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VITAMINS AND MINERALS: WHAT, WHEN AND HOW MUCH
 

VITAMINS AND MINERALS: WHAT, WHEN AND HOW MUCH

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  • If the patient’s duodenum was removed as part of the bariatric surgery, which nutrients are the most likely to be malabsorbed? Iron, Ca++ and Mg++.
  • Which nutrients are most likely to be affected by achlorhydria associated with aging?
  • Name 3 good food sources of iron.
  • Name 3 good food sources of magnesium.
  • Name 3 good food sources of Calcium.
  • Who should be taking vitamin D supplements?

VITAMINS AND MINERALS: WHAT, WHEN AND HOW MUCH VITAMINS AND MINERALS: WHAT, WHEN AND HOW MUCH Presentation Transcript

  • VITAMINS AND MINERALS: WHAT, WHEN AND HOW MUCH TO SUPPLEMENT Elin Zander, RD, CD, CNSD
  • Learning Objectives
    • The learner will be able to identify patient populations that may benefit from vitamin/mineral supplementation.
    • The learner will be familiar with the research about the benefits of micronutrient supplementation to minimize the risk of certain chronic diseases.
    • The learner will understand how to modify dietary intake in order to meet the RDA for vitamins and minerals for adults.
  • Learning Objectives
    • The learner will be able to identify those micronutrients which are unlikely to be found in sufficient quantities in the standard U.S. diet.
    • The learner will be familiar with the U.S. D.R.I. categories and their implications in assessing dietary intake.
  • What are DRI’s?
    • “ Dietary Reference Intakes are the best available evidenced-based nutrient standards for estimating optimal intakes.”
    • 4 DRI’s
      • RDA
      • AI
      • EAR
      • UL
  • Recommended Dietary Allowance
    • Serves as intake goals for healthy individuals
    • Meets or exceeds the estimated requirements of 97-98% of the population
  • Adequate Intake
    • Used when data is insufficient to determine an RDA
    • Likely to exceed the actual requirements of almost all healthy people
  • Estimated Average Requirement
    • The amount estimated to meet the needs of 50% of individuals
    • RDA = 2 standard deviations above EAR
  • Upper Tolerable Intake Level
    • Above which toxicity is likely to occur
  • ADA Position Paper
    • Each individual’s true requirement for a nutrient is unknown.
    • Intakes that fall below RDA or AI should not be interpreted as inadequate w/out also assessing clinical status & biochemical indices.
    • Intakes that meet the RDA or AI should not necessarily be considered adequate w/out also taking into account other clinical factors.
  • ADA Position Paper
    • A healthy diet that provides adequate nutrients is more likely to promote healthy outcomes than will supplementation of individual nutrients.
  • ADA Position Paper
    • Intake of dietary supplements to make up for poor diet have not been proven to be effective in preventing chronic disease with the exceptions of Ca++ and Vitamin D in bone health.
  • Most Likely Deficiencies in US Diets
    • Calcium
    • Potassium
    • Magnesium
    • Vitamins A, C, D & E
    • Vitamin B-12 in older adults
  • Most Likely to be Deficient
    • Iron in adolescent females & premenopausal women
    • Folic acid in pregnant women
    • B-6 for older adults
    • Zinc for older adults & adolescent females
    • Phosphorus for peri-adolescent females
  • High Risk for Nutrient Deficiencies:
    • Restricted food intake
    • Elimination of 1 or more food groups from diet
    • Diet low in nutrient rich foods
    • Older adults
    • Pregnant women
  • High Risk for Nutrient Deficiencies
    • People who are food insecure
    • ETOH dependency
    • Strict vegetarians and vegans
    • Increased nutrient needs due to a health condition
    • Use of medication that decreases absorption, metabolism or excretion of a nutrient
  • Bariatric Surgery
    • Potential for vitamin/mineral deficits despite supplementation.
      • Especially Iron, B12, Folate, D, C, B6, Thiamine, Ca++, Mg++, Zn & Se
    • At risk for osteoporosis, neuropathy, Wernicke’s encephalopathy & anemias
  • Bariatric Surgery
    • Deficiencies mostly occur due to malabsorption from bypassing segments of the GI tract, but also can occur with simply restrictive procedures as well.
    • May also be due to decreased intake and poor tolerance to certain foods.
  • Bariatric Surgery
    • Not all patients are prescribed or are compliant with supplements.
    • Bariatric vitamin preps may not provide enough B12, Folate, or Fe
    • F/U evaluations of micronutrient status are inconsistent
  • Bariatric Surgery
    • Incidence of anemia S/P bariatric surgery as high as 74%
    • Chronic inflammation of obesity creates “iron block”
      • Up to 20% of patients are anemic before surgery
      • Ferritin >200ng/dL suggests Inflammation
      • Ferritin <40ng/dL suggests iron deficiency
  • Pop Quiz!
  • Geriatrics
    • Highest risk population for nutrition deficiencies.
    • 87% of older adults have one or more nutrition related disorders
      • HTN, DM and/or dyslipidemia
    • Nutrition status affects quality of life as well as health.
  • Geriatrics
    • Chronic undernutrition in elderly may be due to
      • Decreased access to food
      • Problems chewing and/or swallowing
    • Poor dentition
    • Oral lesions/infections
    • Periodontal disease
    • Neurological disorders
  • Geriatric Nutrition Risk Factors
    • Decreased ability to smell and taste flavors
      • Also affected by diseases & medical treatments
    • Decreased saliva production
    • Decreased appetite & early satiety
    • Poor gastric motility
  • Geriatric Nutrition Risk Factors
    • Reduced vision
    • Depression
    • Chronic pain
    • Effects of chronic diseases
      • Altered absorption, transport, metabolism or excretion of nutrients
      • Dietary restrictions
      • Drug-nutrient interactions
  • Geriatrics
    • Common micronutrient deficiencies in the elderly
    • Vitamins A, B12, C, D
    • Folate
    • Calcium
    • Magnesium
    • Zinc
  • Consequences of Deficits:
    • Poor wound healing
    • Impaired vision
    • Increased risk for diseases:
      • Certain cancers
      • Osteoporosis
      • Heart disease
      • Hypertension
  • Consequences of Deficits
    • Impaired immune function
    • Altered glucose and lipid metabolism
    • Decreased mental acuity/dementia
    • Depression
    • Bone fractures
    • Declining muscle function
  • Consequences of Deficits
    • Reduced ability to taste
    • Anemia
    • Poor appetite
    • Fatigue
    • Insomnia
  • Geriatrics
    • May benefit from Vitamins B12 & D +/- Ca++ supplements even if eating a healthy diet.
    • Standard multivitamin supplement may decrease risk of heart disease, improve immune function & decrease healthcare costs.
    • Avoid supplements providing high doses of Vitamin E, beta-carotene, & Vitamin A as may increase mortality risk.
  • Pop Quiz!
  • Iron
    • Most common nutrient deficiency worldwide
    • Microcytic, hypochromic anemia is a late sign of, and indicates severe Fe deficiency
      • Use of Hgb for diagnosing Fe deficiency delays detection of IDA
  • Consequences of Fe Deficiency
    • Diminished work capacity
    • Impaired thermoregulation
    • Immune dysfunction
    • GI disturbances
    • Neurocognitive impairment in children
  • Consequences of Fe Deficiency
    • In pregnancy increased risk for:
      • LBW
      • Preterm delivery
      • Perinatal mortality
      • Infant & young child mortality
      • Maternal mortality
  • Consequences of Fe Deficiency
    • Anemia in CHF + CKD (cardiorenal anemia syndrome) increases risk of poor outcomes
    • Early treatment of anemia in CHF and CKD has been shown to decrease LOS and improve patient outcomes and QOL
  • Risk for Iron Deficiency
    • Premenopausal women
    • Young children
    • Elderly hospitalized patients requiring frequent lab draws
    • GIB or any blood loss (including blood donation)
    • Malabsorption
  • Risk for Iron Deficiency
    • Gastric cancer
    • Gastric resection & bariatric surgery
    • Celiac disease
    • Poor intake/vegetarianism
    • IBD
    • CHF
    • Chronic use of NSAIDS
  • Risk for Iron Deficiency
    • CKD
    • Athletes
    • Low income pregnant women
    • African American & Hispanic females
    • Elderly
    • Chronic illness (ACD)
  • Risk for Iron Deficiency
    • H Pylori infection
    • Use of H2 blockers, proton pump inhibitors or antacids
    • Altered hepatic function & protein malnutrition (altered absorption)
  • Stages of Fe Deficiency
    • Negative iron balance
    • Iron depletion
    • Iron deficient RBC synthesis – only after stores are completely depleted
    • IDA
  • Diagnosis of Fe Deficiency
    • Ser Ferritin measures body stores of iron
      • Low value unequivocally identifies IDA
      • <25ug/L suggests early negative iron balance
    • Decreased ser ferritin combined with low transferrin saturation & microcytic, hypochromic RBC is definitive confirmation of IDA
    • Problem: Ferritin is elevated in inflammation
  • Diagnosis of Fe Deficiency
    • Evaluate ser Ferritin, serum transferrin receptor (STfr), & CRP
      • IDA = Low ser Ferritin + elevated STfr + WNL CRP
      • ACD = Normal to elevated ser Ferritin + Normal STfr + CRP >30
      • Concurrent IDA & ACD indicated by elevated STfr and CRP
  • Treating Iron Deficiency
    • Oral supplementation + iron rich food sources
    • Ferrous sulfate or gluconate taken with a source of vitamin C
      • GI side effects common – need to follow for tolerance and compliance
    • Avoid medications and foods that reduce iron absorption
      • Tea tannins/phytates
  • Indications for Parenteral Fe
    • High iron requirements
    • Iron malabsorption
    • Intolerance to oral therapy
  • Parenteral Iron
    • Calculation of parenteral iron replacement dose:
      • Dose(mg)=0.3 X wt(#) X (100 – [actual Hgb(g/dL) X 100/desired Hgb(g/dL])
  • Pop Quiz
  • Magnesium
    • Pregnant women with diets higher in fiber, K+, Ca++, and Mg++ may have reduced risk for developing preeclampsia
    • Mg++ deficiency has been implicated in pathogenesis of cardiac arrhythmias, ischemic heart disease, HTN, CHF, CVAs, and vascular disease associated with DM
  • Magnesium
    • Link between low intakes and HTN
    • Deficiency may be common, especially in the elderly
    • K+ and Mg++ important in the preservation of bone structure with aging.
  • Magnesium
    • Inverse relationship between dietary intake of Mg++ and risk for DM2.
    • Inverse relationship between dietary intake of Mg++ and metabolic syndrome.
    • Important to address Mg++ levels whenever treating hypokalemia and hypocalcemia.
  • Magnesium
    • Consumption of hard vs soft water may decrease cardiovascular risk
    • MgCl & Mg Lactate are more bioavailable than MgO4
      • Enteric coating can decrease absorption & bioavailability
    • Lag of up to 6 days between IV Mg++ infusion and rise in serum levels
  • Pop Quiz
  • Calcium
    • Majority of Americans of all age groups do not meet RDA’s
    • Osteoporosis is prevented by lifelong adequate intake
      • Supplementation in females during pubertal growth spurt can significantly increase bone accretion
  • Calcium
    • Absorption increased by:
      • Adequate vitamin D
      • Higher BMI
      • Fat intake
    • Absorption decreased by:
      • High dietary Ca++ intake
      • Dietary fiber
      • Alcohol intake
      • Physical activity
  • Calcium Supplements
    • CaCitrate
      • more bioavailable than CaCarbonate
      • contains 21% Ca++ (have to take more pills)
      • supplement of choice in patients using H2 blockers or PPI, IBD, achlorhydria or absorption disorders.
  • Calcium Supplements
    • CaCarbonate
      • contains 40% Ca++
      • Best absorbed when taken with a meal
    • Ca Lactate contains 13% elemental Ca++
    • Ca Gluconate contains 9% elemental Ca++
    • Bone meal Ca++ not currently recommended as supplement
  • Calcium Supplements
    • Dosing: absorption best when taken in doses of 500mg or less
    • Look for supplements that have been verified by USP ( www.uspverified.org ) or CL ( www.consumberlab.com )
    • High calcium intakes (>1500mg/day) may increase risk of prostate CA
  • Calcium Fortified Foods
    • Bioavailability varies considerably
      • Calcium citrate malate more bioavailable than tricalcium phosphate/calcium lactate
    • Ca can precipitate out and settle to the bottom of the container (soy & rice milk)
    • High calcium mineral water may be a good source of Ca++
  • Pop Quiz!
  • Vitamin D
    • Promotes Ca++ absorption
    • Maintains ser Ca++ and Phos levels
    • Enables normal bone mineralization
    • Prevents hypocalcemic tetany
    • Promotes bone growth & bone remodeling
  • Vitamin D Functions
    • Modulation neuromuscular function
    • Modulation of immune function
    • Suppression of inflammation
    • Modulation of many genes that encode proteins and regulate cell proliferation, differentiation and apoptosis
  • Vitamin D
    • Humans have evolved to meet the majority of their vitamin D needs by cutaneous synthesis
      • Found in high amounts in only a few foods
      • Highly unlikely to achieve adequate intake from food alone
    • Studies have shown prevalence of hypovitaminosis D to be 36-100% in various populations around the world.
  • Risk of Vitamin D Deficiency
    • Limited exposure to sunlight
      • Use of sunscreen
      • Residing north of LA
    • Kidneys disease
    • Dark skin
    • Elderly
    • Obesity (sequestering of vitamin in subQ fat)
  • Vitamin D – Recent Research
    • Hypovitaminosis D associated with increased risk for mortality due to cardiovascular disease
    • Association between deficiency and poor LE muscle performance, gait imbalance and increased risk of falls
      • Supplementation shown to reduce the risk of falls among older individuals by > 20%
  • Vitamin D – Recent Research
    • Vitamin D may have an important role in regulating the immune system
      • Preadmission vitamin D status may affect the risk and severity of hospital-acquired infections
    • Link between low vitamin D levels and the incident of DM2 and cardiovascular disease.
    • May also play a role in preventing DM1.
    •  
  • Vitamin D – Recent Research
    • Vitamin D status may protect against certain cancers.
    • Link between sunlight exposure and cancer incidence or survival.
    • The risk of developing and dying of prostate, breast, colon, ovarian, esophageal, NHL, stomach, pancreatic, rectal, kidney, lung & bladder cancer correlates with living at higher latitudes.
  • Vitamin D – Recent Research
    • Hypovitaminosis D may increase risk of developing IBD.
      • IBD incidence higher in northern climates.
    • Inverse relationship between vitamin D status and development of MS.
      • Women with the highest vitamin D intakes had a 40% reduction in risk for developing MS.
  • Vitamin D – Recent Research
    • Evidence that vitamin D deficiency associated with musculoskeletal pain in both children and adults
      • Adults and children w/ persistent musculoskeletal pain who did not meet criteria for fibromyalgia are often vitamin D deficient.
  • Vitamin D – Cutaneous Synthesis
    • Adequate synthesis can be achieved by exposing arms and legs to sunlight 2-3 times per week for about 5-10 minutes
      • Depending on where you live & time of year.
    • Synthesis in elderly reduced by up to 70%.
    • People with dark skin color require 5-10 times longer exposure to sunlight.
    • SPF 8 sunscreen reduces synthesis by 95%.
  • Vitamin D
    • Anticipated new DRI’s for Vitamin D
      • RDA increased to 1,000 IU/day for adults
      • UL increased from 2000 IU to 10,000 IU
      • Goal serum levels of D (25[OH] >30ng/mL with optimal levels being 36-40ng/mL
    • Vitamin D3 better than D2
  • Vitamin D Supplementation
    • Enteral formulas inadequate in Vitamin D.
    • Vitamin D content of CPN likely inadequate as well.
      • No high dose form of parenteral vitamin D.
      • No individual form of parenteral vitamin D.
    • Patients may benefit from exposure to UVB light from a tanning bed
  • Pop Quiz!
  • Micronutrients in CPN
    • ASPEN recommendations:
    • Magnesium 8-24mEq/Day
    • Potassium 1-2mEq/kg/Day
    • Sodium 1-2mEq/kg/Day
    • Phosphorus 15-30mMole/Day
    • Calcium 10-20mEq/Day
  • Micronutrients in ANS
    • Transient decrease in ionized Ca++ increases PTH levels and resorption of bone
    • Chronic inadequate Ca++ intake in CPN can lead to secondary hyperparathyroidism & bone disease.
  • Micronutrients in ANS
    • Critically ill patients often have preexisting micronutrient deficiencies
      • Zn, Fe, Se, and vitamins A, B & C
    • Deficiencies may also occur due to inadequate concentrations in TF/PN formulas or because of increased losses/ requirements .
  • Micronutrients in ANS
    • Micronutrient requirements in critically ill patients are not known.
    • Serum levels of some micronutrients are decreased in critical illness/inflammatory response:
      • Vitamins E, C & A
      • Se, Cu, Fe & Zn decreased due to sequestration
  • Micronutrients in ANS
    • Serum levels of vitamins 25(OH)D, B12 & folate are the only ones easily available and of clinical use in assessing vitamin status
    • Interactions between vitamins are complex
      • Vitamin C recycles vitamin E, thus vitamin C deficiency decreases the function of vitamin E
      • Vitamin A function is antagonized by excess vitamin E
      • Requirements for niacin are increased in vitamin B6 and riboflavin deficiencies
  • Micronutrients in ANS
    • Composition of commercially available TE preps far from ideal.
    • Recent autopsy of patients on long term CPN:
      • Tissue levels of Cu, Mn & Cr elevated
        • Recommended decreased doses
      • Recommended higher levels of Se (60-100ug)
  • Manganese (Mn)
    • Risk of toxicity w/ long-term CPN.
      • More likely to occur in cholestatic patients.
        • Primary route of excretion is bile
      • Deposition in the brain has been reported in patients w/ and w/out cholestasis.
      • Mn contamination in PN solutions
      • Current TE produces provides 2-8X the recommended intake
  • Manganese (Mn)
    • Whole blood manganese the most accurate indicator of tissue level
    • Recommendation:
      • Monitor every 3 months in patients w/out cholestasis.
      • Monitor monthly in patients with T Bili >3.5
  • Selenium (Se)
    • Deficiency may be as high as 16% despite addition of Se to CPN
      • Increased risk of deficiency w/ SB resection, IBD & other GI disorders.
    • Risk of toxicity low.
    • Best indicators of recent Se intake & deficiency: Serum selenium, RBC-glutathione peroxidase & urinary Se levels.
  • Selenium (Se)
    • No reliable indicator for toxicity.
    • Recommendation:
      • Add Se to all PNs.
      • Check serum Se prior to starting PN if deficiency is suspected or is being treated.
      • Monitor every 3 months if deficiency found.
  • Zinc (Zn)
    • Deficiency more common in patients w/ increased pancreatic or GI fluid losses
    • Zn balance achieved with 3mg/day in PN
      • Add 17mg/kg of ileostomy or stool output in patients w/ intact SB
      • Add 12mg/kg of fluid losses from proximal SB fistula or duoden- or jejunostomy
  • Zinc (Zn)
    • Serum or plasma Zn not good indicators of status
      • Sequestered by liver during sepsis
    • Recommendation: Check ser Zn if deficiency is suspected or being treated.
  • Chromium (Cr)
    • Present as a significant contaminant of PN solutions
    • No known cases of Cr toxicity in PN patients
    • Excreted in urine, therefore may need to restrict in patients with renal failure
    • Plasma and serum Cr not good indicators of status.
  • Chromium (Cr)
    • Optimal amount to add to PN unknown.
    • Recommendations:
      • Consider smaller doses of for patients with renal failure
      • Patients who develop hyperglycemia and neuropathy should be treated with Cr and monitored for resolution of symptoms.
  • Copper (Cu)
    • Risk of toxicity in cholestatic liver disease
      • ~80% excreted in bile
    • Risk of deficiency with prolonged, excessive GI losses
    • Current TE additives provide > twice the Cu requirement
    • Deficiency can occur in 1-30 months on Cu-free CPN even in cases of cholestasis
  • Copper (Cu)
    • Serum Cu is reliable indicator of Cu deficiency but not toxicity
      • However, Cu typically removed or decreased in CPN if ser Cu elevated in cholestatic patients
    • Recommendation: Check serum Cu if deficiency or toxicity is suspected and every 3 months for patients with elevated T Bili.
  • Iron (Fe)
    • Not typically provided in PN solutions.
    • Not stable in 3-in-1 admixtures.
    • If patient has functional stomach and duodenum can likely supplement orally, taken with a source of vitamin C.
    • Recommendation: Check iron status every 3 months
  • Molybdenum (Mo)
    • May be present as contaminant in PN solutions.
    • Deficiency in PN patients rare.
    • Ser Mo may not be a reliable indicator of status. Elevated plasma methionine may indicate Mo deficiency.
  • Conclusions
    • Assessing micronutrient intake and status of patients is difficult
    • Probably safe to assume that micronutrient status of majority of our patients is far from optimal
    • Understand that many will be unable to improve their dietary intake substantially and consistently
    • When in doubt – supplement!
  • Conclusions
    • Helpful websites:
      • http://ods.od.nih.gov/Health_Information/Vitamin_and_Mineral_Supplement_Fact_sheets.aspx
      • Up to date information on micronutrients
      • http://fnic.nal.usda.gov/interactiveDRI/
      • Individual’s DRI’s based on age, gender and weight
  • Conclusions
    • More Websites:
      • http://www.mypyramidtracker.gov/
      • Compares food intake to DRI’s for most micronutrients
      • http://www.ars.usda.gov/Services/docs.htm?docid=18877
      • Provides list of individual micronutrient content of foods (either alphabetically or by highest to lowest content)
  • Conlusions
    • If your client is taking a supplement – ask them to bring it in so you can look at it!
      • Check nutrients provided
      • Check % RDA provided
      • Check form of nutrient
  • Conclusions
    • Important to know when supplementation is indicated and when it is contraindicated
      • Fe supplements in non-iron deficient men
      • Beta-carotene in smokers
      • Vitamin E before surgery
  • Conclusions
    • Pay attention to drug-nutrient interactions
      • Fe supplements inhibit Zn absorption
      • Zn supplements inhibit Cu absorption
      • Anticonvulsants may increase need for folate
      • Steroids may deplete Ca++ and impair Vitamin D metabolism
  • Conclusions
    • As RD’s we should own micronutrient management in ANS!
  • Questions?