Supplementation for Health, Wellness and Control. · Nutrient-Drug/Disease Interactions...
Transcript of Supplementation for Health, Wellness and Control. · Nutrient-Drug/Disease Interactions...
SupplementationforHealth,WellnessandControl
Preparedby:M.WilliamsMay2018
Objectives
1. Toestablishtheroleofsupplementsforthe
preventionandmanagementofNCDs(HTN&
T2DM)
2. Toidentifykeymicronutrients/supplements
andtheirroleinthepreventionandmanagementofT2DM andHTN
3. Tooutlinecommondrug-nutrient/disease-
nutrientinteractionswithmicronutrients
4. Tosummarizeusingcaseexamplestheeffectsofdrug-nutrientandnutrient-disease interactionsin
T2DMandHTN
DietarySupplementsDietarysupplementsareproductsdesignedtoaugmentyour
dailyintakeofnutrients.
Vitamins Minerals Aminoacids Enzyme Herb
BenefitsofSupplementsinNCDs
Anti-oxidativeMicronutrientsandNCDs• Humanbeingsneedoxygentosurvive
• UtilizationofoxygenproducesROS
• FreeradicalsovertimeresultsindegenerativeCellularfunction
• DevelopmentofNon-CommunicableDiseases(NCDs)
Anti-oxidativeMicronutrientsandNCDs•ExcessiveproductionofreactiveoxygenspeciesisreflectedbyincreasedperoxidationoflipidandDNA,leadingtooxidativestress.
•Freeradicalsarealsoproducedfromexposuretocigarettesmoke,excessexposuretothesun,drinkingalcohol,exposuretolargeamountsofheavymetalsandduringanyinflammatoryresponse
•Thereactiveoxygenspecies(ROS)hasnowbeenidentifiedtoplayafundamentalroleinthepathogenesisofcellularfunctionincludingendothelialdysfunctionandatherosclerosis
•Glucoseauto- oxidation,monocytedysfunctionandnon-enzymaticglycationetc.
Anti-oxidativeMicronutrientsandNCDs•Oxidativestressiscurrentlysuggestedasthemechanismunderlyingallnon-communicablediseasesaschronicdiseaseswithslowerprogressioncausing38milliondeathsperyearglobally,withrisingprevalenceacrosstheworldparticularlyindevelopingcountries.
Anti-oxidants
NeutralizesROS
ReduceProductionofROS
Evert,A.B.andBoucher,J.L.etal;NutritionTherapyRecommendationsFortheManagementofAdultswithDiabetes,:PositionStatementbytheADA,DiabetesCare2013,36;3821-42.Franz,Jetal;Evidence-baseddiabetesnutritiontherapyrecommendationsareeffective:thekeyisindividualization.Diabetes, MetabolicSyndromeandObesity:TargetsandTherapy2014:765–72
Anti-oxidativeMicronutrientsandNCDs
•Thisantioxidantdefencemechanismcanbedividedintotwogroups:1. Anti-oxidativeenzymes,presentinsidethecellssuchassuperoxidedismutase;
catalaseandglutathioneperoxidasewhichpreventsformationoffreeradicals.
Evert,A.B.andBoucher,J.L.etal;NutritionTherapyRecommendationsFortheManagementofAdultswithDiabetes,:PositionStatementbytheADA,DiabetesCare2013,36;3821-42.Franz,Jetal;Evidence-baseddiabetesnutritiontherapyrecommendationsareeffective:thekeyisindividualization.Diabetes, MetabolicSyndromeandObesity:TargetsandTherapy2014:765–72
Anti-oxidativeMicronutrientsandNCDs
2. Certainvitaminsandmineralsandsomespecificphytochemicalshaveamajoranti-oxidativeeffectinthebody.
Evert,A.B.andBoucher,J.L.etal;NutritionTherapyRecommendationsFortheManagementofAdultswithDiabetes,:PositionStatementbytheADA,DiabetesCare2013,36;3821-42.Franz,Jetal;Evidence-baseddiabetesnutritiontherapyrecommendationsareeffective:thekeyisindividualization.Diabetes, MetabolicSyndromeandObesity:TargetsandTherapy2014:765–72
MicronutrientsSupportPhysiologicalProcesses
§Vitaminsandmineralsfunctioninthehumanbodyasmetabolicregulators,influencinganumberofphysiologicalprocesses.
§AllphysiologicalprocesseswithinthebodyaredirectedorinfluencedbyENZYMES
MicronutrientsSupportPhysiologicalProcesses
§Thebasictasksofenzymesaretobuildupandbreakdownvariouschemicalcompounds,usuallyproteins.
§Proteinsformour:§ Cellwalls§ Hormones§ neurotransmittersetc
§Micronutrientsarebiologicalcatalystsastheyserveasco-factorsorco-enzymes
MicronutrientsSupportPhysiologicalProcesses
Vitamins&Minerals
Vitamins&Minerals
FactorsLeadingtoNutrientDeficiencies
Suboptimalmicronutrient
intakecanleadtochronicdisease
Vitaminandmineral
deficienciesoftencanbedifficultto
identify
Malabsorptionofnutrients
Changesinfoodproduction;genetic
engineering,toxicpesticidescanimpactfood
quality
CommonNutrientDeficiencies
Themostcommonnutrientdeficienciesare:• VitaminD• Omega-3s•Magnesium• VitaminsA,EandB12• Iodine• Calcium• Iron• Zinc
BMCBioinformatics2012;13(Suppl14):S10
OsteoporosisInternationalSeptember2013:24(9);2499–2507
DietarySupplementsandDiabetes/HTN
Omega-3(ALA)– DM◦ Antioxidantproperties◦ Promotesglucoseuptakeinmuscles◦ Increasessensitivityofthebodytoinsulin◦ Positiveeffectondiabeticneuropathy◦ Helpswithweightloss
S/E
Hypoglycaemiaanddecreaseironlevels
Omega-3(ALA)- HTN◦ Antioxidantproperties◦ Hasthepotentialtoregulatebloodpressure
S/E
Maycausefluctuationinbloodpressurecontrol
BMCBioinformatics2012;13(Suppl14):S10
DietarySupplementsandDiabetes/HTN
Omega-3(EPA/DHA)Fattyacids- DM◦ Increaselevelsofadiponectin◦ Increasesinsulinsensitivity◦ Decreaseinsulinresistance
Omega-3Fattyacids–HTN◦ Lower bloodpressure◦ Reduce triglycerides◦ Slowthedevelopmentofplaqueinthe arteries◦ Reducethechanceofabnormal heart rhythm
AmericanJournalofClinicalNutrition2010May;91(5):1255-60
AreOmega-3FatsGoodforDiabetes?,PublishedSeptember27,2017byDavidSpero,BSN,RN
RCTsfoundthatOmega-3decreasestheriskofcardiovasculardiseaseandeventssuchasheartattackandstroke.
DietarySupplementsandDiabetes/HTN
CoenzymeQ10(Ubiquinone&Ubiquinol)-DM◦ Helpscellmakeenergyandactsasanantioxidant
◦ Improveshearthealthinpeoplewithdiabetes
S/E◦ Interactsnegativelywithbloodthinnersandbloodpressuremedications
CoenzymeQ10(Ubiquinone&Ubiquinol)-HTN◦ Bloodpressureloweringproperties
S/E◦ Increasesthehypertensiveeffectsofanti-hypertensivemedications.
AmericanJournalofClinicalNutrition2010May;91(5):1255-60
PreventDiseaseJuly26,2016
DietarySupplementsandDiabetes/HTN
Zinc(Protamine)– DM◦ Insulinhomeostasis◦ Reduceinsulinresistance◦ Prolongstheactionandhalflifeofinsulin◦ Promotesinsulinsecretion
S/E◦ Hypoglycaemia
Zinc(Protamine)– HTN◦ Positivelyimpactsarterialbloodpressure
◦ Zincinteractswithotherminerals;especiallycoppertomaintainbloodpressure(8:1)
S/E◦ Excesscancausehypertensionbyincreasingoxidativestressonarteries
AmericanJournalofClinicalNutrition2010May;91(5):1255-60
Granados-SilvestreMAetal.Mineralsanddiabetes,2014;82:97-103
DietarySupplementsandDiabetes/HTN
Magnesium– DM◦ Neededco-factorforcarryingout>300enzymaticreactions,specificallyintheprocessesofphosphorylationand,ingeneral,inthosewheretheuseoftransferenceofATPisnecessary
◦ Promotesuptakeofinsulinbycellsandmaintainsvasculartone.
◦ Intracellularmagnesiumregulatestheactionofinsulin
S/E
Highlevelscanleadtoirregularheartrate,muscleweakness,hypotensionanddifficultybreathing
Magnesium– HTN
ADA,2016◦ Peoplereceivingabout368mg/dayofmagnesiumforaboutthreemonthshadoverallreductionsinsystolicbloodpressureof2.00mmHganddiastolicbloodpressureof1.78mmHg.
◦ Magnesiummightonlybeeffectiveamongpeoplewithmagnesiumdeficiencyorinsufficiency.
S/E
Hypotension
AmericanJournalofClinicalNutrition2010May;91(5):1255-60
NCCIHOngoingResearch§Chromiumeffectsonelevatedbloodglucoselevels
§TheuseofYogaonglucosecontrolinpeopleatriskforDM
§GinkoBilobaExtractondiabetesmedications
AmericanJournalofClinicalNutrition2010May;91(5):1255-60
Nutrient-Drug/DiseaseInteractions§Interactionisaconsequenceofphysical,chemicalorpathophysiologicrelationshipbetweenadrugandnutrient
§Interactionscanoccurbetweenadrugandanutrient,multiplenutrients,dietarypatternorspecificfoods.
§Aninteractionisclinicallysignificantifitaltersthetherapeuticdrugresponseandorcompromisenutritionalstatus
Nutrient-Drug/DiseaseInteractions
§Supplementscontainalargevarietyofmicronutrientsandphytochemicalsthathavebeenassociatedwithhealthbenefits.
§MostsupplementshoweverconsistofcomplexphytochemicalsthatcaninhibitorinducetheactivityofcytochromeP450familyofenzymes
Nutrient-Drug/DiseaseInteractions§Theclinicalsignificanceofanyparticularinteractiondependsontheseriousnessofthedose-relateddrugtoxicityandtheextenttowhichthesystemicdrugconcentrationincreases.
§Thelatterreliesonmultiplefactorsthatinclude:§ Bioavailabilityoftheinteractingdrug
§ Theconcentrationoftheinteractingnutrient
§ Thevulnerabilityofthepatienttotheinteraction
Baileyetal.CMAJ2012.DOI:10.1503/cmaj.120951
Nutrient-Drug/DiseaseInteractions
§Theseinteractionscanresultindecreasedbioavailabilityofdrugcausingtreatmentfailureorincreasedbioavailabilitycausingtoxicityandadverseeffects.
§Thepatient’snutritionalstatusanddietarycomponentswithpharmacologicalactivitycanaffectdrugmetabolismtherebyalteringactionandfunction.
Nutrient-Drug/DiseaseInteractions
§Medicationscanplayasignificantroleindevelopingnutrientdeficiencies.
§ Druginducedmicronutrientdepletionmayberesponsiblefortheunexplainedsymptomsthataffectmedicationcompliance(forexamplezincandACEinhibitors/ARBs)
§Manymicronutrientsarepotentiallyvulnerabletotheeffectsofprescribedmedicineswhenconsumptionisregularandsustained.
Nutrient-Drug/DiseaseInteractions§Medicationscanaffectnutrientsby:
§ Decreasingfoodintake
§ Decreasenutrientabsorption
§ Slowingdownnutrientproduction
§ Interferingwithnutrientmetabolism
§ Increasingnutrientexcretion
CommonDrug-Nutrient/DiseaseInteractions– HTN/DMDrugCategory Interaction/Outcome Recommendations
Anti-hypertensives:ACEInhibitorsARBsCCBsBBsDiuretics
ACEinhibitorsandARBsdepletezincandincreasepotassiumlevels
CCBsandThiazidediureticsdepletepotassium
BBsdepletecoenzymeQ10andVitaminB3
ACEIs/ARBs– Zinc<30mg/day
CCBs/Thiazidediuretics–Potassium<100mg/day
BetaBlockers– CoQ10100-200mg/day,VitB3– 16-18mg/day
CommonDrug-Nutrient/DiseaseInteractions– HTN/DMDrugCategory Interaction/Outcome Recommendations
Diuretics:FurosemideHCTZSpiranolactoneAcetazolamide
Loopandthiazidediureticsdeplete;magnesium,potassiumandzinc
Potassiumsparingdiureticsdepletefolicacid
LoopandThiazidediuretics–Magnesium250mg/dayPotassium<100mg/dayZinc<30mg/day
Potassiumsparingdiuretics:Folicacid400mcg/day
CommonDrug-Nutrient/DiseaseInteractions– HTN/DMDrugCategory Interaction/Outcome Recommendations
OralHypoglycemics:MetforminGlimeperideGlipizidePioglitazoneSitagliptin
Insulin
DepletionofFolicacidandVitaminB12
Omega-3- synergism
VitaminB12– 25-400mcg/day
Folicacid– 400mcg/day
Omega-3 - <300mg/day
CaseActivities
Case#1A68-year-olddiabeticwomanvisitedthecardiologyclinicwiththechiefcomplaintofpalpitation
atrestandwithminimalexertion.ShehadahistoryoftypeIIdiabetesmellitusforaround9
yearstreatedwithMetformin1500mg/day,andPioglitazone45mg/day.
Herothermedicationswereasfollows:Aspirin81mg/day,Atorvastatin20mg/day,Losartan25
mg/dayandCalcium+VitaminD(500mg+200IU)/day.
Case#1Onphysicalexamination,shewastosomeextentpalewithsubicterus,otherwiseunremarkable.
12-leadelectrocardiographywasnormalwhiletrans-thoracicechocardiographyshowednormal
leftandrightventricularsizeandglobalsystolicfunctionwithmildtomoderatemitral
regurgitationandnormalpulmonaryarterialpressure.
Case#1Laboratoryexaminationrevealedseveremacrocyticanaemiawithhypochromia,anisocytosis
andteardropcellsonperipheralbloodsmeartable.
Thyroidandrenalfunctiontestswerenormal.Shehadneitherneuropsychiatricnorgastro-
entrologicsymptoms.
Shewasnottakingproton-pumpinhibitorsorotherantacidmedicationseither.
Case#11. Whatisthesuspecteddiagnosis?
Case#11. Whatisthesuspecteddiagnosis?
Ans:MegaloblasticanaemiarelatedtoMetformin-inducedvitaminB12
§Competitiveinhibitionofcalcium-dependentabsorptionintheileum.Althoughcalciumsupplementationdecreasesthemalabsorption,itdoesnotincreaseserumvitaminB12levels.
2. Whatothermicronutrient/swouldyoubeconcernedaboutandwhy?
Case#1Whatothermicronutrient/swouldyoubeconcernedaboutandwhy?
Ans:ZincandPotassium
Losartan(ARB)hasthepotentialtodepletezincandincreasepotassiumlevels
Case#2A65-year-oldwomanreferredtothepharmacyclinicwiththechiefcomplaintofpalpitationat
restandlowbloodpressure.Shehadahistoryofhypertensionforaround6yearstreatedwith
aninitialmanagementof:
§ HCTZ12.5mg/day,Nifedipine40mg/daythen
§ HCTZ25mg/day+Nifedipine40mg/daythen
§Nifedipine30mg/day+Hctz12.5mg+Losartan75mg/day
Withallthepharmacotherapyadjustmentsthepatient’sbloodpressurewasconsistently
unstableandcompliancebecameachallengeforthepatient.
Case#2Withfurtherinvestigationthepatientinformsthepharmacistatonerefillofhermedicinesthatshedoesnotliketakingprescriptionmedicinesandoftentimesubstitutethemforherbalmedicines.
Thepharmacistadvisedthepatienttostopthatpracticeasthismayaffectheroverallcare.
Case#2Thepatient’sdaughter(anursingstudent)didsomeresearchonlineandrecommendedthefollowingsupplements:
◦ Magnesium500mg/day,
◦ FishOil300mg/dayand
◦ Bcomplex
Afterapproximatelytwomonthsoftakingthesupplementsalongwiththemedicationsthepatientnotedverylowbloodpressurereadingwithhighheartrates.Shecomplaintoflightheadednessalongwithfatigue.
NotethatthepatientnowtakesNifedipine 40mg/day+Losartan50mg/dayalongwiththesupplements
Case#21. Whatdoyoususpectishappeningtothispatient?
Case#21. Whatdoyoususpecttotheproblem/problemswiththispatient?
Ans:
Non-Compliancetopharmacotherapyandconcomitantuseofherbalremedieswithprescribedpharmacotherapy.
DailyallowanceofMagnesiumasasupplementis250mg/daynotexceeding350mg/day.Above350mgMagnesiumcangreatlylowerbloodpressure.
2.Whatothermicronutrient/swouldyoubeconcernedaboutandwhy?
Case#2
2.Whatothermicronutrient/swouldyoubeconcernedaboutandwhy?
PotassiumandZinc– Thiazidediuretics,CCBsandARBsincreasestheexcretionofpotassiumandARBsalsodepleteszinc.
Case#3A55-year-oldmalewasadmittedinApril2011afterbeingfoundlyingnakedinthestreettalkingtohimselfand
cursingpassers-by.Hewastakentothehospitalbyhisrelatives.
Mentalstatusexaminationonadmissionfoundthatthepatientwasconsciousbutunabletoanswerquestions
correctly.Hecoveredhisheadwithaquiltduringtheexaminationfornoobviousreason.Helaughedtohimself,
manifestedinappropriateemotionsandappearedtolackinsightintohiscondition.Hehaddifficulty
concentrating,hadslowedreactions,andgotascoreof20ontheMini-MentalStatusExam(MMSE)—indicating
moderatecognitiveimpairment.
Othersymptomsincludeddiarrhoeaandscalyskin.
Case#3GivenanadmissiondiagnosisofPsychosisNotOtherwiseSpecifiedandwastreatedaccordingly.Afterx3/7oftreatmentthepatientcognitivefunctiondidnotimprove.
Uponfurtherprobingofhisrelativestheysharedthatthepatienthasheartandbloodpressureproblemsfor7yearsandwastakingseveralmedicinesforthatproblem.Includedinthepatient’smedicationwasabetablocker.
Case#3Whatdoyoususpectishappeningtothispatient?
Case#3Whatdoyoususpectishappeningtothispatient?
Ans:VitaminB-3deficiencyduetolongtermuseofbetablocker
WhatisthenameoftheconditionthatisassociatedwithVitaminB-3deficiency?
Case#3
WhatisthenameoftheconditionthatisassociatedwithVitaminB-3deficiency?
Pellagra– diarrhoea,dermatitis,mentaldisorderinducedbyVitaminB-3deficiency.
Conclusion§Supplementssuchasmicronutrientsplayanimportantroleinmetabolicandcellularprocesses.
§TheirdeficiencyduetoanincreaseclearanceordeficiencyiningestionmaycontributetosecondarycomplicationsinchronicdiseasessuchasHTNandDM
§Theiradministrationassupplementsareimportanttoachievinghealth,wellnessandcontrol.
§Administration,however,shouldbecarefullymonitoredtoreachadequatedosesinordertoachievetheexpectedeffects,avoidingreachingconcentrationsthatmayproduceadverseeffects.
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