Quiz Flashcards
Which combination of lifestyle and nutraceuticals would be most useful in treating a patient with insulin resistance
A chromium, magnesium , aerobic exercise
B calcium, vanadium, gluten free diet
C pyridoxine , cinnamon, elimination diet
D biotin , hypericum , resistance training
A
They all help with insulin sensitivity
Hyperinsulinemia can result in A increased free thyroxine B decreased EPA C increased free estradiol D increased total cholesterol
C
Insulin can stimulate ovarian estrogen , androgen , and progesterone secretions in vitro
Insulin resistance and hyperinsulinemia is and example of
A a single factor can often result in multiple symptoms
B multiple factors can underlie a single condition
C multiple conditions can be caused by a single dysfunctional process
D multiple dysfunctions can lead to multiple factors
C
insulin resistance at the receptors leads to hyperglycemia , hyperinsulinemia which leads to a host of other physiological responses
What three factors tend to underlie CVD
A ox stress , inflammation, immunological reactions
B high sens CRP , dysbiosis, autoimmune disease
C hormonal dysfunction , low antiox, MIT insufficiency
D communication, transport, defense and, repair
A
The three factors that tend to underlie CVD are: ox stress, inflammation, immunological factors . 5 finite vascular responses to the infinite number of vascular insults are:
1. Inflammation
2 ox stress
3 auto immune rx
4 after gene expression
5 endothelial , vascular smooth muscle & cardiac dysfunction
Non alcoholic fatty liver disease and pcos are two conditions that may be associated with
A subcutaneous adiposity and inflammation
B visceral adiposity and inflammation
C osteoporosis and gluten sensitivity
D uterine fibroids and hs CRP
B
Visceral fat accumulation and adipose tissue dysfunction have been implicated in here pathogenesis of NAFLD in PCOS
A 53 yo has BMI of 29 and fmh DM, elevated waist circumference and normal waist to hip ratio, Norma BMI you suspect A diabetes B met syn C metabolic obesity D increased muscle mass
D
BMI and waist circumference are both very non specific measures that can wrongly classify healthy high muscle mass patients
Which of the following lab tests is more useful for assessing vulnerable plague
A triglyceride HDL ratio
B lipoprotein associated phospholipase A2 (Lp-PLA2)
C 8 hydroxydeoxyguanosine (8 -OHdG)
D serum iron
B
Lp-PLA2 generates two proinflammatory mediators , lysophatidylcholine and oxidized non esterified fatty acids , which play a role in the development of atherosclerotic lesions and formation of necrotic core, leading to more vulnerable plaques
In a patient with met syn the earliest changes you would expect to see are A elevated 2 hr pp glucose B elevated fasting insulin C elevated 2 hr pp insulin D elevated FBG
C elevated 2 hr pp insulin
2 hr post glucose insulin levels are usually the earliest detectable change indicating met syn
Medium chain triglycerides
A are found in coconut and Palm oils and convert into ketones
B are found in ground flax seeds and convert in cell to alpha linolenic acid
C are found in grass fed and dairy products and convert in liver to omega 9 fatty acids
D are found in deep water fish and convert into the cell into eicosapentaenoic and DHA fatty acids
A
Which of the following are critical for ATP synthesis via electron transport A thiamine and Pantethine B folate and fibrates C vit d and mag D b2 and b3
D riboflavin and niacin
A 68 yo male patient with concerns about a fmh of alzehimers disease based on recent research which of the following nutrients would be most important to test A mag B vit d C iron D vit b6
B iron
Transport of fatty acids into the mitochondria is facilitated by which nutrient A B 5 B taurine C co enzyme q D Carnatine
D carnatine
Which of the following if prescribed in excess is most likely associated with peripheral neuropathy A folic acid B vitamin B6 C vitamin D D iron
B vitamin b6
Which of the following interventions have been shown to help prevent neurodgenerative disease and improve cognitive function
A copper supplements and grounded conductive bed sheets
B DHA and nuclear regulatory factor erythroid derived 2 like 2 NFK2 activators
C adequate sat fat and rem sleep
D high protein diets and phase III sleep
B?
Which of the following is known to increase levels of brain derived neurotrophic factor BDNF A caloric restriction and DHA B exercise and diets high in calcium C low calorie high protein diets D higher calorie diets and vitamin B1
A
Natural killer cell activity is decreased in which of the following conditions
A RA
B chronic fatigue syndrome
Evidence from studies on chronic fatigue patients suggest a correlation between low levels of NK cell activity and severity of CFIDS
A 22 month old girl presents with peri oral and perianal dermatitis sharply demarcated . She has diarrhea. The mother notes the child’s hair is falling out . The child was weaned off breast milk at six months. He older sibling had the same symptom at two. Which is the most accurate statements about the condition
A low serum alkaline phosphates helps with the diagnosis
Zn deficiency negative affects the bone related enzyme alk phos
What would be the best for supporting the endogenous production of nitric oxide
L arginine and tetrahydrobioterin BH4
Arginine is the ultimate source of nitric oxide produced by nitric oxide synthase while BH4 is an essential cofactor for all NOS isoforms
What describes the effect of insulin on beta oxidation
Insulin promotes glucose uptake and fatty acid synthesis . It does this in part by slowing the process of fatty acid metabolism (beta oxidation )
A 76 year old female comes to your office with a recent dx of osteopenia by dexa scan. You want to follow her on a more frequent basis to assess the efficacy of your therapies on bone health. You would order a
Urinary n teleopeptide
N terminal teleopeptide NTx molecules are mobilized from bone by osteoclasts and subsequently excreted in the urine. Elevated levels. Of NTx indicate increased bond reabsorption
Two botanicals to decease inflammation through activity on cox enzymes
Tumeric and ginger contain potent cox 2 inhibitors
What can cause periferal neuropathy if prescribed in excess
Vitamin B6
By what mechanism are IgG mediated antibody interactions cause GI symptoms
Circulating immune complexes
What up regulates ketone production
Medium chain triglycerides they increase production of ketone bodies
Fun med uses the model of s multi directional web to understand the complexity of the body and develop a comprehensive assessment of the patient. This web like interconnection is best described by
Multiple factors can underlie a single condition and multiple conditions can be caused by a single dysfunctional process
The initial phase of gathering oneself in the go to it the core elements for transforming encounter into an environment where insights emerge
Intension and centering
Genetic polymorphisms in the MTHFR gene have been most notably positivity linked to CAD and
Depression: ploymorphisms of genes involved in B vitamin absorption , metabolism, and function such as mthfr are indirectly involved in the synthesis of neurotransmitters including dopamine and serotonin and have been linked to increased incidence of psychiatric and cognitive disorders including schizophrenia , bipolar , and depression
How do you describe the control of adrenaline and or cortisol release during the stress response
ACTH from the anterior pituitary is the signal for the adrenal gland cortex to release glucocorticoids including cortisol
Nebulized glutathione is most indicated in
Emphysema: nebulized glutathione can lead to rapid resolution of emphacemic crises as well as improvement in the chronic course of the disease
What supplement would be good for microscopic colitis
OM3FA curcumin quercetin : both N- 3 fats and curcumin have antiinflammatory effects and quercetin enhances epithelial barrier function
Mitochondropathies have the greatest effect on what type of tissue
Brain and skeletal : Brain and skeletal muscle have both large and dynamic energy requirements and thus are preferentially affected by problems with mitochondria
Arachidonic acid
Is a direct precursor to many proinflammatory prostaglandins and leukotrienes
AA is an omega 6 FA that is upstream to many pro inflammatory FA metabolites including Eicosanoids ( prostaglandins and leukotrienes )
What does DIGIN stand for
Digestion, intestinal permeability , gut microbiota, inflammation / immune nervous system
Molecular mimicry is a process that occurs within the GI tract . It can result in
Autoimmunity : molecular mimmicry occurs when an antigenic fragment looks very similar to a self antigen and the corresponding immune response can produce self reactive lymphocytes
What is non alcoholic fatty liver disease most directly linked to
Met syn ass with insulin dysfunction and met syn
Patient complains of bil neuropathic pain in his feet and has a hx of herpetiformis you suspect
Celiac : bil neuropathy is one of the most frequent neurological manifestations of celiac
What does PTSD stand for
Production, transport , sensitivity, detox
These are the 4 key elements of the hormone cycle that should be considered when examining a patient suspected of having a hormonal dysfunction
Patient on statin has muscle pain and fatigue what would you give
CoQ10 stating deplete and then produce muscle pain, myopathy and rhabdo
What is the relationship between EPA and DHA and systemic inflammation
Both can inhibit a number of aspects of inflammation including production of eiosanoid like prostaglandins and leukotrienes from the omega 6 fatty acid arachidonic acid production of inflammatory cytokines and T cell reactivity
Patient has elevated thyroid antibodies x three years and high and high doses of thyroxine now she is getting fatigue pms and forgetful you should
Get a reverse T3: since increasing doses of T4 are not increasing her metabolic rate you. Should consider investigating whether elevated reverse T 3 ( and RT3:TT3 ratio) are putting the brakes on her metabolism
DMSA can result in system reduction in
Cadmium, calcium, Mercury
It has an affinity for cations both nutritional and toxic
Why are insulins proinflammatory
Estrogens stimulate cox 2 which increases production of inflammatory Eicosanoids
Prolonged cortisol elevations can promote
Immune suppression and adiposity : cortisol is an immune suppressant and it promotes redistribution of adipose tissue which can lead to increased adiposity
BIA
Is used for serial tracking of changes in body composition
BIA is best used longitudinally within an individual patient to track changes over time
What foods should be avoided before a provoked toxic metals test
Fish seafood
Fish shellfish kelp and some other seafoods often contain significant organic arsenic
Which of the receptors has been linked to risk of increased excitotoxicity
NMDA receptors for glutamate are linked to excitotoxicity because large stimuli displace magnesium in the channel lumen and allow large amounts of calcium into neurons
What blocks the action of aromatase
Green tea inhibits the aromatase conversion of testosterone to estrogen and also the 5 alpha reductase conversion of testosterone to DHT
A normal TSH and a normal T4 but sym of low thyroid can develop because
Neither accurately reflect T3 in circulation - free T3 levels have a greater effect on thyroid mediated effects on metabolism than TSH or FT4
What does stress do to the gut
Increases intestinal permeability
Branch chained fatty acids
When BCAA levels are low fatigue can develop via increased CNS uptake of tryptophan
Cofactor of ATP production
Acetyl CoA is the two carbon end product of both carb and FA metabolism . It feeds into the TCA cycle which produces NADH and FADH that feed the electron tranport chain
Estrogen dominant environment increases chances of
PCOS
You worry about rapid weight loss because
Lipolysis mobilizes lipophilic toxins including xenobiotics
What does metformin decrease
Serum B12 and folate
What would you us to treat congestive cardiomyopathy
Ribose, coq10, l carnitine
How would you treat actominophen overdose
The phase two conjugation pathway and primary co factor for detox of acetaminophen are glutathione conjugation, and n acetyl cysteine
N acetylcysteine is the nutrient of choice for the treatment of an acetaminophen overdose . It serves as a source of cysteine for glutathione synthesis
Transdermal progesterone might cause?
Pedal edema because it can be converted to aldosterone
Progesterone is an upstream precursor for the mineral corticoid aldosterone which causes the kidneys to conserve sodium which can precipitate fluid retention
What is the upstream precursor for the mineral corticoid aldosterone
Progesterone is an upstream precursor for the mineral corticoid aldosterone
The conversion of T4 to RT3 is stimulated by what
Low calorie diet : T4 is increasingly converted to metabolism slowing molecule RT3 also by stress cortisol trauma, inflammation (cytokines) toxins , infections, liver kidney dysfunction, and certain meds
62 yo female on PPI osteoporosis is thin and bmi 20 , decreased muscle mass, low protein what would you do
More protein, and exercise BIA strength program and protein
What does DMSA have an affinity for
Cations nutritional and toxic
List what can increase T4 to metabolism slowing RT3
Low calorie diets Stress cortisol Trauma Inflammation cytokines Toxins Infection Liver kidney dysfunction Certain medications
What are a few actions of green tea
Inhibits the aromatase conversion of testosterone to estrogens and also the 5 alpha reductase conversion of testosterone to DHT dihydrotestosterone
What is molecular mimicry
Occurs when an antigenic fragment looks very similar to a self antigen and the corresponding immune response can produce self reactive lymphocytes
Zinc deficiency has a negative affect on what enzyme
The bone related enzyme alkaline phosphatase
What would you order to rule out celiac
A HLA B27
B HLA DQ2 and DQ8
C salivary antigliadin antibody
B HLA DQ 2 and DQ8
HLA DQ 2 and or DQ 8 are present in nearly 99% of celiac cases, thus their absence vertiably rules out celiac disease
ALS appears to be caused in part by Chronic infection Aging Accelerated oxidative stress Deficiencies of dopamine
Accelerated oxidative stress
This is evidenced by familial cases of ALS caused by mutations in the superoxide dismutase (SOD1) Gene
Which of the following is a NF kappa B inhibitor Dioxin Lead Alpha Lipoic acid Vitamin B12
Alpha Lipoic acid
It inhibits the release and translocation of proinflammatory NF-B from cytoplasm to the nucleus
The effect of mindfulness meditation on stress eating :
Inhibits neuro genesis in the brain which may stop the neuronal reinforcement of this pattern of behavior
Stimulates the sympathetic nervous system and may enhance the burning of calories
Increases the parasympathetic tone which may increase her awareness of how much she is eating
Normalizes the HPA axis and may allow for new choices and insights to emerge in the moment
Normalizes the HPA axis and may allow the new choices and insights to emerge in the moment
Mindfulness meditation can reduce stress and allow the patient to make thoughtful food choices instead of stress induced ones
Which of the following is an effective way to limit the action of beta glucuronidase MTHFR Methycobalamine Calcium d glucarate Vitamin D
Calcium D glucarate which provides a substrate for bacterial beta glucuronidase , thereby avoiding enterohepatic - re circulation and preserving phase II glucuronidated substrates for excretion in the stool
Which of the following increases serotonin in the CNS Melatonin Decreasing heart rate variability Lenghten telomeres Meditation
Meditation can increase levels of serotonin in the CNS potentially modulating mood disorders
Which fatty acids inhibit Delta 5 desaturase Arachidonic acid Gamma linolenic acid Dihomo gamma linolenic acid Eicosapentaenoic acid EPA
EPA in an inhibitor of the enzyme delta 5 desaturase D5D that produces -AA
Select the correct statement regarding modifiers of Alzheimer’s disease
Vitamin K supplements are associated with a reduced incidence of AD
Vitamins A supplements
Vitamin E supplements
Vitamin C and E supplements in combination are associated with reduced incidence of AD
Observational studies suggest that higher dietary intake of vitamin C and E might protect against dementia and altzheimers
Why is lipoprotein associated phospholipase A2 (Lp-PLA2) a useful test to assess vulnerable plaque
Lp -PLA2 generates two proinflammatory mediators , lysophosphatidylcholine and oxidized non esterified fatty acids, which play a role in the development of atherosclerotic lesions and formation of a necrotic core, leading to more vulnerable plagues
What is the most common autoimmune disease in the United States
The most common autoimmune disease in the U.S. is Hashimoto’s thyroiditis . It affects between 0.1 % and 5 % of all adults in the western countries
Adequate melatonin decreases the risk of estrogen related diseases primarily by Increasing vitamin d Normalizing the 2/16 ratio Acting as a antioxidant Triggering apoptosis
Melatonin appears to have antioxidant effects which may contribute to its health benefits
Select the best statement regarding branch chain amino acids BCAA
When BCAA levels are depleted fatigue can develop via increased CNS uptake of tryptophan
Nuts are a good source of BCAA because they are high in alanine
The brain is able to consume large amounts of BCAA due to the effects of the small polar amino acid transporter
Skeletal muscles use BCAA as their preferential fuel
When BCAA are depleted eg via exercise there can be an increased uptake of tryptophan in the CNS leading to increased fatigue
Or has gas, bloating, and eczema the most appropriate diet plan is
The fodmap diet The cardiometabolic food plan The elimination diet The core food plan Gas and bloating may be associated with food intolerances , eczema may be associated with food sensitivities or allergies . All of these are best addressed by an elimination food plan
Primary phase 1 bio transformation pathways include Sufation glucuronidation methylation Amino acid conjugation, phosphorylation Acetylation glutathione conjugation Oxidation reduction hydrolysis
Phase 1 reactions use oxidation reduction, or hydrolysis or exposure polar groups to make substances more water soluble
Insulin has which of the following effects Increases small dense LDL particles Lowers triglycerides Deceases hs CRP Increases HDL
There is a strong association between LDL -P and insulin resistance which is driven by elevated insulin levels
Patient who had chemo for prostate cancer , which is now in remission and takes NSAID for knee pain, and lots of stress , he is now having food reactions what is the most likely underlying reason for his nw complaint
Increased intestinal permeability
Insulin resistance :
Is independently predictive of low HDL -c and elevated triglycerides
Enhances beta oxidation of fatty acids
Blocks androgen production by ovarian theca cells
Is associated with increased risk of lung cancer
Insulin resistence initiates a characteristic triad of high triglycerides low HDL cholesterol and high small dense LDL level
How do you describe the web like inter connection of functional medicine
Physiological processes are related such that nothing happens in a vacuum , any change has repercussions throughout the body
48 yo with hx of iron def anemia has fatigue and is menopausal with infrequent night sweats, has bloating after meals you prescribe a highly absorb form of iron and
Low dose estradiol and estriol HCL # A pancreatic enzyme Methycobalamin Her issues with iron may reflect poor absorption , which could be from low stomach acid and the bloating after meals is consistent with Hypochlorhydria
A demonstrated physiological effect of meditation is to Increase norepinephrine Increase serotonin Increase cortisol Decrease dopamine
Increase serotonin - meditation can increase serotonin which may cause increased feelings of contentment and satiety
42 yo female with five years of fatigue , sleep 12-14 hours a night and is exhausted by modest exercise , ex with chronic fatigue you border a salivary panel and expect to find
Elevated levels of cortisol and DHEA
Reduced levels of cortisol and elevated DHEA
Elevated levels of cortisol and reduced DHEA
Reduced levels of cortisol and DHEA
Adrenal insufficiency correlates with stage 3 of selves general adaptation syndrome and is marked by profound fatigue and low levels of both DHEA and cortisol
Dx of microscopic colitis which supplements would you use
Resveratrol, white willow bark, ginko biloba
Calcium zinc milk thistle
Mixed carotenoids vitamin e pycnogenol
Omega 3 fatty acids, curcumin quercetin
Both N - 3 fats and curcumin have anti inflammatory effects and quercetin enhances epithelial barrier function
Which of the following is a cofactor in ATP production Acetyl CoA Carbon dioxide Glucose Fructose
Acetyl CoA is the two Carbon common end product of both carbohydrate and fatty acid metabolism . It feeds into TCA cycle which produces NADH and FADH that feed the electron transport chain.
NAD nicotinamide adenine dinucleotide is a coenzyme found in all living cells NADH is the reduced form NAD is oxidized form
Primary phase 2 enzymes include :
Beta glucuronosyltransferase and sulfotransferase
Pyruvate kinase and hexokinase
Mixed function oxidase and superoxide dismutase
UPD glucuronosyltransferase and sulfotransferase
Phase 2 reactions involve conjugating various substrates with glutathione glucuronide sulfate acetate methyl or amino acid glycine taurine etc groups
Which of the following accurately describes the control of adrenaline and or cortisol release during the stress response
Adrenocorticotrophic hormone ACTH stimulated adrenal medulla to release adrenaline
Corticotropin releasing hormone CRH stimulates the adrenal medulla to release cortisol
Corticotropin releasing hormone CRH stimulates the adrenal cortex to release adrenalin
Adrenocorticotropic hormone ACTH stimulates the adrenal cortex to release cortisol
ACTH from the anterior pituitary is the signal for the adrenal cortex to release glucocorticoids including cortisol
Norma TSH and normal T4 still with symptoms because
Neither accurately reflects the amount of free T3 in circulation
Free T3 levels have a greater effect on thyroid mediated effects on metabolism than TSH or free T4
Deficiency of which of the following leads to mitochondrial decay oxidative damage decreased cytochrome p450 activity and anemia Copper Zinc Magnesium Iron
Iron is part of the cytochrome proteins including p450 complex and is needed to run the electron transport chain. It is also key component in hemoglobin . Oxidative stress is associated with both iron deficiency and iron excess
Insulin resistence
Blocks androgen production by ovarian theca cells
Enhances beta cell oxidation of fatty acids
Is independently predictive of low HDL -c and elevated triglycerides
Is associated with increased risk for lung cancer
Insulin resistance initiates a characteristic triad of high triglycerides low HDL cholesterol and high small dense LDL level
Teen three months in a new house has dull ha in the am since move it is better with ASA you should review with him
Fluorescent lighting in his room and at school
Food allergies
Cell phone use
Stress and chemical fumes in the home
Stress and chemical fumes
Change of environment can trigger dysfunction
What are estrogens three major phase 2 detox pathways
Glucuronidation , sulfation, glycine conjugation
Taurine conjugation sulfation, and glucuronidation
Glucuronidation , sulfation, and methylation
Sulfation , glutathione conjugation, and methylation
Glucuronidation , sulfation, and methylation
Estrogen bio transformation is primarily done through glucuronidation, sulfation, methylation
Which of the following explains why estrogens are pro inflammatory
Estrogens stimulates cox 2 which promotes inflammation
Estrogens activate the aromatase enzyme to increase testosterone and inflammation
Estrogens decrease cortisol which promotes inflammation
Estrogens increase insulin sensitivity which promotes inflammation
Estrogens stimulate cox 2 which increases production of inflammatory eiosanoids
A 15 year old male presents to your clinic with a hx of asthma. And an identified environmental trigger of grass pollen. Which foods could also exacerbate his asthma because of pollen food antigen cross over Celery carrots bananas Potato tomato peaches Melons , bananas cucumbers Apples , apricotes, hazelnuts
Cross reactions have been noted between grass pollen and potatoe, tomatoes peaches
Food sensitivity is commonly mediated by IgG type antibody interactions . The mechanism by which IgG causes symptoms is which of the following Macrophage induction Histidine decarboxylase Circulating immune complexes Mast cell degranulation
With IgG antibodies antigen antibody complexes are likely the primary cause of symptomatic reactions associated with food sensitivities
Select the correct statement regarding transdermal estrogen therapy
Estrone should be given transdermally in the smallest dose to achieve the best clinical effect
Transdermal preparations of estradiol are safer than oral
Estradiol is not recommended as a transdermal agent because it’s levels are difficult to test for in serum
Testing estradiol levels prior to starting transdermal therapy is not recommended because the levels are always fluctuating
Transdermal estrogens bypass the hepatic first pass metabolism effect which can convert estrogen into more harmful metabolites
Transdermal preparations of estradiol are the safest
In a patient with cystic fibrosis which treatment is best for delivering glutathione Oral Neb IV A acetyl cysteine, glycine , glutamine
Neb inhaled is the only known method that increases GSH levels in the epithelial lining fluid (ELE) of the lower resp tract
Which two act as anti inflammatories Devils claw and rhodiola Boswellia , and turmeric Ginger and oregano Licorice and white willow bark
Curcumin downregulates cox 2 and iNOS enzymes, likely by suppressing NF-kB activation. In DBPC trails Boswellia extract has been found to reduce pain and improve physical functioning
Primary phase 2 enzymes include
Pyruvate kinase and hexokinase
Beta glucuronidase and catalase
UPD glucuronosyltransferase and sulfotransferase
UPD glucuronosyltransferase and sulfotransferase
Phase 2 reactions involve conjugating various substrates with glutathione , glucuronide, sulfate, acetate methyl or amino acid ( glycine taurine etc) groups
Select the correct statement about MTHFR
It is believed that the gene variants have survived because they convey protection against colon cancer
This enzyme is required to convert methionine into homocysteine
MTHFR has genetic variants which can cause reduced enzyme activity
The enzyme crosses the blood brain barrier
MTHFR has genetic variants which can cause reduced enzyme activity
MTHFR catalyzes the conversion of folate to 5 methyltetrahydrofolate Which acts as a methyl donor for the methylation of homocysteine back into methionine. Several common genetic variants are known to slow MTHFR activity
Which of the following best describes the effect of insulin on this process of beta oxidation Insulin speeds up beta oxidation Insulin slows down beta oxidation Insulin speeds up the citric acid cycle Insulin slows lipogenesis
Insulin promotes glucose uptake and fatty acid synthesis . It does this in part by slowing the process of fatty acid metabolism beta oxidation
The effectiveness of mind body techniques in improving hormone balance is modulated via the Hippocampus Hypothalamus Amygdala Frontal cortex
The hypothalamic pituitary adrenal axis HPA And the hypothalamic pituitary gonadal HPG can be modulated by meditations effect on the hypothalamus
Transport of fatty acids into the mitochondria is facilitated by which nutrient Taurine Carnitine Coenzyme Q 10 Pantethine B5
Carnitine
The carnitine shuttle helps move fatty acids into the mitochondria for beta oxidation
57 yo female has chronic insomnia she wakes early and cannot get back to sleep you suggest a salivary cortisol and DHEA which of the following lab finding would you expect Elevated morning cortisol Elevated noon cortisol Depressed evening cortisol Elevated DHEA
Elevated morning cortisol
Waking early is associated with elevated morning cortisol
What does an elevated reverse T3 do? (And RT3:TT4 ratio)
It puts the breaks on the metabolism
42 year old with depression strong FMH of same the single most useful nucleotide polymorphism to consider would be CYP1B1 APOE TNF alpha MTHFR
MTHFR polymorphisms are common and can have a major impact on mood disorders . Once identified appropriate supplementation may be effective
With Normal TSH and normal free T4 symptoms of low thyroid function can develop because
Serum levels of T3 do not reflect tissue levels
Neither accurately reflects the amount of free T 3 in circulation
There is scientific disagreement as to the normal reference range for both measurements
Neither accurately reflects the conversion of free T3 to free T4
Neither accurately reflects the amount of free T3 in circulation
Free T 3 levels have a greater effect on thyroid mediated effects on metabolism than TSH or free T4
What is the role of insulin
Insulin promotes glucose uptake and fatty acid synthesis . It does this by slowing the process of fatty acid metabolism ( beta oxidation )
What does calcium D glucarate do
Calcium D glucarate provides a substitute substrate for bacterial beta glucuronidase thereby avoiding enterohepatic recirculation and preserving phase 2 glucuronidated substrates for excretion in the stool
How does meditation improve hormone balance
The hypothalamic pituitary adrenal axis HPA and the hypothalamic pituitary gonadal HPG can be modulated by meditations effects on the hypothalamus
What is acetyl CoA
A 2 carbon common end product of both carbohydrate and fatty acid metabolism . It feeds into the TCA cycle which promotes NADH and FADH that feed the electron transport chain
Which of the following is the most likely mechanism in which exogenously administered estrogens leads to elevations of TSH ?
Estrogens increase the output of all anterior pituitary hormone
Estrogens have a direct effect on stimulating hypothalamic thyroxine
Estrogens increase the conversion of T4 to T3
Estrogens stimulate the production of thyroid binding globulin and therefore decrease the amount of free thyroid hormone
Estrogens stimulate the production of thyroid binding globulin and therefore decrease the amount of free thyroid hormone
Low free thyroid hormone levels feed back to increase TSH release from the anterior pituitary
What is the signal for the adrenal cortex to release glucocorticoids including cortisol
ACTH from the anterior pituitary is the signal for the adrenal cortex to release glucocorticoids including cortisol
Which of the following has proven to affect health the most Perception of socioeconomic status Community norms and values Average yearly income Rural or metropolitan environment
Perception of socioeconomic status
Socioeconomic status is a major health indicator but really the perception of that status that matters the most
Select the correct statement about MTHFR
The enzyme crosses the blood brain barrier
The enzyme is required to convert methionine into homocysteine
MTHFR has genetic variants which can cause reduced enzyme activity
It is believed that the gene variants have survived because they convey protection Against colon cancer
MTHFR has genetic variants which can cause reduced enzyme activity
MTHFR catalyzes the conversion of folate to 5 methyltetrahydrofolate which acts as a methyl donor for the methylation of homocysteine back into methionine . Several common genetic variants are known to slow MTHFR activity
Key nutrients photochemicals known for improving permeability include:
Glycine , vitamin E , grapefruit seed extract
Glutamine , N-Acetyl glucosamine , zinc
Vitamin C , garlic , N acetyl- Cysteine
Glutathione , iodine , berberine
Certain nutrients have been shown to help maintain healthy structure and function of mucosal cells and promote normal intestinal permeability . These include L glutamine, N acetyl -D-glucosamine, zinc, and gamma linolenic acid
Describe phase 2 reactions
Phase 2 reactions involve conjugating various substrates with glutathione, glucuronide, sulfate, acetate, methyl or amino acid ( glycine , taurine, etc.,) groups
Elevated cortisol is associated with
Some types of depression and decreases calcium absorption at the intestines and inhibits bone formation
What is the phase 2 conjugation pathway and the primary cofactor for the detoxification of acetaminophen
Glutathione conjugation and N acetylcysteine
N acetylcysteine is the nutrient of choice for the treatment of an acetaminophen overdose . It serves as a source of cysteine for glutathione synthesis
T is increasingly converted to the metabolism slowing molecule RT3 by
Low calorie diets Stress cortisol Trauma Inflammation cytokines Toxins Infections Liver kidney dysfunction Certain medications
Why are there ethnicity specific reference ranges for waist circumference
Different ethnic groups tend to have varied distributions of subcutaneous versus visceral fat
High levels of what can cause peripheral neuropathy
Vitamin B6
What affect Dow stress have on the gut
Acute psychological stress increases intestinal permeability and chronic psychological stress is also associated with increased intestinal epithelial permeability
What is the signal for the adrenal cortex to release glucocorticoids including cortisol
ACTH from the anterior pituitary is the signal for the adrenal cortex to release glucocorticoids including cortisol
6 month old mom has trouble beast feeding using soy formula bad eczema and a couple ear infections with antibiotics you would
Vitamin A and D
Soy elimination zinc and probiotics
Elimination diet for mom and kid
High quality prenatal for mom and elimination diet
The eczema could be from zinc deficiency and probiotics are indicated following the antibiotic therapy a sensitivity to soy could be preceding the ear infections
Why does exogenously administered estrogen lead to elevated TSH
Estrogens stimulate the production of thyroid binding globulin and therefore decrease the amount of free thyroid hormone
Low free thyroid hormone levels feed back to increase TSH release from the anterior pituitary
Mind body techniques improve hormone balance via the
Hypothalamus
The hypothalamic pituitary axis HPA and the hypothalamic pituitary gonadal HPG can be modulated by meditations effects on the hypothalamus
Dark line in the gingival sulcus could mean
Lead sulfate deposition (buttons lines) or maybe cadmium, bismuth, Mercury, cis platinum, arsenic
Atopy of skin might indicate
Permeability immune balance protein loss , EFA / GLA , an, vit D/A , C
Causes of acne
Deficiency of zinc, vit A, EFA dietary allergens , high GL diet, diary (IGF-1)
What could seborrheic keratosis indicate
Arsenic exposure without adequate diet leads in sk. A diet higher in nutrients which will help the bio transformation and excretion of the arsenic is associated with resolving sk
Clubbing
Inflammatory bowel , sprue
Beau’s lines
Hypocalcemia , zinc def
Koilonychia (spooning )
Low: iron, protein, zinc , cu
Onychorrhexis ridges lines in the nail
Iron, folic acid, protein
Median nail dystrophy
Malnutrition
Leukonychia punctata white specs
Zinc def
Leukonychia white vertical lines
Selenium deficiency
Mees lines wider white vertical lines on nails
Arsenic tox, hodgkins, CHF , leprosy, malaria, chemo, carbon monoxide poisoning , other systemic insults
Functional lab tests to evaluate the toxic patient to look for issues of nutrition and assimilation
Dysbiosis SIBO : overgrowth of pathogenic microorganism
Increased levels of beta glucuronidase
Markers of GI inflammation
Intestinal permeability
Malabsorption deficiency of amylase, pancreatic enzymes , hcl
Leaky gut
Tests to look for toxic damage - oxidative stress
To look for oxidative stress: 8-hydroxy deoxyguanosine 8-OH- dG, lipid peroxides ( thiobarbituric acid reactive substances - TBARS), oxygen radical absorbance capacity (ORAC) , isoprotanes
Functional labs tests to evaluate the toxic patient
Glutathione GSH whole blood
Reflects GSH in the tissues
Deficiency ass with many chronic illnesses
Linear correlation with NK function
Glutathione per oxidase
Se dependent enzyme
Found in cytosol and mitochondria
Superoxide dismutase
Converts (dismutation ) superoxide into oxygen & H2O2 (catalase subsequently converts H2O2 into oxygen and water )
A metalloprotein found in cytosol (Cu Zn dependent) and mitochondria Mn dependent
What is a random unprovoked heavy metals in urine good for?
Excellent for showing current exposures to metals that are excreted by endogenous processes
Reflects the level of heavy metals in the bloodstream during the hours immediately before bladder voiding
Provoked urine for heavy metals tells you
Metals mobilized by provoking agents from aqueous extracellular space
Reflection of total body burden
What is the toxic burden equation
Disease risk = susceptibility x life time exposure x potency
What are the functional medicine principles of detox
Minimize exogenous toxic exposures Ensure adequate hydration Optimize bowel health and elimination Balance and assist phase 1 and 2 bio transformation function Enhance antioxidant reserve Optimize mitochondria function
What do you use to optimize bowel health and excretion during detox
Fiber :
soluble : psyllium , flax, pectin, oat bran, inulin, FOS, fenugreek
Insoluble: rice bran, wheat bran, beet fiber
Cholagogues and choleretics
Artichoke,
Oregon grape root ( mahonia aquifolium) : berberine
Dandelion taracacum officinale
Glucaric acid
What is glucuronidation
A major detoxification process catalyzed by UPD glucuronosyltransferase that convert a vast variety of endogenous compounds , including bilirubin, steroid and thyroid hormones and retinoids or vile acids, into more hydrophilic and therefore excretable metabolites
What regulates glucuronidation
Dual regulatory control
Genetic expression level of isoenzymes , determines the amount of a different isoform available
Activity of individual isoforms to their functional state by specific substances including certain nutrients
What are UPD glucuronosyltransferase enzymes
Members of a super family of enzymes with considerable genetic polymorphisms making some people more susceptible to Gilbert’s
And reduced glucuronidase activity of specific substances in these individuals makes them more susceptible to the effects and endo and exotoxins
List the nutritional support for optimal phase 1 and 2 bio transformation
Phase 1:
Macronutrients and broad spectrum micronutrient support
Antioxidants to quench free radical produced by phase 1 reactions
Phase 2 :
Cofactors for conjugation
Phytonutrients inducers of phase 2 enzymatic reactions
What are the phytonutrient inducers of phase 2 enzymes supplements for
Milk thistle Curcuminoids Carnosol rosmarinus officinalis Indole 3 carbinol Diidolylmethane Sulforaphane
What supplements can be used to optimize glutathione level
Reduced glutathione N acetyl cysteine Lipoic acid Whey protein Magnesium Vitamins C Vitamin E Pantothenic acid SAMe
Supplements to optimize phase 1 & 2 conjugation antioxidant capacity and gene expression
Catechins EGCG Curcuminoids Garlic Indole 3 carbinol Diindolylmethane Sufloraphane Quercitin Milk thistle Lignans Resveratrol Proanthocyanidins Ellagic acid Artichoke extract Rosemary Andrographis Aloe Vera extract
FODMAPS list the three independent mechanisms
Low absorptive capacity of the small intestinal epithelium
Rapid transit through the small bowel
Bacterial overgrowth of the distal small bowel
What is 8-OHdG
A Biomarkers it has been a pivotal marker for measuring the effect of endogenous oxidative damage to DNA and as a cofactor of initiation and promotion of carcinogenesis
What does carnitine do
It transfers long fatty acids across the mitochondria membrane
The secondary causes of mitochondria dysfunction
High oxidative stress High nitric oxide (NO) High SCFA esp propionate High TNF alpha and inflammation Low folate and b vitamins Low mineral co factors Low CoQ 10 Low glutathione Low carnitine
How does the body protect its self from ROS
Enzyme
Catalase (Fe)
Superoxide dismutase - SOD ( Zn, Cu, Mn)
Glutathione per oxidase (Se) and glutathione reductase
Dietary anti oxidants
Vit C for aqueous compartments
Vit E for lipid compartments
Carotenoids, flavonoids , etc
Endogenous anti oxidant molecules
Glutathione
Cysteine
CoQ 10
Lipoic acid
Uric acid
CholesterolWhat molecules are central to assembly of the electron transfer complexes and catalase
Heme and they are therefore at the core of energy formation
enzyme in the heme synthesis pathway required multiple co factors including
Antioxidants (Lipoic acid )
B vitamins ( 2,5,6,7)
Minerals (Mg,Zn, Cu, Fe)
What are the hallmarks of mitochondrial disease
An typical common disease
More than one organ system is involved
Recurrent setbacks or flare up in a chronic disease occur with infection or stress
Unpredictable in time, severity, constellation and presentation
What findings would suggest mitochondria dysfunction
Elevated lactic acid
Amino acids elevated
Alanine
Glycine
Proline
Sarcosine
Tyrosine
Ox stress markers
Organic acids urine
TCA cycle intermediates
Ethylmalonate
3- methyl gluaconate
Dicarboxylic acids
Acylcaritines
Low free carnitine
Elevated actyl free carnitine ratioWhat transports fatty acids into the mitochondria matrix for oxidation
L carnitine
Co enzyme Q10 does what
Serves as a coenzyme (cofactor upon which enzyme depend for their function ) for several key enzymatic processes
List three activities in which CoQ10 is involved
Production of cellular ATP via ETC
Potent antioxidant removes super oxides and inhibits free radicals from destruction of cell membranes
Inhibits LDL oxidation
Alpha Lipoic acid is a
Co factor in multi enzyme complexes that catalyze oxidative decarboxylation of a keto acids as pyruvate dehydrogenase complex
List the actions of alpha Lipoic acid
Reduces inflammation by blocking activation of stress activated signaling pathways
Increases glucose metabolism - activates AMPK in periphery inhibits in the brain
Increases insulin sensitivity decreases triglycerides synthesis
Decreases diabetic complications
Increases intracellular and mito glutathione
Translation metal chelator
List some of the conditions you were us alpha Lipoic acid for
Liver disease Amanita poisoning Radiation exposure Neurodgenerative dz DM Neuropathy Insulin resistence Met syn Hyper triglycerides PCOS
What are the principles of the IFM mito food plan
Phyto density Low glycemic Anti inflammatory anti oxidant Fats and oil Cooling impact Fasting caloric restriction carb retriction Organic clean food
Exercise and fatigue
Exercise frees FFA from adipose
FFA completes for TRP binding on plasma proteins increasing plasma TRP
Skeletal muscle consumes BCAA
Less BCAA competition for transport into CNS increase TRP transport into CNS
Graded exercise creates biogenesis and tolerance to tryptophan load
46 yo w/ BMI 33 worried about br ca risk mother had at 60 has a normal CRP and low 2/16 estrogen ratio which is the appropriate therapy Increased cruciferous veg Genetic counseling Calcium vitamin K vitamin D Increased resistance training
Increasing cruciferous veg can help increase the 2:16 ratio and decrease the risk of breast cancer
Select the most common manifestation of iron overload from the options below Peripheral neuropathy GERD Chronic depression SOB
Iron overload can lead to cytotoxicity and it is a risk for peripheral neuropathy
IFM mnemonic DIGIN stands for
Digestion, intestinal permeability , gut microbiota, inflammation /immune, nervous system
DIGIN mnemonic helps provide framework for assessment of gut dysfunction
What do elevated levels of N terminal teleopeptide (NTx) indicate
Increased bone reabsorption
N terminal teleopeptide molecules see mobilized from bone by osteoclasts and subsequently excreted in the urine
52 yo homeless man with darkened skin , flakey skin, sun exposed skin on his face and hands, decreased taste, tongue fissuring , and somewhat disoriented . What supplement would you consider B 1 thiamine B 2 riboflavin B6 pyridoxine B 3 niacin
B 2 riboflavin
B2 deficiency can lead to various problems with dry , flakey, cracked skin, particularly at the corners of the mouth, a sore, red, or burning tongue, and impaired nervous system function
Without ribo dry skin, corners of mouth, red sore tongue that burns, and impaired nervous system
What three foods have a cross over pollen food antigen crossover reaction with grass pollen?
Potato tomato peaches
List three nutrients that support the energy production in cardiac myocytes
Ribose, coQ10, and L carnitine
Transport of fatty acids into the mitochondria is facilitated by
The carnitine shuttle helps move fatty acids into the mitochondria for beta oxidation
What is elevated cortisol associated with
Some types of depression
Decreases calcium absorption at the intestines and inhibits bone formation
Fish, shellfish, kelp, and other seafood contain
Significant organic arsenic
Arginine is
The ultimate source of nitric oxide produced by nitric oxide synthase
What is Tetrahydrobioterin (BH4)
An essential cofactor for all NOS isoforms
What do phase one reactions use to introduce or expose polar groups to make substances more water soluble
Phase one reactions use oxidation, reduction, or hydrolysis to introduce or expose polar groups to make substances more water soluble
What is the phase two conjugation pathway and primary cofactor for the detoxification of acetaminophen
Glutathione conjugation and N acetylcysteine
N acetylcysteine is the nutrient of choice for the treatment of an acetaminophen overdose. It serves as a source of cysteine for glutathione synthesis
What does Lipoic acid do
Inhibit the release and translocation of proinflammitory NF-B from the cytoplasm to the nucleus
What does curcumin do
Downregulates cox 2 and iNOS enzymes likely by suppressing NF-kB activation
In trials what have they found with boswellia
It reduces pain and improves physical functioning
The heart generates what percent of its ATP through beta oxidation
60-90% the heart generates the vast majority of its energy through the breakdown of fatty acids in beta oxidation
What is the effect of insulin on beta oxidation
Insulin promotes glucose uptake and fatty acid synthesis . It does so in part by slowing the process of fatty acid metabolism (beta oxidation)
Estrogen biotransformation is primarily done through
Glucuronidation, sulfatation, or methylation
Why does exogenously administered estrogen lead to elevated TSH
Estrogens stimulate the production of thyroid binding globulin and therefore decrease the amount of free thyroid hormone
Low free thyroid hormone levels feed back to increased TSH release from the pituitary gland
57 year old woman with chronic insomnia wakes early and cannot get back to sleep . What do you suspect you will find on salivary panel
Elevated morning cortisol
How do EPA and DHA decrease inflammation
They are omega three fatty acids which can inhibit a number of aspects of inflammation including production of Eicosanoids like prostaglandins and leukotrienes from omega six fatty acid arachidonic acid production of inflammatory cytokines and T cell reactivity
Deficiency of which of the following leads to mitochondrial decay, oxidative damage, decreased cytochrome P 450 activity and anemia Zinc Mag Copper Iron
Iron
Iron is part of the cytochrome proteins including p450 complex and is needed to run the electron transport chain. It is also a key component in hemoglobin . Oxidative stress is associated with both iron deficiency and excess
Ethnicity affects the standards for which of the following markers of met syn Triglycerides Waist circumference HDL BMI
Waist
Different ethnic groups tend to have varied distributions of subcutaneous versus visceral fat, so some ethnicity specific references ranges for waist circumference have been developed
Which fatty acid inhibits delta 5 desaturase
Eicosapentaenoic acid EPA
EPA is an inhibitor of the enzyme delta 5 desaturase (D5D) that promotes AAa
Select the most common manifestation of iron overload GERD Peripheral neuropathy Sob Chronic depression
Iron overload can lead to cytotoxicity , and is a risk factor for peripheral neuropathy
Eating two fatty fish meals weekly has been shown to Increase osteoporosis Increase risk of infection Decrease risk of cad Decrease risk of RA
Fish intake has been linked to decreased risk of cad and reduced severity of RA
Saccharomyces boulardi has been shown to be effective in which of the following conditions GERD C. Diff IBS Pancreatic insuffciency
A significant decrease in reocurrance of c diff was observed in patients treated with antibiotics and s boulardi
Why are estrogens pro inflammatory
Estrogens stimulate cox 2 which promotes inflammation
Estrogens stimulate cox 2 which increases production of inflammatory Eicosanoids
Factors that contribute to proper production of thyroid hormones
Iron Iodine Tyrosine Zinc Selenium Vitamins E, B2, B3, B6, C, D
Phase one reactions
Oxidation
Reduction
Hydrolysis
Dehalogenation
Introduce or expose a functional group on the parent compound
Render parent more polar
May activate inert compounds eg pro drugs and pro carcinogens
Nutrients used on phase one
Riboflavin B2 Niacin B 3 Pyridoxine B6 Folic acid Glutathione Branch chained amino acids Flavonoids Phospholipids Nuts for phase one: ribo (riboflavin) and nancy (niacin) were pyromaniac s (pyridoxine) and frolicked (folic acid) around with gluts (glutathione ) waving about branches (BCAA ) with flav (flavonoids) and phos (phospholipid )
Reactions of phase two
Sulfation Glucuronidation Glutathione conjugation Acetylation Amino acid conjugation Methylation Covalent linkage between parent compound and a polar water soluble moiety Phase two products are generally metabolically inactive and prepared for elimination by bile or urine
Nutrients used in phase two
Glycine Taurine Glutamine N acetylcysteine Cysteine Methionine Nuts for phase two: 2 gluts (glycine glutamine) had torrid (taurine) affair in a cistern (n acetylcysteine) and then too meth (methionine)
What are endotoxins
End products of metabolism
Bacterial endotoxins
What are exotoxins
Drugs Agri chemicals Food additives Household Pollutants contaminants Microbial
What is the toxic equation
Total toxic load = total toxic exposure - ability to detox + excrete toxins
List the causes of mitochondria dysfunction
High oxidative stress Exposure to medication Exposure to heavy metals Exposure to chemicals Exposure to PCBs Exposure to pesticides MIT became dysfunctional from: heavy metal, too many chemicals , PCB's , and pests, and then taking meds
What enzymes protect the body from ROS
Catalase Fe
Superoxide dismutase - SOD (Zn, Cu, Mn)
Glutathione peroxidase (Se) and glutathione reductase
What dietary anti oxidants protect the body from ROS
Vitamin C for aqueous compartments
Vitamin E for lipid compartments
Carotenoids, flavonoids, etc
What endogenous anti oxidant molecules does the body use to protect from ROS
Glutathione, cysteine , CoQ10, Lipoic acid , uric acid, cholesterol
Gluts fell into cistern with ten Qs and dropped some acid Uric pulled them out with chol they all fought off ROS
What leads to brain derived neurotrophic factor (BDNF)
Caloric restriction
Exercise
DHA
Mental exercise
What do you do to support the mitochondria
Good nutrition
Stay cool and hydrate
Prevent infection
Supplements
CoQ10
Omega 3 FA
Exercise
Avoid toxinsAndroid obesity
Apple shape
Above the waist
Over fat over vat
Think met syn
Gynoid obesity
Pear shape
Below the waist
Over fat over sat
Think gut / detox/ HPATG dysfunctions hypothalamic pituitary adrenal axis
What leads to insulin resistance and hyper insulinemia
Inability to suppress hepatic glucose production so elevated serum glucose so glucose toxicity leading to further impaired insulin secretion
Over production of FFA by adipose cells so stimulates gluconeogenesis increases muscle insulin resistence impairs insulin secretion so elevated serum glucose and glucose toxicity leading to further impaired insulin secretion
Increased muscle cell resistance to insulin action so elevated serum glucose so glucose toxic ip leading to further impaired insulin secretion
What genetic variant is associated with MI and atherosclerosis
9P21 33 gene enhancers are located in the 9P21 region are implicated in inflammatory pathways .
What is the pathophysiology of CHD/CAD
Endothelial dysfunction early Abnormal vascular compliance /vsmh / cardiac Hypertrophy late Inflammation Oxidative stress Immune vascular dysfunction
Heart energy
Mostly fatty acids then glucose
Microalbuminuria
One of the earliest abnormalities in vascular system and kidney tha reflects endothelial dysfunction and increased vascular permeability
High correlation with progression to proteinuria, renal disease, LVH, and future CVD, CHD, MI, CHF, and CVA
Linear relationship of albumin creatinine ratio ACR starting below 5 mg/gm
Triggers tubular renin angiotensive aldosterone system (RAAS) activation via megalin / cubilin receptors and inflammatory oxidative stress reaction with NFkB/AP-1
Reduced best with BP control with RAAS drugs and also with omega 3 fatty acids and Lipoic acid
The following symptoms of swelling and bleeding gums loosening of teeth and weakening of connective tissue and bruising are related to
Vitamin c deficiency
Vitamin C plays a crucial role in the formation of collagen, a major component of connective tissue. Connective tissue has structural and supportive functions which are indispensable to blood vessels and all tissues within the body.
What is one of the actions of carnitine
Carnitine facilitates the transport of fatty acids into the mitochondria
The carnitine shuttle helps move fatty acids into the mitochondria for beta oxidation
The car shuttle fatty acids into MIT to join beta oxidation
Elevated formiminoglutamate (FIGLU) is associated with what nutrient insufficiency
Folic acid
FIGLU is an intermediate compound formed in the metabolism of histidine to glutamate. Tertrahydrofolate (THF) is required to convert FIGLU into glutamate, therefore FIGLU is used as an indicator of folic acid THF deficiency
Patient with concerns of weight gain of thirty pounds , he has made no changes get but is sampling low fat foods, and has purchased a pair of walking shoes. What phase is he in
Preparation for change
Intentional acts designed to facilitate the change process illustrates that the patient is preparing for change
What is glutathione conjugation
Phase two reaction in the liver glutathione combines with toxins and converts them into water soluble mercaptates effectively detoxifies acetaminophen and nicotine
What is glucuronidation
Glucuronidation is the addition of glucuronic acid to a substrate. It is often involved in zenobiotic metabolism of substances such as drugs, pollutants , bilirubin, androgens, estrogens, mineralocorticoids, fatty acid derivatives, retinoids, and bile acids.
Which fatty acid inhibits delta 5 desaturase
EPA
Emily kills delta force five
Hyper keratosis Pilari can be caused by
EFA Vitamin A Vitamin C Zinc Certain B vitamins SNPs for elongases and desaturases SIBO Malabsorption Emily, Adrienne , zackery, B,Malory , Bo , all scratching back of arms and sniping paper
What could cause acne in an eight year old
Not enough zinc vitamin-A or EFA
PFC MVP
Protein Fats and oils Carbs and fiber Minerals Vitamins water and fat soluble Phytonutrients
How to decrease IgG reactions
Avoid Quercitin Vitmain C EFA Vitamin C Bromelain Nettle
What are estrogen’s three major phase two pathways
Taurine conjugation sulfation and glucuronidation
Glucuronidation sulfation and glycine conjugation
Sulfation glutathione conjugation and methylation
Glucuronidation sulfation methylation
Glucuronidation sulfation methylation
Calcium D glucarate can limit the action of
Beta glucuronidase
What is glucuronidation
The addition of glucuronic acid to a substrate
Often used in xenobiotic metabolism of substrates such as drugs, pollutants, bilirubin, androgens Estrogens, mineralocorticoids
Glutathione conjugation
A phase two detoxification reaction in the liver ; glutathione combines with toxins and converts them into water soluble mercaptates
Imagery can help with anxiety because
It activates brain function in ways that are different from the actually experience and will therefore help protect from the negative impacts of a bad experience
The right brain appears to have special links to emotion . Right brain processes are rapid, complex, whole pattern, spatial, and are specialized for visual imagery
Research shows that elimination diet to be effective in what condition
Eosinophilic esophagitis
Recent research suggests that which two interventions may be useful in diverticulitis
Vitamin d and probiotic
What conditions are considered non IgE allergies Atopic Asthma Eosinophilic gastroenteritis Migraines
Eosinophilic gastroenteritis
Two primary mechanisms that relate diet to systemic disease
Free radical production and nutritional insufficiencies
Amount of trans medium chain fatty acids
Balance of fatty acids and carbs derived from grains
Oxidative stress and glycemic load
Oxidative stress and glycemic load
Elemental diet have been shown to be particularly useful in
Inflammatory bowel disease and RA
The activity of delta 6 desaturase an enzyme required for conversion of DGLA to GLA may be impaired by
Alcohol
Factors known to inhibit D6D activity include alcohol , aging, diabetes, and radiation
Alpha Lipoic acid
Inhibits the release and translocation of proinflammatory NF kappa B from the cytoplasm to the nucleus
High glycemic foods
Tend to increase inflammation via NF kappa B and can increase serum hs CRP
Triggers of autoimmunity
A combination of genetic susceptibility with an environmental trigger. These triggers commonly include trauma infection toxins foods
Enterohepatic re circulation is
The cycling of drugs , xenobiotics, and metabolites after excretion in the biliary system which are then reabsorbed in the intestine
Enterohepatic recycling occurs by biliary excretion and intestinal reabsorption of a solute sometimes with hepatic conjugation and intestinal de conjunction
Fasting as what effect on biotransformation
Fasting generally inhibits the action of phase two enzyme systems
Phase two biotransformation systems are all highly nutrient and energy dependent and fasting decreases the availability of both
What is smoking effect on the family of c P450 enzymes
Cigs induce CYP - 1A2
Polycyclic aromatic hydrocarbons (PAH) in tobacco smoke are believed to be responsible for the induction and cytochrome P450 CYP1A2 and possibility CYP 2 E 1
Glutathione
Is s tripeptide made of glutamate, cysteine , glycine , and the rate limiting substrate of its synthesis is sulfa containing acid cysteine
Phase 1 and 2 detox pathways
Phase 2 biotransformation conjugated reactive intermediates from phase 1 and makes them less lipophilic and more easily excreteable in bile and urine
Select the correct statement about Gilbert’s syndrome
Associated with insufficient conjugation of bili with glucuronic acid
UPD glucuronosyltransferase production is suppressed by EGCG flavonoids
Affects the glucuronidation of phase one
In the UGT - 1A1 28 variation there is an increase in UGT enzyme production
Is associated with insufficient conjugation of bilirubin with glucuronic acid
Gilbert’s syndrome is characterized by episodes of mild intermittent jaundice in the absence of liver disease . It is found in approximately 6-12% of the population. Mutations in the UGT 1A1 Gene especially homozygosity for the UGT 1A1 28 variant are responsible
Metallothionein
The production of Metallothionein proteins is especially dependent on the availability of cysteine
Cysteine is a critically important sulfur bearing amino acid in glutathione synthesis as well as in Metallothionein synthesis
Toxin induced models of Parkinson’s disease related to heavy metals include
Mn, Cu, Pb, Hg
DMSA is an effective chelator for
Mercury and lead
DMSA and other dithiol agents have a binding affinity for, lead, mercury, cadmium, arsenic, bismuth, tin, nickel, thallium
Lipolysis and detox
Lipolysis can be expected to increase the burden on phase two biotransformation systems
Lipolysis mobilizes lipophilic toxins which need to be conjugated by the phase 2 detox system in the liver to facilitate excretion
During the adaptive phase of stress response
Cortisol levels raise but DHEA levels stay flat or decline causing a rise in the cortisol DHEA ratio
What is the normal action of 17/20 lyase
17/20 lyase is a key enzyme in the steriodogenic pathway whose activity is down regulated in situations of acute stress an effect that is part of the cortisol steal
Describe cortisol steal
In the cortisol steal enzyme action is altered such that pregnenolone goes to cortisol production leaving less to be converted to DHEA and the sex hormones
What would an elevated cortisol do to thyroid hormones
Decline in T3 and increase in RT3
What nutrient would help lower thyroid antibodies in hashimotos
Selenium
Why is it important to test thyroid auto antibodies
Symptoms of thyroid dysfunction may occur in the presence of normal thyroid hormone levels
Inhibition of the enzyme 17/20 lyase results in
Decreased testosterone production
Fewer 17-20 year old men less testosterone
17/20 lyase converts 17 OH progesterone and 17 OH pregnenolone into androgens DHEA and androstenedione
Conjugated equine estrogens
Increase inflammatory markers regardless if given with or without synthetic progestin
CEE generally increase plasma CRP and interlukin 6 (IL-6)
What would you expect in a woman with low levels of SHBG and symptoms of estrogen dominance
Higher levels of insulin
There is a significant inverse association between levels of SBHG and fasting seum insulin in both genders
What effects does progesterone have on estrogen
It decreases the effect of estrogen
List two aromatase inhibitors that will limit conversion of testosterone into estrogen
Chrysin and green tea extract are known aromatase inhibitors that will limit conversion of testosterone into estrogen
Low free testosterone is associated with
Insulin resistance
Studies in healthy men have shown an inverse correlation between testosterone and insulin levels
What inhibits the aromatase conversion of testosterone to estrogen and also the 5 alpha reductase conversion of testosterone to DHT
Green tea
Recent trials have reported what potential adverse events in testosterone replacement ?
Myocardial infractions
What two conditions have been implicated in the pathogenesis of NAFLD and PCOS
Visceral fat accumulation and adipose tissue dysfunction
Not subcutaneous adiposity and inflammation
List the five finite vascular responses to the infinite number of vascular insults
Inflammation Oxidative stress Autoimmune reactions Altered gene expression Endothelial , vascular smooth muscle , and cardiac dysfunction
Insulin resistence at the receptors leads to hyperglycemia , hyperinsulinemia which leads to a host of other physiologic responses including
Increased free estradiol insulin can stimulate ovarian estrogen androgen and progesterone secretion in vitro
List two interventions that can help prevent neurodegenerative disease and improve cognitive function
DHA and nuclear regulatory factor (erythroid derived 2 ) like NRF2 activators
DHA is highly concentrated in the brain and supports optimal function of the brain , eyes, immune system. Activation of Nrf2 stimulates production of important antioxidants which also protect brain function
What modifiable behaviors can upregulated BDNF transcription
Exercise, DHA , caloric restriction
Older adults with too little what in the blood may have twice the risk of Alzheimer’s disease as seniors with sufficient levels
Vitamin D
What is 8 Hydroxy-deoxyguanosine
8 OHdg is one of the major products of DNA oxidation . It’s concentration is a measurement of oxidative stress specific to DNA
What two nutrient are critical for ATP synthesis via the electron transport pathway
Riboflavin and niacin
NAD nicotinamide adenine dinucleotide and FAD flavin adenosine dinucleotide serve as electron shuttles in the Mitochondria . Niacin Aka nicotinic acid , is a building block of NAD and riboflavin is a central component of FAD
What organ system consumes the least amount of cellular ATP
Kidney
Patient with increased BMI waist circumference was it to hip ratio and BIA is
Android obese
A potent source of oxidative stress is
Peroxynitrite (*ONO2)
Imagery is helpful because
It is the language of the right brain and can facilitate insight into issues
The right brain appears to have special links to emotion. Right brain thought processes are rapid , complex, whole pattern spatial and are specialized for visual imagery
Insufficient copper, zinc, iodine, iron, and or zinc can cause
Smell and taste disorders
Zinc deficiency is associated with decreased smell, there are also associations between smell and copper iodine and iron
Deficiency of what vitamin is associated with seb derm and pain knots in the distal finger joints
B6
Exercise prescription should have
Frequency, duration, intensity
For optimal wound healing , as far as omega fatty acids are concerned , you need
Relatively equal consumption of omega 3 and 6 fatty acids
Om3 and om6 are both required for the body to function but generally have opposite effects when it comes to the inflammatory response . However inflammation is a important component in wound healing so om6 deficiency would be a problem
Riboflavin B2 deficiency is associated with what medical problems
Gum disease, angular blepharitis glossitis and seborrhea
What to ABCD of functional medicine assessment stand for
Anthropometrics , biomarkers , and functional labs, clinical indicators from nutritional assessment and lifestyle assessment
Most likely etiology of SIBO is
Hypochlorhydria
Low stomach acid allows more bacteria to survive which can colonize the gut
What dose hydrochloric acid do
Helps sterilize the bolts, denatures proteins, activates proteolytic pepsinogen to pepsin, prepares minerals for optimal absorption, and triggers the release of downstream digestive fluids from the pancreas and gallbladder
What is a symptom of low hydrochloric acid
Bloating or belching immediately after a meal
Low acid in the stomach can lead to dyspeptic symptoms following meals due to insufficient digestion in the stomach and down stream in the GI tract becasue chyme acidity triggers the exocrine pancreass and gallbladder to expel their critical digestive secretion into the duodenum
What is intestinal dysbiosis
Microbial imbalance within the intestinal tract
Unlike frank infection intestinal dysbiosis occurs when there is imbalance among beneficial and commensal microbial species in the gut
In published studies probiotics have been found to be useful for
Asthma, inflammatory bowel disease, ibs
Positive associations have been found between negative changes in the intestinal microbiome and chronic diseases including IBD , IBS, other allergic disorders, cancer, CVD, metabolic syndrome, obesity
4 triggers of autoimmune disease
Trauma infection toxins foods
Auto immunity is usually a combination of genetic susceptibility with an environmental trigger . These triggers commonly include trauma, infection, toxins, and foods
Molecular mimicry occurs when
There are sequence similarities between foreign and self peptides sufficient to result in the cross activation of auto reactive T and B cells by pathogen , toxins , or food derived peptides
The activity of delta 6 desaturase an enzyme required for conversion of DGLA to GLA may be impaired by
Alcohol aging, diabetes , radiation
What does lipolysis do in detoxing
Lipolysis mobilizes lipophilic toxins , which need to be conjugated by the phase 2 detox system in the liver to facilitate excretion
It can be expected to increase the burden on phase 2 biotransformation systems
Inhibition of the enzyme 17/20 lyase would result in
Decreased testosterone production
17/20 lyase converts 17/OH progesterone and 17 OH Pregnelone into the androgens DHEA and androstenedione
Most potent source of oxidative stress is
Peroxynitrite ONO2
