VITAMINS AND MINERALS: WHAT, WHEN AND HOW MUCH

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VITAMINS AND MINERALS: WHAT, WHEN AND HOW MUCH TO SUPPLEMENT Elin Zander, RD, CD, CNSD

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

Page 1: VITAMINS AND MINERALS: WHAT, WHEN AND HOW MUCH

VITAMINS AND MINERALS: WHAT, WHEN AND HOW MUCH

TO SUPPLEMENT

Elin Zander, RD, CD, CNSD

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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.

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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.

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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

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Recommended Dietary Allowance

• Serves as intake goals for healthy individuals

• Meets or exceeds the estimated requirements of 97-98% of the population

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Adequate Intake

• Used when data is insufficient to determine an RDA

• Likely to exceed the actual requirements of almost all healthy people

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Estimated Average Requirement

• The amount estimated to meet the needs of 50% of individuals

• RDA = 2 standard deviations above EAR

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Upper Tolerable Intake Level

• Above which toxicity is likely to occur

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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.

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ADA Position Paper

A healthy diet that provides adequate nutrients is more likely to promote healthy outcomes than will supplementation of individual nutrients.

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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.

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Most Likely Deficiencies in US Diets

• Calcium• Potassium• Magnesium• Vitamins A, C, D & E• Vitamin B-12 in older adults

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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

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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

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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

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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

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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.

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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

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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

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Pop Quiz!

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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.

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Geriatrics

• Chronic undernutrition in elderly may be due to –Decreased access to food–Problems chewing and/or swallowing

Poor dentitionOral lesions/infectionsPeriodontal diseaseNeurological disorders

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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

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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

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Geriatrics

• Common micronutrient deficiencies in the elderly

• Vitamins A, B12, C, D• Folate• Calcium• Magnesium• Zinc

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Consequences of Deficits:

• Poor wound healing• Impaired vision• Increased risk for diseases:–Certain cancers–Osteoporosis–Heart disease–Hypertension

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Consequences of Deficits

• Impaired immune function• Altered glucose and lipid metabolism• Decreased mental acuity/dementia• Depression• Bone fractures• Declining muscle function

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Consequences of Deficits

• Reduced ability to taste• Anemia• Poor appetite• Fatigue• Insomnia

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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.

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Pop Quiz!

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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

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Consequences of Fe Deficiency

• Diminished work capacity• Impaired thermoregulation• Immune dysfunction• GI disturbances• Neurocognitive impairment in children

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Consequences of Fe Deficiency

• In pregnancy increased risk for:–LBW–Preterm delivery–Perinatal mortality–Infant & young child mortality–Maternal mortality

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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

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Risk for Iron Deficiency

• Premenopausal women• Young children• Elderly hospitalized patients requiring

frequent lab draws• GIB or any blood loss (including blood

donation)• Malabsorption

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Risk for Iron Deficiency

• Gastric cancer• Gastric resection & bariatric surgery• Celiac disease• Poor intake/vegetarianism• IBD• CHF• Chronic use of NSAIDS

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Risk for Iron Deficiency

• CKD• Athletes• Low income pregnant women• African American & Hispanic females• Elderly• Chronic illness (ACD)

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Risk for Iron Deficiency

• H Pylori infection• Use of H2 blockers, proton pump

inhibitors or antacids• Altered hepatic function & protein

malnutrition (altered absorption)

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Stages of Fe Deficiency

• Negative iron balance• Iron depletion• Iron deficient RBC synthesis – only after

stores are completely depleted• IDA

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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

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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

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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

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Indications for Parenteral Fe

• High iron requirements• Iron malabsorption• Intolerance to oral therapy

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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])

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Pop Quiz

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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

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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.

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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.

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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

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Pop Quiz

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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

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Calcium

• Absorption increased by:–Adequate vitamin D–Higher BMI– Fat intake

• Absorption decreased by:–High dietary Ca++ intake–Dietary fiber–Alcohol intake–Physical activity

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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.

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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

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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

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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++

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Pop Quiz!

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Vitamin D

• Promotes Ca++ absorption• Maintains ser Ca++ and Phos levels• Enables normal bone mineralization• Prevents hypocalcemic tetany• Promotes bone growth & bone

remodeling

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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

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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.

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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)

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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%

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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.

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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.

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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.

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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.

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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%.

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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

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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

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Pop Quiz!

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Micronutrients in CPN

ASPEN recommendations:Magnesium 8-24mEq/DayPotassium 1-2mEq/kg/DaySodium 1-2mEq/kg/DayPhosphorus 15-30mMole/DayCalcium 10-20mEq/Day

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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.

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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 .

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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

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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

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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)

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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

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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

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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.

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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.

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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

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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.

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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.

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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.

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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

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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.

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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

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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.

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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!

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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

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Conclusions

• More Websites:http://www.mypyramidtracker.gov/– Compares food intake to DRI’s for most

micronutrientshttp://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)

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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

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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

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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

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Conclusions

• As RD’s we should own micronutrient management in ANS!

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Questions?