5-Nutrition

Question 1

All of the following are considered “shortfall nutrients,” meaning more than 25% of the US population does not have adequate intake, EXCEPT:

A) Fiber

B) Potassium

C) Vitamin C

D) Vitamin E

E) Saturated fats

Answer 1

E.
The food components that Americans get too much of are:
1. added sugars: candies, desserts and sugar sweetened beverages,
2. processed grains: white flour, white rice and white pasta,
3. cholesterol mostly from animal foods,
4. sodium: processed and packaged foods,
5. saturated fats: meats, dairy, eggs, processed foods and oils and
6. trans fat: hydrogenated plant oils, processed foods (trans fats are banned after 2018).

Answers A through D listed the shortfall nutrients: fiber, potassium, Vitamin C and Vitamin E, which are predominately found in nutrient-dense, whole, plant-based foods. Less than 9% of the US population consumes more than two cups of vegetables daily.

Question 2

The top five sources of saturated fats in the US include all of the following EXCEPT:

A) Cheese

B) Refined grain-based desserts

C) Dairy-based desserts

D) Chicken

E) Walnuts

Answer 2

E.
The top five sources of saturated fats in the US are: cheese, pizza, refined grain-based desserts, dairy desserts and chicken. Walnuts are high in polyunsaturated fats and low in saturated fats.

Question 3

Which statement is NOT TRUE about the clinical findings in the study, “Effects of a dietary portfolio of cholesterol-lowering foods versus Lovastatin on serum lipids and hypercholesterolemia,” by DA Jenkins et al, in the American Journal of Clinical Nutrition, 2006:

A) Diets that focus on low saturated fat and increased viscous fiber, plant sterols, vegetable protein and nuts appear to reduce low density lipoproteins (LDL-cholesterol) levels similarly to the initial therapeutic dose of a Lovastatin 20 mg (a first generation statin medication).

B) Study participants were able to lower their LDL cholesterol more than 50%, which is equal to the amount it would drop using a statin (cholesterol lowering medication).

C) Participants were randomized to one of three interventions: a very low saturated fat; a very low saturated fat diet plus Lovastatin 20 mg; or a diet that was high in plant sterols, soy protein, viscous fiber and almonds.

D) The Food and Drug Administration (FDA) now permits health claims that foods that deliver adequate amounts of plant sterols reduce the risk for coronary heart disease (CHD).

E) The portfolio diet group showed a reduction in the cardiovascular inflammatory marker c-reactive protein (CRP).

Answer 3

B.
Participants who ate the dietary portfolio of cholesterol-lowering foods, (plant sterols, soy protein, nuts and viscous fiber) were able to lower LDL-cholesterol concentrations >20%. This was statistically significantly compared to the control group and almost equal (no significant difference found) to the response to Lovastatin 20 mg, a first-generation statin medication.

Question 4

Which dietary intervention showed significant regression in coronary artery stenosis after one year of following a comprehensive lifestyle intervention that included: a low-fat vegetarian diet, smoking cessation, moderate exercise and stress management?

A) DASH Diet

B) Ornish Diet

C) Mediterranean diet

D) CHIP program

E) Walnuts

Answer 4

B. Ornish Diet

A. DASH Diet for hypertension: a combination of vegetables, low salt and low-fat dairy, which has been found to be adequate first-line treatment for essential hypertension.

B. The Ornish diet for coronary artery disease (CAD): a low-fat, plant-based diet reversed coronary artery disease stenosis in one year and maintained reversal at the five year follow-up.

C. Mediterranean diet for secondary prevention of coronary artery disease: the Mediterranean diet was found to be superior to a prudent Western diet in preventing recurrence of coronary artery disease events.

D. CHIP program and diet for diabetes: The CHIP multifactorial lifestyle intervention was effective in treating type 2 diabetes.

E. Walnuts for hyperlipidemia and hypertension: adding a daily serving of walnuts to ad libitum diet (as you desire) showed effectiveness in lowering serum cholesterol.

Question 5

All of the following are TRUE in regard to nutrition and physical activity prescriptions EXCEPT:

A) The US Preventative Services Task Force (USPSTF) recommends that nutrition and physical activity counseling for people who are overweight and have chronic disease is intensive and focused on specific behavioral interventions.

B) Patients receiving physical activity prescriptions and advice from their health care provider increased their exercise by 18 minutes per week.

C) Nutrition prescriptions are believed to be helpful in changing patients’ behavior toward food.

D) Nutrition prescriptions can be written for prevention and treatment for multiple chronic diseases, such as diabetes and heart disease.

E) Nutrition prescriptions are not one of the 15 Physician Competencies for Prescribing Lifestyle Medicine.

Answer 5

E.

Nutrition prescriptions are one of the 15 Physician Competencies for Prescribing Lifestyle Medicine.

Question 6

The SMART Basic Nutrition Prescription Guidelines include all of the following EXCEPT:

A) A specific type of food.

B) Realistic goals of budget, time and foods available.

C) Achievable and attainable goals for who will be doing the cooking and shopping.

D) Time commitment for the prescription (frequency and duration).

E) The role of the physician or medical provider.

Answer 6

E. The SMART acronym for nutrition prescriptions includes:
Specific type of foods.
Measurable, meaning how much of the food.
Achievable/attainable goals for who will be doing the cooking and the shopping.
Realistic goals for what food is available, the budget, time commitment and what will the patient actually do.
Time connected, meaning what is the frequency for eating the food, and for what duration of time is the prescription written.

The doctor or health care provider’s roles are not part of the patient’s written prescription.

Question 7

All of the following are true about the macronutrient fat EXCEPT:

A) Poly-unsaturated fats include omega 3s and omega 6s.

B) Mono-unsaturated fats include nuts, avocado, olive oil and canola oil.

C) Saturated fats include lauric acid, stearic acid, palmitic acid and myristic acid.

D) The largest source of saturated fats in the American diet is cheese.

E) Trans fats made from partially hydrogenated vegetable oil are not associated with increased risk of heart disease.

Answer 7

E.
Trans fats are associated with increased risks of heart attacks and strokes. Starting in 2018 in the US, trans fats are no longer allowed to be used by the food industry.

Question 8

All of the following statements about dietary fiber are true EXCEPT:

A) The best sources of fiber are found in meat and dairy products.

B) Women should consume at least 25 grams of fiber daily.

C) Men should consume at least 38 grams of fiber daily.

D) Fiber has been shown to decrease the risk of colon cancer.

E) Fiber is not digested, and it increases stool bulk and viscosity.

Answer 8

A.
The best sources of fiber are legumes, whole grains, vegetables, fruits, nuts and seeds. Meat and dairy products do not contain fiber.

Question 9

Which of the following food groups DO NOT increase inflammatory markers?

A) Foods fried in oils.
B) Salad dressings and spreads made from hydrogenated oils.
C) Breads made with lard or butter.
D) Cruciferous vegetables.
E) High glycemic index processed grains.

Answer 9

D. Cruciferous vegetables.

Anti-inflammatory foods include all of the following:
Cruciferous vegetables (broccoli, cauliflower and Brussels sprouts)
Cabbage and bok choy
Dark berries and fruits
Allium vegetables
Carotenoids
Dark green leafy vegetables

Question 10

Advanced Glycation End-Products (AGEs) are a family of oxidative stressors found in proteins and glucose that cause inflammation and cell damage. Certain types of food preparation can increase the AGEs. The best way to prepare food in order to decrease the amount of AGEs produced is:

A) Smoking

B) Roasting

C) Frying

D) Boiling

E) Grilling

Answer 10

D.
Foods that are fried, smoked, grilled, baked or roasted have higher AGEs. Foods that are prepared with moist heat cooking, such as boiling, stewing and broiling, have fewer AGEs.

Question 11

Reducing the intake of what micronutrient will decrease the risk of hypertension:

A) Calcium

B) Magnesium

C) Sodium

D) Potassium

E) Vitamin C

Answer 11

C.
Sodium restriction typically reduces blood pressure by 2.5 to 7 mmHg. According the American Heart Association, the ideal limit of sodium should be less than 1.5 grams daily, with the upper limit being 2,300 mg daily. The largest sources of sodium in the US are processed foods and canned foods.

Question 12

Which of the following statements about type 2 diabetes is FALSE?

A) Higher fiber intake reduces the risk of diabetes.

B) Processed sugars like syrup, malt and fruit concentrate can increase blood sugar levels.

C) Artificial sweeteners create dysbiosis, which can alter weight control.

D) Processed grains have a higher glycemic index.

E) Aggressive therapeutic lifestyle changes cannot decrease or reverse diabetes.

Answer 12

E.
Type 2 diabetes is generally a reversible disease with aggressive therapeutic lifestyle changes, such as: reducing dietary saturated fats, trans fats, processed sugars and processed grains; eliminating artificial sweeteners; and increasing daily exercise.

Question 13

All of the following are TRUE about cancer and diet EXCEPT:

A) Anti-cancer nutrition goals include: support the immune system, decrease inflammation, and eat real food, not supplements.

B) Foods high in saturated fats, foods high in sugar, and processed and red meat increase the risk of colon and breast cancer.

C) Obesity increases the risk of breast cancer.

D) Prostate cancer risk is decreased with the consumption of red and processed meats.

E) Antioxidant-rich foods, such as carrots, berries, nuts and green leafy vegetables, decrease the risk of cancer.

Answer 13

D.
The risk of breast, colon and prostate cancer are increased with the consumption of red meat, processed meat, highly processed grains, added sugars, high saturated fats and trans fats.

Question 14

Which one of the following statements best describes a situation with ZERO risk of developing heart disease from hypercholesterolemia?

A) Trans-fatty acid consumption is associated with an increased risk of heart disease.

B) A whole food, plant-based diet, as demonstrated in the Lifestyle Heart Trial, produces regression of plaque stenosis and reduction in cholesterol.

C) A decrease in HDL may occur with a plant-based diet, but the ratio of the drop of LDL compared to HDL still provides a benefit.

D) If the serum total cholesterol is 90 to 140 mg/dl (2.327 - 3.620mmol/L), and the LDL is less than 70 mg/dl (1.810mmol/L), there is no evidence of atherosclerotic plaque formation or risk of heart disease.

E) Eating an omnivorous diet decreases the risk of heart disease.

Answer 14

D.
Facts learned from 2013 Baylor University Conference: If the serum total cholesterol is 90 to 140 mg/dl (2.327 - 3.620mmol/L), there is no evidence that cigarette smoking, systemic hypertension, diabetes, inactivity or obesity produces atherosclerotic plaques. Hypercholesterolemia is the only direct atherosclerotic risk factor, the others are all indirect. Optimal LDL is 50 to 70 mg/dl (1.293 - 1.810mmol/L). Plaque progression ceases with total cholesterol < 150 mg/dl (3.879mmol/L).

Question 15

The Diabetes Prevention Program (DPP) trial was the first major study to compare lifestyle intervention to medications to prevent diabetes. All are true about the DPP trial EXCEPT:

A) Metformin showed a 31% reduction in developing diabetes.

B) Lifestyle intervention showed a 58% reduction in the incidence of diabetes.

C) The two major goals of the lifestyle intervention were a 7% weight loss and 150 minutes weekly of physical activity similar to brisk walking.

D) Participants were placed on a strict diet.

E) Behavioral and self-management strategies for weight loss and physical activity were taught to participants.

Answer 15

D. Participants were not placed on a strict diet.
Rather, they were encouraged to gradually achieve the fat and calorie levels through: better choices of meals and snack items; healthier food preparation techniques; and careful selection of restaurants, including fast food and the items offered. The initial focus of the dietary intervention was on reducing total fat rather than calories. This allowed participants to accomplish a reduction in caloric intake while at the same time emphasizing overall healthy eating. It also streamlined the self-monitoring requirements, which was important given the diversity of educational and literacy levels among participants. After several weeks, the concept of calorie balance and the need to restrict calories as well as fat was introduced.

The calorie goals were calculated by estimating the daily calories needed to maintain the participant’s starting weight and subtracting 500 to 1,000 calories per day (depending on initial body weight) to achieve a one to two pound per week of weight loss. The fat goals, given in grams of fat per day, were based on 25% of calories from fat. Four standard calorie levels were used: 1,200 kcal per day (33 grams fat) for participants with an initial weight of 120 to 170 lbs; 1,500 kcal per day (42 grams fat) for participants with a weight of 175 to 215 lbs; 1,800 kcal per day (50 grams fat) for participants with a weight of 220 to 245 lbs; and 2,000 kcal per day (55 grams fat) for participants weighing >250 lbs. The fat and calorie goals were used as a means to achieve the weight loss goal rather than as a goal in and of itself. Therefore, if a participant reported consuming more than the calorie or fat goal but was losing weight as planned, the coach did not emphasize greater calorie or fat reduction.

*Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. Knowler et al. N Engl J Med. 2002 Feb 7;346(6):393-403.

Question 16

The pathogenesis of diabetes is best described as:

A) Insulin resistance in muscle facilitates the development of fatty liver. Increased fatty acids produced by the liver damage pancreatic beta cells, suppressing glucose-mediated insulin secretion, and leading to hyperglycemia.

B) Muscle insulin resistance determines the rate at which fatter liver digresses.

C) Eventually the pancreas is unable to produce sufficient amounts of leptin to push glucose into the cells, so serum glucose levels rise.

D) Loss of sensitivity to insulin causes a decrease in adipose tissue and leptin levels.

E) Increasing caloric intake in the early stages of insulin resistance can reverse the disease process.

Answer 16

A.
Insulin resistance begins to occur as inflammatory mediators cause damage to liver and beta cells and as muscle and adipocyte cells begin resisting further fat storage. Adipocytes are key factors in the development of insulin resistance. As weight gain occurs, adipocytes undergo hyperplasia and hypertrophy (that is, they grow in number and in size) and begin accumulating in ectopic tissues, such as the liver and muscle cells. Intramyocellular fat accumulation disrupts insulin receptors via production of lipotoxic mediators, causing insulin resistance. Muscle insulin resistance determines the rate of fatty liver progression. Fatty liver progression and the deposit of fatty acids in pancreas are responsible for the rate of hepatic insulin resistance (failure to appropriately respond to blood glucose levels) and beta cell dysfunction.

Question 17

Which is NOT considered a current trend in US food consumption:

A) 40% of food consumption comes from processed foods.

B) 25% comes from animal-based foods.

C) 6% comes from processed plant-based foods.

D) 6% comes from unprocessed vegetables, fruits, legumes, grains, nuts and seeds.

E) The current US average intake of sugar is 13% of calories per day or about 13 teaspoons (52 grams) of sugar per day.

Answer 17

A.

63% of US food consumption comes from processed foods with added fats, oils, sugars and refined grains.

Question 18

Epigenetics are the non-DNA sequence components of genetic inheritance. Key epigenetic influencers are:

A) Diet and lifestyle

B) Sleep deprivation

C) High fat diets

D) Hyperglycemia

E) All of the above

Answer 18

E.

Diet, exercise, sleep, obesity and hyperglycemia are able to up-regulate or down-regulate gene expression

Question 19

The outcome of the The Nurse’s Health Study Eight-Year Follow-Up showed:

A) Meat-eating Adventists compared to non-meat-eating Adventists showed a 97% increased risk for diabetes in men and a 93% increased risk in women.

B) Every 5% increase in calories from animal protein resulted in a 30% increase in risk of diabetes.

C) People who ate a plant-based diet that specifically emphasized healthy plant-based foods had ~34% lower risk of diabetes. Whereas, plant-based diets that were high in less healthy plant foods (such as processed foods) had a 16% increased risk for diabetes.

D) HgbA1c dropped more than three times for participants on a plant-based diet compared to participants on the American Diabetic Association diet (ADA).

E) Consuming processed meat more than five times per week was associated with an increased risk of type 2 diabetes.

Answer 19

E.
The Nurses’ Health Study Eight-Year Follow-Up showed that the consumption of processed meat greater than five times weekly increased the risk of diabetes.

The Adventist Health Study showed regular meat consumption was associated with two times greater risk of diabetes. Among meat eating Adventists compared to non-meat eaters, there was a 97% increased risk of diabetes in men and 93% increased risk in women.

The EPIC study showed that for every 5% of calories consumed from animal protein, there was a 30% increase in diabetes.

The National Institutes of Health (NIH) study compared a plant-based diet to the American Diabetes Association diet (ADA). It found that participants following the plant-based diet dropped their HbA1c three times more, decreased their LDL cholesterol twice as much, lost more weight and had greater reductions in medications.

Data from three large cohorts (Nurses’ Health Study 1984-2012, Nurses’ Health Study 1991-2011, Health Professionals Follow-up Study 1986-2010) found the type of plant-based diet is important in diabetes risk. A plant-based diet that specifically emphasized healthy plant-based foods had ~34% lower risk of diabetes. Whereas, plant-based diets that were high in less healthy plant foods (such as processed foods) had a 16% increased risk of diabetes.

Question 20

A positive patient prescription for foods to increase in one’s diet include all the following EXCEPT:

A) Eat seven different colors of fruits and vegetables per day.

B) Increase fiber intake to more beneficial levels: 40 grams per day for women, and 45 grams per day for men.

C) Vitamin D intake of: 600 IUs daily for people age one to 70 years old, and 800 IUs daily for people over 70 years old.

D) Consume at least half of your grain intake as whole grains.

E) Limit trans fats as much as possible.

Answer 20

E.
Limiting trans fat intake as much as possible is an example of a negative food prescription. Negative food prescriptions are usually not as well received and should be cautiously prescribed. Generally, adding in healthy foods is easier to accomplish then limiting unhealthy foods.

Question 21

According to the 2013 American College of Cardiology (ACC)/ American Heart Association (AHA) Guidelines on the Assessment of Cardiovascular Risk, the “A” recommendations include all of the following except:

A) Reduce the percent of calories from saturated fat to less than 5 to 6% of daily calories.

B) Eliminate trans fats in the form of processed foods and animal proteins.

C) Consume a dietary pattern that emphasizes intake of unprocessed vegetables, fruits and whole grains (e.g., DASH, whole foods, plant-based or Mediterranean).

D) Reduce the total caloric intake from fat to less than 10% of the total daily intake.

Answer 21

D.
Although Dean Ornish, MD has found that reversing coronary artery stenosis requires the total daily caloric intake from fat to be less than 10% of the total daily intake, that’s not one of the American College of Cardiology (ACC) / American Heart Association (AHA) guidelines.

Question 22

Which of the following is incorrect about weight maintenance:

A) When calorie content is held constant, there is little to no evidence that food groups or beverages have a unique impact on body weight.

B) There is moderate evidence that increasing whole grains, vegetables and fruits may protect against weight gain.

C) There is little evidence that children who consume more sugar-sweetened beverages have higher body weights.

D) There is moderate evidence that adults who consume sugar-sweetened beverages have higher body weights.

Answer 22

C.

There’s strong evidence that children who consume sugar-sweetened beverages have higher body weights.

Question 23

All of the following are true of epigenetics (mechanisms that control gene expression), EXCEPT:

A) They can be altered by lifestyle changes to improve short- and long-term clinical outcomes by changing gene expression.

B) Epigenetics is unaffected by diet, exercise, sleep and stress.

C) The ability of lifestyle change to turn on or off genes was demonstrated in prostate cancer outcomes by Dean Ornish, MD in the GEMINAL study.

D) The GEMINAL study demonstrated down-regulation of oncogenes that are known to promote prostate cancer.

E) The GEMINAL study demonstrated an up-regulation of cancer-fighting genes.

Answer 23

B. All of the above are correct except B.

Epigenetic changes can all be induced by diet, exercise, sleep, stress, obesity and many other environmental factors.

Question 24

Regarding the prevalence or risk of developing diabetes, all of the following are true EXCEPT:

A) There is an 80% higher prevalence of diabetes in men who consume meat versus those who don’t.

B) For non-vegetarians, the age-adjusted risk of diabetes (as noted on death certificates) was the same for males and females.

C) Consuming more than five eggs per week was associated with an increased risk of developing diabetes.

D) Diabetes risk increased significantly as total protein intake increased.

E) None of the above; all statements are true.

Answer 24

B.
Compared with vegetarians, the relative risk of diabetes on the death certificate, adjusted only for age, was 2.2 (1.5, 3.4) for male non-vegetarians and 1.4 (1.0, 1.9) for female non-vegetarians. [188] During 10 years of follow-up, 918 incident cases of diabetes were documented. Diabetes risk increased with higher total protein (hazard ratio 2.15 [95% CI 1.77 to 2.60] highest versus the lowest quartile) and animal protein (2.18 [1.80 to 2.63]) intake. Adjustment for confounders essentially did not change these results. Further adjustment for adiposity measures attenuated the associations. Vegetable protein was not related to diabetes. Consuming 5% energy from total or animal protein at the expense of 5% energy from carbohydrates or fat increased diabetes risk. Diets high in animal protein are associated with an increased diabetes risk. Our findings also suggest a similar association for total protein itself instead of only animal sources. In this study, high total and animal protein intake, but not vegetable protein intake, was associated with increased diabetes risk. We observed that both high total and animal protein were associated with higher diabetes risk. Fat intake did not change much over the quartiles of protein intake, and the association was not altered after correction for fat intake. Moreover, after correction for meat or dairy intake, the association between total and animal protein and diabetes remained, suggesting a detrimental role for protein per se in diabetes risk.

Question 25

Developing practical strategies for assisting patients with dietary changes begins with a discussion about the role of nutrition in their current conditions and in preventing future conditions. Which of the following is a recommended step for providers to help patients adopt healthy dietary changes?

A) Formally track all of the patient’s meals and beverages for one month.

B) Provide advice to eat at least two servings per day of fruit and at least two servings per day of vegetables.

C) Offer nutrition prescriptions for specific foods that promote health.

D) Ask the patient to check weight once a week.

E) All of the above are recommended steps.

Answer 25

C.
Positive food prescriptions can help patients focus on including nutrient-dense, low-calorie foods like fruits, vegetables, whole grains and legumes rather than focus on caloric restriction. Though patients who regularly track food intake on their own show higher rates of weight loss, this is very tedious to complete. Usually, formal tracking of all the patient’s meals and beverages for one month would be too time consuming to complete and review in a provider visit. A three-day food log or 24-hour recall may be options that could be completed within the time of a visit. Most studies show a benefit from eating more than five servings of fruits and vegetables a day, with increasing benefits with more servings. Weight checks can be helpful for weight maintenance, but they may cause patient to focus more on meeting a number instead of forming healthy habits and behaviors.

Question 26

For 20 diabetic men who changed to a low-fat, high-fiber near-vegetarian diet, insulin use was discontinued in eleven patients, and insulin dose decreased in the other 9 men within:

A) Weeks, independent of weight loss.

B) Months, independent of weight loss.

C) Weeks, but only if weight was lost.

D) Months, but only if weight was lost.

E) Days, but only if weight was lost.

Answer 26

A.
Researchers tested the effect of a low-fat, high-carbohydrate (9% of energy from fat, 70% from carbohydrate) near-vegetarian diet containing 65 grams of fiber and 65 grams of cholesterol per day. Participants were 20 normal-weight men with insulin-treated type 2 diabetes, and it was a 16-day trial. Energy intake was individualized to prevent changes in body weight. By the end of the study period, insulin use was discontinued in 11 participants and, in the rest of the participants, it was reduced from a mean of 26 to 11 units per day (P < 0.001). Despite this reduction in medication use, mean fasting plasma glucose concentration still decreased from an average of 164 mg/dL to 152 mg/dL (amount decreased was not significant).

Question 27

In results from the Adventist Health Study-2 among white subjects, a dose-dependent drop in blood pressure was noted as diets became more plant-based. Which of the following is true regarding this dose-dependent effect?

A) Blood pressure-lowering effects occurred in those with a BMI of > 25 for systolic blood pressure only.

B) After adjusting for age and gender, vegans and lacto-ovo-vegetarians had significantly lower blood pressure compared to omnivores.

C) Blood pressure-lowering effects were different for individuals consuming alcohol.

D) Adjustment for BMI resulted in reversal of the dose-response blood pressure-lowering effect for vegans, lacto-ovo and partial vegetarians.

E) None of the above are true.

Answer 27

B.
For BMI of <18 to >32, there is a linear association with blood pressure, from lowest to highest for both systolic and diastolic. Adjusted for age and gender, significantly lower blood pressure was found in non-treated vegans and lacto-ovo-vegetarians compared to omnivores. Adding alcohol intake to the models studied did not identify an alcohol effect, however alcohol intake was infrequent and small. For vegans, lacto-ovo vegetarians and partial vegetarians, effects were reduced (but not reversed) after adjustment for BMI.

Question 28

A study by Pierce JP, et al. assessed whether fruit and vegetable intake and physical activity in obese women affected breast cancer survival. This study demonstrated that:

A) Within all fruit and vegetable intake and physical activity level categories, women who were obese had apparent increased mortality compared with those who were not obese.

B) Compared to non-obese sedentary women with low fruit and vegetable intake, obese women in the same category had greater chances of survival.

C) Mortality of physically active obese women consuming high amounts of fruits and vegetables was similar to that of non-obese, physically active women consuming high amounts of fruits and vegetables.

D) Mortality rates were highest for obese and non-obese physically active women consuming low amounts of fruits and vegetables

E) None of the above.

Answer 28

C.
The study found women who were obese but had high levels of physical activity (≥ 540 MET-min/wk) and ate high amounts of fruits and vegetables daily (>5 servings per day) had the same mortality rates as women who were not obese but also had high physical activity and high fruit and vegetable intake. [Pierce et. al. Greater survival after breast cancer in physically active

Question 29

In the course of development of diabetes, the insulin resistance in muscle facilitates the development of fatty liver during positive energy balance. Which of the following statements regarding the major pathophysiological abnormalities involving insulin is incorrect:

A) Fatty liver causes resistance to insulin suppression of hepatic glucose output.

B) Fatty liver insulin resistance results in raised plasma triacylglycerol.

C) Exposure of beta cells to increased levels of fatty acids (derived from circulating and locally deposited triacylglycerol) suppresses glucose-mediated insulin secretion.

D) Insulin resistance seen in muscle immediately decreases following achievement of normoglycemia.

E) None of the statements are incorrect; all are true.

Answer 29

D.
Normoglycemia can be achieved as part of the normal physiologic process of a functioning pancreas and liver and of responsive muscle and adipose cells or through medications, exercise or lifestyle changes. Medication use will not reverse the cause of muscle resistance. Although changing to a whole food, plant-based diet can improve insulin resistance, this effect can take several days to several years and is not instantaneous with achievement of normoglycemia.

[Weickert. Impact of Dietary Fiber Consumption on Insulin Resistance and the Prevention of Type 2 Diabetes. J Nutr. 2018;148(1):7-12.]

Question 30

Epigenetic modifications provide a mechanism by which external environmental factors can modify genetic predisposition for health and disease. Which of the following statements is incorrect?

A) Epigenetics influence gene transcription and subsequently organ function.

B) Epigenetics could be involved in age-related and lifestyle-related diseases, such as type 2 diabetes.

C) Only maternal nutrition during pregnancy contributes to epigenetic programming of the risk for future diseases.

D) DNA methylation in humans is influenced by diet, birth weight and exercise.

E) None; all of these are correct.

Answer 30

C.
Environment in utero is a significant contributor to epigenetic programming. A substantial component of metabolic disease risk has a prenatal developmental basis with greater methylation of RXRA chr9:136355885+ measured at birth being strongly correlated with greater adiposity in later childhood. Novel research demonstrated that paternal nutrition and lifestyles during the peri-conceptional period also contribute to the offspring’s epigenetic programming and risk of future diseases. “One link between environment and disease is epigenetics influencing gene transcription and subsequently organ function. We have previously shown that epigenetic modifications may accumulate during aging, and that DNA methylation in humans is influenced by diet, birth weight, and exercise, suggesting that epigenetics could be involved in age-related and life style–related diseases such as Type 2 Diabetes. Indeed, studies from our group and others have identified epigenetic modifications in patients with Type 2 Diabetes.”

[Duhl et al. Neomorphic agouti mutations in obese yellow mice. Nat Genet. 1994;8(1):59-65.]

Question 31

Find the three dietary components that increase total blood cholesterol levels, and order them from the most to the least damaging in terms of increasing blood cholesterol:

a) Dietary cholesterol
b) Polyunsaturated fats
c) Saturated fats
d) Egg whites
e) Trans fats
f) Insoluble fiber

A) Dietary cholesterol > saturated fats > trans fats

B) Trans fats > saturated fats > dietary cholesterol

C) Trans fats> dietary cholesterol > egg whites

D) Saturated fats > trans fats > egg whites

E) Saturated fats > poly unsaturated fats > dietary cholesterol

Answer 31

B. Trans fats are the most damaging fats and are formed by adding hydrogen to liquid vegetable oils to make them solid. Trans fats also occur naturally in meat and dairy products. They are known to increase LDL cholesterol and lower HDL cholesterol, increasing risk for heart disease. Saturated fats come mainly from meat and dairy products. Plant foods that contain saturated fats include coconut, coconut oil, palm oil and cocoa butter. The American Heart Association recommends keeping the amount of saturated fat in the diet to less than 5 to 6% of total daily calories. The 2015 Dietary Guidelines no longer include a recommendation to limit dietary cholesterol to less than 300 mg a day. But the guidelines acknowledge this does not mean dietary cholesterol should not be limited, as diets lower in dietary cholesterol are associated with lower risk of heart disease and obesity. Of note, foods high in dietary cholesterol are mainly higher in saturated fats, except those egg yolks and shell fish that are high in cholesterol but low in saturated fat. [2015 USDA Guidelines, https://health.gov/dietaryguidelines/2015/guidelines/chapter-1/a-closer-look-inside-healthy-eating-patterns/.]
Poly unsaturated fats may help improve blood cholesterol levels, especially if they are used to replace saturated and trans fats. Egg whites do not contain any fat or dietary cholesterol. Insoluble fiber is a carbohydrate, and that may help lower cholesterol levels by not allowing it to be reabsorbed in the colon.

Question 32

The leading source of saturated fat in the American diet is:

A) Beef

B) Chicken

C) Eggs

D) Cheese

E) Meat

Answer 32

D. Cheese.
Foods that are high in saturated fat (more than 8 grams of saturated fat per serving) include higher fat cuts of beef, pork and lamb, salami, sausages and other processed meats, many fast foods (e.g., cheeseburgers), coconut and coconut oil. Cheese is moderately high in saturated fat with 4 to 7 grams per serving, but it’s consumed in high quantities, making it the number one source of saturated fat in the US

Question 33

Which of the following statements are true?

a) Insoluble fiber is mostly found in legumes, fruits and oats.
b) Plant foods contain more than 100,000 phytochemicals associated with protection against major chronic diseases. Animal products contain no phytochemicals.
c) Macro-nutrient profiles influence the micro-nutrient density.
d) It’s difficult to find atherosclerosis or coronary heart disease in societies with total blood cholesterol levels below 150 mg/dL (3.879mmol/L).
e) The best way to lose weight is to outline a daily 60-minute exercise program and do it with a partner!

A) All statements are true.

B) Only statements b, c and d are true.

C) Only statements a, b and d are true.

D) Only statements c and e are true.

E) None of the statements are true.

Answer 33

B.Only statements b, c and d are true.
Insoluble fiber is mainly found in vegetables, wheat, wheat bran, nuts and seeds. Legumes, fruits and oats are high in soluble fiber (Answer A). Phytochemicals are only produced by plants (Answer B). Foods should be viewed as “packages,” not as sources of individual nutrients. Therefore, in a food “package” the macronutrient profiles of fat, carbohydrate and protein influence the micronutrient density. A food package of steak will be high in protein and saturated fat and low in antioxidants. Leafy green vegetables will be high in carbohydrates, have some protein, be low in fat and contain high amounts of vitamins and minerals. (Answer C). When total dietary cholesterol is less than 150, progression of plaque development in blood vessels appears to cease even in the presence of other risk factors like smoking, hypertension, obesity and diabetes (Answer D). Exercise is great for maintenance of weight loss, but caloric restriction must be included weight loss (Answer E).

Question 34

Match the listed diets with documented main outcomes. (Diets can have more than one match). Please sort the answers in order from 1-4 to match the diet listed below.

1. Dash diet
2. Esselstyn diet
3. Ornish diet (+lifestyle intervention)
4. Portfolio diet

A) Reduced hypertension

B) Regression of coronary artery disease and atherosclerosis and coronary event rate was 100 times higher over four years in those who did not adhere versus those who did.

C) Regression of coronary artery disease and atherosclerosis, Telomere length increased, and Inhibition of prostate cancer cells

D) As effective in lowering LDL cholesterol as statin

Answer 34

Reduced hypertension
1. Dash diet

Regression of coronary artery disease and atherosclerosis and coronary event rate was 100 times higher over four years in those who did not adhere versus those who did.
2. Esselstyn diet

Regression of coronary artery disease and atherosclerosis, Telomere length increased, and Inhibition of prostate cancer cells
3. Ornish diet (+lifestyle intervention)

As effective in lowering LDL cholesterol as statins
4. Portfolio diet

Question 35

Mechanisms that influence endothelial lining integrity include:

a) Diminishment in nitric oxide.
b) Tri methyl amines oxides (TMAO).
c) Diminishment of endothelial progenitor cells to replace senescent injured endothelial cells.
d) Absence of intestinal bacteria in vegans, which disables the production of pro-atherogenic TMAO.
e) The presence of intestinal bacteria in the gut of omnivores can turn the lectin and carnitine found in red meat, chicken and fish into pro-atherogenic TMAO.

A) All statements are true.

B) Only statements a and e are true.

C) Only statements a, b and e are true.

D) Only statements b and e are true.

E) None of the statements are true.

Answer 35

A. All statements are true.

All of these mechanisms have been shown to impact endothelial integrity.

Question 36

Which of the following statements are TRUE?

a) The World Health Organization (WHO) declared red meat a group 1 human carcinogen.
b) Coconut oil has been shown to reduce Alzheimer’s disease.
c) Ground up flax seed is an excellent source of omega 3 fats.
d) A more optimal daily dietary fiber content would be 45 to 55 grams (almost twice the recommended amount).
e) A simple way to select low sodium foods is to use a product where the number of milligrams of sodium listed on the label is it not higher than the numbers of calories listed per serving.

A) All statements are true.

B) Only statements a, c, d and e are true.

C) Only statements c, d and e are true.

D) Only statements b and e are true.

E) None of the statements are true.

Answer 36

C. Only statements c, d and e are true.
The World Health Organization (WHO) has not declared red meat a group 1 carcinogen, but it was labeled as group 2A. This means it’s probably carcinogenic to humans, but insufficient evidence exists to rule out chance or bias as the cause. Processed meats have been labeled group 1, meaning they are carcinogenic to humans. Coconut oil has not been shown to reduce Alzheimer’s disease. The other statements are true.