the harm and benefit of supplements and vitamins

1. ‫غذایی‬ ‫رژیم‬ ‫مکملهای‬
Dietary Supplements
By : Somayyeh Nasiripour,pharm.D-
Ph.D.
Assistant professor at IUMS
Assistant professor at IUMS

2. ‫تعریف‬
‫آمريكا‬ ‫در‬
‫غذايي‬ ‫ماده‬ ‫چند‬ ‫يا‬ ‫يك‬ ‫حاوي‬ ‫كه‬ ‫شود‬ ‫مي‬ ‫اطالق‬ ‫محصولي‬ ‫به‬ ‫غذايي‬ ‫مكمل‬
‫مثل‬ ‫ويژه‬
‫آمينه‬ ‫اسيدهاي‬ ،‫گياهي‬ ،‫معدني‬ ‫مواد‬ ،‫ها‬ ‫ويتامين‬‫بوده‬ ‫مواد‬ ‫ساير‬ ‫يا‬
‫صورت‬ ‫به‬ ‫و‬
‫شده‬ ‫مصرف‬ ‫دهان‬ ‫راه‬ ‫از‬ ‫مايع‬ ‫يا‬ ‫كپسول‬ ،‫قرص‬
‫باعنوان‬ ‫برچسب‬ ‫و‬
dietary supplement
‫باشد‬ ‫داشته‬.
2

3. • Use of any dietary supplements: 50% of
Americans (aged ≥ 1 year)
• Regular use of multivitamin–multimineral (MVM)
supplements: 30% to 40% of Americans
• Nearly 16% of prescription drug users also
report having taken a dietary supplement at the
same time

4. •‫سال‬ ‫در‬ ‫که‬ ‫ان‬‫ر‬‫ای‬ ‫در‬ ‫ای‬ ‫مطالعه‬ ‫در‬2010‫میان‬ ‫از‬،‫است‬ ‫شده‬ ‫منتشر‬
1004‫ان‬‫ر‬‫ته‬ ‫غرب‬ ‫در‬ ‫بالغ‬ ‫فرد‬:
–42%‫می‬‫مکمل‬ ،‫ویتامین‬ ‫مولتی‬ ‫مکمل‬ ‫گذشته‬‫یکسال‬ ‫طی‬ ‫اد‬‫ر‬‫اف‬‫یا‬ ‫ال‬‫ر‬‫ن‬
‫بودند‬ ‫کرده‬ ‫استفاده‬ ‫دو‬ ‫هر‬ ‫ی‬‫حاو‬ ‫مکمل‬
–4/9%‫ی‬‫حاو‬ ‫مکملهای‬‫از‬Omega-3 fatty acids or fish
oil‫بودند‬ ‫کرده‬‫استفاده‬
IRANIAN JOURNAL OF ENDOCRINOLOGY AND METABOLISM (IJEM) NOVEMBER
2010; 12(4 (SN 52)):375-365.

5. •‫سال‬ ‫اواخر‬ ‫از‬ ‫که‬ ‫ای‬ ‫مطالعه‬ ‫در‬2010‫سال‬ ‫اواسط‬ ‫تا‬2011‫در‬
‫ی‬ ‫س‬‫ر‬‫بر‬ ‫گیاهی‬‫غیر‬ ‫مکملهای‬ ‫مصرف‬ ‫گردید‬ ‫انجام‬ ‫گیالن‬ ‫استان‬‫شد‬:
•‫میان‬ ‫از‬1425‫و‬ ‫ن‬‫ز‬676‫بالغ‬ ‫مرد‬
•‫ویتامین‬ ‫مولتی‬ ،‫کلسیم‬ ،‫آهن‬ ‫مکملهای‬ ‫از‬ ‫یکی‬ ‫مصرف‬ ‫ان‬‫ز‬‫می‬/‫مولتی‬
‫ماهی‬ ‫غن‬‫و‬‫ر‬ ‫و‬ ‫ال‬‫ر‬‫مین‬
•‫آقایان‬ ‫در‬20%
•‫خانمها‬ ‫در‬48/4%

6. o‫حدود‬ ‫که‬‫شود‬ ‫می‬‫ده‬‫ز‬ ‫تخمین‬29000‫در‬ ‫غذائی‬‫مکمل‬ ‫نوع‬
‫سال‬ ‫هر‬‫در‬ ‫و‬ ‫د‬‫ر‬‫دا‬ ‫وجود‬ ‫دنیا‬ ‫ار‬‫ز‬‫با‬1000‫هم‬‫جدید‬ ‫ل‬‫محصو‬
‫شود‬ ‫می‬ ‫عرضه‬‫ار‬‫ز‬‫با‬‫به‬.
o‫محصوالت‬ ‫این‬ ‫تولید‬‫گسترش‬ ‫ی‬ ‫اساس‬ ‫علت‬=‫ب‬ ‫ی‬‫ر‬‫سودآو‬‫ی‬
‫آنها‬ ‫نظیر‬
o‫صنای‬ ‫عنوان‬‫به‬ ‫ا‬‫ر‬ ‫ها‬‫مکمل‬ ‫تولید‬ ‫صنعت‬ ،‫دنیا‬ ‫در‬‫ه‬‫ز‬‫و‬‫امر‬‫ع‬
‫شناسند‬ ‫می‬‫ی‬‫دالر‬ ‫ن‬‫بیلیو‬

7. •‫ند‬‫ر‬‫دا‬ ‫ی‬‫کالر‬ ‫کم‬ ‫غذایی‬‫یم‬‫ژ‬‫ر‬ ‫که‬ ‫ادی‬‫ر‬‫اف‬(‫از‬ ‫کمتر‬1600‫ی‬‫کالر‬
‫ز‬‫و‬‫ر‬ ‫در‬)
•‫پایبندند‬ ‫کامل‬ ‫ی‬‫گیاهخوار‬‫یم‬‫ژ‬‫ر‬ ‫به‬ ‫کسانیکه‬
•‫ی‬‫ر‬‫و‬‫بار‬ ‫سنین‬‫در‬ ‫یا‬ ‫دار‬‫ر‬‫با‬ ‫خانمهای‬
•‫ند‬‫ر‬‫ندا‬ ‫غذایی‬‫یم‬‫ژ‬‫ر‬ ‫از‬ ‫کافی‬ ‫یافت‬‫ر‬‫د‬ ‫که‬ ‫ساملندانی‬
•‫انتخاب‬ ،‫ی‬‫بیمار‬ ‫و‬ ‫پزشکی‬ ‫ایط‬‫ر‬‫ش‬ ‫دلیل‬ ‫به‬ ‫که‬ ‫ادی‬‫ر‬‫اف‬‫های‬
‫ند‬‫ر‬‫دا‬‫محدودی‬ ‫غذایی‬

8. • Decrease disease risk
• Compensate for perceived nutritional
deficiencies
• Provide energy
• Adhere to physician recommendations
• Promote general health

9. •‫داد‬ ‫نشان‬‫آمریکا‬ ‫متحده‬ ‫ایاالت‬‫در‬ ‫ملی‬ ‫ای‬ ‫مطالعه‬:
–‫احتیاطات‬‫و‬ ‫ایط‬‫ر‬‫ش‬،‫علت‬ ،‫جایگاه‬‫د‬‫ر‬‫مو‬ ‫در‬ ‫کنندگان‬‫مصرف‬ ‫د‬‫ر‬‫موا‬ ‫بیشتر‬‫در‬
‫کنند‬ ‫نمی‬‫صحبت‬ ‫خود‬ ‫ساز‬‫و‬‫دار‬ ‫یا‬‫پزشک‬ ‫با‬‫مکملها‬‫مصرف‬.
•‫آنها‬ ‫با‬‫مانی‬‫ر‬‫د‬ ‫خود‬‫و‬‫ها‬‫مکمل‬ ‫مصرف‬ ‫به‬ ‫مردم‬‫دن‬‫ر‬‫آو‬‫و‬‫ر‬ ‫دالیل‬:
–‫است‬‫مردم‬‫دسترس‬ ‫در‬ ‫نسخه‬ ‫به‬ ‫نیاز‬‫ن‬‫بدو‬ ‫ها‬ ‫ده‬‫ر‬‫او‬‫ر‬‫ف‬‫این‬
–‫هستند‬ ‫خطر‬‫بی‬ ‫و‬ ‫ایمن‬‫طبیعی‬‫های‬ ‫ده‬‫ر‬‫آو‬‫ر‬‫ف‬‫که‬‫ر‬‫تصو‬ ‫این‬(‫های‬‫مکمل‬‫د‬‫ر‬‫مو‬ ‫در‬‫با‬
‫گیاهی‬ ‫و‬ ‫طبیعی‬ ‫منشا‬)
–‫گسترده‬‫تبلیغات‬

10. Nutrition Survey in older children (>4)
 1.5% of boys and 5% of girls were anaemic
 13% and 27% were mildly iron deficient
 10% of boys and 20% of girls a poor intake of
zinc
 Vitamin A deficiency were 10% and 11%
 For magnesium the respective figures were 12%
and 27%
Why we use dietary supplements?
10/30/2016
10

11. • Distinguished from Drugs:
• Drugs are intended to diagnose, cure,
mitigate, treat, or prevent disease
• Both intended to affect structure and function
of body
• Drug must undergo FDA approval after
clinical studies to determine effectiveness and
safety
• D/S no pre-market testing
‫غذایی‬‫یم‬‫ر‬‫ژ‬‫مکملهای‬:‫غذا؟‬‫یا‬ ‫و‬‫دار‬

12. • Distinguished from Foods:
– Foods not intended to affect structure
and function of body.
– D/S intended only to supplement diet:
• Not represented for use as
conventional food
• Not intended as sole item of a meal
or the diet”
‫غذایی‬‫یم‬‫ر‬‫ژ‬‫مکملهای‬:‫غذا؟‬‫یا‬ ‫و‬‫دار‬

13. ‫غذایی‬‫یم‬‫ر‬‫ژ‬‫مکملهای‬:‫غذا؟‬‫یا‬ ‫و‬‫دار‬
‫غذایی‬ ‫های‬ ‫مکمل‬:
•‫شوند‬ ‫می‬‫مصرف‬ ‫ش‬‫ر‬‫گوا‬ ‫دستگاه‬ ‫اه‬‫ر‬‫از‬
–‫اکی‬‫ر‬‫خو‬‫شکل‬:‫و‬،‫قطره‬،‫اکی‬‫ر‬‫خو‬‫ل‬‫آمپو‬،‫ل‬‫ژ‬‫سافت‬،‫ل‬‫انو‬‫ر‬‫گ‬،‫پودر‬،‫شربت‬،‫قرص‬،‫ل‬‫کپسو‬‫قه‬‫ر‬
‫اکی‬‫ر‬‫خو‬‫های‬
•‫ند‬‫و‬‫ر‬‫نمی‬ ‫کار‬ ‫به‬ ‫تنها‬ ‫غذایی‬‫وعده‬ ‫یک‬ ‫یا‬‫و‬ ‫معمولی‬ ‫غذای‬‫یک‬ ‫عنوان‬ ‫به‬
•‫آن‬ ،‫چربیها‬ ،‫قندها‬ ،‫آمینه‬ ‫اسیدهای‬ ،‫گیاهان‬،‫معدنی‬‫مواد‬، ‫ها‬ ‫ویتامین‬‫زیم‬
‫ک‬‫تکمیل‬ ‫مواد‬ ،‫متابولیت‬،‫شده‬ ‫تغلیظ‬ ‫ماده‬‫یک‬ ،‫ها‬ ‫بیوتیک‬‫و‬‫پر‬ ،‫ها‬‫یا‬ ‫و‬ ‫ننده‬
‫ه‬‫ر‬‫عصا‬
•‫ی‬‫گیر‬‫ه‬‫ز‬‫اندا‬‫قابل‬ ‫ثابت‬‫و‬‫خاص‬ ‫ن‬‫فرموالسیو‬ ‫ای‬‫ر‬‫دا‬
•‫ی‬‫ر‬‫د‬ ‫ایش‬‫ز‬‫اف‬،‫ای‬ ‫تغذیه‬ ‫نیاز‬ ‫تکمیل‬ ‫ر‬‫منظو‬ ‫به‬ ‫انسان‬‫در‬‫برد‬‫ر‬‫کا‬ ‫جهت‬‫افت‬
‫باشند‬ ‫می‬‫یک‬‫ژ‬‫فیزیولو‬ ‫اثر‬ ‫یک‬‫ایجاد‬‫یا‬ ‫و‬ ‫ای‬ ‫تغذیه‬

14. ‫غذایی‬‫یم‬‫ر‬‫ژ‬‫مکملهای‬:‫غذا؟‬‫یا‬ ‫و‬‫دار‬
•‫تک‬ ‫ا‬‫ر‬ ‫غذایی‬ ‫یم‬‫ژ‬‫ر‬ ‫در‬ ‫اولیه‬ ‫مغذی‬ ‫ماده‬ ‫چند‬ ‫یا‬ ‫یک‬ ‫کمبود‬ ‫یا‬ ‫و‬ ‫فقدان‬‫میل‬
‫نمایند‬ ‫می‬
‫و‬
•‫م‬ ‫دستگاههای‬‫اختالالت‬ ‫از‬ ‫ی‬‫پیشگیر‬ ‫یا‬ ‫و‬ ‫عملکرد‬ ‫تقاء‬‫ر‬‫ا‬ ‫طریق‬ ‫از‬‫ختلف‬
‫کنند‬ ‫می‬ ‫اهم‬‫ر‬‫ف‬ ‫ا‬‫ر‬‫سالمت‬ ‫ایش‬‫ز‬‫اف‬ ‫موجبات‬ ‫بدن‬
•‫ب‬ ‫یک‬ ‫از‬ ‫مانی‬‫ر‬‫د‬‫یا‬ ‫و‬ ‫ی‬‫پیشگیر‬ ،‫ی‬ ‫تشخیص‬ ‫ادعای‬ ‫هیچگونه‬
ً
‫ضمنا‬‫ی‬‫یمار‬
‫ند‬‫ر‬‫ندا‬ ‫ا‬‫ر‬ ‫خاص‬

17. Serving Size
•‫باشد‬ ‫مي‬ ‫انه‬‫ز‬‫و‬‫ر‬ ‫ت‬‫ر‬‫صو‬‫به‬ ‫ل‬‫محصو‬ ‫مصرف‬ ‫ر‬‫دستو‬
•‫واحدها‬ ‫ه‬‫ز‬‫اندا‬Serving size):)‫از‬ ‫ها‬ ‫مکمل‬ ‫د‬‫ر‬‫مو‬ ‫در‬3–1‫عدد‬
‫است‬ ‫متغیر‬ ‫ز‬‫و‬‫ر‬ ‫در‬
•‫ا‬‫نیز‬ ‫و‬ ‫مغذی‬ ‫ماده‬ ‫و‬ ‫موثره‬ ‫مواد‬ ‫ان‬‫ز‬‫می‬ ‫د‬‫ر‬‫مو‬ ‫در‬ ‫قضاوت‬ ‫در‬ ‫موضوع‬ ‫این‬‫ز‬
‫شود‬ ‫لحاظ‬ ‫باید‬ ‫اقتصادی‬ ‫بعد‬.

18. Dietary reference intakes (DRIs)
represent four concepts
• Recommended Dietary Allowance
• average daily intake that is sufficient to meet the
dietary requirement of nearly all healthy peopleRDA
• Adequate Intake
• is used when the RDA cannot be determined
AI
• Estimated Average Requirement
EAR
• Tolerable Upper Level
• maximum daily intake of a nutrient that is likely to
pose no risk of adverse effectsUL

19. Daily Value
• The Percent Daily Value on the Nutrit containing 60
mg vitamin C is considered to provide 100% of the
daily value
• If the label lists 15 percent for calcium, it means
that one serving provides 15 percent of the calcium
you need each day

20. ‫بر‬ ‫ها‬ ‫مکمل‬ ‫برچسب‬ ‫خصوصیات‬
‫ان‬‫ر‬‫ای‬ ‫قوانین‬ ‫اساس‬
•‫ی‬ ‫س‬‫ر‬‫فا‬ ‫بان‬‫ز‬ ‫به‬‫چسب‬‫بر‬‫اطالعات‬ ‫ائه‬‫ر‬‫ا‬
•‫جمله‬ ‫درج‬"‫ی‬‫و‬ ‫ی‬‫پیشگیر‬،‫تشخیص‬ ‫برای‬‫ل‬‫محصو‬ ‫این‬‫ا‬
‫باشد‬ ‫نمی‬‫ی‬‫بیمار‬ ‫مان‬‫ر‬‫د‬"

21. ‫انه‬‫و‬‫پر‬ ‫ه‬‫ر‬‫شما‬ ‫درج‬
‫و‬ ‫بهداشتی‬IRC
‫شکل‬‫و‬ ‫تعداد‬
‫ده‬‫ر‬‫فرآو‬
‫مصرف‬ ‫طریقه‬
‫شده‬ ‫توصیه‬
‫ت‬‫ر‬‫عبا‬ ‫درج‬"
‫یمی‬‫ژ‬‫ر‬ ‫مکمل‬
‫غذایی‬"
‫و‬‫تولید‬‫یخ‬‫ر‬‫تا‬
‫ء‬‫انقضا‬
‫مصرف‬‫میزان‬
‫شرایط‬
‫ی‬‫نگهدار‬
‫منع‬‫د‬‫ر‬‫موا‬
‫و‬‫مصرف‬
‫ها‬‫ر‬‫هشدا‬
‫و‬ ‫س‬‫ر‬‫وآد‬ ‫نام‬
‫تماس‬ ‫ه‬‫ر‬‫شما‬
‫د‬‫ر‬‫وا‬ ‫شرکت‬
‫کننده‬
‫د‬‫ر‬‫موا‬
‫مصرف‬

23. — Vitamins
• vitamins (with the exception of vitamin D)
cannot be synthesized by humans, they need
to be ingested in the diet to prevent disorders
of metabolism
• Pregnancy and alcohol consumption may
increase requirements for some vitamins.

25. Testing
• — Measurement of serum levels of several
vitamins is widely available
• Inadequate intake or low serum levels of some
vitamins can be associated with biochemical
abnormalities.
• As examples, the serum concentration of
homocysteine rises with diets low in folic acid,
methylmalonic acid rises with low intake of
vitamin B12, and parathyroid hormone rises
with low intake of vitamin D
• improve with increasing intake

26. FOLIC ACID
• Folate is the natural form of the vitamin
found in food and is present in green, leafy
vegetables, fruits, cereals, grains, nuts, and
meats.
• Folic acid is the synthetic form of the vitamin
that is included in supplements and food
fortification, has many of the same biologic
effects as folate, but is more bioavailable and
therefore more effective dose for dose

27. • Overall, the only well-established benefit of
folic acid supplementation is the prevention
of neural tube defects because folate is
required for normal cell division

28. Flate in Cancer
• Biologic and observational evidence suggest that sufficient folate
intake might prevent cancers in certain populations at risk as
Folate deficiency may contribute to aberrant DNA synthesis and
carcinogenesis
• In a 2013 meta-analysis of randomized trials of folic acid in patients
with colorectal adenoma (3 trials; n = 2652) or for prevention of
cardiovascular disease (10 trials; n = 46,969), during an average of
5.2 years of treatment, there was no significant difference in overall
cancer incidence for patients assigned to folic acid or placebo (7.7
versus 7.3 percent; RR 1.06, 95% CI 0.99-1.13)
• One limitation of the included trials is that the average duration of
intervention (five years) is short and may not be sufficient to
characterize long-term benefits or harm of folic acid
supplementation. In addition, the trials do not address underlying
nutrition status and other preventive measures.

29. Since the evidence is
inconclusive, we recommend
not taking folic acid
supplementation for the sole
purpose of reducing cancer
risk.

30. Folic acid in Cardiovascular disease
• High levels of homocysteine are associated with
an increased risk of cardiovascular disease.
• Supplementation with folic acid, vitamin B6,
and vitamin B12 can lower homocysteine levels.
• However, meta-analyses of randomized trials of
supplementation for secondary prevention do
not support the hypothesis that these vitamins
prevent cardiovascular disease

31. Folic aci & risk of hypertension
• High folate intake may reduce the risk of
hypertension.
• Still There is insufficient evidence to
recommend folic acid supplementation to
reduce the risk of hypertension

32. Folic aci & hearing loss.
• There is conflicting observational evidence
about whether increased serum folate levels
are associated with a decreased risk of age-
related hearing loss

33. • Calcium/vitamin D

34. • first step in the prevention or treatment of osteoporosis is ensuring
adequate nutrition, particularly maintaining an adequate intake of
calcium and vitamin D
• Vitamin D enhances intestinal absorption of calcium and phosphate.
Low concentrations of vitamin D are associated with impaired calcium
absorption, a negative calcium balance, and a compensatory rise in
parathyroid hormone, which results in excessive bone resorption.
• calcium and vitamin D alone are insufficient to prevent bone loss

35. OPTIMAL INTAKE
postmenopa
usal women
• 1200 mg of calcium (total of diet and supplement) and
800 int. units of vitamin D daily with osteoporosis
premenopausal
women or in men
with osteoporosis
• 1000 mg of calcium (total of diet and supplement) and
600 int. units of vitamin D
We recommend not administering yearly high-dose (eg, 500,000
units) vitamin D.
total intake of calcium (diet plus supplements) should not routinely exceed
2000 mg/day

36. • Optimal intake can be achieved with a combination of
diet plus supplements
• prefer that as much as possible (at least half) of the
calcium come from dietary sources.
• supplements are not less effective than calcium found
naturally in dairy products. However, supplements may
have more adverse effects, particularly kidney stones.

39. Calcium
•cheapest and therefore often a good first choice
•absorption is better when taken with meals
•poorly absorbed in patients taking proton pump inhibitors or H2 blockers
•calcium carbonate is 40 percent elemental calcium, so that 1250 mg of calcium carbonate
contains 500 mg of elemental calcium
Calcium
carbonate
•, calcium citrate is well absorbed in the fasting state, and equally absorbed compared with
calcium carbonate taken with a meal
•patients taking PPI or H2 blockers, calcium citrate is a first line calcium
calcium
citrate
supplementation in excess of 500 mg/day should be given in divided
doses
labeling reports the amount per “serving” instead of the amount per tablet, it is
important to verify that the patient is taking the correct number of tablets per
serving

40. Nephrolithiasis
• Ingested calcium is absorbed in the intestines and later
excreted in the urine
• Although this suggests that a diet high in calcium might
promote stone disease, the opposite effect is seen as the
risk of stone formation appears to be reduced in both men
and women.
• In contrast, calcium supplements may slightly increase the
propensity to form stones, at least in older women
• In the Nurses' Health Study, a higher dietary calcium intake
was associated with a lower incidence of stone disease
(multivariate relative risk 0.65 for highest versus lowest
quintile of calcium intake) while calcium supplements were
associated with a small increase in risk (relative risk 1.2 in
supplement users compared with nonusers)

41. Cardiovascular disease
• risk of cardiovascular disease (CVD) is controversial
• There may be benefits of calcium supplementation on risk factors, such as
a reduction in weight, blood pressure, and in serum cholesterol
concentrations (of about 5 percent) in patients with mild to moderate
hypercholesterolemia.
• in one study After seven years, calcium plus vitamin D supplementation
had no significant effect on the incidence of myocardial infarction
• However, the findings of two meta-analyses evaluating calcium or calcium
with or without vitamin D supplementation (eight and nine trials,
respectively) raised some concern about an increased risk of myocardial
infarction (MI) in patients randomly assigned to calcium versus placebo (
• In contrast to the findings with calcium supplements,
prospective cohort studies showed either no relationship or
an inverse relationship between dietary calcium intake and
risk of heart disease death or MI

42. Vit D

44. • Thus, all adults who do not have regular
effective sun exposure year round should
consume at least 600 to 800 international
units (units) of vitamin D3 (cholecalciferol)
daily
slightly higher dose of vitamin D supplementation (at
least 1000 and 800 to 1000 int. units daily, respectively)
to older adults (≥65 years) to reduce the risk of
fractures and falls

45. DEFINING VITAMIN D SUFFICIENCY
• UpToDate editors, favor maintaining the serum 25(OH)D concentration
between 20 and 40 ng/mL (50 to 100 nmol/L), whereas other experts,
including other UpToDate editors and the author of this topic, favor
maintaining 25(OH)D levels between 30 and 50 ng/mL
• Experts agree that levels lower than 20 ng/mL are suboptimal for skeletal
health
• minimum level of 30 ng/mL (75 nmol/L) is necessary in older adults to
minimize the risk of falls and fracture
concerns were based upon the increase in fracture in patients
treated with high dose vitamin D and conflicting studies describing a
potential increased risk for some cancers (eg, pancreatic, prostate)
and mortality with levels above 30 to 48 ng/mL

46. D insufficiency appears to be common
Dark skinned
Obese
Taking medications that accelerate the metabolism
of vitamin D (such as phenytoin
Hospitalized on a general medical service
&Institutionalized
Limited effective sun exposure due to protective
clothing or consistent use of sun screens
• Osteoporosis
Malabsorption, including inflammatory bowel
disease and celiac disease

47. (IOM) has defined the upper limit for
vitamin D as 4000 units daily for healthy
adults

48. Pregnancy
• The optimal serum 25(OH)D level in pregnancy is unknown, but should be
at least 20 ng/mL
• report suggesting a recommended daily allowance of 600 int
• In pregnant women with vitamin D deficiency, the safety of 50,000 int.
units of vitamin D weekly for six to eight weeks has not been adequately
studied,
• so some UpToDate editors treat vitamin D deficient and insufficient
pregnant women more slowly by giving a total of 600 to 800 int. units of
vitamin D3 daily. For pregnant women with vitamin D deficiency, other
UpToDate editors agree with ACOG and the Endocrine Society that 1000 to
2000 int

49. The role of Vit D 3
• Physiologic doses of vitamin D attenuate bone loss and may decrease fracture
rate.Osteoporosis
• randomized trials showing a reduction in risk of falls (relative risk reduction as
high as 20 percent) following vitamin D supplementation, particularly when the
baseline vitamin D status is poor
Falls
• biologic reasons why vitamin D may protect against cancer, evidence for this
effect in humans is mixed and expert groups have not recommended vitamin D
supplements for the specific purpose of preventing cancer
•
Cancer
All-cause
mortality

50. • Thus, although some data suggest an
association between vitamin D deficiency and
cancer, the direction of the association may
depend upon the serum 25OHD
concentration.
• The current evidence is insufficient to support
large dose vitamin D supplementation for
cancer prevention or treatment.

51. Other unproven effect of vit D3
• n a review of four interventional randomized trials and a
meta-analysis of six trials, however, there was no effect of
supplementation on cardiovascular outcomes, including
myocardial infarction and stroke [ 66,72 ]. The meta-
analysis also did not show a significant effect of vitamin D
supplementation on cardiovascular risk factors (lipids,
glucose, blood pressure)
CARDIOVASCULAR
DISEASES AND
HYPERTENSION
•In a meta-analysis of eight trials evaluating the effect of vitamin D
supplementation on glycemia, there was no effect of
supplementation on glycemia or incident diabetes [ 66 ]. However, a
subsequent trial in severely vitamin D deficient Asians living in New
Zealand revealed a modest improvement of their insulin sensitivity
after six months of vitamin D supplementation
DIABETES AND
METABOLIC
SYNDROME
• In one trial, 243 patients with depression and low serum 25-hydroxyvitamin D
levels (mean 19 ng/mL [47 nmol/L]) were randomly assigned to vitamin D
supplementation (40,000 int. units weekly) or placebo [ 95 ]. After six months,
there were no differences in depressive symptom scores
NEUROPSYCHIATRIC
FUNCTION

52. • Vitamin D
– Reducing fracture risk in Osteoporosis
• In postmenopausal women:
vitamin D 800 IU + calcium 1200 mg daily
• In premenopausal women and men:
vitamin D 400 to 600 IU + calcium 1000 mg daily
– Falls
• Vitamin D supplementation (700 to 1000
Units/day) reduces the risk of falls in elderly
– Cancer: Not recommended
– Infectious diseases: Not recommended
– Autoimmune diseases: Not recommended
– Cardiovascular diseases: Not recommended

53. ANTIOXIDANT
VITAMINS
vitamin
A,
Vitamin
c
Vitamin
E

54. systematic review and meta-analysis of randomized trials of
antioxidant supplements for the prevention of
gastrointestinal cancers found no decreased risk with
supplementation

55. vitamin A consists of
• mostly found in animal sources of food
• the form supplied by most supplements
• Source: liver, kidney, egg yolk, and butter
• absorption and storage of preformed vitamin A
(eg, in animal liver or dietary supplements) is
efficient, and toxicity can occur if excessive
quantities are ingested.
preformed
vitamin A
(retinol)
• found in plants
• There are many forms of provitamin A, but beta-
carotene is only one that is metabolized by
mammals into vitamin A.
• Source: in green leafy vegetables, sweet potato and
carrots
• metabolism of provitamin A (beta-carotene) into
active vitamin A is a highly regulated step, so
excessive intake of vitamin A from plant sources is
very unlikely to cause toxicity
provitamin A
carotenoids
(beta-carotene
and others)

56. DEFICIENCY
• it is still the third most common nutritional deficiency in
the world
• night blindness, complete blindness, and advanced stages
of xerophthalmia occur in many malnourished children and
adults
• )
• xerophthalmia can also be seen in resource-rich countries
in patients with disorders associated with fat
malabsorption, such as cystic fibrosis, celiac disease,
cholestatic liver disease such as primary biliary cholangitis,
small bowel Crohn disease, and pancreatic insufficiency

57. diagnosis of vitamin A deficiency
serum retinol levels (levels less than 20
micrograms/dL
the ratio of retinol:RBP (a molar ratio
<0.8

58. Clinical manifestations
Xerophthalmia
Poor bone growth
• Supplementation with vitamin A at the
community level in resource-limited countries is
recommended by the World Health Organization
because of its beneficial effects on immunity
Impairment of the
humoral and cell mediated
immune system via direct
and indirect effects on the
phagocytes and T cells

59. Periodic supplementation is recommended for
populations endemic for vitamin A deficiency, at
the following doses (where 1 microgram retinol
= 3.3 international units)
supplements should be provided as
frequent small doses not exceeding
10,000 international units daily or
25,000 international units, given weekly
for a minimum of 12 weeks during
pregnancy until delivery

60. chronic ingestion of large amounts of synthetic (or
"preformed") vitamin A (about 10 times higher than the
Recommended Dietary Allowance (RDA), or about 50,000
international units )
metabolism of provitamin A (beta-carotene, from plant
sources) is highly regulated, so excessive ingestion of this
form of vitamin A is very unlikely to cause toxicity.
As an example, individuals who ingest large amounts of
provitamin A (from plant sources) may develop yellow-
tinged skin (carotenemia) without developing vitamin A
toxicity

61. Treatment of vitamin A toxicity consists of
stopping vitamin A supplements and restricting
vitamin A-rich foods (especially sources of pre-
formed vitamin A, such as liver, kidney and egg
yolk).

62. Benefit of vit A
Cancer
Diets rich in beta carotene appear to be associated with lower risks of cancer.
However, clinical trials of beta carotene supplementation have not confirmed a
beneficial effect, and some suggest that beta carotene supplements may
modestly increase the risk for lung cancer, but not other cancers.
Another study showed an increase in both prostate cancer incidence
and mortality (23 and 15 percent, respectively) among subjects
randomized to β-carotene [41]. The excess risk appeared to resolve over
time once supplements were stopped

63. There is currently no strong
evidence that vitamin A and
carotenoid supplements
reduce the risk of cancer.

64. Cardiovascular disease
Randomized trials of vitamin A and β-carotene have
shown no benefit for primary or secondary
prevention of coronary heart disease (CHD)

65. Immunity
Vitamin A improves immunity in children living in developing
countries where dietary intake is inadequate and life-
threatening infectious diseases are common

66. Fractures
Women in the highest quintile of total vitamin A intake had a relative risk for
hip fracture of 1.48 compared with women in the lowest quintile.
Thus, patients should be cautioned against diets high in retinol (preformed
vitamin A), especially if they have other risk factors for osteopenia, and
should avoid vitamin A supplements, including multivitamins containing
preformed vitamin A, if their dietary intake is high.

67. Vitamin C

68. • found in citric fruits and many types of vegetables.
• Vitamin C may have a minor role in preventing the
common cold, specifically for persons involved in
high-intensity physical activity in extreme cold
climates.
common cold,
• Large randomized trials have found no
reduction in cancer in patients given vitamin C
supplementation
cancer
• Randomized trials have shown no benefit of
vitamin C for primary or secondary prevention
of coronary heart disease (CHD)
Cardiovascular
disease
Kidney stones Vitamin C increases urinary oxalate excretion
and may increase the risk of kidney stones.

69. Vitamin E

70. SOURCES
• abundant in olive and sunflower oils, and
is the predominant form in the European
diet
• The primary bioactive form of vitamin E
• Alpha-tocopherol has eight isomers, but
only four of these (RRR-, RSR-, RRS-, and
RSS-are efficiently maintained in human
plasma
alpha-
tocopherol
• is abundant in soybean and corn oil, and is
common in the American diet.
Gamma-
tocopherol

71. RRR-isomer (formerly and incorrectly called D-alpha-tocopherol) is the
only form found in foods; it is sometimes known as "natural source"
vitamin E.
Many synthetic vitamin E supplements or fortified foods
contain all the eight isomers of alpha-tocopherol; these are
known as "all racemic" or "DL" alpha tocopherol, and have
approximately half of the activity of "natural source" vitamin E
Synthetic vitamin E contains seven other
isomers (termed "all-racemic vitamin E" or
DL-alpha-tocopherol), and has lower
activity and possibly more toxic potential
than the RRR-isomer. ).

72. 1 mg RRR-alpha tocopherol = 1.47 international
units "natural source" vitamin E (D-alpha-
tocopherol) = 2.2 international units "all
racemic" vitamin E (DL-alpha-tocopherol).

73. ACTIONS of Vitamin E as alpha-
tocopherol)
works as a free radical scavenger,
vitamin E are independent of the antioxidant/radical
scavenging activity, including inhibition of cell
proliferation, platelet aggregation, and monocyte
adhesion

74. Deficiency of vitamin E has been connected
to cardiovascular events
, trials of vitamin E supplementation (which
typically use "all-racemic" vitamin E) have
generally shown no effect in prevention of
heart disease

75. Like other fat-soluble vitamins, bioavailability of
alpha-tocopherol depends upon physiologic
mechanisms for fat digestion and absorption.
This process requires lipolytic function of pancreatic
enzymes

76. REQUIREMENTS
daily allowance (RDA) for vitamin E
is 15 mg of dietary alpha-
tocopherol per day for adolescents
and adult men and women
This is the equivalent of 22 international units of
RRR-alpha-tocopherol (the form that is supplied by
some supplements and is marketed as "natural-
source" vitamin E), or 33 international
units of all-rac-alpha-tocopherol (the synthetic
form used for the majority of supplements)

77. The recommended UL is 1000 mg of alpha-tocopherol daily
(approximately 1,500 international units of natural
source or 2,200 international units of synthetic
vitamin E) for adults without fat malabsorption or other cause
of vitamin E malabsorption.
We do not recommend supplementation near this
level except when necessary to correct a
deficiency state.

78. Most studies suggest that
pharmacological doses of vitamin E
supplementation in doses of 100 to
400 international units (67 to 272 mg
RRR-alpha tocopherol) per day are
safe for most patients
). Vitamin E supplementation with a
dose ≥400 IU/day was associated
with a significantly increased risk of
all-cause mortality

79. The benefit of vitamin E supplementation in
pharmacologic doses on cancer, cardiovascular disease,
stroke, dementia, and liver disease (such as nonalcoholic
fatty liver disease) continue to be evaluated.

80. Effective serum vitamin E level = Alpha-
tocopherol / (cholesterol + triglycerides)
A normal ratio is >0.8 mg alpha-
tocopherol/gram total lipids.

81. Overview of dietary trace minerals

82. • minerals that are required by adults in
amounts greater than 100 mg/day or make
up less than 1 percent of total body weight
Macrominerals
• defined as minerals that are required in
amounts between 1 to 100 mg/day by
adults or make up less than 0.01 percent of
total body weight
Trace elements
(or trace
minerals)
• are defined as minerals that are required in
amounts less than 1 mg/day
Ultra-trace
minerals

83. CHROMIUM

84. • — In 1957, a compound extracted from pork
kidney was termed "glucose tolerance factor"
because it corrected hyperglycemia in rats
• Glucose tolerance factor was ultimately found
to be chromium (Cr).
. Cr supplementation in DM patients improved glucose
tolerance and respiratory quotient, which indicates a
preference for fat metabolism and reduced utilization of
carbohydrates as an energy source

85. • grains, cereals, fruits, vegetables,
and processed meats
• absorbed predominantly in the
small intestine and is transported
in the circulation bound to
albumin and transferrin
Dietary
sources

86. • setting of zinc and iron deficiency,
• suggesting that these minerals compete for
intestinal absorption
• Vit C
enhanced
absorption
• include certain drugs such as antacids, which
contain magnesium, calcium, or aluminum salts.
• Nonsteroidal antiinflammatory drugs that inhibit
the production of prostaglandins also reduce Cr
absorption
Decreased
absoption

87. Deficiency
TPN
hospitalized patients with increased catabolism and
metabolic demands in the setting of malnutrition
short bowelsyndrome,
burns,
traumatic injuries

88. dietary reference intake
— The adequate intake of Cr for adults is 20 to 35 mcg per day
There is little evidence to
support Cr
supplementation in
individuals without Cr
deficiency.

89. COPPER

90. • The variability in the copper content of food
reflects the variability in the copper content of
soil.
• The acidic environment in the stomach
facilitates solubilization of copper by
dissociating it from copper containing dietary
macromolecules

91. Risk factors for Copper deficiency
Foregut surgery, including gastrectomy or
gastric bypass
Premature infants receiving milk formulas
without adequate copper supplementation
Chronic diarrhea or other malabsorptive
conditions including celiac disease
Chronic peritoneal dialysis or hemodialysis
Excessive zinc ingestion

92. The RDA for copper is 340 mcg daily for young
children and rises to 900 mcg daily for adults [
The UL is 1 mg daily in young children and 10 mg
daily for adults

93. IODINE

94. • dietary importance of iodine lies in the
metabolism and homeostasis of the thyroid
gland
• Iodine deficiency is associated with goiter,
hypothyroidism, mental retardation, and
increased neonatal and infant mortality.

95. The RDA for iodine is 90 mcg daily for children 1
to 8 years old, 120 mcg for children 9 to 13 years,
and rises to 150 mcg daily for older
adolescents and adults.
During pregnancy and lactation, the RDA is 220
and 290 mcg daily, respectively

96. IRON

97. • Body contains3.5 gr iron ( 2.5 gr founfd in Hgb)
• Mostly stored as ferritin or hemosiderin in liver , spleen
,BM, hepatocyte
• Despite RBC turnovering , Iron stores are well preserved as
iron is recovered
• Only 0.5-1 mg / day is lost and more during mense &
pregnancy
• 10% of Iron from diet is absorbed so we need 10 – 12 mg
iron /day
• GI absorption is increased to 3- 5 fold during Iron deficiency
• Animal sources( hem iron ) absorbed better than nonhem

99. Choice of preparation
• Ferrous fumarate – 33 % Fe
• Ferrous sulfate 20 %
• ●Ferrous gluconate – 11%
There is no evidence that one of the above iron preparations is more
effective than another for this purpose.
A large number of other oral iron-containing preparations and nutritional
supplements are available, including the heme iron polypeptide Proferrin.
They are generally more expensive than those described above and may
not have been subjected to randomized clinical trials in patients with iron
deficiency.
Some (eg, enteric coated, sustained release preparations) may be both
more expensive and poorly absorbed.
Accordingly, we do not recommend their use.

100. MANGANESE

101. • Meat, fish, poultry, dried fruit, and nuts are good
sources of manganese, but absorption is very
variable
Dietary
sources —
• high dietary intakes of
calcium, phosphate, and fiber
Absorption
is decreased
• in the setting of iron
deficiency
Absorption
is icreased
Deficiency leads to poor growth, decreased fertility, ataxia,
skeletal deformities, and abnormal fat and
carbohydrate metabolism

102. • Manganese deficiency in humans is very
unusual, but has been reported in individuals
on a highly restricted diet.
— The recommended intake for manganese is expressed as an
Adequate Intake (AI), because of the limited data available to
determine the population needs
The tolerable upper limit for manganese is 2 mg daily in toddlers,
and up to 11 mg daily for adults

103. SELENIUM

104. • Seafood, kidney and liver, and meat are good
sources of seleniumsource
• associated with skeletal muscle dysfunction and
cardiomyopathy and may also cause mood
disorders and impaired immune function ,
macrocytosis, and whitened nailbeds [
Deficiency
• (TPN) were historically not supplemented with
selenium. Several cases of selenium deficiency in
chronic TPN users have been reported with
cardiomyopathy and skeletal muscle dysfunction

105. potential roles
•A number of studies have shown a linear relationship between
selenium deficiency and a reduction in CD4 cell counts in HIV-
infected patients
•Natural killer cell activity is enhanced when selenium is
supplemented in the diet of selenium depleted individuals
Immune
function
• studies support a possible relationship between Se and
cancer mortality
• As a result, a number of studies have investigated the
role of selenium supplementation for prevention of
cancer
Cancer
• In theory, the antioxidative effect protects lipid
membranes, inhibits oxidative modification of low
density lipoprotein, and suppresses platelet
aggregation
Cardiovascular
disease
• — Animal models suggest that low doses of selenium
may improve glucose metabolism,
• clinical studies in humans suggest that selenium
supplementation does not confer benefit and may
increase the risk of type 2 diabetes
Glucose
metabolism

106. supplementation may be
beneficial for individuals with
low selenium intake, but could
be detrimental to those with
normal or high selenium intake
Selenium toxicity occurs with excess dietary intake, either
through diets naturally high in selenium or "megadose"
supplementation

107. The RDA for selenium is 20 mcg daily for young
children,
rising to 55 mcg daily for adults

108. ZINC

109. • In 1961, a link was established between zinc
deficiency, endemic hypogonadism, and dwarfism
in rural Iran
• zinc deficiency may significantly increase the
incidence of and morbidity and mortality from
diarrhea and upper respiratory tract infections
• Meat and chicken, nuts and lentils are excellent
sources
Along with iron, iodine, and vitamin A, zinc deficiency
is one of the most important micronutrient deficiencies
globally

110. Deficiency
• Mild dietary zinc deficiency impairs growth velocity while
severe depletion of zinc leads to growth retardation.
• Other clinical manifestations of zinc deficiency include
delayed sexual maturation, impotence, hypogonadism,
oligospermia, alopecia, dysgeusia (impaired taste), immune
dysfunction, night blindness, impaired wound healing, and
various skin lesions
• zinc deficiency, have been described in chronic diseases such
as malnutrition, malabsorption syndromes (such as chronic
inflammatory bowel disease), prolonged
breastfeeding,pregnancy, elderly individuals with poor diet
quality & gastric bypass for obesity and TPN
In these cases, the dietary zinc deficiency may have been
exacerbated by medications that increase urinary losses of zinc,
including thiazides, loop diuretics, and angiotensin receptor
blockers.

111. Zinc supplementation in diabetic patients
may improve immune function, but also
increases the HbA1c levels and leads to
worsening glucose intolerance
Zinc has also been used to treat the
common cold, but probably has little
clinical value.
Zinc supplementation during pregnancy for women
with mild zinc deficiency appears to promote fetal
growth and reduce the risk of premature birth and
infant diarrhea

112. Mild zinc deficiency appears to be common, especially in
developing countries. Individuals in developing countries
are at risk of zinc deficiency because the diet is relatively
low in zinc and contain significant amounts of phytates
(which reduce zinc absorption
There is some evidence supporting the role of zinc
supplementation to increase growth velocity in children, and
several studies have suggested a benefit of zinc
supplementation in children with acute diarrhea in
developing countries

113. rising from 3 mg daily in early childhood to 8 mg daily
for adult women, and 11 mg daily for adult men.
Requirements are slightly higher during pregnancy
and lactation

114. Nutrient-Nutrient Interaction In
Multivitamin Supplements

115. do the nutrients in multivitamin/mineral supplements
interact in any way that could damage (or maybe
enhance) their efficacy in the body?
• It sounds convenient to take one dose of a multivitamin a day and
be done with it.
• However, doing so would actually work against your efforts to
cover all your bases on vitamin and mineral needs. This is because
several micronutrients impair the uptake of other micronutrients.
• You could say that they essentially cancel each other out.
• But few supplement companies will actually educate you on this
fact. Instead, they prey on the consumer’s wish for convenience and
create products based on convenience, not science.
• producing multivitamins that are devoid of critical micronutrients or
in far too inadequate doses to be of any real benefit.

116. • Copper and zinc are chemically similar to iron. Since
absorption is a process dictated entirely by chemistry
(charge, molecular shape, etc.), copper, zinc, and iron all
share similar absorption mechanisms.
• receptor has been shown to be involved in the absorption
of not only iron, but also copper and zinc - although with
different affinities for each mineral.
• Studies have shown that it has the highest affinity for iron.
• So what does this mean on a nutritional level? If these
nutrients were to be taken at the same time, its likely that
some nutrients will be left out unabsorbed and, effectively,
useless to the body.

117. • The acidic environment in the stomach facilitates
solubilization of copper by dissociating it from copper
containing dietary macromolecules
• Deficiency neurologic manifestations include ataxia,
neuropathy, and cognitive deficits that can mimic
vitamin B12 deficiency
• Hematologic features of copper deficiency include
anemia (usually microcytic) and neutropenia
• If iron supplements are given, these can worsen copper
deficiency because excess iron competes with copper
and decreases net copper absorption
Iron, Copper & Zinc

118. • It is suggested that supplemental iron (38-65 mg/day), but
not dietary levels of iron, may decrease zinc absorption and
substantially impact copper absorption.
• Similarly, competition studies have shown that high levels
of zinc and copper may interfere with iron uptake.
• While some data suggests that zinc has no effect on copper
absorption when given as a one-time mixture, clinical study
has noted that taking large quantities of zinc (50 mg/day or
more) for several weeks significantly impact copper
bioavailability.
• It is thought that high zinc intake induces the production of
a copper-binding protein, which “traps” the mineral and
prevents its absorption

119. • Magnesium and manganese, two common minerals found
in multivitamin supplements, also interact with iron.
• Magnesium may decrease non-heme iron absorption if the
two nutrients are taken together.
• Calcium is suggested to decrease non-heme iron absorption
when both are consumed at the same meal. This may only
be a problem in those who are initially iron-deficient,
suggests the National Institutes of Health (NIH).
• If you are iron-deficient or think you are at risk for
deficiency, the NIH recommends to “minimize this
interaction by separating your intake of calcium and iron.”
Iron, Calcium, Magnesium & Manganese

120. • Vitamin C, an antioxidant found in all of our tested
multivitamins, is suggested to enhance non-heme iron
absorption when both nutrients are eaten together,
according to the CDC.
• Vitamin A – beta-carotene, specifically - also appears to
enhance iron absorption, according to the National
Institutes of Health. It is suggested to move iron from its
storage site to red blood cells, where it is used to build
hemoglobin. However, studies suggest that vitamin A is
unlikely to enhance iron absorption in those who have
adequate levels of vitamin A; it is more likely to improve
iron status in those with low levels of vitamin A.
Iron & Vitamins C and A

121. • According to “An Evidence-Based Approach to Vitamins
and Minerals,” vitamin A (in high doses) may reduce
absorption of vitamin K.
• Nutrient interactions can vary in nature; that is,
affecting absorption may not be the only way in which
vitamins can influence the activity of other vitamins.
• As it turns out, vitamin E has a similar overall effect on
vitamin K as does vitamin A, although not by inhibiting
its absorption. Vitamin E achieves functional vitamin K
deficiency by inhibiting the activity of vitamin-K
dependent enzymes – effectively rendering vitamin K
useless, even if it is absorbed
Vitamin A, E & K

122. • Zinc can inhibit amino acid uptake!
• Since it’s important to take a multivitamin with a meal,
such as breakfast, a multivitamin that includes zinc
could interfere with your body’s ability to take up the
amino acids from the protein you consumed at
breakfast. And that could interfere with muscle growth
• Zinc also interferes with copper uptake. Copper is
something that you do want in your multivitamin.
• Zinc induces the intestinal synthesis of a copper-
binding protein called metallothionein.
Metallothionein traps copper within the cells in the
intestines and prevents its absorption into the
bloodstream
• iron interferes with zinc absorption,
• you should skip the zinc until another time of day

123. Calcium is another big problem in
multivitamin supplements
• Calcium interferes with zinc, iron and
manganese absorption
• So these two minerals, calcium and
magnesium, should also be completely absent
from your multivitamin and be taken
separately at another time of day.

124. Phosphorus is a fourth
mineral that you do not
want in your multivitamin.
The typical diet is already
quite rich in phosphorus.
Having it in your
multivitamin may raise
phosphorus levels too high
problematic because it can prevent the conversion of vitamin D to its
active form, 1,25-dihydroxyvitamin D, in the kidneys.

125. Missing Multis
Another problem with most multis is that they completely
skip out on some critical micronutrients altogether such as
vit K , iodine, chromium,copper

126. • . Recent research suggests that far more people
are deficient in vitamin K than originally believed.
• Research also shows that supplementing with
vitamin K2 alleviates the symptoms of vitamin K
deficiency and provides a host of health benefits,
including protection against heart disease and
cancer, enhanced brain function, skin health,
boosting testosterone production and promoting
the formation of bone
vit K

127. • Another missing or under-dosed
micronutrient in many multis is iodine, which
is critical for maintaining healthy thyroid
function
• So if your multi is not proving you iodine at
100% of the DV or RDA, then it’s a problem
iodine

128. • usually absent or severely under dosed.
• This is problematic because most diets are
quite low in chromium
• You could take a separate chromium
supplement, but this is one of the minerals
that is best to get in your multivitamin.
• That’s because chromium uptake is enhanced
when it’s taken at the same time as vitamin C,
which should be in your multi.
chromium

129. • another mineral often missing completely or present in
an adequate amount.
• Since higher intakes of zinc can lead to copper
deficiency, and you should be certain to get 30 mg of
zinc daily (separate from your multivitamin),
• Evidence suggests that you should get copper and zinc
at a 1:10 ratio for optimal health.
• Since you should be getting in 30 mg of zinc each day,
your multivitamin should provide a full 3 mg dose of
copper
Copper

130. Vitamin and Mineral Dusting
• Vitamin K, iodine, chromium, copper, selenium
and the B vitamins are all typically under dosed, if
included at all, in most multivitamins.
• Other minerals that are also usually under dosed
include selenium, molybdenum and manganese.
• These minerals and vitamins should at the very
least provide 100% of the Daily Value (DV) or RDA
for them.

131. Wrong Form
Most multis also use cheap, ineffective, or even potentially dangerous forms of
certain vitamins and minerals

132. • Vitamin A is often provided in multivitamins mainly as
preformed vitamin A (retinol) in the form of retinyl
palmitate or retinyl acetate.
• These forms are rapidly absorbed, but slowly cleared
from the body, which can lead to toxicity and liver
problems if too much is consumed.
• Beta-carotene, on the other hand, is a much safer form
of vitamin A to take as it only becomes active vitamin A
when needed in the body.
• To avoid possible vitamin A toxicity, your multivitamin
should provide all of its vitamin A from beta-carotene.
vitamin A

133. • K1: comes from plants, specifically green leafy
vegetables, such as lettuce and spinach, as well as
broccoli. Although this form of vitamin K is fine, it
is not that necessary in a multivitamin since few
people are vitamin K1 deficient.
• K2(menaquinone): comes from fermented
products, such as cheese & fermented soybeans.
Vitamin K

134. . While both vitamins K1 and K2 appear to be
involved in blood clotting, K2 provides benefits that
go far beyond that.
Research suggests that being deficient in vitamin K
may lower testosterone levels
The body requires so little vitamin K1 that just about everyone gets
enough from their diet. Vitamin K2, on the other hand is required at a
much higher dose and provides more benefits

135. dietary requirement vit K , expressed as
adequate intake (AI) is 90 micrograms daily in
women and 120 micrograms daily in men

136. • another mineral that is typically given in a
cheap, less-effective form, such as chromium
chloride
• Chromium picolinate is a combination of
chromium and picolinic acid. The addition of
the picolinic acid enhances the uptake of
chromium.
Chromium

137. • Many companies will try to tell you that methylcobalamin is the
best form of B12 to use. While this is one of the active forms of
B12, it just one of the active forms.
• There are two active of forms. The other active form of B12 is
adenosylcobalamin, also known as dibencozide.
• While some multivitamins provide both of these, the problem is the
stability of these active forms.
• There is evidence that they are not very stable and therefore, do
not provide the actual dose of B12 listed on the label.
• The only way to consume a stable form of B12 that is readily
converted to both methylcobalamin and adenosylcobalamin in the
body is by taking the cyanocobalamin form of B12.
vitamin B12

139. Coenzyme
Q10
 Coenzyme Q10 is involved in ATP
generation
 It functions as a lipid-soluble
antioxidant
 Its reduced form, CoQH2,inhibits
protein and DNA oxidation
 It has been suggested that CoQH2
is a more efficient antioxidant
than vitamin E
 its tissue (but not blood) concentration
exceeds severalfold
that of vitamin E

140. Coenzyme
Q10
 In human organs, the coenzyme Q
content increases three- to
fivefold during the first 20 years
after birth,followed by a
continuous decrease, so that in
some tissues the concentration
may be lower at 80 years than
at birth

141. Coenzyme Q10 (CoQ10)
 Acute myocardial infarction: 120 mg/day
 AIDS: 200 mg/day
 Alzheimer's disease: 120 mg 3 times/day
 Angina: 60 mg/day
 Breast cancer: 90 mg/day in combination with
multivitamin/multimineral supplementation
 Cardiomyopathy: 100-600 mg/day

142. Coenzyme Q10 (CoQ10)
 Cardioprotection during surgery: 150 mg/day for 7 days
prior to bypass surgery; 600 mg in divided doses in the 24
hours prior to surgery
 Congestive heart failure: 2 mg/kg/day or 100-600 mg/day
 Exercise performance: 90 mg/day
 Hypertension: 75-360 mg/day; average dose: 225 mg/day
 Migraine: 100 mg 3 times/day

143. Coenzyme Q10 (CoQ10)
 Muscular dystrophy: 100 mg/day in divided doses
 Parkinson's disease: 300-1200 mg/day
 Periodontal disease: 5 mL/day of 200 mg/mL
CoQ10 dispersed in corn oil divided doses

144. INTERACTIONS Depletion
 CoQ10 may decrease
response to warfarin
 Hydralazine, thiazide
diuretics, HMG-CoA
reductase inhibitors,
sulfonylureas, beta
blockers, tricyclic
antidepressants,
chlorpromazine,
clonidine, methyldopa,
diazoxide, biguanides,
haloperidol.
REPORTED INTERACTIONS

145. Coenzyme
Q10
 Various degrees of myopathy,
myalgia, and rhabdomyolysis
have been reported in statin-
treated patients, and it is possible
that these conditions are related
to decreased muscle coenzyme
Q content.

146. Acetyl-L-carnitine/"-lipoic acid
supplements

147. as a popular combination anti-aging
• A report that combined lipoic acid and dimercaptosuccinic
acid provided therapeutic benefits to reduce renal damage
from lead acetate in male Wistar rats (Sivaprasad et al.,
2004).
• A report that "-lipoic acid treatment partially but
significantly reversed diabetes in streptozotocin diabetic
rats (Kumar & Prashanth, 2004).
• A report that lipoic acid pretreatment attenuated ferric
chloride-induced seizures in male S-D rats (Meyerhoff et al.,
2004).
• A report indicating that acetyl-L-carnitine had beneficial
effects in animal models of Parkinson’s disease (Beal, 2004

148. • Supplemental "-lipoic acid is currently used in
Germany to treat peripheral nerve
degeneration resulting from diabetes.
• It has also been used as a therapeutic agent
for hepatic coma, chronic hepatitis, cirrhosis
of the liver, and has been partially successful
in treating glaucoma

149. There are no standard doses for acetyl-L-carnitine
and "-lipoic acid supplements. The highest doses
recommended for acetyl-L-carnitine (no salt
specified) and for "-lipoic acid are 1,500 and 600
mg/day, respectively

150. QUERCETIN

151. • has antioxidant and anti-inflammatory effects
which might help reduce prostate inflammation
• Quercetin is a plant pigment (flavonoid).
• It is found in many plants and foods, such as red
wine, onions, green tea, apples, berries, Ginkgo
biloba, St. John's wort, American elder, and
others. Buckwheat tea has a large amount of
quercetin.
• People use quercetin as a medicine.

152. Quercetin is used for treating conditions of
the heart and blood vessels including
• (atherosclerosis), high cholesterol, heart disease,
and circulation problems. It is also used for
diabetes, cataracts, hay fever, peptic ulcer,
schizophrenia, inflammation, asthma, gout, viral
infections, chronic fatigue syndrome (CFS),
preventing cancer, and for treating chronic
infections of the prostate. Quercetin is also used
to increase endurance and improve athletic
performance.

153. CHOLINE

154. How does it work?
• Choline is similar to a B vitamin.
• It is also found in foods such as liver, muscle meats,
fish, nuts, beans, peas, spinach, wheat germ, and eggs.
• It is used in many chemical reactions in the body.
• Choline seems to be an important in the nervous
system.
• In asthma, choline might help decrease swelling and
inflammation

155. Potential role
• Choline is used for liver disease, including chronic hepatitis and
cirrhosis. It is also used for depression, memory loss, Alzheimer's
disease and dementia, Huntington's chorea, Tourette's disease, a
brain disorder called cerebellar ataxia, certain types of seizures, and
a mental condition called schizophrenia.
• Athletes use it for bodybuilding and delaying fatigue in endurance
sports.
• Choline is taken by pregnant women to prevent neural tube defects
in their babies and it is used as a supplement in infant formulas.
• Other uses include preventing cancer, lowering cholesterol, and
controlling asthma.

156. COLLOIDAL MINERALS

157. • Colloidal minerals are taken from clay or shale deposits..
• Despite safety concerns, colloidal minerals are used as a
supplemental source of trace minerals and as a dietary
supplement to increase energy.
• They are also used for improving blood sugar levels in
diabetes, treating arthritis symptoms, reducing blood cell
clumping, reversing early cataracts, turning gray hair dark
again, flushing poisonous heavy metals from the body,
improving general well-being, and reducing aches and
pains.

158. Inositol

159. • Inositol is a vitamin-like substance. It is found in many
plants and animals. It can also be made in a laboratory.
• Inositol is used for diabetic nerve pain, panic disorder, high
cholesterol, insomnia, cancer, depression, schizophrenia,
Alzheimer’s disease, attention deficit-hyperactivity disorder
(ADHD), autism, promoting hair growth, a skin disorder
called psoriasis, and treating side effects of medical
treatment with lithium.
• Inositol is also used by mouth for treating conditions
associated with polycystic ovary syndrome, including failure
to ovulate; high blood pressure; high triglycerides; and high
levels of testosterone.

160. Lutein

161. • Lutein is called a carotenoid vitamin. It is related to beta-carotene
and vitamin A. Foods rich in lutein include broccoli, spinach, kale,
corn, orange pepper, kiwi fruit, grapes, orange juice, zucchini, and
squash. Lutein is absorbed best when it is taken with a high-fat
meal.
• Many people think of lutein as “the eye vitamin.” They use it to
prevent eye diseases including age-related macular degeneration
(AMD), cataracts, and retinitis pigmentosa.
• Some people also use it for preventing colon cancer, breast cancer,
type 2 diabetes, and heart disease.
• Many multivitamins contain lutein. They usually provide a relatively
small amount of 0.25 mg per tablet.

162. PARA-AMINOBENZOIC ACID PABA
Overview Information

163. • Para-aminobenzoic acid (PABA) is a chemical found in the folic acid vitamin
and also in several foods including grains, eggs, milk, and meat.
• PABA is taken by mouth for skin conditions including vitiligo, pemphigus,
dermatomyositis, morphea, lymphoblastoma cutis, Peyronie's disease,
and scleroderma. PABA is also used to treat infertility in women, arthritis,
"tired blood" (anemia), rheumatic fever, constipation, systemic lupus
erythematosus (SLE), and headaches. It is also used to darken gray hair,
prevent hair loss, make skin look younger, and prevent sunburn.
• PABA is best known as a sunscreen that is applied to the skin (used
topically).
• PABA doesn't seem to be taken by mouth as often as it used to be,
possibly because some people question its safety and effectiveness

164. SAW PALMETTO

165. • Saw palmetto is a plant. Its ripe fruit is used to make medicine.
• Saw palmetto is best known for its use in decreasing symptoms of
an enlarged prostate (benign prostatic hypertrophy, BPH). According
to many research studies, it is effective for this use.
• Saw palmetto is used for treating certain types of prostate
infections. It is also sometimes used, in combination with other
herbs, to treat prostate cancer.
• Some people use saw palmetto for colds and coughs, sore throat,
asthma, chronic bronchitis, chronic pelvic pain syndrome, and
migraineheadache. It is also used to increase urine flow (as a
diuretic), to promote relaxation (as a sedative), and to enhance
sexual drive (as an aphrodisiac).

166. RICE BRAN

167. • Rice bran is used for treating diabetes, high blood pressure, high
cholesterol, alcoholism, obesity, and AIDS;
• for preventing stomach and colon cancer;
• for preventing heart and blood vessel (cardiovascular) disease;
• for strengthening the immune system;
• for increasing energy and improving athletic performance;
• for improving liver function; and
• as an antioxidant.
• Rice bran oil is also used for high cholesterol.
• Some people apply rice bran directly to the skin for an allergic skin
rash called eczema (ectopic dermatitis).

168. •Any question ?