Vitamins and Minerals: What , When and How Much to Supplement

1. Vitamins and Minerals: What, When and How Much to Supplement ElinZander, RD, CD, CNSD

2. 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.

3. 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.

4. 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

5. Recommended Dietary Allowance • Serves as intake goals for healthy individuals • Meets or exceeds the estimated requirements of 97-98% of the population

6. Adequate Intake • Used when data is insufficient to determine an RDA • Likely to exceed the actual requirements of almost all healthy people

7. Estimated Average Requirement • The amount estimated to meet the needs of 50% of individuals • RDA = 2 standard deviations above EAR

8. Upper Tolerable Intake Level • Above which toxicity is likely to occur

9. 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.

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

11. 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.

12. Most Likely Deficiencies in US Diets • Calcium • Potassium • Magnesium • Vitamins A, C, D & E • Vitamin B-12 in older adults

13. 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

14. 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

15. 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

16. 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

17. 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.

18. 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

19. 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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21. 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.

22. Geriatrics • Chronic undernutrition in elderly may be due to • Decreased access to food • Problems chewing and/or swallowing Poor dentition Oral lesions/infections Periodontal disease Neurological disorders

23. 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

24. 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

25. Geriatrics • Common micronutrient deficiencies in the elderly • Vitamins A, B12, C, D • Folate • Calcium • Magnesium • Zinc

26. Consequences of Deficits: • Poor wound healing • Impaired vision • Increased risk for diseases: • Certain cancers • Osteoporosis • Heart disease • Hypertension

27. Consequences of Deficits • Impaired immune function • Altered glucose and lipid metabolism • Decreased mental acuity/dementia • Depression • Bone fractures • Declining muscle function

28. Consequences of Deficits • Reduced ability to taste • Anemia • Poor appetite • Fatigue • Insomnia

29. 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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31. 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

32. Consequences of Fe Deficiency • Diminished work capacity • Impaired thermoregulation • Immune dysfunction • GI disturbances • Neurocognitive impairment in children

33. Consequences of Fe Deficiency • In pregnancy increased risk for: • LBW • Preterm delivery • Perinatal mortality • Infant & young child mortality • Maternal mortality

34. 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

35. Risk for Iron Deficiency • Premenopausal women • Young children • Elderly hospitalized patients requiring frequent lab draws • GIB or any blood loss (including blood donation) • Malabsorption

36. Risk for Iron Deficiency • Gastric cancer • Gastric resection & bariatric surgery • Celiac disease • Poor intake/vegetarianism • IBD • CHF • Chronic use of NSAIDS

37. Risk for Iron Deficiency • CKD • Athletes • Low income pregnant women • African American & Hispanic females • Elderly • Chronic illness (ACD)

38. Risk for Iron Deficiency • H Pylori infection • Use of H2 blockers, proton pump inhibitors or antacids • Altered hepatic function & protein malnutrition (altered absorption)

39. Stages of Fe Deficiency • Negative iron balance • Iron depletion • Iron deficient RBC synthesis – only after stores are completely depleted • IDA

40. 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

41. 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

42. 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

43. Indications for Parenteral Fe • High iron requirements • Iron malabsorption • Intolerance to oral therapy

44. 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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46. 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

47. 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.

48. 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.

49. 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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