Test 2 Inflammation Flashcards
What help in the storage of fats? What helps in the release of fat as FFA’s?
Storage: Chylomicrons, VLDL (lipoprotein lipase)
Release:
ATGL, HSL (hormone sensitive lipase)
What neurotransmitters are signals in weight management?
NE
Dopamine
Serotonin
Orexin
What are the 8 category causes of obesity
- Genetics
- Sedentary lifestyle
- Inflammation (overeating and adipose produce inflammatory signals)
- Sleep patterns/stress (increased cortisol which increases appetite)
- taste, satiety and portions
- obesogens
- viruses
- gut micro flora
What are examples of obesogens that are one cause of obesity?
Endocrine disrupters
BPA, phthalates
What country spends the least amount of money on food? Most?
US
Most: azerbaijan
<16 BMI
Severe thinness
16-16.9
17-18.5
Moderate thinness
Mild thinness
Normal BMI
18.5-24.9
Pre-obese BMI
25-29.9
Obese class 1, 2, 3 BMI
1: 30-34.9
2: 35-39.9
3: 40+
Health waist circumference in males? Females?
Men: < 40
Female: < 35
Healthy waist to hip ratio men? Women?
Men: <0.95
Female: <0.8
Waist to height ratio male and female:
Underweight
Slim
Underweight Male and female: <0.35
Slim-male: 0.35-0.43
Female: 0.35-0.42
Waist to heigh ratio male/female-healthy?
Male: 0.43-0.53
Female: 0.42-0.49
Waist to height ratio male/female—obese?
Male: 0.58-0.63
Female: 0.54-0.58
Rate of weight loss for BMI 27-35?
0.5-1lb/wk for 6mo
Rate of weight loss for BMI >35?
1-2lbs/wk for 6 months
Lifestyle modifications for weight loss?
-Goal setting (Increase walking/1fruit at lunch) -Self-monitoring (diary/weigh ins) Stimulus control (ABC) Cognitive restructuring (challenge/correct negative thoughts)
Dietary modifications for weight loss
- restricted energy diets
- formula diets/meal replacements
- commercial programs
- very low calorie diets
- fasting
Restricted-energy diet
Calorie deficit of 500-1000
Focus on whole plants
Limit alcohol and high sugar
Formula diets/meal replacements
Lean cuisine, slim fast/cliff bars
Used to promote structure/portion sizes
Very low calorie diets
<800 cal/d
Only used on those with >30 BMI
Fasting
<200cal/d
50% of rapid weight loss is fluid
Increases likelihood of gout/gallstones
What diet is best for preservation of lean mass: alternate day fast or very low calorie?
Alternate day fasting
And on fasting days may eat up to 500 cal for female and males 600 cal
Recommended amount of physical activity for weight loss?
60-90 min/day
Weight maintenance: 150–250min/wk
What are some weight loss medications often prescribed?
Orlistat
Lorcaserin
Phentermine-topiramate
Orlistat
Pancreatic lipase inhibitor
GI upset, leaky stools
Ex: Xenical
Alli
Lorcaserin
Serotonin receptor agonist that acts as an appetite suppressant
HA, cough, fatigue, constipation (do not take with antidepressants)
Ex: Belviq
Phentermine-topiramate
Appetite suppressant
Tingling of hands and feet, dizziness, trouble sleeping and birth defects
Ex: Qsymia
Supplement for weight loss
CLA—required in 3.4g/day
Used to reduce body fat and build muscle
What supplements may act as fat burners?
Bitter orange
Green Tea Extract (heart arrythmias)
Raspberry ketones
What nutritional deficiencies are prominent in patients who have undergone bariatric surgery?
Iron
Ca
Vit D, B12
General causes of unintentional weight loss
Wasting-chronic infection Poor food intake Malabsorption Hormonal imbalances (thyroid) Increase in activity without increase in energy intake Poor living situation CA (cancer)
What are some major risk factors for CVD?
HTN Age Diabetes Microalbuminuria Family history
What are some modifiable risk factors for CVD?
Lipoproteins High LDL High TG High TMAO Low HDL Inflammatory markers (CRP, fibrinogen)
What are lifestyle risk factors for CVD
Smoking Poor physical activity Poor diet Stress Lack of sleep Alcohol
What are co-morbidities for CVD
HTN
Obesity
Metabolic syndrome
Desirable level for:
Total cholesterol
<200
Desirable level for:
HDL
> 60
Desirable level for:
LDL
<100
Desirable level for:
Triglycerides
<150
What is metabolic syndrome?
Having 3+ of the following:
Waist circumference > 40(M), >35 F TG: >150 HDL: <40 BP: >130/85 Fasting glucose: >110
What are some recommended swaps for decreasing risk of CVD?
- Swap trans fat for MUFA/PUFA
- Swap saturated fat for PUFA
- Do not swap UFA for carbs
Diets proved to decrease risk of CVD?
- Mediterranean
- DASH
- Vegan
What are the basics of the Mediterranean diet?
0-1 serving: eggs/dairy 0-2: vegetable oils 1-2: nuts/seeds 3-4: fruits 6-9: veggies 5-12: whole grains 1-3: legumes/soy
***mostly whole grains, veggies, and fruits
What are the basics of the DASH diet?
Low fat, low sodium diet
- plant based
- lean meats
- nuts
- seeds
- low-fat diary
- high potassium, mg, Ca, fiber
25-30% fat (MUFA) 25% protien
Limit foods that have more sodium than calories!!
Nutritional therapy for elevated LDL?
- Consume high veggies, fruits, whole grains. Some: low-fat dairy, poultry, fish, legumes/nuts
- Limit sweets, sugar sweetened beverages and red meat
- Aim for 7-10% of energy from saturated fat
- Avoid trans fat
- Exercise 3-4x/wk of mod/Vig.
Nutritional therapy for elevated TG
- Eat high veggie, fruit, whole grain. Some: low fat diary, poultry, fish, legumes, and nuts
- Limit sweets, sugar sweetened beverages and red meats
- 2-4g of EPA & DHA daily (omega 3)—FISH!!
- 3-4x/wk exercise
Normal BP
> 120
>80
Elevated BP
120-129 and >80
High BP stage 1
130-139 or 80-89
High BP stage 2
140+ or 90+
Hypertensive crisis
180+ and/or 120+
What 3 food/nutrients have the largest affect on BP?
Sodium (less than 2300mg)
Plant-based diet
Weight loss (3-5% body weight)
What is the nutritional therapy for hypertension?
- High veggies, fruits, whole grains. Some: low-fat dairy, poultry, fish, legumes, nuts
- Lower Na, increase K intake
- 3-4x/wk exercise
What are the 3 most preventable risk factors for chronic disease?
Unhealthy diet
Smoking
Physical inactivity
Deficiency
Low level of nutrient found in blood that CAUSES a specific disease
Insufficiency
Subclinical or deficiency nutrient pools due to chronic poor intake
Deficiency vs insufficiency-which MC to see in practice
Insufficiency
What are some chemical mediators in inflammation?
Cytokines
Lipid-derived compounds (prostaglandins, leukotrienes, thromboxanes)
ROS
Estimated that 30% of patients baseline level of inflammation is due to _______ produced by________q
Cytokines produced by adipocytes
More adipocytes= more inflammation
Gut inflammation precedes weight gain and adipocytes inflammation and can cause M2 macrophages to switch to M1 that have what effects?
M1: pro-inflammatory
Microbicidal
TH1 Rxn
Tissue damage
M1 means “kill”
Pathway of inflammation
- Diet/stress lead to changes in the gut microbiome. (More LPS-lipopolysaccharides produced with high fat diet.).
- Gut changes:
—> increased LPS activates NF-kB—> stimulate production of inflammatory cytokines—> produce ROS (also increase NF-kB) - Immune cell activation—aka systemic inflammation
What are some biomarkers of chronic inflammation
CRP
TNF-a
ESR
Liver: ALT/AST (liver inflammation), GGT (liver disease) Eosinophils (allergies, parasites, autoimmune, CA) Lipid peroxides (oxidative stress)
What are some nutrient modulators of inflammation
Omega 3/6 Mg Zn B complex vitamins Flavonoids
What are the co-enzymes and cofactors for AA and EPA?
Mg, Zn,
Vitamin A, C, B6, Niacin
Coenzyme: desaturase and elongase
What mineral acts as a calcium-channel blocker and low dietary intake is a major risk factor for chronic disease?
Magnesium
What are Mg’s balanace parterns?
Mg: Ca and Zn
What mineral is associated with obesity-induced inflammation?
Magnesium
RDA for Magneium (roughly)
310-320mg
What foods is Mg rich in?>
Nuts/seeds
What mineral deficiency causes decrease production of T-lymphocytes?
Zinc
Low Mg and Zn alter what?
Gut permeability
=leaky gut
What is the biomarker for zinc deficiency?
Alkaline phosphate
What is zincs balance partner
Copper
What mineral is required for signaling during inflammatory reactions?
Zinc
Zinc rich foods?
Oysters**
Beef, crab
S/s of zinc toxicity? Deficiency?
Tox: metallic taste
Def: lack of taste
What vitamin is most important for methylation? And stimulated epigenetic-induced gene expression
B complex
What vitamin alters redox status within organelles
B complex
Functions of B complex
- methylation
- stimulated epigenetic-induced gene expresssion
- alters redox status
Zinc functions
- signaling during inflammatory reactions
- maintain gut permeability (+ Mg)
- maintains production of T-lymphocytes
Magnesium functions
- ca+ channel blocker
- decreases risk for chronic disease
Flavinoids and example foods they are found in
Phytonutrients that often provide color to plants
Ex: alpha lipoic acid Curcumin (turmeric) Quercetin (everything) Lycopene (tomatoes) Catechins (tea/coffee/wine/chocolate) Epigallocatechin-3-gallate (green tea)
What are on the anti-inflammatory index?
Turmeric Fiber Flavones Tea Beta-carotene Isoflavones Mg Omega 3
Increased inflammation leads to increase in what other health issue
Mental health
What constitutes the mind diet
Green leafy: 6x/wk Nuts: 7/wk Berries: 2/wk Beans: 3/wk Whole grains: 3+/d Fish: 1/wk Poultry: 2/wk Olive oil Wine: 1glass/d
Avoid:
Red meat: <4/wk Butter: <1TBsp/d Cheese: <1/wk Sweets: <5/wk Fast food: <1/wk
What are some side effects of chronic inflammation
- energy dysregulation due to mitrochondrial dysfunction
- changes in gut microbiome
- alter body fat distribution
Plus many diseases: CA, CVD, Alzheimer’s, DM, Arthritis,Autoimmune, neurologic, pulmonary etc.
What decreases bone mineral density?
Imbalance in protein and low calcium intake
High animal protein and low calcium triples risk of fracture
What does protein do to the acid load?
Increases
What increases PRAL (potential renal acid load)
Proteins Bread Jello Pudding Bacon Walnuts Sunflower seeds Peanuts
What are alkaline/decrease PRAL?
Fruits Veggies Herbs/spices Brown sugar Molasses Cocoa Coffee
Neutral foods in regards to PRAL
Corn Butter Oils Cows milk Honey White sugar Water Tea
What things affect calcium absorption?
- protein increases
- foods with mineral binders (phytate/oxalate) lower absorption
- doses less than 500mg at a time
What minerals have an affect on bone density
Calcium
Potassium/Magnesium (eat more)
Sodium (eat less)
Vitamins that have an effect on bone density
Vitamin A, D, K
Ca:P ratio ideal for bone
> 1
What is the nutritional therapy for GERD?
General
5R protocol
Remove Replace Reinoculate Repair Rebalance
What should you remove for GERD?
Arginine Alcohol Caffeine Chocolate High fat Spicy food Acidic food Smoking Stress
What should you replace with GERD?
Betaine HCL
What should you re-inoculate in GERD?
Lactobacillus acidohilus
What should you repair with GERD
DGL
Antioxidant rich foods
Fish oil
What should you rebalance with GERD
Breathing
Exercise
Meditation
What are micronutrients of concern in patients with stomach conditions
B12
Iron
Ca
What are some natural eradicators of H. Pylori
Green tea Broccoli Black currant oil Kimchi Probiotics (lactobacillus/bifidobacterium)
Etiology of constipation
Lack of fiber or fluid intake ***
Low energy intake
Iron + Ca supplements (binders)
Lack exercise
Nutritional therapy for constipation
- Increase whole grain intake to 6-11/d
- Increase veggies to 5-8/d
- High fiber cereals to get at least 25g-F, 38g-M
- Increase fluid intake to 2L/d
Treatment for diarrhea
Replenish fluids
Limit: lactose, sugar alcohols, fructose and lots of sucrose
Try probiotics
Test for fat malabsorption
72 hour fecal fat test
> 6g/24hrs
S/s of fat malabsorption
Pale, greasy, smelly stools
Diarrhea WITHOUT distention or gas
Frothy
Test for protien malabsorption
Fecal nitrogen
Serum albumin
S/s of protein malabsorption
Edema
Muscle atrophy
Test for carb malabsorption
Hydrogen breath test
S/s of carb malabsorption
Watery diarrhea
Flatus
Abdominal distention
Test for fluid/e-lyte malabsorption
Serum electrolyte panel
Creatinine
Urea nitrogen
S/s of fluid/e-lyte malabsorption
Tachycardia
Dry mouth
Test for bile salt malabsorption
Serum 7-a-hydroxy-4cholesten-3-one
S/s of bile salt malabsorption
Watery diarrhea
Generally, how do you test for micronutrient malabsorption
Serum tests
What is leaky gut
Increased intestinal permeability
What might cause leaky gut
Infections, medications, dysbiosis
What patients might you find leaky gut in?
Celiac, crohns, MS, IBS, SIBO
What test is done to diagnose leaky gut?
Lactulose-mannitol test
Lactulose—non-absorbable disaccharide
Mannitol—sugar alcohol
Celiac disease 4 step pathyphysiology
Genetic susceptibility
Exposure to gluten
Environmental trigger
Autoimmune response
Requires all 4 to cause celiac
What is the physiology behind celiac disease
Autoimmune reaction to protein that over time causes damage to small intestinal lining—villi that leads to medical complications and malabsorption
Nutritional celiac disease symptoms
Anemia (low iron/folate) Increased fx risk Clotting issues (Vit K Def) Delayed growth Lactase deficiency
Extraintestinal s/s of celiac disease
- malaise
- arthritis
- dermatitis herpetiformis
- infertility
- hepatitis
- ataxia
- psychiatric syndromes
***cluster diseases: hepatitis, type 1 diabetes, hashimotos, and celiac
Cluster/associated disorders with celiac disease
Autoimmune cluster: type 1 diabetes Thyroiditis Hepatitis GI malignancy IgA deficiency
Dermatitis herpetiformis seen with which disease?
Celiac disease
Celiac disease vs. gluten sensitivity/intolerance
Disease: autoimmune disease where the body attacks itself
Tests to diagnose
Intolerance: NO immune rxn
Could be due to IBS and is diagnosed using elimination diet
Diagnosing celiac disease for high probability cases (anemic, dermatitis herpetiformis, psychiatric issues, C. HA, GI issues)
Duodenal biopsy and TTGA IGA.
Yes if both positive.
If only one + —> HLA DQ2, IgA level, DGP IgG
Diagnosing celiac disease in low probability group
*** test TTGA & IgA.
+ TTGA= duodenal biopsy
- TTGA but low IgA—> TTGA IgG…if positive= duodenal biopsy
-TTGA and normal IgA= unlikely
MUST BE EATING GLUTEN DURING TESTING
Diagnosing kiddos under 2 years with celiac
Screen for TTGA and DGP (IgA and IgG)
Nutritional therapy for celiac disease
Gluten free for life
Avoid: wheat, rye, barley and malt
Up to 50g/d of oats potentially tolerated
Initial nutritional therapy for gluten patients
1-2months: limit sugars, diary, lactose and sucrose
Then follow diet recommendations of avoiding, wheat, rye, barley and malt
What are some safe gluten-free options?
Grains and flour: amaranth, bean flours, corn, rice, soybean, potato, quinoa, flax
Alcohol: wine, distilled liquor, gluten free beer
Cheese, eggs, meats, fish, beans, legumes, nuts, seeds, fruits, veggies normal
What are some hidden sources of gluten?
- Medications
- Communion wafers
- Toothpaste, mouthwash, lipstick
- Cross contamination
Nutritional deficiencies in celiac patients
Niacin riboflavin B12 folate Iron
+(Ca, Mg, Vit D —at time of diagnosis)
Refractory celiac disease
Patients who do not respond to a gluten free diet
Present with severe malabsorption diarrhea and weight loss
Gluten free diets high in what?
Saturated fats
Starch
Sucrose
(Recall low in niacin, riboflavin, folate, B12 and iron and fiber)
What is a nutritionally complete gluten free diet?
- focus on foods naturally gluten free
- 5 fruits/veggies per day
- add amaranth, quinoa and buckwheat
- meat, fish and dairy
What is the 5R protocol for gluten related disorders
Remove: gluten grains Replace: digestive enzymes, DPP-IV Reinoculate: VSL #3 Repair: L-glutamine, zinc, vitamin A Rebalance: mindful eating and relaxation
Replace what in those with celiac?
Digestive enzymes
DPP-IV (dipeptidylpeptidase)
Reinoculate what in those with celiac?
VSL #3
Repair what in those with celiac
L-glutamine
Zinc
Vitamin A
What are the most common burst boarder enzyme deficiencies?
Lactose intolerance and fructose malabsorption
What is the most common form of cab malabsorption
Lactose intolerance
How is lactose intolerance diagnosed?
Hydrogen breath test
How is fructose malabsorption diagnosed
Hydrogen breath test
What is the protein requirement for those with IBD
1.3-1.5g/kg/d
Supplements required for those with IBD
Folate B6,12 Iron Zinc Mg K Fe Omega 3 PERT (pancreatic enzyme replacement therapy) Boswelia
IBD 5R protocol
Remove: food triggers. Mc: cereal, milk, egg, veggies/citrus fruits
Replace: digestive enzymes
Reinoculate: VSL #3
Repair: boswelia serrata, zina, vitamin A, mastic gum
Rebalance: meditate, yoga, deep breathing, acupuncture (moxibustion)
What are the IBS subtypes?
IBS-C (constipation)
IBS-D (diarrhea)
IBS-M (mixed)
Unsubtyped IBS-insufficient evidence to meet the others
FODMAP diet. What is it and for what?
Fermentable oligo, di, and monosaccharides and polyols restriction
Limit fermentable foods (sugars, oligosaccharides and sugar alcohols)
Start very restrictive and then slowly add things back in
What are the foods to eliminate on the FODMAP diet?
Dairy: all except lactose free and hard cheese
Non-dairy: NO: coconut milk, beans, hummus, lentils (yes to almond and rice milk and nuts/seeds)
Grains: only wheat free grains
Fruits: avocado, apples, canned fruit, cherries, guava, mango, pear, papaya, peach, plum, prunes, watermelon
Veggies: artichokes, asparagus, beets etc
What is diverticular disease associated MC with?
Obesity Low fiber Vitamin D deficiency Sedentary lifestyle NSAID use
Nutritional therapy for diverticular disease
- High fiber
- Probiotic
You CAN have nuts, seeds, corn, popcorn and berries
SIBO
Small intestinal bacterial overgrowth
Overproliferation of bacteria in the SI that is normally only found in the LI potentially due to low stomach acidity, liver/gallbladder disease or pancreatitis
What probiotics are avoided with SIBO
Lactobacillus acidophilus and lactobacillus fermenti
Produce D-lactate that could cause life threatening lactic acidosis
Causes of SIBO
Low stomach acidity
Liver or gallbladder disease
Pancreatitis
What diet is useful for treating SIBO?
FODMAP
5R protocol for SIBO
Remove: microbes using antibiotics, artificial sweeteners
Replace: betaine HCl
Reinoculate: introduce prebiotic-free probiotic
Repair: omega 3 from cold water fish, L-glutamine, zinc, vitamin A
Rebalance: eat every 3-5hr, acupuncture, deep breathing yoga
What are the two forms of IBD? And which is MC?
Chron’s and ulcerative colitis
Chrons
What test can you order to test for liver function
AST/ALT tests
GGT
Nutritional requirements for liver disease
B vitamins
Vit ADEK (if steatorrhea)
Mg and Zn
(Avoid Iron)
Herbal supplements for liver disease
Milk thistle
Contains antioxidants that may reduce free radicals
Diets at risk for gallstones
Low fiber
High fat diet
High animal protein diet
(Vitamin C may be protective to gallstones)
Nutritional recommendations for those with cholecystitis/gallstones
Low fat diet: 30-45g/d
Supplement Vitamin C
Increase citrus foods
Ox bile (bile salt supplement)
What lab tests can assess pancreatic function?
- Secretin stimulation test (pancreatic secretions)
- Glucose tolerance test (endocrine function)
- 72 hour fecal fat test (exocrine function)
- Fecal elastase <15mcg/g = insufficiency
What are the nutritional recommendations for patient with pancreatitis?
- Easy digestible carbs (sugar/starches)
- low fat (not producing enzyme—> cannot digest)
- PERT
- ADEK, B12 supplements
How can kidney stones be prevented?
- FLUID!!!!!
- Juicies (cranberry for struvite and black currant for uric acid)
- Reduce Animal protein—> limit food with + PRAL
- Reduce Oxalate + increase Ca (binds oxalates and doesnt allow them to be absorbed)
- Na: K <1
- Decrease: citrate, fructose, Vit C supplements and high doses of VitD
- Increase B6 and EPA (omega 3)
Calcium stones
Associated with increased intake of calcium.
To prevent, make sure ca is taken with meals to balance urinary oxalate
Oxalate stones. Etiology and recommendation
Fatty malabsorption
Low Vit B6
Excess Vit C
Lack of oxalobacterformigens
=Limit oxalate containing foods
What are oxalate containing foods
Rhubarb Spinach Strawberries Chocolate Wheat bran/whole grain wheat Nuts Peanuts Beets Tea High dose turmeric
Pathway of fat malabsorption oxalate stones
Increased lipids in the SI cause ca++ to bind to them instead of oxalate and oxalate is then free to be absorbed by the body
Uric acid stones. Etiology and recommendation
MC due to low urine pH
(Too many acidic foods, too few alkaline foods)
= limit meat, fish, poultry
Avoid Oran meat, anchovies, sardines, broth and gravy
Treatment for inflammation
Increase omega 3
Decrease omega 6
Increase:
B Vitamines
Mg, Zn
Lifestyle recommendations for inflammation
Weight loss
Decrease smoking and alcohol
MIND DIET!!!
Poultry 2x, beans 3x, berries 2x, nuts 5x, fish 1x, whole grain 3xd, veggies 1xd
Avoid: added sugars, processed grains, refined oils, trans fat
Recommendation for weight loss
BMI 27-35: .5-1lb/wk, 35+ = 1-2lb/wk
Increase protein 20-25%
Strong bone dietary recommendations
Protein
Limit excess fiber
Vit D, K
Ca, K, Mg
LIMIT Vit A (excess) and Na
Limit caffine, alcohol, smoking
Decrease high acid foods
Ca: P >1
Recommendations for CVD
- Decrease trans fat, sugars, starches, Na
- increase omega3, K
- Mediterranean diet: moderate fat, olive oil, plants, legumes
- DASH diet: low fat, plants, moderate protein
General Mediterranean diet vs DASH
Mediterranean