CNM N1 S2 Sample Paper 2

Question 1

Gina has come to see you as she is suffering with regular urinary tract infections. Describe how cranberries may help. What therapeutic dose
would be suitable? (2 marks)

Answer 1

Superfoods; slide 69. The bacteria associated with UTIs (Escherichia coli) often contain fimbriae, which enables their epithelial attachment. Cranberry impedes
this attachment.
Juice — 300 to 500 mL / daily (divide into two doses); or capsules dried powder
250 to 500 mg daily.

Question 2

The ketogenic diet has shown to be associated with long-term weight
management. Explain what the proposed mechanisms are for the ketogenic
diet and weight-loss (3 marks)

Answer 2

Answer: Pop diets; slide 23
Lack of glucose in the diet leads to a decrease in insulin, in turn reducing lipogenesis and increasing lipolysis.
Appetite-suppressant effect of ketosis related to modification of levels of hormones that influence appetite — ghrelin and leptin.
Increased metabolic cost of gluconeogenesis and the thermic effect of protein.

Question 3

What safety considerations do you need to consider when supplementing with high intakes of resveratrol? (2 marks)

Answer 3

Phytonutrients; slide 60
* High intakes of resveratrol (e.g. supplements) could increase the risk of
bleeding when taken with anticoagulant drugs. 1 mark
* Resveratrol inhibits the activity of cytochrome P450; thus high intakes of resveratrol (e.g. from supplements) could theoretically increase the bioavailability and toxicity of drugs that undergo extensive first-pass
metabolism by CYP450 (statins, immune-suppressants, calcium channel blockers, etc.) 1 mark

Question 4

When considering facial analysis, state which health problem may be connected to brown shadows under the eyes (1 mark)

Answer 4

Advanced nat CT;

Slide 44. liver ‘stagnation

Question 5

For individual amino acids to be used as an energy source or to be stored as fat, they need to undergo ‘deamination’. Explain deamination and where it occurs (2 marks)

Answer 5

Answer: Protein; slide 2
removal of the nitrogen-containing amino group from amino acids and occurs primarily in the liver.

(slide 20) (protein)

Question 6

Explain how wheatgrass can support weight loss (2 marks)

Answer 6

Superfoods; Slide 30
Can reduce appetite and increase hormonally driven signals of satiety (e.g. CCK), supporting healthy weight management. Its effects can also be attributed to its role in balancing blood sugars (reducing cravings).

Question 7

Explain the negative effects of trans fat on the body (2 marks)

Answer 7

Trans fats stiffen cell membranes, making them prone to oxidation. This also
alters their protective action and permeability, impeding normal cell function. *
Trans fats alter blood triglyceride and cholesterol profiles and are linked to an
increased risk of cardiovascular disease, insulin resistance and cancer

Lipids; slide 13

Question 8

List FOUR key nutrients needed for mitochondria to generate ATP, through
Acetyl CoA formation, the Krebs Cycle and the Electron Transport Chain (2
marks)

Energy metabolism; slide 12

Answer 8

Magnesium, Manganese, Iron, Sulphur, CoQ10, Copper, Vitamin B1, B2, B3, B5
and alpha-lipoic acid.

Question 9

Calculate the energy provided by a snack consisting of 10 grams of fat, 20
grams of protein and 10 grams of fibre – show your working (3 marks)

Energy metabolism; slide 11.

Answer 9

(1 mark per point, max 3 marks)
10 x 9Kcal (fat) – 90kcal
20 x 4kcal (protein) – 80kcal
10 x 2kcal (fibre) – 20kcal
Total 190kcal

Question 10

Glucosamine supplementation is most associated with arthritis. Name a condition not associated with joint health where it has been found to be beneficial (1 mark)

Ortho; slide 27

Answer 10

IBD and intestinal permeability

Question 11

Name FOUR key signs and symptoms associated with the clinical imbalance Defence and Repair (2 marks)

Advanced nat CT; Slide 24

Answer 11

Recurring infections, fatigue, poor wound healing, skin issues, autoimmune conditions, intestinal permeability, low vitamin D and antioxidants in the diet. High free radicals.

Question 12

What are lectins and list TWO ways in which lectin content can be reduced or inactivated (3 marks)

Pop diet models; slide 17

Answer 12

Lectins are water-soluble and often found on the outer surface of foods (1 mark)
soaking in water for many hours before cooking greatly reduces the content.
Similarly, cooking with wet, high-heat methods such as boiling inactivates most
lectins. Sprouting legumes and grains is another way to decrease lectins.

Question 13

How would you describe the energetics of seaweed? (1 mark)

Superfoods; Slide 11.

Answer 13

cooling, moistens dryness.

Question 14

Describe TWO ways renal function decreases with age (2 marks)

Life stages; slide 74

Answer 14

Kidney cortex volume decreases. Number of renal cysts increase with age.
Nephrosclerosis increases with age, with a decline in nephron numbers and the
GFR.

Question 15

Outline ONE supplement formation and list an advantage and disadvantage
for the formation (3 marks)

Supps in practice; slide 23/24. 1 mark for form, 1 mark for advantage, 1

Answer 15

Tablets: Cheaper, easier to produce large quantities. Generally contain more
excipients so try to avoid. Capsules: Fewer excipients but not efficient for large
doses. Powders: Good for bigger doses; e.g. glutamine. Not suitable for sticky
ingredients, ones that attract moisture, e.g. phosphatidyl serine or fruit powders,
where there is a toxicity risk, or where ingredients are unstable. Liquids:
Excellent absorption but more expensive and less stable. Many, such as fish oils,
need antioxidants such as vitamin E added to prevent oxidation. Enteric formulations: Excipients, such as shellac or cellulose acetate phthalate (CAP), used to ensure tablets survive stomach acid so that they don’t release contents
until the small intestine. Commonly used for good garlic capsules. Spore form: Good form to enable probiotics to survive the stomach acid and reactivate in the intestines. Chewable formulations: As vitamins and minerals may taste unpleasant, most vitamin and mineral powders are coated before they are compressed into tablets. Slow-release formulations: Cheaper slow-release tablets contain hydrogenated fats to hold the tablets together longer.

Question 16

.Name ONE compound formed from intestinal bacteria metabolism of lignans (1 mark)

Phytonutrients; slide 38

Answer 16

the phytoestrogen compounds enterodiol and
enterolactone. 1 mark for either

Question 17

Explain why protein intake is essential during adolescence (1 mark)

Life: slide 64

Answer 17

Inadequate protein can = loss of lean BM and delayed growth

Question 18

Explain why you might supplement with quercetin for someone presenting with an immune response? (2 marks)

Phyto; slide 25 (1 mark for each)

Answer 18

Anti-inflammatory — quercetin inhibits LOX and COX and is also a potent downregulator of NF-κB.
Antihistamine — quercetin inhibits histamine release by mast cells.

Question 19

Discuss the various forms of iron supplementation, including the
advantages and disadvantages. What adverse reactions may occur and
who should take caution when supplementing iron, including drug
interactions (15 marks)

Supps in practice; slide 66,67,68
(1 mark for correct name – max 6 marks

Answer 19

• Ferrous salts (ferrous fumarate, ferrous sulphate, and ferrous gluconate) are
  the best absorbed iron supplements.
• Ferrous citrate: * Well absorbed and generally tolerated well.
• Ferrous fumarate: * Well absorbed but may inhibit the absorption of vitamin E.
• Ferrous sulphate: * Orthodox version of iron; most studied form. * Can cause
  nausea and constipation. * May interfere with vitamin E absorption. * Higher
  dosages may be given than other forms.
• Ferrous bisglycinate: * Chelated iron that is claimed by its manufacturers to be
  highly bioavailable and without the adverse effects of ferrous sulphate.
• Ferrous lactate (Iron II lactate): * Derived from the action of lactic acid on iron
  fillings; can be vegan or animal derived. In fortified foods and baby formula.
• Caution: * Overdosing iron is toxic in children; can be fatal.
• Has pro-oxidant effects — can cause free radical damage.
• It also feeds bacteria ― avoid in GI bacterial overgrowth.
• Always check serum ferritin and transferrin levels before supplementing.
• With males, beware of haemochromatosis.
• A minor overload of manganese can exacerbate iron deficiency.
• Having too little can also cause problems.
• Consider levels of other minerals before supplementing.
• Drugs interactions: * Thyroxine, levodopa, tetracyclines, fluoroquinolones,
  penicillamine. (0.5 per drug – max 2 marks)
• Iron adverse reactions include: * Nausea, diarrhoea, constipation, heartburn,
  upper gastric pain. * (0.5 per reaction – max 2 marks)
• Taking with food seems to decrease adverse effects. *
• Toxicity: Organ damage and death. *
• Toxicity is more common in conditions such as: - Haemosiderosis: Overload
  of iron in organs or tissues. (1 mark with explanation). - Haemochromatosis
  (iron overload) ― often genetic condition causes the body to absorb more
  than normal (1 mark with explanation). - Thalassaemia and sideroblastic
  anaemias. (0.5 per condition) –

Question 20

Describe Chlorophyll including its composition and energetics. Explain its
benefits and clinical applications with tips on practical use (15 marks)

Answer: Superfoods; slide 6 to 10

Answer 20

• (1 mark per point unless indicated)
• Description: One thing many superfoods have in common is chlorophyll.
  Plants use chlorophyll to trap light; it is used in photosynthesis to produce
  ATP. (2 marks)
• Energetics: Cooling, calming for Yang excess.
• Gives plants and algaes their green colour.
• Rich sources of chlorophyll include dark green leafy vegetables like spinach,
  rocket, parsley or cress. (0.5 each – max 2 marks)
• Composition: The basic structure of chlorophyll is similar to haemoglobin, with
  a porphyrin ring, but the central atom is magnesium instead of iron (2 marks).
• Chlorophyll is a good source of vitamins A, C, E, K; magnesium, iron, calcium
  and potassium (0.5 each – max 2 marks)
• Benefits and clinical applications 10 marks:
• Detoxification:
• Chlorophyll can bind with certain carcinogenic chemicals, e.g. heterocyclic
  amines found in cooked meat, polycyclic aromatic hydrocarbons (tobacco
  smoke, grilled / charred meats) and aflatoxins (food-borne toxins produced by
  certain fungi). . (0.5 each – max 2 marks)
• Also positively influences detoxification of carcinogens in the liver by downregulating phase I enzymes and inducing phase II.
• Antioxidant:
• Decreases oxidative damage including that induced by chemical carcinogens
  and radiation treatment with its high antioxidant content. (2 marks)
• It also appears able to promote endogenous antioxidant activity
• Benefits and clinical applications: *
• Reduces inflammation:
• Shown to inhibit the pro-inflammatory TNF-α gene, which can be activated by
  lipopolysaccharides (LPS) released from bacteria. (2 marks)
• This can be from intestinal bacterial infections / intestinal permeability.
• Supports energy production:
• Rich in magnesium which is required for production of ATP.
• Promotes wound healing:
• Applied topically (cream / ointment), chlorophyllin has been used to aid wound
  healing since the 1940s.
• Deodorant properties:
• For example can reduce colostomy, ileostomy or incontinence odour with
  tablets of 100–200 mg / day
• Chlorophyll is ‘alkalising’ with its high alkaline mineral content:
• Excess acidity in the body contributes to a range of diseases including cancer,
  osteoporosis, arthritis and kidney stones. (0.5 each – max 2 marks)
• While the body has mechanisms to prevent acidaemia (blood pH < 7.35 —
  can be life threatening), the pH within and around body cells can become
  more acidic causing alterations to normal cellular function. (2 marks)
• Tissues can become acidic due to certain diseases, drugs, diet (sulphurcontaining amino acids, processed foods, refined grains and sugar, alcohol,
  table salt and phosphoric acid (in soft drinks). (0.5 each – max 2 marks)
• Practical use: * Eat chlorophyll-rich food raw or cook / steam slightly.
• Overcooking destroys chlorophyll; retaining the ‘green’ retains the benefits.
• Note: chlorophyll supplements are usually ‘chlorophyllin’: a semi-synthetic
  mixture of sodium copper salts derived from chlorophyll.
• During synthesis, magnesium is replaced with copper.

Question 21

Discuss in detail the various roles of protein in the functioning of the body, providing examples for each (15 marks)

: Protein; Slide 12 to 19

• (1 mark per point unless indicated)

Answer 21

• (1 mark per point unless indicated)
• Each protein has a specific function that is determined during protein
  synthesis.
• Functions include:
• Structure of body tissues, e.g. Collagen.
• Movement e.g. Actin and myosin fibres (in muscles).
• Carrier molecules, e.g. Haemoglobin.
• Storage molecule, e.g. Ferritin (iron).
• Fluid balance in the blood, e.g. Albumin.
• Enzymes (for reactions in the body).
• Hormones (e.g. Insulin) and cell membranes.
• Immune function, e.g. Antibodies.
• Clotting mechanisms, e.g. clotting factors.
• Alternative energy source
• Growth and Maintenance:
• Proteins are the building blocks of muscles, blood, skin, and most body
  structures. (2 marks)
• Bones are formed of a collagen matrix, which provides a framework for
  minerals to deposit on.
• Actin and myosin filaments involved in muscle contraction are also proteins.
• Collagen provides building material for ligaments, tendons, blood vessel walls,
  dermis, etc. (0.5 each – max 2 marks).
• Proteins are also needed for the replacement of cells, e.g. of skin, GIT cells
  etc
• Hormones and Receptors: (max 4 marks)
• Some hormones are derived from cholesterol, whilst others are made from
  amino acids.
• These include: - Tyrosine + Iodine → thyroid hormones.
• For example: Iodine (e.g. seaweed) and tyrosine (e.g. fish) supports thyroid
  hormone production. (2 marks for examples)
• Tyrosine → dopamine, norepinephrine, epinephrine. (2 marks)
• Tryptophan → serotonin, melatonin. (2 marks)
• Two polypeptide chains → insulin.
• One polypeptide chain → glucagon, PTH, calcitonin. (2 marks)
• Cell membrane proteins are receptors for hormones.
• Enzymes:
• Enzymes are proteins that speed up biological reactions.
• For example, the digestive enzyme ‘amylase’ digests starch.
• Immunoglobulins (or Antibodies): (Max 4 marks)
• Immunoglobulins are proteins found in blood and bodily fluids.
• They are used by the immune system to identify and neutralise foreign
  materials such as bacteria and viruses.
• The most abundant antibody in the blood is IgG, whilst IgA is found in bodily
  secretions (e.g. tears, saliva, mucus, sweat).
• The first antibody to appear in response to antigen exposure is IgM, whilst
  allergic reactions are associated with IgE release (2 marks)
• Transport:
• Some proteins combine with other substances in the blood or within cells to
  provide a mode of transport. Insufficient transport of vital nutrients and
  products will negatively impact health. * For example, albumin can bind to
  calcium, zinc and B6, as well as steroids and fatty acids. Transferrin’s bind to
  iron. Ceruloplasmin binds to copper. Haemoglobin transports oxygen in the
  blood. * Note: Protein malnutrition, hypochlorhydria (low stomach acid) or liver
  dysfunction can be the cause of low serum albumin.
• Buffers: (Max 4 marks)
• Some amino acids have side chains (R-groups) that can easily pick up or let
  go of hydrogen ions (H+), helping to regulate the acid-base balance in body
  fluids. (2 marks)
• Proteins that contain a lot of these amino acids therefore make good buffers,
  helping to keep the acid-base balance of body fluids such as the blood. (2
  marks)
• The amino acid histidine is the best buffer at our healthy physiological pH
  range (7.35 – 7.45).
• Another amino acid, cysteine can also act as a buffer within the normal
  human pH.
• Fluid Balance: (Max 4 marks)
• Proteins attract water.
• This osmotic pressure from proteins (i.e. albumin) in fluid is called ‘oncotic
  pressure’.
• If protein levels fall too low, water leaks out of the blood vessels and
  accumulates in interstitial spaces = oedema.
• Protein-related causes of oedema include: - Excessive protein losses due to
  kidney disease. - Inadequate protein synthesis due to liver disease. -
  Inadequate dietary intake of protein (malnutrition). This explains the
  appearance of ascites (a distended, fluid-filled abdomen) in the worlds
  poorest countries. (0.5 per point – max 2 marks)
• Glycoproteins: (Max 4 marks)
• Mucins – found in mucus and saliva; provide a protective, lubricating barrier.
• ABO blood (type) antigens.
• Hormones – incl. Luteinising Hormone (LH), Follicle Stimulating Hormone
  (FSH) and Thyroid Stimulating Hormone (TSH) (0.5 each)
• Major Histocompatibility Complex – cell surface receptors involved in adaptive
  immunity (e.g. antigen presentation).
• Proteoglycans (a subclass of glycoprotein) are bound to glycosaminoglycans
  (GAGs) and found in the extracellular matrix (2 marks) e.g. chondroitin
  sulphate, found in cartilage – shock absorbs. (1 mark)