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

Welcome, my name is Divine. This is episode 650 of the Divine Intervention Podcast. And into this podcast we're going to focus on nutrition, right? Nutrition and the USMLE. As many of us know, the USMLE is, I mean, they've always tested nutrition. I don't know why this is such a big shocker to people. The thing is, basically, across step one, step two, see, again, step three, starting in June of this year, they're going to start testing nutrition in a more enhanced fashion, if you may. So I just kind of want to talk through many of the key concepts so that you're going to ready for your exams. So I'm going to call this the USML Es 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 USML Es, 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. So you're going to see, I'm not going to do any political anything, right? I'm going to hit on the things that are high yield, right? And again, I think it's kind of important to keep some key things in mind, just statistically, right? Like diet is the one of the leading causes of death, right? Diet is linked to cardiovascular disease, which one 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 pre-diabetes and all those things, right? So it's just key to keep these things in mind. Now, I'll say the USML Es 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, 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? So I think the first thing I want to talk about here as a foundation for all of this, or the difference between macro and micronutrients, right? Again, you may think some of these things are like filler, but you'd be surprised by how they go after these, right? So remember, micronutrients 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 USML Es love to emphasize, right? So like for example, diets that have been shown to really help with cardiovascular disease are things like the Mediterranean diet, things like the dash diet, right? 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 effective intervention for lowering blood pressure? I hope your lifestyle intervention, I hope you're saying weight loss, right? So remember weight loss is number one, it's more effective than the dash diet, right? But the dash diet helps not just with high blood pressure, it also helps with cardiovascular disease, right? But the Mediterranean diet has also been shown to lower blood pressure and also lower presence risk for cardiovascular disease, right? And then don't forget that if you want to reduce a person's risk of having like colorrectal problems and also lowering their cholesterol, fiber, a high fiber diet is very, very helpful for those kinds of people, right? Well, if they give you a question about a person that has heart failure, right? Then a low sodium diet is going to 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 going to be very, very helpful, right? So the thing is, it's very important to you, exams to recognize that hey, for this particular kind of patient, this particular kind of diet will be helpful in ameliorating their problems, right? And then another classic set of things they also love to test are the different kinds of food processing, right?

So remember like there's foods that are on processed, there's foods that are minimally processed, there's foods that are ultra processed, right? Ultra processed foods obviously are going to 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 new trends that are in the original food have been stripped off. And then number two, another reason why ultra processed foods are also bad is because 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 the literals health health consequences, right? So just something you want to keep at the back of your mind for your exams, right? And then also you want to make sure you know about the vitamins and the key high yield points of vitamins, right? So remember like vitamin A, for example, we know that vitamin A is necessary for the maintenance of specialized epithelium, right? Like epithelium, you'll find like in the eye, for example, right? So the thing is if a person has a vitamin A deficiency, don't be surprised, the person is going to have like, they may present it as a person having an accident at night, right? 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, their Xeroxamia, right? XEROPHTHALMA, right?

You know, make sure you can identify B2 spots on fontoscopic exam on, on, on your exams, right? And then you know, vitamin B1, I'm just going to go in alphabetically, vitamin B1, remember, wernichic or socalf berry berry, right? I mean, wonder like why does vitamin B1 deficiency cause all these problems? Well, the thing is, vitamin B1 is, is thymine, right? And again, if you remember from step one, thymine is used for many things, right? Like we use it for the pyruvate hydrogenase complex, and we use it for the TC cycle, right? The TC cycle, right? The, the crep cycle, right? So, especially in the form thymine pyruphosphate, right? Thymine pyruphosphate, right? So, the thing is, if you have issues with thymine, right? Then these reactions are not going to work, right? Your pyruvate hydrogenase complex, your TC 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 going to struggle. Well, what are some examples of these tissues, things like your heart, things like the brain, right? If you notice when people have, when people have antecedents of thymine deficiency, like berry berry or renegade cross-ocha, 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 have wet berry berries, called wet, because again, they don't have good energy production with their cardiac milestones, 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 going to have a demon, right? So, hence the term wet berry berry, right? René-Kirkorskokops, right? Parts of the brain that use high amounts of energy, like the thalamus, the hypo thalamus, the mammillary bodies, those things can have infarctions, right? Because again, there is not enough energy, right? So, keep that in mind with vitamin B1, and then vitamin B3, again, you're like, ooh, the vine there is vitamin B2. The thing is, for the USE, it is a nutrition vitamin B2, probably doesn't really matter very much, right? But for vitamin B3, it certainly matters, right? Remember, pelagra, pelagra, pelagra, right? You're three days dermatitis, diarrhea, and dementia, right? And then the fourth day, I guess, is death. And don't forget your causes of pelagra, right? Basically, that's a nice indeficiency, right? So, remember, there are many causes, right? So, like, for example, if you have like a new... And I might know a said reabsorption defect in the proximal tubio, right? Where you can already absorb triptophan, then that's going to be a problem, right? Because triptophan is used to mignyocin, right?

Or if you have something like carstenoid syndrome where you're using a lot of your triptophan to mix aerotonic, then you're not going to have enough left to mignyocin that can cause problems, right? So, just kind of keep that at the back of your mind on exams, right? So, pelagra, right? Keep that in mind with vitamin B3, the efficiency, right? Vitamin B6, the efficiency 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 Cedar Oblastic Anemia, right? Don't forget about the link twice on Isodin, right? Remember, the neuropathy happens because, again, you need vitamin B6 to make neurotransmitters, right? So, if you want to go from glutamate to GABA, you need vitamin B6, right? Glutamidicurboxylase is the thing that makes that conversion. You need vitamin B6 as a cofactor. Well, the thing is vitamin B6 is used as a cofactor for glutamidicurboxylase, right? So, if you don't have an ovidamin B6, you have more glutamate and less GABA, right? Remember glutamil is an excitatory neurotransmitter, so that's going to cause you to have seizures, right? And then, in terms of the Cedar Oblastic Anemia with B6 deficiency, don't forget, it's the first step of hym synthesis, right? Where you take glycine and succinochoe and make delta amino-levelinic acid, that reaction requires amino-levelinic acid synthase, right? Remember, ALA synthase is the reclimitin enzyme of hym synthesis.

That enzyme uses vitamin B6 as a cofactor, right? So, if you don't have enough vitamin B6, then hym synthesis is going to be impaired, and you're going to have Cedar Oblastic Anemia, right? And then, so, again, don't forget the association with Isonize. Isonize basically prevents the activation of vitamin B6, because vitamin B6 for it to work, it actually does need to get activated, right? It gets activated by a phosphokinase enzyme. That phosphokinase enzyme depends on vitamin B6 for 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 B6, so it's almost like a functional vitamin B6 deficiency, right? And then, remember, for your exams, don't forget vitamin B9 and fully deficiency, right? So, like, make a lumbastic anemia, neuro tube defects, don't forget that, right? Again, remember, the amygdala-oblastic anemia rice is because in the S phase of DNA synthesis, right? Like, the synthesis phase of the cell cycle, the S phase, you need full it, right? Full it is absolutely necessary to make DNA, right? So, when you have a fully deficiency, you're going to have impaired DNA production, and that's going to get you in trouble, right? And then, also, don't forget your neuro tube defects. You need a little full it 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 going to have issues with collagen, right? Remember, C in vitamin C and C in collagen, right? Collagen needs vitamin C for its proper synthesis, right? So, you're going to have things like scurvy, you're going to have things like poor wound healing, you're going to have things like bleeding gums, right? Keep that in the back of your mind for your exams, right? And then, vitamin D, right, think about it in terms of rickets, right? Rickets, rickets, rickets, because you need vitamin D to help you mineralize osteoid, right? In your bones, we're just going to think bone, bone, bone problems, right? And remember, vitamin D helps you reabsorb calcium and phosphate in your gut. It really helps you maintain a good solubility product, right? So, you're going to have things like rickets, osteomalatia, hypocalcemia, and things like that, right? Vitamin D deficiency is a very permanent cause of secondary hyper-parathyroidism on your exams, because you have hypocalcemia, right? So, because if you don't reabsorb a non-calcium from your gut, you have hypocalcemia, so you won't have negative feedback, so your PT is going to rise, right? And then remember, vitamin E deficiency, right? It can cause himolytic anemia, right? You're like, divine, why would vitamin E deficiency cause himolytic anemia? That doesn't make any sense. Well, let me explain. The thing is, vitamin E is necessary for the proper functioning of a selma in brains, right?

Proper function of selma in brains, right? So, you know, if you have a vitamin E deficiency, you will have improper red blood selma in brains, right? So, those red blood cells are going to be less resistant to himalosis. You're going to have a lot of himalosis, right? In fact, remember that vitamin E deficiency on the USMLE exams is associated with acanthocytosis, 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 going to be crop, and if your myelin is crop, you're going to have neurologic dysfunction, right? The asserting pathways that really depend on myelin, like your spinal cerebellar truck, right? So, when you have a vitamin E deficiency, you may have a taxi, because your spinal cerebellar truck doesn't work as well. Again, I know some of you may be like, man, the vine is just spit-balling, but I promise you, many of these things I'm going over here, they're very, very high yield to know for you exams. The thing is, nutrition, the USMLE is going to have a field day with this, why? Because it reflects multi-systems processes and disorders, right? That's probably one of the hardest sections of the USMLE is to prepare for. Right? And then vitamin K deficiency, right? So, 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, Poxyriductase to work. But what does vitamin K, Poxyriductase do? Well, vitamin K, Poxyriductase, it leads to the gamma-cavoxylation and activation of factors 279 and 10, and protein CNS, right? So, if you have a vitamin K deficiency, those things are not going to work. Your clotting factors are basically not going to work, right? So, your correlation cascade is not going to work, or so you're going to bleed, right? You're going to have an elevated PT, an elevated PT, and INR and things like that. Right? So, don't forget, right? And how can you get these deficiencies? Remember, vitamin 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, Crohn's disease that is really missing up your small intestine, right? Or you see a person that has, like, the faggastric bypass. Our gastric bypass has a very solid association of 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, 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, a lipase does come 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? Lipase is needed for the emulsification of fat. Lipase plays a role in you being able to wrap so fat and fat-soluble vitamins, right? So, that can cause problems, right? So, like, for example, people that have lipase problems are going to be people, for example, the half cystic fibrosis, or people that have chronic pancreatitis, for example, on your exams, right? And then remember, the thymine deficiency is going to 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 isonize it, isonize it, isonize it, isonize it, right? And then don't forget B12 with vegans, right? B12 with vegans, a vegan, you know, a person that eats a lot of plant products, well, good luck, right? Or if you have, like, brain issues andemia, where you have autoimmune destruction of your parietal cells, or intrinsic factor, that can also cause problems, right? Or if you have a terminal alien problem, like, Crohn's disease, for example, remember, Crohn's disease always affects the terminal alien, right?

So, that can cause a B12 deficiency, right? So, you just keep that at the back of your mind for, for example. And also, one kind of weird thing that you may see on your test, I don't know how many resources don't talk about this, but this is metforming. Metforming can cause B12 deficiency, metforming specifically in habits, the reabsorption of the B12 intrinsic factor complex in your terminal alien, right? So, metforming has a stronger seasonal, but I mean, B12 deficiency. That's something you just certainly keep at the back of your mind for your exams, right? And then fully deficiency, again, 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 reabsorbe, uh, a full eat in the GI tract, right? In the, in the, in the genion of the GI tract, right? So, if you have, uh, if, if, if you're an alcoholic, alcohol in hebe is that enzyme, right? So, you're not going to be able to reabsorb fully, so you're going to get in trouble with fully deficiency. And also, people can also have fully deficiency because, um, a, a, a gastric bypass, right? Or you can also get fully deficiency because you're just using up your full eat 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 fully, we have like weeks of fully in our bodies, right?

So, if you lack fully, you're, you're going to get in, in, in big trouble, right? Uh, so what, all of some situations that can make you use a full eat. Well, for example, if a person has hemolytic anemia, let's say you have like, sickle cell disease, or you have here, these are cirrhocytosis. 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 fully very fast, right? So if the average person maybe has like 10 weeks worth of fully, this will be like two weeks worth of fully because they just use it so, so fast, right? So again, it's pretty high up to know this for your, for your exams, right? Uh, it's pretty high up to know this for your exams. Uh, pretty high up to know this for your exams, right? And then in terms of your, so those are the vitamins, right? Again, this is probably going to be something that's going to be a multi-part series, but we'll see. Let me just, stuff in as much as I can with the spot cast, right? So let's talk about minerals, right? So remember iron deficiency. Don't forget that with, uh, you know, you can cause micro-cidic anemia, right? Because again, um, if you don't make enough iron, then your red blood cells will try to maintain a constant MCHC. I've explained this in previous spot cast, right? So your red blood cells, they have like a goal of maintaining a constant, uh, mean, composition of hemoglobin concentration, right?

So, um, if you don't have enough heat, right? Which is a problem you'll 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 composition of hemoglobin concentration, right? So that's the mechanism behind the microsytosis, right? So iron deficiency anemia is going to cause microsytosis, right? You're going to see things like pica, representing it in ice shapes, it in sand and things like that. Coilonecia, right? Issues with, uh, with the nails. Uh, make sure you can identify coilo-nicia on your exam. So it's pel-k-o-i-l-o-n-y-c-h-i-a, right? And then don't forget like zinc deficiency, zinc deficiency is going to cause poro-want healing, uh, what's the other thing we've talked about that causes poro-want healing? Vitamin C, right? Remember vitamin C, right? So vitamin C zinc, keep those in, in mind, right? Uh, dysguzia, right? So like in per-taste, uh, taste alopecia, think of that with zinc deficiency. Iron-dine deficiency, right? Remember, you can see iron-dine deficiency, you know, just from, again, a poor diet, right? You can also see an iron-dine deficiency from a person taking a drug like a mutorum, for example, right? So you can cause hypothyroidism, you can cause glider, right? And then again, if you have a calcium vitamin D deficiency, right? Calcium is a mineral, vitamin D is a vitamin, right? Uh, I can cause bone problems, right?

And then remember magnesium, the 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, uh, that can cause arrhythmias like a, you can prolong your cutie, can lead to, uh, V-tag, V-fip, uh, truss out the plant, right? You can have seizures from hypomagnesemia, and it can also cause hypocalcemia and hypokillemia, right? Because remember, the transporters in your body that help you hold on to, uh, calcium and potassium, did depend on magnesium for proper functioning, right? So if you have hypomagnesemia, those things are not necessarily going to work very, very well, right? So again, again, the USML Es, they just like to, uh, again, uh, because I know some people just see, oh, the USM Ns are going to test nutrition. And then they just kind of narrow out their minds to, oh, nutrition, okay, they're just going to, no, like they're going to integrate it with biochem. They're going to integrate it with heme, they're going to integrate it with neuro, they're going to integrate it with, uh, pregnancy, with pediatrics, with GI, with pharmacology. That's how they're going to 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 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, we check your oxygen saturation or whatever. Well, the thing is, there are certain people who should obtain nutrition vital signs on, right? So what these classic people, 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 what these people, well, these are going to be people that have like weight loss, right? People that have chronic diseases, right? People that have food insecurity, right? You know, they're like people that live in poverty, right? Trust me, I understand what, what that means. I have certainly lived in poverty, you know, just like my grown-up here is lived in quite a bit of poverty there. You know, grown-up in Nigeria was a tough life, right? Well, put a half GI disease, right? People that have like, for example, Crohn's disease, or people that have had gastric bypass, right? Keep those people in mind, people on GOP1 agonist, right? Especially if they are not smart about their diets, they can also develop nutritional 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? Thymine deficiency, magnesium deficiency and things like that, right? People that have had, again, biiatric 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 mind, right? So, what are the components of a nutritional vital sign? Well, you should typically ask them like, hey, what's your diet like? What do you usually eat in a typical day, right? Have you had any recent week loss or weekend, right? Do you run out of food? Are you worried about where the next meal is going to come from? Do you have any nausea, vomiting, diarrhea? 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 week loss medications, right? That's like GEOPY1 Aganis, for example, right? Or do you have any control or religious food practices, right? These are all things you ask about when you're assessing a person in nutritional vital signs, right? And the thing is our friends at the NBME's, sometimes they like to give you a question on the exam, where do you match it to a physical exam finding, right?

So, they'll either give you a question about deficiency and they'll 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 string, we've kind of talked about some of these, right? 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? Mosul loss. Think of a person that's on a GEOPY1 Aganist, right? Or a person that has like rapid week loss, right? 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. You also do a lot of strength or resistance training, right? A demon, a demon physical exam can be a sign that a person is high-poabumini-mek, right? It can be a sign that a person has liver disease, because remember, you need argument to maintain adequate amounts of on-quatic pressure in the body, right? So, like if they have a demon, right, that should get you down like that low-abumine pathway, right? So, you can tell you that maybe they have an infrotex syndrome, or maybe they have like a protein restricted diet, maybe they have like a shokal, for example, right? Or they have a liver problem, right?

So, keep that in mind, right? A pro-want healing should make you think of vitamin C deficiency, and 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 glositis, 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, sorry, B1, B6 and B12 deficiency, B1, B6 and B12 deficiency, right? And also think of a vitamin E deficiency as well with neuropathy, right? Remember that spinal cerebellular tract business that I kind of 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 for skin changes, also don't forget, come on, divine think, think of a pelagra, right? Pelagra, yeah, vitamin B3, nice in deficiency, right? I remember also, poor Want 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, 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 can basically put, put, put your trouble on your, on your exams, right?

And typically when you're worried about these people that have these nutritional problems, what are some key labs you want to get? You want to get like a CBC, right? To assess them for anemia, CMP, to assess them for electrolyte 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, full late levels, vitamin D levels, magnesium, phosphate, calcium, zinc, right? Look at their A1s, they look at their lipids, right? So, again, just keep that at the back of your mind for your, for your exams, right? And then, let's talk about this whole thing about food insecurity, right? This is probably one of the highest-yoda themes on the exams, right? So, you know, food insecurity is basically like having limited access to enough food, not just enough food, but like, nutritious food, right? Nutrition food, right? Nutrition 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 want to 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 going to find in a, in a food desert, for example, right? Where it's like, oh, they have all this fast food around.

They have McDonald's, they have all these stains around, right? But then, they don't have like good grocery stores that sell like healthy food. And they just have convenient stores and fast food, right? Convenient 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 nutritious calories, right? The fact that you have calories does not mean you have nutritious calories, right? And the thing is, sometimes on your exams, they'll give you these questions where you have to pick out statements as your answer, right? So, like, for example, if you want to access a pressing for food or nutrition insecurity, you can ask them like, hey, in the last 12 months, where you worried, you know, that food would run out before you had money to buy more, right? Or in the last 12 months, did you buy food that, did you, you know, did the food you buy 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 food, right? Do you have enough money to buy food, right? And the thing is on your exams, beyond the 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, SNAP, supplemental nutrition assistance program, right? So, you should make sure you know about that.

The WIC 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 GOP, when they're diagnosed, there's nothing wrong with pairing them up 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 nutrition, right? You want people to make behavioral changes. The thing is, friends and the NBM is they want you to use certain tools, right? 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 got to know those things for your exams, right? So, like, for example, believe it or not, you may be like, divine, how would they ever test a smart goal on the exams? 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 NBM is what they will do is they will give you a series of answers. And an answer will reflect a smart goal.

And then you'll see a bunch of answers that, you know, they are very non-specific recommendations like move more. Again, they are not going to put move more, right? But either healthier meal or stop consuming soda and things like that. And then they will be an answer that reflects this smart algorithm, right? So, like, for example, if you tell a patient, hey, replace soda with water at lunch 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 smart goals on your exams, right? And then another thing I'm going to talk about again, that's the thing I know nothing about this nutrition of a thing is. It's kind of like a grab bag of just different topics, right? So, just make sure you know about a metabolic syndrome, right? So, remember that a metabolic syndrome, what are the key components of the metabolic syndrome, right? Central obesity, right? High blood pressure, high triglycerides, low HDL, and elevated fasting glucose, right? Again, please don't be be wise on your exams. 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 pick nutritional interventions for people that have the metabolic syndrome, right?

So, 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 fasts that are unsaturated, over like saturated or transphatic, right? Limit ultra-process foods, right? Reduced sodium, right? Again, a low sodium diet is very helpful for food that have high blood pressure, and food that have heart failure in your test, right? Food that have what? High blood pressure, the two Hs, right? High blood pressure, heart failure in your test, right? And again, if a person wants to lose weight, they should basically like, be in a calorie deficit, right? And again, remember on your exams, they can test between the two kinds of fat. Remember, there is the visceral fat, right? That's around your organs, and then there's the one that's like subcutaneous and what not. The one that's the most dangerous is the visceral fat, right? So keep that in the back of your mind for your exams, right? Keep that in the back of your mind for your exams, right? And then, again, I've kind of talked about this, but I think as you just highlight this, just for you to look out for these patient 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 your exams, right? What are the patients that are at high risk 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, biometric surgery patients, things like that, right? People that have alcohol use the disorder, talked about the deficiencies they can develop, eating the disorders, right? Anorexia, bulimia, right? Postop patients, people that are postop, right? ICU patients, right? Remember, ICU patients, many of them can have to be on TPN or something like that, right? People that have food insecurity, people that have dysphesia, 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 calcium dial to calcium trial, we find it in the kidneys, right? So, people that have CKD, people that have heart failure, people that have cirrhosis, right? Remember, cirrhosis, is that cirrhosis, hypo, hypo will be albuminemia, right? So, just keep this at the back of your mind for your exams, right? And then remember, when people start, 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 less if you get admitted to the hospital. Usually, this is going to be a hospital-based problem, right? They get admitted to the hospital. And then you notice that this person starts having like arrhythmias, you know, you start feeding them, you start having arrhythmias and all these issues, right? And they become unconscious on responsive and then they die. If you see something like this, I really want you to think of, sorry about that, I really want you to think about refidding syndrome, right? So, remember, was the most common cause of death in refidding syndrome is going to be low phosphate, right? Because again, when you start eating after a period of starvation slash fasting or porn nutrition, then insulin is going to get released in like huge gobs, right? And as you release tons of insulin, you're going to drive a lot of fast feeding to yourselves. That's going to cause hypophosphatemia, right? Many people think hypophosphatemia has been, I know it's not, it can actually kill you, right? So, like literally the most common cause of death, very high, the most common cause of death in refidding syndrome is low phosphate, right? And remember, other labs, right, that you can get if you have hypophosphatemia, right? You can, you know, cause, you know, low potassium, low magnesium, right? You can have time in deficiency, right? You can have all these fluid shifts.

So, just be careful, right? These people you may want to supplement these electrolytes and you may want to do like gradual 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? Like, when you're like, you've done like a long fast and you just want to eat out the wazoo, right? Well, don't eat out the wazoo because you're going to have problems, right? You may notice that if you eat a big large male after you've had a fast, you notice that you kind of feel dizzy and all those things. Believe it or not, you say electrolyte and normalities you have. You have like very mild refidine syndrome kind of going on there, right? So keep that at the back of your mind for your exams. All right. Now, what's another high-yield thing that they love to test with nutrition on the USML Es? I'm going to see if I can pack in everything with this podcast. Let me try my best. So it's going to be a long one, right? So just buckle up, right? Again, on your exams, they like you to know some drug nutrient interactions, right? You definitely want to know these things, right? So don't forget, like if you're if you're on warframe, remember warframe can, you want to make sure you're taking consistent amounts of vitamin K, right? Make sure to keep consistent amounts of vitamin K. Don't have your vitamin K levels be all over the map, right?

When you're taking warframe, just be consistent. So that after a while, your body kind of finds a good level of iron and kind of keeps you there, right? Remember, I sonyze it and B6 deficiency. Right? So if a person is taking it, I sonyze it. They should be taking paradoxo, phosphate, right? Informing, remember, I mean, forming can cause a B12 deficiency. And then don't forget your proton pump inhibitors. PPI's, you know, people kind of give them out like candy in hospitals, but I'm like, gee, what are these people doing? If you don't need a PPI, it shouldn't be on a PPI because it causes a bunch of problems, right? It can cause B12 deficiency, right? Because remember, PPI's 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 tomorrow in intrinsic factor, it needs to be separated from the animal product that you consumed. You need that high-pricellity of the stomach for that to happen. Well, PPI is going to shut down that high-pricellity. So that can get you in quite a bit of trouble. Right? So PPI's can cause B12 deficiency. They can cause mark 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 ultra-pich of your stomach as happens when you take a PPI that can impair magnesium absorption, right? You can even cause calcium problems. Right?

So again, PPI's B12 magnesium and calcium, right? And they remember loop diuretics, right? Your loops, your thazides, they can cause, your loops, let me focus on your loops first. Right? So loops, loose calcium, right? So loops can cause you to have hypocalcemia, hypokylamia, right? They can cause hypomagnesemia. Right? So, remember loops, they make you volume depleted, right? So that's going to crank up the activity of your reading and your tensing out of the doctrine system. 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? You're going to start losing a lot of potassium in your urine, right? You're going to have a hypocalemia because remember our doctrine makes you excrete potassium, right? So just keep that in the back of your mind, right? And they remember thazides can cause hypercalcemia, they can cause hypokylamia, right? Remember thazides, or like loops that make you loose calcium, thazides help you reabsorb a lot of calcium. So thazides may actually be good for poor to have osteoporosis, if you have osteoporosis and high blood pressure, right? And then don't forget your ACE inhibitors, your ARBS, your Spurinolactone, which is an outdoor receptor antagonist, they can cause hypercalemia, right? And then don't forget statins, right? Remember the grapefruit juice interaction, right? So grapefruit prevents the breakdown of your statins, right?

Your statin levels can really rise and that can be a problem. Then don't forget your monamine oxides inhibitors, right? With a tyramine hypertensive crisis, don't forget levolyroxene, levolyroxene can be chileethevely by a lot of stuff, right? So don't take your senthroid when you're taking a calcium or iron, right? Just be careful, right? Just be careful there. And remember your tetracycline, that your fluorocrylonal loans, right? Again, don't take them with things that can chileet them and reduce their bioavailability, like calcium iron and magnesium, right? And again, don't forget alcoholism. I'm telling you like it's going to be really strange for the US Emily Storite nutrition exam and not include alcoholics, right? Alcoholism causes a bunch of problems, right? So don't forget your alcohol with 5-in-deficiency, fully deficiency and a B6 deficiency, right? And then I think one of the things you'll keep at the back of your mind, right, is the difference between food allergy and food intolerance, right? So food allergy versus a food intolerance, right? So remember, food allergy is immune mediated, right? Is immune mediated, right? So typically the person who, what are some classic symptoms you're going to see in those people on your exams? You're going to see things like odicaria, they're going to be eating a lot, they're going to have angiodeba, they're going to have wheezing, vomiting, low blood pressure, and aphelaxis, right?

And obviously, if they have an aphelactic shock, right? You're going to go ahead and trade them with intramuscular epinephrine, right? Not intravenous epinephrine, guys, please be careful, please, please, please. I've seen too many people make this mistake on the US Emily's, don't join that, those ranks, don't join those ranks, right? Please, please, please, right? You don't give intravenous epinephrine for an aphelaxis. No, no, right? You know, no, right? That's what we're really doing, guys. Please, for your exams, for patients that have a laxia, give them intramuscular epinephrine, right? Seems like a small point, but I've seen too many medical students get sacrificed by this on your exam, right? And then, so food allergy, that's what I've just described, right? 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 lactose intolerance, right? Typically, when people have food intolerance, they're going to have, like, bloating, gas, diarrhea, abdominal pain, after the eardom meal. That's very different from odicaria, angiodeema, whizzing, and things like that. They're not going to have an aphelaxis, right? So, again, be careful about all that.

The pressing consumes milk, they have bloating afterwards, that's going to be food intolerance, that's going to be food intolerance, right? And again, remember, I talked about the pregnant population earlier. Remember, if you're pregnant, 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, diabetes, cancer, right? Many amazing things that breastfeeding does for people, right? And remember, if a woman is pregnant, right? If a woman is breastfeeding or she's pregnant, you know, she should take folic acid, especially when pregnancy reduces the risk of neuro tube defects, right? When you're pregnant, you're going to need more iron, right? You're going to need more iron, you're going to need more iron because your blood volume goes up. You need iron to make that extra blood. 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, 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 morning sickness, remember to give her vitamin B6 and doxilamine, right?

Because again, that morning sickness can make people start developing nutritional deficiencies, right? Nutritional deficiencies, and then don't forget about gestitional diabetes again. That's another thing they love to test in that arena, right? In that arena, right? Remember, if an infant is being exclusively breastfed, that infant has to get vitamin D supplementation because breast milk, I'm sorry, is not very rich in vitamin D, right? It's not very rich in vitamin D. And again, remember, do not give honey to a child that is under each one because of the risk of botulism, right? Because again, remember, as a, you know, newborns, they don't have any GI flour, right? So if you consume, if you consume honey, right? You're going to consume the spores, and then the spores, since you have no GI flour, there's literally like no competition for a newborn, right? So those spores are going to germinate, you're going to make toxins inside the GI tract of the fetus, and then the child is going to develop botulism and be a floppy baby, right? So you don't, you don't want that, right? You don't want to, you don't want that, right? So just going to keep that at the back of your mind, right? And then one other rule I'm going to talk about on your exams, if your gut works, use it, if your gut works, use it, right? In general, if possible, always go with the interior nutrition, especially if you have a functional GI tract, right?

But you know, just for whatever reason you have in a liquid or a link, take go for interior nutrition, right? Go for interior nutrition, go for interior nutrition, go for interior nutrition, right? Go for interior nutrition, right? So like for example, although there are some risks with interior nutrition, like you can aspirate, like you can have diarrhea, the tube can be polyplaced and all those things, right? So generally after you please like a feed into, make sure you do like an abdominal radiograph, just to confirm a proper, proper policeman, right? 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? It's not usable, right? So like for example, if a person has like, like really severe bowel obstruction or shot bowel syndrome, right? Well, you have like terrible, terrible, terrible ilias, well, you have like a high-upodifestula, right? Or you've tried the interior tube feeding and it's not working, then in that case you can consider a TPN, right? But remember TPN can, you have to get a lot of a bunch of problems, right? So like catheter has related infection. I mean, you're literally putting food into a catheter. What do you think is going to happen? Like literally what do you think is going to happen there? Of course, the bugs are also going to want that food, right? So you can have like a central line of straight up bloodstream infection with that.

You can have like thrombosis of the catheter, right? You can develop like a colistasis in the liver, right? You can have like a calcolicic studies from that. You can develop a feeding 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 going to see these things pop up on your exams. You're going to see these things pop up on your exams, right? So again, the USM is they're kind of moving away from just like the facts with like these isolated efficiencies to more like just clinical application, right? So again, you still need to know some of your step on 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 might podcast that, oh, the vine, 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 through, it's easy, right? You go through drive through other 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 USM. That's the truth, right? So I'm not going to spoon feed facts to you. No, that's not my goal with this podcast. If you want someone to spoon 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 USM, the facts are not going to be presented to you in a clean fashion, right? They're going to 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 going to go ahead and stop here. If you like the way I teach, you're going to love my classes. I teach a bunch of classes over Zoom, have a 20-hour step two step three class. I have a 50-hour step two step three class, have a last minute review, that's for step two step three. I have a bio-stats class, I have a social science ethics and quality improvement class, I have a test taking class. So these last three classes, bio-stats, social sciences and test taking strategies class, that's for step one, two, step three, right?

And then I also offer tutoring for like shelf exams, medical school exams, complex exams, even board exams for like internal medicine and stuff I do offer tutoring for those. So if you're interested, just should be an email. I can give you some more information. I mixed study plans for people. And I also hope with things like ERAS applications, personal statements, recommendation letters and things of that nature. I've actually started working with people for the 2026, 2027 cycle. I feel like before I used to worry about that kind of work like in 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 every year. All right. And then I'll have these podcasts on Apple Google and Spotify. So if you're interested, just check that out. And then I also have another website called divine intervention life lessons.com, divine intervention life lessons.com. So many of you know, no Christ follower. So every week I post like one or two podcasts from a biblical perspective address a life lesson. I have almost 400 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 You Tube channel, divine intervention, USM, podcasts and videos, right? Sometimes post videos and podcasts that I make. So thank you for listening to me today. I will see you God willing. Episode 651. But again, listen to this podcast.

You're going to see this material on you 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.

Impaired function of Vitamin K-dependent carboxylase, leading to decreased synthesis of clotting factors II, VII, IX, and X, resulting in elevated PT/INR.

Vitamin B12 deficiency (Cobalamin).

Dermatitis, Diarrhea, and Dementia (Pelagra).

Visceral fat.

Fat-soluble vitamins (A, D, E, K) due to impaired bile salt/fat absorption.

Allergy is immune-mediated; Intolerance is non-immune (often enzyme deficiency).

Night blindness (Nyctalopia) and Xerophthalmia.

Poor wound healing, taste dysgeusia, and alopecia.

Vitamin C (Ascorbic Acid).

Alcoholics, patients with GI surgery/malabsorption (e.g., gastric bypass), and those with chronic inflammatory bowel disease (IBD).

They promote excessive excretion of calcium, potassium, and magnesium in the urine.

Because B12 is primarily found in animal products, and vegans lack sufficient dietary sources.

Night blindness (Nyctalopia) and Xerophthalmia.

Poor wound healing, taste dysgeusia, and alopecia.

Vitamin C (Ascorbic Acid).

Alcoholics, patients with GI surgery/malabsorption (e.g., gastric bypass), and those with chronic inflammatory bowel disease (IBD).

They promote excessive excretion of calcium, potassium, and magnesium in the urine.

Because B12 is primarily found in animal products, and vegans lack sufficient dietary sources.