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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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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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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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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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?