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Clinical Medicine: Nutrition

Most widely used method to gauge obesity? What is the threshold for obesity? Body Mass Index (BMI); 30
Term used for BMIs between 25-30? Overweight
Where are FFAs released from intra-abdominal fat transported to? Liver
Involved in metabolism, particularly where heat generation is necessary (thermogenesis). Small amount present in humans. Minimal amounts in obese. Metabolically active. Brown adipose tissue
Composed of 1) Adipocytes and 2) Vascular stroma fraction of preadipocytes, endothelial cells, macrophages, fibroblasts. Central to energy storage and mobilization of this energy store highly regulated. Causes trouble in body. White Adipose Tissue (WAT)
Adipose tissue is formed by what 3 processes? 1) Pre-adipocyte hyper-trophy/plasia 2) Angiogenesis (by endothelial cells...structure that adipocytes will form on) 3) Inflammation of macrophages
What is inhibited or induced with angiogenesis? (2) 1) Adiponectin gene transcription inhibited 2) Leptin and PAI-1 gene transcription induced.
What doers lipoprotein lipase do? Hydrolyzes chylomicrons and VLDL to mobilize and release fatty acids and glycerol into the blood
What activates hormone-sensitive lipase to hydrolyze stored triglycerides to FFA and glycerol? Norepinephrine; due to starvation or a dysfunctional excess
Chronic elevation of Free Fatty Acids or TNF-alpha inhibits: Insulin Secretion
What increases or decreases as a normal live becomes a fibrotic one? Insulin increases, Leptin increases, Fatty acids increase, Adiponectin decreases.
Augmented by large adipocytes, signaling molecule relating to long-term nutritional/fat mass status to brain. Downregulates hunger Leptin
Anti-atherosclerotic effects,inhibits hepatic glucose production, reduced in insulin resistances, metabolic syndrome, type 2 diabetes, obesity Adiponectin
2 adipokines that modulate CV homeostasis: 1) mediates obesity-related cardiac and vascular dysfunctions (fatty acid binding protein). 2) Protects against obesity-related CV disease through pleiotropic actions 1) A-FABP 2) Adiponectin
T/F: A-FABP and Adiponectin have the opposite functions True
What happens to adipocytes with obesity? Enlarged adipocytes start secreting higher levels of FFA and TNF-alpha causing a chronic low grade inflammation and an unhealthy cross talk with macrophages
Major lipid metabolism effects of adipose tissue Increases dense LDL causing CV problems
Major inflammation effects of adipose tissue TNF-alpha and IL-6 up; Increase C Reactive protein and PAI-1
Major coagulation effects of adipose tissue Increased PA-1 -> more likely to have MI due to thicker blood
T/F: BMI of 25-30 are more closely associated with atherosclerosis and MIs than waist circumference False, Waist circumference more closely associated
What do HTN, diabetes, smoking, dyslipidemia, and obesity lead to? What does that lead to (4)? What does this all lead to? Endothelial dysfunction! Leads to decreased NO, increased COX activity, inflammation, increased endothelin. This all leads to a pro-atherogenic environment.
Name a DM, depression, seizure, HTN medication and a hormone that can cause wt gain DM: insulin, TZDs sulfonylureas; Dep: Tricyclic; Seizures: Valproic acid; HTN alpha and BBs; hormone: steroids/progesterone
What waist circumferences are considered obese in men and women 40 and 35 inches
What BMI is considered extreme obesity? > or =40
T/F: Asians have a higher risk for metabolic syndrome at a lower waist circumference than Americans True
T/F: Patient should inhale when waist circumference is measured False, should exhale
T/F: CT or MRI considered gold standard of measuring intra-abdominal adiposity False, waist circumference is...non-invasive and is strongly correlated with said imaging measurements.
For Dx, 3/5 of the following must be present 1. Fasting glucose > or equal to 100 or Rx 2. BP > or equal to 130/85 or Rx 3. Triglycerides > or equal to 150 or Rx (HIGH) 4. HDL <40 in men or <50 in women (LOW) 5. Waist circumference of > or equal to 40in in men or > or equal to 35in in women.
First action for management of metabolic syndrome lifestyle measures
What diet is the best? WHATEVER DIET PATIENT WILL COMPLY TO; Mediterranean DOES have outcome studies proving its worth.
Initial wt loss goal? Rate of wt loss goal in lbs and caloric intake? 10%; 1-2 lbs a week; 500-1,000 calories; slow wt loss is more stable than fast wt loss
How can leptin interfere with a diet? Interferes by stabilizing wt loss; increases food intake and decreases energy expenditure, plateauing wt loss and creating diet adherence problems.
Though arbitrary (no outcome studies), what is the recommended BMI to start pharmacotherapy with co-morbidities? Surgery? 27; 35
Pancreatic lipase inhibitor that blocks the absorption of up to 1/3 of ingested fat. Also lowers LDL, and A1c in diabetics. Annoying side effects and is expensive. Orlistat (Xenical)
Obese patients with best benefit taking Orlistat (Xenical) (4) 1) Don't feel hungry or preoccupied with food 2) Increased CV risk 3) Older 4) Take multiple medications
Adverse of Orlistat (2) 1) Steatorrhea/diarrhea 2) Loss of fat soluble vitamins w/ potential for malnutrition
Serotonin 2c agonist that activates receptor in brain to decrease food consumption and promote satiety (Drug, Adverse) Belviq (locaserin); HA, dizziness, euphoria, hallucinations, fatigue, hypoglycemia, bradycardia
Chronic wt management w/ 1+ comorbidity combining phentermine and topiramate; adverse Qsymia; cognition, fatigue, dizziness (same as Belviq) AND suicidal thought/behavior
Restrictive Surgery: definition and most common type; others include uses bands or staples to create food intake restriction; Laparoscopic Gastric Banding (Lap-Band) is lowest risked and used the most. Other include Vertical Banded Gastroplasty (VBG) and Gastric banding
Combined Restrictive and Malabsorptive Surgery: Definition and most common type creating a stomach pouch with bypass where stomach is connected to jejunum or ileum (bypassing duodenum). Roux-en-Y Gastric Bypass (RGB) is most commonly performed bypass procedure
Indications for Wt loss surgery (5) 1) 100+lbs overweight 2) BMI>40 3) BMI>35+DM 4) Psych stability 5) Non-surgical efforts have failed
Complications of wt loss surgery are directly correlated to the skill of the surgeon
Late complications of wt loss surgery (5) 1) Incisional hernias, 2) B12/Fe deficiency as it bypasses duodenum, 3) wt loss failure, 4) zinc (characteristic face rash), 5) osteoporosis
T/F: In a study over 6 years, RYGB (Roux-en-y Gastric Bypass) failed 28% of the time. False, not even close! 28% of wt was reduced from baseline. 96% lost and kept 10% off while 76% lost and kept 20% off. They also had a 62% Diabetes remission. (LONG STORY SHORT: ALL OUTCOMES IMPROVED AFTER SURGERY)
The science devoted to the study of dietary needs for food & the effects of food on organisms Nutrition
Nutrients that the body cannot make for itself and must be obtained from foods. Essential Nutrients
Nutrients required by the human body in the greatest amounts: water, carbohydrates, protein and fats Macronutrients
Vitamins, minerals, & trace elements needed by the body in very small amounts Micronutrients
Higher nutrient to energy/calorie (veggies/kale/blueberries) Nutrient Dense
More calories compared to nutrients (chips) Energy Dense
the quality or state of being healthy in body and mind, especially as the result of deliberate effort (building blocks to be healthy) Wellness
3 components of wellness 1) Nutrition 2) Physical activity 3) spirtuality
amount of energy required to raise the temperature of 1g of water by 1 degree C calorie
What is a Calorie? Kcal or 1,000 calories
Primary source of dietary energy in almost every culture world-wide Carbohydrates
Starch and cellulose polysaccharides
Glucose, fructose or galactose monosaccharides
sugar (glucose+fructose), Lactose (glucose+galactose), maltose (glucose x2) Disaccharide
Naturally decreases a year or 2 after birth lactase
Does not occur by itself in food galactose
Resistant to being broken down by isomaltase at intestinal brush border and raises blood sugar faster amylopectin
Need 35 grams/day; indigestible portion of plant. Slows digestion and can lower cholesterol by binding bile w/ food fiber
2 possible pathways of carb metabolism 1) build up of glucose in blood stream 2) transportation to liver -> stored as glycogen or converted into fat
The oxidation of glucose to pyruvate yielding ATP Glycolysis
Energy currency of cell ATP
glucose -> glycogen glycogenesis
glycogen is released from liver and muscle and converted back to glucose 6 phosphate & used to make ATP. Controlled by glucagon (pancreas) and epinephrine (adrenal glands) glycoenolysis
The process by which glucose is made from non- carbohydrate materials, such as pyruvate. Lactic acid, some amino acids, & glycerol can be converted into glucose. Occurs mainly in the liver. gluconeogenesis
bond that can form between proteins or lipid molecules and monosaccharides such as glucose & fructose glycation
What monosaccharide can lower HDL fructose...especially high-fructose corn syrup
What kind of carbohydrates raise blood sugar slowly, also stimulating insulin? complex carbohydrates (veggies, fruits, beans, legume, whole grains)
Large energy store, but not the largest. Most satiating of macronutrients. Contains nitrogen (source of amino acids both essential and non-essential) Protein!
Breaks down proteins in stomach pepsin
Examples of Essential nutrients (just list a few) Histidine, (iso)leucine, lysine, methionine, phenylalanine, tryptophan, valine, threonine
Point of inflection body begins catabolizing proteins to maintain serum levels
Where do branch-chained amino acids (BCAA) get pushed to why do we want them there? What pushes them there. Pushed to muscles and kidneys by insulin which is good because that why they aren't competing for tryptophan which -> serotonin
What end-product increases with acidosis and fasting? ammonia (high levels indicate poor kidney function)
Calorically dense but least satiating, improves absorption of vitamins DAKE. Unlimitedly stored Fats or lipids
Emulsifier in food industry and emulsifies triglycerides in stomach phospholipids
largest/densest of lipoproteins, transports exogenous triglycerides Chylomicrons
transports lipids to tissues VLDL
Removal of fatty acids from VLDL; also transports lipids to tissues LDL
transports cholesterol from cells to liver HDL
What does a high fiber diet to do cholesterol? Increases. Binds cholesterol that will draw out cholesterol and excrete it. This causes inactivated cholesterol to be activated.
2 Ways hypertriglyceridemia can occur? What is it a characteristic feature of? 1) reduction in insulin action 2) intake of carbohydrates; in other words, characteristics feature of hyperinsulinemia and insulin resistant states
Linolenic acid; preferentially incorporated into the brain and retina Omega 3
Arachidonic acid Omega 6
No more than how much cholesterol per day? 300 mg
In a fed state, entry of amino acids and monosacchardies to portal circulation stimulates release of WHAT? proinsulin
What 5 things does insulin stop? 1) Gluconeogenesis 2) Glucoenolysis 3) Lipolysis 4) Ketogenesis 5) Proteolysis
What 5 things does insulin do? 1) Glucose uptake in muscle and adipose 2) Glycolysis 3) Glycogen synthesis 4) Protein synthesis 5) Uptake of ions (esp K and phosphate)
Calories out percentages: 70%: basal metabolic rate, 15%: physical activity, 15% thermic effect of food
T/F: 3,500-4,000 Kcals= 1 lb of fat True
Problem with Mediterranean diet? High in oils which is calorically dense
What did the Lyon diet heart study show? Mediterranean diet was effective
3 cancers associated with obesity and/or poor nutrition 1) Colon 2) Breast 3) Lung
Low Carb Diet Get full fast -> lower caloric intake
Low Fat/Vegetarian Diet associated with decrease in cancer and cardiometabolic disease
Mediterranean Diet emphasis on olive oil, veggies, fruits, nuts, seeds, beans, legumes with limited meat and wine intake.
Mixed/balanced/combination Diet DASH, prevents HTN and DM and has demonstrated weight loss. Rich in fruits and veggies with some lean meat and dairy. Minimal processed foods.
Paleolithic Diet Avoids processed foods, grains, dairy... Includes veggies, fruits, nuts, seeds, lean meats.
What should you supplement or decrease with alcoholism? For ascites? Add thiamine in alcoholism; decrease salts and fluids with ascites
T/F: Body stores of vitamins and minerals typically deplete w/in weeks False, some can last for years
What are the fat soluble vitamins? Water soluble? Fat: D, A, K, E; Water: and all the B vitamins
Vision and cell differentiation Vitamin A
Calcium and phosphate metabolism and cell differentiation Vitamin D
antioxidant Vitamin E
blood clotting Vitamin K
Biggest worldwide cause of vitamin deficiency low content or density of vitamins and minerals in food (inadequate caloric intake)
Thiamine: What vitamin, Fn, Deficiency, Sx, Cautions B1; metabolism of carbs; alcohol and low magnesium impair absorption/function; Sx: Wernicke-Korsakoff (delirium), wet beriberi (CHF), dry beriberi (peripheral neuropathy); provide thiamine whenever you give IV glucose
Wernicke-Korsakoff Sydrome: Sx of Wernicke, Sx of Korsakoff, Difference Sx of W: Confusion 2) Ataxia/tremors 3) Ophthalmoplegia (nystagmus, diplopia, ptosis). Sx of K: 1) Loss of memory 2) Confabulation 3) Hallucinations. Difference: not as acute
High-output heart failure, reduced systemic vascular disease, wide pulse pressure -> aortic insufficiency Wet beriberi
Riboflavin: what vitamin? deficiency? Sx: B2; deficiency not common; Sx: non-specific, but usually on mucocutaneous surfaces (cheilosis)
Niacin: what vitamin? Fn? What causes deficiency worldwide and in North America, early Sx, later Sx B3; important in oxidation/reduction rxns; NA: alcoholism and carcinoid; worldwide: corn-based diet; Early Sx: bright red glossitis, later Sx: Pelagra: 1) Dementia 2) Diarrhea 3) Depression 4) Death, Casal's Necklace
Pyridoxine: what vitamin? Fn? Deficiency? Toxicity? Sx? B6; Fn: protein, NT synthesis; D: Isoniazide and L-dopa so give 25 mg w/it. Toxicity: same Sx as deficiency. Sx: peripheral neuropathy, abnormal ECG, personality changes (depression/confusion)
Folic Acid: what vitamin? Fn? Dx? B9; Fn: purine/pyrimidine synthesis; Dx: serum folate, normal MMA w/ elevated homocystine, Macrocytic, megablastic anemia w/ hypersegmented leukocytes
Folate toxicity warnings: (2) 1) Supplements can correct anemia, but don't correct neurologic sequelae from B12. 2) Rule out B12 before giving folate in someone with megablastic anemia (check MMA)
Vitamin B12: Fn? Source? Absorption? Dx? Sx? Fn: involved w/ DNA synthesis; Source; animal origin; Absorption: actively absorbed and mediated by Intrinsic Factor; Dx: MMA; Sx: cognitive impairment, impaired vibratory sensation
Vitamin C: Fn? Deficiency? Associated diseases? Fn: immune functions and connective tissue metabolism; D: smokers have high turnover, no fruits/vegetables; associated with Scurvy: fragile blood vessels including petechiae and perifollicular hemorrhages, delayed wound healing, microcytic anemia, fatigue
Vitamin D: Fn? Dx? Risk for deficiency? Sx? Associated diseases? Fn: hormone and hormone precursors having to do with parathyroid. Dx: 25(OH)D3 (calcidiol); Deficiency: Elderly and nursing home residents; Sx: impaired mineralization of skeleton, increased bone alk phos; AD: osteomalcia, Rickets
Vitamin D biggest actions (2) 1) Immune system: stimulates immunogenic and anti-tumor activity; decreases risk of autoimmune disorders 2) Inhibits parathyroid hormone secretion
Vitamin A: Fn? Dx? Deficiency? Sx? Fn: absorbed in small intestine, reproduction, integrity of mucosal and epithelial surfaces, sterol synthesis, night vision; Deficiency: endemic in areas that are chronically poor. Sx: Night blindness an early Sx. Bitot's spots, diarrhea, etc
Most common cause of pediatric blindness in world? Vitamin A
Vitamin A: Effect in smokers? Toxicity? Increases incidence of lung cancer in smokers; too much -> increased intracranial pressure, vertigo, diplopia, and possibly death
Vitamin E: Evidence of cancer, eye, HD, cognitive decline prevention? Stroke? No; increased hemorrhagic stroke by 22%, decreased ischemic stroke by 10%; increased prostate cancer
Vitamin K: Indications and if it doesn't correct w supplementation? ABX therapy can aggravate management of warfarin (may cause them to bleed) and if K doesn't correct deficiency, pt has liver disease
Inorganic substances required for body processes Minerals
Works with insulin and is required for release of energy from glucose Chromium
Necessary for absorption and use of iron in the formation of hemoglobin Copper
Regulates growth, physical and mental development, metabolic rate Iodine
What can hypomagnesemia cause? Hypocalcemia
Possible reasons of iron deficiency? (5) older: colon, younger female: menstrual; 1) GI blood loss, 2) copper deficiency, 3) Hepcedin effects 4) Vit C deficiency, 5) Pyridoxine deficiency
T/F: Iron deficiency and anemia are synonymous False, Deficiency -> anemia
Major role of zinc? What other nutrients help with this process? wound healing; protein, zinc, vit C, vit A
Wilson's Disease (genetic) copper accumulated in brain and liver
Critical for fluid balance, nutrient support, nerve impulses, removal of wastes, muscle contraction, chemical rxns and more WATER
T/F: If you are health and have a normal diet, it is still beneficial to take a multivitamin, especially one with A, C, and E False, no need. Folic acid for young women and Vitamins D and B12 in the elderly.
4 characteristics of Marasmus Simple starvation; 1) decreased metabolic rate 2) wt loss mainly from fat and lean muscle 3) impaired wound healing and immune function 4) normal albumin levels
Characteristics of stress starvation 1) Catabolic cytokine response: increased metabolic rate, 2) Vascular permeability (-> edema) 3) ADH/Aldosterone increase 4) Epinephrine, glucagon, cortisol increase 5) low albumin 6) wt gain 7) loss in body protein 8) High mortality
Ex: worm infestation or other disease on top of poor nutrition Kwashiorkor
T/F: rates of malnutrition have dramatically decreased since the 1970s False, they've hardly changed at all. COPD big factor...takes so much effort to breathe
10% loss of lean body mass immune suppression and increased risk of infection
15-20% of lean body mass impairs wound healing
30% of lean body mass development of spontaneous wounds
2 ways malnutrition can occur 1) Insufficient intake 2) excessive physiologic demand
any nutrition imbalance that affects both the underweight and overweight Malnutrition
state of protein deficiency despite adequate nutrient intake. Kwashiokor
umbrella term for both marasmus and kwashiokor Protein calorie malnutrition
T/F: Regardless of the of BMI hospitalized patients, most suffer from undernutrition TRUE; may just be junk they are eating!
What happens to renal function during malnutrition? Reduces GFR and concentrating ability (inability to handle Na and acid load
What to look for on physical exam for malnutrition: (3) 1) body fat 2) muscle (concave temple) 3) fluid accumulation
Want albumin higher or lower in patient? Higher! >4
Gold standard for estimating energy needs? Harris Benedict Equation
Calorie needs: moderate, severe, burns Mid moderate stress 25-30 kcals/kg/day Moderate to severe 30-35 kcals/kg/day Burns/thermal injury 35-40 kcals/kg/day
How much do you enterally feed obese patients? 80% of their needs; called permissive underfeeding
When do you start enteral nutrition? 24-48 hours from admission and when they are hemodynamically stable
5 CONTRAs of entereal feeding 1) Severe ileus 2) Bowel obstruction 3) Hemodynamic instability 4) Severe malabsorption (short gut) 5) Post surgery (studies actually show it heals bowel at a slow trickle)
Parental feeding goal for ICU pts 80% (permissive underfeeding)
3 reasons for parental nutrition 1) 7 days of hospitalizaion and EN not feasible or target calories not consistently met 2) malnourished on admission and EN not feasible 3) Surgery planned
CONTRA parental nutrition (2) 1) unstable 2) terminally ill
Standard combo of TPN D25%, Lipids 2% and Amino acids 4%
Metabolic complication that occurs when nutrition support is started in severely malnourished patients. Sx? Refeeding Syndrome; increase in insulin drives electrolytes into cells and they bottom out, leading to serious arrhythmias
Gram positive infx w/ TPN? Consider line source
Gram negative infx w/ TPN? gut translocation
T/F: If you overfeed patients, CO2 will go up True!
What does fiber decrease? Slow entrance of glucose and lipids thereby decreacing glycemia, lipemia, insulinemia
What test is used to see if we are getting a response with TPN? Pre-albumin
What is the approach to nutrition with renal failure? (2) 1) Restrict nitrogen, 2) monitor electrolytes and fluid intake
Created by: crward88