NUT 116a final
integrative and functional medicine
*Coordination of conventional (Western) AND complementary approaches to health *Emphasizes holistic, patient-focused approach *Treats the WHOLE PERSON (mental, emotional, functional, spiritual)
manipulative and body-based methods
*Focuses on the structures and systems of the body, including the bones and joints, soft tissues, and circulatory and lymphatic systems *Based on manipulation and/or movement of one or more part of the body *For pain management, relief
functional medicine
*assesses the underlying causes of disease using a systems-oriented approach and engaging both patient and practitioner in a therapeutic partnership *Focuses on patient-centered care, beyond just the absence of disease; considers personal factors including genetics; integrates Western and complementary medicine
reductionist, deficiency,
A ____ approach is used for DS (vitamin & mineral) research: ⚫ Vitamins and minerals are isolated and synthesized ⚫ Studied one by one Recommended levels of essential nutrients are set to prevent _______ Tolerable upper intake levels established (UL)
Cytochrome P450, CYP3A4
A lot of metabolism (1st pass metabolism) of drugs happens in the ______ (before reaching the liver) through _________ enzymes —about 60% of medications are metabolized by a subtype of this type of enzyme called ___________ (abbreviation)
asterisk
A/n _____ under the "% DV" heading indicates that a DV has not been established yet for that nutrient
REE, REE
ART allows for regain of fat free body mass, in part b/c it decreases ______ (abbrev.)- increased expenditure due to cytokines, protein turnover, etc. However, ______ is elevated in all groups of HIV infected women compared to controls, regardless of ART and viral load
viral load, CD4, older
After initiation of HAART: *plasma ________ decreases, *____ counts increase and *life expectancy is increased. The benefit is greatest in _____ subjects, presumably because younger subjects are in better general health with "healthier" immune systems to begin with.
drug
Any chemical used for prevention, treatment of symptoms, or cure of diseases
integrative and functional medical nutrition therapy, personalized
At the center of the IFMNT (________) radial is ____ nutrition care (ADIME)
SIV
Both strains of HIV evolved from ________; jumped from chimps to humans via human consumption and mutation of the virus
unreported, insurance
CAM challenges include: *Not many well designed clinical trials *No standardized credentialing *Lack of training for physicians/pharmacists on CAM treatments *Most CAM use is ______ *Mostly not covered by _____
native american/alaska native
CAM use is highest among which racial/ethnic group? *Native american/alaska native *White *Asian *Black *Hispanic
CD4, 200
CDC diagnosis of HIV is based on _____ counts; less than _____= HIV+
B, 200, 499
Category ____ HIV= some HIV symptoms; CD4 counts between _____ and ____ (category 2)
A, 500
Category _____ HIV= no symptoms (= category 1 CD4 counts; >____)
C, 200, AIDS
Category _____ HIV= opportunistic infections/symptoms present; CD4 counts <_____ (category 3); definition of ______
cytokine, protein, malabsorption
Causes of nutritional/metabolic effects of HIV: 1) Elevated immune response= constant inflammatory condition= dysregulation of ______ mediators 2) _____ turnover rates elevated (from breakdown by cytokines) 3) _____ leading to malnutrition (and decreased lean body mass)- virus can infect intestinal cells & **** them up 4) Increased risk for other chronic diseases
Grapefruit
Compounds in _____ inhibit CYP34A, decreasing body's ability to carry out phase I metabolism—changing the effectivness of many drugs, esp. statins
c, chronic
Condition for which CAM is most frequently used: a) Neck pain b) Joint pain c) Back pain d) Anxiety CAM is mostly used to treat (acute/chronic) conditions
opportunistic infections, cytokines
Control of ______________ in HIV+ individuals has eliminated most rapid weight loss, and the advent of protease inhibitor drugs has diminished wasting (loss of > 10% of body weight). *However, weight loss of a lesser degree is still common and is associated with elevated plasma proinflammatory ______.
non-vitamin, non-mineral
Critical issues for ______/______ DS research: ⚫ Source Identification ⚫ Composition, stability, contaminants, adulterants ⚫ Interactions (ex. St. John's Wort) − Between product components − With pharmaceuticals − With dietary components ⚫ Dose response ⚫ Masking/blinding not always done ⚫ Mechanisms of action
risk, post
DS/Food *Products assumed to be safe *In absence of benefit, any _____ is unacceptable (pre/post)-market approval
weight, malnutrition, CD4
Decreased _____ is associated w/ increased risk of death in HIV+ individuals. Wt loss & micronutrient ______ impairs immune function & increases rate of drop of ______ cells.
albumin
Decreased plasma _____ (malnutrition, liver disease), results in less bound & more free drug...therefore increases the pharmacological action of those drugs that bind to it
dietary supplements, higher, improvement
Demographics of people who take the most _____ ______: • Older Adults • Females • Non-Hispanic White • Higher Education level • Tend to have (lower/higher) nutrient intakes from food sources Motivation: "health _____" (not just making up for deficiencies) Often used in conjunction w/ prescription meds
food, safe, manufacturers, FDA
Dietary Supplements are regulated as ____ (not drugs) ...assumed _____ unless proved otherwise *_______ are responsible for ensuring safety and compliance with regulations (no gov/t pre-market approval, formulation standards, etc.) *______ provides guidance and good manufacturing practices
membrane transport
Drug absorption & distribution is affected by membrane permeability. *_______ _____ proteins in intestinal epithelial cells act as "gatekeepers" to regulate uptake & efflux of nutrients/drugs
diuretics, reabsorption
Drug effects in nutrient EXCRETION: *______ increase urinary output & may also ↑ excretion of some nutrients *Drugs that decrease nutrient _______ in renal tubule (ex. immunosuppressant cyclosporin & Mg)
luminal, bile acid, calcium, b12, calcium, chemotherapy
Drug effects on nutrient ABSORPTION include: *Influence transport time of food and nutrients in the gut (ie. laxatives) *Affecting ____ _____ activity influences absorption of fat, fat-soluble vitamins, etc. (cholestyramine) *Antacids decrease absorption of _____ and _____ *Corticosteroids decrease absorption of _______ *_____ drugs disrupt enterocyte replication
folic acid, complex, b6, seizure
Drug effects on nutrient METABOLISM: *Compete with vitamins or vitamin metabolites for specific enzymes (ex. methotrexate competes w/ _________) *Drugs may form a _______ with a nutrient making it unavailable for use by the body (ex. isoniazid interacts with _____) *Anti ______ drugs may increase metabolism of vitamin D, leading to low serum concentrations
Xenobiotic
Drugs are a type of _______ metabolized by the body (substance that is foreign to a biological system) Potential for drug/nutrient interaction
less
Drugs that are bound to plasma proteins tend to be (more/less) active than free/unbound drugs
adrenergic, serotoninergic
Drugs that cause a REDUCTION in appetite (anorectic agents): *_____ agents (stimulate excretion of norepinephrine) ex. amphetamines *_____ agents (inhibit re-uptake of serotonin or norepinephrine)
increasing
Drugs that influence nutrient INGESTION by ______ appetite can be 1) Unintentional (corticosteroids) 2) Intended (drugs used to treat AIDS-related wasting syndrome or cancer-related cachexia
dysgeusia, hypogeusia
Drugs that influence nutrient INGESTION: Drugs can alter or diminish TASTE perception or saliva production: *_____ (alterations in taste perception; Ex. unpleasant aftertaste); *_______ (reduced acuity of taste perception)
protein, fat, pH
Effects of food on drug EXCRETION *High- ______ diets promote increased renal excretion of barbiturates, theophylline and phenytoin * High fiber diets can increase the excretion of _____ -soluble compounds *Hydration status *Foods can change urinary ____ (acidic urine= increased clearence of alkaline drugs; alkaline urine= increased clearence of acidic drugs)
Mind-body interventions
Examples of _______ include: Meditation Relaxation techniques Tai chi, yoga Healing touch Art, music, dance therapy Hypnosis
biofield therapy, energy therapy
Examples of _________ (which are a type of ____ _____): Qi gong - gentle exercise with both external/internal movements Reiki - therapist channels energy via touch Therapeutic touch
manipulative and body-based methods
Examples of _________ include: Acupuncture Chiropractic Massage Reflexology
electromagnetic field therapy, energy therapy
Examples of __________ (which are a type of _____ ____): Pulsed electromagnetic fields Magnet Therapy
dietary supplement, dietary, mouth
FDA definition of a __________: A product (other than tobacco) that: − Is intended to supplement the diet − Contains one or more _____ ingredients: ⚫ Macronutrients ⚫ Vitamins, Minerals, Amino Acids ⚫ Herbs or other botanicals ⚫ "Other" dietary substances − Is intended to be taken by _____
Pharmacokinetics, cytochrome P450
Factors that can affect drug ______: *Age & body weight *Pregnancy status (pregnancy increases blood volume) *Smoking and drinking habits- alcohol increases # of _____ enzymes- which are responsible for metabolizing/deactivating drugs- so drug doses that would normally be sufficient may not be in alcoholics *GI physiology *Liver or kidney disease *Pharmacogenetics *Drug-drug and drug-nutrient interactions
Mind-body interventions
Focuses on the interactions among the mind, body, and behavior Uses the mind to affect physical functioning and promote healing
Retrovirus
HIV is a _______, an RNA virus that reproduces by transcribing its RNA into DNA and then inserting the DNA into a cellular chromosome
african
HIV is most prevalent in ____ countries. Majority of new infections among minority groups, women, and youth with poor access to healthcare
error, evolution
HIV replication is _____- prone, so point mutations are frequent, allowing rapid _____ under selective pressure. Such pressure may come from cross-species "jumps", the host immune response, or anti-retroviral drugs.
CVD
HIV+ individuals have about 2x risk of developing _____ (abbrev.)
Lipodystrophy, buffalo hump, mitochondrial, adipocyte
HIV- associated _______ syndrome: abnormal distribution of fat in the body, in HIV infection, often accompanied by loss of fat stores in areas of body *increased visceral adiposity most common *peripheral fat loss (limbs, face) *___________ (fat accumulation behind the neck) Caused by HIV itself (increase in gene expression of pro-inflammatory genes) and toxicity of ART drugs (_______ toxicity and altered _____ functionality)
1, 2, 2, 6
HIV/AIDS Medical Nutrition Therapy Recommendations: 1) RD should provide at least ____ to ___ MNT encounters/yr for people with HIV (asymptomatic) and at least ___ to ___ MNT encounters/yr for people with HIV (symptomatic) or AIDS Increased effectiveness of treatment w/ increased freq. of visits
candida, nutrient, metabolic, oxidative
How does HIV cause weight loss? *Decreased food intake (esp. during opportunistic infections- anorexia/decreased appetite) - Fungal infection of oral cavity (_______) causes pain in the mouth *Impaired ______ absorption (usually a problem w/ enteric infection) *_______ alterations (REE increases, increased protein turnover, acute phase proteins & ____ stress)
homeopathic medicine, alternative whole medical system
Illness is a normal response of the body as it attempts to heal itself; treatment philosophy of "like heals like"; meds contain small amounts of active substances that promote the body to heal itself A type of ____ ____ ____ ____
absorption, distribution, metabolism, excretion
In pharmacokinetics, ADME stands for ________.
obesity
Increasing prevalence of ______ in ART treated HIV+ adults (highest in non-white females); may contribute to health problems of future
reverse transcriptase inhibitors,
Key Recommendations for HAART/ART: Give three drugs: 1. Two _____________ 2. One other drug from another class: 1. NNRTI 2. Protease inhibitor 3. Integrase inhibitor 4. CCR5 antagonist
ART, HAART
Major concerns about _____/_____ (3 or more antiretroviral meds): 1) Cost 2) Drug resistance 3) Complicated drug schedule & meal timing 4) Side effects
visceral, dyslipidemia, insulin
Metabolic consequences of HIV-associated lipodystrophy syndrome (increased CVD and atherosclerosis risk) 1) _____ adiposity 2) _____ (increased chol. & TG, decreased HDL) 3) Decreased _____ sensitivity 4) HTN
HIV, vertical
Modes of ______ transmission: Sexual Contact (heterosexual or homosexual) Sharing Needles Contaminated Blood Products Mother to Infant (______ transmission)
U, subtle
NUTRIENTS: have ___-shaped dose-response curves, do not function in isolation, act on multiple tissues & organ systems, are typically consumed in various forms in mixed meals, and effects are usually ______ compared to drugs
appetite, exercise, growth
Non-nutrient therapies for HIV-associated wasting: 1) ____ stimulants 2) ______ 3) _____ hormone
mixture
Non-vitamin/non-mineral supplements are hard to study because *Can't use reductionist approach *Whole plant or parts of plants used, rather than individual components; active components usually consist of a _____ of different chemical compounds found in the plant
macronutrient
Nutritional management of HIV: 1_)_____ therapy (depends on current wt, CVD risk, etc.)- Protein v important to buffer catabolism 2) Exercise 3) Symptom management (N/V/D, anorexia, etc.) 4) Food & water safety and sanitation 5) Micronutrients (AT RDA- NOT ABOVE)
first pass metabolism
Phenomenon in which the liver (and/or intestine) metabolizes some of a drug before it can circulate through the body, particularly when the drug has been taken orally.
mitochondrial toxicity, adipocyte, mitochondrial, polymerase
Potential cellular mechanisms of longer term consequences of ART (ex. osteoperosis, CVD, DM, hepatotoxicity): 1) ________ (from reverse transcriptase inhibitors)- inhibition of _______ DNA _____ 2) altered ______ functionality
toxic, pre
Prescription drugs: Products assumed to have ___ potential Benefit > risk under conditions of use (post/pre)-market approval
CD4, CCR5, reverse transcription, budding
Process of HIV infection: 1) Free virus binds to host cell receptors (____ and ____) & empties contents into host cell 2) Single strands of viral RNA are converted to DNA via _____ _____ 3) Viral DNA is combined w/ the cells' own DNA 4) When infected cell divides, viral DNA is transcribed and translated into viral proteins 5) Immature virus "pushes" out of the host cell via a process called ______
naturopathic medicine, alternative whole medical system
Promotion of disease prevention and healing through natural holistic means including diet, herbal therapies, other whole body and mind/body practices. A type of ____ ____ ____ ____
HIV-2
Related to viruses that infect monkeys and sooty mangabeys Not often encountered outside of West Africa
Dietary Supplement Health and Education Act, foods, safety, dietary supplements
The DSHEA (___________) of 1994: *Defined a category of ____ called dietary supplements *Established a framework of _____ standards (describing standards for adulteration) *Outlined good manufacturing practices for the industry *Established the office of _____ ____ within the NIH
food safety modernization act, proactive, recall
The _____ of 2010: *Tried to help the FDA be ____ rather than reactive *Requires registration of manufacturers w/ the FDA *Allows FDA to est. PREVENTION-BASED controls *Requires verification of ingredient suppliers *Gives FDA mandatory _____ authority
FTC
The _____ oversees: Advertising of dietary supplements Print and broadcast ads, infomercials, catalogs, and direct marketing materials
FDA
The _____ oversees: Labeling of dietary supplements Packaging, inserts, and promotional materials
USP
The ______ evaluates dietary supplement production for quality, purity, potency, performance and consistency.
dietary supplement and non-prescription drug consumer protection act, domestic, serious adverse event
The ________ of 2006: *Dietary supplement labels must contain a _____ address or phone number *Manufacturer must maintain these records To prevent a _____ ____ ___: death, life threatening experience, inpatient hospitalization, persistent or significant disability or incapacity, birth defect, and/or medical or surgical intervention to prevent an outcome described above
50 to 59
The age range that uses CAM the most is 18 to 29 30 to 39 40 to 49 50 to 59 60 to 69
women
The burden of HIV infection is increasing among ______ (particularly in sub-Saharan Africa)- increased risk of vertical transmission to infants
Cytochrome P450
The general name for a large class of enzymes that play a significant role in drug metabolism and drug interactions.
d
The majority of CAM spending is on a) Yoga and Tai Chi b) Massage therapy c) Chiropractics d) Multivitamin, non-mineral, natural products
natural products
The most common type of CAM therapy in the US Herbs, botanicals, vitamins, minerals Often marketed as dietary supplements
RDA
The only people who really need dietary supplements are people whose intake of a nutrient are CONSISTENTLY lower than the ______ for that nutrient
Pharmacokinetics
The process by which drugs are absorbed, distributed within the body, metabolized, and excreted (ADME) Interaction between drug products & nutrients/foods
Pharmacodynamics
The study of what the drug does to the body
vitamin D, CD4
The subjects who were ______ deficient had the lowest recovery level of ____-Tcells...Sufficient had the best recovery of the cells. The recovery was worsened by younger age and lower BMI
active, able
The unbound (or Free) drug is biologically (inactive/active) and (able/not able) to interact with receptors
Polypharmacy, malnutrition
The use of multiple medications on a regular basis (usually >4). Often in older people. Key points: *May contribute to risk of ______ *The impact of loss of taste/smell often leads to weight loss & malnutrition *Drug-nutrient interactions can lead to nutrient deficiencies *Malnutrition may increase risk of fraility and other geriatric symptoms
CD4, opportunistic
There is a strong INVERSE relationship between VIRAL LOAD and ________ count. As HIV progresses, increased # of _____ infections due to weakened immune system
ATP binding cassette, solute carrier proteins, peptide transport proteins
Transporters for Drugs, Nutrients & Endogenous Substrates *______ _____ ______ transporter family (ABC transporters) *______ ____ _____ (SLC) transporters *Organic anion transporting polypeptide (OATP) family of drug transporters *_____ _____ ______ (PEPT) transporters These transporters carry drugs AND nutrients- COMPETITION is a potential issue
grapefruit juice
Types of drugs affected by _________: *Statins (used to lower chol.) *Ca channel blocker drugs (to lower BP) *Immunosuppressant drugs
pH, malnutrition, food
Ways that FOOD can affect DRUG METABOLISM: 1) ____- certain drugs require acidic or basic environments for metabolism, and digestion involves gastric acid secretion- why some drugs to be take w/ food and some w/o 2) ______ can damage integrity of GI enterocytes and ↓ absorption 3) Gastric emptying/GI motility (ie. vomitting & diarrhea; high-fat meals slow gastric emptying) 4) Presence of ____ (can increase or decrease drug metabolism)
T2DM
Yoga has been shown to be an effective treatment tool for _____ (abbrev.)
integrative and functional
_____ MNT: *PERSON-CENTERED interventions *Each client functions in an environment with internal and external factors that influence interactions between the mind, body, and spirit *Utilizes a systems assessment that includes biochemical biomarkers, genomic assessments and environmental toxicology; and includes therapeutic approaches including conventional and complementary therapies
drugs, targeted, precise
_____ classically have a sigmoid dose-response curve, have a drug-receptor interaction model, have a specific defined chemical structure and metabolic effects, may act at single site or multiple tissues More ______ and _____ than nutrients
Dyslipidemia, statins, insulin, niacin
_____ interventions: 1) Diet & lifestyle 2) Switching ART drug cocktail 3) ____ (block chol. synthesis) 4) Drug treatment of _____ resistance 5) _____ (decrease TGs) 6) Fibrates (antihyperlipidemics)
St. John's Wort
_____: herbal supplement used to treat depression; INCREASES C-P450/CYP3; decreases effectiveness of HIV meds by ~50%
Coumadin
_____= a blood thinner; vitamin K is recycled in the body; this drug interrupts that cycle; vitamin K-rich foods interfere w/ the actions of this drug
integrative medicine
______ _______: reaffirms the importance of the relationship between practitioner and patient, focuses on the whole person, is informed by evidence, and makes use of all appropriate therapeutic approaches, healthcare professionals and disciplines to achieve optimal health and healing
highly active antiretroviral therapy (HAART), opportunistic, hormonal
______ a strategy for treating HIV-infected people with a combination of antiretroviral drugs; reduces viral burden & destruction of immune cells; *Prevention and treatment of _____ infections *Modulation of altered ____ balance *Maintenance and restoration of nutritional status
Phase 1
______ reactions: NON-SYNTHETIC Oxidation/reduction of a drug into a more polar form by Cyt.P450 enzymes (esp. CYP3A4) in the liver AND small intestine
Phase 2, more
______ reactions: SYNTHETIC; polar group is added to a drug; more polar= (more/less) readily excreted in urine
Biotransformation
______ reactions: one or more biochemical reactions involving a parent drug; occurs mainly in the liver and produces a metabolite that is either less active OR more active
alternative (whole) medical systems
_______ (a type of CAM): specific theories of health and balance that have developed outside the influence of conventional medicine ie) Traditional Chinese Medicine & Ayurvedic medicine
Fusion inhibitors
_______ (a type of antiretroviral drug)- prevent viruses from successfully fusing with the host cell
megavitamin therapy, orthomolecular
_______ aka _______ medicine: massive doses of vitamins ex) high doses of vitamin C to treat colds
optimal health
_______ as defined by integrative & functional MNT: something other than the absence of disease, conceived as an integrated function of biology, environment, and behavior; and measured as a product of physical, mental, social, and spiritual variables
MAOIs
_______ inhibit the breakdown of tyramine in the liver. Increased levels of tyramine can lead to high blood pressure, HYPERTENSIVE CRISIS, and eventually cerebrovascular accident and death. Therefore people taking this type of drug must restrict their intake of tyramine so that their blood pressure does not rise to dangerous levels.
deficiency
_______ of nutrients (proteins, tocopherol, retinol, essential fatty acids, Zn, Cu, Se, K) can decrease the efficiency of drug metabolizing systems, decreasing the biotransformation of drugs
Primary HIV infection
________ is characterized by: *flu-like symptoms *reduction in CD4 cell counts *increased viral load
Traditional Chinese Medicine, alternative whole medical system
_________: Wide range of methods; seeks balance of body forces; use of herbal supplements, acupuncture, qi gong tai chi and other mind/body approaches A type of _____ ____ ____ ____
Ayurvedic medicine, alternative whole medical system
__________: Traditional medicine from India; strives for balance of 3 body humors or "doshas" through lifestyle actions (yoga, meditation, diet, herbal supplements) A type of ____ ____ ____ ____
complementary and alternative medicine (CAM)
a group of diverse medical and healthcare systems, practices, and products that are not generally considered to be a part of conventional (Western) medicine
botanicals
a plant or plant part valued for its medicinal or therapeutic properties, flavor, and/or scent
Joint Commission
an independent, not-for-profit organization that evaluates and accredits healthcare organizations; requires drug-nutrient interactions to be addressed
NSF
certification by the _______ means that product testing and evaluation for contaminants has been completed and the dietary supplement means their standards.
structure/function claims, does not
claims on the label that describe how a nutrient or dietary compound affects: *the structure or function of the human body *a benefit related to a nutrient deficiency disease ex) Calcium builds strong bones ex) Vitamin C prevents scurvy (Does/does not) require specific authorization
health claims, risk, FDA
describe a relationship between a food or dietary compound and a disease or health-related condition *can only claim ____ reduction; *requires authorization with the _____
reverse transcriptase inhibitors
drug that treats AIDS by blocking reverse transcriptase, an enzyme needed to make copies of HIV
CYP3A4
enzyme that metabolizes ~60% of drugs
alternative medicine
health care practices and products used in place of conventional medicine
parenteral nutrition
nourishment provided via IV therapy
Nutraceuticals
product isolated or purified from foods and generally sold in medicinal forms not usually associated with food (ie. fish oil)
energy therapies
propose to manipulate people's invisible energy fields. Types: Biofield therapy Electromagnetic field therapy
herbs
subset of botanicals, generally refers to the above ground parts
HIV-1
the most prevalent and pathogenic type of HIV virus; found WORLDWIDE
complementary medicine
therapy used along with conventional medicine