Pamantasan ng Cabuyao

Banay banay, Cabuyao City, Laguna 4025, Philippines

COLLEGE OF HEALTH AND ALLIED
SCIENCES

COURSE TITLE: CARE OF CLIENTS WITH PROBLEMS IN NUTRITION AND GASTRO-INTERNAL,

METABOLISM ENDOCRINE, PERCEPTIONS AND COORDINATION, ACUTE AND CHRONIC
COURSE CODE: NCM116 Related Learning Experience
LEVEL OFFERING: Level 3, Second Semester AY 2023
NUMBER OF UNITS: 3

CARBOHYDRATES METABOLISM

NUTRITION
Nutrition is defined as “the science of how the body utilizes food to meet requirements for development
growth, repair and maintenance.
CARBOHYDRATES

 Play several crucial roles in the metabolic processes of living organisms

 Most abundant organic molecule on earth
 They serve as energy sources and as structural elements in living cells
 Carbohydrates are defined as aldehyde or keto derivatives of polyhydric alcohols
 For example: Glycerol on oxidation is converted to D-glyceraldehyde, which is a carbohydrate
derived from the trihydric alcohol (glycerol)
 the monosaccharide glucose is a prominent energy source in almost all living cells, major
emphasis is placed on its synthesis, degradation, and storage
 Living cells are in a state of ceaseless activity
 To maintain its “life,” each cell depends on highly coordinated biochemical reactions
 Carbohydrates are an important source of the energy that drives these reactions
 All carbohydrates have the general formula (CH2O)n ( CH 2 O ) n , where n is the number of
carbons in the molecule. Therefore, the ratio of carbon to hydrogen to oxygen is 1:2:1 in
carbohydrate molecules

CLASSIFICATION OF CARBOHYDRATES
FUNCTIONS OF CARBOHYDRATES

 One of the primary functions of carbohydrates is to provide your body with energy. Energy
production from carbohydrates will be 4 k calories/g (16 k Joules/g)

 Storage form of energy (starch and glycogen)

 If your body has enough glucose to fulfill its current needs, excess glucose
can be stored for later use.
 This stored form of glucose is called glycogen and is primarily found in the
liver and muscle.
 The liver contains approximately 100 grams of glycogen. These stored
glucose molecules can be released into the blood to provide energy
throughout the body and help maintain normal blood sugar levels between
meals.
 Unlike liver glycogen, the glycogen in your muscles can only be used by
muscle cells. It is vital for use during long periods of high-intensity
exercise. Muscle glycogen content varies from person to person, but it’s
approximately 500 grams.
 In circumstances in which you have all of the glucose your body needs
and your glycogen stores are full, your body can convert excess
carbohydrates into triglyceride molecules and store them as fat.
 Your body can transform extra carbohydrates into stored energy in the
form of glycogen. Several hundred grams can be stored in your liver and
muscles.
 Carbohydrates help preserve muscle
 During periods of starvation when carbohydrates aren’t available, the body
can convert amino acids from muscle into glucose to provide the brain
with energy. Consuming at least some carbs can prevent muscle
breakdown in this scenario.
 They promote digestive health
 Unlike sugars and starches, dietary fiber is not broken down into glucose.
 Instead, this type of carbohydrate passes through the body undigested. It
can be categorized into two main types of fiber: soluble and insoluble.
 Soluble fiber is found in oats, legumes and the inner part of fruits and
some vegetables. While passing through the body, it draws in water and
forms a gel-like substance. This increases the bulk of your stool and
softens it to help make bowel movements easier.
 In a review of four controlled studies, soluble fiber was found to improve
stool consistency and increase the frequency of bowel movements in
 those with constipation. Furthermore, it reduced straining and pain
associated with bowel movements.
 On the other hand, insoluble fiber helps alleviate constipation by adding
bulk to your stools and making things move a little quicker through the
digestive tract. This type of fiber is found in whole grains and the skins
and seeds of fruits and vegetables.
 Getting enough insoluble fiber may also protect against digestive tract
diseases.
 One observational study including over 40,000 men found that a higher
intake of insoluble fiber was associated with a 37% lower risk of
diverticular disease, a disease in which pouches develop in the intestine
 Fiber is a type of carbohydrate that promotes good digestive health by
reducing constipation and lowering the risk of digestive tract diseases.

 Glycoproteins and glycolipids are components of cell membranes and receptors.

 Structural basis of many microorganisms.

IMPORTANCE OF GLUCOSE

➢ Glucose is a major carbohydrate

➢ It is a major fuel of tissues
➢ It is converted into other carbohydrate
 Glycogen for storage
 Ribose in nucleic acids
 Galactose in lactose of milk
 They form glycoproteins and proteoglycans
 They are present in some lipoproteins (LDL)
 Present in plasma membrane:glycocalyx
 Glycophorin is a major integral membrane glycoprotein of human erythrocytes

METABOLISM
MAJORPATHWAYS

FASTING BLOOD SUGAR

 Refers to the amount of glucose present in the blood of diabetic prior to eating. When fasting blood
glucose levels are elevated even before consuming any food, it is a sign that you have diabetes.
Doctors also rely on fasting blood glucose results in order to make medical decisions.
 A diabetic knows instantly whether to be concerned by looking at his or her fasting glucose sugar
level.To diagnose diabetes, a fasting test is performed, and these results are compared to glucose
levels taken after the patient eats.
 Diabetics should ideally test fasting blood glucose readings at least once every 24 hours.Blood
tests provide the data for FBS.
 Extremely high blood glucose not only shows that you are eating too many carbohydrates and
foods that are high in processed sugar, but they can also be a precursor to diabetic coma.
 Those that are not diabetic should not have fasting blood glucose numbers more than 125 mg/dl. A
reading of more than 125 mg/dl could mean you are pre-diabetic or have type 1, 2 or 3 diabetes.
 Blood glucose readings that are taken after meals should be significantly higher. Diabetic that have
unhealthy lifestyles can have severely elevated fasting blood glucose readings that are very high.
 ORAL GLUCOSE TOLERANCE TEST

 An oral glucose tolerance test (OGTT) measures how well your body processes glucose, or blood
sugar. Glucose is your body’s primary source of energy.
 Often, an OGTT is used to diagnose prediabetes and diabetes, especially when gestational
diabetes is a concern.

It may also be used to test:

 reactive hypoglycemia
 acromegaly, a hormonal condition that causes excess growth
 impaired beta-cell function
 insulin resistance

An OGTT is a type of blood test. It requires taking several blood samples over a set amount of time.

TYPES OF OGTT

 Standard OGTT: A 2 hour 75gm oral glucose tolerance test is use to test for diabetes. A fasting
blood sample is collected before to test glucose level.
 I/V Glucos Tolerance Test: Test is taken for malabsorption patients.
 Mini Glucose Tolerance Test: As per WHO, here 2 samples are collected, fasting and 2 hours post
glucose load.

Before doing an OGTT, a doctor might perform a glucose challenge test first. This is a shortened version of
the OGTT.

A glucose challenge test requires no fasting. During the test, you’ll drink a beverage containing 50 grams of
glucose. After 1 hour, a healthcare professional will take a blood sample to check your blood sugar level.

If your blood glucose is higher than 140 mg/dL, it might indicate diabetes. In this case, you’ll need an
OGTT.

An OGTT requires some preparation. You’ll need to fast for about 8 hours before the test is performed. This
means you can’t eat breakfast or drink any liquids, except water, beforehand.
An OGTT includes the following steps:

 A health worker will take a blood sample from your fingertip, earlobe, or a vein. They’ll test the
sample for blood glucose, which will serve as a baseline measurement.
 You’ll drink a concentrated glucose beverage. Most solutions contain 75 grams of glucose.
 You’ll sit or lay down for 1 hour.
 After 1 hour, healthcare staff will take a blood sample.
 A healthcare professional may take another blood sample after 2 hours and again at 3 hours.
 A medical team will measure the blood glucose levels at each test time.

Between testing times, you’ll need to stay still and avoid drinking a lot of water. That’s because excessive
movement and hydration can alter the results.You might receive an OGTT without receiving a glucose
challenge test first.

INDICATIONS

 Patients with family history of diabetes.

 Massive obesity
 H/O recurrent infection
 Patients with delayed healing wounds
 Woman who have H/O stillbirth, premature birth or large baby
 Patients with transient glycosuria or hyperglycosuria

CONTRAINDICATIONS

 In proven case of DM
 OGTT is required only in doubtful cases, it is not recommended to follow up of patients
 The test should not be carried acutely ill patients

COMPLICATIONS

 Infection if the area is not properly sterilized before the sample is taken
 Excessive bleeding from the area
 Bruising and swelling
 Feeling light headedness

PRECAUTIONS

 The patient is instructed to eat a carbohydrate diet for 3 days prior to the test. Diet containing about
35-50 gms of carbohydrate should be taken
  The patient should avoid certain drugs for at least 2 days prior to the test
 The patient should abstain from smoking
 Stressful exercise is to be avoided prior to test
 Exercise is to be avoided also

MEDICATIONS SHOULD BE AVOIDED

 Diuretics (thiazide specially)

 Corticosteroids
 Synthetic Estrogen
 Phenytoin (Dilantin)

ADVANTAGES

 OGTT is considered the most effective way to determine in case of GDM

 Managing sugar level decrease the chances of baby growing larger for dates
 Managing sugar level may decrease the risk of intervention in labor and birth

DISADVANTAGES

 It is time consuming
 Test result may be influenced by stress, illness or medications
 Blood is less stable after collection due to improper handling or storage of blood

RISK OF OGTT

 These tests have no serious risk. It has some risks include:

 Nausea
 Stomach discomfort
 Diarrhea
 Constipation
 Bloating
 Headache

PREPARATIONS

 Normal diet for 3-5 days

 Diet containing about 30-50 gm of carbohydrate should be taken on the evening before the test
 To remain fasting overnight
 Avoid going to the bathroom before test as urine samples may be needed
 75gm glucose is to be administered
 Avoid smoking
GLYCOSYLATES HEMOGLOBIN HBA1C

 Hemoglobin is the substance inside red blood cells that carries oxygen to the cells of the body.
Glucose (a type of sugar) molecules in the blood normally become stuck to hemoglobin
molecules - this means the hemoglobin has become glycosylated (also referred to as
hemoglobin A1c, or HbA1c). As a person's blood sugar becomes higher, more of the person's
hemoglobin becomes glycosylated. The glucose remains attached to the hemoglobin for the life
of the red blood cell, or about 2 to 3 months.
 A blood test can measure the amount of glycosylated hemoglobin in the blood. The glycosylated
hemoglobin test shows what a person's average blood glucose level was for the 2 to 3 months
before the test. This can help determine how well a person's diabetes is being controlled over
time.

INDICATION
The test for HbA1c is used to diagnose and monitor diabetes.
 The test is used to indicate how well the diabetes has been controlled over the last few months.
People with diabetes are advised to have this test every 3 to 6 months, or more frequently if it is
not under control. By testing for glycosylated hemoglobin, the doctor discovers what the average
blood glucose level has been for the previous 2-3 months

 This is important. The higher the HbA1c, the greater the risk of developing complications such as
problems with your eyes and kidneys

PREPARATION
 No preparation is needed for this test.

SPECIMEN

➢ EDTA is the anticoagulant of choice for all methods

➢ No special preparation, fasting specimens are not required
➢ Most methods require cell lysis with a hemolyzing reagent provided by the manufacturer prior to
loading
➢ Typically, whole blood may be stored up to 7 days at 2-8 degrees Celcius
➢ Heparinized samples
○ should be assayed within 2 days and may not be suitable for other methods
(ELECTROPHORESIS)

METHODS
 1. Cation-exchange chromatography
2. Affinity Chromatography
3. Immunoassay
4. Gel electrophoresis
5. Enzymatic assay

IMMUNOASSAY

 The latex enhanced immunoassay for HbA1c is based on the interactions between antigen
molecules HbA1c and HbA1c specific antibodies coated on latex beads
 This cross-link-reaction results in changes in the solution turbidity which is proportional to the
amount of the antigen in the samples

AFFINITY CHROMATOGRAPHY

Principle

 M-aminophyl boronic acid is immobilized by cross linking to beaded agarose or other matrix
( e.g.,glass fiber)
 The boronic acid react with the cis-diol groups of glucose
 Dissociation – by Sorbitol
 Detection- Absorbance of bound and non bound fractions measured at 415nm

ION EXCHANGE CHROMATOGRAPHY

 Hemoglobin variants are separated based on charge difference

 Bed – cation exchange resin (negatively charged)

THE PRINCIPLE

 Cation exchange chromatography

Procedure

 Preparation of hemolysate
 Preparation of column
 Bring the column to room temperature
 Remove the caps
 Snap the tip off the bottom
 Push the upper disc down to the resin surface
 Let the column drain completely to waste
REFERENCE RANGE

 Glycated Hb is expressed as a percentage

Normal (non-diabetic) <6.4%

Good Control 6.5-8.5%
Not Control >8.5%

INTERPRETATION

 Glycated Hb should be routinely monitored at least every 3 months in all insulin treated patients
 Sources of errors
 Hemolytic disease
 Shortened red blood cell survival (sicle cell disease)
 Recent blood loss
 High glycated hemoglobin
 Iron deficiency anemia
 The effect of hemoglobin variants such as Hb F, S and C

THYROID AND ANTERIOR PITUITARY GLAND

HYPOTHALAMUS
 Thyroid Function Test’s

Test Normal Range Indication

Triiodothyronine (T3) Tests Total T3 A higher-than-normal level of T3 may be a sign of:
 a thyroid hormone 60 to 180 ng/dL  Overactive thyroid gland (for example, Graves
 plays an important 0.92 to 2.76 nmol/L disease)
role in the body's  T3 thyrotoxicosis (rare)
Free T3
control of 130 to 450 pg/dL  Toxic nodular goiter
metabolism (the 2.0 to 7.0 pmol/L
many processes
that control the rate
of activity in cells
and tissues).
Thyroxine (T4) Test FREE T4 A higher than normal level of T4 may be due to
 a blood test that 0.9 to 2.3 ng/dL conditions that involve an overactive thyroid, including:
helps diagnose 12 to 30 pmol/L  Graves disease
thyroid conditions.  Taking too much thyroid hormone medicine
The thyroid is a  Thyroiditis
small, butterfly-  Toxic goiter or toxic thyroid nodules
shaped gland at the  Some tumors of the testes or ovaries (rare)
base of your throat.  Getting medical imaging tests with contrast dye
Your thyroid makes that contains iodine (rare, and only if there is a
hormones that problem with the thyroid)
control the way  Eating a lot of foods that contain iodine (very
your body uses rare, and only if there is a problem with the
energy. These thyroid)
hormones affect A lower than normal level of T4 may be due to:
your weight, heart,  Hypothyroidism (including Hashimoto disease
body temperature, and other disorders involving an underactive
muscle strength, thyroid)
and even your  Severe acute illness
mood. In children,  Malnutrition or fasting
thyroid hormones  Use of certain medicines
affect growth, too.
There are two forms of T4
in your blood:
1. Free T4 is the
active form of
thyroxine hormone
that enters your
tissues where it's
needed.
2. Bound T4 is
thyroxine that
attaches or binds to
certain proteins
which prevent it
 from entering your
tissues.
Used to check:
 Hypothyroidism
 Hyperthyroidism
 Disorders of the
pituitary gland
 Abnormal findings
of other thyroid
blood tests, such as
TSH or T3
 Symptoms of an
overactive thyroid
 Symptoms of an
underactive thyroid
 Hypopituitarism
(the pituitary gland
does not produce
enough of its
hormones)
 Lump or nodule in
the thyroid
 Enlarged or
irregular thyroid
gland
 Problems becoming
pregnant
Thyroid-stimulating TSH levels  Abnormally high TSH levels usually mean that
hormone Test 0.45 to 4.12 mU/L your thyroid is underperforming. Your pituitary
 A TSH test is a gland reacts to a lack of thyroid hormones by
blood test that producing extra TSH to make up the
measures this difference. This is called hypothyroidism.
hormone. TSH  Low TSH levels usually mean that you’re
levels that are too producing too much thyroid hormone. Your
high or too low may pituitary gland responds accordingly by
be a sign of a decreasing TSH production to get thyroid
thyroid problem function under control. This is called
hyperthyroidism.

TRH Stimulation Thyroid Procedure: Result

Test 1. Obtain 1 The key feature of the TRH stimulation test is the
 A a diagnostic test ampule of TRH change in TSH level after the TRH injection8.
that involves taking from pharmacy  Normal thyroid function: TSH rises by 2.0
an intravenous (IV) (500 µg). μU/mL or more within 60 minutes. Normal
dose of TRH to 2. Draw baseline response is 20 minute TSH value higher than
assess its effect on thyroid-stimulating 60 min TSH.
 your thyroid hormone.  Hyperthyroidism: TSH rises by less than 2.0
hormones. 3. Inject μU/mL within 60 minutes.
 can provide intravenously (IV)  Primary Hypothyroidism: TSH rises by more
information that 500 µg of TRH than 2.0 μU/mL for most people who have
may be useful in over a 1 minute primary hypothyroidism.
distinguishing period.  Secondary hypothyroidism: TSH rises by less
different types of 4. Thirty minutes than 2.0 μU/mL for about half of those with
thyroid problems.  after start of IV secondary hypothyroidism; flat response is
 this test is meant to injection, draw seen in pituitary disease.
be performed in the another TSH  Tertiary hypothyroidism: TSH rises by less
morning after level. than 2.0 μU/mL for about 10 percent of those
overnight fasting 5. Optional-60 with tertiary hypothyroidism. 60 min value
from food and minutes after start higher than 20 minute value.
drink. of IV injection,
 Thyroid hormone draw another TSH
production requires level.
many steps. Your
hypothalamus,
located in your
brain, monitors the
conditions of your
body and secretes
thyrotropin-
releasing hormone
(TRH) when you
need more thyroid
hormones. TRH
prompts your
brain's pituitary
gland to release
thyroid-stimulating
hormone (TSH).
 TSH stimulates the
thyroid gland itself
to make thyroid
hormones, T4 and
T3, which increase
your body's
metabolism to
provide you with
energy.

Radioactive iodine uptake Abnormal results mean:

test Normal Values
 Radioactive iodine  Increased (greater than 35% at 24 hours is
uptake (RAIU) tests 6 hours: 3 to 16% considered elevated):
thyroid function. It 24 hours: 8 to  Hyperthyroidism
 measures how  Hashimoto's thyroiditis (early)
much radioactive 25%  Goiter
iodine is taken up  Decreased:
by your thyroid  Hypothyroidism
gland in a certain  subacute thyroiditis
time period.  iodine overload (excessive
 Fast for 8 hours iodine ingestion)
before the test.
Procedure:
 You are given a pill
that contains a tiny
amount of
radioactive iodine.
After swallowing it,
you wait as the
iodine collects in
the thyroid.
 The first uptake is
usually done 4 to 6
hours after you take
the iodine pill.
Another uptake is
usually done 24
hours later. During
the uptake, you lie
on your back on a
table. A device
called a gamma
probe is moved
back and forth over
the area of your
neck where the
thyroid gland is
located.
 The probe detects
the location and
intensity of the rays
given off by the
radioactive
material. A
computer displays
how much of the
tracer is taken up
by the thyroid
gland.

 The test takes less

than 30 minutes,
but you will need to
come back twice to
have the scans
performed.