Goals for nutritional tx plan:
- decrease sx / pain / discomfort
- prevent chronic disease
- increase function (cellular / interpersonal / social)
- JOY in eating: intuitive. intelligent.
- integration & respect with/of our bodies
What do we learn about our tastes from kids?
- they are malleable, responding to exposure
* preferences shift as we seek novelty and variety
Obstacles to implementing successful nutrition plans:
- judgement / guilt / shame
- unrealistic ideals
- authoritative physician attitude
- orthorexia
- inflexibility
- reductionist / mechanistic / dualistic thinking
Name 2 benefits of increased adiponectin output:
- improved insulin sensitivity
* decreased systemic inflammation
In a female with high cortisol/DHEA ratio, DHEA replacement can improve:
anxiety scores
EPA/DHA can improve neuro function via:
membrane fluidity and integrity
5-HTP and amino acids are important for:
neurotransmitter precursor availability
Sleep hygiene and melatonin help regulate:
the sleep / wake cycle
What might you use to support psycho-emotional wellness:
- mindfulness / awareness practice
- aesthetic enjoyment
- social networks and belonging
- personal purpose / mission / goals
Where do we make ATP?
- Krebs cycle
- Ox phos
- Beta oxidation
Name 2 sources of ROS:
- mitochondria-dependent reactions
* phase 1 detox - CYP450
What are some effects of excess ROS?
- insulin resistance / endocrine disorder
- neurodegenerative disease
- heart disease
- allergy and autoimmunity
- GI disorder
- cancer
Name 2 carotenoids:
- beta-carotene
* lycopene
Polyphenols:
anthocyanin and isoflavones are examples of:
flavonoids
Polyphenols: EGCG stands for ________ and is an example of:
ellagic acid
a phenolic acid
Resveratrol is categorized as a:
stillbene (polyphenols)
Phase I - CYP450: generates reactive __________ from __________, (minimal/moderate) support needed to facilitate.
intermediates
xenobiotics
minimal
Phase II - conjugation: an elaborate __________ system, requires more support with increasing ___________ load.
antioxidant
xenobiotic
Name 2 non-hepatic biotransformations:
- Intestinal CYP3A4 enzymes - many drugs, carcinogens
* antiporter “phase 3” - MDR1 gene products
Describe the detox mechanisms of Turmeric:
- induces glutathione transferase, NADPH, and quinone transferase
- modulates/inhibits CYP450 1A1 (procarcinogenic)
Describe the detox mechanisms of Zinc:
- induces metallothioneins
- transport/storage of Zn and Cu
- transport of toxic metals (Hg, Cd) for hepatic/renal glutathione conjugation + excretion
- useful in therapeutic fasting
What are some examples of pro-inflammatory states?
- stress
- reduced sleep
- dysbiosis
- oxidative stress
- endocrine disruption
- may lead to immune sensitization –
Prostaglandin and leukotriene synthesis is dependent on ________________ of the cell membrane.
Increase n-__ composition facilitates anti-inflammatory PGs and LTs and reduces production of ______________.
fatty acid composition
n-3 (omega-3)
pro-inflammatory mediators
Anti-COX, -LOX, etc culinary spices:
Turmeric - inhibits NF-kB, COX2, LOX, anti-apoptotic proteins
Ginger - inhibits COX 1 / 2, 5-LOX, gene induction
T/F: The immune system educated the microbiota.
False - microbiota educate the immune system!
Gut _______ barrier prevents immune ____________ by ectopic macromolecules.
mucosal
sensitization
Healthy mucosa and microbiota are essential for:
digestion and nutrient absorption
Catecholamine concentration (particularly NE) is sensed by intestinal bacteria, and co-regulates ________ behaviors: (3)
Virulence -
- growth rates
- adhesion/colonization
- exotoxin production
You can feed commensal bacteria with: (3)
- fruit and veg
- fiber
- prebiotic / FOS supplement
You can supplement commensal bacteria with: (2)
- fermented foods
* probiotics
Starve gut pathogens by _______________ or kill with ________________.
Simple carbohydrate restriction
botanical and Rx antimicrobial tx
Structural integrity comes down to 4 considerations:
- musculoskeletal tissues
- integumentary barrier
- membrane permeability and fluidity
- ECM homeostasis (MMP)
MMP stands for:
matrix metalloproteinase - process bioactive molecules, degrade ECM proteins
What tx might you offer to improve structural integrity?
- DHA intake - alters mitochondrial membrane phospholipid FA concentrations, maintains barrier function
- α-tocopherol, Vit C, selenium - inhibits MMP3, synergistic effects
Metabolic syndrome review:
- insulin resistance w/ increased output
- elevated fasting glucose
- depressed HDL
- elevated TGs
- HTN (>140/90)
- abdominal adiposity (>9 WHR)
Fasting insulin values that demonstrate insulin resistance:
> 25 mIU/L OR
> 174 pmol/L
Causes of elevated fasting insulin:
- acromegaly
- Cushings syndrome
- insulinoma
- iatrogenic (corticosteroids, OCPs, levodopa)
What is a shortcoming of the WHO and ATP criteria for metabolic syndrome dx?
Proposed solution?
they do not account for ethnic variation in defining obesity / central adiposity
– ratio of waist to height: >1:2 correlated with great risk
How many US adults are “idiopathically” hypertensive?
> 30% over 20 y.o.
>3% of children/adolescents
What are some supposed effects of hyperinsulinemia on the cardiovascular system?
- atherogenesis
- increased plasminogen activator inhibitor -> increased risk of coronary thrombosis, accelerated atherosclerosis
- dyslipidemia -> atherogenesis
Reactive (____________) and spontaneous (___________) hypoglycemia can either present with a predominantly Autonomic or ___________ picture, or both.
r - post-prandial
s - fasting state
autonomic or neuroglycopenic
Autonomic ssx of hypoglycemia:
- anxiety
- palpitations
- tachycardia
- tremor
- pallor
Cholinergic ssx of hypoglycemia:
- hunger
- diaphoresis
- paresthesias
Neuroglycopenic ssx of hypoglycemia:
- headaches
- cognitive impairment
- fatigue
- altered behavior / affect
- motor dysregulation
severe - - seizure
- coma
Other ssx of hypoglycemia that are less defined:
- irritability
- depression
- sleep cycle dysregulation
- abdominal pain
- myalgia / arthralgia
- dizziness / vertigo
What is Whipple’s triad?
- ssx of hypoglycemia
- low plasma glucose
- sx resolution with increased glucose
Describe the pathophysiology (pathway) of hypoglycemia:
high refined carb intake (rapid absorption) -> hyperglycemia -> exaggerated insulin response -> hypOglycemia -> exaggerated food-seeking response -> hyperglycemia -> …
Conditions that contribute to hypoglycemia:
- hypothyroidism
- hypoadrenalism
- hepatic disease / dysfunction
Dietary tx of hypoglycemia:
Avoid: * refined carbs * caffeine * alcohol * concentrated sugars Include: * high-protein foods * complex carbs * elimination diet
Supplemental tx of hypoglycemia:
- chromium picolinate 200-1000 µg
* magnesium 400-800mg
Diabetes tx plan:
Goal - improve insulin sensitivity
- wt loss (less adipose, more adiponectin)
- avoid refined carbs / sugar
- chromium 200-1000 µg
- toxicant avoidance (PCBs in dairy, fish, animal fat)
- aryl hydrocarbon receptor (AhR) modulators
- protective: I3C, curcumin
- avoid: PCBs, PCDDs, PCDFs
- anti-inflammatory protocols
- CoQ10 100-400mg (dec ROS)
How might you minimize inflammation in your DM pt?
- weight loss (dec TNF⍺, IL-1b, RBP4)
- anti-inflammatory diet
- fatty acid therapy (3-6g EPADHA, 2-4g GLA)
- curcumin 1-2g
- ALA 600mg (inhibits NF-kB)
- therapeutic fasting (induces autophagy/mitophagy)
How might you support your DM pt on the neuro/psych level?
- B12 1mg/day - requisite for metformin users
* mindful eating / awareness practice
How might you support your DM pt with digestion/absorption/microflora?
- dec refined carbs (inc commensals, dec pathogenic)
- inc soluble fiber (legumes, whole grains, non-starch veg)
- SIBO assessment / tx
- probiotic (food / supplement)
Recommendations for structural integrity in DM?
- chromium picolinate
- protein intake 20-30% of calories
- exercise
Cautions in treating DM:
- ensure regular blood glucose monitoring
- monitor serum K+ and renal function
- maintain contact with other providers in care team - prevent hypoglycemia, hypotension, hypocholesterolemia
Describe pathogenesis of asthma:
allergen exposure -> mucosal peptide generation -> induces Th2 -> excess inflammatory cytokine / adhesion molecule production/activation (eos, basos, monos) -> IgE overproduction -> mast cell degranulation -> bronchospasm
Nutritional considerations in asthma:
- allergy elimination diet (gold standard) - consider grains, dairy, eggs, chocolate, fish, soy, legumes
- food additive avoidance - sulfites, tartrazine, sodium benzoate, MSG, aspartame
- breastfeed >4 months
- vegan diet
- reduced-energy diet (for wt loss)
- low trans-fat diet
- antioxidant therapy
- pyridoxine
What are some sources of dietary sulfites?
- dried fruits
- wine
- fruit juice
- molasses
- pickled foods
- dried potatoes
- wine vinegar
T/F: Molybdenum may be considered to treat sulfite-sensitive asthmatics, as it is a necessary cofactor for sulfite kinase, and should be co-administered with Zn.
False - sulfite oxidase / take with Copper
Low vitamin B__ is often observed in asthmatics. _________ can be supplemented to bind histamine, and prevent mast cell ________________. Co-administer __.
B6
pyridoxine
degranulation
Mg
Supplementation considerations for asthma:
- B6
- pyridoxine 50-200mg
- Mg 200-800mg
- fish oil 2-4g (EPA-DHA)
- vit D3 1-2000 IU
Idiopathic pulmonary fibrosis (IPF) is a chronic, progressive, lethal interstitial lung dz characterized by destruction of ________ cells and hyperplasia of ___________ cells, and subsequent ____________ deposition.
type 1 alveolar cell destruction (gas xchg) type 2 alveolar cell hyperplasia (surfactant) collagen deposition (fibrosis)
Characteristic histological pattern of IPF:
UIP - usual interstitial pneumonia
Risk factors for IPF:
- FHx of pulmonary fibrosis
- smoking
- GERD
- DM II
- occupational inhalant exposure (dust, smoke, gases, etc)
IPF nutritional txs:
- anti-inflammatory diet
- high fruit intake (limited evidence)
- elimination diet
- NAC
________ function may be central to reversing pulmonary arterial HTN. Name 3 ways:
Mitochondrial
- targeted drug therapy
- high dose antioxidants
- improve membrane integrity to normalize potential
PAH nutritional txs:
- Mg 300-600mg - vasodilation
- Genistein 50mg - inc NO, dec endothelin
- EFAs 3-6g - inc mitochondrial membrane integrity
- L-arginine 50-100 mg/kg TID - inc NO, dec endothelia
COPD is an obstructive lung disease characterized by incomplete (inhalation/exhalation). Increased oxidative stress in the lung tissue results in hyperactivation of: (4)
exhalation
- neutrophils (elastase/MMP)
- macrophages (pro inflammatory cytokines)
- fibroblasts
- mucus-producing cells
COPD risk factors:
- smoking
- 2nd hand smoke
- air pollution
- dust/particulate inhalation
COPD prevention:
- dietary antioxidants (preserve lung fxn)
- Vit C
- EPA/DHA
- reduce risk factors
COPD nutritional txs:
- high antioxidant diet (high catechin)
- allergy elimination diet
- antioxidant supplementation
- resveratrol 180mg TID (inc GSH, Pa02; dec macs)
- curcumin 2g (inhibits NFkB)
- Vit C 2-3g (tissue repair, host immunity)
- NAC 1.2g+ (dec sx, exacerbations)
- Mg 300-600mg (inc mm tone)
- K+ 2g
- Vit A 5000 IU (host immunity, epithelial repair)
- EFAs 2g+
- L-carnitine 2-4g (inc mm tone)
- proteolytic enzymes (bromelain 3000GDU)
Key ssx of bronchiectasis: (4)
- chronic cough
- mucopurulent sputum
- SOB
- hemoptysis
Bronchiectasis txs:
- proteolytic enzymes (bromeliad, trypsin)
- NAC 600-1200mg (mucolytic)
- Vit D 1-2000 IU (AI, dec infx)
- allergy elimination diet
_____ is an acute inflammatory pulmonary condition occurring in the critically ill, with a __% mortality rate. It occurs in 3 phases:
ARDS 40% * acute (up to 7 days) * fibroproliferative (weeks) * resolution (months to a year)
ARDS risk factors:
- multiple transfusions (any reason)
- advanced age
- cigarette smoking
- drug OD (narcotics, tricyclic antiD, salicylates)
ARDS nutritional txs - phase 1 and 2:
Phase 1, 2 - inpatient
- enteral feeding
- EFA
- Vit E
- Taurine
- NAC 40-210mg/kg
ARDS nutritional txs - phase 3:
Phase 3 - outpatient
- diet
- EFA therapy 2-4g
- NAC 300-400 mg TID
- Supplements (curcumin 1g, boswelia 400mg)
RRP nutritional txs:
- I3C 200mg BID (brassicas)
* Vit D 1-2000 IU
Pulmonary hemosiderosis (PH) nutritional txs:
dietary modifications - links to:
* milk hypersensitivity
* celiac
elimination diet
Sarcoidosis nutritional txs:
- melatonin 20mg (dec lesion, inc lung fxn)
- flaxseed oil (ALA) 4-8g
- low dose fish oil 1-3g
- curcumin 1-2g
- low calcium diet
- Vit D (gran tissue overproduces 1a-hydroxylase)
Sarcoidosis therapeutic goals:
- bone mineral density preservation (w/steroid tx)
- dec disease activity (anti-inflammatory)
- dec opportunistic infx (antimicrobial peptide)