Exam 1 Flashcards
What percentage of inpatients are malnourished upon arrival?
- 30-50%
Possible benefits of etoh consumption
- Moderate intake - Elevated HDL, lower serum lipoproteins
What is nutrient density labeling?
- Rating that gives proportion of nutrients in food eg. NuVal - Higher score = nutrient dense, healthier
Adiposity rebound in children
- Increase in body fat in preparation for pubertal growth spurt
What is the most popular supplement?
- Multivitamin
How much glucose (roughly) is needed to avoid ketone production?
- 50 g/day for brain consumption - 200 g/day is required from diet
Reasons to recommend supplements to patients
- Inflammation - Oxidative stress - Loss of organ reserve - Hypomethylation - Dysglycemia - Meds previously rx interfere with nutrient absorption
What is the most common source of mono-unsaturated fat?
- Olive oil
Where does majority of weight gain come from in babies 1-4?
- 40% of weight gain from fat. This is the main dietary energy source (40-50%) during infancy.
Hartnup dz. What is this a defect in? Presentation?
- Deficiency in transporter for typtophan. - Neurologic and skin manifestations.
Nutrients given to optimize wound healing
- Vit C, zinc
What is a cohort study?
- Observational study - Observe group of individuals from either historical perspective (retrospective) or start following them from now til X time fram (prospective)
Which FAs are essential?
- Omega 6 and Omega 3 polyunsaturated
Goal setting mnemonic for behavior modification program
- SMART - S: specific - M: measurable - A: attainable - R: relevant - T: timely/time-bound
Epinephrine’s effect on glucose state
- Increase glycogen breakdown - Increase gluconeogenesis from lactate and AAs - Increase mobilization of fat via activation of HSL
Biotin. Role, deficiency (and causes) and clinical characteristics, source
1.) B7: CO2 xfer rxns, carboxylation rxns 2.) a.) Causes = raw egg ingestion, IBD, achlohydria (absence or low HCl production/secretion in stomach), anticonvulsant drug therapy, sulfonamide therapy b.) Clinical = depression, hallucinations, myalgia, paresthesia, anorexia, nausea, alopecia, scaly dermatitis, hypo-/hyper-glycemia, impaired lipid metabolism c.) Yeast, liver, kidney, synthesized by microflora
Define constipation in peds population
- Delay or difficulty in passing stools for 2 or more weeks
Effect of angiotensin
- Vasoconstriction - Thirst and release of ADH (retention of water) - Na conservation at PCT - Aldosterone release from adrenals
What is the best anthropometric method for determining CVD risk?
- Waist to Hip ratio - At risk male >= 0.95 - At risk female >= 0.86
When should a baby/toddler/child drink cow’s milk? Why?
- Not until age 1 - Renal solute load is too high (renal failure, dehydration, GI bleed) - Not sufficient in vitamins, minerals, EFAs.
Which PUFAs are better – cis or trans?
- Cis
When is TPN recommended?
- GI tract out of commission
CHO counting for T1DM
- 15 g of CHO is 1 CHO serving/exchange - Each gram of CHO is 4 kcal - Therefore: 1 CHO serving = 60 kcal
You are a pediatrician and a mother comes into your office with a fresh baby at only at 4 days. She is concerned that the newborn may have lost weight. You assess and note that the baby has lost 5% of its birth weight. Is this normal?
- Yes, ~6% weight loss in first few days of life. Will regain by 7 to 10 days.
Vitamin D pathway
- 7-dehydrocholesterol to D3 (in skin with UVB exposure) - D2 and D3 to calcidiol (25-hydroxy vit D) in liver - Calcidiol to calcitriol (1, 25-hydroxy vit D = active form) and calcitroic acid (24, 25-hydroxy vit D = inactive form)
In what populations should B12 supplementation be considered? Symptoms of deficiency?
- Strict veggies, over age 50 (stomach acid decreases), stomach surgery, PPIs, metformin, anesthesia, elevated MCV values, high homocysteine levels, low serum B12 - Symptoms: fatigue/lethargy, depression, poor memory, numbness/tingling in hands/feet.
Why vit D and Ca deficiency following roux-en-Y surgery?
- Duodenum is main Ca absorption site - Vit D required for Ca absorption
Magnesium. Role, deficiency and clinical characteristics
- Role: bone mineralization, cell membranes (bound to PLipids), enzymes (hydroxylation of Vit D in liver) - Deficiency: nausea, vomiting, anorexia, muscle weakness, spasm/tremors, personality changes, hallucinations. Low K and Ca. Deficiency usually associated with alcoholism and renal dz.
When to supplement molybdenum?
- Functions in sulfur metabolism - Symptoms: fatigue, brain fog
Is pre-albumin and albumin an indicator for protein/nutritional status?
- Pre-albumin and albumin = overall prognosis of severity of illness. Not accurate of nutritional/protein status. - Why? Inflammatory cytokine production, infection, surgery, cortisone can decrease albumin. Dehydration falsely elevates albumin. Same factors for pre-albumin.
What are the vitamins that play a role in one-carbon transfer pathway? Function of this pathway? Describe the pathway.
- Folate (B9) is substrate for cobalamin (B12) - Function = production/maintenance of new cells, DNA/RNA synthesis - Pathway: see image in study guide
It was a busy night on the hospital serve. Your team has 5 new patients and handoff was a little sketchy from the night float folks. They left a note to start TPN, bud didn’t tell you which patient. Given the list of patients below, which of the following patient would be the most appropriate patient for parenteral nutrition? A.) 35 yo healthy male who sustained head trauma from a motorcycle accident and is unconscious for his second day in a row. B.) 85 yo male previously healthy with pneumonia and decreased level of consciousness who has intubated last night. C.) 45 yo female who has delivered her 6th child last night. She has had significant bleeding and is being transferred to the ICU from the mother and baby floor. D.) 65 yo male with hx of multiple intubations for COPD exacerbation. He has lost 20 lbs in the last month and he has been on a vent for the last 3 days. The ICU team does not think he will be weaned off the ventilator for at least another week. E.) 22 yo male musician who has aspiration pneumonia from rx drug abuse and etoh. He is currently unable to take nourishment by mouth but is alert and answering questions appropriately after spending the night in the ED and starting IV vanc, levaquin and ceftazidime.
- Answer = D
Recommended CHO source for diabetics
- Whole grains - High ratio of amylose to amylopectin foods - Large, intact, unhydrated starch granules - Viscous fibers - Reduced ripeness - Minimal food processing, cooking and storage
LDL function
- Derived from VLDL, cholesterol-rich with vit E, taken up by liver via LDL receptors, can move cholesterol from arteries
Are vitamin supplements recommended for children?
- Nope, unless specific need
Chemical messengers involved in pathophysiology underlying obesity
- Leptin - Ghrelin - GLP-1 - Adiponectin
Risk factors for obesity
- CVD - DM - CVA - HTN - DM - CA - Gynecologic abnormalities - Osteoarthritis - Gallstones
Micronutrient that is part of vitamin B12
- Cobalt
What is considered successful weight loss maintenance?
- Losing 10% of initial body weight and maintaining that for at least one year.
Effect of dietary fiber
- Slow GI transit time = smaller peak glucose concentrations postprandially - Decrease lipoprotein concentration - May lower all-cause and CVD mortality - May decrease colorectal cancers
Target HDL levels
- Men: >= 40 mg/dl - Women: >= 50 mg/dl
What is chylothorax?
- Abnormal connection b/w pleural space and lymphatic drainage of small intestine - Accumulation of lymph in pleural cavity (milky pleural effusion)
Normoglycemia
70-100 mg/dl fasting and <140 mg/dl at 2 hours post-prandial
During solid introduction in infancy, where should CHOs come from?
- Cereals, fruits and veg - No from juice or other high-sugar snacks.
Pantothenic acid. Role, deficiency and clinical characteristics, source
1.) B5: acyl xfer rxns (CoA) 2.) Numbness/tingling (burning feet syndrome) fatigue – very rare 3.) Egg yolk, liver, kidney
Iron overload. Causes, symptoms, tx
- Causes: overdose, hemolytic anemia, hemochromatosis (incl. hereditary), thalassemia, sideroblastic anemia - Symptoms: vomiting, diarrhea, tissue damage - Tx: phlebotomy, chelation
Effect of aldosterone on sodium
- Conserve sodium = inc in BP
Vitamin D. Role, deficiency and clinical manifestations (children vs adult), sources
- Role: regulator of bone metabolism, primary calcium (and phosphate), other roles emerging (cell differentiation, immunity) - Deficiency: a.) Adult: osteomalacia (softening of bone) b.) Child: rickets - Sources: skin synthesis, liver, fish, fortified dairy, eggs
Is BMI alone to make assessments of disease risk?
- No. BMI + waist circumference
Selenium. Role, deficiency and clinical characteristics, source
- Role: protect cells against destruction by peroxide and free radicals (glutathione peroxidase cofactor), iodine metabolism - Deficiency: a.) Keshan (+ Cocksackie virus infection): cardiomyopathy, CHF, necrosis of heart b.) Kashin-Beck’s: osteoarthropathy, degeneration/necrosis of joints/cartilages of legs/arms c.) Poor growth, myalgias, weakness, loss of pigmentation - Source: grains, meat, poultry, fish, dairy
Causes of chronic diarrhea in child
1.) Osmotic diarrhea - Lactose malabsorption - Excessive juice intake - Fructose intolerance 2.) Inflammatory diarrhea - Infection - Celiac - IBS - Monitor electrolytes here
Supplements that lower risk for AMD (age-related macular degeneration)
- Lutein, zeaxanthin, vit E, vit C, Zn, folate, B6, B12.
What nutrients affect iron?
- Ascorbic acid enhances non-heme absorption - NB! Iron is dependent on Cu to be mobilized from stores - Iron decreases absorption of Zn - Pb inhibits activity of heme synthesis
Nutritional changes for constipation peds pt
- Ensure proper mixing of formula without cereal - Use apple or prune juice
Which protein is digested more quickly?
- Plant-based (whey) - Eggs are digested slowest
When is drug therapy recommended for tx of obesity?
- BMI 30+ or 27+ with comorbidities - With weight loss
Spoon nails indicate
- Malnutrition, esp methionine, cysteine, Fe - DM
Cognitive and sensory deficits
- Thiamin, niacin, pyroxidine, B12 deficiency
Symptom (s) common in hypomagnesemia patients. Which medication can cause this?
- Constipation - Others: RLS, muscle cramps, HTN, HAs, insomnia - Med = PPIs
Insulin regulation
+: increase BGL, increase AAs, increase FAs, incretin hormones, ACh -: leptin, SNS via alpha-2 agonists (eg. NE)
ADA macronutrient recommendation
CHO (45-65 % of total calories)
Protein (10-35% of total calories) – if nephropathy, protein to ~10%
Fat (20-35% of total calories): saturated <10%
Cholesterol <300 mg/day
Dietary fiber: 38 g/day male; 25 g/day female
Cystinuria. What is this a defect in?
- COAL transporter defect. COAL = cysteine, ornithine, arginine and lysine - Loss of AAs in feces and urine
HDL function
- Transfer apo C2 and apo E to chylomicrons and VLDL to regulate their metabolism - Take up cholesterol from LDL and VLDL and phospholipids from VLDL - Reverse transport of cholesterol from peripheral tissues
Diets that are base producing
- vegetables, fruits and tubers
Wasting of muscle
- Protein deficiency
When is mechanical soft food recommended?
- Bad teeth or edentulous
How do kidneys compensate to acidotic diets?
- Removes non-metabolizable anions - Conserves citrate - Increases excretion of ammonium - Lower urine pH as a result = uric acid stone production
Niacin deficiency can be secondary to what other vitamin? What other AA? Drug?
- Riboflavin (B2), pyridoxine (B6) - Tryptophan - Isoniazid
Is vitamin E protective against CVD?
- Most studies show that it is not. When taken with vitamin C, seems to reduce formation of small and large atherosclerotic plaques.
St. John’s wort used for?
- Mild to moderate depression, not neurologic depression
Niacin. Role, deficiency and clinical characteristics, source
1.) B3: electrons xfer rxns as NAD 2.) pellagra – 4Ds – dementia, diarrhea, dermatitis, death 3.) tuna, liver, beef, poultry, mushrooms
Which plaques (hard or soft) are more likely to lead to MI?
- Soft
Risk of HTN in obese
- 2-6 fold increased risk
What affects uptake of fluoride?
- Al, Ca, Mg, Cl reduce uptake - Phosphate, sulfate increase uptake
What is a term birth? Low birth weight?
Term = 37-42 weeks LBW = \< 2500 g (5 ½ lbs)
Statins depletes what important energy producing structure/molecule?
- CoQ10
What is the protein digestibility corrected AA score?
- Ranking of protein based on type and amount of AA in it factoring in how much of it we need. - High = 1.00 (egg white, casein, soy)
Define minerals
- Periodic table elements, not broken down or digested
Most common mineral deficiency
- Mag. 50-75% of population
What macrominerals does our body need? Which is needed most?
- Calcium (most) - P, Mg, Na, K, Cl, S
Nutritional changes to be made in acute diarrhea peds patient
- Mild: normal diet, avoid high sugar beverages, try BRAT diet, increase fluid intake - Moderate: increase fluids, pedialyte - Severe (+ tachypnea, tachycardia, lethargy): hospitalize
Pandemic vs epidemic vs outbreak
- Outbreak: dz occurs in greater numbers than expected in community, region - Epidemic: ID spreads rapidly to many people - Pandemic: global dz outbreak
What is a case-control study?
- Observational study - Compare group of individuals with dz vs those without dz
Sulfur. Role, deficiency and clinical characteristics, sources
- Role: sulfur-containing AAs, vitamins (B1, B7), CoA and glutathione, found in hair, skin, nails as part of keratin - Deficiency: unknown - Source: protein foods
Follicular hyperkeratosis
- Vit A and C deficiency
How should dietary intake be altered during periods of illness or injury?
- Illness/injury = hypermetabolic state - Increase fat and CHO intake to minimize protein degradation and lipolysis
Pathologies related to excess etoh consumption
- Fatty liver (high NADH:NAD ratio = increase lipid synthesis, decreased removal), cirrhosis (acetaldehyde), lactic acidosis, vitamin deficiencies (etoh competes with some dehydrogenases)
Pros/cons for WtoH ratio
- Good for detecting health risks for obese - Not so good for detecting true malnutrition
Short-term and long-term complications for DM
- Short-term: keto-acidosis, hyperosmolarity, lactic acidosis - Chronic: long-term damage to eyes, kidneys, nerves, heart and BVs
Chromium. Role, deficiency and clinical characteristics, source
- Role: normal use of BGL and function of insulin, glucose intolerance factor - Deficiency: glucose intolerance, glucose and lipid metabolism abnormalities, insulin resistance, hyperinsulinemia - Source: fruit, veg, liver, grains
Clinical considerations for chromium
- Improves glycemia in DM patients if already deficient
Should I learn herbal supplements?
Should I learn herbal supplements?
AAs responsible for removing nitrogenous waste
- Alanine and glutamine (also glucose-alanine cycle)
Tetany
- Ca, Mg deficiency
If supplements are required, is a multivitamin superior to individual pills?
- No.
On the glycemic index (GI) scale, which foods are quickly digested and absorbed?
- High on GI (processed CHOs)
Types of enteral nutrition
- Nasogastric (NG) tube: nares to stomach - Gastric tube (G-tube): tube inserted through small incision in abdomen into stomach for long term enteral nutrition. Specific type is PEG, which is percutaneous endoscopic gastrostomy placed endoscopically. - Jejunostomy tube (J-tube): surgically/endoscopically inserted through abdomen into jejunum.
How does protein digestion differ to that of lipids and CHOs?
- Minimal digestion in mouth of protein. Lipids via salivary lipase and CHOs via salivary amylase.
Supplements to tx AMD (age-related macular degeneration)
- Slow progression with vit C, vit E, beta carotene, Zn and Cu. - Note: lutein, zeaxanthin, omega 3 don’t have an effect.
Formula for protein allergy
- Protein hydrolysate - Amino acid-based formula
Characteristics of failure to thrive in child
- Small head circumference - Muscle wasting - Weight loss/poor weight gain
What FAs increased risk for CVD?
- Saturated (long-chain)
What vitamin masks a vit B12 deficiency?
- Folate (B9), can alleviate anemia, but neurologic problems go undetected
Best iron form
- Ferrous
Meds that induce weight gain
- Glucocorticoids, steroids (prednisone) - Antipsychotics/mood stabilizers (lithium, clozapine, risperidone) - SSRIs, MAOIs, TCAs - DM meds (insulin, glyburide, glipizide) - Antiepileptic
NaCl and K recommendation daily
< 2300 mg/day of NaCl
4700 mg/day of K
What percentage of cancer results directly from inheriting genes associated with cancer?
- ~ 5-10%
Goals of T2 diabetes management
- Achieve near-normal BG and BP levels - Improve lipid profiles - Modify nutrient intake and lifestyle to delay or prevent onset of chronic complications of DM
What is an apo-B 48 deficiency?
- Defective chylomicron synthesis leading to TG accumulation in intestinal cells
Which lipoproteins are atherogenic? Non-atherogenic?
- Atherogenic: chylomicron remnants, VLDL remnants, LDL - Non-atherogenic: chylomicrons, HDL, VLDL
Calcium. Role, deficiency and clinical characteristics, sources
- Role: bones/teeth component (~99% found here), cellular processes (membrane permeability), muscle contraction, blood clotting, enzyme activation - Deficiency: rickets, osteomalacia, osteoporosis, tetany - Source: dairy, sardines, greens
Types of failure to thrive
- Source - Primary = social, environmental deficit - Secondary = disease state
What are causative factors for vascular dz?
- HTN - DM - Increased platelet aggregation (may be d/t low fruit, veg, fish) - Hypercoagulable state (obesity, high saturated fat, cholesterol) - Cigarettes - Insufficient exercise
You are in charge of a free clinic in Chicago, IL. You realize that all your patients are at risk of malnutrition and institute a series of cooking classes to help your patients learn to prevent malnutrition. What specific risk factor for malnutrition applies to all your patients? a.) recent weight loss b.) surgical stress c.) iatrogenic d.) lower income e.) increased nutrient loss
- Answer = D
Nutrient deficiencies to monitor for after roux-en-Y surgery?
- Iron (esp Roux-en-Y), B12, folate, Ca, Vit D
In what location does the majority of digestion and absorption of proteins occur?
- small intestine - all enzymes responsible for protein digestion except for pepsin are active here
What are the risks of too much protein?
- Pre-renal azotemia – abnormally high levels of nitrogen-containing compounds - Increased kidney burden - Kidney stones - Osteoporosis
How to assess growth in babies and toddlers? Older children?
- 0-36: Use weight/age, length/age, weight/length and head circumference - 2-18: Use weight/age, height/age, BMI/age (note: BMI is from growth chart, not same as adults – overweight considered 85-94th percentile on growth chart, obese as >95%)
Nutrient hypothesized to decreased length of cold and improve immunological status
- Zinc
Hypothesized conditions resulting from chronic metabolic acidotic state
- Insulin resistance, DM, HTN, CVD, CKD
How does the body deal with nitrogen? Is it stored? How does it maintain balance?
- Nitrogen is eliminated in urine. We cannot store excess AAs. - Therefore N determined by need. - Balance: In (diet) – Out (feces, urine) = 0
Define dietary reference intake (DRI), recommended daily allowance (RDA), adequate intake (AI) and estimated average requirement (EAR).
- DRI: term for reference values to plan and assess nutrient intake. This includes RDA, AI, EAR and TUL. - RDA: average daily level of intake sufficient to meet nutrient requirement of nearly all healthy people (97-98%) - AI: evidence insufficient to develop RDA, this level assumed to ensure nutritional adequacy - EAR: level expected to satisfy needs of 50% in an age group based on scientific review
Selenium deficiency leads to what other deficiency?
- Iodine deficiency
Most common complaint following bariatric surgery
- Constipation: dehydration, decreased fluid post-op, increased water needs, Ca/Fe supplements post-op
What is gestational DM?
- Increased placental hormones = insulin resistance during pregnancy. - Risk for T2 DM following pregnancy is increased
How to differentiate anemia d/t folate vs cobalamin deficiency?
- Symptoms largely indistinguishable. GI manifestations, no neurologic abnormalities. - Use Schilling test
Which form of magnesium is better absorbed?
- Citrate and malitate forms better absorbed than oxide
BMR (basal metabolic rate) for a male and female? How do you factor in level of activity?
- Female (weight in lbs x 10), male (weight in lbs x 11) - Multiply by activity: sedentary (x 20%), light (x 30%), moderate (x 40%), very active (x 50%) - Eg. 125 lb women: 1250 caloreies = BMR. Energy expenditure: 1250 calories x 20% (sitting, typing) = 250 calories, so 1500 calories total per day.
What is USP certification?
- Product evaluated by third party and suitable for sale
What immune cells make active vit D?
- Macrophages and dendritic cells
Diseases that predispose to obesity
- PCOS (hyperinsulinemia, misfunctioning insulin – resistance?) - Hypothyroidism (low metabolism) - Adrenals overproduce cortisol
Who is at risk for T2 DM?
- BMI >= 25 - 1st degree relative - Birth to baby >= 9 lbs - Hx of gestational DM - Physically inactive - AA, Hispanic, Native American, Asian American, Pacific Islander - HDL 250 mg / dl - Impaired glucose tolerance - Elevated fasting glucose - HTN
What is the most effective single intervention for preventing cancer in animal studies?
- ~20-40% restriction/reduction of energy intake from food
Necrotizing enterocolitis. What is it? What newborns are at risk? Nutritional intervention?
- Acute inflammatory bowel disorder characterized by ischemic necrosis of GI mucosa. Fatal often, surgery required. - Preemies, LBW - Parenteral nutrition for 14-21 days post-op, transition to EN, recovery = 2 x RDA for protein and 25% more kcals than normal for age with more frequent feedings
Which vitamins have higher risk for toxicity in general? Why?
- Fat soluble, can be stored in body fat
When is soy formula used?
- Infants with galactosemia, congenital lactase deficiency, family who are veggie - This formula has higher protein content. Phytates from soy and fiber oligosaccharides interfere with absorption of Ca, phosphate, Zn and Fe.
VLDL function
- Transport TGLs, cholesterol and vit E from liver to muscles and other organs. - LPL cleaves more slowly than on chylomicrons. Remnant VLDL go back to liver to make LDL cholesterol.
Describe cobalamin transport in body
- B12 ingested and travels to stomach with R-binder released from salivary gland. B12 with associated proteins. Proteins are degraded in stomach and R-binder (haptocorrin aka transcobalamin I) associates with vitamin B12 to protect it in acidic environment. - Intrinsic factor (from parietal cells) is released from stomach and is passed into duodenum. Proteases degrade haptocorrin in duodenum and IF binds vit B12. - B12 absorbed in terminal ileum where it associates with transcobalamin II in blood.
Ginseng used for?
- Body tone increase, energy levels, reduce stress
Transporter for glucose? Galactose? Fructose?
- SGLT1 (co w/Na): gluc , galactose - GLUT 5: fructose - Basolateral membrane has GLUT 2 for all monosaccharides
Affect of processing grains
- Endosperm (CHO, protein region) kept, while bran (fiber and some vitamins and minerals) and germ (nutrients, fats, vitamins) are removed.
What is the deal with corrected age for premature infants? Til when is this used and for what?
- Must make an adjusted age for premature infant. Eg. If infant born at 32 weeks and is currently 3 months old, the corrected age is 1 month. - Use for all premies until 24 months when assessing growth, nutritional needs, feeding, developmental milestones. Correct height until 42 months and head circumference until 18 months.
Thiamin. Role, deficiency and clinical characteristics, source
1.) B1: decarboxylations of alpha-keto acids and 2-keto sugars, nucleic acid and fatty acid synthesis, membrane and nerve conduction 2.) Beriberi (dry, wet, infantile) and Wernicke-Korsakoff encephalopathy a.) Dry/neuritic (less severe, chronic): wrist/foot drop, loss of tendon reflexes, paresthesia b.) Wet: swelling of heart, tachy, edema c.) Infantile: heart failure, dyspnea, cyanosis 3.) yeast, pork, legumes
Describe how atherosclerotic plaques are formed
- Free radicals attack PUFAs and apoB in LDL creating fragments - Fragmented LDL not recognized by LDL receptor so it binds to other receptors - Scavenger receptor on macrophages bind LDL and create foam cells - LDL more likely to be oxidized the longer it stays in circulation - High LDL increases amount of uptake into endothelium of arteries - Foam cells deposit cholesterol creating plaque
Small lunula on nails
- Likely vit B deficiency
Which omega FAs are pro-inflammatory? Anti-inflammatory?
- Omega 6 is pro-inflammatory - Omega 3 is anti-inflammatory
What happens to excess CHO after intake?
- If glycogen stores are full, it is largely converted to TGLs
According to Women’s Health Initiative study where dietary fat intake was lowered, what was the impact on cancer and CV disease rates?
- Minimal decrease. May indicated that low fat diets are not significant in decreasing rates of these diseases. Type of fat could be important.
In terms of antioxidant defense, which are more effective at reducing markers of oxidative stress: whole fruits/veg or supplements from these?
- Whole food source is more beneficial.
Cortisol’s effect on glucose state
- With glucagon, activates key gluconeogenesis enzymes - Maintains glucose production from protein and facilitates fat metabolism
Diets that predispose susceptible individuals to gout
- high meat/low dairy
Chylomicron function
- Transport fat-soluble molecules (TGLs, cholesterol, A, beta-carotene, C, D, E, K) from intestine to other organs. Cleavage by LPL to release molecules to various sites.
Methods for nutrition assessment
- Direct: examine individual, measure objective criteria - Indirect: use community health indices that reflect nutritional influences
Nitrogenous waste is mostly excreted where?
- Urine
Stages in stages of change model
- Precontemplation: no intention to change over next 6 months 2. Contemplation: aware of problem, thinking about change in next 6 months 3. Preparation: intends to change within next 30 days, may have made small changes 4. Action: actively engaged in behavior change for less than 6 months 5. Maintenance: engaged in behavior change for at least 6 months
Mercury poisoning effect
- Ataxia, visual problems, mental retardation, NM problems
Define BMI for adult obesity vs that of childhood obesity
- Adults: >30 - Children: >95th percentile on BMI growth chart
Phentermine/topiramate
- Phentermine: decrease appetitie - Topiramate: anticonvulsant, decrease appetite, prolongs satiety feeling - Contraindicated in CVD, HTN, glaucoma, hyperthyroidism, drug abuse, MAOI use within 14 days
Only AA completely oxidized for energy
- Leucine to acetyl-CoA
What is the plasma protein responsible for mobilization of iron? What mineral is it dependent on?
- Ceruloplasmin, dependent on Cu
Which populations are at-risk for HTN?
- Obese - DM - Advanced age - Lower SES - Sedentary lifestyle - AA, Hispanic – why? Thrifty gene? - Alcohol abuse - Family hx
Do T2 diabetics have insulin deficiency?
- Not complete, but mild
Function of VEGF in cancer
- mediates cancer cell proliferation and tumor growth by inducing angiogenesis - strong association to aggressive cancers
Iodine. Role, deficiency and clinical characteristics, source
- Role: thyroid hormone synthesis - Deficiency: enlarged thyroid gland, myxedema, cretinism, increased lipids a.) Hypothyroidism: goiter, decreased cold tolerance, overweight, coarse hair - Source: iodized salt, seafood
Examples of microminerals
- Cr, Cu, Fl, I, Fe, Mn, Mo, Se, Zn
Cracked lips
- Vit B2 deficiency or dehydration
Cobalamin. Role, deficiency and clinical characteristics, source
1.) B12: methylation of homocysteine to methionine (needs 5-methyl THF therefore B9), methylmalonyl CoA to succinyl CoA, myelin sheath production 2.) Pernicious anemia, neurologic deterioration, cognitive impairment 3.) Meat, fish, shellfish, poultry, milk
Describe adaptation to fasting/starving
- Glucagon up when fasting state is occurring - Hepatic glycogen stores used first for glucose - AA substrates used in liver and kidney for gluconeogenesis - After ~2 days of starvation, brain switches to ketone bodies (from liver) for fuel, RBCs use glucose
ABCD of nutrition assessment
A: anthropometric measurements (weight, height, BMI, waist, skin fold, BP etc.) B: biochemistry, medical tests C: clinical D: dietary
What factors are associated with cell growth, carcinogenesis and tumor production?
- Insulin (or c-peptide), IGF-1, VEGF, estrogen, cytokines
Antioxidant enzymes in the body and their cofactor requirement
- Superoxide dismutase (Cu, Zn, Mn) - Glutathione peroxidase (Se) - Catalases
Function of plasma proteins
- Oncotic pressure - Transport - Clotting - Enzymatic rxn - Nitrogenous waste removal
Difference between glycemic index and load
- GI: How quickly a food containing 50 g of CHO causes blood sugar level to rise - Glycemic load: GI x CHO content in serving divided by 100. Accounts for portion size.
Function of vitamins
- Cofactors in enzymatic rxns - Regulatory molecules - Antioxidants
Insulin actions
+: glucose uptake (muscle, adipose), AA uptake and protein synthesis, FA synthesis and esterification, glycogen synthesis, glycolysis -: BG levels, gluconeogenesis, lipolysis, proteolysis
Is breast milk sufficient to support fat requirements by infant?
- Yes. Formula requires supplementation with DHA and EPA omega-3s.
How to check fat store status? Muscle status? Fluid status?
- Fat store: orbital fat, triceps skin fold, fat over ribs - Muscle store: temporalis, pectoralis/delts, interosseous, lats, traps, quads, gastroc - Fluid status: ankle/sacral edema, ascites
Diarrhea
- Protein, niacin, folate, B12 deficiency
Clinical features of malnutrition
- Loss of adipose in triceps, chest, hands and shoulder - Muscle wasting at deltoids and quads - Nail, skin, mouth and eye changes
Which FA is most detrimental to health? Why?
- Trans fats - Increases LDL, decreases HDL and increases inflammatory cytokines (IL6, TNF-alpha, CRP), endothelial dysfunction
What is a methyl trap? What deficiency causes this?
- B12 is methyl acceptor. If deficiency here, methyl is trapped at MTHF (methyltetrahydrofolate).
Glucose, lipid targets in diabetes
Glucose
Fasting: 90-130
Random: < 180
Hgba1c: < 7%
Lipids
HDL >50 mg/dl
LDL <100 mg/dl
Trig <150 mg/dl
Remembering your sim lecture on lab testing and your supplemental nutrition lecture on lab testing, which of the components of a CMP would be least useful in a nutritional assessment? a.) electrolytes b.) liver function (AST and ALT) c.) protein status (total protein and albumin) d.) calcium
- Answer = B
Hallmarks of cancer
1.) Evasion of growth inhibitory signals 2.) Evasion of apoptosis 3.) Unlimited replication 4.) Sustained angiogenesis 5.) Invasion and metastasis 6.) Growth signal autonomy
Medications that decrease absorption of Zn
- Gastric acid neutralizing/decreasing drugs – ie. antacids, H2 receptor blocker meds, PPI
Clinical considerations for iodine supplementation
- Hypothyroidism
Anemia, numbness in hands and feet
- B12 deficiency
You are counseling a patient about losing weight. You say with every ____ kg loss in weight, your systolic BP drops _____ mmHg.
- 10 kg, 5-20 mmHg
Characteristics of metabolic syndrome from insulin resistance. How many of these characteristics to diagnose?
1.) Elevated TGLs 2.) Low HDL 3.) HTN 4.) Elevated BGL 5.) Increased intra-abdominal fat/central obesity - Must have 3 out of 5
What can mostly white nails with darker rims indicate?
- Liver problems (hepatitis)
4 stages of human milk expression
1.) Colostrum (first days): low fat, high protein (immunological substances)/vit/minerals and electrolytes 2.) Transition (7-14 days post): fat, calories and lactose increases 3.) Mature milk (2 weeks-7 months post): above remain high 4.) Extended: macronutrients similar to previous stage, micronutrients gradually decreasing
Obesity tx
- Alter diet - Increase physical activity - Behavior therapy - Pharmacology - Surgery
Increased bleeding times
- Vit K deficiency
Classes of lipoproteins
- Chylomicrons - LDL - HDL - VLDL
Swollen/slick tongue
- Riboflavin, niacin, folate, B12, Fe or protein deficiency
Hormones of satiety and hunger, functions – include location of release
- CCK: SI, triggered by feeding and causes release of digestive ez from exocrine pancreas, also bile from GB - PYY: pancreas, response to elevated levels of BG - GLP-1: increases insulin secretion/sensitivity, decreases glucagon secretion, inhibits acid secretion and gastric emptying of stomach - Leptin: adipose, released upon signal that we have eaten enough or fat stores are sufficient, binds to receptors in hypothalamus = stop eating - Ghrelin: stomach and pancreas (epsilon), stomach empty causes secretion and increases hunger, gastric acid secretion and GI mobility
Your patient is on a vent and was just admitted to the ICU for pneumonia, sepsis, and respiratory failure. Because this patient has severe COPD and was on the vent for 10 weeks last time they were in the hospital, you decide to provide nutritional support at the earliest opportunity. What method of delivery would you be most likely to use? a.) NG tube b.) J-tube c.) TPN d.) Pureed diet e.) Full diet
- Answer = A
Effect of the following fats on cholesterol synthesis: a.) saturated, b.) MUFA, c.) PUFA
a.) raises b.) neutral c.) will not raise – so neutral?
Phosphorus. Role, deficiency and clinical characteristics, sources
- Role: bones/teeth component, cell membranes, phospholipids, anion in cell, ATP production, acid-base balance - Deficiency: NM skeletal, hematologic, renal manifestations, osteomalacia - Source: meat, poultry, fish, eggs, dairy, legumes
Diets that are neutral
- refined sugars, fats and nuts
Cold hands
- Mag, B12, Fe or niacin deficiency
T/F. Digestibility of plant protein is higher than animal protein.
- False, lower.
Types of thickened liquids
- Thin liquids: water or juice - Nectar thickened: milkshake thick - Honey thickened: honey, cream soup - Pudding thickened: holds shape on spoon
What factors are protective against vascular dz?
- Higher dietary fiber - Folate - Anti-oxidants - Vit K - Lower sodium - Higher intake of K and mag - Fish intake
What is the most common dietary deficiency? Susceptible groups? Symptoms of this deficiency? Lab findings?
- Fe. Also most common cause of anemia worldwide. - Susceptible: infants/young children, adolescents, premenopausal women, pregnant women - Symptoms: pallor, dizziness, palpitations, pica, fatigue, dyspnea, angular stomatitis - Lab: decreased Hb, microcytic anemia, decreased serum Fe, increased serum TIBC, decreased serum ferritin
Foods with high K
- Potato, spinach, avo
Vitamin used to tx hypercholesterolemia
- Niacin (B3)
Paresthesias/numbness in stocking-glove distribution
- Thiamin deficiency (beriberi)
Fatigue and pallor
- Fe deficiency
Why are vit K shots needed at birth?
- Placental transfer of vit K is low, GI synthesis is deficient in newborns d/t lack of microbiota in gut - Injection give to prevent bleeding or hemorrhage.
When is tube feeding recommended?
- Dysphagia, cannot swallow – prevents chocking or aspiration
Foods that are good for brain health
- Shellfish (omega 3s, B12) - Whole grains - Dark leafy greens - Nuts - Beans
Minerals that causes copper deficiency
- Zn = decreased Cu absorption - Mo = increased Cu excretion
Xerosis of skin and eyes, night blindness
- Vit A deficiency
Orlistat
- Lipase inhibitor that blocks fat absorption from gastric/duodenal mucosa - Side effects: flatulence, fecal discharge, fecal urgency, incontinence, fatty stool, oily spotting
How many times per week should HTN patient engage in exercise? What form?
- Moderate to vigorous exercise 3-4 times per week for 40 minutes - Any form – aerobic or resistance
Leptin obesity hypothesis
- Leptin resistance. Years of over-stimulation of leptin receptors. Leptin increased, activity diminished. No signal to stop eating.
Appropriate Ca:Mg supplementation
- 1:1 or 2:1
White specks on nails
- Zn deficiency
Hawthorn used for?
- Heart-related conditions
Ways to determine how much feeding?
- Harris Benedict equation - Indirect calorimetry - Resting energy expenditure. Stress factors multiplies REE for critical illnesses.
Why is it that higher sodium diet allows for higher glucose uptake?
- SGLT1 transporter (co w/Na)
Folic acid. Role, deficiency and clinical characteristics, source
1.) B9: source of one carbon moieties (DNA synthesis), AA metabolism 2.) Megaloblastic anemia, neural tube defects, vascular dz 3.) Brewer’s yeast, liver, green leafy veg, lima beans
Grading of atherosclerotic vascular dz
- Mild: small tears/fatty streaks - Moderation: accumulation of cholesterol, Ca and cell debris bulging into lumen - Severe: thrombus formation after plaque rupture = clot downstream
Ginko biloba used for?
- Aging conditions such as poor circulation and memory loss
Define glycogenesis, glycogenolysis, glycolysis, gluconeogenesis. During what state (fed vs non-fed) does each occur at higher rate?
- Glycogenesis: glucose – glycogen in fed state - Glycogenolysis: glycogen – glucose in non-fed state - Glycolysis: glucose – pyruvate (if o2) in fed state - Gluconeogenesis: glucose made from non-CHO sources (lactate, pyruvate, glycerol, certain AAs) in non-fed state
Why could high protein diet predispose one to osteoporosis?
- Calcium pulled out of bones to maintain neutral pH has been hypothesized.
Deficiency in linoleic acid (omega 6) results in
- Dry scaly skin rash, increased infection, impaired wound healing, immune dysfunction
Pale fissured tongue
- Fe deficiency
How much should a baby weigh by 6 months and 1 year?
- Double weight by 6 months, triple by 1 year.
Signs of severe dehydration
- Extreme thirst - Extreme fussiness/sleepiness in infants children. Irritability/confusion in adults - Very dry mouth and MM - Lack of sweat - Little urine, dark yellow or amber - Sunkey eyes, sunken fontanels in infants - Low BP, tachycardia
T/F. Behavioral patterns is the leading contributor to premature deaths.
- True. ~40% of all premature deaths are d/t behavioral patterns.
Contents of lipoprotein
- TGLs, cholesterol bound to FAs, free cholesterol, phospholipids, proteins
Levels of public health preventions/interventions
- Primordial: population level (eg. ban smoking in restaurants) - Primary: intervention for susceptible population (eg. low CHO in AA population) without disease - Secondary: intervention for diseased individual who is asymptomatic - Tertiary: intervention for diseased individual who is symptomatic
What does a floating stool indicate?
- Decreased/absent fat absorption. Therefore fat soluble vitamins are impacted.
What is glycemic index?
- Measure of rise in glucose and the timeframe over which this rise occurs after CHO consumption. Lower GI foods affect blood sugar and insulin levels less as they require more processing.
What are the guidelines published in the Dietary guidelines for Americans 2010?
- Balance calories with physical activity - Consume more fruits, veggies, beans and nuts - Each whole grains, fat-free and low-fat dairy - Increase intake of fish/seafood - Consume less Na, saturated fats, trans fats, cholesterol, added sugars and refined grains
Limitation of PPN than TPN
- Limited by osmolality??? - Short term use (less than 2 weeks) - Frequent rotation of site required - Volume too high for vein to sustain
Glucagon actions
+: glycogenolysis, lipolysis (activation of hormone-sensitive lipase), gluconeogenesis, ketogenesis -: synthesis of glycolytic enzymes, rate of glycolysis, glycogen synthesis
Lab studies to order to assess for nutritional status
- CBC - BMP - Prealbumin - Micronutrient levels - Lipid panel
Examples of ultratrace minerals
- Ni, Si, V, As, B, Co, Sn, Li, Al, Cd, Hg, Pb
Ratio of K/Na in Western diet. Effect of low K
- Ratio of K/Na is 0.4/1 - Effect: increase BP, increase salt sensitivity, increase bone turnover, increase risk for kidney stones
Can one recover from fatty liver? Liver fibrosis? Cirrhosis?
- Fatty liver: yes, fully - Fibrosis: yes, but with scar tissue remaining - Cirrhosis: irreversible
Describe LDL receptor expression with high vs low cholesterol diet
- High cholesterol = fewer receptors expressed with more circulating LDL - Low cholesterol = more receptors expressed with low circulating LDL
Screening tools for nutritional deficiencies
- Nutritional risk screening tool (NRS-2002) - Malnutrition universal screening tool (MUST) * do you think we should know much else about these?
Five stages of epidemiological transition. Describe each, age expectancy
1.) Infectious dz/famine (before 1850s): infections, deficiencies - ~30s 2.) Receding pandemics (1850s): improved sanitation, decrease in infections, higher salt – 30-50s 3.) Degenerative dz (1950s): improved SES, improved diet / activity – 50-55 4.) Delayed degenerative (1970s): decreased risky behaviors, improved tx - ~70s 5.) Inactivity, obesity, diabetes (1990s)
Lipid-soluble antioxidants
- Vit E (alpha- and gamma-tocopherol) - Alpha- and beta-carotene - Lycopene - Lutein
Echinacea used for?
- Strengthen body’s immune system, used for prevention against colds and flu
Bleeding gums/gum dz
- CoQ10, vit C or folate deficiency
BMI scale
- 30-40: obese (grade 2) - >40: very obese (grade 3)
Clinical considerations for selenium supplementation
- hyperlipidemia, hypothyroid - children with poor growth, individuals following raw food or vegan diet, microcytic anemia (iron deficiency)
3 essentials to motivational interviewing
- Conversation - Collaborative - Evocative
Copper. Role, deficiency and clinical characteristics, source
- Role: utilization of iron stores, lipids, collagen, tyrosinase (melanin synthesis), NT synthesis, antioxidant (SOD), gene expression - Deficiency: hypochromic anemia, neutropenia, hypopigmentation, demineralization of bone, impaired immune function - Source: liver, meat, shellfish, grains, legumes, eggs
MNA tool
- Screening and assessment tool that identifies geriatric patients age 65+ who are malnourished or at risk for malnutrition
What triggers renin release?
- Low BP, low plasma volume, low plasma Na, edema, activation of renal nerve
Drugs that may lower melatonin
- NSAIDs, beta-blockers, agents lower vit B6 in body, diazepamn, estradiol, somatostatin, temazepam, verapamil, vit B12
Transverse linear depressions on fingernails
- Severe infection, malnutrition, zinc deficiency, HoTN, Hocalcemia, uncontrolled DM
Glucagon regulation
+: low blood glucose, increased circulating AAs, SNS via alpha-2 agonists (eg. NE) -: hyperglycemia, increased circulating FAs, somatostatin
Deficiency in alpha-linolenic acid (omega 3) results in
- Neurologic abnormalities: numbness, paresthesia, blurred vision, difficulties walking
What is one of the earliest markers from lab during a nutritional deficiency?
- Total lymphocyte count
What is the recommendation for breastfeeding cessation and introduction to solids?
- 6 months. Wean off. Depending on physical activity of child (raise head, crawling etc), will determine texture of food and also feeding style.
Which vitamins are water soluble? Fat soluble?
- Water: B, C - Fat: ADEK
Most fatty acids have how even or odd carbons?
- Even
How to make fat soluble vitamins/nutrient water soluble? Vice versa?
- Micellization makes it water soluble - Liposomes makes it fat soluble – reduces toxicity at higher dosages
Function of proteins
- Growth, maintenance and movement - Enzymes - Hormones - Immunity - Gene transcription, translation regulation - Fluid/electrolyte balance - Acid/Base balance - Transport, storage
What is considered healthy intake of etoh?
- No more than 2 drinks/day for men and 1 for women
Dietary assessment Qs
- Favorite lunch, how often do you eat it? - What is on grocery list? - Frequency of cooking? - What do you cook mostly? - Frequency of grocery store visits?
Very low calorie diets. Who are they approved for? #calories per day?
- Approved for those with BMI 30+ with obesity co-morbidities - 800 or fewer calories per day to promote rapid weight loss while maintaining lean muscle mass. High protein.
Xerosis of skin
- EFA deficiency - If skin and eyes xerosis + night blindness = Vit A deficiency
Vitamin K. Role, deficiency and clinical manifestations (children vs adult), sources
- Role: blood coag (1972), bone growth, post-translational mod of proteins, Gla protein in skeletal tissue and kidney - Deficiency: a.) Adults: defective blood clotting b.) Children: hemorrhagic disease of newborns - Sources: gut flora, dark green leafy veg
Easily pluckable, corkscrew hair
- Protein and/or vit C deficiency
What can very pale nails indicate?
- Anemia, CHF, liver dz, malnutrition
What vitamins are considered energy releasing and why?
- B vitamins. Coenzymes in the Krebs (and feeder) cycles.
Four periods of growth in peds population
- Infancy: birth-2 - Preschool: 3-6 - Middle: 7-10 - Adolescence: 11-18
Is it normal for a breastfed infant to not have a BM for a few days?
- Yes, up to one week
Bone tenderness
- Vit D deficiency
Effect of protein/fat to CHO absorption
- Slows absorption
Vitamin used to tx Maple Syrup urine dz
- Thiamin (B1). Can also tx some megaloblastic anemias and lactic acidosis
What is chyluria?
- Abnormal connection bw urinary tract and lymphatic drainage system of intestines - Milky urine
Evolutionary perspectives on obesity per Speakman
- Adaptive: positive selection by natural selection for those with fat accumulation historically, fat deposition = survival, selection of thrifty genes, modern times we have abundance of food therefore disadvantageous 2. Maladaptive: obesity never advantageous, it is rare occurrence, evolutionary exposure to cold = high levels of brown adiposte (thermogenic), ability to burn off excess energy without obesity 3. Neutral: contradiction to thrifty gene, drifty gene, obesity never advantageous to humans, many genes involved in weight reduction, lower and upper limit set by starvation and predation respectively, upper intervention point genes are subject to drift/mutation
Besides lung involvement, where else are pathologies seen with CF patient?
- Pancreatic enzymes are prevented from being released = GI symptoms such as foul smelling stools, flatulence, cramping, steattorhea, fat malabsorption = fat soluble vitamin deficiency. - Liver tubules obstructed = liver dz = cirrhosis
Lead poisoning effect
- Neurological, kidney, hematological damage (decrease in heme synthesis d/t d-aminolevulinate dehydratase and ferrochelatase decrease)
CV cocktail list
CV cocktail list
Black cohosh used for?
- Menopausal conditions, painful menstruation, uterine spasms, vaginitis
What are the two forms of vitamin K and their functions?
- K1: by plants, role in clotting - K2: animal source, role in calcium utilization
Arthralgia or joint swelling
- Vit C deficiency
When should parenteral nutrition be given to infants?
VLBW (< 1500 g) and ELBW (< 1000 g)
Give within 24 hours of birth
Zinc. Role, deficiency and clinical characteristics, source
- Role: energy metabolism, protein synthesis, collagen formation, alcohol detox, CO2 elimination, sexual maturation, taste & smell, immunosuppression - Deficiency: poor wound healing, subnormal growth, anorexia, abnormal taste/smell, changes in hair/nail/skin, retarded repro system development - Source: oysters, wheat germ, beef, liver, poultry, whole grains
What is folate deficiency during pregnancy associated with?
- NT defect. Deficiency in first trimester.
What malnutrition screening score indicates a risk for malnutrition? How is this score assessed?
- Score of 2 or more - Ask the following questions: 1.) Have you lost weight recently without trying? If so, how much? 2.) Have you been eating poorly because of a decreased appetite?
Cambridge abx resistance trial result
- When person takes probiotics with antibiotics (serially), less likely to become abx resistant.
Pyridoxine acid. Role, deficiency and clinical characteristics, source
1.) B6: coenzyme in transamination, decarboxylation, trans-/de-sulfhydration rxns 2.) Dermatitis, glossitis, convulsions, fatigue, seizures, neurological dysfunction 3.) Liver, fish and meat
What states does the body require additional protein clinically?
- Critically ill (immobilization, pneumonia, ulcerative colitis) - Burns/multiple traumas - Why? These conditions are characterized by hypermetabolic state!
Types of fiber, function
- Soluble: oats, legumes, fruit, Metamucil. Function = slow gastric emptying, increases bulk, lower LDL by interfering with cholesterol absorption - Insoluble: whole grains, bran, legumes, veggies, fruit. Function = increase water in GI, speed colon emptying.
What can rippled/pitted nails indicate?
- Early sign of psoriasis or inflammatory arthritis
Delayed wound healing
- Zinc deficiency
Type of lipoprotein and function
- Endogenous cholesterol and TGs are converted into IDL, LDL and VLDL. These are the bad cholesterol and deliver cholesterol to tissue. - HDL (good cholesterol) returns cholesterol and various lipids back to liver
Clinical considerations for zinc supplementation
- Immunity, SOD production, T & E production, calcium absorption
Compare and contrast physical vs emotional hunger
- Physical: gradually, different foods, physical hunger cues (stomach growling), physical need for nourishment, deliberate choices and awareness during eating, continues or stops in response to satiety, feelings of nourishment and satisfaction. 2. Emotional: suddenly, specific food, above neck, taste for particular foods mind is thinking about, emotion pairing, disconnected eating, overeating results d/t disregard of satiety signals, feelings of guilt.
Effect of diet on Ca
- High Na = increase urine excretion - High protein = pull Ca out of bone to maintain pH = excretion - Caffeine = increase excretion, decrease absorption - Alcohol = reduced absorption - Fruit / veg = basic = increase pH = decrease excretion - Boron with mag = increase excretion
Which antioxidants protect lipid-rich environments in body? Aqueous environments?
- Lipid-rich: alpha-tocopherol (Vit E) and carotenoids (vit A derivatives) - Aqueous: albumin, uric acid, ascorbic acid
Dementia
- Thiamin, niacin, B12
Why folate deficiency following roux-en-Y surgery?
- Vit B12 required for absorption of folate? Not sure how or why?
Fluoride. Role, deficiency and clinical characteristics, source
- Role: mineralization of bone and teeth - Deficiency: dental caries, bone problems - Source: fish, meat, legumes, grains, drinking water (fortified)
Describe toxicity of vitamin K
- Natural forms are non-toxic - Synthetic form (menadione) combines with sulfhydryl groups leading to oxidation of membrane phospholips leading to hemolytic anemia and hyperbilirubinemia.
Sodium. Role, deficiency and clinical characteristics, sources
- Role: water movement, electrolyte (cation)/pH balance, nerve transmission, muscle contraction - Deficiency: anorexia, nausea, muscle atrophy - Source: salt, meat, seafood, dairy
What is the primary substrate for gluconeogenesis?
- Protein (certain AAs have COOH side-chain)
Dietary supplement health and education act 1994
- No evidence of efficacy required - No evidence of safety required - No label claim for treating or preventing dz - No mechanism for rapid FDA intervention
Diets that are acid producing
- meat, dairy, eggs, lentils and grains
Riboflavin. Role, deficiency and clinical characteristics, source
1.) B2: electron xfer rxns (FAD) 2.) Pellagra-like symptoms (decreased synthesis of niacin – secondary niacin deficiency): cheilosis, angular stomatitis, glossitis, hyperemia, dermatitis, edema of mouth 3.) liver, beef, dairy
Clubbing of fingernails
- CF, lung CA, Hodgkin’s lymphoma, cirrhosis, Crohn’s, UC, Graves dz
What is an interventional/RCT (randomized control trial)?
- Take cohort and assign individuals to intervention group or control group. Treat/manipulate one group and leave other group alone and see if hypothesis of treatment/manipulation to intervention group changes risk / outcome etc. - Gold standard
Vitamin A. Role, deficiency and clinical manifestations (children vs adult), sources
- Role: vision (retinal = prosthetic group for rhodopsin in rods), metabolites involved in growth failure, growth / differentiation of epithelial, nervous, bone tissue and immune function, transcriptional regulator - Deficiency: a.) Adult: night blindness, xeroderma (dry skin), xerophthalmia, Bitot’s spots (white accumulation in eye) b.) Child: poor dark adaptation, xerosis (dry skin), keratomalacia - Sources: liver, dark green leafy veg, orange fruits and veg
Factors that have lead to the obesity epidemic in the US
- Less than half of Americans meet CV recommendations for exercise - Portion sizes - Refine CHO consumption - Media, marketing
When determining assessing an obese individual, what else besides anthropometric and clinical data must be assessed?
- Social hx - Family hx - Food/nutrition behavior
T/F. HFCS is more similar to fructose.
- False, more similar to sucrose (glc + fructose)
Causes of cobalamin deficiency
- Pernicious anemia: parietal cells fail to secrete IF - Diphyllobothrium latum (tapeworm from raw fish) - Non-supplemented vegan diet
Should we learning apolipoprotein function?
Should we learning apolipoprotein function?
What are the limitations of using BMI to assess for obesity or overweight?
- Measure of body weight, not excess fat. Doesn’t take into account lean mass or distribution of fat. - Loses accuracy in very and poorly fit - Loses accuracy in very old
Vitamin E. Role, deficiency (and causes) and clinical manifestations (children vs adult), sources
- Role: antioxidant (membrane integrity prevents oxidation of UFAS), enzymatic activities, gene expression, cell signaling, retinal degeneration, ceroid pigment accumulation, hemolytic anemia, neurological issues - Deficiency: abetalipoproteinemia (rare genetic dz), fat malabsorption a.) Children/adult: neuropathy, myopathy b.) Infants: anemia - Sources: vegetable oil, nuts, green vegetables
Central concept behind motivational interviewing
- Ambivalence – identify, evaluate, resolve
Oxidative pathway for fatty acid degradation
- Beta-oxidation - Acetyl-CoA (from even chain FAs) into Krebs - Propionyl-CoA (from odd chain FAs) converted to succinyl-CoA into Krebs
Common biochemical indices for malnutrition
- D, B12, folate, A, C, B6, thiamine, Ca, Zn, Fe
Factors affecting absorption of P
- PTH and Vit D stimulate absorption - Grains decrease bioavailability - Mag, Al, Ca impair absorption
Why is Fe deficiency common following roux-en-Y surgery?
- Low gastric acid prohibits iron cleavage from food - Absorption inhibited as no nutrient exposure to proximal jejunum or duodenum - High intolerance to iron-rich meats following surgery
3 stages of folate deficiency
- Decreased serum folate 2. Decreased serum folate, hypersegmented neutrophils 3. Decreased Hb, macroovalocytes, increased MCV
Which FAs increase LDL?
- Saturated (long-chain) and trans-fats
Complications of enteral feeding
- Clogged tubes - Aspiration/regurgitation - Ileus - Diarrhea - Infection
Physician fish oil study
- 22K male physicians q 12 years - 1 serving/week of cold water fish - Risk of cardiac arrest (sudden death) decreased by 50%
How to diagnose pernicious anemia
- Macrocytosis on CBC - Elevated methylmalonic acid and homocysteine levels - Schilling test (B12 and IF deficiency)
Clinical considerations of vit D supplementation
- Muscle weakness, depression, inflammation, osteopenia/osteoporosis
Effect of hypokalemia on BP and risk of stroke
- Increases BP and risk of stroke via RAS and vasoconstriction
Water-soluble antioxidants
- Vit C - Urate - Glutathione - Bilirubin
Current USDA food guide
- Myplate.gov
Causes of lipid malabsorption. Treatment?
- Pancreatic pathologies (lack of, CF, insufficiency) - Shortened bowel, celiac, Crohn’s - Bile duct obstruction • Tx = milk and coconut oil containing MCTs
Iron. Where is most iron in body? How is it stored and where? Where is the point of regulation? What is the difference between heme and non-heme iron?
- Most in Hb - Stored as ferritin in liver, spleen and bone marrow - Absorption is point of regulation. Not able to excrete iron readily or easily. - Heme iron is that found in animal sources. Non-heme iron is that found in both animal and non-animal sources.
In terms of behavior modification weight loss programs, which are more successful – individual or group?
- Individual
What type of FAs are DHA and EPA?
- Omega 3s. AHA recommends pts with CHD should consume 1 g of this per day preferably from oily fish.
Chronic supplementation of Zn leads to what other nutrient(s) deficiency? What pathology does this lead to?
- Excessive intake leads to decreased Cu absorption - Cu required for Fe mobilization, so Zn toxicity leads to sickle cell anemia d/t Fe deficiency
Selenium supplements have been show to reduce what pathology?
- Cancer according to early study, later study disproved
Energy from 1 g CHO vs 1 g fat vs 1 g etoh
- CHO: 4 kcal/g - Fat: 9 kcal/g - Etoh: 7 kcal/g
Organs able to convert gluconeogenic AAs to glucose
- Liver and kidney
Red scaly skin on face
- Vit B2 deficiency
Cell type associated with subclinical inflammation in white fat in obesity
- Macrophages
Iron deficiency anemia lab results
- Low H&H, low MCV (microcytic anemia), low serum Fe, low ferritin, high RDW
During a clinical assessment and physical exam what areas of the body should be paid special attention to for detecting nutritional deficiencies and malnutrition? Which is the assessment advantageous over others? Limitations?
- Hair, angles of mouth, gums, nails, skin, eyes, tongue, muscles, bones and thyroid gland - Advantage: fast, easy, inexpensive, non-invasive - Limits: doesn’t detect early cases
What is the best anthropometric measure that predicts mortality?
What is the best anthropometric measure that predicts mortality?
Molybdenum. Role, deficiency and clinical characteristics, source
- Role: metabolism of purines/pyrimidines/pteridines/aldehydes and oxidation - Deficiency: if diet high in antagonists such as Tungsten, long term TPN a.) hypermethioninemia, increased urinary xanthine (low blood), sulfite excretion, low blood uric acid b.) esophageal cancer - Source: soybeans, lentils, grains
Methods of measuring body fat
- Underwater weighing - Whole-body air displacement plethysmography - DEXA - Near-infrared interactance - Bioelectrical impedance
Genetic diseases related to Cu metabolism
- Wilson’s dz: defect in transporter for excretion = accumulation in liver, brain (mental degeneration), kidney leads to damage of organs - Menke’s syndrome: defect in transporter to fetus or through intestine after birth = slow growth, mental degeneration, kinky white hair
Iron. Role, deficiency and clinical characteristics, source
- Role: component of Hb and Mb for O2 transport, enzyme component - Deficiency: fatigue, anemia, palpitations, dysphagia - Source: liver, meat, legumes, leafy green veg, fortified grains
How do diets between pre-agricultural, current Western and Mediterranean diets differ?
- Highest CHO consumption in Western, with highest fiber in pre-agricultural - Protein highest in pre-agricultural, same in Western and Med diets - Fats highest in Med diet (high in monounsaturated and omega 3 polyunsaturated). Lowest fat consumption in pre-agricultural with high omega 3 polyunsaturated consumption. Western diet is high in consumption of saturated fats.
Which form of vitamin D is more active – D3 or D2?
- D3
Chloride. Role, deficiency and clinical characteristics, sources
- Role: anion, maintain pH, enzyme activation, gastric acid - Deficiency: anorexia, failure to thrive, lethargy, metabolic acidosis - Source: salt, seafood, dairy, meat, eggs
Is linolenic acid the bad or good PUFA?
- Good omega 3 - Linoleic is the not so great omega 6
Function of IGF-1 in cancer
- suppresses apoptosis and initiates cell cycle progression (G1 to S)
Compare lab results for B12 and folate deficiency
- Both low H&H - MCV high or normal in B12 deficiency; high (macrocytic) in folate deficiency - High serum Fe - High ferritin - High RDW - B12 (down or normal), high in folate deficiency - Folate high in B12 deficiency, folate low in folate deficiency
Evening primrose oil used for?
- Arthritis, PMS, CV dz, hyperactivity in children
You are in an office setting. Your next patient is an eighteen year old female who has completed 3 marathon’s this year. You wonder if you should be worried about her weight and body fat percentage. Of the screening tools easily available in your office, which would be the most readily available? a.) BMI b.) Waist to hip ratio c.) DEXA d.) NRS-2002 e.) Underwater weighing
- Answer = A
If patient is diabetic and overweight, what should the weight loss goal be?
- 10% of current weight or to achieve a BMI
Glycemic index affect on satiety, obesity, risk for T2 DM, coronary heart dz
- Satiety: reduced, rapid return of hunger - Obesity: increased prevalence - T2 DM: increased risk d/t insulin resistance - CHD: increased risk d/t dyslipidemia and oxidative stress (inflammatory cytokines and CRP)
Diarrhea and dysgeusia
- Zn deficiency
Tx of GE reflux in infants
- Common in infants, usually resolves in 10-12 months - Not a problem unless it interferes with growth. Could be from allergy to mom’s milk or formula. - Don’t thicken formula with cereal! This causes rapid weight gain and less calories from protein and fat.
What micronutrient may have a role in controlling BGL of T2 DM patients?
- Chromium reduces HbA1c, FBGL and fasting insulin
Function of estrogen in cancer
- stimulates cell proliferation, inhibits apoptosis and induces VEGF and angiogenesis - metabolized into DNA-reactive metabolites
Percentage of America that is overweight
- ~2/3rds with 35% obese (BMI > 30)
Most common fatty acid consumed n Western diet
- Linoleic acid (omega 6)
Function of macrominerals
- Cellular activity, osmotic properties of fluids, bones/teeth, cofactors
Vitamin C (ascorbic acid). Role, deficiency and clinical characteristics, source
1.) antioxidant, collagen synthesis, immune function, absorption of non-heme iron (animal or plant source) 2.) a.) Scurvy: 4 Hs = hemorrhage, hyperkeratosis, hypochondriasis, hematologic abnormalities. Also fatigue. 3.) fruits, vegetables
Diagnostic criteria for DM
- Fasting plasma glucose >=126 mg/dl after an overnight fast OR - Random plasma glucose >=200 mg/dl with classic symptoms or a hyperglycemic crisis OR - Plasma glucose > 200 mg/dl 2 hours after 75 g OG OR - Hemoglobin A1c level > 6.5 % Note: besides random glucose, these values need to be confirmed on a subsequent day
Feverfew used for?
- Migraine headaches, menstrual cramps
What nutrients is breast milk deficient in?
- Vit D - Give iron supplement at 4-6 months – iron fortified formula can cause constipation.
Manganese. Role, deficiency and clinical characteristics, source
- Role: enzyme activator, brain function, collagen, bone, growth, urea synthesis, glucose and lipid metabolism, CNS function - Deficiency: impaired growth, skeletal abnormalities, impaired CNS function, nausea, vomiting, dermatitis, decreased hair/nail growth, low cholesterol - Source: wheat, legumes, fruit, seafood, poultry, meat
How does nutrient excess lead to cancer?
- Metabolic syndrome increases CA risk through metabolic disturbances/inflammatory state promoting genetic instability - Production of ROS damaging cellular structures = inflammation - Impaired functioning of ER = unfolded proteins = inflammation - Accumulation of long-chain fatty acyl CoA = inflammation - Hyperinsulinemia = cancer growth/metastases
Which is a better predictor for CAD – TGLs or LDL?
- LDL - TGLs correlate more to CVA
Pros/cons of biochemical nutritional assessments
- +: detects early changes in body metabolism/nutrition before clinical signs, precise/accurate/reproducible, validates data from dietary methods - -: time consuming, expensive, no large scale application, trained staff
Fat function
- Energy - Fat-soluble vitamin absorption (ADEK) - Insulate, cushion, lubricate - Membranes (phospholipids) - Metabolic products (inflammatory mediators, gene regulators) - Signal transduction
Disaccharides
- Sucrose (table sugar): glucose + fructose - Lactose: gal + glc - Maltose: glc + glc
Why B12 deficiency following roux-en-Y surgery?
- Lack of HCl and pepsin in stomach prevents B12 cleavage from food. - Also surgery affects release of intrinsic factor from parietal cells. - Also intolerance to meat and milk
How does Na/K intake differ between Western and primitive diets?
- High Na to low K in Western. Reverse in primitive.
Central line ridges on fingernails
- Malnutrition, deficiency in Fe, folate - Medication
Water. Function, distribution
- Function: solvent, regulate body temp, lubricate joints/GI/eyes, transport - Distribution: 60% intracellular, 40% extracellular (~30% interstitial, ~10% intravascular)
Basic structure of lipids, types of fatty acids (sources in diet)
- Glycerol backbone with fatty acids attached - Types of fatty acids: 1.) Saturated: meat, dairy, coconut, palm, cocoa butter 2.) Monounsaturated: olive oil, avocado, canola oil 3.) Polyunsaturated (omega 6): corn, soy, sun/safflower oils 4.) Polyunsaturated (omega 3): ocean fish, flax seed, some in canola and soy 5.) Partially hydrogenated polyunsaturated (trans): frying/baking oils, margarine
Dysphagia or odynophagia
- Iron deficiency - (d/t Plummer-Vinson syndrome)
What happens to calcium levels within the cell when magnesium levels are normal or low?
- Magnesium deficiency allows too much calcium into the cell.
Criteria used to make diagnosis of malnutrition
- At least 2 of the following: a.) decreased energy intake b.) weight loss c.) decreased body fat d.) decreased muscle mass e.) fluid accumulation f.) decreased grip strength
Effect of dietary fructose
- Decrease LDL particle size - Increases lipogenesis in comparison to glucose - Fibrosis of liver - Hyperuricemia - Chronic low level inflammation *note: weak evidence that HFCS uniquely contributes to overweight / obesity
Effect of vitamin D on blood calcium, PTH. What is the active form? Released from where? What is the relationship between PTH and calcitriol?
- Low blood calcium stimulates PTH from parathyroid. PTH stimulates release of Ca from bone and synthesis of calcitriol (active form – 1,25-hydroxy vit D). Also calcium is retained in kidney as a result of PTH. - Calcitriol acts on gut to cause higher absorption of Ca. - As PTH goes down, vit D goes up.
Saw palmetto used for?
- enlarged prostate
Types of bariatric surgery – pros/cons
- Gastric banding: less invasive, simple, fast recovery, weight loss dramatic, more likely to rebound, vomiting, slippage - Sleeve gastrectomy: 75% stomach removed, restrictive, simpler, lower risk than bypass, doesn’t affect absorption, rare deficiencies, irreversible, new, no long term data - Roux-en-Y (gastric bypass): bypass distal stomach/duodenum and first segment of jejunum, rapid weight loss, co-morbid conditions and risk factors improve, good long term results, irreversible, nutritional deficiencies common (Ca, Fe), life long supplements, dumping syndrome (HoTN, tachy, syncope, flushing, abdominal cramping, diarrhea, nausea, vomiting) d/t osmotic overload (fluid shift from blood to intestine)
Brittle nails indicate
- Severe malnutrition, osteopenia, thyroid dz
When is pureed food recommended?
- Bad teeth/edentulous and tongue
How to assess for adequate breastfeeding?
- Weight gain consistent - Voiding - Stools (more than formula) - Feed on demand at least q 2-3 hours - Feeding 10-20 min/side - Activity and vigor of infant
What happens to protein need from birth throughout childhood?
- Need decreases as growth slows after infancy then increases again at puberty
At risk populations for malnutrition
- Lower income - Institutionalized - Age - Intentional weight loss d/t dieting - Disease - Surgery - Physiologic stress - Iatrogenic (meds, procedures) - Vomiting, diarrhea - Fragile/loose skin - Psych
Potassium. Role, deficiency and clinical characteristics, sources
- Role: water, electrolyte (cation)/pH balance, cell membrane transfer - Deficiency: muscle weakness, arrhythmias, paralysis - Source: fruits, potatoes, dairy
What vitamin requires Zn for digestion?
- Folate (B9).
Your patient had recently been involved in a motorcycle accident. He was wearing a ¾ face helmet and landed directly on the point of his jaw. This resulted in his mandible being fracture in 4 different locations. As a result, his mouth will be wired shut for the next 8 to 12 weeks. Which of the following would be the best diet alternative for your patient? a.) full diet b.) mechanical soft c.) puree d.) liquid – oral e.) liquid – NG tube
- Answer = D
What happens with too much methylfolate without adequate B12?
- Note: methylfolate is the most active form of folate - Block of methionine cycle. - Increased homocysteine levels - Inhibition of methylation - Strand breaks in DNA d/t increase in uracil and decrease in thymidine
Define malnutrition. Two forms?
- Def: nutrient-deficient either macro or micro which causes harm to body composition, function or clinical outcome - Forms: 1.) Kwashiokor: inadequate protein, adequate CHO 2.) Marasmus: inadequate protein and energy (other macronutrients: CHO, fat)
3 saturated fats that O’Shea cares about
Myristic (14:0)
Palmitic (16:0)
Stearic (18:0)
What is the threat of excessive zinc?
Excess zinc blocks copper absorption, which in turn will deter the use of iron from transferrin, leading to both copper and iron deficiency.
Toxicity of Cd, Pb, Al, Hg
Cd: causes osteomalacia by antagonizing Ca metabolism
Pb: hematologic damage, decrease heme synthesis, neurologic issues, kidney issues, children x 5 more susceptible
Al: renal encephalopathy, neurotoxicity
Hg (mercury): ataxia, vision problems, NM problems in infants, mental retardation
