contain at least vitamin C (approx 500 mg corresponding to 830% of RDA, see also note 11) and E (approx 200 IU corresponding to 660% of RDA) as well as some minerals including selenium, zinc, copper, manganese.

5 1 Look for products which contain standardized extracts of phytonutrients. Coloured fruits and vegetables are known to be rich in carotenoids, some of which such as lutein and zeaxanthin tend to accumulate at the level of the macula. These may include beta- and alpha-carotene, lycopene, citrus bioflavonoids, quercitin, bilberry (anthocyanins), pine bark (pycnogenol), red cabbage, red wine concentrate, grape skin, elderberry, green tea, soy isoflavone concentrate, citrus terpene, broccoli, garlic, rosemary, turmeric, spirulina, aloe vera, ginkgo biloba, papaya, echinacea, as well as bee products such as pollen, propolis and royal jelly. Dosage is usually suggested by manufacturers and/or by health care professional. Read product labels carefully and/or ask for details to the manufacturers. A diet with a strong vegetable component (without having to be a vegetarian) provides a very broad range of antioxidants and thus appears to be an important defense against oxidative stress. Metro & Cow (Clin Terapeutica 2006 157 /6) 597-10) demonstrated the effects of the diet on AC of individuals: 50 healthy subjects were requested to consume 2-3 fruit portions (especially pineapple), 3-5 portions of vegetables (especially tomato) and 2-3 glasses of green tea on a daily basis for approximately 2 months as an addition to a basic diet. Results showed that an antioxidant rich diet increased both plasmatic total antioxidant capacity and endogenous antioxidant levels and reduced the lipid peroxidation of membranes, suggesting a reduction of the oxidative stress. 1 Some supplements may interact with prescription and OTC drugs (refer to note 10 too). Some supplements can have unwanted effects during surgery. For all these reasons, it is important to fully inform your doctor about the vitamins, minerals, herbals or any other supplements you are taking, especially before elective surgery. You may be asked to stop taking these products at least 2-3 weeks ahead of the procedure to avoid potentially dangerous supplement/drug interactions - such as changes in heart rate, blood pressure and increased bleeding - that could adversely affect the outcome of your surgery.

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1 Nutrients are not drugs - so do not expect an immediate results. Most people report a positive improvement in their health within 2-3 months. The most noted effects are increased energy, mental acuity, emotional stability and better skin that is a general well being. Often the most exceptional benefits are noted when significant dietary and lifestyle changes are put into action. 1 Strenuous physical exercise especially without appropriate training promotes conditions of OS. Practice regular but moderate physical activity. It is essential to avoid a sedentary lifestyle, but it is equally important not to overdo any sport. 7 1 If not enough sleep is had over a long period of time, it could be useful to take melatonin (2-3 mg a day). 1 You can take a double dosage of Vitamin C (1 g) and E (400 UI). Antioxidant cocktails may be also enriched with vitamin B group and A, cofactors such as coenzyme Q10, reduced glutathione, lipoic acid. 1 Recommended Dietary Allowance (RDA) is the daily dietary intake level of a nutrient considered sufficient to meet the requirements of nearly all (97–98%) healthy individuals in each life-stage and gender group. 1 Some supplements may interact with each other as well as with prescription and OTC medicines. For example: Coumadin (a prescription medicine), ginkgo biloba (an herbal supplement), aspirin (an OTC drug) and vitamin E (a vitamin supplement) can each thin the blood, and taking any of these products together can increase the potential for internal bleeding. Combining St. John's Wort (an herb extract) with certain HIV drugs significantly reduces their effectiveness. St. John's Wort may also reduce the effectiveness of prescription drugs for heart disease, depression, seizures, certain cancers or oral contraceptives.

8 STEP 3. General advices 1. Supplement programmes should be periodically reassessed: every 2-3 months at the beginning of treatment and subsequently at least once every 6 months. Individual requirements should decrease as subjects get healthier but there are conditions where supplementation may need to be increased:

♦ individuals leading a stressful lifestyle with poor eating habits

♦ women who are pregnant or are planning a pregnancy

♦ women who are breast feeding

♦ children - especially those that are ‘picky’ eaters

♦ individuals on a restricted diet

♦ individuals with a genetic defect and/or malabsorption disorders

♦ individuals recovering from surgery or a serious illness

♦ individuals who rely heavily on stimulants - such as caffeine, alcohol, nicotine and sugar

♦ the elderly who tend to rely on convenience foods and have poorer appetites. 2. It is essential that supplements are taken under the best conditions, to achieve maximum absorption, and assimilation by the body. Unless the medical professional has advised otherwise, it is best to take supplements with one glass of water. See below some suggestions:

♦ Water Soluble Vitamins: the B vitamins and Vitamin C can be taken on an empty stomach or with food. Do not take B vitamins in the evening as they may exacerbate or trigger insomnia.

♦ Fat Soluble Nutrients: vitamins A, D and E, essential fatty acids (omega 3 & 6) and CoQ10 are best taken with food.

♦ Amino Acids: amino acids are best taken one to three hours away from food.

♦ Minerals: with the exception of zinc, minerals are best taken with food. Calcium and magnesium are best taken in the evening (and can help you sleep). Special caution should be taken during iron-based therapies; for example, vitamin C boosts iron absorption, instead vitamin E improves tolerance of iron supplementation.

♦ Herbs: herbs are best taken with a little food or as a tea. It is best to consult a fully trained herbalist. 3. If supplements are taken, the goal should be stay within the vitamin safety zone, that range beginning at the RDA11 and ending at a level that is still safe and well below the toxicity 9 level. It is not easy for a vitamin-consuming public to decide where to draw the line between safe and excessive micrograms, milligrams or international units, IU. “There are no officially established limits for maximum doses. There are no reference guides or tables you can check to see what levels of vitamins trigger harmful effects” says Paul Saltman, Ph.D., a professor of biology doing research in nutrition at the University of California at San Diego. "That's because the danger levels vary from person to person and depend on factors such as weight, health status, metabolism, diet, nutritional status, the form of the nutrient and how often you take it”. For these reasons, under no circumstances should any supplements be taken without the expert guidance of a physician. Many supplements contain active ingredients that have strong biological effects and their safety is not always assured in all users. Even at lower dosages, always monitor both the FORT and FORD and respect the feedback your body provides. In addition, if a dietary supplement has been advised in place of drugs or in combination with any drug, the health care provider should be informed first6,12. 4. To avoid oxidative stress status, dietary supplements are appropriate in the following individuals:

♦ vegetarians or vegans. In these cases you may not consume enough calcium, iron, zinc and vitamins B12 and D. You can get these nutrients naturally from non-meat sources, such as fortified soy products, green leafy vegetables, legumes, whole-grain products and nuts. If you are not able to regularly consume these foods, dietary supplements may be necessary.

CLINICAL INVESTIGATION ADVISED:

♦ FORT & FORD

♦ BLOOD IRON AND FERRITIN HAEMOGLOBIN,

♦ CALCIUM

♦ PHOSPHORUS LEVELS

♦ postmenopausal woman. After menopause, women experience a sudden drop in estrogen levels, which increases bone loss. To keep bones strong and to decrease bone loss, you need calcium as well as vitamin D — the vitamin essential for absorbing calcium. Women who don't obtain enough calcium and vitamin D through foods could benefit from taking a calcium supplement with vitamin D. 10

CLINICAL INVESTIGATION ADVISED:

♦ FORD, FORT and URIC ACID

♦ BASAL PROLACTIN LEVEL

♦ CORTISOL SERUM

♦ URINARY CALCIUM

♦ PHOSPHORUS HYDROXYPROLINURIA

♦ N and C TELOPEPTIDES FROM COLLAGEN DEGRADATION

♦ ALKALINE PHOSPHATISE

♦ TOTAL CHOLESTEROL, CHOLESTEROL HDL, TRIGLYCERIDES

♦ smokers. Tobacco decreases the absorption of many vitamins and minerals, including vitamin C, folate, magnesium and calcium. But dietary supplements won't make up for the major health risks caused by smoking. The safest option is to avoid all tobacco products.

CLINICAL INVESTIGATION ADVISED:

♦ FORT AND FORD

♦ CEA

♦ VENOUS HEMOGASANALYSISALPHA-1 ANTITRYPSIN

♦ BREATH FUNCTION TESTS

♦ BLOOD PRESSURE

♦ During pregnancy or trying in individuals attempting to conceive. During this time, you need more of certain nutrients, especially calcium, folate and iron. Scientific evidence shows that pregnancy is a condition exhibiting increased susceptibility to oxidative stress. In fact doctors usually recommend a dietary supplement during pregnancy.

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CLINICAL INVESTIGATION ADVISED:

♦ FORT AND FORD

♦ B12 AND FOLIC ACID LEVELS

♦ SIDERIMIA

♦ FERRITIN

♦ HOMOCYSTEINE

♦ URINE TESTING

♦ BLOOD PRESSURE GLUCOSE TESTING

♦ Excessive drinkers. Long-term excessive alcohol consumption can impair the digestion and absorption of several vitamins and minerals, including vitamin B1, iron, zinc, magnesium and folate. Excessive drinking is defined as more than two drinks a day for men under age 65 and more than one drink a day for men over 65 and women. Taking dietary supplements, however, won't make up for the major health risks caused by excessive alcohol consumption

CLINICAL INVESTIGATION ADVISED:

♦ FORT AND FORD

♦ RBV

♦ WBC

♦ HAMEOGLOBIN

♦ IRON FERRITIN

♦ LIVER FUNCTION TESTS

♦ CEA,

♦ ALPHAFETOPROTEIN GAMMA GT

♦ BLOOD PRESSURE

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♦ Obese people especially with glucose level impairment and high blood pressure. Psychologically, being overweight can affect your body image and damage self- esteem. In some cases this can cause social anxiety and depression. Common physical problems include: difficulties breathing, difficulties walking or running, increased sweating, pain in the knees and back, skin conditions such as acne These conditions are often known as obesity-related diseases and are some of the most common causes of death before the age of 75. This is why obesi ty increases your risk of mortality.

CLINICAL INVESTIGATIO ADVISED:

♦ FORT AND FORD

♦ URIC ACID

♦ ORAL GLUCOSE

♦ LOAD GLYCEMIA,

♦ GLYCATE HAMOGLOBIN

♦ BLOOD & URINARY ELECTROLYTES.

♦ BLOOD PRESSURE

♦ LIPID PROFILE

♦ BODY COMPOSITION ANALYSIS

• Heavy psychophysical prolonged stressful lifestyle and potential malnourishment.

CLINICAL INVESTIGATIO ADVISED:

FORT, FORD URIC ACID B12 AND FOLIC ACID BLOOD IRON FERRITIN ALBUMIN PROTDEMIA AND ELECTROPHORESIS BASAL PROLACTIN 13 THYROID FUNCTION TES TS ANTI THYROID ANTIBODIES LIPID PROFILE BLOOD PRESSURE BMI 5. One of the issues relating to the efficacy an d safety of dietary supplements is bioavailability. After you swallow a vitamin or supplement, it goes through digestive system, where it's broken down, and eventually enters in bloodstream. Bioavailability is the term used to describe how easily and effectively nutrients can be absorbed and used by the body. High bioavailability means a supplement is easily absorbed. Thereafter, to be truly effective and functional, the bioavailability of a supplement must be higher as much as possible. Sometimes substances are just naturally well-received by body. Other times the bioavailability of active ingredients depends on the presence of "enhancers" (e.g., vitamin C with iron) and "inhibitors" (e.g., iron with zinc and vice versa). Also interactions with drugs would have an influence. New formulations also have a significant impact on bioavailability: some manufacturers use special, high-quality ingredients to enhance bioavailability or new delivery technology such as the system called ‘enteric coating’. This is a sort of barrier applied to capsule or tablet forming a protective coating that allows it to reach the intestines without being dissolved in the acidic environment of the stomach. After passing through the stomach the coating then disintegrates in the small intestine (duodenum) ensuring high percentage of bioavailability.

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