DIP Ep 650: The Clutch Nutrition Podcast (For Step 1-3)

starting in June of this year, uh they're gonna start testing uh, you know, nutrition in a more enhanced fashion, if you may. So I just kinda wanna talk th talk through many of the key concepts so that you're kinda ready for your for your exams. Um so I'm gonna call this the USMLEs and uh and nutrition, right? And again, remember nutrition is not just about biochemistry, right? That's probably like the big bent that they used back in the day, right?

But the US MLEs they are basically moving toward testing, you know, whether, you know, future physicians can connect nutrition science to like patient care. you know, like preventing disease and things like that, you're you're gonna see I'm not gonna do any political anything, right? I'm gonna hit on the things that are that are high Right. Um and again I think it's kind of important to keep some key things in mind, just statistic Diet is the

one of the leading causes of death, right? Diath is linked to cardiovascular disease, which we know is the most common cause of death.

Right, diet is linked to cancer, right? Because the thing is, all these things are related, like your diet to high blood pressure, to obesity, to diabetes, to prediabetes, and all those things, right? So um it's just key to keep these things in mind. Now I'll say the USMLEs with regards to nutrition, what are some key things they love to emphasize for each of the concepts? Number one, what's the mechanism? Right? Number two

How do you manage this problem? Right. Number three, um, what should you look for? Like what are the key things you should look for that should make you realize that this patient has this problem, right? So I think the first thing I want to talk about here as a foundation for all of this. the difference between macro and micronutrients, right? Again you may think some of these things

filler, but you'd you'd be surprised by how they how they go after these, right? So remember macronutrients are like the big foods, right? Like your carbs, your proteins, your fiber, your fat, right? And then micronutrients are more of your vitamins and minerals, right?

And remember, there is all these different diets that the USMLEs love to emphasize, right? So like for example, uh diets that have been shown to really help with cardiovascular disease are things like the Mediterranean diet, things like the Dash diet, right?

Uh dash stands for dietary approaches to stop hypertension, right? Remember the dash diet is actually very effective for lowering a person's blood pressure. Although let me ask you this what is the most in effective intervention for lowering blood pressure? Uh hope you're you know lifestyle intervention. I hope you're saying uh weight loss, right? So remember weight loss is number one, it's more effective than the dash die.

Right. But the DASH diet helps not just with high blood pressure, it also helps with um cardiovascular disease, right? But the Mediterranean diet has also been shown to lower blood pressure and also lower percentage risk for cardiovascular disease, right? And then don't forget that

Uh, if you want to reduce a person's risk of having like colorectal problems and also lowering their cholesterol, a fiber, a high fiber diet is very, very helpful for those kinds of people, right? Or if they give you a question about a person that has heart failure. Right, then a low sodium diet is gonna be very, very helpful for those kinds of people because if you pursue a low sodium diet, that's going to reduce your volume overload and that's gonna be very very

Right. So the thing is it's very important on your exams to recognize that hey for this particular kind of patient, this particular kind of diet will be helpful in ameliorating their their problems. Right. And then another uh classic set of things they also love to test are the different kinds of you know, food processing, right? So remember like there's fruits that are unprocessed

There's foods that are minimally processed. There's foods that are ultra-processed, right? Ultra-processed foods obviously are gonna be the worst of the bunch, right? And why are ultra-processed foods so bad? Well, the thing is, many times a lot of the key nutrients that are in the original food have been stripped. And then number two, another reason why ultra processed foods are also bad is because Um

Uh many times you use all these industrial ingredients that are like not natural, so the body cannot process them very well, right? And some of those things are linked to delirious health health uh consequences, right? So just something you want to keep at the back of your mind uh for for your exam.

Right. And then also you want to make sure you know about the vitamins and the key high-you points about the vitamins. Right. So remember like vitamin A, for example. Uh we know that vitamin A is necessary for the maintenance of specialized epithelium, right? Like epithelium you find like in the eye, for example, right?

The thing is if a person has a vitamin A deficiency, don't be surprised the person is gonna have like they may present it as a person having an accident at night, right? Um accident at night, you know, or they cannot read things very well, you know, at night, right? Because it can cause line but night blindness. It can cause their zero xerophthalmia, right? X-E-R-O-P-H-T-H-A-L-M-I-A. Right?

Uh you know, make sure you can identify betwe spots on phonoscopic exam on on on your exams, right? And then you know, vitamin B one. I'm just gonna go in uh Alphabetically, vitamin B one remember Wernicke, Korsakov, Berry Berry, right? And you may wonder like why does vitamin B one deficiency cause all these problems? Well, the thing is, uh vitamin B one is is thiamine, right? And again, if you remember from step one,

Uh thiamine is used for many things, right? Like we use it for the pyruvia hydrogenase complex. And we use it for the uh TCA cycle, right? The the grep cycle, right? So uh especially in the form of thiamine pyrophosphate, right? Thymine pyrophosphate, right? So

The thing is if you have issues with uh uh thiamine, right, then these reactions are not gonna work, right? Your uh pyrovidi hydrogenase complex, your TCA cycle, and those are energy energy generating pathways, right? So if those energy generating pathways do not work Then

Tissues that use high amounts of energy are gonna struggle. Well, what are some examples of these tissues? Things like your heart, things like the brain, right? If you notice when people have berry berry, when people have antecedents of thymine deficiency like berry berry or Renic. If you notice, many times their symptoms are centered around the heart and neurologic tissue because those two kinds of tissues use high amounts of energy, right?

So, like for example, people can that have wet berry berries called wet because again, they don't have good energy production with their cardiac myocytes, right? So their heart doesn't have very good pump function. So they can start having heart failure, right? And when you have heart failure, you're gonna have a demo. So hence the term wet berry berry. Right? Renicarsocops, right? Parts of the brain that use high amounts of energy, like the thalamus, the hypothalamus, the mammulary body.

Those things can have infarctions, right? Because again, there's not enough energy, right? So keep that in mind with vitamin B1 and then vitamin B3. Again, you're like, Oh, the vine, there's vitamin B2. Uh, the thing is, for the USML is on nutrition, vitamin B2 probably doesn't really. much right but for vitamin B3 certainly matters right remember Pelagra Pelagra Pelagra right your three D is dramatitis diarrhea and dementia right and then the fourth D I guess is death.

And don't forget your causes of Pelagra, right? Uh basically that's a niacin deficiency, right? So remember there are many causes, right? So like for example, if you have like uh uh new uh uh an amino acid reabsorption defect in the proximal tube.

right where you cannot reabsorb tryptophan, then that's gonna be a problem, right? Because tryptophan is used to make niacin, right? Or if you have something like cars noid syndrome where you're using a lot of your tryptophan to make serotonin, then you're not gonna have enough left to make niacin. That can cause problems. Right. Um so just kinda keep that at the back of your mind on on exams, right? Um so Pelagra, right? Keep that in mind with vitamin B three deficiency.

Vitamin B6 deficiency is one you definitely want to know about, right? Don't forget about neuropathy, right? With that, don't forget about seizures. Don't forget about stereoblastic anemia, right? Don't forget about the link to isonias.

Right. Remember the neuropathy happens because again, you need vitamin B six to make neurotransmitters, right? So if you want to go from glutamate to GABA, uh you need vitamin B six, right? Glutamate decarboxylase is the thing that makes that conversion. You need vitamin B six as a co-host. The thing is vitamin B C is used as a cofactor for glutamine decarboxylase, right? So if you don't have enough vitamin B say

you'll have uh more glutamine and less GABA, right? And remember glutamine is an excitatory neurotransmitter, so that's gonna cause you to have seizures, right? And then in terms of the cereblastic anemia with B6 deficiency, don't forget. The first step of heme synthesis, right? Where you take uh glycine and suxinal coA and make delta amino levolinic acid, that reaction requires aminolevolinic acid synthase, right? Remember, ALA synthase is the rate limiting enzyme of heme synthesis.

That enzyme uses vitamin B six as a cofactor, right? So if you don't have enough vitamin B6, then heme synthesis is going to be impaired and you're going to have sideroblastic anemia, right? And then um so again don't forget the association with with isoniacid. Isoniacid basically prevents the activation of vitamin B6 because vitamin B6 for it to work it actually does need to get activated right uh it gets activated by a phosphokinase enzyme that phosphokinase enzyme depends on vitamin B.

Functioning right, so if you don't have enough vitamin B6, that phosphokinase is not going to work, right? So you're not going to activate uh B6. Um so it's almost like a functional vitamin B six uh deficiency, right? And then remember for your exams, don't forget vitamin B9 and fully deficiency, right? So like megaloblastic anemia, neurotube defects, don't forget that, right? Again remember the

Megaloblastic anemia arises because in the S phase of of of of uh of uh DNA synthesis, right? Like the synthesis phase of the cell cycle, the S phase. Uh, you need folate, right? Folate is absolutely necessary to make DNA, right? So when you have a folate deficiency.

you're gonna have impaired DNE production and that's gonna get you in trouble, right? And then also don't forget your your neurotube defects. You need a lot of folate for the proper development of the neurologic system, right? And then don't forget vitamin C, right? When you have a vitamin C deficiency, you're gonna have issues with Uh collag collagen, right? Remember C in vitamin C and C in collagen, right? Collagen needs vitamin C.

for proper c for its proper synthesis, right? So you're gonna have things like scurvy, you're gonna have things like poor wound healing, you're gonna have things like bleeding gums, right? Keep that at the back of your mind for your exams, right? And then vitamin D, right, think about it in terms of rickets, right? Rickett, rickets, rickets, because you need vitamin D.

To help you uh mineralize osteoid, right, uh in your bones. So you're gonna think bone bone bone problems, right? And remember, vitamin D helps you reabsorb calcium. maintain a good solubility product, right? So you're gonna have things like rickets, osteomyelasia, hypocalcemia, and things like that, right? Vitamin D deficiency is a very prominent cause of secondary hyper parathyroidism on your exams because you have hypocalcemia, right? So

Because if you don't reabsorp enough calcium from your gut, you'll have hypocalcemia so you won't you'll have uh negative you you won't have negative feedback so your pth is gonna is gonna rise right and then remember vitamin e deficiency right can cause hemolytic anemia right you're like divine why would vitamin e deficiency cause hemolytic anemia that doesn't make any sense

Well let me explain. The thing is uh vitamin E is necessary for the proper functioning of uh cell membranes, right? Proper function of cell membranes, right? So uh you know If you have a vitamin E deficiency, you'll have improper red blood cell membranes, right? So those red blood cells are going to be less resistant to hemolysis. You're going to have a lot of hemolysis, right? In fact, remember that vitamin E deficiency on the USMLE exams is associated with acanthocytosis.

Uh, acanthocytosis, right? And also, vitamin E is also necessary for the proper functioning of myelin, right? Myelin needs vitamin E.

Right. So if you have a vitamin E deficiency, your myelin is gonna be crop. And if your myelin is crop, you're gonna have neurologic dysfunction, right? There are certain pathways that really depend on myelin, like your spinal cerebellar tract, right? So when you have a vitamin E deficiency, you may have ataxia because your spinal cerebellar tract doesn't work as well.

Uh again, I know some of you may be like, man, the vine is just spitballing, but I promise you many of these things I'm going over here. They're very, very high yield to know for your exam. Um the thing is nutrition, the US MLEs are gonna have a field with this. Why? Because it reflects multi-systems processes and and disorders, right? That's probably one of the hardest sections of the US MLEs to to prepare for. Right.

And then vitamin K deficiency, right? So um don't forget the bleeding, right? And why would you bleed with vitamin K deficiency? Again, they can ask you about the mechanisms behind these things. It can be a nutrition question, but it's a mechanism question, right? Remember you need vitamin K for vitamin K epoxy reductase to work. Well what does vitamin key poxide reductes do? It leads to the gamma carboxylation and activation of factors two, seven, nine and ten.

and protein CNS, right? So if you have a vitamin K deficiency, those things are not gonna work, or your clotting factors are basically not going to work, right? So your coagulation cascade is not gonna work, right? So you're gonna bleed, right? You're gonna have an elevated PT, elevated PTT and INR and things.

So don't forget, right? And how can you get these deficiencies? Remember, vitamins A, D, E, and K, those are your fat-soluble vitamins. You can get those deficiencies if you have malabsorption for any reason, right? So, say for example, you have things like celiac disease. Right. Or you have like a Crohn's disease that is really messing up your small intestine.

Right. Or you see a person that has like uh they've had gastric bypass, right? Gastric bypass has a very solid association with people developing or having malabsorption, especially if they're not wise and they don't take supplements like their physicians recommend that they do. Right. And then remember

Um, so keep those in mind for vitamins A, D, E, and K. And also, if you have pancreatic problems, right, you can also have fat-soluble vitamin deficiencies, right? Because remember, uh, lipase does come from your from your pancreas, right? So if lipase comes from your pancreas and you have like A pancreas issue because you like you have cystic fibrosis.

or whatever, right? Then you won't release lipase, right? Lipes is needed for the emulsification of fat. Lipase plays a role in you being able to reabsorb fat and fat soluble vitamins, right? So that can cause problems, right? So like for example, people that have lipase problems are gonna be people, for example, that have cystic fibrosis.

or people that have chronic pancreatitis, for example, on your on your exams, right? And then remember the thiamine deficiency is gonna be in an alcoholic or a gastric bypass patient. or a person that is malnourished or a person that has an eating disorder, right? Like a person that has anorexia or a person that has bulimia, for example. Right? I've kind of talked about the causes of vitamin B3 deficiency. Right? B6 again think of isonized, isonized, isonized.

Right. And then don't forget B twelve with vegans, right? B twelve with vegans. Um a vegan, you know, person that eats a lot of plant products, well, good luck, right? Or if you have like pernicious anemia where you have autoimmune destruction of your parietal cells or intrinsic father.

That can also cause problems, right? Or if you have a terminal ileum problem like Crohn's disease, for example, remember Crohn's disease always affects the terminal alien, right? So uh that can cause a B12 deficiency, right? So just keep that at the back of your mind for for exams. And also one kind of weird thing that you may see on your test. I don't know why many resources don't talk about this, but this is metformin. Metformin can cause B12 deficiency. Metformin specifically inhibits.

the reabsorption of the B twelve intrinsic factor complex in your terminal ileum, right? Petformine has a strong association with a vitamin B twelve deficiency. That's something you should certainly keep at the back of your mind for your exams, right? And then fully deficiency, again, you can think you can think of that if you have like a poor diet or you're an alcoholic, right? So there's an enzyme that helps you reabsorb uh

uh foliate in the in the gi tract, right? In the in the jejunum of the GI tract, right? So if you have uh If if if if you're an alcoholic, alcohol inhibits that enzyme, right? So you're not gonna be able to reabsorb fully, you're gonna get in trouble fully deficient. And also people can also have fully deficiency because uh

uh they've had gastric bypass, right? Or you can also get fully deficiency because you're just using up your foliate so fast, right? The thing is it takes time to develop a B12 deficiency. It doesn't take very long to develop a fully deficiency because the thing is B12, we have years of B12 in our bodies, right?

But folate, we have like weeks of folate in our bodies, right? So if you lack folate, you you're gonna get in uh in in big trouble, right? Uh so what what are some situations that can make you use up folate? Well, for example, if a person has hemolytic anemia, let's say you have like sickle cell disease.

Or you have heritage serocytosis. Those people they are always making new red blood cells, right? So because these people are always making new red blood cells, they use up their full ear very fast, right? So if the average person maybe has like 10 weeks worth of fully these people may have like two weeks worth of fully because they just use it so so fast right so again it's pretty high yield to know this for your for your exams right uh it's pretty high yield to know this for your exam

Uh pretty high yield to know this for your exams, right? And then in terms of your so those are the vitamins, right? Again, this is probably gonna be something that's gonna be a multi part series, but we'll see. Let me just

stuffing as much as I can with this podcast. Right. So let's talk about minerals. Right. So remember iron deficiency. Uh don't forget that with uh uh you know you can cause microcytic anemia, right? Because again, um if you don't make enough

iron, then your your red blood cells will try to maintain a constant MCHC. I've explained this in in pre previous podcasts, right? So your your red blood cells they have like a goal of maintaining a constant uh mean carpuscular hemoglobin concentration, right? So Um if you don't have enough heme, right? Which is a problem you will run into if you don't have enough iron. then your red blood cells have to get smaller.

To give you a constant MCHC, a constant mean corpuscular hemoglobin concentration, right? So that's the mechanism behind the microcytosis, right? So iron deficiency anemia is going to cause microcytosis. Right, you're gonna see things like pika, right? A person eating ice chips, eating sand, and things like that. Koilonikia, right? Issues with the with the nails. Uh make sure you can identify. Koilonikia on your exams.

I L O N Y C H I A, right? And then don't forget like zinc deficiency. Zinc deficiency is gonna cause poor wound healing. Uh what's the other thing we've talked about that causes poor poor wound healing? Vitamin C, right? Remember vitamin C, right? So vitamin C, zinc, keep those in in mind.

Right. Uh dysgusia, right? So like in impaired taste, uh taste alopecia, think of that with zinc deficiency, iodine deficiency. Remember, you can see iodine deficiency, you know, just from again a poor diet, right? You can also see an iron iodine deficiency from a person taking a drug like amount. For example, right? So it can cause hypothyroidism, it can cause goiter, right? And then again, if you have a calcium vitamin D deficiency, right? Calcium is a mineral, vitamin D is a vitamin.

Right. Uh it can cause bone problems, right? And then remember magnesium deficiency, very, very common in alcoholics, right? Alcohol specifically inhibits the reabsorption of magnesium in your GI tract, right? Uh in your GI tract, right? So that can certainly cause problems, right? So remember hypomagnesemia.

That can cause arrhythmias, like uh it can prolong your QT, it can lead to uh VTAC, VFAP, uh torsat the point, right? You can have seizures from hypomagnesemia, and it can also cause hypocalcemia and hypokemia.

Right. Because remember the transporters in your body that help you hold on to uh calcium and potassium they depend on magnesium for proper functioning, right? So if you have hypomagnesemia, those things are not necessarily gonna work very, very well. Right. So again, again the US MLEs they just like to Uh again I uh because I know some people just see oh the US Ms are gonna test nutrition.

And then they just kind of narrow out their minds to oh nutrition. Okay, they're just gonna no like they're gonna integrate it with biochem, they're gonna integrate it with heme, they're gonna integrate it with neuro, they're gonna integrate it with uh pregnancy, with pediatrics, with GI with pharmacology. That's how they're gonna integrate it, right? So again, like just be be smart about be be smart about this, right? Be smart about this, right? So

So on your exams, one thing you want to kind of keep in mind, I guess, is this whole concept of a uh nutrition vital sign, right? Nutrition vital sign. You know, kind of like we take vital signs when you come into the hospital, right? You know, we check your blood pressure, we check your heart rate, we check your respiratory rate. Oxygen saturation or whatever. Well, the thing is there are certain people you should obtain nutrition vital science.

on, right? So who are these classic people? You you may be surprised that you'll get a question on your exams and the right answer will just be to obtain a nutrition vital sign, right? So who are these people? Well, these are going to be people that have like weight loss, right? People that have chronic disease.

Right, people that have food insecurity, right? You know, they're like people that live in poverty. Right, trust me, I understand what that means. I certainly lived in poverty. Uh Just my my grown up years l lived in quite a bit of poverty there. Um, you know, growing up in Nigeria was a was a tough life, right? But people that have GI disease, right? People that have like, for example, Crohn's disease or people that have had uh gastric bypass.

Right. Um keep keep those people in mind. People on GLP want agonists, right? Especially if they're not smart about their diets, they can also develop uh nutritional uh deficiencies, right? People that have alcohol use disorder. You see all the things I've talked about that's linked to alcohol, right? Like B1 deficiency.

Right. Thymamine deficiency, uh, magnesium deficiency and things like that, right? People that have had again bariatric surgery, people that have cancer, right? People that are pregnant, right? The thing is these different populations, they all have like specific nutritional needs, people that have renal disease, people that are frail.

Right. Always always keep this at the back of your at the back of your mind, right? So w what are the components of a nutritional uh vital sign? Well, w you you should typically ask them like, Hey, what's your diet like? Right? What do you usually eat in a typical day, right? Have you had any recent weight loss or weight gain, right? Uh, do you run out of food? Are you worried about where the next meal is gonna come from? Right? Do you have any nausea, vomiting, diarrhea? You know.

Uh do you have like restrictive eating patterns, right? You should always ask these things. Are there any supplements you take? Any special diets you take? Are you on weight loss medications, right? That's like GLP one agonies, for example, right? Or do you have any cultural or religious food practices, right? These are all things. Uh these are all things you ask about when you're assessing a person's nutritional vital signs, right? And the thing is our friends at the MBMEs.

Sometimes they like to give you a question on the exam where they match it to a physical exam finding, right? So they will either give you a question about a deficiency and they want you to pick up the physical exam finding that's associated with it.

or give you a bunch of physical exam findings. I want you to pick up the nutritional deficiency that's associated with that. Right. So for example, right, keep in mind like what are some We've kind of talked about some of these, but what are some physical exam findings you should keep in mind?

Think of temporal wasting, right? Temporal wasting should make you think of a person that probably has cancer or something along those lines, right? Muscle loss. Think of a person that's on a GLP1 agonist, right? Or a person that has like rapid weight loss, right? Uh remember when you're losing weight, it's not just fat you're losing, you're also losing muscle. That's why many times it's recommended that you take a lot of protein and you also do a lot of strength or resistance training, right?

Adema edema on physical exam can be a sign that a person is hypoalbuminemic, right? It can be a sign that a person has liver disease because remember you need albuminem. to maintain adequate amounts of onchodic pressure in the body. Right. So like if they have edema, right, that should get you down like that low abumine pathway, right? So you can tell you that maybe they have nephrotic syndrome.

or maybe they have like a protein restricted diet, maybe they have like Washoko, for example, right? Or they have a liver problem, right? So keep that in mind, right? Uh pro wound healing should make you think of vitamin C deficiency. It should make you think of a zinc deficiency. Right. And the thing is many of these vitamin deficiencies, especially the B vitamins, they can cause things like glossitis.

They can cause kilosis, so like cracking of the lips, right? Neuropathy, you see neuropathy, think of a b6 deficiency, think of a b12 deficiency, right? B6 deficiency and a b sorry, B1, B6 and B12 deficiency. B1, B6 and B12 deficiency, right? Um and also think of a vitamin E deficiency as well with neuropathy, right? Remember that spinocerebellar tract business that I

kinda talked about, right? You see a person that has like easy bruising, think of scurvy and vitamin C deficiency. You see skin changes again, think of scurvy and vitamin C deficiency, right? And also think of uh for skin changes also do not forget uh Come on, divine think. Uh think of uh Pelagra, right? Pel Pelagra, yeah. Vitamin B three, niacin, nicine deficiency.

Right. I remember also poor wound healing, don't forget zinc, right? So kind of keep these at the back of your mind. Alopecia, think of you see a person losing their hair, think of a zinc deficiency. Right. Think of a zinc deficiency. Think of a zinc deficiency. Yeah, that's the thing with this nutrition. There's just so many ways they

basically put you put puts you in trouble on your on your exams, right? And typically when you're worried about these people that have these nutritional problems. Uh what are some key labs you want to get? You want to get like a C B C

right to assess them for anemia, CMP, to assess them for electrode abnormalities, right? Go ahead and check their albumin, right? Go ahead and check their albumin, check their pre albumin, right? Check their iron studies, B12 levels, folate levels, vitamin D levels, magnesium, phosphate, calcium, zinc, right? Look at their A1C, look at their their lipids, right? So again just keep that at the back of your mind for

Right. And then let's talk about this whole thing about uh food insecurity, right? Uh this is probably one of the highest yield uh themes uh on the exams, right? So um, you know Food insecurity is basically like having limited access to enough food. And not just enough food, but like Nutritious food, right? Nutritious food, right? So food insecurity is where you have limited access to enough food. And then nutrition insecurity is where you have limited access to food that supports health.

So I wanna know the difference between these two things. Food insecurity is I don't have an access to enough food. Nutrition insecurity is I don't have access to nutritious food, food that's actually healthy, that makes me have good health, right? These are things you're gonna find in a in a food desert, for example, right? Where it's like, Ooh, they have all this fast food around, they have McDonald's, they have uh all these things around, right? Uh but then

They don't have like good grocery stores that sell like healthy foods and they just have convenience stores and fast food, right? Convenience stores and fast food. Right. So the thing is just be careful. The fact that you're consuming calories does not mean that it's uh nutritious uh calories, right?

The fact that you have calories does not mean you have uh nutritious calories, right? And the thing is sometimes on your exams, they'll give you these questions where you have to uh pick out statements as you answer, right? So like for example, if you wanna assess a person for food or nutritional insecurity, you can ask them like, Hey, uh, in the last twelve months

Uh were you worried, you know, that food would run out before you had money to buy more, right? Or in the last twelve months, uh did you buy food that did did you D you know, did did the food you buy not not last, right? Or you don't have money to get more. You know, just basically assessing like, hey, do you have enough money to buy buy? Right? Uh do you have enough money to buy food? Right. And the thing is on your exams, beyond this screening, it is very high yield to know.

That you should refer these people to programs that can help with their food insecurity. Right? So, what are some of these programs? Well, the SNAP program, the supplemental nutrition uh SNAP Supplemental Nutrition Assistance Program, right? So you should you should uh make sure you know about that. The wake program. Women, infants and children program. You should know about that, right? Food pantries, food banks, right? You should certainly know about those things.

Right. Even one kind of weird thing that they love to test on the exams is that when people are placed on a GLP one agonist, uh there's nothing wrong with pairing them up with a registered uh dietitian, right? With a registered dietitian.

Right. And then the thing is if you want people to make behavioral changes, right? Because again this is another big thing with with nutrition, right? Uh you want people to make behavioral changes The thing is our friends and at the MBMEs, they want you to use certain tools. So, like for example, motivational interviewing is a big one, right? And also they want you to use smart goals. I know some of you are like, Oh divine, this is like

Gibberish again, smart goals you do need to know, right? I know many of you know this already, right? Specific, measurable, achievable, relevant, time-bound. You you gotta know those things for your exams, right? So like for example, believe it or not, you may be like, Divine, how would he ever test a smart goal on the exam?

Well, they will give you a question where a person wants to make a lifestyle change in terms of just health healthier eating. And then our friends at the MBMs, what they'll do is they'll give you a series of answers. And an answer will reflect a smart And then uh y you'll see a bunch of answers that

you know, their very non specific recommendations like move more. Again, they're not gonna put move more, right? But eat a healthier meal or stop consuming soda and things like that. And then there will be an answer that reflects this smart uh you know, uh algorithm, right? So like for example, if you tell a patient, Hey, replace soda with water at launch five days this week, that's smart, right? It is specific, it is measurable.

It's achievable. It's relevant and it's time-bound, right? So just make sure that when you're giving patients advice on nutrition, right, make sure that it reflects this smart mantra. That's the classic way they go after a smart goal. On your exams, right? And then another thing I'm gonna talk about again, that's the thing annoying thing about this nutrition of a thing is it's kind of like a grab bag of just different.

Right. So just make sure you know about a metabolic syndrome, right? So remember metabolic syndrome, what are the key components of the metabolic syndrome, right? Uh central obesity, right? High blood pressure, uh high triglycerides, low H D L and elevated fasting glucose, right? Again, please don't be

LDL is not like, oh, high LDL is not part of the metabolic syndrome criteria. It's low HDL that is that is part of it, right? And the thing is on your exams, they'll want you to uh pick nutritional interventions for people that have the metabolic. Right. What should these people do? Well, they should reduce the consumption of beverages that contain a ton of sugar, right? They should eat more fiber, right? Make sure you emphasize that, hey, in your diet,

Make sure you're having vegetables, fruits, legumes, whole grains, nuts, things like that, right? And then always go for fats that are unsaturated, over like saturated or or trans fat, right? Limit ultra-processed foods, right? Reduce sodium, right?

Uh again, a low sodium diet is very helpful for people that have high blood pressure and people that have heart failure on your test, right? People that have what? High blood pressure, the two HS, right? High blood pressure, heart failure on your on your test, right? And again, if a person wants to lose weight, they should basically like be in a calorie. Right. And again remember on your exams they can test between the two kinds of fat. Remember uh there is the

Visceral fat, right, that's around your organs and then there's the one that's like subcutaneous and whatnot. The one that's the most dangerous is the visceral fat, right? So keep that at the back of your mind for your for your exams, right? Uh keep that at the back of your mind. Right. And then again I've kind of talked about this, but I think I should just highlight this just for you to look out.

populations on your test, right? The thing is for these nutrition questions, there are so many things you need to combine together to get these questions right on But we're not going to be able to at higher rates. for developing nutritional problems on your exams. People that are old, right? They may not have a good diet. People that have cancer.

Right, they may not want to eat. People that have chronic GI disorders like inflammatory bowel disease, biratric surgery patients, things like that, right? People that have alcohol use disorder. I've talked about the deficiencies they can develop. Eating disorders, right? Anorexia, bulimia. Right. Post stop patients, people that are post stop, right? ICU patients, right? Remember ICU patients, many of them can have to be on TPN or something like that.

Right. Uh people that have food insecurity, people that have dysphagia, people that have like an esophageal problem, people that have CKD, right? CKD can make you develop a vitamin D deficiency because remember one alpha hydroxylase, the enzyme that converts calciol to calciol, we find it in the KD. Right. So put a C K D, Puta have heart failure, put off cirrhosis, right? Remember cirrhosis uh is a sort of hypo hypoabom abominemia, right? So just keep this at the back of your mind for for your

Right. And then remember when people start uh if you get a question on your exams about a person that, you know. Has one of these problems, right? Or is in one of these patient populations, and then they get on a proper diet, especially maybe let's say they get admitted to the hospital. Usually, this is gonna be a hospital-based problem, right? They get admitted to the hospital.

And then you notice that uh this person starts having like arrhythmias, you know, you start feeding them, they start having arrhythmias and all these issues, right? And they become unconscious, unresponsive, and then they die. Um, if you see something like this. I really want you to think of uh

uh sorry about that. I really want you to think about refeeding syndrome, right? So remember, what's the most common cause of death in refeeding syndrome? It's gonna be low phosphate, right? Because again, when you start eating after a period of starvation/slash fasting or poor nutrition, Then insulin is going to get released in like huge gaps, right? And as you release tons of insulin, you're going to drive a lot of phosphate into your cells. That's going to cause hypophosphor.

Temia, right? Uh many people think hypophosphatemia is benign. No, it's not, it can actually kill you, right? So like literally the most common cause of death, very high yellow. The most common cause of death in in Rafidian syndrome is low, is low photos.

Right, and remember all their labs, right, that you can get if you have hypophosphatemia, right? It can you know cost you know low potassium, low magnesium, right? You can have thiamine deficiency, right? You can have all these fluid shifts, right? So just be careful, right? These people, you may want to supplement these electrolytes.

And you may want to do like gradual re-reintroduction of food instead of giving them like big time amounts of food, right? You know, like when a person is done fasting, you know, you've probably had this experience, right? um when you're like you've done like a long fast and you just wanna eat out the wazoo, right? Well don't eat out the wazoo because you're gonna have problems, right? You may notice that if you eat a big large meal after you

You notice that you kind of feel dizzy and all those things. Believe it or not, it's electrical abnormalities you have. You have like a very mild refeeding syndrome uh kind of going on there, right? So keep that at the back of your mind. Alright, now what's another high yellow thing that they love to test with nutrition on the US MLEs?

So it's gonna be a long one, right? So just buckle buckle up, right? Uh again on your exams, they they like you to know uh some drug nutrient interactions, right? You you definitely wanna know these things, right? So don't forget, like if you if you're on Warfarin, uh remember Warfarin can

Uh you you you want to make sure you're taking consistent amounts of of vitamin K, right? Make sure you're taking consistent amounts of vitamin K. Don't have your vitamin K levels be all all over the right when you're taking warfarin just be consistent so that after a while your body kind of finds a good level of in our and kind of keeps you there right remember isoniacid and b6 deficiency right so if a person is taking isoniac they should be taking paradoxal

Fate, right? Uh metformin, remember uh metformin can cause a bit of a deficiency, right? And then don't forget your proton pump inhibitors. PPIs, you know, people kind of give them out like candy in hospitals. Gee, what are these people doing? Uh, if you don't need a PPI, you shouldn't be on a PPI because it causes a bunch of problems, right? It can cause B12 deficiency, right? Uh, because remember, PPI is reduce the acidity of your stomach, and that pH of your stomach.

Is actually very necessary for you to separate B12 from the food that you consume, right? So the thing is for B12 to marry an intrinsic factor, it needs to be separated from the You need that hyperacidity of the stomach for that to happen. Well, PPI is kind of shut down that hyperacidity. So that can get you in in quite a bit of trouble, right? So PPIs can cause B12 deficiency, they can cause MARC deficiency because magnesium sometimes is reabsorbed in the stomach, right? And again, it's a

It's a pH sensitive process, right? So if you have an altered pH of your stomach happens when you take a PPI that that can impair magnesium absorption, right? It can even cause calcium problems, right? So again, PPI is B12, magnesium, and and calcium, right? And they remember lube diuretic. Right, your loops, your thazides, they can cause your your loops, let me focus on your lobes first, right? So lopes lose calcium, right? So lopes can cause you to have hypocalcemia, uh hypo

Kalemia, right? They can cause hypomagnesemia, right? Remember, loops they make your volume depleted, right? So that's gonna crank up the activity of your rhino and your tensin aldosterone system. And when you crank up the activity of that system, When you crank up the activity of that system, when you crank up the activity of that system, right, uh you're gonna start losing a lot of potassium in your in your urine, right? You're gonna have uh hypochalemia because remember our dosterone.

uh makes you excrete potassium, right? So just keep that at the back of your mind, right? And then remember thiazides can cause hypercalcemia, they can cause hypo hypokalemia, right? Remember thiazides on like loops that make you lose calcium, thiazides help you reabsorb a lot of calcium. So thazides may actually be good for people that have an osteo

If you have osoporosis and high blood pressure, right? And then don't forget uh your ACE inhibitors, your ARBs, your spironolactone, which is an outdoor receptor antagonist, they can cause a hyperkelemia, right? And then don't forget statins, right? Remember the grapefruit juice interaction, right? So grapefruits uh prevents the breakdown of your statins, right? So your statin levels can really rise and that can be a problem. Uh

Uh then don't forget your monoaminoxidase inhibitors, right? With a tyramine hypertensive crisis. Uh don't forget livothyroxine. Livothyroxine can be kelethed heavily by a lot of stuff, right? Uh don't eat don't don't take your your synthroid when you're taking uh calcium or iron, right? Uh just just be careful, right? Just be careful.

And then remember your tetracyclines and your fluoroquinolones, right? Uh again, don't take them with things that can kill them and reduce their bioavailability like calcium, iron and and magnesium, right? And again, don't forget alcoholism. I'm telling you like

strange for the US M List to write a nutrition exam and not include alcoholics, right? Alcoholism causes a bunch of problems, right? So uh don't forget your alcohol with thymine deficiency, fully deficiency and a B6 uh uh deficiency, right? And then

I think one of the things you should keep at the back of your mind, right, is the difference between food allergy and food intolerance, right? So food allergy versus a food food intolerance, right? So remember uh food allergy is immune mediated, right? Is immune mediated, right? So typically the person

What are some classic symptoms you're gonna see in those people on your exams? You're gonna see things like audicaria, they're gonna be itching a lot, they're gonna have angioedema, they're gonna have wheezing, vomiting, low blood pressure, and aphylaxis. Right, and obviously, right, if they have an aphylactic shock, right? Uh, you're gonna go ahead and treat them with. Muscular epinephrine, right? Not intravenous epinephrine, guys. Please be careful. Please, please, please.

Uh I've seen too many people make this mistake on the US MLEs. Don't don't join that those ranks. Don't join those ranks, right? Uh don't y please, please, please, right? You don't give intraphenosepinephrine for an aphylaxis. No, no, right? You know No. Right that that's where Rhythmia's guys are. Please, for your exams, for a person has an aphilaxis, give them intramuscular epinephrine, right? Things like a small point, but I've seen too many medical students uh get sacrificed by this on your

on the exams, right? And then so food allergy, that's what I've just described. How about food intolerance? Food intolerance is non-immune. It is not immune-mediated, right? Typically it's going to be caused by like some kind of enzyme deficiency.

Right. So like for example, if a person has a lactase deficiency, which is very common in African Americans and also very common in Asians, they can have a lactose intolerance, right? Typically when people are having food intolerance, they're gonna have like bloating, gas, diarrhea, abdominal pain after they eat a meal. That's very different from audicaria, angioedema, wheezing, and things like that. They're not gonna have an aphy an aphylaxis, right? So again.

Be be be careful about that. A person consumes milk, they have bloating afterwards. That's gonna be food intolerance. That's gonna be food intolerance, right? And again, remember, I talked about the pregnant population earlier. Remember, if you're if you're pregnant,

Right. If you're pregnant, encourage breastfeeding as much as is possible, right? Literally encourage breastfeeding as much as is possible. Right. You know, breastfeeding is very helpful. It has so many benefits for the child, right? It reduces the child's risk of asthma, allergies.

uh diabetes, cancer, right? Many amazing things that breastfeeding does does for people, right? And remember if a woman is pregnant, right? Uh if a woman is breastfeeding or she's uh pregnant, you know, she should take folic acid, especially when pregnant so you reduce the risk of neurotube defects, right?

Uh, when you're pregnant, you're gonna need more iron, right? You're gonna need more iron, you're gonna need more iron because your blood volume goes up. You need iron to make that extra blood. Uh you should avoid alcohol while you're pregnant, right? Because alcoholism can cause, you know, fetal alcohol syndrome and many there's no safe level of alcohol during pregnancy.

Right. Avoid fish, uh consuming like big amounts of fish, right? Especially fish that tends to be very high in mercury, right? And again, remember if a woman has like uh morning sickness, remember to give her vitamin B6 and doxylamine, right? Uh because again, that morning sickness can make people start developing nutritional deficiency. Right, uh nutritional deficiencies and then don't forget about gestational diabetes again. That's another thing they love to test in that arena.

Right. In that arena. Right. And then remember if a infant is being exclusively breastfed, that infant has to get a vitamin D supplementation because breast milk, I'm sorry, is not very rich in vitamin vitamin D. Right. It's not very rich in vitamin D. And again, remember, do not give honey to a child that is under age one because of the risk of botulism, right? Because again, remember as a uh um you know, newborns they they don't have any GI flora, right? So i if you consume uh

Uh, if you consume honey, right, uh you're gonna consume the spores. And then the spores, since you have no GI flora, there's literally like no competition for a newborn, right? So those spores are gonna germinate. You're gonna make toxin inside the GI tract of the fetus and then the child is gonna develop botulism and be a be a floppy baby, right? So you don't you don't want

Right, you don't wanna you you don't want that, right? So just kind of keep that at the back of your mind, right? And then one other rule I'm gonna talk about on your exams, if your gut works, use it. If your gut works, use it, right? So in general, if possible, always go with interior nutrition.

Especially if you have a functional GI tract, right? But you know, just for whatever reason you have inadequate oral intake. Go for interal nutrition, right? Uh go for interior nutrition. Go for interior nutrition. Go for interior nutri nutrition, right? Um go for inter nutrition, right? Um so like for example, although there are some risks with inter nutrition, right? Like you can aspirate

I can have diarrhea, the tube can be polyplaced and all those things, right? So generally after you place like a a feeding tube, make sure you do do like an abdominal radiograph just to confirm a proper proper placement, right? Uh but so when should you use TPN on your exam? So you should use TPN where for whatever reason the GI tract is not usable, right?

uh is not usable. Right. So like for example if a person has like m b like really severe bowel obstruction or short bowel syndrome, right? Or they have like terrible, terrible, terrible alias, or they have like a high output of fistula, right? Or you've tried enteral uh tube feeding and it's not working, then in that case you can consider T P N right? But remember T P N can

Yeah, we have a bunch of problems, right? So, like uh like a cathar associated infection. I mean you're literally putting food into a catheter. What what do you think is gonna happen? Like literally, what do you think is gonna happen there? Of course, the bugs are also gonna want that food, right? So uh you can have like a a central line associated bloodstream infection with that. You can have like thrombosis of the catheter, right? Um

You can develop like uh cholestasis in the liver, right? You can have like a a calculus cholesterolis from that. You can develop refeating syndrome, right? So just kind of keep that at the back of your mind for for example, right? So again, please, please, please, all these things I've kind of talked about, right? You know, these key themes.

Make sure you know them, right? Make sure you know them. I'm telling you these things, you're you're gonna see these things pop up on your exams. You're gonna see these things pop up on your exams, right? So again, the US Ministry are kind of moving away from

just like the facts with like these isolated deficiencies to more like just clinical application, right? So again you still need to know some of your step one classic knowledge, but honestly you need to start knowing all these other side things, right? So And that's the thing that sometimes people hate about these my podcasts that oh divine, you're kind of going in this direction, this direction, this direction, this direction.

The thing is that's the reality of your exams, right? Again, the fact that something is nice and clean does not make it nice and good, right? Nice and clean doesn't always mean nice and good, right? It's like, for example, if you go through drive-thru, it's easy, right? You go through drive-thru at a food place, it's easy, right? But most times that food is garbage.

Right. So that's the thing. Like the thing is for me, whenever I make podcasts, my goal is to try to make it as integrative as possible. Because that's the reality of the US ML exams. That's the truth.

Right. So I'm not gonna spoon feed facts to you. No, that's not my goal with this podcast. If you want someone to spawn feed facts to you, you should not be listening to this podcast. You should consult some other resource that is cleaner for you, right? But the fact that something is clean does not necessarily make it helpful for you.

Right? Because on the US MLE exams, the facts are not gonna be presented to you in a clean fashion, right? They're gonna go with multiple integrations, right? Pull many things together. Right. So the thing is you need to get comfortable with this uncomfortable method of thinking so that you're well prepared for your exams. All right. So I'm gonna go ahead and stop here. Um if you like the way I teach, you're gonna love my classes.

I'm I teach a bunch of classes over Zoom. I have a twenty hour step, two, step three class. I have a 50-hour step two step three class. I have a last-minute review that's for step two, step three. I have a biostats class, I have a social science ethics and quality improvement class.

uh I have a test taking class. So these last three classes biostats, social sciences and uh last uh test taking strategies class, that's for step one, two, step three. Right. And then I also offer children for like shelf exams, uh medical school exams, uh uh Comlex exam. I

Even uh board exams for like internal medicine and stuff, I do offer tutoring for those. So if you're interested, just shoot me an email. I can give you some more information. I make study plans for people and also help with things like ERAS applications, personal statements, recommendation letters and things of that.

nature. I've actually started working with people for the twenty twenty six uh twenty twenty seven cycle. I feel like uh the the before I used to worry about that kind of work like in uh like June, but now it's like people are beginning to work on the applications earlier because this process is just becoming more and more competitive uh every year. All right. And then I have these podcasts on Apple, Google and Spotify. Uh so if you're interested, just check that out. And then I also have um

Another website called Divine Intervention Life Lessons dot com. Divine Intervention Life Lessons.com. So many of you know I'm a Christ follower, so every week I post like one or two podcasts where from a biblical perspective I address a life lesson I have almost four hundred podcasts on there. There's actually an Apple podcast associated with that called the Divine Intervention Life Lessons Podcast.

And then remember I do have a YouTube channel, Divine Intervention, USML Podcasts and Videos, where I sometimes post videos and podcasts that I make. So thank you for listening to me today. I will see you, God willing, episode 651. Uh, but again, listen to this podcast. You're gonna see this material on your exam, whether you like it or whether you like it or not. All right, so have a wonderful day. God bless you, and bye for now. Thank you.