CNM N1 S2 Sample Paper 3)

Question 1

Your client Edith presents in clinic with oedema. What are THREE protein
related issues that could be the cause behind this? (3 marks)

: Proteins; slide 18. (1 mark per point, max 3 marks)

Answer 1

Excessive protein losses due to kidney disease.
Inadequate protein synthesis due to liver disease.
Inadequate dietary intake of protein (malnutrition).

Question 2

List FOUR contraindications for fasting (2 marks)

Pop diet models; slide 61

Answer 2

Pregnancy and breastfeeding. Infants. Severe liver, heart or kidney disease.
Emaciation and debility. Eating disorders (e.g. anorexia nervosa). Prescription /
recreational drugs. Adrenal exhaustion. Diabetes only under supervision.

Question 3

Describe TWO reasons why vitamin C and TWO reasons why magnesium
are important nutrients for a client who is 1 month postpartum (4 marks)
Life stages; slide 16

Life stages; slide 16

Answer 3

Vitamin C - 2 marks. 1 mark for any of the following
- Co-factor for collagen synthesis (aids in wound healing postpartum).
- Increases absorption of non-haem iron
- Depleted in times of stress (adrenals).
- Synthesis of thyroxine and adrenal steroid hormones (postpartum thyroiditis).
- Mag - 2 marks. 1 mark for any of the following
- Mg needed to convert ADP to ATP (essential for energy postpartum).
- Absorbed by foetus in pregnancy & lactation.
- ↓ levels can contribute to PPD

Question 4

Which type of fatty acid is mostly produced in the gut by bacterial
fermentation of carbohydrates/fibre? (1 mark)
Answer: Lipids; slide 10

Lipids; slide 10

Answer 4

Short chain fatty acids

Question 5

What is HIIT and what does it create in the body? (2 marks)

Energy metabolism; Slide74

Answer 5

Short bursts of intensive exercise alternated with low-intensity recovery, typically
only performed for 10-30 minutes. HIIT creates an oxygen debt which is repaid
via EPOC - Excess Post-exercise Oxygen Consumption - whereby oxygen intake
increases post-exercise.

Question 6

What are the TWO main clinical applications of Maca? (2 marks)

Answer: Superfoods; Slide 80. F

Answer 6

Fertility and sexual function: Increases libido,
protects against benign prostatic hyperplasia, improves erectile dysfunction, and
increases sperm count, motility and semen volume. * Maca does not appear to
change serum testosterone and oestradiol levels but can interfere with androgen
receptors. The aphrodisiac properties are related to lipids in maca called
‘macamides’. * Enhances energy and cognition: Maca can improve mood and
cognitive function, which is thought to be through its action on the
endocannabinoid system, as well as GABA and choline content. * Provides
sustained energy can also be associated with its warming energetic properties —
useful for sports performance and fatigue

Question 7

What are TWO effects of alcohol on breast milk? (2 marks)

(1 mark each max 2) Life stages; slide 27.

Answer 7

Alcohol: Easily enters breast milk and significantly diminishes the amount of
breast milk consumed by the infant.
– It changes the taste of the breast milk.
– Even low doses of alcohol are not metabolised efficiently by the infant
which suppresses feeding and causes sleepiness.
– Alcohol interferes with lactation by inhibiting the hormone oxytocin.

Question 8

Name FOUR foods where phosphatidylserine may be found (2 marks)
Ortho; slide 44.

Ortho; slide 44.

Answer 8

We obtain most phosphatidylserine from dietary sources, for example White
beans, whole grain barley, carrots, mackerel, herring, organ meats.

Question 9

When energy is in short supply the body can source energy from where? (2
marks)

Energy metabolism; Slide 8

Answer 9

• Glycogen in the liver and muscles. Fat. Protein (a last resort in cases of
  starvation
  or malnutrition –amino acids are liberated from tissues such as skeletal muscle).
  (0.5 per point)

Question 10

Name TWO medications that interact with calcium supplements (2 marks)

Answer – Supps in practice; Slide 62

Answer 10

Corticosteroids, Levothyroxine, Oestrogen & progesterone therapy, Quinolone,
Tetracyclines. (1 mark each- max 2 marks).

Question 11

.How does alpha lipoic acid support diabetic neuropathy? (2 marks)

Ortho; slide 21.

Answer 11

ALA supplementation reduces oxidation of the myelin sheath. (1 mark)
ALA improves neuropathic sensory symptoms including pain, burning, numbness,
prickling of the feet and legs. Seems to reduce symptoms of peripheral
neuropathy in diabetes patients (1 mark)

Question 12

Sandra is finding it difficult to exercise due to her osteoarthritis. What
dosage is suggested for the use of MSM in osteoarthritis? (1 mark)

Ortho; slide 26.

Answer 12

For osteoarthritis, 500 mg 3x daily up to 3 grams twice daily has been used

Question 13

.On conducting a physical examination, you notice your client has clubbed
nails. Name TWO causes of nail clubbing (2 marks)

Answer: Advanced case taking; Slide 53

Answer 13

Causes of clubbing include: Pulmonary and cardiovascular causes (80%). *
Gastrointestinal causes (about 5%), hyperthyroidism, idiopathic.

Question 14

Explain why spirulina is considered anti-inflammatory (2 marks)

Answer: Superfoods; Slide 19.

Answer 14

Reduces the production of pro-inflammatory
cytokines by inhibiting the NF-κB pathway. Phycocyanin in spirulina also has
COX-2 inhibiting effects.

Question 15

.Name TWO conditions where research indicates that gamma-linolenic acid
may elicit a therapeutic response (1 mark)

Lipids; slide 62

Answer 15

Rheumatoid arthritis, ADHD and Eczema

Question 16

Your client follows a very low-fat carbohydrate diet and you suspect she is
in ketogenesis. Describe how the body is using fat for fuel? (2 marks)

Lipids; slide 20.

Answer 16

Ketones are made when glucose is in short supply. This occurs overnight, and
during dieting or fasting – 1 mark.
By a process known as ketogenesis, acetyl-CoA is converted to the ketones
acetoacetate or β-hydroxybutyrate (β-OHB).1 mark.

Question 18

Phytosterols have shown to be helpful to support prostate health. What
enzymes are inhibited by phytosterols and what are the implications of
this? 2 marks)

Phytonutrients; slide 65

Answer 18

. Inhibits 5-alpha-reductase and aromatase,
reducing the formation of dihydrotestosterone and oestradiol which stimulate
prostate growth.

Question 19

What is the type of excipient that is used in supplements, allowing
formulations to flow easily through machinery? (1 mark)

Supps in practice; slide 26

Answer 19

Flow agents (1 mark)

Question 20

SECTION B (45 marks)
1. Discuss the nutrient quercetin including details of its food sources. Explain
the key functions and therapeutic uses with regards to cardiovascular
disease, immune health and cancer (15 marks)

Phytonutrients; slide 22 to 25
- (1 mark per point unless indicated)

Answer 20

• Quercetin is the most abundant of the flavonoids.
• It is also a building block for other flavonoids (e.g. kaempferol):
• Quercetin has a fast excretion rate so needs to be consumed regularly for
  therapeutic use.
• Therapeutic dosage range: 150‒1500 mg / day.
  Food sources: * Onions (especially red), apples (especially the peel), grapes,
  capers, asparagus, tomatoes, kale, brassica vegetables and berries
  (blueberries, bilberries, blackberries, elderberry, cranberry and goji. (0.5 per
  food – max 3 marks)
• Functions:
• Cardiovascular health:
• Quercetin is a powerful antioxidant protecting the vascular endothelium.
• It inhibits LDL oxidation.
• Shown to have vasodilatory effects (via nitric oxide release), reduces platelet
  aggregation and lowers blood pressure (in those hypertensive) via ACEinhibiting properties. (2 marks)
• Supports athletic performance (endurance) by ↑ blood circulation.
• Dosage: 150 mg‒1000 mg per day.
• Therapeutic uses:
• Cardiovascular diseases (e.g. coronary artery disease) — incl. prevention. *
  Hypertension. * Hyperlipidaemia. * Previous myocardial infarction. * Exercise
  performance. (0.5 each – max 2 marks)
• Anti-cancer:
• Its anti-tumour functions occur by a variety of mechanisms: ‒ Shown to
  induce cell cycle arrest (e.g. in leukaemic, prostate and ovarian cancer cells)
  — induces apoptosis (2 marks).
• It can inhibit blood vessel growth.
• In prostate and breast cancers, quercetin targets the VEGFR-2-mediated
  angiogenesis pathway.
• Evidence of anti-metastatic properties.
• Shown to reduce head / neck skin damage during radiotherapy.
• Shown to increase the efficacy of some types of chemotherapy including:
  Cisplatin, busulfan, topotecan, cyclophosphamide, gemcitabine (0.5 each –
  max 2 marks)
• Functions:
• Immune system:
• Anti-inflammatory — quercetin inhibits LOX and COX, and is also a potent
  down-regulator of NF-κB. (2 marks)
• Anti-histamine — quercetin inhibits histamine release by mast cells.
• Reduces inflammation in the brain (and is hence protective against
  Alzheimer’s and Parkinson’s, of which inflammation is an exacerbating factor).
• Therapeutic uses:
• Hay fever. Histamine reactions e.g. urticaria, hives. * Asthma. * Prostatitis. *
  IBD. * Arthritis (e.g. RA, osteoarthritis). (0.5 each – max 3 marks)
• Xanthine oxidase:
• Quercetin can inhibit xanthine oxidase (normally converts purines → uric
  acid).
• Gout

Question 21

Discuss the TWO highly therapeutic compounds found in broccoli
sprouts. Detail the benefits and clinical application (15 marks)

Superfoods; Slide 40 – 43
- (1 mark per point unless indicated)

Answer 21

• As with other sprouts, broccoli sprouts are nutritionally rich and contain
  sulphur compounds called ‘glucosinolates’.
• The glucosinolates in brassica vegetables produce two highly therapeutic
  compounds: sulforaphane and I3C (1 mark for each – must mention to
  gain full marks) (which are 20–50 times more abundant in broccoli sprouts).
• I3C promotes phase II liver detoxification and is able to support the liver’s
  deactivation of oestrogen.
• As a result, broccoli sprouts can be used in cases of oestrogen dominance,
  such as that typically seen in endometriosis, fibroids, breast and ovarian
  cancer. (2 marks)
• For these clients, aim for up to 50 g of broccoli sprouts / day (or consider
  supplementing I3C)
• Benefits / applications of sulforaphane:
• Induces phase II detoxification enzymes; down regulates phase I enzymes
  (can be used in a liver support protocol). (2 marks)
• Anti-inflammatory (through inhibition of the NF-kB and TNF-α).
• Anti-carcinogenic, through various mechanisms, including: –
• Inducing expression of the tumour-suppressing p21 gene (1 mark).
• Induction of phase II enzymes — enhancing the detoxification and elimination
  of activated carcinogens. (2 marks)
• Increasing antioxidant defence and inhibiting angiogenesis. (2 marks)
• Benefits and clinical applications:
• Cardiovascular disease:
• Decreases risk by reducing inflammation and oxidative damage that can lead
  to endothelial dysfunction. (2 marks)
• Also lowers LDL, whilst increasing HDL.
• Respiratory health:
• Promotes detoxification of environmental toxins (e.g. diesel fumes) from the
  lungs (via phase II enzymes expressed in lung cells) and reduces associated
  upper airway inflammation. (2 marks)
• Helicobacter pylori infection:
• Shown promise in helping to eradicate H. pylori infection, to protect the gastric
  mucosa — reducing the risk of gastritis and gastric cancer. (2 marks)

Question 22

Leo has been diagnosed with IBS and has heard a FODMAP diet may
help. Describe what a FODMAP diet is and how a client would follow it,
including examples of low and high FODMAP foods (15 marks)
- (1 mark per point unless indicated)
Popular Diets; slide 31 to 35
- (6 marks for explaining what a FODMAP diet is)

Answer 22

• • FODMAPs — An acronym for fermentable oligosaccharides, disaccharides,
    monosaccharides and polyols. (0.5 per point – max 2 marks)
• FODMAPs are short-chain carbohydrates found in certain foods.
• They are poorly absorbed in the small intestine and ferment in the colon
  aggravating GI symptoms.
• The low FODMAP diet was developed at Monash University in Melbourne,
  Australia.
• It was designed to help combat IBS and is used as a therapy for other bowel
  disorders.
• FODMAPs are found in many foods and are not an issue for most.
• In fact, colonic bacteria utilise them as a fuel source.
• In people with GI issues where gut motility is altered and / or the gut wall is
  highly sensitive, the increased water and gas generated as bacteria ferment
  FODMAPs which can cause GI symptoms including pain, bloating, diarrhoea
  or constipation. (2 marks)
• FODMAPs are also problematic in those with SIBO because they provide fuel
  for bacteria that are already causing issues by residing in the small intestine
  where they don’t belong.

TABLE ON THE SAMPLE DIDNT COPY

• 0.5 per food – max 2 marks for high fodmap foods
• 0.5 per food – max 2 marks for low fodmap foods
• (5 marks for how to follow the diet)
• The FODMAP diet involves three stages:
• 1. Restriction — strict avoidance of all high FODMAP foods, 2–6 weeks.
• 2. Reintroduction — high FODMAP foods are progressively reintroduced to
     identify which types of FODMAPS and how much are tolerated, 8–12 weeks.
• 3. Personalisation — amount and type of FODMAPS are tailored to the
     individual. Possibly longer term.
• It is important to note that a strict FODMAP diet is not intended for long-term
  use.
• FODMAPs are important because of their role as prebiotics to support healthy
  gut flora.
• If clients need to undertake the FODMAP diet, consider nutrient-dense food
  alternatives to some of the foods they will temporarily need to avoid.
• Garlic contains high amounts of fructans which are water-soluble and may
  leach into food. Opt instead for garlic infused oil.
• The bulbs of spring onions and leeks are also high in fructans whereas the
  green tops are not and still provide flavour. Don’t throw the bulbs away! Place
  them in a glass with water and the leaves will grow back (change the water
  every 2‒3 days). (2 marks)