15 mark questions??? Flashcards
Nutritional Pharmacology
Nutritional therapists need to exercise caution when their clients are on certain groups of drugs. Explain the reasons for this and provide examples of groups of drugs where caution is needed, some of the key nutrient interactions and diets that may affect medications.
- Need to know drug side effects and interactions, find out all the clients prescription and OTC drugs
- why are they taking it?
- Duration?
- How often?
- Dose - Consider Narrow Therapeutic Index drugs (Digoxin, Warfarin, Lithium) - these can become toxic/ineffective at only slight changes in blood concentrations.
- Key nutrients to be cautious with:
- Garlic - statins and beta blockers and wafarin
- Ginkgo: avoid with anticoagulents (increased risk of bleeding)
- Grapefruit - CYP450 enzyme inhibition - can make certain drugs less effective and others more toxic (Digoxin, Statins)
- Pomegranate - similar to grapefruit
- Green leafy veg - increase the metabolism of warfarin (contain Vit K - reduces anti-clotting effect of warfarin / contain indoles that increase the metabolism of Warfarin)
- Soy - decreases levothyroxine and interferes with Tamoxifen
- Dairy - binds to antibiotics (take 4 hours apart)
Key diets to be cautious with:
- High protein diets - reduces L-dopa absorption and transport to the brain via the BBB)
- High fibre diets - can reduce serum levels of antidepressants (decreases intestinal absorption)
- Salt restriction - can increase lithium to toxic levels (salt involed in the active transport of lithium
Nutritional Pharmacology
Some medications can affect levels of nutrients in the body, discuss with examples.
- Statins: CoQ10 (blocks synthesis of precursor to cholesterol and CoQ10
- Antibiotics - destroy microbiome -
B vitamin-producing bacteria and vit K - therefore depplete B vits and K - Metformin - causes the malabsorption of B12 and B9
- Diuretics - cause increased urinary loss of Ca, Mg, K, folate and B vitamins, vitamin C also
- Antacids - reduced Hcl - reduces solubility and absorption of: Ca / Fe / Cr / Folate
- Thyroxine - increases bone turnover and depletes C
- OCP - has many nutrient depletion potentials:
- Reduces absorption
- Increases excretion
- Increases protein-binding and liver enzyme action
- Interferes with conversions to active forms
- Reduced liver storage of Vit A
- Reduced B12 protein binding
Nutritional Pharmacology
Your client has come to you with a list of several medications and is asking if they should stop some of these. How would you go about your nutritional consultation to ensure that you have all the information you need for your protocol to be safe and what recommendations would you give your client regarding stopping medication?
- OTC drugs - explain side effects and how they relate to a client’s signs/symptoms - remove any that provide no benefit/cause harm
- Get all the details of prescribed drugs:
- Name
- why taking
- Duration
- How often?
- Dosage - Got to the BNF and check side effects -talk through with client
- Always refer a client back to their GP for a conversation about reduction/coming off a medication - don’t not advise on this
Write a GP letter - list symptoms/timeline
- Never advise a client to abruptly stop any medication (PPI withdrawal)
Nutritional Pharmacology
Describes the various factors that can affect a drug’s pharmacokinetics and pharmacodynamics
Pharmacokinetics - factors affecting it:
A
Drug
Made
End
- Absorption:
- GIT motility / Diarrhoea
- Malabsorption - coeliac
- Competition - presence of other substances (Diary and Fe)
- Lipid soluable and small molecules - better absorbed
- Acid drugs - in an acidic environment
- Liquid over solid - Distribution:
- Plasma protein binding drugs - completion
- Drugs that bind to other tissues
- Blood brain barrier/placenta - barriers to distribution - Metabilism: Phase i and II liver detoxification
- Gentic SNPs
- Environment - high toxic load - Excretion: main routes: urine/faeces
- Renal dysfuntion
- Entero-hepatic circulation - lipid soluble metabolite reabsorbed
Pharmacodynamics - factors affecting it:
- Advancing age
- Genetic mutations
- Malnutrition
- Medical conditions (Parkinson’s/Alzheimers)
Nutritional Pharmacology
Outline your approach to supporting a client coming off a PPI medication after taking it for GORD (support with PPI withdrawal). What are the side effects of long term PPI use?
- What was the dose/duration of PPI use?
- rebound reflux (sudden withdrawal) - gradually reduce PPI (with GP support) - Remove triggers
- Tomato
- Coffee
- Fatty food
- Spicy food - Avoid:
- drinking with food
- overeating - 4 hour window between meals
- Elevate in bed
- Weight-loss
- Wear loose clothing
- Introduce
- Mg rich food
- B12
- Vit A
- Betaine HCL
- Bitters - Repopulate: probiotics
- Repair: Slippery Elm / Marshmallow
- Rebalance - stress
Detoxification & Nutrigenomics
How would you support a client’s phase II detoxification - include diet and lifestyle as well as any nutrients/co-factors
- Go organic
- Xenobiotics - minimise explosure
- Stop smoking
- Avoid caffeine
- Avoid chargrilled or smoked foods
- Eliminate alcohol
- Avoid uncecessary meds
- Avoid plastics
These increase phase II activity (may overwhelm Phase II)
Ensure adequate cofactors:
- B-complex (NB alcohol depletes Bs)
- B-vit rich foods: wholegrains, legumes, mushrooms, sunflower seeds, pistashios, eggs
- Branch chain AAs (‘LIV for the branch’: Leucine, Isoleucine, Valine)
Consider SNPs: CYP1A1 (oestrogen), CYP1A2 (caffeine), CYP2E1 (ethanol)
Detoxification & Nutrigenomics
Discuss 2 Phase I detoxification SNPs and how you would support a client who had these.
- CYP 1A1 - this SNP can reduce activity of the CYP 1A1 enzyme:
- oestrogen / PAHs / Solvents
Avoid
- charred meats
- smoking
- industrial pollutants
- Xeno-oestrogens
Include:
- Plant foods / phytonutrients
- Sulphur-rich foods
- Cruciferous vegetables (I3C / Sulphur)
- CYP 1A2 - metabolises caffeine - a SNP can cause SLOW caffein metabolism
- Avoid all caffein intake
- Caffeine>300mg/day is damaging to the brain
Detoxification & Nutrigenomics
Explain the role of glutathione in Phase I AND Phase II detoxification, the effects and risks of reduced levels in the body and how you would support a client to increase levels
A key antioxidant
1. Protects against reactive metabolites in Phase I
2. Glutathione conjugation in Phase II (added to a phase I metabolite to make it conjugated/less reactive)
- Cysteine: rate-limiting AA for synthesis (include food sources: eggs, legumes, sunflower seeds, chicken)
- Low levels: Neurodegeneration, Autoimmunity, CVD, liver disease.
- Glutathione binds to mercury - transports it out of cells and out of the brain (across the BBB)
Increase levels by:
1. Decrease toxic load and oxidative stress
2. Optimise sleep for melatonin
3. ALA - recycles glutathione
4. Milk thistle
5. NAC supplement
6. Glutathione lyposomal
7. Cruciferous veg (Glucosinolates boost Glutathione)
8. Cordyceps - increase production
9. Consider SNP: GSTM1 (absent gene?) - support oxidative stress reduction (rainbows, cruciferous, ALA)
Detoxification & Nutrigenomics
How would you support a client’s phase II detoxification - include diet and lifestyle as well as any nutrients/co-factors
- Support Nrf2 gene expression
Transcription factor protein that controls gene expression - key to regulating detoxification and production of endogenous antioxidants AND Promotes Phase II
- Phytonutrients regulate Nrf2 activity: turmeric / broccoli / garlic / green tea / lycopene / resveratrol
- Support all the conjugation pathways:
Ma’s gag!!!
- Methylation:
Methionine / B12 / B6 - Acetylation
B1/B5/Vit C - Sulphation:
sulphur-containing AAs: cysteine / methionine and sulphur rich foods.
Molybdenum - Glutathione:
AAs: cysteine, glycine, glutamine;
Se/B6/Zn - Amino Acid conjugation:
glycine-rich foods - Glucuronidation:
Turmeric
Detoxification & Nutrigenomics
How would you go about optimising elimination
- Remove alcohol / NSAIDs - damaging to the GIT
- Hydrate
- Lubricate: mucilage (flax, chia, psyllium)
- Increase fibre: soluble and insoluble - bulk and prebiotic
- Support mucosal barrier - bone broth/cabbage juice /slippery elm etc
- Support microflora
Detoxification & Nutrigenomics
Oestrogen metabolism
Explain the different pathways and issues with oestrogen metabolism and how you would optimise it
- Oestrogen liver genes/pathways
Phase I
- CYP1A1 - 2OH (neutral/beneficial)
- CYP1B1 - 4OH - DNA damage (quinones)
- COMT - methylation of 2OH and 4OH metabolites - Phase II: sulphation and glucuronidation (SNPs) SULT / UGT
- Raised beta-glucuronidase - e-coli/dysbiosis
4 Support:
- optimise gut flora
- Calcium D glucarate - inhibits betaglucuronidase
- Increase cruciferous veg (broccoli sprouts - IC3
- Increase fibre
- Avoid dairy / alcohol / caffeine
- Organics
- Avoid BPA
Detoxification & Nutrigenomics
Discuss detoxification support in a clinical setting including how to support clients with different fasting protocols, consider different client needs for e.g. a particularly depleted client.
- Castor Oil Pack - rincinoleic acid
- General support
- Reduce toxic load
- Assess GIT health - weed, seed, feed / mucosal health?
- Support elimination routes
- Food that support detox: brassicals / alliums/fibre
- Rainbows/phytos
- Proteins for conjugation (phase II)
- B vits - B12/folate
- Saunas - Water fast - 4 days
- Fasting mimicking diet for client with heavy toxic load
Discuss the role of glutathione in detoxification and how you might support it
- Antioxidant
- protects against reactive metabolites/intermediaries phase I
- Conjugation in Phase II - rate limiting AA - cysteine (legumes/Sunflower seeds/eggs)
- Low levels - CVD / neurodegenerative disease / autoimmunity
- Decreased with heavy toxic load (decrease toxic load
- Increase it:
- ALA - recycles it
- Milk thistle
- NAC - for cysteine
- Liposomal glutathione supplement
- Cruciferous veg - boost levels
- Cordyceps - boost levels
Assessment & Diagnostics
Functional testing - compare with conventional testing, provide pros and cons and how to interpret functional tests.
- Functional: focus on how body systems are functioning
Diagnostic: focus on diagnosing illness (markers)
- Pros of functional testing:
- Deeper understanding of imbalances
- Able to target a plan more
- Quantitative measure of progress - Cons of functional testing:
- Private
- Expensive
- Hard to interpret
- not diagnostic - GPs ot interested - interpretation
- snapshop in time - need CONTEXT
- look for patterns - correlation with symptoms/case history/diet of the client
- consider anything that could have skewed results
Assessment & Diagnostics
SIBO testing
Discuss the methodology of SIBO testing, including what is being analysed and the substrates used and any specific considerations/preparation to carryout before the test. What might be a positive result for SIBO?
- SIBO - fermentation of carbs in the SI: test looks at raised hydrogen and/or methane
- Breath test: take a subsrate
- lactulose
- Glucose
- Fructose
collect breath samples every 20-30 minutes for 90 mins in total.
Looking for a high presentation of gas BEFORE transition to LI
- Considerations: 24 hours before DO NOT eat microbiota-feeding foods
Allowable: eggs, meat, fish, plain steamed white rice, clear meat broth, fats/oils - Positive result
Hydrogen of over 20ppm before 90 mins
Methane of over 12 ppm before 90 mins
Combined of over 15 ppm before 90 mins
Assessment & Diagnostics
Vaginal microbiome
Your client has had a vaginal microbiome test done, what markers might you see if she is experiencing bacterial vaginosis and how might you go about supporting the vaginal microbiome?
- Markers for BV:
- pH - high >4.5 - indicates BV associated bacteria and dysbiosis (healthy acid pH is 3.8-4.5)
- Interleukin Beta-1 - elevated >220 - indicates BV (an inflammatory marker made when the epithelial cells break apart (infection)
- Lactobacilli - Low levels and too much diversity (no lactobacilli dominance)
- Support:
- Avoid soap
- Antibiotics and copper coil - avoid
- Avoid excessive simple carbs / alcohol / smoking
- No douching
- include vaginal probiotics
- Support oestrogen during menopause: flax, black cohosh
- Pre/probiotic foods
Assessment & Diagnostics
OAT
Discuss the benefits and downsides of organic acid testing and what markers you might look for. What clients might benefit from these tests?
OAT - benefits
- Overview of metabolic function
- Able to see any nutrient deficiencies
- Helps guide plan
- Highlights areas for further investigation
OAT - downsides
- Hard to interpret
- Diet can impact results
- not measuring the vitamin direction - metabolites only
Markers:
- nutritional function
- Krebs
- NTs
- Glycolysis
- Ketones and fatty acid oxidation
- detox
- amino acid metabolites
- Bacterial and mould metabolites
Clients might benefit:
- CFS
- Nut deficiencies
- Mito dysfunction
- Mood disorders
Herbal Medicine
Discuss the different applications of herbs (internal and external), how they are prepared and their pros and cons. Give examples of herbs/conditions for each application
- Infusions
- 2 tsp of herb as a tea/infusion x 3 daily
- Delicate flowers/leaves
- hydrating
- Good compliance (teas)
- Chamomile - tension - Decoctions
- 1 tsp dried herb per cup x 3
- Bring to boil than 15 mins simmer
- Roots / barks / fruits
- Extract water soluable phytochemicals
- Dandelion root - Syrups
- Make a decoction then add sugar or honey (2:1)
- 2 tsp x3 (children 1/2 tsp-1tsp)
- Coughs/Throat
- Sugar - T2DM / palatable for children
- Thyme syrup for coughs - Tinctures
- Steep herbs in mix of water and alcohol
- High extraction
- Concentrated
- Fast action
- Good compliance
- Long shelf-life (5 years)
- different strengths: 1:1 ‘fluid extracts’ - stongest
- Minimum 25% alcholol
- Adult dose 5ml x3
- Alcoholics and those who abstain for religious reasons
5.Glycerites
- gycerine - good if cannot consume alcohol
- Sweet taste - children
- Mouth and throat remedy
- Short shelf-life (3 months)
- laxitive
- Powders
- Food form/whole herb ingested - good assimilation
- Mucilaginous foods: slippery elm/marshmallow
- 1 tsp x2 - Standardised extracts
- active constituents - stronger
- Don’t have a balance of all phytochemicals
- resemble pharmaceuticals - side effects - Infused oils
- steeping herbs in oil
- Calendula / comfrey / garlic - Essential oils
- extracting volitile oils via distilation
- Highly concentrated
- Max 20 drops per 100g - Ointments/creams/lotions
- ointments: infused oils and beeswax/cocoa butter (thick/greasy - dry, cracked skin)
- Cream: infused oils with water and emulsifying wax - moisturising - skin issues, wounds
- Lotion: more water than creams - tin texture - cool hot, inflamed skin - poultice
- crushed herbs held in palce with a bandage
- Comfrey leaf - musularskeletal inflammation - fracture healing - Compress:
- herbal infusion/decoction soaked cloth
- calendula flower compress for skin conditions
Herbal Medicine
Discuss herbal medicine dosage guidelinees
- follow recommended dosage on product label
2.Dose: client age/weight/sensitive/chronic/acute?
- Teas - 2 tsp 3 x daily (1 tsp for roots/barks)
- Commercial teabags - 2 bags per cup x 3
- Age doage appropriate
- 2 years 1/16
- 4 years 1/8
- 6 years 1/4
- 9 years 1/2
- 12 years 3/4
- 14 years full adult dose OR 3/4 dose - Older people - lower immune/liver function
- 80 years 3/4
- 90 years 1/2
Herbal Medicine
Discuss herbal medicine safety, including herb-drug interactions and contraindications and how nutritional therapists should engage with herbal medicine.
herbal medicine safety
- Adverse effects
- Rare
- Sensitivities - salicylates
- photo sensitive - St John’s Wort
- GIT disturbance - diarrhoea
Don’t exceed therapeutic dose/reputable suppliers - Pregnancy/breadfeeding
- risk of birth defects (wormwood)
- Stimulate menstruation (yarrow)
- Stimulate evaculation (senna)
- Nursing mothers: phytochemicals can enter breastmilk (fennel OK for mild production)
- Safe herbs: German chamomile (relaxation/GIT antispasmodic) / Echinacea (immunity) / ginger (morning sickness) - herb-drug-nutrient interactions
- Additive herbs: garlic/turmeric - warfarin
- Antagnonistic herbs: St John’s wort CYP450 - speeds it up - drug clearance sped up
- Beneficial interaction: turmeric and NSAIDs - Always cross-check - ANP
- Narrow Therapeutic Index drugs - limits of competence
- Refer to a herbalist - cross-refer
