Cancer Flashcards
cancer is the second leading cause of death in developed countries, after heart diseases and CVD. true or false
False, it is THE leading cause of death
what is the main cause of cancer? through which evidence?
environmental factors including diet is a large part of the cause of cancer. this is seen through the differences in cancer prevalence worldwide ad changes in prevalence among population that migrate
which factors interact which can cause cancer development
interactions between genetics, endogenous milieu [hormones and oxidation] and exogenous exposures
nutritional factors may contribute to about ____ of tumors
30%
what is the most important risk factor for developing cancer
age
what is the most prevalent type of cancer in men? and in women?
- prostate cancer
- breast cancer
which is the most deadliest type of cancer in men? and in women?
lung cancer for both
cancer definition
uncontrolled growth of abnormal cells in the body
characteristics of cancerous cells (7)
- escape normal growth signals
- can replicate indefinitely, can form tumors
- can avoid programmed cell death (apoptosis)
- cal alter energy metabolism
- can avoid immune surveillance
- can invade other tissues (metastasis)
- can develop a blood supply (angiogenesis)
what are benign tumors
they are non cancerous, do not invade and metastasize
what are the steps involved in carcinogenesis
activation/initiation of cell due to chemical/radiation/virus exposure -> genetic change -> initiated cell -> selective clonal expansion -> preneoplastic lesion -> genetic change-> malignant tumor -> genetic change -> clinical cancer -> genetic change -> cancer metastasis
what are the effect of chemical/radiation/virus exposure on cell nucleus
- activation of potooncogenes
- inactivation of timor-suppressor genes
- inactivation of genomic stability genes
what causes selective clonal expansion
- defects in terminal differentiation
- defects in growth control
- resistance to cytotoxicity
- defects in programmed cell death
what is epigenetics and its role in cancer
factors happening between genotype and phenotype that will affect gene structure, function and expression [DNA methylation, acetylation of the histones] - they include environmental factors including nutrition [promote or suppress risk of cancer[
the inherited genetic mutation involving BRCA1 gene increases risk of ____ and ____ cancer
breast and ovarian cancer
_____ of the promoter region of Timor suppressor genes causes its silencing
hypermethylation [epigenetic change]
what is nutritional genomics and proteomics
interactions between diet and genes and their products [ie. proteins]
carcinogens found in foods, PUFA, and iron can cause ____
oxidative damage to DNA
_______ or ____ can decrease oxidative damage to DNA
antioxidant nutrients (vitamin C and E) or cofactors in antioxidant enzymes (selenium, copper)
there is a direct role of ____ in DNA synthesis, repair and methylation
folate
____ found in green tea, apples and chocolate and ____ affect gene expression in cell culture
catechizes and flavonoids
what are the effects of bioactive food compounds [nutrients, natural components, contaminants] on carcinogenesis
DNA repair, cell differentiation, hormone regulation, carcinogen metabolism, inflammatory response, apoptosis, cell growth cycle
___, ___ and ___ account for 30% of all cancers
tobacco and diet and obesity
what does “incidence of cancer cases” refer to?
number of new cancer cases diagnosed in a given population during a specific period of time, often a year because cancer can be cured treated
-> prevalence is used for T2D, HTN, CVD referring to proportion of individuals because of chronic factor
why has the number of cancer cases diagnosed each year has been increasing?
because of the growing and aging population
cancer rates have been increasing over the years. true or false
false, when the effect of age and population size are removed, the risk of cancer has been decreasing => not developing more cancers than before
which cancers are seen at higher incidence in developed countries
breast, prostate, colon
which cancer is seen at higher incidence in developing countries
liver cancer [hepatitis B + aflatoxin]
what is a descriptive type of study addressing diet and cancer and what are its limitations?
cancer rates in populations having different diets are compared [first observation students done to generate hypothesis]
however, diet is only one of many variables and nutrient intake data are difficult to collect
what is a case-control type of study addressing diet and cancer and what are its limitations?
retrospective study - earlier diets reported by patients with a specific type of cancer are compared with matched controls without cancer
however, possible recall bias and selection bias may occur and proxy respondents with rapidly fatal cancers
what is a prospective cohort type of study addressing diet and cancer and what are its limitations?
incidence of cancer is compared in persons whose diets (and other factors) are determined before follow-up begins
however, thousands of people need to be enrolled and health monitored for many years for statistical power + difficult for rare types of cancers
what is an interventional type of study addressing diet and cancer and what are its limitations?
incidence of cancer in 2 groups randomized to specific interventions is compared
however, adherence to dietary changes is difficult, blinding is often not possible, optimal dosages need to be ascertained, duration is unknown and may be long
what are some research approaches used for diet and cancer interactions
- dietary data often collected using food frequency questionnaire
- biochemical indicators may be useful for some nutrients (serum oxidative markers, vitamin D)
what are the main recommendations given by the American cancer society 2012 for cancer prevention
- achieve and maintain a healthy weight throughout life
- be physically active
- eat a healthy diet, with an emphasis on plant foods
- limit processed meat and red meat
- eat at least 2 1/2 cups of vegetables and fruits each day
- choose whole grains
- limit alcohol intake
obesity is highly associated with which types of cancers
colon, post-menopausal breast cancer, and kidney cancer
why is there an association between obesity and cancer
if initiated cell is put in an environment that contains alot of energy substrates promoting cell division -> more chances to proliferate and cause cancer
what are the mechanisms involved between energy balance, growth rates, obesity and cancer
- levels of metabolism of hormones (insulin, estradiol) and growth factors IGF-1
- effects on inflammation and immune function
- increased reflux -> increased risk of esophagus cancer
what is some evidence of healthy weight and prevention of cancer
- intentional weight loss may reduce risk of postmenopausal breast cancer and possibly others
- modest weight loss improves insulin sensitivity and hormone metabolism
thoughts on correlation between dietary fat/refined sugar and cancer
it was thought that high fat der was promoting cancer [breast, colon, prostate] BUT in reality more fat intake has associated with higher energy intake so the effect on cancer is due to excess ENERGY not fat itself or type of fat
what is more important when considering a healthy diet for cancer risk
PATTERN
red mean and processed meat associated with ____ cancer
colorectal
what is the correlation between processed meat an colorectal cancer? what is the proposed mechanism
50% increased risk with 25g increment of processed meat.
- preservatives (nitrites and salt) -> nitrates -> nitrosamines [linked to Amino residues] which are cancerous
- cooking at high temperature which generates polycyclic aromatic hydrocarbons PAH and heterocyclic amines
- heme promotes formation of nitrosamine
what are some specific fruit/vegetable associations with promising protective effects?
- lycopene -> prostate cancer
- cruciferous vegetables and several cancer sites
- allium vegetables and stomach cancer
- folate rich F&V and colon cancer
providing isolated nutrients such as beta-carotene, vitamin C and E, selenium has shown benefits in reducing cancer risk. true or false
false - no benefits shown, could possible increase risk => not recommended to take antioxidant supplements
what is the proposed mechanism of fibres and lowering GI cancers
they dilute or bind potential carcinogens, limit contact with mucosa by speeding transit, alter colonic flora, reduce pH, serve as substrate to flora producing short-chain fatty acids
dietary fibres probably protects against ____
colon cancer
what are the proposed mechanisms between alcohol consumption and increased cancer risk
- production of acetaldehyde -> DNA damage
- for breast cancer, alcohol may increase estrogen levels
dairy products and dairy consumption is associated with decreased risk of ____
colon cancer
proposed mechanism of calcium intake and reduced risk of colon cancer
binding toxic secondary bile acids and ionized fatty acids to form soaps in the lumen, or reducing proliferation and inducing apoptosis in the mucosal cells
what is the threshold for beneficial effects of calcium intake on colon cancer
700-800mg/day
which factor has convincing level of evidence on decreasing risk of cancer? [with associated cancer]
physical activity - colon cancer
which factors have convincing level of evidence on increasing risk of cancer? (4) [with associated cancer]
- overweight and obesity (many cancers)
- alcohol (oral cavity, pharynx, larynx, esophagus, liver, breast)
- processed meat (colorectal)
- high-dose beta-carotene supplements (lung)
- aflatoxins (liver)
which factors have probable level of evidence on decreasing risk of cancer? (4) [with associated cancer]
- physical activity (breast)
- dairy products and calcium (colorectal)
- whole grains and fibre (colon)
- coffee (liver and uterus)
which factors have probable level of evidence on increasing risk of cancer? (2) [with associated cancer]
- red meat (colorectal)
- salt preserved foods (stomach)
which factors have limited-suggestive level of evidence on decreasing risk of cancer? (2) [with associated cancer]
- food containing carotenoids, vitamin C [fruits and veg] (oral cavity, oesophagus, stomach, colorectal)
- fish, vitamin D
which factor has limited-suggestive level of evidence on increasing risk of cancer? [with associated cancer]
- grilled + barbecued meat and fish (heterocyclic amines, PAH) nitrosamines
which factors have limited-no conclusion level of evidence on decreasing risk of cancer? [with associated cancer]
omega-3 FA, carotenoids, vitamins B6,B12, folate, C, D, E, Se, non-nutrient plant constituents, garlic, soy, sugar, tea
primary tumor
first tutor identified, classified according to size and invasion of surrounding tissues
secondary tumor
other tumors of the same histological origin as the primary, located nearby
metastasis
invasion of distal tissue and organs
how are tumors diagnoses
- biochemically through biomarkers
- imaging techniques (MRI, CT, PET, chest X-ray, ultrasound, mammogram, bone scans
- biopsy, laparoscopy
carcinomas
epithelial tissue
sarcomas
connective tissue
lymphomas
lymphatic system
gliomas
glial cells of CNS
adenocarcinomas
glands
leukemias
bone marrow
why is it important to stage the cancer
staging the progression of the cancer is the driving point of approach to treat cancer [treatment options and prognostication]
what is the TNM system for staging cancer
- primary Tumor [T: T1 to T4]
- lymph Nodes [N: N0 to N3]
- Metastasis [M: M0 or M1]
what are the different stages of cancer
- stage 0: carcinoma in situ (early form)
- stage 1: localized
- stage 2: early locally advanced
- stage 3: late locally advanced
- stage 4: metastasized
what are the 5 anti-cancer treatments
- surgical removal
- radiotherapy
- chemotherapy
- biological therapies
- hematopoietic stem cell transplantation
- gene therapy
what is the first choice for curative treatment for cancer
surgical removal
what is the principle/mechanism of action of radiotherapy
it aims at killing cancerous cells using ionizing ration altering DNA to control the growth/kill malignant cells
when is radiotherapy treatment used
for curative treatment or adjacent with other treatment regimen (surgery) and it is targeted for tumors with relatively limited damage to surrounding tissues
what are the side effects go radiotherapy
- head and neck [most side effects]: mucositis, dyspepsia, dysphagia, esophagitis => high risk of malnutrition
- abdomen and pelvis: diarrhea, malabsorption, radiation enteritis
what is the mechanism of action of chemotherapy
cytotoxic drugs that block DNA and RNA synthesis or cell division at different stages
what is the limitation of chemotherapy
not very specific so it acts on other healthy cells that are replicating rapidly -> epithelial cells are the most affected => side effects
what is the most commonly used biological therapy for cancer and how does it work
immunotherapy: use body’s own immune system to eradicate cancer cells
what are biological therapies used for
to treat cancer itself, progression or side effects
what is the typical first line treatment given for chemotherapy
alkylating agents - cisplatin and carboplatin
what are some common side effects to chemotherapy agents
- bone marrow suppression
- N/V, stomatitis, diarrhea
- alopecia
- anorexia
- renal toxicity (cisplatin)
- hepatotoxicity (5-fluorouraci)
- cardiotoxicity (doxorubicin)
what are drug classes used in biological and targeted therapy
- selective estrogen receptor modulators [tamoxifen - treat breast cancer]
- signal transduction inhibitors [mTOR inhibitors]
- angiogenesis inhibitors
- monoclonal Ab delivering radioisotopes or toxins
- cytokines (∞, IL-2)
- hematopoietic growth factors
definition of cachexia
complex metabolic syndrome associated with underlying illness and characterized by loss of muscle with to without loss of fat mass. The prominent clinical feature is weight loss
low muscle mass can occur at all BMIs. true or false
true:
- underweight with low MM
- normal wt w/ low MM
- obese with low MM
- morbid obese with low MM
what do we call low muscle mass with excess fat
sarcopenic-obesity
what does muscle wasting predict in terms of cancer
predicts poor cancer-associated outcomes
what are the consequences of low muscle mass
increased: fatigue, disease progression, treatment-induced toxicity, less cues completed
decreased: host response to tutor, performance status, survival
what is the overall prevalence of cachexia in cancer patients
50% [almost half of cancer patients will develop cachexia]
dual contribution of ______ and ______ to cachexia
metabolic change and reduced food intake
what are the metabolic changes that contribute to cachexia development
hypercatabolism and hypoanabolism due to systemic inflammation and catabolic factors
what are the consequences of metabolic changes and reduced food intake leading to cachexia
negative energy and protein balance
what is the difference between primary and secondary anorexia
primary - from systemic inflammation affecting hypothalamus and regulation of appetite and satiety
secondary - comes from anti-cancer treatment with all the side effects
what are the major differences between starvation and cachexia
- cachexia: accelerated loss of lean mass in cachexia, increase in REE, increase in protein degradation [increased protein turnover], insulin resistance
- long-term starvation: severely affects body fat, reduced caloric intake, treated decrease in TEE, decrease in REE
what are there 3 stages of cachexia
- precachexia [weight loss <5%, anorexia and metabolic change]
- cachexia
- refractory cachexia [<3 months expected survival ]
what are the 5 markers of cachexia
- weight loss and changes in body composition [loss of fat and fat-free mass]
- inflammation and acute phase response
- hypermetabolism
- metabolic alterations
- anorexia
what is the obesity paradox in terms of cancer survival
obesity will increase the risk of cancer but if you have cancer with higher BMI, you will survive longer, independent of degree of weight loss => stores of energy that can used by host has a protective effect
which factors result in a poor prognostic for survival
muscle of low quality (inter muscular adipose tissue) + high degree of weight loss + low BMI
what is the acute-phase response
coordinated adaptations of the body to limit and clear the tissue damage caused by hydrolyses released from inflammatory, injured or malignant cells
acute-phase proteins are synthesized by _____ and can either be _____ or ____
hypatocytes
positive (increased []) or negative (decreased [])
which are the negative acute phase proteins
albumin transferrin tranthyretin thyroxine-binding globulin IGF-1 alpha-fetoprotein
acute phase response is modulated by ____
cytokines
which pro-inflammatory cytokines have been found in high levels in some cancer
- TNF-alpha
- IL-1 and IL-6
- IFN-gamma
- LIF
what are the effects of cytokines
- decreases appetite and food intake (reduces substrate supply to muscle), GI functions [decreased gastric emptying], blood flow
- inhibit lipoprotein lipase, growth hormone and IGF-1 signalling
- induces insulin resistance (IL-6)
- catabolic effect
- increases proteolysis (skeletal muscle wasting)
in cachectic individuals, we see an increase in ____ and decrease in _____ in regards to metabolism
increase in REE and decrease in TEE
how do cachectic individuals lose weight if they have overall decreased TEE
the energy intake is more decreased than reduction of TEE -> weight loss
what are the metabolic alterations in regards to lipids during cachexia
- increased turnover of fatty acids
- increased lipolysis, FFA
- decreases LDL activity
- increased VLDL, hypertriglyceridemia
what are the metabolic alterations in regards to glucose during cachexia
- glucose is the preferred fuel for tumors
- tumors produce lactate -> cori cycle (uses ATP)
- increased gluconeogenesis -> increased proteolysis in the muscle
- insulin resistance
what are the metabolic alterations in regards to proteins during cachexia
- negative nitrogen balance
- increased protein turnover and muscle proteolysis (provides AA for gluconeogenesis, acute-phase protein synthesis and tumor growth)
- decreased muscle protein synthesis
- increased hepatic protein synthesis for acute phase proteins
most of the skeletal muscle degradation in cancer cachexia and many wasting conditions is done through which pathway?
ATP-dependent ubiquitin-proteasome pathway
during cachexia, there is a decrease in ___ factors and an increase in ____ factors
decrease in anabolic
increase in catabolic
which anabolic factors are decreased during cachexia
- insulin
- IGF-1
- growth hormone
- thyroid hormone
- testosterone
which catabolic factors are increased during cachexia
- glucagon
- cortisol
- pro-inflammatory cytokines
- prostaglandins
- tumor-derived factors
tumors increase _____, _____, _____ and in turn _____ which are all energy demanding explaining the elevated _____
lipolysis, cori cycle, proteolysis and in turn gluconeogenesis
-> energy demanding -> elevated REE
normally, repletion suppresses ______ and in turn inhibits feeding where as depletion activates these stimulating feeding
hypothalamic orexigenic signals (NPY)
normally, repletion activates ______ and in turn inhibits feeding and increase energy expenditure where as depletion suppresses these stimulating feeding
anorexigenic signals (POMC)
in cachexia, there is dysregulation of homeostasis in regulation of appetite and food intake due to persistent activation of ______ neurons
POMC => anorexigenic signals that inhibit feeding and increase energy expenditure
what could cause early satiety in cancer patients
- reduce GI motility
- increased gastric emptying time
- autonomic dysfunction and opioid analgesics
what are the cutoffs of diagnosing cachexia
- weight loss >5% OR
- BMI <20 and weight loss >2%, reduced food intake/systemic inflammation]
- appendicular muscle mass consistent with sarcopenia and any degree of weight loss >2%
cachexia can be treated. true or false
false, it can only be MANAGED
which are some therapeutics agents in cancer cachexia that could increase appetite
- pro gestational agents
- corticosteroids
- cannabicoids
which are some therapeutics agents in cancer cachexia used for symptom management
- antiemetics
- antidepressants
- corticosteroids
- anti GI motility agents
- narcotics and other analgesics
what are the 4 targets for cachexia therapy making it a multi-modal approach
- energy intake
- activity
- inflammation
- mental health/anxiety
which factors of cancer affect nutritional status
- presence of tumor
- host response
- anti-cancer treatment
what are the consequences of a compromised nutritional status during cancer
- decreased quality of life
- decreased réponse to treatment
- decreased survival
what is nutritional screening
process of identifying characteristics known to be associated with nutritional problems
what is nutritional assessment
process of assessment of body compartments and analysis of structure and function of organ systems and their effects in metabolism
how to calculate (unintentional) weight loss
% weight loss = (initial weight - current weight)/initial weight *100
_______ is the most powerful independent variable that predicts mortality in cancer
unintentional weight loss
classification of severity of weight loss
1 week: 1-2% (sig), >2% (sev) 1 month: 5% (sig), >5% (sev) 3 months: 7.5% (sig), >7.5% (sev) 6 months: 10% (sig), >10% (sev) unlimited: 10-20% (sig), >20 (sev)
what are the 2 most important factors of the dietary assessment in cancer patients
ENERGY and PROTEIN intake
-> sufficient energy required to use dietary protein correctly and avoid nitrogen losses
what is the major component of prognostic of development of cachexia
loss of muscle mass
which tools are used to asses loss of muscle mass
- anthropometry: mid-upper arm muscle area MAMA
- urinary creatinine
- 3-methyl-histidine excretion
- Bioelectrical impedance BIA
- DXA: appendicular muscle mass index
- CT sci or MRI
how is mid-upper arm muscle area calculated
calculated from mid-arm circumference and triceps skinfold
what is considered a low mid-upper arm muscle area
<15th percentile for age and sex
why is urinary creatinine a tool used for assessing loss of muscle mass
urinary creatinine is a metabolite of creatine phosphate, mainly found in skeletal muscle => index of muscle mass
why is 3-methylhistidine a tool used for assessing loss of muscle mass
3-methylhistidine is released from actin and myosin degradation -> marker of myofibrillar protein degradation
about bioelectrical impedance
- estimates fat-free mass [body fat by difference]
- based on body water
=> 2 compartment model
how does DXA assess loss of muscle mass
imaging technique based on different tissue density - measures bone, lean soft and fat tissues resulting in total lean body mass and appendicular muscle mass
____ correlates with muscle mass
muscle strength
what are some functional tests that can be done to assess loss of muscle mass
- gait speed (4m walking test)
- chair rise (test leg strength and power - time for 5 chair rises)
- 6min walking tee (endurance test)
- balance test
with inflammation, which could occur during cachexia albumin levels tend to be ____
lower
what are some biochemical tests that can be abnormal due to cancer
- vitamin B12 (high with leukaemia, liver mets and low with gastrectomy)
- calcium (high with mets, lymphomas, parathyroid tumor)
- folate (low with some drugs)
- glucose (high with corticosteroids, pancreatic cancer)
- hemoglobin (low with radio and chemotherapy, leukaemia, lymphoma)
- potassium (high in treatment with cisplatin)
- lymphocyte count (low with radio/chemotherapy, leukaemia, corticosteroids)
what are the consequences/treatments for low hemoglobin due to radio/chemo therapy, leukaemia, lymphoma
- hypochromic anemia: respond to iron supplement
- megaloblastic anemia: folat for b12 supplement
- normochromic anemia: blood transfusion
what are some indications of dehydrations
- high blood concentrations of: blood electrolytes, blood urea nitrogen, creatinine, hematocrit
- urine specific gravity
- clinical signs: low BP, thirst, rapid heart rate, skin dryness
many inflammation/catabolic markers may be present during cancer but usually measured as ____ and ____
C-reactive protein and albumin
which tool is used to categorize the degree of inflammation in cancer patients
the Glasgow prognostic score
what is the Glasgow prognostic score based on
CRP: low <10mg/L or high >10mg/L
Albumin: low <35g/L or normal >35g/L
what does LOW CRP and NORMAL albumin reveal according to the Glasgow prognostic score
GPS = 0 -> no cachexia
what does LOW CRP and LOW albumin reveal according to the Glasgow prognostic score
undernourished
what does HIGH CRP and NORMAL albumin reveal according to the Glasgow prognostic score
pre-cachexia
what does HIGH CRP and LOW albumin reveal according to the Glasgow prognostic score
refractory cachexia
what is the patient-generated subjective global assessment
- adaptation to SGA because it involves symptoms of oncology patients
- screening/assessment tool
- 2 sections: 1 filled by patient one by health-care professional
- numerical score: useful for triage to initiate intervention
what are the 4 sections of the patient form of the PG-SGA
- weight loss
- food intake
- symptoms related to cancer/treatment
- activities and function
what are the 3 possible nutrition diagnoses following nutritional assessment of cancer patients
- involuntary weight loss
- malnutrition
- dehydration
what is the intent of a preventative nutritional intervention
in prevision of treatment that will affect nutritional status (or pre-cachexia)
what is the intent of an adjuvant nutritional intervention
to improve nutritional status to initiate and support anti-cancer treatments (or in cachexia)
what is the intent of an palliative nutritional intervention
to improve or maintain quality of life when anti-cancer treatments have stopped (refractory cachexia)
what are the goals of nutrition therapy in cancer patients
- increased lean body mass (or weight stabilization if active weight loss)
- predispose to a better response to radio or chemotherapy
- increase immunocompetence
- symptom management
- improve perception of well-being
what is the recommendation regarding energy requirements for cancer patients
- 25-30kcal/kg/day [adjusted to ideal body weight if obese]
- determine current intakes and recommend increased intakes when severe weight loss
- patients with obesity may not need more energy but do need more protein
what are the recommendations regarding protein intake for cancer patients
- 1.0-1.5g/kg/d
- 1.2-2.0 g/kg/d id inactivity and systemic inflammation are present
- 1.0-1.2 g/kg/d with kidney disease
multivitamin/mineral supplements may be recommended in amounts close to ____
DRIs
which diets may be harmful for cancer patients?
> diets that restrict energy intake in patients with or at risk pf malnutrition
keto diets: can cause weight loss -> lean muscle mass loss
what is the best route of nutritional administration?
oral route
what are the different rote sos nutritional administration
- oral
- enteral
- parenteral (last resort)
what is the treatment for hematological cancers
hematopoietic stem cell transplantation
what has to be done for hematopoietic stem cell transplantation
total body irradiation as a conditioning regimen
what is the outcome of total body irradiation for hematopoietic stem cell transplantation
- eradicate malignant cells
- immunosuppression
what is the nutrition approach for hematopoietic cell transplantation
- avoid foods t risk of causing infections
- adopt safe food handling during period of neutropenia
- provide enteral nutrition when GI tract is intact and oral intake is inadequate
- parental nutrition for patients unable to ingest or absorb adequate nutrients for a prolonged period
what are some promising nutrition therapies for cachexia
- omega-3 fatty acids [may have protective effects on chemo-induced toxicities, neuroprotective effects]
- amino acids [anabolic response]
what could be recommended for omega-3 FA intake for most cancer patients
<5g/day
which specific amino acids have shown positive effects in cachexic patients
- leucine (stimulates protein synthesis and insulin secretion -> anabolic properties
- glutamine and arginine (increase immune competence, help wound healing)
inactivity induces _____
muscle loss
___ + ___ = lean body mass and strength in elderly and in bed-ridden patients
resistance exercise + nutritional supplements
exercise is ____ and potentiates the ____ effect of nutrition
anabolic
anabolic
a multimodal intervention, combining ____, _____ and ______ approaches, that must include individual nutritional counselling and bleary intervention has the best chances of success
dietary, physical exercise, and pharmacological
