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