AUTOIMMUNE CNS Dec 2020 MNT Mega Quizlet

FATIGUE (other choices = exophthalmous, tachycardia, tremor of extremities)

***Hyperthyroid symptoms do NOT include:

___________is a glycoprotein secreted by parietal cells (in the fundic region of the stomach) of the gastric mucosa in the gastric juice that is necessary for the absorption of dietary vitamin B12

Intrinsic factor (IF)

o In autoimmune Hashimoto's thyroiditis, supplementing with____________ may exacerbate the condition.

Iodine Because iodine stimulates production of TPO, this in turn increases the levels of TPO Abs dramatically, indicating an autoimmune flare-up. o Some people develop symptoms of an overactive thyroid, whereas others have no symptoms despite tests showing an elevated level of TPO Abs. Therefore one must be cautious regarding the use of high-dose iodine; however, a clinical evaluation and/or assessment (such as UI excretion laboratories) may help reveal whether iodine supplementation is warranted

It has been suggested that drinking large amounts of tea may increase the risk of developing ______________whereas other studies suggest a protective role

RA

What 3 measurements are useful in the diagnosis of RA?

RF (Rheumatoid Factor), anti-nuclear antibodies (ANA), and antibodies to citrullinated protein antigens (ACPAs).

True or False In hemolytic anemia, there is decreased RBC production - result of disordered iron metabolism

True o Important to not confuse with iron deficiency anemia

True or False: Neurological problems such as MS, Parkinson's, and ALS are all considered to be autoimmune conditions.

True An autoimmune disease develops when your immune system, which defends your body against disease, decides your healthy cells are foreign. As a result, your immune system attacks healthy cells. Depending on the type, an autoimmune disease can affect one or many different types of body tissue. Most common types: rheumatoid arthritis, lupus, celiac disease, Sjogren's syndrome, multiple sclerosis, ankylosing spondylitis, type 1 diabetes, alopecia areata

which type of hemolytic anemia occurs when § Immune system attacks and destroys own RBCs when blood is exposed to 32-50OF

cold antibody hemolytic anemia · IgM antibodies that normally attack bacteria attach to RBCs and cause agglutination (binding in clumps) · RBCs are prematurely destroyed

A deficit of vitamin B12 leads to impaired maturation of _____________owing to interference with DNA synthesis

erythrocytes

What hormone can exacerbate endometriosis

estrogen

Researchers have identified changes in several genes that may influence the risk of developing psoriatic arthritis. The most well-studied of these genes belong to a family of genes called the ______________

human leukocyte antigen (HLA) complex

What are the top 4 clinical findings of T1D?

hyperglycemia, electrolyte imbalance, ketoacidosis, dehydration

existing or occurring across the entire wall of an organ or blood vessel. Describing Inflammatory bowel disease.

transmural

presence of ketone bodies in the urine

ketonuria

Healing options for Fibro from Digestive connection

- look for underlying cause -take vitamin D (2000-10,000 IU a day -alkaline diet -metabolic cleansing -investigate food and environmental allergies -ascorbigen (100mg) and broccoli powder (400mg) -MVM -B1 (thiamine phyrophosphate) 25-100mg a day- cosupplement with magnesium -vitamin C (3000mg a day) -Magnesium (500-1000 magnesium citrate or mag glycinate) -arginine (500-1000mg) -5HTP (200-600mg a day0 -capsaicin -SAMe (200mg) -Sulfur containing supplements-DMSO, taurine, glucosamine, reduced glutathione -methionine (1000 to 2000mg) -Myer's cocktail -Malic acid (apples)- 6 to 12 tablets of 300mg -quercetin (500-1000 mg 3-4x a day) -glucosamine sulfate (500mg 2-4x a a day0 -digestive enzymes -probitoics -Coq10 (60-100mg a day) -glutamine

Assessment for SLE

-ANA positive -anti-DNA -low complement -elevated sedimentation rate -sometimes low white blood cell counts -low platelets -Decreased conversion of 25-hydroxyvitamin D to it active form, 1, 25-dihydroxyvitamin D (calcitriol), is possible because of renal impairment.

Symptoms of SLE

-Common symptoms include extreme fatigue, painful or swollen joints, muscle pain, sensitivity to the sun, unexplained fever, skin rashes most commonly on the face, mouth ulcers, pale or purple fingers or toes from cold or stress (Raynaud's syndrome), and kidney insufficiency -Butterfly rash -Vasculitis, or inflammation of the blood vessels, develops in many organs, impairing blood supply to the tissue

MNT for SS

-First goal is to relieve oral symptoms and reduce the eating discomfort from the difficulty of chewing and swallowing -Limit foods that worsen oral symptoms (citrus fruits, hot/spicy foods) -After consumption of sugary foods or beverages, the teeth should be brushed and rinsed with water immediately to prevent dental caries probiotic supplementation in RA patients might also benefit patients with SS and other autoimmune conditions, to shift their microbiome away from a disease promoting and proinflammatory pattern · Increase good quality omega-6 fats in your diet - Primrose oil 1000-6000mg a day · Check for HCL · Practice relaxation and stress management · Optimize fat soluble vitamins Elimination diet

MNT for IBD (Primer)

-L-glutamine (at least 35 g/day) -Omega 3 fatty acids (1800-2000mg a day of EPA combined with 00-1200mg/day DHA) -Boswelia serrata (inhibits 5-lipooxygenase and reduces synthesis of inflammatoryleukotrienes), Uncaria tomentosa (cat's claw; inhibits activation of NF-κB and nitric acid production) goldenseal (300 mg/day; inhibits bacterial adhesion to enterocytes). Herbs that (anecdotally) may reduce inflammation in IBD (at 100 mg/day to 200 mg/day) include garlic, ginger, licorice root, onion, slippery elm bark powder, turmeric and white willow bark. Herbs that can improve colonic microbial balance include artemesia, garlic and goldenseal Individuals with IBD should avoid foods that stimulate production of prostaglandin PGE2 (sugars, meats and allergenic foods) and correct the likely nutritional deficiencies accompanying chronic intestinal mucosal damage (especially those involving calcium, potassium magnesium, zinc and all antioxidant nutrients)

Functional tests for scleroderma (digestive connection)

-SIBO breath test -vitamin D -Stool -food and environmental sensitivities -DHEA and cortisol -liver function -silicon antibodies -nutrient testing such as homocysteine -h pylori testing -EFA testing

Pathogenesis of IBD (Primer)

-Symptoms of IBD result from excessive inflammatory responses to a "trigger" that cause local autoimmune-like destruction of the intestinal mucosa. -During an inflammatory episode, intestinal villi are damaged, producing nutrient malabsorption and increased intestinal permeability with pathologic translocation. Intestinal permeability remains increased even in the absence of active inflammation. Increased intestinal permeability interacts additively with food sensitivities and nutrient intolerances to produce systemic comorbidities. In addition, IBD may be accompanied by a markedly increased sensitivity to commensal bacteria.; About 2/3 of all GALT lymphocytes are terminally-differentiated TH-1 T-helper lymphocytes that secrete interferon-γ (IFN-γ) when activated. IFN-γ activates local phagocytes and is chemoattractant for neutrophils. Active lesions of IBD are rich in IFN-γ, tumor necrosis factor-α (TNF-α) and the proinflammatory interleukins (IL), IL-1, IL-6, IL-8 and IL-12 that increase secretion of IFN-γ by TH-1 T-helper lymphocytes. In contrast, antiinflammatory IL-2, IL-4, IL-5 and IL-10 that inhibit the secretion of IFN-γ by TH-1 T- helper lymphocytes are absent Intramucosal bacterial antigens stimulate activation of nuclear transcription factor NF-κB in a subpopulation of GALT macrophages (suggesting that IBD also has elements of a primary "mutant macrophage" disease). Activation of NF-κB triggers overproduction of TNF-α, which then acts in an autocrine/paracrine manner to stimulate IL-12 secretion by both affected and unaffected macrophages. In turn, IL-12 stimulates TH-1 T-helper lymphocyte secretion of IFN-γ; IFN- γ stimulates macrophage secretion of IL-1, IL-6, IL-8 and TNF-α; and IL-1, IL-6, IL-8 and TNF-α stimulate macrophage secretion of IL-12 in a positive feedback loop while inhibitingTH-2 T-helper lymphocyte secretion of antiinflammatory IL-2, IL-4, IL-5 and IL-10. Interleukin imbalance, triggered and reinforced by aberrant macrophages, results in an imbalance of TH-1 and TH-2 T-helper lymphocytes and causes excessive secretion of pro- inflammatory reactive oxygen species, nitric oxide and prostaglandin PGE2 and inhibition of sIgA secretion. -Consequently, there is increased bacterial secretion of adhesion molecules and proteolytic enzymes which facilitate bacterial penetration of the mucosa. -

Pathophysiology of fibromyalgia

-There are no obvious signs of inflammation or degeneration in the tissues. -The cause is not known, but it appears to be related to altered central neurotransmission, resulting in increased soft tissue sensitivity to substance P, a neurotransmitter involved in pain sensation. -The incidence is higher in women 20 to 50 years of age. - There is often a history of prior trauma or osteoarthritis. -Aggravating factors include sleep deprivation, stress, and fatigue (Gould page 176) Digestive connection page 388 -Can be a physical manifestation of emotional trauma -often have low acetylcarnitine synthesis or viral infections as trigger Reference sheet for CNS group ● Histological/functional changes in muscle tissue ● Mitochondrial Defects: ● Increased oxidative stress ● Hypothalamic-pituitary-adrenal (HPA) alterations Increased Inflammatory/immune activation state: ● Alterations In Gut Flora -○ Several studies have demonstrated that 90- 100% of patients with FM had SIBO in a dose-response relationship ● though it occurs most often in women than men (ratio 7:1) and often starts in middle age > 50 y/o

Risk factors of hemolytic anemia

-autoimmune disease -sick cell disorders -o Alpha and beta thalassemia -Inherited hemolytic anemia -

What are some of Calcium's interactions

-can interact with iron, Mg, Mn and zinc. -May depress zinc in postmenopausal women. -Over 2g can decrease Mg absorption taken together. - Ca and Mn taken together results in decreased absorption of Mn foods high in oxalic acid and phytates can reduce absorption of Ca

MNT for SLE

-eliminate food allergies, increase intake of antioxidant-rich foods and nutrients, follow a vegetarian diet -alter intake of dietary fats and oils. -Because kidney problems are common, total protein intake must be adjusted accordingly -Treatment of symptoms includes sunlight avoidance, use of sunscreen, -Supplementation of 2000 IU/d Vitamin D is recommended - nutritional counseling to improve intake of Vit D, Calcium, and omega-3 PUFAs, and fiber -More than 50% of patients have used CIM to reduce symptoms that include NAC, turmeric, and mind-body methods -Vitamin A has also shown beneficial effects, alone or in combination with low-dose immunosuppressive drugs, in lupus nephritis and cytokine modulation in both mouse models and patients with SLE -Selenium -NAC (Krause) -Vitamin E (mixed tocopherols) -Fish oils (EPA + DHA) -Turmeric (Krause) -Probiotic (Lactobacillus & Bifidobacterium)

GI symptoms of pernicious anemia

-nausea -vomiting diarrhea

Name the anemic symptoms of pernicious anemia

-pallor -weakness -fatigue -shortness of breath -headache

neurological symptoms

-tingling of extremities -burning of extremities -parenthesis and numbness

Approximately ____ to _____% of the U.S. population over the age of 51 years has clinical B12 deficiency, and it is thought that 10% to 20% have subclinical deficiency (

1 to 2

What other nutrients are included as part of an MNT prescription for RA (Rakel)?

1. CLA 2.5g/day (borage oil, evening primrose) 2.5mg/day 2. Vitamin E 800 units 3. vitamin C 250mg 2x/day 4. Selenium 5. Magnesium 400-750mg/day

List some of the botanicals that can be included as part of an MNT prescription for RA?

1. Ginger (Rakel) 2. Turmeric (Rakel) 3. black currant seed oil

Which of the following may cause goiter? 1. Hyperthyroidism 2. Hypothyroidism 3. Lack of iodine in the diet 4. Pheochromocytoma

1. Hyperthyroidism 4. Pheochromocytoma Gould CH 16 page 419

Which of the following is recommended for immediate treatment of hypoglycemic shock? 1. If conscious, immediately give sweet fruit juice, honey, candy, or sugar. 2. If unconscious, give nothing by mouth (require intravenous glucose 50%). 3. Treat immediately with insulin. 4. Give large quantity of clear fluids for shock.

1. If conscious, immediately give sweet fruit juice, honey, candy, or sugar. 2. If unconscious, give nothing by mouth (require intravenous glucose 50%). Gould CH 16 page 410

Explain the process of B12 absorption

1. The fundic region of the stomach release pepsin, which help release B12 from its binding proteins. Once detached, B12 attaches to a salivary protein called R protein or haptocorrin 2. The B12-haptocorrin protein complex passes through the stomach to be secreted by pancreatic proteases in the duodenum. 3. Once released, B12 attaches to a glycoprotein called IF that is secreted by parietal cells. 4. The B12-IF complex once in the distal ileum attaches to IF receptors in the intestinal enterocytes, where the complex is endocytosed by the ileul enterocytes, 5. B12 associates itself with a carrier protein TCII which carries B12 to other parts of the body 6. This is why IF is important B12 is important for B12 absorption. A lack of IF can cause malabsorption of B12.

Blood glucose levels are increased by: 1. glucocorticoids. 2. glucagon. 3. epinephrine. 4. norepinephrine. 5. parathyroid hormone (PTH)

1. glucocorticoids. 2. glucagon. 3. epinephrine. Gould CH 16 page 403

Enteral nutrition may influence the course of CD via a number of mechanisms. What are they?

1. glutamine content 2. prebiotic composition 3. bowel rest 4. gut permeability 5. gut flora (due to prebiotics) 6. omega-3 fat composition 7. reducing antigenic load

What 3 types enteral formulas are available for CD according to Rakel?

1. polymeric- intact nutrients (carbs, proteins, lipids) the most palatable and affordable 2. semi elemental- partially hydrolyzed nutrients (peptides, starch polymers, simple sugars, glucose, and fats esp MCT) 3. elemental - completely hydrolyzed nutrients (amino acids, monosaccharides, fatty acids, vitamins, minerals), not palatable, costly

Name some of the dietary recommendations for RA

1. vegan, gluten free diet (Krause) 2. Elimination diet - dairy, wheat, citrus, nuts (Rakel) 3. Intermittent fasting (Krause, Digestive Connection) 4. Diet rich in Omega-3 fats (Rakel, Krause, Digestive connection) 5. Anti-inflammatory/Mediterranean Diet (Krause) 6. Adequate B vitamins 7. Adequate Ca and Vitamin D

As a trace element, iodine is present in the human body in amounts of_____________ to _____________mg and 70% to 80% of it is located in the thyroid gland

10-15 o Ninety percent of it is organically bound to a protein produced in the thyroid gland called thyroglobulin (Tg). Iodide is actively absorbed in the thyroid gland to help produce the biochemically active thyroid hormones T4 and T3

· At present, a fasting blood sugar equal to or greater than ___________ mg/dL, taken on more than one occasion, confirms a diagnosis of diabetes

126

Which of the following applies to diabetic macro-angiography? 1. It affects the small arteries and arterioles. 2. It is related to elevated serum lipids. 3. It leads to increased risk of myocardial infarction and peripheral vascular disease. 4. It frequently causes damage to the kidneys. a. 1, 3 b. 1, 4 c. 2, 3 d. 2, 4

2. It is related to elevated serum lipids. 3. It leads to increased risk of myocardial infarction and peripheral vascular disease. Gould CH 16 page 412

An acid pH of about ________ is needed, such as that found in the healthy stomach

2.3

____________ of patients will have DQ1 gene type have mucosal inflammation

20%

o WHO recently increased recommended iodine during pregnancy from ______________ to _________ mcg/day

200-250

o Ensure iodine intake of ___________ mg/day, at least 3 months before conception.

250 Such intake is not required in women who are on treatment for either hypo- or hyper-thyroidism

approximately _________percent of affected individuals have at least one close family member with psoriasis or psoriatic arthritis

40

Between___________ and __________ % of people with psoriasis develop psoriatic arthritis, according to most estimates

5-10

What percentage of all patients diagnosed with diabetes are diagnosed with T1D?

5-10%

o Changes in ______________ occur as a result of stress, poor nutrition, illness, selenium deficiency, drug therapy, toxic metals (cadmium, mercury, lead), free radicals

5-deiodination

o Avoid iodine intake >_______ mg/day.

500

Low-GI (glycemic index)foods are those with a GI of less than ____________.

55

o The thyroid gland must capture an estimated minimum of ______________mcg of iodide (the ionic form of iodine) daily to ensure an adequate supply for the production of thyroid hormone

60 mcg

Although some T3 is produced in the thyroid, approximately _________________is generated outside the thyroid gland, primarily by conversion via a deiodinase enzyme from T4 to T3 in the liver and kidneys.

80% to 85%

Dr. Mark Pimental reports that _________ % of patients with fibro have SIBO

78% Digestive connection pg 388

· TSH-R Ab (thyroid receptor antibodies) or TSI (thyroid stimulating immunoglobulins) are present in about __________% of cases of Graves disease

80

_______________ of patients with SS are women

90%

Signs and symptoms of Fibro

: ~ Generalized aching pain ~ Marked fatigue ~ Sleep disturbances ~ Depression ~ In some individuals, irritable bowel syndrome or urinary symptoms due to interstitial cystitis (Gould page 176) Digestive connection page 387 -Less often symptoms include -sensitivity to chemicals -intolerance to cold and heat, bright lights -bladder issuess -Raynaud's -difficult concenctrationg -mood changes -dry eyes -skin -painful menstruation- dizziness -nasal congestion -numbness or swelling in hands or feet

In what autoimmune disease is the elimination diet is not appropriate because it is too restrictive and not relevant to their care. Intervention to prevent malnutrition, possibly keto, and monitor dysphagia

ALS

Which of the following is an important component in the nutritional assessment of patients with rheumatoid arthritis? a. ADLs b. Degree of malabsorption c. Blood glucose control d. Nitrogen balance

ANS: A Because rheumatoid arthritis (RA) can affect mobility, activities of daily living (ADLs) should be assessed. An inability to perform basic self-care skills can have a negative impact on the patient's ability to feed herself. Support in the form of caregivers or adaptive equipment may be needed to ensure nutritional adequacy. Malabsorption is not a consequence of RA. Blood glucose control depends on the presence of diabetes and other lifestyle factors. Nitrogen balance may be used to monitor protein status; however, simple monitoring of the patient's weight and anthropometric measures gives an idea about protein status without need for a nitrogen balance study. REF: p. 799 CH 39 Krause

Current research suggests that which of the following play a role in the inflammatory process? a. Polyunsaturated fatty acids b. Monounsaturated fatty acids c. Omega-3 and omega-6 fatty acids d. Medium-chain triglycerides

ANS: C Omega-6 fatty acids promote production of cytokines, which then go on to stimulate the inflammation process. Leukotriene B5 is also produced and contributes to inflammation by acting as a weak inflammation inducer and chemotactic agent. By substituting omega-6 fatty acids with omega-3 fatty acids, production of antiinflammatory mediator proteins, such as leukotriene B4, increases. Because MCTs are artificially produced, they have not been investigated in regard to a role in inflammation. REF: p. 804 CH 39 Krause

Polycystic ovary syndrome (PCOS) is characterized by which of the following biochemical and endocrine abnormalities? a. Elevated testosterone, insulin resistance, and impaired glucose tolerance b. Thyrotoxicosis, iodine deficiency, and elevated estrogen c. Impaired glucose tolerance, increased T4 conversion, and hypertension d. Low blood calcium, thyroid receptor hypersensitivity, and elevated cortisol

ANS: A Biochemical and endocrine abnormalities in women with PCOS include elevated levels of androgens (dehydroepiandrosterone, testosterone, and androstenedione), hyperinsulinemia (which results from insulin resistance), impaired glucose tolerance, and hyperlipidemia. Hyperandrogenism is responsible for many of the symptoms of PCOS, such as reproductive and menstrual abnormalities, hirsutism, and acne.

Which of the following contributes to the development of type 1 DM? a. Autoantibodies that contribute to the destruction of beta-cells b. Insulin resistance and beta-cell failure c. Increase in insulin-antagonist hormone levels d. Diet and sedentary lifestyle

ANS: A Immune-mediated diabetes mellitus (DM) is the form of type 1 DM that results from autoimmune destruction of the pancreatic beta-cells. This results in the patient's inability to produce insulin. Idiopathic type 1 DM is the other form, and it is DM that has no known etiology. Insulin resistance and beta-cell failure are what lead to the development of type 2 DM. Diet and sedentary lifestyle can contribute to this development. Gestational diabetes mellitus develops because of an increase in the release of insulin-antagonist hormones during pregnancy. These increased hormone levels contribute to an insulin resistance in the pregnant woman. Krause CH 30

Which of the following conditions is NOT a disease of autoimmune origin? a. OA b. RA c. SLE d. Scleroderma

ANS: A Osteoarthritis is not autoimmune in origin. Rheumatoid arthritis, systemic lupus erythematosus, and scleroderma are all conditions with autoimmune origins. REF: p. 797 CH 39 Krause

Before 1960, reports surfaced that soy formula-fed infants were developing hypothyroidism. The addition of what supplement to these formulas ameliorated this problem? a. Iodine b. Selenium c. Iron d. Tyrosine

ANS: A Soybean, an important source of protein in many developing countries, has goitrogenic properties when iodine intake is limited. The isoflavones, genistein and daidzein, inhibit the activity of TPO and can lower thyroid hormone synthesis. Furthermore, soybean interrupts the enterohepatic cycle of thyroid hormone metabolism. Since the addition of iodine to soy-based formulas in the 1960s, there have been no further reports of hypothyroidism developing in soy formula-fed infants. REF: p. 625

How do sulfonylureas and meglitinides help to lower blood glucose levels? a. Promoting beta-cell secretion of insulin b. Decreasing the insulin sensitivity of the receptor cell c. Increasing glucose formation from liver glycogen d. Decreasing deamination of protein

ANS: A Sulfonylureas and meglitinides are oral glucose-lowering medications that act as insulin secretagogues. Their action is to stimulate the pancreatic secretion of insulin. Biguanides and thiazolidinediones are insulin-sensitizing medications that lower insulin resistance and decrease hepatic glucose production from glycogenolysis and gluconeogenesis. REF: p. 599, Krause CH 30

What condition occurs when rebound hyperglycemia follows an episode of hypoglycemia? a. Somogyi effect b. Cushing syndrome c. Dawn phenomenon d. Hyperglycemic hyperosmolar state

ANS: A The Somogyi effect may be caused by excessive exogenous insulin administration. In response to the hypoglycemia that results, the counterregulatory hormones are secreted to promote gluconeogenesis. This results in an increase in blood glucose levels. Cushing syndrome is a rare condition involving the excessive secretion of cortisol. The dawn phenomenon involves an increase in morning blood glucose because of an increased need for insulin. The hyperglycemic hyperosmolar state is a complication in older adults with diabetes. In this condition, the patient has a very high blood glucose level but no ketones. REF: p. 613, Krause CH 30

How are thromboxanes involved in the inflammation process? a. Activation of platelet aggregation b. Activation of cytokines c. Attraction of neutrophils and macrophages d. Production of arachidonic acid

ANS: A The role of thromboxanes in the inflammatory process is to promote platelet aggregation in the area of inflammation and to release growth factors and proteases. Cytokines are proteins that promote the production of prostaglandins, a group of mediators involved in a variety of physiologic processes. Leukotrienes promote the attraction of neutrophils, macrophages, and fibroblasts into the area of inflammation. Arachidonic acid is a fatty acid precursor of various prostaglandins. REF: p. 792 CH 39 Krause

More than 90% of people with autoimmune thyroid disease have a genetic defect affecting their ability to metabolize what? a. Vitamin D b. Flavonoids c. Selenium d. Tyrosine

ANS: A Vitamin D is considered a prohormone with antiproliferative, differentiating, and immunosuppressive activities. Vitamin D also appears to work with other nutritional factors to help regulate immune sensitivity and may protect against development of autoantibodies. REF: p. 628

Which of the following areas lacks blood vessels and nerves? a. Epidermis b. Dermis c. Subcutaneous tissue d. Fatty tissue

ANS: A REF: 142 Gould CH 8

Thyroid health has been shown to be impacted by the elimination of which foods? a. Seafood b. Gluten c. Mushrooms d. Barley

ANS: B A variety of food antigens could induce antibodies that cross-react with the thyroid gland. Eliminating gluten-containing grains has been suggested for treatment of hypothyroidism of unknown origin. Selenium has been shown to enhance thyroid function; mushrooms, barley, and seafood are good sources of selenium. REF: p. 622

Some plant foods (cauliflower, broccoli, cabbage) exert antithyroid activity through what mechanism? a. Binding iodine species b. Inhibiting thyroid peroxidase c. Increasing thyroglobulin antibodies d. Stimulating cortisol

ANS: B Cyanogenic plant foods (cauliflower, broccoli, cabbage, Brussels sprouts, mustard seed, turnip, radish, bamboo shoot, and cassava) exert antithyroid activity through inhibition of TPO. The hydrolysis of some glucosinolates found in cruciferous vegetables (e.g., progoitrin) may yield goitrin, a compound known to interfere with thyroid hormone synthesis. REF: p. 625

Which of these is NOT a product of the thyroid? a. Thyroxine (T4) b. Calcitonin c. Reverse T3 (rT3) d. Triiodothyronine (T3)

ANS: C Reverse T3 (rT3) is derived from T4 through the action of deiodinase. It is an isomer of T3 but is not itself produced by the thyroid. REF: p. 619

What should the person with type 1 DM do when planning to exercise? a. Strictly adhere to dietary restrictions. b. Decrease insulin dosage dependence on duration and intensity of exercise. c. Plan to exercise when the insulin is peaking. d. Take an extra injection of insulin.

ANS: B Decreasing the amount of insulin injected is necessary to prevent hypoglycemia that can occur during exercise. Prolonged or intensive exercise may require a modest decrease of 1 to 2 U of rapid- and short-acting insulin before and possibly after exercise. As an alternative, the person with type 1 DM may ingest carbohydrate before or after exercise to prevent hypoglycemia. Exercising at the time of insulin peak action and providing extra insulin can increase the likelihood of hypoglycemia. REF: p. 598, Krause CH 30

What drug(s) is(are) the first line of therapy for controlling the inflammatory process seen in arthritis? a. Corticosteroids b. Salicylates c. Gold salts d. Methotrexate

ANS: B For the control of pain and inflammation in rheumatoid arthritis, salicylates and nonsteroidal antiinflammatory drugs are first used. Methotrexate is a secondary medication used, but it is a folate antagonist and could contribute to neutropenia with long-term use. Corticosteroids have other metabolic derangement effects when used continuously. Use of gold salts can promote proteinuria. REF: p. 802 CH 39 Krause

Iodine deficiency is often a culprit in thyroid disorders. However, in which of these thyroid conditions may supplementing with iodine exacerbate the condition? a. Adrenal fatigue b. Hashimoto thyroiditis c. Polycystic ovary syndrome (PCOS) d. Graves disease

ANS: B In autoimmune Hashimoto thyroiditis, supplementing with iodine may exacerbate the condition. Because iodine stimulates production of TPO, this in turn increases the levels of TPO antibodies (TPO Abs) dramatically, indicating an autoimmune flare-up. Some people develop symptoms of an overactive thyroid, but others have no symptoms despite tests showing an elevated level of TPO Abs. Therefore, one must be cautious regarding the use of iodine. Furthermore, although iodine deficiency is the most common cause of hypothyroidism for most of the world's population, in the United States and other westernized countries, Hashimoto thyroiditis accounts for the majority of cases. REF: p. 622 Krause CH 31

Thyroid health in some adults can be improved by increasing the conversion of T4 to T3. This can be accomplished by a. supplementing with tyrosine. b. correcting zinc deficiencies with zinc glycinate or zinc citrate. c. increasing naturally occurring flavonoids in the diet. d. cautiously supplementing with lipoic acid.

ANS: B Nutritional agents that help support proper deiodination by the type 1 5'-deiodinase enzyme include selenomethionine (as L-selenomethionine) and zinc (as zinc glycinate or zinc citrate). Human studies have repeatedly demonstrated consequent reduced concentrations of thyroid hormones when a zinc deficiency is present. Supplementation with tyrosine does not appear to have a beneficial effect on elevating thyroid hormones. Synthetic flavonoid derivatives can decrease serum T4 concentrations and inhibit both the conversion of T4 to T3 and the metabolic clearance of rT3 by the selenium-dependent 5'-deiodinase. Naturally occurring flavonoids appear to have a similar inhibitory effect. Lipoic acid reduces the conversion of T4 to T3. REF: p. 628

What must a patient demonstrate to be a candidate for use of oral glucose-lowering medications? a. Functioning alpha-cells in the pancreas b. Functioning beta-cells in the pancreas c. Functioning gastrointestinal mucosa d. Resistance to insulin at all times

ANS: B Oral glucose-lowering medications may be used in the treatment of patients with type 2 DM; therefore, the patient has to have beta-cell function for the production of insulin. The mechanisms of action for the oral glucose-lowering medications include the stimulation of pancreatic insulin secretion. Other mechanisms of action include reducing insulin resistance at muscle and adipose tissue and decreasing hepatic glucose output. REF: p. 599, Krause CH 30

Which of the following conditions is characterized by hardening of the skin and visceral organs? a. Gout b. Scleroderma c. Fibromyalgia d. Sjögren syndrome

ANS: B Scleroderma is a chronic, systemic sclerosis or hardening of the skin and visceral organs characterized by deposition of fibrous connective tissue. REF: p. 808 CH 39 Krause

Which of the following may have a beneficial effect in the treatment of patients with Sjögren syndrome? a. Increase frequency of meals. b. Moisten foods with sauces or gravies. c. Limit fiber. d. Increase citrus fruits.

ANS: B Sjögren syndrome is a chronic autoimmune inflammatory disease that affects the exocrine glands, particularly the salivary and the lacrimal glands, leading to dryness of the mouth (xerostomia) and of the eyes (xerophthalmia). Modification of dietary habits to cope with oral symptoms, particularly to improve biting (cutting fruits, vegetables, and meats in small pieces), chewing (making foods softer by preparing them as soups, broths, casseroles, or as tender cooked vegetables and meats), and swallowing (moistening foods with sauces, gravies, yogurts, or salad dressings) often helps. Foods that worsen oral symptoms should be limited, like citrus fruits, as well as irritant, hot, or spicy foods. REF: p. 805 CH 39 Krause

Which of the following is an autoimmune disorder that presents with severe fatigue, painful or swollen joints, and skin rashes? a. Chronic fatigue syndrome b. Systemic lupus erythematosus c. Raynaud syndrome d. Scleroderma

ANS: B Systemic lupus erythematosus (SLE) involves inflammation, resulting in extreme fatigue, arthritis, unexplained fever, skin rashes, and kidney problems. SLE has a genetic predisposition for the overproduction of type 1 interferon and other cytotoxic cells that can affect all organ systems. Chronic fatigue syndrome is characterized by extreme fatigue that does not improve with rest. Raynaud syndrome is an ischemia or coldness in the fingers that makes it difficult to perform fine motor functions. Raynaud syndrome may be one of the symptoms that happen in scleroderma, which is a progressive disorder that involves the deposition of fibrous connective tissue in the skin and visceral organs. REF: p. 808 CH 39 Krause

Although some T3 is produced in the thyroid, approximately 80% to 85% is generated outside the thyroid in which organs? a. Nervous system and adrenal glands b. Liver and kidneys c. Pancreas and gastrointestinal tract d. Hypothalamus and pituitary gland

ANS: B T3 is primarily produced by conversion of T4 in the liver and kidneys. The pituitary and nervous system are capable of converting T4 to T3, so they are not reliant on T3 produced in the liver or kidney. REF: p. 620

__________ is NOT a symptom of type 1 DM. a. Hyperglycemia b. Loss of thirst sensation c. Weight loss d. Polydipsia

ANS: B The common symptoms of type 1 diabetes mellitus include hyperglycemia, polyuria, polydipsia, weight loss, dehydration, electrolyte disturbance, and ketoacidosis. Type 1 DM tends to increase the thirst sensation as opposed to blocking it. REF: p. 588, Krause CH 30

Which of the following statements about glycemic index (GI) is TRUE? a. Consuming low-GI meals (<70) improves overall glycemic control. b. Specific carbohydrate foods can have a variable GI. c. When compared with an equal amount of starch, sucrose promotes a greater glycemic response. d. The GI of glucose is lower than the GI of white bread.

ANS: B The difficulty of working with the GI concept is that the GI of an individual food may vary. This is part of the reason that the ADA has not fully adopted GI and glycemic load as approaches to meal planning. Low-GI foods are those with a GI of less than 55. Selection of low-GI foods may help in fine-tuning postprandial glycemic response, but research presents inconsistent results in relation to overall glycemic control. Equal amounts of starch and sucrose result in identical glycemic responses. The GI of glucose is 100. The GI of white bread is 70. REF: pp. 595-596, CH 30

Which of the following is one of the ADA's MNT goals for all people with diabetes? a. Promote weight loss. b. Achieve blood glucose control. c. Limit dietary cholesterol. d. Limit intake of simple carbohydrates.

ANS: B Achieve blood glucose control. The first MNT goal for all people with diabetes is to achieve and maintain normal blood glucose levels and lipid and lipoprotein profiles and blood pressure levels that reduce the risk for vascular disease. The other MNT goals include preventing or slowing the progression of chronic complications of diabetes mellitus, addressing the individual's nutritional needs, and limiting food choices only based on evidence while maintaining the pleasure of eating. Diabetes may affect children and pregnant women, and weight loss is not important to maintaining health in these population groups. Diabetes is associated with CVD risk and MNT but dietary cholesterol is no longer restricted for CVD prevention. Research evidence does not substantiate a recommendation to limit simple carbohydrate intake in the treatment of diabetes. REF: p. 605, CH 30 Krause

Botanical preparations have been found in animal studies to influence thyroid activity. Commiphora mukul (guggulsterones from guggul extract) has strong thyroid stimulatory action, demonstrated by a. increasing cortisol production. b. decreasing iodine uptake by the thyroid. c. increasing TPO activity. d. decreasing serum T4 concentrations.

ANS: C Administration of 1 mg of Commiphora mukul/100 g body weight increases iodine uptake by the thyroid, increases TPO activity, and decreases lipid peroxidation, suggesting that increased peripheral generation of T3 might be mediated by this plant's antioxidant effects. REF: p. 628

Which of the following is NOT true about amylin? a. It is a glucoregulatory hormone. b. It is produced in pancreatic beta-cells. c. It counteracts the effects of insulin. d. Deficiency is associated with TIDM.

ANS: C Amylin, a glucoregulatory hormone, is also produced in the beta-cells of the pancreas and is cosecreted with insulin. It works in concert with insulin to regulate postprandial serum glucose levels and suppresses glucagon secretion. REF: p. 587

Which of the following CAM therapies has been demonstrated as effective in the treatment of rheumatoid arthritis? a. Copper bracelets b. Echinacea c. Borage and evening primrose oil d. Thunder god vine

ANS: C Gamma-linolenic acid is an omega-6 fatty acid found in the oils of borage and primrose oil that can be converted to the antiinflammatory PGE-1. Copper bracelets have been suggested to allow for absorption of copper through the skin, but no studies have substantiated this. Echinacea therapy is among a number of CAM therapies that the Arthritis Foundation recommends that people with rheumatoid arthritis should not use. Thunder god vine has been used in China to treat patients with a number of autoimmune disorders, but no consistent, high-quality vine preparations are available in the United States. REF: p. 791 CH 39 Krause

Which spices are included in the "antiinflammatory diet"? a. Thyme, cayenne, and cloves b. Oregano, lemon peel, and thyme c. Ginger, curry, turmeric, and rosemary d. Cayenne, cumin, and parsley

ANS: C Ginger, curry, and turmeric are specifically included in the antiinflammatory diet because of their antiinflammatory effects CH 39 Krause .

Low energy, cold hands and feet, fatigue, hypercholesterolemia, muscle pain, depression, and a positive test result for thyroid peroxidase antibodies could all be indicative of what condition? a. Diabetes mellitus b. Graves disease c. Hashimoto thyroiditis d. Polycystic ovary syndrome (PCOS)

ANS: C Hashimoto thyroiditis is an autoimmune disorder in which the immune system attacks and destroys the thyroid gland. It is the most common form of hypothyroidism. The TPO Abs test is the most important because TPO is the enzyme responsible for the production of thyroid hormones and the most frequent target of attack in Hashimoto thyroiditis. REF: p. 622

Graves disease is an autoimmune disease in which the thyroid is diffusely enlarged (goiter) and overactive, producing an excessive amount of thyroid hormones. It is the most common cause of hyperthyroidism (overactive thyroid) in the United States. What is the primary target of circulating autoantibodies in this disease? a. Insulin receptors b. Thyroid-stimulating hormone (TSH) receptors c. Thyrotropin-releasing hormone (TRH) receptors d. Cortisol receptors

ANS: C In Graves disease, the TRH receptor itself is the primary autoantigen and is responsible for the manifestation of hyperthyroidism. The thyroid gland is under continuous stimulation by circulating autoantibodies against the TRH receptor, and pituitary TSH secretion is suppressed because of the increased production of thyroid hormones. These thyroid-stimulating antibodies cause release of thyroid hormone and Tg and stimulate iodine uptake, protein synthesis, and thyroid gland growth. REF: p. 627

What does insulin promote in regard to the metabolism of lipids? a. Lipolysis in the liver b. An increase in serum free fatty acids c. Lipogenesis in the liver d. The breakdown of fat stores in adipose tissue

ANS: C In regard to lipids, insulin stimulates the conversion of pyruvate to fatty acids in the liver as part of the process of lipogenesis. Insulin's anticatabolic activities in relation to lipids include the inhibition of lipolysis and the prevention of excessive ketone production. Insulin's transport activity includes the activation of lipoprotein lipase to facilitate the transport of triglycerides into adipose tissue. REF: p. 593, Krause CH 30

What is the recommendation for self-monitoring of blood glucose? a. Every morning and every night before bed b. When there is a change in activity level or diet c. Four or more times daily for type 1 DM and one to four times for type 2 DM d. At least eight times a day for type 1 DM

ANS: C Patients with type 1 DM should perform SMBG four times or more daily, including before each meal and at bedtime. Patients with type 2 DM should perform SMBG one to four times daily to help in achieving glucose goals. Whenever they add to or modify their therapies, patients with either DM should test more often. REF: p. 603, Krause CH 30

Which of the following is characteristic of Sjögren syndrome? a. Excessive sweating and salivation b. Temporomandibular joint symptoms c. Diminished production of tears and saliva d. Diminished production of hydrochloric acid

ANS: C Sjögren syndrome is an autoimmune disorder that affects tear and salivary glands. These tissues are attacked by the immune system, and destruction of the glands leads to decreased production of tears and saliva. Temporomandibular joint symptoms occur in the jaw. REF: p. 805 CH 39 Krause

Which of these is NOT required for the production of thyroxine (T4) and triiodothyronine (T3)? a. Thyroid peroxidase (TPO) b. Tyrosine c. Thyroid-binding globulin (TBG) d. Iodide

ANS: C The synthesis of T3 and T4 requires tyrosine, a key amino acid involved in the production of thyroid hormone, and the trace mineral iodine. Two additional molecules of iodine bind to the tyrosyl ring in a reaction that involves thyroid peroxidase (TPO), an enzyme. When T4 is released from the thyroid, it is primarily in a bound form with thyroid-binding globulin (TBG), a protein that transports thyroid hormones through the bloodstream but is not required for production. REF: p. 620

A group of self-reacting antibodies found in the sera of rheumatic patients a. include CRP. b. are known to suppress the immune system. c. are known as rheumatoid factor. d. are known as eicosanoids.

ANS: C The term rheumatic factor is used to refer to a group of self-reacting antibodies found in the sera of rheumatic patients. It is used to screen for and monitor rheumatic disease along with CRP. Eicosanoids are modulators of the inflammation process that include prostaglandins. REF: p. 792 CH 39 Krause

What is a raised, thin-walled lesion containing clear fluid called? a. Papule b. Pustule c. Vesicle d. Macule

ANS: C REF: 143 Gould CH 8

Dietary intervention is a key therapeutic tool in managing patients with thyroid disease. In the absence of nutritional deficiencies, what is the main goal of nutritional support? a. Maintaining vitamin sufficiency b. Decreasing oxidative stress c. Increasing iodine concentrations d. Reducing antithyroidal antibodies

ANS: D A variety of food antigens could induce antibodies that cross-react with the thyroid gland. A food elimination diet using gluten-free grains and possible elimination of casein, the predominant milk protein, might be considered for patients with hypothyroidism of unexplained origin. REF: p. 628

Maintaining thyroid hormone function throughout the aging process appears to be an important hallmark of healthy aging. What characteristic is an indicator of thyroid health in centenarians? a. Decreased free T4 and rT3 levels b. An increased libido c. Constant cortisol production d. The absence of circulating thyroid autoantibodies

ANS: D Because unhealthy aging is associated with a progressively increasing prevalence of organ-specific and nonorgan-specific autoantibodies, the absence of these antibodies may represent a significantly reduced risk for cardiovascular disease and other chronic age-related disorders. REF: p. 624

Which of the following is NOT a potential acute complication of type 1 DM? a. Hypoglycemia b. Hyperglycemia c. Ketoacidosis d. Blood vessel damage

ANS: D Blood vessel damage may be either microvascular or macrovascular in nature; however, this occurs because of long-term exposure of the blood vessels to the physiologic changes that commonly occur with diabetes, such as hyperglycemia, hyperlipidemia, and hypertension. Hypoglycemia, hyperglycemia, and ketoacidosis are acute complications of diabetes mellitus because each of these can occur rapidly in relation to alterations in the patient's lifestyle, health, or use of medications. REF: p. 613, Krause Ch 30

Selenium deficiency, inadequate protein, excess carbohydrates, chronic illness, and stress (high cortisol levels) can all impact what thyroid metabolic process? a. Thyroid-stimulating hormone (TSH) production b. Organification of iodide c. Thyroid-binding globulin (TBG) T4 transport d. 5'-Deiodinase conversion of T4 to T3

ANS: D Changes in 5'-deiodination occur in a number of situations, such as stress, poor nutrition, illness, selenium deficiency, and drug therapy. Toxic metals such as cadmium, mercury, and lead have been associated with impaired hepatic 5'-deiodination in animal models. Free radicals are also involved in inhibition of 5'-deiodinase activity. REF: p. 622

Which of the following is NOT a microvascular disease associated with hyperglycemic patients? a. Retinopathy b. Neuropathy c. Nephropathy d. Peripheral vascular disease

ANS: D Microvascular diseases are ones that affect smaller blood vessels and nerves. Retinopathy, neuropathy, and nephropathy have been the three primary microvascular diseases that develop from uncontrolled diabetes mellitus. Peripheral vascular disease is classified as a macrovascular disease because it involves larger blood vessels. Krause CH 30

Which of the following would NOT result in postprandial (reactive) hypoglycemia? a. Rapid glucose absorption b. Excessive insulin secretion c. Insufficient glucagon secretion d. Excessive hepatic gluconeogenesis

ANS: D Postprandial or reactive hypoglycemia occurs within 2 to 5 hours after eating. During this period of time, the body absorbs glucose and responds to increased blood glucose levels by secreting insulin. However, during this same time, as glucose is being provided by the diet, the liver is not stimulated to produce additional glucose through gluconeogenesis. A defect in glucagon response could contribute to the hypoglycemia by not triggering gluconeogenesis. REF: p. 615, Krause CH 30

What is the role of prostacyclin or PGI2? a. Converts arachidonic acid into PGE1 b. Converts arachidonic acid into PGE2 c. Promotes platelet aggregation d. Inhibits platelet aggregation

ANS: D Prostacyclin relaxes smooth muscle and inhibits platelet aggregation and therefore has an antiinflammatory effect. Prostacyclin, similar to thromboxane (PGE1) and leukotriene (PGE2), is produced from arachidonic acid precursor. REF: p. 792 CH 39 Krause

Which insulin peaks in activity 2 to 3 hours after injection? a. Lispro (Humalog) b. Detemir (Levemir) c. NPH d. Regular

ANS: D Regular insulin is short-acting insulin that peaks within 2 to 3 hours of injection. Lispro is rapid-acting insulin that peaks within 1 to 2 hours. NPH is intermediate-acting insulin that peaks between 4 and 10 hours after injection. Detemir is long-acting insulin that stays in the blood system from 18 to 24 hours without a "peak" time of activity. Patients receiving detemir should be monitored 10 to 12 hours after injection for effects of the insulin. REF: p. 601, Krause CH 30

Which feature associated with the joint of a person affected with gout is different from the joint of a person affected with rheumatoid arthritis? a. Bone erosion b. Inflamed synovium c. Bone spurs d. Presence of tophi

ANS: D Tophi are deposits of uric acid that crystallize on the bone and cartilage, leading to damage of the joint. In rheumatoid arthritis, inflammation of the synovial fluid damages the cartilage and bone, leading to bone erosion and loss. Osteoarthritis is characterized by the presence of bone spurs in the joint. REF: p. 806 CH 39 Krause

affects joints of spine and pelvis, .most often develops in young adult men and it lasts a lifetime

Ankylosing Spondylitis (AS)

A 16-year old teenage girl with Type I diabetes seeks counseling for erratic blood glucose levels. She is on the school track team and works out in the afternoons for 1 ½ hours. Her meal plan consists of 3 meals, a pre-exercise snack of one fruit, and a bedtime snack of ½ cup cereal and 1 cup of milk. Her insulin regimen is 3 units of regular insulin before breakfast and 2 units of regular insulin before dinner, and equal amounts of NPH mid-morning and at bedtime. Lately her pre-dinner blood glucose levels have been low. What would be the most effective nutrition intervention for her? A. Reduce the mid-morning NPH insulin by one unit and add a protein exchange to the afternoon snack. B. Increase the bedtime insulin and add another bread exchange to the bedtime snack. C. Reduce the afternoon exercise to 45 minutes and have her carry fruit juice with her in case she feels dizzy or weak. D. A & B

Answer: A - The most effective intervention would be to reduce the mid-morning NPH insulin by one unit and add protein exchange to the afternoon snack. NPH is an intermediate-acting insulin which has its peak effect in the afternoon. Reducing the amount of NPH by one unit and adding protein to the pre-exercise snack will help eliminate low blood glucose levels before the evening meal.

A patient with MS has been treated with corticosteroids long term. What nutrition intervention is appropriate? A. Supplementation with vitamin D and calcium B. Increasing complex carb intake C. Supplementation with antioxidants D. Promoting the Atkins diet

Answer: A. Supplementation with vitamin D and calcium

Which of the following is most true about Multiple Sclerosis: A. Current research indicates that MS is really Lyme disease B. It is a condition of demylenization of the nerve sheath C. It is due to a decline in L-dopa D. Multiple sclerosis is not affected by season or latitude and longitude

Answer: B. It is a condition of demylenization of the nerve sheath

Which of the following amino acid-derived neurotransmitters is linked to the etiology of ALS (Lou Gehrig's disease)? A. Tyrosine B. Arginine C. Tryptophan D. Glutamate

Answer: D. Glutamate; Glutamate is a neurotransmitter that sends signals in the brain and throughout the nerves in the body. Glutamate plays an important role during brain development. Normal levels of glutamate also help with learning and memory. Having too much glutamate in the brain has been associated with neurological diseases such as Parkinson's disease, multiple sclerosis, Alzheimer's disease, stroke, and ALS (amyotrophic lateral sclerosis or Lou Gehrig's disease). Problems in making or using glutamate have also been linked to a number of mental health disorders, including autism, schizophrenia, depression, and obsessive-compulsive disorder (OCD). Research in the early 1990s determined that ALS patients have raised levels of glutamate in the fluid bathing the brain and spinal cord. In fact, 40 percent of sporadic cases of ALS are characterized by this elevated glutamate in cerebrospinal fluid (CSF). Abundant evidence points to glutamate as a destructive factor in ALS. The first and so far only approved specific treatment for ALS is riluzole, a drug that modulates glutamate.

Which type of manifestation is related to joint? Pick from articular and extra-articular

Articular

symmetric polyarthritis of peripheral joints with pain, tenderness, & swelling of affected joints

Articular manifestations of RA

What other two autoimmune conditions exist in high frequency with T1D?

Autoimmune thyroid disease (17-30%) & Celiac Disease (1-16%)

Two nutrients, ___________ and ______________are needed to produce thymidine to help build DNA

B12 and folate · Deficiencies in thymidine caused abnormalities in rapidly dividing cells, esp red blood cells · DNA formation in RBC precursor leaves to premature apoptosis causing a dip in the number of RBC's causing anemia.

What short chain fatty acid is important in the pathogenesis of IBD, but can also be used therapeutically to induce remission of symptoms?

Butyrate

With what do the plasma copper levels seen in patients with rheumatoid arthritis correlate? a. Dietary intake of copper b. Type of medication c. Degree of joint inflammation d. Degree of malabsorption and diarrhea

C-degree of joint inflammation Plasma copper levels correlate with the degree of joint inflammation. As plasma copper levels decrease, the inflammation diminishes. Elevated plasma levels of ceruloplasmin, a carrier protein for copper, may have a protective role because of its antioxidant activity. Krause CH 39

What nutrients do corticosteroids deplete?

Ca, Vit D, Potassium, Selenium, Cu, vitamin C, zinc , magnesium

Limited cutaneous scleroderma (LcSSc)- CREST syndrome

Calcinosis (abnormal calcium deposits in skin)- hard whitish areas on elbows, knees, and fingers Raynaud's phenomenon Esophageal dysmotility (difficulty swallowing) or GERD Sclerdactyly (skin tightening in fingers) Telangectasias (red spots on the skin)

Synthroid depletes which mineral?

Calcium

_____________ has been shown to counteract the effects of elevated thyroxine

Carnitine

According to the international medical bibliography, autoimmune Hashimoto's thyroiditis and ____________ are clearly associated

Celiac Disease This might be explained partly by the increased immunosensitivity of CD patients, as part of an autoimmune polyglandular syndrome (APS), by the deficiency of key elements such as selenium and iodine due to malabsorption (Stazi and Trinti, 2010) or due to antibodies that affect both target-tissues

An autoimmune condition of the small intestine and/or colon

Chron's disease

pathophysiology of scleroderma

Collagen deposition in the arterioles and capillaries reduces blood flow to the skin or internal organs. Collagen deposits, inflammation, and fibrosis with decreased capillary networks develop in the skin.

Mass of sebum, keratin, and debris blocking the opening of a hair follicle

Comedone

Common sites of inflammation and tissue destruction in SLE

Common sites include the kidneys, lungs, heart, brain, skin, joints, and digestive tract.

Symptoms of SLE

Common symptoms include extreme fatigue, painful or swollen joints, muscle pain, sensitivity to sun, unexplained fever, skin rashes most commonly found on face, mouth ulcers, pale or purple fingers or toes from cold or stress (Raynaud's), and kidney problems

What are some Drug nutrient depletions of SLE drugs?

Corticosteroids (Prednisone, Dexamethasone, Methylprednisolone)- depletes Ca, Vit D, Potassium, Selenium , Cu, vitamin C, zinc , magnesium NSAID's -deplete vitamin E, folate DEPLETE folic acid and vitamin C, which can be replaced with a dietary supplement (such as a multiple vitamin). Also depletes melatonin hydroxychloroquine-May DEPLETE Calcium and Vitamin D. AVOID magnesium as it may reduce blood levels of this drug.

condition of congenital hypothyroidism in children that results in a lack of mental development and dwarfed physical stature; the thyroid gland is either congenitally absent or imperfectly developed

Cretinism

granuloma is a small area of inflammation. Granulomas are often found incidentally on an X-ray or other imaging test done for a different reason. Typically, granulomas are noncancerous (benign) Common in which IBD condition?

Crohn's Disease

_______________ is a transmural inflammatory disorder which can involve the entire gastrointestinal tract but usually is limited to the small intestine or colon.

Crohn's disease Primer

True or False In which IBD condition, does interference with digestion and absorption lead to hypoproteinemia (low protein), avitaminosis (low vitamins), malnutrition, and possibly steatorrhea (fatty stools) and why?

Crohn's disease because granulomas and damaged walls of the small intestine can impair the ability of the small intestine to absorb food. The inflammation also stimulates intestinal motility, decreasing the time available for digestion and absorption.

Dry, rough surface or dried exudate or blood

Crust

Functional labs for Bechet's

Digestive connection -Intestinal permeability -organic acid testing -lactose intolerance testing -testing for gluten and antigliadin antibodies -IgE, IgG, IgM, and environmental sensitivity testing

Presently _________________are being used in a variety of autoimmune conditions like RA, ankylosing spondylitis, psoriatic arthritis, juvenile idiopathic arthritis, Crohn's disease or ulcerative colitis, multiple sclerosis and lupus

DMARDs

For hypothyroidism, ideal intake for magnesium should be based on the ______________

DRI Magnesium supplements are available as magnesium oxide, magnesium chloride, magnesium citrate, magnesium taurate, magnesium orotate, as well as other amino acid chelates. In the treatment of magnesium deficiency, organic bound magnesium salts, such as magnesium citrate, gluconate, orotate, or aspartate recommendations were made due to their high bioavailability

Healing options for Bechet

Digestive Connection -Metabolic cleansing -Eat antioxidants- 5-12 servings of fruits and vegetables. Vit C, Vitamin E, Glutathione, trace minerals, selenium, NAC, phcogenol -Vitamin E- 800-1000 IU (d-alpha tocopherol with mixed tocopherols) -2000mg vitamin C daily -BG-104- chinese herb (anti-inflammatory, reduce sedimentation rate, antioxidant) -balance pH -acupuncture -investigate allergies and sensitiviites -probiotics and prebiotics -stress management

supplements for SS

Digestive connection · E-mixed - 800-1000 IU (high tocotrienol) · Vitamin C- 2000mg · Licorice- DGL- GD-PSF (herbs) · Probiotics and probiotic rich food (lactobacillus for canker sores)

Possible causes of Bechet's

Digestive connection -environmental exposure -viral or bacterial infection -low glutathione levels -SOD activity diminished -low vitamin C/ high malondialdehyde ( a metabolite produced when there is lipid peroxidation) -lower levels of vitamin A and E, beta carotene -Leaky gut syndrome -

Nutrient impacts in fibro

Digestive connection pg 388 -vitamin D -Coq10 -B1, B6 arginine 5 HTP SAMe EFA antioxidants niacin Magnesium malate antioxidants

Associated conditions in fibromyalgia

Digestive connection pg 388 -hypothyroidism -anemia RA Lyme rheumatic disorders -Cancer -dsybiosis -blood sugar imbalances Reference sheet from CNS group ● SIBO ● Chronic fatigue syndrome. ● Endometriosis. ● Irritable bowel syndrome. ● Interstitial cystitis. ● Temporomandibular joint dysfunction (TMJ). ● Vulvodynia ● Hepatitis C ● Lyme Disease ● Chlamyida ● Mycoplasm infection ● Cancer ● Autoimmune diseases ● Hypothyroid ● vD deficiency ● Hemochromotosis ● Xenobiotics

Functional labs

Digestive connection pg 391 -SIBO -OAT -micronutrient analysis -adrenal stress test -food and environmental testing -oxidative stress evaluation -provocation testing for heavy metals -hormone testing

____________ is a less serious version of SLE affecting only the skin.

Discoid lupus erythematosus

Symptoms of SS

Dryness of mouth (xerostomia), eyes (xerophthalmia), thirst, burning sensation in oral mucosa , inflammation to tongue (glossitis), difficulties in chewing and swallowing (dysphagia), severe dental caries, oral infections (candidiasis), progressive dental decay, and nocturnal oral discomfort

altered taste

Dysgeusia

distorted sense of smell

Dysosmia

Shallow, moist cavity in epidermis

Erosion

______________ is hypothyroidism associated with a severe systemic illness that causes decreased peripheral conversion of T4 to T3 , an increased conversion of T3 to the inactive rT3 , and decreased binding of thyroid hormones

Euthyroid sick syndrome o Conditions commonly associated with this syndrome include protein-calorie malnutrition, surgical trauma, myocardial infarction, chronic renal failure, diabetic ketoacidosis, anorexia nervosa, cirrhosis, thermal injury, and sepsis.

Primary ________________syndrome is a group of disorders characterized by pain and stiffness affecting muscles, tendons, and surrounding soft tissues (not joints).

Fibromylagia Gould page 176 (CH 9)

What is the biggest nutritional depletion that a patient taking methotrexate for RA would have to be concerned about?

Folate

In the treatment of rheumatic autoimmune conditions, methotrexate and sulfasalazine can deplete _________________ and cyclosporine can deplete __________, while _____________ can reduce its effectiveness

Folate, magnesium , Chinese skullcap and St. John's wort

In IBD, coinciding with the interactions between the ______________________ and the intestinal microbial population, acute bowel inflammation produces diarrhea, which reduces the efficiency of dietary fiber fermentation and butyrate production.

GALT (gut associated lymphoid tissue)

A hereditary condition in which red blood cells break down when the body is exposed to certain drugs.

Glucose-6-phosphate dehydrogenase deficiency

_____________ is the most common form of hypothyroidism

Hashimoto's thyroiditis

Cyanogenic plant foods (cauliflower, broccoli, cabbage, Brussels sprouts, mustard seed, turnip, radish, bamboo shoot, and cassava) exert antithyroid activity through inhibition of the TPO enzyme

Goitrogens

Signs and symptoms of scleroderma

Gould Chapter 8 Hard, shiny, tight, immovable areas of skin are present. ~ Fingertips are narrowed and shortened, and the Raynaud phenomenon may be present, further predisposing the individual to ulceration and atrophy in the fingers. ~ The facial expression is lost as the skin tightens, and movement of the mouth and eyes may be impaired (Fig. 8.7). ~ The cutaneous form may also affect the microcirculation of various organs, eventually causing renal failure, intestinal obstruction, or respiratory failure due to pulmonary hypertension. -Intestinal involvement is frequent (90%) - significant cause of morbidity. Most common manifestation is esophogeal reflux if left untreated can lead to Barrett's syndrome -also delayed gastric emptying in 10-75% of people with systemic scerloderma Vascular damage, nerve dysfunction, smooth muscle atrophy, and fibrosis causing hypomotility which may lead to SIBO, malabsorption, malnutrition, diarrhea, pseudo obstruction

What bacterial infection is associated with pernicious anemia that causes peptic ulcer disease and chronic gastritis

H pylori · Both conditions are associated with hypochlorhydria, reduced production of IF by epithelial cells in the stomach, vitamin B12 malabsorption, and pernicious anemia. There is also a correlation between autoimmune gastritis and pernicious anemia.

Atrophic glossitis, also known as Hunter glossitis, occurs when many papillae are lost. This results in changes in the tongue's color and texture. This type of glossitis typically gives the tongue a glossy appearance.

Hunter's / Moeller's glossitis

Develops more frequently in type 2, blood sugar levels of 800-1500 mg/dl. Dehydration is more severe due to extremely high blood sugar levels. Hypovolemia results in a decreased perfusion to the brain and results in a coma. Hyperglycemia and dehydration develop because of the relative insulin deficit, but sufficient insulin is able to prevent ketoacidosis: type 2 diabetics have insulin, but have a decreased effect of insulin

Hyperosmolar hyperglycemic nonketotic coma

heat intolerance, weight loss, alterations in appetite, frequent bowel movements, changes in vision, fatigue and muscle weakness, menstrual disturbances, impaired fertility, mental disturbance, sleep disturbances, enlarged thyroid, tremors

Hyperthyroid symptoms

Fatigue, forgetful, depression, heavy menses, dry coarse hair, mood swings, weight gain, hoarse voice, constipation, dry skin

Hypothyroid symptoms

*Be careful, the thyroid is in front of the parathyroid. *Can be caused by hyperthyroid treatments CARDIOVASCULAR- Bradycardia, decreased cardiac output, cool skin, cold intolerance NEUROLOGIC- Lethargy, slowed movements, memory loss, mental dullness, confusion PULMONARY- Dyspnea, hypoventilation INTUGUMENTARY- Cool, dry skin; brittle, dry hair GASTROINTESTINAL- Decreased appetite, weight gain, constipation, increased serum lipid levels REPRODUCTIVE- Decreased libido, erectile dysfunction. Hypercholesterolemia PRIMARY- Decreased TH, Increased TSH SECONDARY (pituitary cause)- Decreased TH, Decreased TSH *Can cause coma when not treated. *Monitor and record bowel movements.

Hypothyroidism symptoms

Type _____ antibodies Prevent binding of IF and B12

I

Type _____ antibodies- prevents binding of IF-Vit B12 is ileal receptor

II

Type ________antibodies -type III target parietal cells

III

What are the two forms of T1D?

Idiopathic (no known etiology) & Immune-Mediated (autoimmunity, infections, toxic chemicals, etc.).

The most likely mechanism of action for vitamin A in SLE is via __________________cytokine regulation, and possibly others like IL-6

L-17 and transforming growth factor (TGFβ),

Name some top non vitamin supplements for IBD therapy and treatment.

L-glutamine, Omega-3 fats, boswellia, Probiotics (L rhamnosus, S. boulardii,), prebiotics, colostrum, synbiotics, NAC

tightly packed set of papules that thickens skin; caused by prolonged intense scratching

Lichenification

Two subtypes of scleroderma

Limited cutaneous scleroderma (LcSSc): thickened skin distal to elbows and knees, face and neck -More likely to be associated with anticentromere antibodies (ACA) and Raynaud's syndrome Better prognosis Diffuse cutaneous scleroderma (dcSSC): involves trunk and proximal part of upper and lower limbs -More likely to be associated with internal organ involvement Worse prognosis

T3 is produced in the thyroid, but approx. 80-85% is generated in __________ and ____________

Liver and kidneys Pituitary and nervous systems are also capable of converting T4 to T3

Two major forms of scleroderma

Localized- affecting one or two locations Systemic- AKA diffuse- found throughout the body. Can rapidly progress and make it more serious. Generalized symptoms include fatigue, muscle pain, and arthritis

flat, colored spot on the skin

Macule

______________as the name implies, are characterized by very large, immature, nucleated erythrocytes.

Megaloblastic anemias,

Disorder of inner ear that can lead to vertigo and hearing loss

Meniere's Disease · Can occur at any age but usually starts between young-middle-aged adulthood (40-50 yrs.)

Drugs therapy for SS

Methotrexate (DMARD's) The muscarinic receptor agonists pilocarpine (Salagen) and cevimeline (Evoxac) may be used for the treatment of dry mouth and dry eyes only in patients with residual gland function B-cell depletion therapy with rituximab (anti-CD20) improves the stimulated whole saliva flow rate and lacrimal gland function, as well as other variables including RF levels, extraglandular manifestations (arthritis, skin vasculitis), fatigue, and quality of life, indicating a major role of B cells in the pathogenesis of SS IL-1 and TNF-α play a major role in the development of SS . Blocking IL-1 (anakinra) is beneficial in the treatment of SS, whereas blocking TNF-α (etanercept) is ineffective in controlling SS symptom Antimalarials (hydroxychloroquine), besides improving salivary flow, can help SS patients with arthromyalgia. The use of corticosteroids may be used in patients with extraglandular manifestations, although they have no effect in salivary or lacrimal flow rates

Treatment for Scleroderma (Ch 8 Gould)

NSAIDs Corticosteroids Vasodilators (for vascular disease)

Pharmacologic Treatment for Psoriatic arthritis

NSAIDs, DMARDS, Immunosuppressants

Vitamin B12 deficiency is an important modifiable risk factor for _____________ in men and women.

Osteoporosis

first and only FDA approved treatment for oral ulcers of Bechet's disease

Otezla (apremilast)

Referring to a secreted molecule that acts on a neighboring cell.

Paracrine

a benign tumor of the adrenal medulla that causes the gland to produce excess epinephrine

Pheochromocytoma

excessive thirst

Polydyspia

affects neck/shoulder/hips, "pain in many muscles" it may be caused by an inflammatory condition of blood vessels such as temporal arteritis (inflammation of blood vessels in the face, which can cause blindness if not treated quickly) Most sufferers wake up in the morning with pain in their muscles; however, there have been cases in which the patient has developed the pain during the evenings.

Polymyalgia Rheumatic (PMR)

affects muscles of head/neck/torso/upper arms & legs, "inflammation in many muscles" more common in adult women Symptoms include pain with marked weakness or loss of muscle mass in the muscles of the head, neck, torso, and upper arms and legs. The hip extensors are often severely affected, leading to particular difficulty in ascending stairs and rising from a seated position. Early fatigue while walking is caused by weakness in the upper leg muscles dysphagia occurs in ⅓ of patients

Polymyositis (PM)

Associated conditions with psoriatic arthritis

Psoriasis, hypothyroidism

NSAIDs, methotrexate for resistant disease, infliximab and other anti-TNFs may be used

Psoriatic Arthritis treatment

Alternative names include arthropathic psoriasis psoriatic arthropathy

Psoriatic arthritis

DIP joint involvement, rash w/ silvery scale on elbows and knees, pitting nails and swollen fingers. Signs and symptoms include stiff, painful joints with redness, heat, and swelling in the surrounding tissues. When the hands and feet are affected, swelling and redness may result in a "sausage-like" appearance of the fingers or toes (dactylitis).

Psoriatic arthritis

Caused by overly-sensitive blood vessels within fingers & toes that are more affected by cold and stress. Blood vessels narrow substantially, causing decrease in blood flow and associated color change

Raynaud's Phenomenon

Risk factors of Fibro

Risk Factors & Causes: ● Other diseases: ○ Lupus ○ Rheumatoid Arthritis ○ Ankylosing Spondylitis ● Familial genetics (ATP5c1 or ATP5g3 SNP (p. 254 Fx MNT)) ● Increased intestinal permeability ● Inflammation ● Obesity ● Stressful or traumatic events, such as car accidents/ illnesses. Repetitive injuries

A recent study showed that injections and oral supplements with SAMe significantly reduced muscle tenderness and pain points. why?

SAMe is produced in our bodies from methionine. It is the active methylating agent for many enzyme reactions throughout the body, especially the brain It is probably the sulfur that is needed In this study, oral dose of 200mg given as daily injection or 400mg given orally 2x a day

·_______________refers to hypothyroidism with other endocrine disorders, including Addison's disease (adrenal insufficiency), hypoparathyroidism, and diabetes mellitus, all of which may be autoimmune in nature.

Schmidt's syndrome

Within the liver and kidney, the enzyme responsible for production of T3 is a _____________-dependent enzyme called 5-deiodinase, an enzyme that removes one molecule of iodine from T4 to form either T3 or rT3

Selenium

______________, as selenocysteine, is a cofactor for 5-deiodinase

Selenium If selenium is deficient, the deiodinase activity is impaired, resulting in a decreased ability to deiodinate T4 to T3. In animals, deficiencies of selenium are associated with impaired 5-deiodinase activity in the liver and kidney, as well as reduced T3 levels o Evidence suggests a strong linear association between lower T3 /T4 ratios and reduced selenium status, even among individuals considered to be euthyroid based on standard laboratory parameters o This association is particularly strong in older adults, possibly as the result of impaired peripheral conversion

Deiodinase inhibitors include

Selenium deficiency Inadequate protein too much carbohydrate high insulin chronic stress(cortisol) Cd, Hg, Pb and other heavy metal toxins Compromised liver/kidney function

Behcet's disease

Silk Road disease Vasculitis Can cause sores in mouth and genital area ● Inflammation of blood vessels and the eyes ● Causes various issues throughout the body Common in Northern Turkey Other symptoms -● Eye inflammation -o Blindness is more common in the Middle East and Japan (severe cases) -Joint pain -● Brain, nerves, lung (rare) intestinal tract, and kidneys are also affected. -o Abdominal pain, blood in the stool caused by lesions similar to the mouth and genital area. GI lesions can lead to intestinal bleeding and rupturing.

-Chronic autoimmune inflammatory disease that affects the exocrine glands, particularly the salivary and lacrimal glands, leading to dryness of mouth (xerostomia) and eyes (xerophthalmia) -Patients may also suffer from extra glandular disorders affecting the skin, lung, kidney, nerve, connective tissue, and digestive system -Some patients may develop disturbances in smell perception (dysosmia) and in taste acuity (dysgeusia) -Increased levels of IL-1 & IL-6 in the saliva of SS patients suggest that TH1 response participates in the pathogenesis of the disease -Recent studies indicate that dysbiosis may play a role in SS pathogenesis.

Sjogren's Syndrome (SS)

What diet has received the most attention for treatment of IBD, particularly Ulcerative colitis?

Specific Carb Diet

Diet that eliminates disaccharides (lactose, sucrose, maltose), digestible saccharides (Starch), but allows monosaccharides (glucose, fructose, galactose). Foods to avoid are cereals, legumes, potatoes, sweeteners. Allowed foods are meat, poultry, fish, eggs, nut flour, peeled veggies, age cheese, homemade yogurt, honey. Gluten and lactose are eliminated

Specific carbohydrate diet

enlargement of the spleen

Splenomegaly

Most common clinical features include inflammatory back pain, asymmetric peripheral oligoarthritis, predominantly in lower limbs, and enthesitis (inflammation at the site where tendon attaches to bone)

Spondylarthritis

Medical Nutrition Therapy for Psoriatic arthritis

Strict gluten and dairy-free diet Avoid yeast & eggs Avoid alcohol, caffeine, sugar Exercise regularly Maintain healthy weight Cease smoking Limit alcohol use Relaxation and stress management strategies, emphasis on life-work balance Turmeric (curcumin) Fish oil supplements (EPA/DHA) Vit D Probiotics Balneotherapy (bathing in mineral springs) Capsaicin L-carnitine Cold/Hot Packs Sleep Stretching & exercise to prevent joint stiffness Massage

· Excessive thirst (polydipsia), excessive hunger (polyphagia), frequent urination (polyuria), impaired wound healing, infections, weight loss, itchy skin, blurred vision, dry mouth

Symptoms of T1D

____________________is a chronic inflammatory disease that affects a number of systems; therefore it can be difficult to diagnose and treat. -The name of this systemic disorder is derived from the characteristic facial rash, which is erythematous and occurs across the nose and cheeks, resembling the markings of a wolf -Characterized by the presence of large numbers of circulating autoantibodies against DNA, platelets, erythrocytes, various nucleic acids, and other nuclear materials (antinuclear antibodies [ANAs]) -deposited in connective tissues anywhere in the body, activating complement and causing inflammation and necrosis

Systemic lupus erythematosus (SLE)

A common pathogenesis of pernicious anemia is _____________cells attack parietal cells of gastric mucosa leads to gastric injury and lack of production of IF

T

What are three main differences between T1D and T2D?

T1D involves autoimmune destruction. Patients in T1D are thin, where in T2D they are overweight. Plasma insulin is low in T1D, and elevated in T2D. Treatment in T1D is insulin replacement, but in T2D is diet, exercise and hypoglycemic agents, sometimes insulin replacement

_____________ is considered to be the most metabolically active thyroid hormone.

T3 Although some T3 is produced in the thyroid, approximately 80% to 85% is generated outside the thyroid gland, primarily by conversion via a deiodinase enzyme from T4 to T3 in the liver and kidneys. The pituitary and nervous system are also capable of converting T4 to T3 , and so are not reliant on T3 produced in the liver or kidney. Within the liver and kidney, the enzyme responsible for production of T3 is a selenium-dependent enzyme called 5-deiodinase, an enzyme that removes one molecule of iodine from T4 to form either T3 or rT3 · Some is produced in the thyroid, but approx. 80-85% is generated in liver and kidneys. Pituitary and nervous systems are also capable of converting T4 to T3

IBD is characterized by imbalance of ____________ and causes excessive secretion of pro- inflammatory reactive oxygen species, nitric oxide and prostaglandin PGE2 and inhibition of sIgA secretion.

TH-1 and TH-2 T-helper lymphocytes

the single best screening test for primary thyroid dysfunction for the vast majority of outpatient clinical situations

TSH

Why is weight change is an important measure of RA severity?

The characteristic progression of malnutrition of RA is attributed to excessive protein catabolism evoked by inflammatory cytokines and by disuse atrophy resulting from functional impairment.

Medications used for oral ulcers

Topical medications TNF inhibitors systemic glucocorticoids Other agents -otezla -methotrexate -azathiprine -cyclsporine- -tetracycline -colchicine -thalidomide -dapsone pentoxifylline sulfasalzine -aspirin Magic mouthwash

Treatment or healing for Fibro from Gould

Treatment includes stress reduction, regular early morning exercise, rest as needed, local applications of heat or massage as needed, and low doses of antidepressants, such as the tricyclic antidepressants or selective serotonin-norepinephrine reuptake inhibitors (SNRIs). A new drug, Lyrica (pregabalin), has been approved for fibromyalgia and mediates the pain pathway. Nonsteroidal antiinflammatory drugs (NSAIDs) have been helpful to some individuals. Massage therapy is helpful as is occupational therapy to identify strategies to deal with pain and fatigue.

AD and Parkinson's are considered Autoimmune True or False

True

True or False "Bowel rest" is contraindicated because intentional starvation of enterocytes and colonocytes will exascerbate lesions and delay healing

True

True or False A TSH test does not screen for autoimmune disease. If autoimmune thyroid disease is suspected, additional tests must be done

True

True or False · The thyroid also produces calcitonin, a hormone that helps regulate the amount of blood calcium.

True

True or False o Historically it has been thought that low thyroid function may contribute to anemia. Recent studies suggest that low thyroid function may be secondary to low iron status or anemia

True

True or False - In IBD, interleukin imbalance, triggered and reinforced by aberrant macrophages, results in an imbalance of TH-1 and TH-2 T-helper lymphocytes and causes an excessive secretion of pro-inflammatory ROS, nitric oxide and prostaglandin PGE2 and inhibition of sIgA secretion

True

True or False Crohn's lesions are characterized by skip lesions

True

True or False Hemolytic anemia is also characterized by Raynaud's disease and Splenomegaly, mottled discoloration of skin

True

True or False- A concern with long-term ulcerative colitis is the increased risk of colorectal carcinoma, which may be predicted by detection of metaplasia and dysplasia in the mucosa

True

True or False: Diabetes may affect children and pregnant women, and weight loss is not important to maintaining health in these population groups

True

True or False: In diabetes, there is a risk that hypoglycemia may develop with exercise, particularly strenuous or prolonged exercise.

True

True or False: Low serum levels of P5P correlates with increased markers of inflammation and continuous use of NSAIDs also impairs pyridoxine metabolism by a mechanism related to COX inhibition

True

True or False: One or more autoantibodies are usually present in 85-90% of individuals when fasting hyperglycemia is detected early

True

True or False: People with T1D are low in a glucoregulatory hormone known as amylin

True

True or False: Peripheral vascular disease is classified as a macrovascular disease because it involves larger blood vessels.

True

True or False: Research evidence does not substantiate a recommendation to limit simple carbohydrate intake in the treatment of diabetes.

True

True or False: The first MNT goal for all people with diabetes is to achieve and maintain normal blood glucose levels and lipid and lipoprotein profiles and blood pressure levels that reduce the risk for vascular disease

True

True or False: · Smoking is the environmental risk factor that is most associated with RA followed by coffee consumption

True

True or False: · The HLA-DR/DQ alleles can be either predisposing or protective for T1D

True

True or False; RA patients often have intakes below the DRI for folic acid, calcium, Vit D, Vit E, zinc, Vit B6, Vit B12, and selenium. ·

True

True or false Pernicious anemia affects not only the blood but also the gastrointestinal tract and the peripheral and central nervous systems

True

True or false o . Authors concluded that vitamin D preparations may reduce thyroid autoimmunity in levothyroxine-treated women with Hashimoto's thyroiditis and normal vitamin D status

True

True or false: diabetic ketoacidosis occurs more often in T1D

True

·True or False Crohn disease often develops during adolescence, whereas ulcerative colitis more frequently appears in the second or third decade.

True

patients with Hashimoto's thyroiditis undergo celiac serologic tests (serum IgA and IgG gliadin antibodies [AGA-IgA, AGA-IgG], IgA transglutaminase antibodies [TGA], and serum IgA endomysium antibodies [EMA]),

True and that if any of the celiac serologic tests is positive, the patients must be investigated with gastroduodenoscopy and duodenal biopsy

In ALS, more men are affected than women. No cure, 90% with no family history, average onset is mid 50's

True Studyforxyz CLINICAL INTERVENTION AND MONITORING

The synthesis of these hormones requires _______, a key amino acid involved in the production of thyroid hormone, and the trace mineral iodine.

Tyrosine

Which IBD condition is characterized by watery and sometimes bloody stools with mucous? Pick from Crohn's disease or UC.

UC (ulcerative colitis)

Which IBD condition is more associated with · tenesmus (persistent spasms of the rectum associated with a need to defecate).

Ulcerative colitis

A membrane bound sac that contains materials involved in transport of the cell.

Vesicle

Because of drug-induced alterations of specific vitamin and mineral levels, mounting evidence supports supplementation beyond the minimum levels for which nutrients in RA?

Vit D, E, Folic Acid, B6, and B12.

What are some supplement herb interactions?

Vitamin C- Copper (1500mg vitamin C can decrease Cu transporting protein) Vitamin E (mixed tocopherols)- interacts with vitamin K- a vitamin E metabolite can inhibit vitamin K dependent gamma- glutamyl carboxylase activity Fish oils (EPA + DHA)- can interact with blood thinners , anticoagulants, and increase bleeding Vitamin D - can impair absorption of calcium. K2 can increase absorption Turmeric-interacts with antiplatelet and anticoagulant drugs, Etoicxib, Tacrolimus, Talinolol

Topical corticosteroids; ultraviolet A therapy; micropigmentation or tattooing

Vitiligo treatment

Which type of hemolytic anemia is the most common type, with presence of autoantibodies that attach to and destroy red blood cells at temperature equal to or greater than normal body temperature

Warm antibody hemolytic anemias

Diagnostic tools for psoriatic arthritis

X-rays MRI Rheumatoid Factor (RF)

dry mouth

Xerostomia

Nulliparae is often associated with endometriosis. What does it mean?

a woman who has never given birth

Which of the following is an important component in the nutritional assessment of patients with rheumatoid arthritis? a. ADLs b. Degree of malabsorption c. Blood glucose control d. Nitrogen balance

a-ADL's Because rheumatoid arthritis (RA) can affect mobility, activities of daily living (ADLs) should be assessed. An inability to perform basic self-care skills can have a negative impact on the patient's ability to feed herself. Support in the form of caregivers or adaptive equipment may be needed to ensure nutritional adequacy. Malabsorption is not a consequence of RA. Blood glucose control depends on the presence of diabetes and other lifestyle factors. Nitrogen balance may be used to monitor protein status; however, simple monitoring of the patient's weight and anthropometric measures gives an idea about protein status without need for a nitrogen balance study. Krause Ch 39

How is the articular cartilage damaged in rheumatoid arthritis? a. Enzymatic destruction by the pannus b. Inflamed synovial membrane covers the cartilage c. Fibrous tissue connects the ends of the bones d. Blood supply to the cartilage is lost

a. Enzymatic destruction by the pannus Gould Ch 9 page 175

. Goiters occur more frequently in persons living in the: a. Great Lakes or mountainous regions. b. southwest United States. c. temperate regions. d. areas bordering the oceans.

a. Great Lakes or mountainous regions. Gould CH 16 page 419

46. Which of the following is caused by Graves' disease? a. Hypermetabolism b. Decreased size of thyroid gland c. Bradycardia and hypothermia d. Decreased blood levels of T3, T4, and TSH

a. Hypermetabolism Gould CH 16 page 420

What is/are the effect(s) of thyrotoxic crisis? a. Hyperthermia and heart failure b. Hypotension and hypoglycemia c. Toxic goiter and hypometabolism d. Decreased stress response

a. Hyperthermia and heart failure Gould CH 16 page 420

. Compensation mechanisms occurring in the early stage of diabetic ketoacidosis include: a. Kussmaul's respirations. b. polydipsia. c. ketonuria. d. seizures.

a. Kussmaul's respirations. Gould Ch 16 page 410

Why is amputation frequently a necessity in diabetics? a. Necrosis and gangrene in the feet and legs b. Lack of glucose to the cells in the feet and legs c. Severe dehydration in the tissues d. Elevated blood glucose increasing blood viscosity

a. Necrosis and gangrene in the feet and legs Gould CH 16 page 412

Choose the statement that applies to type 1 diabetes mellitus. a. Onset often occurs during childhood. b. Relative insufficiency of insulin or insulin resistance develops. c. It can be treated by diet, weight control and exercise, or oral hypoglycemics. d. Complications rarely occur.

a. Onset often occurs during childhood. Gould CH 16 page 406

Which of the following may cause insulin shock to develop? a. Strenuous exercise b. Missing an insulin dose c. Eating excessively large meals d. Sedentary lifestyle

a. Strenuous exercise Gould CH 16 page 409

Which one of the following develops hypoglycemia more frequently? a. Type 1 diabetic patients b. Type 2 diabetic patients c. Patients with a poor stress response d. Patients with a regular exercise and meal plan

a. Type 1 diabetic patients Gould Ch 16 page 406

Diabetes may cause visual impairment through damage to the lens; this is referred to as: a. cataracts. b. macular degeneration. c. myopia. d. strabismus.

a. cataracts. Gould CH 16 page 415

All these tissues use glucose without the aid of insulin EXCEPT: a. liver. b. digestive system. c. exercising skeletal muscle. d. brain.

a. liver. Gould CH 16 page 406

Systemic effects of rheumatoid arthritis are manifested as: a. nodules in various tissues, severe fatigue, and anorexia. b. headache, leukopenia, and high fever. c. swelling and dysfunction in many organs. d. progressive damage to a joint.

a. nodules in various tissues, severe fatigue, and anorexia. Gould Chapter 9 page 176

Ankylosis and deformity develop in rheumatoid arthritis because: a. skeletal muscle hypertrophies. b. fibrosis occurs in the joint. c. replacement cartilage changes alignment. d. ligaments and tendons shorten.

a. skeletal muscle hypertrophies. Gould Chapter 9 page 176

. Gastric mucosal injury forms auto antibodies to gastric mucosal cells. There are 3 types of antibodies,, name them

a. Type I- prevent binding of IF and B12 b. Type II antibodies- prevents binding of IF-Vit B12 is ileal receptor Type III antibodies -type III target parietal cells

In IBD, reduced _____________ availability compromises intercellular barrier integrity and increases intramucosal translocation and inflammation

acetyl CoA

Are inherited autosomal recessive disorders that cause an impaired rate of synthesis of one of the two chains alpha or beta of Hb A.

alpha and beta thalassemia

MNT for MS

anti inflammatory diet, antioxidants, evaluate Vit D and linoleic acid evaluate vit D status Studyforxyz CLINICAL INTERVENTION AND MONITORING

term for hormones that act on same cells that secrete them

autocrine

Stools that are more liquid and contain mucus and frank blood are typical of: a. diverticulitis. b. ulcerative colitis. c. Crohn's disease. d. celiac disease.

b- Ulcerative colitis Gould CH 17

What is a characteristic difference between Crohn disease and ulcerative colitis? a. Age at disease onset b. Segmental versus continuous distribution of the disease throughout the GI tract c. Clinical features of diarrhea, food intolerance, and dehydration d. Medical management with steroids and diet

b-Segmental versus continuous distribution of the disease throughout the GI tract Whereas Crohn disease appears as segments of diseased bowel separated by segments of healthy bowel, in ulcerative colitis, the disease is continuous throughout the bowel. Both diseases occur more frequently between the ages of 15 and 30 years. Diarrhea, food intolerances, and dehydration are experienced in both diseases. The medical management for both diseases involves treatment with corticosteroids and manipulation of the diet during flare-up episodes. Krause CH 28

What is the typical joint involvement with rheumatoid arthritis? a. Random single joints, progressing to involve other joints b. Bilateral small joints, symmetrical progression to other joints c. Abused or damaged joints first, then joints damaged by compensatory movement d. Progressive degeneration in selected joints

b. Bilateral small joints, symmetrical progression to other joints Gould Ch 9 page 177

What is the most common cause of type 1 diabetes mellitus? a. Increased glucose production in the liver b. Destruction of pancreatic cells by an autoimmune reaction c. Increased resistance of body cells to insulin action d. Chronic obesity

b. Destruction of pancreatic cells by an autoimmune reaction c. Gould CH 16 page 406

Which signs are typical of Graves' disease? a. Facial puffiness, bradycardia, and lethargy b. Exophthalmos and tachycardia c. delayed physical and intellectual development d. Goiter and decreased basal metabolic rate (BMR)

b. Exophthalmos and tachycardia Gould CH 16 page 420

Which of the following is present with pernicious anemia? a. Pancytopenia b. Hypochlorhydria c. Leukocytosis d. Multiple infarcts

b. Hypochlorhydria Gould Ch 10 pg 195

. Why does hypocalcemia cause tetany? a. Skeletal muscle contractions are weaker. b. Nerves to skeletal muscle are more excitable. c. Calcium is not stored in skeletal muscle cells. d. Serum phosphate levels are low.

b. Nerves to skeletal muscle are more excitable Gould CH 16 page 415

What is a common effect of long-term use of glucocorticoids to treat rheumatoid arthritis? a. Leukocytosis b. Osteoporosis c. Severe anemia d. Orthostatic hypotension

b. Osteoporosis Gould Ch 9 page 177

Why do abnormally low hemoglobin values develop with pernicious anemia? a. Decreased production of erythrocytes b. Shorter life span of erythrocytes c. Abnormal structure of hemoglobin chains d. Deficit of folic acid

b. Shorter life span of erythrocytes Gould CH 10 page 195

Goiters may be caused by: a. hypothyroid conditions only. b. either hypothyroid or hyperthyroid conditions. c. hyperthyroid conditions only. d. fungal infections such as candidiasis.

b. either hypothyroid or hyperthyroid conditions. Gould CH 16 page 419

In individuals with pernicious anemia, antibodies form to: a. vitamin B12. b. intrinsic factor or parietal cells. c. mucus-producing glands. d. hydrochloric acid.

b. intrinsic factor or parietal cells. Gould CH 10 page 195

Juvenile rheumatoid arthritis (JRA) differs from the adult form in that: a. only small joints are affected. b. rheumatoid factor is not present in JRA, but systemic effects are more severe. c. onset is more insidious in JRA. d. deformity and loss of function occur in most children with JRA.

b. rheumatoid factor is not present in JRA, but systemic effects are more severe. Gould Ch 9 page 177

In IBD, acute ______________ deficiency may predispose to disease activation

butyrate IBD may be a disease of "local energy deficiency" with all other aspects and symptoms secondary to deranged intermediary metabolism within the intestinal mucosa. Butyrate inhibits activation of NF-κB in macrophages and acute butyrate deficiency may predispose to disease activation. In contrast, butyrate enemas have been reported to induce remission of symptoms and healing of lesions. Oral butyrate also has induced symptomatic relief.

What should patients with Crohn disease be monitored for when experiencing diarrhea? a. Calcium and phosphorus status b. Magnesium and iron status c. Zinc and potassium status d. Iron and selenium status

c- zinc and potassium status Although maldigestion, malabsorption, and drug-nutrient interactions may contribute to the need for overall vitamin and mineral supplementation in patients with Crohn disease, diarrhea experienced by the patient promotes the reduction of potassium, selenium, and zinc stores in particular. Krause CH 28

A group of self-reacting antibodies found in the sera of rheumatic patients a. include CRP. b. are known to suppress the immune system. c. are known as rheumatoid factor. d. are known as eicosanoids.

c-are known as rheumatoid factor The term rheumatic factor is used to refer to a group of self-reacting antibodies found in the sera of rheumatic patients. It is used to screen for and monitor rheumatic disease along with CRP. Eicosanoids are modulators of the inflammation process that include prostaglandins. Krause CH 39

Which of the following CAM therapies has been demonstrated as effective in the treatment of rheumatoid arthritis? a. Copper bracelets b. Echinacea c. Borage and evening primrose oil d. Thunder god vine

c-borage and evening primrose oil Gamma-linolenic acid is an omega-6 fatty acid found in the oils of borage and primrose oil that can be converted to the antiinflammatory PGE-1. Copper bracelets have been suggested to allow for absorption of copper through the skin, but no studies have substantiated this. Echinacea therapy is among a number of CAM therapies that the Arthritis Foundation recommends that people with rheumatoid arthritis should not use. Thunder god vine has been used in China to treat patients with a number of autoimmune disorders, but no consistent, high-quality vine preparations are available in the United States. Krause CH 39

What is the basic pathology of rheumatoid arthritis? a. Degenerative disorder involving the small joints b. Chronic inflammatory disorder affecting all joints c. Systemic inflammatory disorder due to an autoimmune reaction d. Inflammatory disorder causing damage to many organs

c. Abused or damaged joints first, then joints damaged by compensatory movement Gould Ch 9 pg 175-177

What is caused by hyperparathyroidism? a. Hypocalcemia b. Tetany c. Bone demineralization d. Deficit of vitamin D

c. Bone demineralization Gould CH 16 pg416

Which of the following are signs of diabetic ketoacidosis in an unconscious person? a. Pale moist skin b. Thirst and poor skin turgor c. Deep rapid respirations and fruity breath odor d. Tremors and strong rapid pulse

c. Deep rapid respirations and fruity breath odor Gould CH 16 pg 409

Which of the following hormonal imbalances causes diabetes insipidus? a. Increased insulin b. Decreased glucocorticoids c. Deficit of ADH d. Deficit of T3 and T4

c. Deficit of ADH Gould CH 16 page 407

. What causes loss of consciousness in a person with diabetic ketoacidosis? a. Toxic effects of excessive insulin b. Excessive glucose in the blood c. Metabolic acidosis d. Lack of glucose in brain cells

c. Metabolic acidosis Gould CH 16 page 411

What kind of control mechanism is indicated when increased blood glucose levels stimulate increased secretion of insulin? a. Control by releasing hormones b. Control by tropic hormones c. Negative feedback control d. Hypothalamus/hypophysis coordination

c. Negative feedback control Gould Ch 16 page 403-404

Why does polyuria develop with diabetes mellitus? a. Increased thirst and hypoglycemia b. Ketoacidosis c. Osmotic pressure due to glucose d. Diabetic nephropathy

c. Osmotic pressure due to glucose Gould Ch 16 page 407

Which of the following distinguishes septic arthritis? a. Multiple joints that are swollen, red, and painful at one time b. Presence of mild fever, fatigue, and leukocytosis c. Purulent synovial fluid present in a single, swollen joint d. Presence of many antibodies in the blood

c. Purulent synovial fluid present in a single, swollen joint Gould Chapter 9 page 178

Where does inflammation usually begin in an individual with ankylosing spondylitis? a. Costovertebral joints with progression down the spine b. Cervical and thoracic vertebrae, causing kyphosis c. Sacroiliac joints with progression up the spine d. Peripheral joints and then proceeds to the vertebrae

c. Sacroiliac joints with progression up the spine Gould Chapter 9 page 178

What is a precipitating factor for diabetic ketoacidosis? a. Skipping a meal b. Anorexia c. Serious infection d. Insulin overdose

c. Serious infection Gould CH 16 page 410

Why does glucosuria occur in diabetics? a. Excess ketoacids displace glucose into the filtrate. b. Excess water in the filtrate draws more glucose into the urine. c. The amount of glucose in the filtrate exceeds the renal tubule transport limit. d. Sufficient insulin is not available for glucose reabsorption.

c. The amount of glucose in the filtrate exceeds the renal tubule transport limit. Gould CH 16 page 407

Which statement applies to menisci? a. They are found in the hip joints. b. They are secretory membranes in joints. c. They prevent excessive movement of joints. d. They are found in the shoulder joint.

c. They prevent excessive movement of joints. Gould Ch 9 page 163

What causes numbness and tingling in the fingers of individuals with untreated pernicious anemia? a. Persistent hyperbilirubinemia b. Increasing acidosis affecting metabolism c. Vitamin B12 deficit causing peripheral nerve demyelination d. Multiple small vascular occlusions affecting peripheral nerves ANS: C REF: 195

c. Vitamin B12 deficit causing peripheral nerve demyelination Gould CH 10 page 195

Early signs of hyperglycemia include polyphagia, which means: a. thirst. b. increased urine output. c. hunger. d. glucose in the urine.

c. hunger. Gould Ch 16 page 411

Polydipsia occurs with diabetes mellitus when: a. lack of insulin causes hunger. b. ketone levels rise in the blood. c. polyuria causes dehydration. d. glucosuria causes ketoacidosis.

c. polyuria causes dehydration.

Polydipsia occurs with diabetes mellitus when: a. lack of insulin causes hunger. b. ketone levels rise in the blood. c. polyuria causes dehydration. d. glucosuria causes ketoacidosis.

c. polyuria causes dehydration. Gould CH 16 page 407

a disorder of the lips characterized by crack-like sores at the corners of the mouth

cheilosis

Which of the following is NOT an articular manifestation of RA? a. chronic inflammation in synovial membranes b. damage to joint cartilage and bone c. weakening of surrounding muscle, ligaments and tendons d. Generalized bone loss

d-Generalized Bone loss Krause pg 1954 Volume 15

ow may a fistula form with Crohn's disease? a. Lack of peristalsis, leading to dilated areas of intestine b. Fibrosis and thickening of the wall, causing obstruction c. Erosion of the mucosa, causing bleeding d. Recurrent inflammation, necrosis, and fibrosis, forming a connection between intestinal loops

d-Recurrent inflammation, necrosis, and fibrosis, forming a connection between intestinal loops Gould CH 17

n the MNT for inflammatory bowel disease, which of the following is LEAST likely to be used? a. Low-residue diet b. Parenteral nutrition c. Lactose-free or reduced diet d. High-fiber diet

d-high fiber diet Krause CH 28 The medical nutrition therapy for patients with inflammatory bowel disease is highly variable and individualized depending on acuteness and exacerbation of the disease. Because of problems with flare-ups and diarrhea, low-residue and lactose-free diets may be instituted. Commonly, parenteral nutrition may be used to promote nutritional repletion or to maintain nutritional status when oral and enteral intakes are not tolerated. A high-fiber diet is least likely to be used because the presence of fiber could aggravate the affected regions of the bowel. However, investigation into the use of prebiotic foods and fibers may help control the intestinal flora associated with IBD.

What is the most common cause of endocrine disorders? a. Malignant neoplasm b. Infection c. Congenital defect d. Benign tumor

d. Benign tumor Gould CH 16 page 406

What is the cause of diabetic ketoacidosis? a. Excess insulin in the body b. Loss of glucose in the urine c. Failure of the kidney to excrete sufficient acids d. Increased catabolism of fats and proteins

d. Increased catabolism of fats and proteins Gould CH 16 page 408

Which of the following best describes the characteristic erythrocyte associated with pernicious anemia? a. Hypochromic, microcytic b. Normochromic, normocytic c. Elongated, sickle-shaped d. Megaloblastic or macrocytic nucleated cells

d. Megaloblastic or macrocytic nucleated cells Gould CH 10 pg 201

21. Which of the following can result from a malabsorption problem? a. Aplastic anemia b. Sickle cell anemia c. Thalassemia major d. Pernicious anemia

d. Pernicious anemia Gould CH 10 pg 195

Which of the following often causes hyperparathyroidism? a. A malignant tumor in the parathyroid glands b. End-stage renal failure c. Osteoporosis d. Radiation involving the thyroid gland and neck area

d. Radiation involving the thyroid gland and neck area Gould Ch 16 page 412-413

What is a common outcome of fibrosis, calcification, and fusion of the spine in ankylosing spondylitis? a. Damage to the spinal nerves and loss of function b. Frequent fractures of long bones c. Impaired heart function d. Rigidity, postural changes, and osteoporosis

d. Rigidity, postural changes, and osteoporosis Gould Ch 9 page 178-179

hich of the following indicates hypoglycemia in a diabetic? a. Deep, rapid respirations b. Flushed dry skin and mucosa c. Thirst and oliguria d. Staggering gait, disorientation, and confusion

d. Staggering gait, disorientation, and confusion Gould CH 16 page 409

In the Diabetes Control and Complications Trial (DCCT), which of the following was demonstrated? a. Strict control of protein intake, particularly animal protein, improves glucose control. b. Minimizing the number of meals and snacks per day decreases hyperglycemic episodes. c. Strict control of carbohydrate intake, particularly simple sugars, improves glucose control. d. Strict control of blood glucose reduces long-term complications of diabetes.

d. Strict control of blood glucose reduces long-term complications of diabetes. In the DCCT, subjects with type 1 diabetes mellitus were provided with either intensive treatment involving multiple insulin injections daily or conventional treatment with only one or two insulin injections daily. The subjects who monitored their blood glucose and used intensive insulin therapy experienced a 50% to 75% reduction in the risk progression of retinopathy, nephropathy, and neuropathy. The trial did include prescribed meal plans but did not evaluate the effect of macronutrient content or number of meals on glucose control. REF: p. 593 ANS: D, Krause CH 30

Why is pernicious anemia treated with injections of vitamin B12? a. An immune reaction in the stomach would destroy the vitamin. b. Digestive enzymes would destroy the vitamin. c. The vitamin irritates the gastric mucosa. d. The ingested vitamin would not be absorbed into the blood.

d. The ingested vitamin would not be absorbed into the blood. Gould CH 10 page 195

How do many oral hypoglycemic drugs act? a. To replace insulin in patients with insulin-dependent diabetes mellitus (IDDM) b. To transport glucose into body cells c. To prevent gluconeogenesis d. To stimulate the pancreas to produce more insulin

d. To stimulate the pancreas to produce more insulin Gould CH 16 page 409

40. Differences between type 1 and type 2 diabetes include which of the following? a. Type 1 diabetes weight gain is common, and type 2 weight loss often occurs. b. Type 1 diabetes leads to fewer complications than does type 2 diabetes. c. Type 1 diabetes may be controlled by adjusting dietary intake and exercise, but type 2 diabetes requires insulin replacement. d. Type 1 diabetes occurs more frequently in children and adolescents, and type 2 diabetes occurs more often in adults.

d. Type 1 diabetes occurs more frequently in children and adolescents, and type 2 diabetes occurs more often in adults. Gould Ch 16 page 406-407

Diabetic retinopathy results from: a. degeneration of large blood vessels supplying the eye. b. abnormal metabolism in the lens of the eye. c. neuropathy affecting the optic nerve. d. obstruction or rupture of retinal blood vessels.

d. obstruction or rupture of retinal blood vessels. Gould CH 16 page 412

How does the joint appear during an exacerbation of rheumatoid arthritis? a. Relatively normal b. Enlarged, firm, crepitus with movement c. Deformed, pale, and nodular d. Red, warm, swollen, and tender to touch

d. Red, warm, swollen, and tender to touch Gould Chapter 9 page 177

Causes of malnutrition in IBD

decreased food intake, malabsorption, excessive nitrogen loss, and increased nutrient requirements secondary to the catabolic effects of chronic illness. Drugs that are used in the treatment of IBD may aggravate nutritional deficiencies. Note-Decreased food intake is almost universal in both ulcerative colitis and Crohn's disease

antidiuretic hormone is not secreted adequately, or the kidney is resistant to its effect

diabetes insipidus Gould CH 16 page 407

As dehydration develops, the glomerular filtration rate in the kidney decreases, and excretion of acids becomes more limited, resulting in decompensated metabolic acidosis. What is another term for this?

diabetic coma

acidity of the blood caused by the presence of ketone bodies produced when the body is unable to burn sugar; thus, it must burn fat for energy

diabetic ketoacidosis

may influence the course of disease progression of rheumatoid arthritis (Arava, Cuprimine, Cytoxan, Rheumatrex, Ridaura, Hyroxychloroquine, Sulfasalazine, Methotrexate)

disease-modifying antirheumatic drugs (DMARDs)

Joints between the middle and distal phalanges of the fingers and of the toes

distal interphalangeal

what does xerostomia refer to? Hint- often an extra-articular symptom of RA

dry mouth

· Primary manifestation of endometriosis-

dysmenorrhea (painful periods or menstrual cramps) · Dyspareunia (painful intercourse)

difficulty swallowing, often see as an extra-articular symptom of RA

dysphagia

bulging eyes

exophthalmos

Symptoms of severe warm antibody hemolytic anemia

fever, chest pain, syncope, cardiomyopathy (enlarged heart), or heart failure

Small, deep, linear crack or tear in skin

fissure

In IBD, ). If if a patient is receiving sulfasalazine, what supplement is required?

folic acid supplementation is required (800 mcg/day)).

The isoflavones, ______________ and ____________ in soybeans inhibit the activity of TPO and can lower thyroid hormone synthesis.

genistein and daidzein o Furthermore, excessive intake of soybeans may interrupt the enterohepatic cycle of thyroid hormone metabolism. However, high intakes of soy isoflavones do not appear to increase the risk of hypothyroidism when iodine consumption is adequate

inflammation of the tongue

glossitis

oral manifestations of pernicious anemia

glossitis (in patches) -burning of mouth -taste alterations -tongue inflammation -atrophied papillae -beefy red tongue Hunter's Moeller's glossitis

o The hydrolysis of bioactive compounds called ________________ found in cruciferous vegetables may yield goitrin, a compound known to interfere with thyroid hormone synthesis.

glucosinolates o The hydrolysis of indole glucosinolates results in the release of thiocyanate ions, which can compete with iodine for uptake by the thyroid gland. o increased exposure to thiocyanate ions from cruciferous vegetable consumption, however, does not increase the risk of hypothyroidism unless accompanied by iodine deficiency. o However, steaming, cooking, or fermenting may reduce the levels of goitrogens in goitrogenic foods

When excess glucose spills in the urine, this is called ________, as the level of glucose in the filtrate exceeds the capacity of the renal tubular transport limits to reabsorb it

glucosuria

presence of glucose in the urine

glucosuria

Which amino acid stimulates proliferation of "replacement" enterocytes and colonocytes and may accelerate lesion healing in IBD.?

glutamine Supplemental L-glutamine also increases intracellular glutathione concentrations in enterocytes and colonocytes. Beneficial effects of L- glutamine require supplementation with at least 35 g/day orally in adults.

o Selenium participates in the antioxidant network. It is a cofactor for ____________, an enzyme whose main biologic role is to protect the organism from oxidative damage.

glutathione peroxidase

destruction of red blood cells

hemolysis

characterized by an inadequate number of circulating red blood cells due to the premature destruction of red blood cells by the spleen

hemolytic anemia

What disease is associated with red blood cells being destroyed faster than they can be replaced?

hemolytic anemia o Due to too much hemolysis in the body o Leads to low erythrocyte count and low total hemoglobin

The biosynthetic processes resulting in the creation of thyroid hormones within the thyroid gland are controlled by feedback mechanisms within the _______________ axis.

hypothalamicpituitary-thyroid axis(HPT)

Benefits of selenium include :

improve the production of T3 and lower autoantibodies to thyroid hormones while improving energy production improved deiodination of T4 , which may improve ATP formation by supporting improved mitochondrial activity.

Measure of the rate of which an ingested food causes the level on insulin in the blood to rise. Recently considered the gold standard for glycemic rating according to Bryan Walsh

insulin index

o Achlorhydria interferes with the early digestion of protein in the stomach and with the absorption of _______;

iron thus an iron deficiency anemia may be present as well

TPO is a glycosylated heme enzyme that is __________ dependent

iron o Treatment of anemic women with impaired thyroid function with iron improves thyroid-hormone concentrations, while T4 (hormone replacement medication) and iron together are more effective in improving iron status

Thick scar resulting from excessive growth of fibrous tissue

keloid

The most common cause of vitamin B12 deficiency is _______________ which may result from an autoimmune reaction, particularly in older individuals;

malabsorption from chronic gastritis, which is common in alcoholics and causes atrophy of the gastric mucosa; or from inflammatory conditions such as regional ileitis The condition may also be an outcome of such surgical procedures as gastrectomy (removal or resection of part of the stomach), in which the parietal cells are removed, or resection of the ileum, which is the site of absorption.

Pernicious anemia is the common form of _______anemia that is caused by the malabsorption of vitamin B12 owing to a lack of intrinsic factor (IF) produced in the glands of the gastric mucosa

megaloblastic

any disease of the kidney

nephropathy

What 3 herbs can interact with thyroid medications?

o Bladder wrack- o Bugleweed- o Celery seed-

Non-menstrual abdominal pain more than 2-3 days per month associated with endometriosis

o Constipation o Meteorism (rapid accumulation of gas in the intestine) more than one day per week o defecatory urgency o incomplete defecation o urinatory urgency in 1/5 of urination events o dysuria (pain or difficulty) during or at the end of urination more than 1/5 of the time

What are the 4 markers of immune destruction of beta cells?

o Islet cells autoantibodies o Autoantibodies to insulin o Autoantibodies to glutamic acid decarboxylase (GAD65-protein on surface of beta cells) o Autoantibodies to the tyrosine phosphatases (IA-2 & IA-2beta)

Risk factors of endometriosis

o Lower body mass index and lower body fat o Gut dysbiosis o Decreased vitamin A and retinoic acid metabolites o Estrogen dominance

Peak incidence of hemolytic anemia

o Peak incidence 50-70yr olds

Two types of hemolytic anemia

o Warm antibody hemolytic anemia o Cold antibody hemolytic anemia

Symptoms of Cold antibody hemolytic anemia

o fatigue, dizziness, headaches, cold hands and feet, pale skin, dark urine, jaundice, chest pain, pain in back or legs, vomiting or diarrhea, heart problems (arrythmia, heart murmur, enlarged heart, heart failure)

Small, firm, elevated lesion

papule

numbness and tingling, first sign of electrolyte imbalance

parathesia

Which fiber component increases fiber fermentation capacity appear to ameliorate the severity of symptoms and reduce the frequency of symptomatic episodes, and stimulates recovery of damaged villi in IBD?

pectin

Similarly, oral supplementation with prebiotic/probiotic combinations containing Bifidobacteria, Lactobacilli, fructooligosaccharides and _______________ and that increase fiber fermentation capacity appear to ameliorate the severity of symptoms and to reduce the frequency of symptomatic episodes.

pectin Pectin also stimulates recovery of damaged villi. Supplemental digestive enzymes may decrease the fermentable sugar supply to the colon and reduce the production of acetyl CoA-suppressing SH2.

A deposit of fatty material on the inner lining of an arterial wall

plaque

excessive thirst

polydispia

excessive hunger

polyphagia

excessive urination that results from glucose in the urine exerting osmotic pressure in the filtrate, resulting in a large volume of urine to be excreted with the loss of fluid and electrolytes (eg, sodium and potassium) from the body tissues.

polyuria

Patients with RA have increased nutrient requirements such as _______________ and ________________

protein, antioxidant vitamins

elevation of skin containing pus

pustule

degenerative disease of the retina

retinopathy

A progressive skin disorder with possible systemic effects, characterized by collagen deposits and inflammation;

scleroderma

chronic progressive disease of the skin and internal organs with hardening and shrinking of connective tissue Digestive connection- autoimmune, thickening and loss of elasticity of skin, joints, digestive tract (esophagus), lungs, thyroid, scarring in heart and kidneys

scleroderma

Associated disorders with Raynaud's Phenomenon

scleroderma, lupus, but can include RA, Inflammatory Myositis, and Sjogren's Syndrome

What nutrients improve T4 to T3 conversion?

selenium and zinc

Symptoms of this form of the disorder involve pain and stiffness in the back or neck, and movement is often impaired. Joints in the arms, legs, hands, and feet may also be involved.

spondylitis, which is inflammation in the joints between the vertebrae in the spine. (sometimes seen in psoriatic arthritis )

tension; prolonged, continuous muscle contraction

tetany

toxic condition characterized by hyperthermia, tachycardia, nervous symptoms, and rapid metabolism; also known as thyroid storm.

thyrotoxic crisis

Cavity with loss of tissue from the epidermis and dermis, often weeping or bleeding

ulcer

An autoimmune condition of the colon only

ulcerative colitis

In severe acute episodes of which IBD condition does a serious complication, toxic megacolon, may develop, as inflammation impairs peristalsis, leading to obstruction and dilation of the colon, usually the transverse colon

ulcerative colitis

In which IBD condition are there other manifestations of immune abnormalities elsewhere in the body, including iritis, ankylosing spondylitis, arthritis, and nephrolithiasis?.

ulcerative colitis

________________ is a mucosal inflammatory disorder that involves only the colon

ulcerative colitis

Age range when psoriatic arthritis develops

usually occurs between the ages of 30 and 50. However, both conditions may occur at any age

What are some nutrient impacts of SS?

vitamin D vitamin B6 , vitamin B12 , folate, and iron, fat soluble vitamins

· Generally considered an autoimmune disorder where immune system attacks melanocytes (pigment cells) · Disease that causes loss of skin color in blotches. Extent and rate of color loss is unpredictable · Can affect skin on any part of body, and may also affect hair & inside of mouth

vitiligo · About 15-20% of cases are also affect by at least one other autoimmune disorder, particularly autoimmune thyroid disease, RA, T1DM, Psoriasis, Pernicious Anemia, Addison Disease, or Systemic Lupus Erythematosus

localized loss of skin pigmentation characterized by milk-white patches

vitiligo · Loss of pigment in skin, hair (scalp, eyebrow, eyelash, beard), eyes, mouth (inside), genitals

dry eyes

xerophthalmia

Proposed mechanisms of endometriosis

§ Migration of endometrial tissue up through fallopian tube during menstruation § Development from embryonic tissue at other sites § Spread of endometrium through blood or lymph § Transplantation of tissue during surgery such as cesarean section

MNT for Meniere's Disease

· Adhering to a reduced-sodium diet

What are the nutrient interactions for iodine?

· Amiodarone contains high dose of iodine and can affect thyroid function. · Medications for hyperthyroidism can increase risk of hypothyroidism. · Potassium iodide can decrease anticoagulant effects of warfarin. · Lithium (bipolar disorder) can inhibit the release of thyroid hormones by the thyroid gland. When used in combination of high dose potassium iodide, hypothyroidism can occur.

Associated diseases of Grave's disease

· Celiac Disease and/or Gluten Sensitivity Other autoimmune diseases

Diagnostic test for cold hemolytic anemia

· Cold - several types of tests - CBC detects agglutination o Evidence of hemolytic anemia o Examination for enlarged spleen or liver o Coombs test - antiglobulin test for specific antibodies § Almost always positive for IgM

Pharmacologic Treatment(s) for Hemolytic anemia

· Corticosteroids - prednisone · Plasmapheresis (removal of antibodies from the blood) · Intravenous immunoglobulin (IVIG) - strengthens the immune system · Splenectomy · Immunosuppressive drugs - Rituximab · Blood transfusions

Associated disorders of hemolytic anemia

· Disorders leading to hemolytic anemia o Inherited blood disorders - sickle cell disease, thalassemia o Autoimmune disorders o Bone marrow failure o Infections · Glucose-6-phosphate dehydrogenase deficiency

MNT for vitiligo

· Functional foods and healthy diet (focus on antioxidants), with nutrients, from a variety of sources, could be considered an integral part of treatment

Pharmacological treatment for Meniere's Disease

· Gentamicin is >80% effective with vertigo · Other drugs include diazepam (valium), lorazepam (Ativan), promethazine (phenegan), dimenhydrinate (Dramamine Original Formula), and meclizine hydrochloride (Antivert, Dramamine Less Drowsy Formula)

MNT diet therapy for pernicious anemia

· High-protein diet (1.5 g/kg of body weight) is desired for liver function and for blood regeneration · Increased amounts of green leafy veggies (contain iron & folic acid) · Meats (esp. beef and pork), eggs, milk, and milk products are particularly rich in B12 (rule out egg & diary allergies or intolerances) ·

Clinical findings of Grave's disease

· Increased blood levels of thyroid hormone: Thyroxine (T4) and Triidothryroxine (T3) · Reduced TSH · Smooth, diffuse, nontender goiter in neck · Racing pulse (esp. after exercise), loud heart sounds · Mild protrusion of eyes · Vitiligo (areas with loss of pigmentation), as well as increased pigmentation of areas such as skin creases and knuckles can been seen · Thin hair or alopecia · Separate of nail from nail bed

MNT for endometriosis

· Increased consumption of vitamin A rich foods Herbs/Supplements · Melatonin - 10 mg/day (efficacy in phase II clinical trial) · Vitamin A and retinoic acid metabolites · Sodium butyrate to improve gut dysbiosis and permeability

Nutrient impacts of Grave's disease

· Iodine · Se · Zn · Vit D · Vit E Vit C

MNT for hemolytic anemia

· Lifestyle - Reduce risk of RBC breakdown and risk of infections o Avoid the cold, wear warm clothes, keep house warm · Avoid Fava beans with G6PD deficiency Herbs/Supplements · Vitamin E-responsive hemolytic anemia o Vitamin E - antioxidant - involved in protecting the membrane from oxidative damage o Vitamin E Deficiency - early hemolysis of RBCs o IRON SUPPLEMENATION SHOULD NOT BE GIVEN · Folic acid supplements (mechanical hemolytic anemia)

Pharmacologic Treatment(s) for endometriosis

· NSAIDs - ibuprofen · Hormonal suppression of estrogen or increase in progesterone o Hormonal contraceptives o Progestins · GnRH antagonists (temporary menopause-like state) · CYP19A1/aromatase inhibitors · Surgical removal of ectopic endometrial tissue

Name some of the herbs and supplements that can support T1D.

· Niacinamide (shown to prevent some of the immune-mediated destruction of pancreatic beta-cells and may help reverse some of the damage · Epicatechin (specifically green tea extract for polyphenols that exhibit significant antiviral activity against rotaviruses and enteroviruses, both suspected of being involved in development of T1DM · Vitamin D(dose according to blood levels) · Vitamin C · Vitamin E (mixed tocopherols) · Fish oils (EPA + DHA) · High potency multi-vitamin and mineral formula

Symptoms of Grave's disease

· Non-painful goiter (most common), weakness, sweating, insomnia, weight loss, nervousness, frequent/loose stools, heat intolerance, irritability, racing heartbeat/palpitations, warm/thin/moist skin, stare, tremor, diffuse enlargement of thyroid, exophthalmos (bulging eyes) · The excessive thyroid hormones may cause a serious metabolic imbalance called thyrotoxicosis

Supplements for pernicious anemia

· Oral Vit B12 (methylcobalamin, active form of B12 in sublingual tables is preferable to cyanocobalamin): ----2,000 mcg/d for at least one month, followed by 1.000 mcg/d (Pizzorno "Encyclopedia of Natural Medicine for dosing) · Folic acid: 800-1200 mcg/3x/day · Individuals prescribed Metformin for diabetes, 10-30% have reduced Vit B12 absorption (it negatively affects the calcium-dependent membrane and the B12-IF complex by decreasing the absorbability by the illeal cell surface receptors.

What inhibits iron absorption?

· Polyphenols · Oxalates · Phytates · Phosvitin · Calcium · Zinc · Manganese Vitamin E Manganese

Drug/Herb/Supplement Interactions for hemolytic anemia

· Prednisone Interactions/Depletions o Major interactions: grapefruit, St. John's wort o Moderate interactions: activated charcoal, ashwagandha, berberine, CBD, cannabis, echinacea, lactobacillus, licorice, melatonin, milk thistle, probiotics, Schisandra, turmeric, valerian, vitamin D & E o Moderate depletions: calcium, chromium, magnesium, Vitamin D o Insignificant depletion: zinc · Rituximab interactions/depletions o Major interactions: grapefruit, St. John's wort o Minor interactions: activated charcoal, ashwagandha, CBD, cannabis, echinacea, German chamomile, lactobacillus, licorice, melatonin, probiotics, Schisandra, selenium, sodium, sodium bicarbonate, turmeric, valerian, Vitamin E o Possible depletion: vitamin E.

MNT suggestions from Krause for Grave's disease

· Protein: 0.8 g/kg/day · Iodine (once autoimmune disease has been ruled out): 150 mcg/day · Selenium (as L-selenomethionine):75-200 mcg/day · Zinc (as zinc citrate): 10 mg/day · Vitamin D (as D3 or cholecalciferol): 1000 IU/day · Vitamin E (as D-alpha tocopherol succinate):100 IU/day · Vitamin C (as ascorbic acid): 100-500 mg/day · Guggulsterones (from guggul extract):100 mg/day · Ashwaganda:100 mg/day · Reduce or eliminate o Gluten (found in wheat, rye, oats, and barley) o Processed soy o Excessive uncooked goitrogenic foods o Stress

Pathophysiology of hemolytic anemia

· RBCs are destroyed faster than they can be replaced Could be due to; -· Immune system makes antibodies that attack your RBCs · Anemia of chronic disease - inflammation, infection, autoimmune disorders, chronic kidney and liver disease, malignancy o

Symptoms of Meniere's Disease

· Recurring episodes of vertigo, hearing loss, ringing in ear (tinnitus), feeling of fullness in ear, episodes are often associated with nausea & vomiting

Diagnostic tests for hemolytic anemia

· Reticulocyte count-increased · Blood smear for shape of RBCs · Normal or increased ferritin levels o Serum iron and TIBC = low · Positive Coombs test - looks for Abs against RBCs · G6PD deficiency test · Hemoglobin in urine · Increased LDH · RBC count, hemoglobin, hematocrit · Serum bilirubin - broken down hemoglobin · Haptoglobin test - combines with hemoglobin from broken down RBCs - low level indicates hemolytic anemia · Hemoglobin electrophoresis - shows different kinds of hemoglobin present · Test for paroxysmal nocturnal hemoglobinuria (PNH) · Osmotic fragility · Donath-Landsteiner test · Bone marrow test

Nutrient impacts of Hashimoto's

· Selenium · Iodine · Iron · Magnesium · Vitamin D · Zinc

What enhances iron absorption?

· Sugars- fructose and sorbitol · Acids- ascorbic, citric, lactic, tartaric · Meat, poultry, fish · Mucin

Diagnostic tests for pernicious anemia

· The erythrocytes appear macrocytic or megaloblastic and nucleated on microscopic examination and are reduced in number in the peripheral blood. · Hypersegmented granulocytes (multiple lobes of nucleus), and decreased number (Youtube video) · The bone marrow is hyperactive, with increased numbers of megaloblasts. · The vitamin B12 level in the serum is below normal. In the Schilling test, an oral dose of radioactive vitamin B12 is used to measure absorption. o B12 stores are depleted after several years without intake o Holo-TCII (low is a sign of early B12 deficiency) o Becton-Dickinson SimulTRAC Radioassay measures serum B12 & serum folate simultaneously in a single test tube · Overall concentration of hemoglobin is low due to decreased erythrocytes (Youtube video) The presence of hypochlorhydria or achlorhydria confirms the presence of gastric atrophy. · Other labs that may help with diagnosis included, Measurements of Unsaturated B12 Binding Capacity, IF antibody (IFAB), the Schilling test (measures cobalamin by assessing increased urine radioactivity after an oral dose of radioactive cobalamin), tests to determine serum homocysteine & methionine levels o IFG & Schilling urinary excretion tests can determine whether the deficiency is caused by lack of IF

Pathophysiology of endometriosis

· The presence of endometrial tissue outside the uterus on structures such as the ovaries, ligaments, or colon o Fibrous tissue may cause adhesions and obstruction in involved structures - urinary bladder and colon § Degenerates, sheds, and bleeds - no exit point for the blood leads to local inflammation and pain § Pain recurs with each cycle - leads to formation of fibrous tissue

Pharmacologic Treatment(s): for Vitiligo

· Topical corticosteroids, antioxidants, tacrolimus & pimecrolimus, prostaglandin E, and Vit D derivatives

Risk factor for Meniere's disease

· Unknown but symptoms appear to be the result of abnormal build-up of fluid in inner ear. Factors that affect the fluid, which might contribute to Meniere's, included: Improper fluid drainage due to anatomic abnormality, abnormal immune response, viral infection, genetic predisposition

What nutrients or foods interact with iron?

· Vit A= vit A deficiency exacerbates iron deficiency, however iron and Vit A together can improve anemia · Vit E= iron interferes with absorption of vit E, take separately · Manganese= can inhibit iron absorption and inverse is true, co-supplement · Copper= required for normal metabolism of iron and RBC formation, copper deficiency can also lead to anemia · Zinc= high dose of iron can inhibit absorption of zinc · Calcium= Decreases absorption of heme and non-heme iron, supplement separately

Name the top vitamin and mineral supplements for IBD therapy and treatment

· Vitamin A, Vitamin B12, Vitamin D, Vitamin K, Vitamin E, Vitamin C ·Folate, Calcium, Chromium, Iron, Magnesium, Selenium, Zinc

Preventative measures for hemolytic anemia for Glucose-6-phosphate dehydrogenase deficiency

· avoid triggering substances o Fava beans, naphthalene (found in moth balls), and certain medicines

Pathophysiology of Grave's disease

· the common denominator is the presence of antibodies against receptors in thyroid-stimulating hormone (TSH). · TSH-R Ab (thyroid receptor antibodies) or TSI (thyroid stimulating immunoglobulins) are present in about 80% of cases

Symptoms of hemolytic anemia

· unusual weakness and fatigue, tachycardia, breathing difficulties, headache, jaundice, unhealthy pale appearance (pallor), dark urine and/or splenomegaly

What are some of the diagnostic tests for SS?

▪ Blood/Urine Tests o SS-A (Ro) and SS-B (La) antibodies o Antinuclear Antibody (ANA) o Rheumatoid Factor o Erythrocyte Sedimentation Rate (ESR) o C-Reactive Protein (CRP) o Immunoglobulins o Serum Protein Electrophoresis and Serum Immunofixation o Complement Proteins o Urinalysis ▪ Schirmer's Test - determine if the tear glands are producing enough tears to keep the eyes adequately moist. ▪ Ocular Surface Staining ▪ Salivary Gland Function (Parotid Scintigraphy) ▪ Labial Gland (Lip) Biopsy - salivary glands just under the inner surface of the lip ▪ Sialometry ▪ Ultrasound of the Major Salivary Glands

Nutrient impacts of SS

▪ Cermak et al. "reported women with Primary SS had a significantly higher intake of energy, glutamate, carbohydrates, lactose, phosphorus, caffeine, thiamine, and riboflavin when compared to the control." ▪ Tovar et.al "indicated patients with PSS were deficient in B6 due to limited intake not to abnormal uptake mechanisms." ▪ Erten et al. "found that pSS patients were deficient in vitamin D." ▪ Fat soluble vitamins (esp vitamin A) (from Digestive Connection) ▪ Malnutrition or weight loss are not common in SS patients, although deficiencies of several nutrients are common. These include vitamin D (Garcia-Carrasco et al, 2017), vitamin B6 , vitamin B12 , folate, and iron

Nutrient impacts of Bechet's

● Case control study in Iran found 57% and 17% of Behcet's patients had vitamin D deficiency and insufficiency respectively (112 Behcet's patients and 112 control patients enrolled).

drugs for Bechet's

● Corticosteroids o Prednisone → main treatment to suppress inflammation and immune function ● Colchicine o Mouth sores, genital sores and possibly pain. ● Immunosuppressants o Methotrexate o Azathioprine o Cyclophosphamide o Cyclosporine ● Biologics o Anti-TNF (Tumor Necrosis Factor) o Infliximab o Etanercept o Tocilizumab (more severe cases) ● Apremilast o Mouth ulcers ● Eye drops, mouthwashes, skin ointments (depends on the severity, these can be used before the above medications).

herbs or supplements for Bechet's

● Zinc Sulfate