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73 Cards in this Set
- Front
- Back
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albumin vs prealbumin (HL, normal level, use)
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albumin:
HL 14-21 dd normal 3500-5000 mg/dl decreases IRT stress, infection, edema, overhydration prealbumin: HL 2 dd normal 20-40 mg/dl better indicator of nutrition b/c short HL |
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Zn deficiency causes...
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Lose smell/taste
Sign of severe malnourishment |
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Protein/biotin deficiency causes...
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Brittle hair and nails
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Lack of niacin (B3) causes...
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tongue fissuring
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Essential FA deficiency causes...
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Dry skin
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BMI (normal, obese class 1/2/3)
At what waist circumference and BMI is there clinically significant increase in risk? |
18.5 to 25 normal
30-35 obesity class 1 35-40 obesity class 2 40+ obesity class 3 WC increased risk @ F > 35in M > 40in BMI 25-35 increased risk |
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When do enteral and when do parenteral support?
For each, what are short vs. long term types? |
Enteral if:
- ventilated - mechanical problems, i.e. dysphagia - malabsorption - GI tract must function Short term: NG or OG Long term: PEG or G/J-tube Parenteral if: - basically only if you cannot do enteral - bowel is obstructed/ischemic/immotile - cannot gain enteral access - unresponsive vomiting/diarrhea - hypotension Short term: PPE (isotonic, high volume) Long term > 2wk: TPE (hypertonic, low volume, OK for CHF) |
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What is refeeding syndrome?
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Metabolic and electrolyte abnormalities due to a drastic increase in calories.
Occurs when you have chronic malnutrition, weight loss, or calorie restriction. |
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MCV qualifications for normocytic, microcytic, and macrocytic
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Normal 80-100
Micro <80 Macro >100 |
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Causes of anemia
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Deficient:
- iron - folate - EPO (due to uremic toxins hurting kidney) Can be exacerbated in K-restricted renal pts if they eat leafies, bananas, oranges, refried beans, potatoes, or chocolate |
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BUN is proportional to...
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dietary protein, catabolic state, GI bleed
inversely proportional to liver disease, renal fxn, and treatment efficacy |
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Secondary hyperparathyroidism
Causes, effects, treatment |
Causes:
Chronic kidney disease increases Pi and decreases Ca. PTH increases in response to low Ca to protect bones. Then Ca is taken from bone to preserve serum Ca, and you get bone disease. Treat with phosphate binders, and with vitamin D analogues to suppress PTH and increase Ca. |
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Signs of anorexia vs. bulimia
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Anorexia:
Controlled Restricted emotions Cold intolerance, bradycardia, muscle wasting, amenorrhea Bulimia: Not controlled Unrestricted emotions Parotid enlargement, dental erosions, conjunctivitis, scratches on hands |
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Binge eating vs bulimia
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2x/wk for 6mo = BED
for 3mo w/ other symptoms = bulimia |
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Treatment of eating disorder
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Wellbutrin (antidepressant) contraindicated due to seizures (but topiramate is an anticonvulsant).
Anti-depressants effective for bulimics/BED but NOT for anorexics. Topiramate for BED (technically an anticonvulsant). |
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Pediatric BMI (by percentile)
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Underweight <5
Normal 5-85 Overweight risk 85-95 Overweight >95 |
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Diet by month (1-12)
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1-4 breast milk
4-6 iron fortified cereal 6-8 strained veggie/fruit 8-9 chopped finger food, meat, citrus 10 bite size cooked food 12 table food |
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Why not drink cow's milk before 1yo?
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Too much solute for kindeys
Too little vitC/Fe/essential FA/antibodies |
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Pregnancy nutrition
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Varied diet but no raw foods
Folate 400ug/day, best as folic acid because better absorbed (help make RBC, support rapid placental/fetal growth, prevent neural tube defects before wk6, prevent low birth weight or premature birth) Fe and Ca (for mom not fetus, as fetus will draw it out of mom's bones) Increase caloric intake by 300kcal/day |
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Weight gain in pregnancy based on pre-pregnancy BMI
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Underweight gain 30-40lb (1.1/wk)
Normal gain 25-35lb (0.9/wk) Obese gain 10-20lb (0.5/wk) |
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Breast feeding
-- whey protein -- increased caloric demand -- benefits of human milk -- duration |
Human whey protein is alpha lactalbumin.
Benefits: Lower casein protein (bovine milk has 82 casein/18 whey) More fat in hind milk More medium chain FA More bioavailable Fe, Zn Start to wean at 6mo |
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After high intensity workout, what ratio of carb:protein do you want?
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4:1 carb/protein (chocolate milk)
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Vitamins/minerals that benefit an athlete
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B vit, antioxidants, Fe, electrolytes
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Female athlete triad components
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IN BRIEF:
1) Disordered eating (do not treat with estrogen) 2) Osteoporosis (because estrogen helps Ca absorption) 3) Amenorrhea (for 3mo, due to less GnRH>LH pulsing, treatable with estrogen) FULL INFO: Disordered eating -- limit caloric intake, skip meals, use diet pills -- better to target nutrition than to replace estrogen Osteoporosis -- Amenorrhea contributes to this, since estrogen helps with Ca absorption -- need to reach peak bone mass b/t 25-35, b/c density declines after 40 Amenorrhea -- No menses for >= 3mo (athletes normally have secondary amenorrhea, which is absence of 3 consec cycles) -- The main, primary problem -- Starvation, weight loss, high-fiber low-fat veggie diet, strenuous training, body fat < 17%, eating disorder -- All those things cause hypothalamic dysfxn (less GnRH pulsing, so reduced LH pulsing from pituitary) -- treat THIS with estrogen replacement, as well as increased caloric intake and reduced training intensity |
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Normocytic anemia causes
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Marrow production defects
Hemolysis Protein malnutrition Chronic renal failure Hemorrhage |
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Macrocytic anemia causes
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B12, folate deficiency
Chemotherapy Liver disease SEE MEGALOBLASTIC ANEMIA |
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Microcytic anemia causes
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Iron deficiency
Thalassemia (defective Hb chain synthesis) |
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Megaloblastic anemia
-- what is it -- what causes it -- symptoms |
Impaired DNA synthesis, so cells that have rapid turnover are affected, and make cytoplasm faster than nucleus, so end up with large volume but higher RNA/DNA ratio and hypersegmented nuclei (if neutrophil)
Caused by B12 def usually due to malabsorption secondary to gastrectomy, acid secretion inhibitors, inadequate IF, distal ileal disorders like sprue/enteritis/resection, tapeworm/bacteria competing for B12 Symptoms = glossitis, anorexia, diarrhea, numbness in extremities, ataxia, irritability, axonal degen |
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How is iron absorbed and what helps absorption?
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Absorbed in duod & prox jej
Requires acidic gastric pH to convert from ferric to ferrous form (2+ is more absorbable). Vitamin C also reduces ferric to ferrous, aiding absorption (although no effect on HEME iron absorption). Heme form in animal products is more absorbable than plant nonheme form. Among nonheme iron, ferrous gluconate (organic) is better absorbed than ferrous sulfate (inorganic). |
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Iron deficiency anemia:
-- Causes of deficiency -- Symptoms -- Blood tests show -- Treatment |
Causes:
- infant, eating disorder, athlete > may not get enough - vegetarian > cannot absorb (too much Pi) - blood loss Signs: - pale - concave nails - PICA - mouth fissures - less unique: SOB, fatigue, learning problems, sensitivity to cold/infections, heart murmurs Blood tests show decreased: - Fe - MCV, color - Hb - Hct - ferritin Treatment: - Fe supplementation (increased RBC & Hb w/in 3wk) - Vitamin C for absorption - No tea, bran, spinach, or multivitamins |
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Folate deficiency
-- Where absorbed -- Causes -- Signs -- Blood tests -- Treatment |
Abs in acidic duodenum
Caused by alcoholism, methotrexate, meat eaters, renal disease, leafy vegetables... more commonly caused by malnourishment (versus B12 def) Causes macrocytic anemia, sore mouth, weight loss, heartburn, constipation/diarrhea, burning red tongue, NO NEURAL ABNORMALITIES, neural tube defects in child if pregnant Blood tests show macrocytic anemia (MCV>100), decreased Hb/folate, increased homocysteine BUT NOT METHYLMALONIC ACID (both are increased in B12 def) Treat with daily 1mg supp, you will be normal in 1-2mo |
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Metabolic changes with age
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VO2max decreases 10%/10y after 25yo
Fewer mitos, ATP gen due to accum of ROS stress Muscle glycogen and pH decrease, so you lose skeletal muscle mass and you fatigue |
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Plasma changes with age
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Cholesterol increases
Urate increases Protein decreases K down (diuretics) Creatine up (renal impaired) Ca (up = hyperparathyroidism, down = osteomalacia) Alkaline PPTase (up = osteomalacia or Paget's) Glucose up (diabetes) TSH changes due to hyper/hypo-thyroidism |
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Nutritional requirements for:
Short term memory Problem solving Dementia Cognition Brain tissue |
Short term memory: B12, C
Problem solving: B12, C, riboflavin, folate Cognition: B12, folate, B6, Fe Brain tissue: B6 Dementia: thiamine, Zn |
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Common diseases in elderly caused by nutritional def
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Osteomalacia = vitD def, Ca def, PTH increased
Hypothyroidism Dehydration Hormone imbalance Hypoglycemia (poor clearance of sulfonylureas) |
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BMI's that indicate:
A) diet/exercise/behavior B) pharmacotherapy C) Laparoscopic adjustable gastric banding surgery D) bariatric surgery |
25-27 A w/ comorbidities
27-30 A, B(w/) 30-35 A, B, C(w/) 35-40 A, B, D(w/) >40 A, B, D |
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Contraindications for LAGB (laparoscopic adjustable gastric banding surgery)
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Hx of noncompliance
Psychiatric problems Unlikely to survive surgery |
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Meds that cause weight gain
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Oral hypoglycemics
Psych meds Prednisone Antidepressants |
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Meds that cause weight loss
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Metformin, topamax, prozac, wllbutrin
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Nutrient deficiencies following bariatric surg
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Iron in post-menopausal women or anemics
Calcium with 2,000IU/d or 50,000IU/wk of vitamin D Vitamins A, E, K DO NOT TAKE Ca/Fe/vitamins at same time b/c limits abs |
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Blood sugar cutoffs for diabetes
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Fasting glucose
Normal 60-100 mg/dl Diabetes >125 |
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Goals for blood sugar control
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Fasting 90-110
2hr post meal 100-140 A1c < 7% Also BP<130/80 Chol<200, LDL<100, HDL>40 |
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1 serving CHO, and goals
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15 grams is a serving, and you want 3-5/meal (so 9-15/day)
Usually half a cup 1/3 cup of rice/oatmeal/potato/pasta 1 cup milk 1.5 cups low starch veggies |
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Drugs for diabetes
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alpha-glucosidase inhibitors prevent carb breakdown, so they cannot be absorbed
Metformin blocks liver glucose production Inject insulin |
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Cancer recommendations
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Eat variety of foods
-- 5 fruits/veggies daily -- limit red meat -- whole grains physically active stable adult weight limit ethanol healthy social environment |
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What is LD50?
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Give a huge dose and kill every animal, then decrease it until only half die
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Four reasons to conduct therapeutic drug monitoring?
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Narrow therapeutic range
Drug has symptoms similar to disease being treated Drugs affect renal/hepatic clearance (NSAID) Strange absorption pattern, i.e. a low affinity and high affinity receptor |
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What does BACTERIAL botulinum toxin do?
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cleaves SNARE, so you cannot release ACh, so you get paralysis
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There are three types of relevant fungal mushroom toxins. What do they do?
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Alpha-amanitin causes liver failure via inhibition of RNA polymerase II
Muscimol causes salivation, lacrimation, sweating, nausea, diarrhea, breathing problems, and coma Aflatoxin B is from mold and causes cancer, liver failure/necrosis/cirrhosis |
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What system do TTX and deltamethrin (insecticide) affect?
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TTX blocks voltage-gated Na channel. Deltamethrin is a nervous agent, particularly affecting skin and facial sensation.
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What are the 6 components of snake venom?
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Phosphodiesterase = acts as exonucleotidase, decreases BP, heart stops pumping
Collagenase and hyaluronidase = wound spreads as it digests ECM, causing edema Phospholipase Arginine ester hydrolase = hydrolyzes linkages Thrombin-like enzymes = prevent thrombin formation AChE = paralysis |
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What are the effects of industrial toxins?
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Liver:
- cirrhosis - steatosis - necrosis - cancer If asbestos, lung inflammation. |
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AMPK vs Akt
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AMPK increases food intake and cell growth. Akt inhibits cell growth.
Leptin inhibits AMPK and ghrelin activates AMPK. Insulin activates Akt. |
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Leptin pathway
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Leptin signals via JAK-STAT and via AMPK/Akt crosstalk with insulin.
Leptin/insulin > POMC/CART @ arcuate nucleus > a-MSH > CRH (regulate energy consumption) |
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Monogenic obesity causes
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POMC deficiency
MC4 receptor deficiency (a-MSH cannot fxn) Leptin receptor deficiency Homozygous missense mutation in leptin itself, treatable via daily leptin injection |
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Treatment for obesity
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Sibutramine (increase NE/5-HT)
Orlistat (block absorption of fat in intestine) Bariatric surgery Block NPY/ghrelin Boost MC4 receptor (for a-MSH) |
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PPAR subtypes, and how PPAR influences obesity
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PPARg in liver/adipose = regulates adipose tissue, lipid synth/storage
PPARa in liver increase oxidation/uptake of FA PPARd regulate heat and prevents fat accum In obesity, too much PPARg in liver/muscle, too little in adipose, causing too much fat to be stored in liver/muscle, making it hard for them to use glucose |
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Effects of obesity on metabolism
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Adipose tissue is overloaded, causing uncontrolled lipolysis, causing increased circulation of FA and lipids, as well as uncontrolled leptin/adiponectin/IL-6 production.
Liver packages excess circulating FA as VLDL and ketones, exacerbating hyperlipidemia. Hyperlipidemia interferes with mito metabolism, impairing insulin sensitivity. Also consider effects of PPARg. |
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Agents that stimulate hunger
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NPY/AgRP @ arcuate nucleus (inhibited by leptin and PYY, stimulated by ghrelin)
Orexins, dynorphin |
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Agents that inhibit hunger
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Leptin/insulin (see leptin signaling)
GLP-1 (slows gastric emptying) CCK (prod by intestine after meal) > NTS satiety center 5-HT, NE |
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Where are signals indicating energy need integrated into signals affecting hunger?
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Hypothalamus
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Arsenic toxicity
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PDH cannot use thiamine > metabolic prob > apoptosis > acidosis
K channel inhib > neuro/CV scavenge with sulfur (garlic), supplement with K diarrhea, stomach pain, fingernail pigmentation, lose hair, coma |
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Aluminum toxicity
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requires impaired renal fnx
bone!!! present with fractures ROS in brain displace Fe from transferrin = microcytic anemia, like pb poisoning |
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Cadmium toxicity
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lung infection > bone/renal/lung problems, may have gout
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Lead toxicity
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colic/vomit, brain (ataxia), anemia > nephritis, gout, hypertension, foot-drop
anemia b/c interferes with incorporating Fe in protoporphyrin for Heme normally worse in kids, who better absorb Pb via GI |
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Mercury toxicity
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GI infection > tremor, neurasthenia
elemental: gets to RBC, CNS toxicity organic: absorbed in GI > brain/liver/kidney/skin inorganic: renal problems inhibit Na/K and ACh M receptor and ROS protection |
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Bismuth toxicity
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renal > brain
blue/black gum line sulfhydril combination, as in many other metals |
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How is CBL/B12 absorbed?
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Binds IF in stomach, then absorbed in distal ileum.
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In what situations are you likely to be CBL/B12 deficient?
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Vegetarian/macrobiotic/alcoholic
Pernicious anemia (no IF bc autoimmune parietal cell destruction) More than 100cm of distal ileum removed (or rendered nonfxnal due to Crohn's) decreases B12/IF absorption Achlorhydria (cannot secrete gastric acid/pepsin... you need pepsin to separate B12 from food protein) Long term proton pump inhibitors Gastrectomy/gastric sleeve decreases IF production Celiacs def in folate and B12 |
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Symptoms of CBL/B12 deficiency?
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Symptoms are megaloblastic anemia, nerve damage (tingling), inflammation of tongue, ataxia, dementia
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In CBL/B12 deficiency, blood tests show:
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Megaloblastic anemia
Decreased cobalamin Increased homocysteine Increased methylmalonic acid (in folate def, you ONLY see increased homocysteine) |
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What is the Schilling test?
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1) inject radiolabeled CBL, take urine 24hr, measure CBL
2) if abnormal give IF... if it normalizes then you have pernicious anemia 3) if still not normal, give antibiotics and then pancreatic enzymes to see if you have bacteria or pancreatic problem |
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How to treat a vegetarian with CBL/B12 deficiency?
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Treat with daily soy milk enriched with B12 if vegetarian
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