Lecture 17,18 Vitamins, Minerals And Other Supplements, Nutritional Deficiences Flashcards
Roles of vitamins and minerals in health
Essential for maintaining various physiological functions, supporting metabolism and ensuring overall health and well being
Bone health
Immune function
Blood health and oxygen transport
Nerve fx
Antioxidant protection
What are the water soluble vitamins
Vitamin B1 (thiamine)
Vitamin B2 (Riboflavin)
Vitamin B3 (Niacin)
Vitamin B6 (Pyridoxine)
Vitamin B7 (Biotin)
Vitamin B12 (Cyanocobalamin)
Folic Acid (Folate)
Vitamin C (Ascorbic acid)
What are the Fat Soluble Vitamins
Vitamin A,D,E,K
What are the 5 main Minerals
Calcium,iron,zinc,selenium,magnesium
Functions and sources of vitamin B1 (thiamine)
Fx: Needed for energy, metabolism and nerve function
Source: pork, whole grains, cereals
Functions and sources of vitamin B2 (Riboflavin)
Fx : energy needed for metabolism, normal vision and skin health
Source: milk, vegetables, whole grains
Function and source of vitamin B3 (niacin)
Fx: required to produce hemoglobin, maintain blood glucose
Sources: meat, fish, whole grain, cereals, vegetables
Function an sources of Vitamin B5 (panthothenic acid)
Fx: coenzyme for energy metabolism
Source: liver,kidney,egg yolk, legumes, broccoli
Function and source of Vitamin B6 (Pyridoxine)
Fx: coenzyme needed for protein metabolism, red blood cell production
Source; Meat, fish, poultry, legumes etc..
Function and sources of Vitamin B7 (Biotin)
Fx: coenzyme needed for energy metabolism
Sources: egg yolk, liver, yeast, bananas, grapefruit
Function and source of Vitamin B12 (Cyanocobalamin)
Fx: required for red blood cell formation, DNA synthesis, neurological function
Source: meat, fish, shellfish, eggs
Function and source of Folic acid
Fx: coenzyme needed for making DNA and new cell growth
Source: legumes, green leafy veggies, liver, breakfast cereals
Function and source of VitaminC (Ascorbic acid)
Fx: antioxidant; coenzyme for protein metabolism, immune system health, aids in iron absorption
Source: citrus fruits and vegetables
Vitamin A function and sources
Fx: vision, health skin, mucous membrane, bone and tooth growth
Source : milk, cheese, cream, butter,
beta carotene ( from plant source): leafy, dark green vegetables
Function and source of Vitamin D
Fx: calcium metabolism, cell differentiation, immunity, insulin secretion
Source: salmon, sardines, tuna and fish oils, milk products
Vitamin E function and sources
Fx: antioxidant protection from free radicals
Source: nuts, seeds, vegetable oils, egg yolk
Vitamin K function and sources
Fx: blood clotting, bone formation
Sources broccoli, soybeans, dark green leafy veggies
Calcium function and sources
Fx: mineralization of bones and teeth, contraction and dilation, blood clotting
Source: diary, kale, broccoli
Function and sources of Iron
Fx: component of hemoglobin, muscle metabolism, healthy connective tissue
Source: meat, poultry, fish, legumes, nuts and seeds
Function and sources of Zinc
Fx: involved in cellular metabolism, catalytic activity, immune fx, protein and DNA synthesis
Sources: meat, fish, seafood
Function and sources of Selenium
Fx: thyroid hormone fx, DNA synthesis, reproduction
Sources: organ meats, seafood, plant sources
Magnesium function and sources
Function: cofactor in more than 300 enzyme systems involved in protein synthesis, muscle and nerve function
Sources: Green leafy veggies, nuts, seeds, whole grains
What are the 6 stages of food processing
Ingestion
Digestion
Absorption
Transport
Metabolism
Excretion
Risk factors for vitamin deficiencies
Dietary factors
Malabsorption conditions
Increased nutrient requirements
Medication use
Chronic medical conditions
Alcohol and substance use
Lifestyle and environmental factors
Genetic and physiological factors
Cultural and social influences
Risk factors for vitamin deficiencies
Dietary factors, examples
Poor dietary habits
Restricted diets (vegan)
Food insecurity
Elderly population
Unbalanced diets
Risk factors for vitamin deficiencies
Malabsorption conditions
Gastrointestinal disorders ( celiac disease, IBD, chronic diarrhea)
Postbariatric surgery ( reduced absorption of iron, calcium, vitamin B12)
Chronic pancreatitis ( reduce A,D,E,K)
Risk factors for vitamin deficiencies
Increase nutrient requirements
Pregnancy and lactation
Infancy and adolescence
Aging
Chronic diseases
Risk factors for vitamin deficiencies
Medication use
Effects of PPI,Metformin,Diuretics,Anticonvulsants,Corticosteroids
PPI- reduce stomach acid (B12,calcium,magnesium)
Metformin - B12 deficiency
Diuretics - pottasium, magnesium, calcium depletion
Anticonvulsants - Vitamin D
Corticosteroids- deplete calcium and potassium
Risk factors for vitamin deficiencies
Chronic medical conditions
- effects of liver disease, kidney disease, heart failure
Liver disease- impaired vitamin storage and metabolism (A,D,E,K)
Kidney disease - loss of water soluble vitamins due to dialysis
Heart failure - potential for increased nutrient needs due to medication use and fluid balance issues
Risk factors for vitamin deficiencies
Alcohol and substance use disorders
Chronic alcohol consumption - reduced absorption - especially Thamine
Substance use disorders, vitaminC, B vitamins, iron, calcium, and magnesium
Risk factors for vitamin deficiencies
Lifestyle and environment
Effects of Smoking, Sunlight exposure, physical activity
Smoking - potential higher vitamin C requirements, and potential deficiencies in folate and Vitamin E
Sunlight exposure- vitamin D deficiency
Physical Activity levels - increase nutrient demand
Risk factors for vitamin deficiencies
Genetic and physiological factors
Genetic disorders - hemochromatosis, phenylketonuria
Obesity- altered metabolism and nutrient distribution
Risk factors for vitamin deficiencies
Cultural and social influences
Cultural and dietary practices -may exclude specific food groups
Religious dietary restrictions- fasting or food restriction
Patient assessment for vitamin supplementation
Collecting- patient history
Dietary habits
Lifestyle factors
Social determinants of health
Medication history
Past medical history
Symptoms suggestive of deficiencies
Collecting dietary history from patients
24 hours dietary recall
Food frequency questionnaire
Typical day diet assessment
Food group inquiry
Patterns and restrictions ( vegan, vegetarian, gluten free, lactose free, allergies)
Cooking skills and knowledge
Collecting lifestyle factors from patients
Smoking
Alcohol use
Physical activity
Collecting past medical history and medication history
Conditions like Celiac disease, IBD, Gastric bypass surgery
Medications: PPI,Diuretics,Anticonvulsants, vitamins, minerals
What are some symptoms of deficiencies
Fatigue
Hair loss
Brittle nails
Dental issues
Mood changes
Abnormal bruising or bleeding
Follow up and monitor for patients
Repeat lab tests if needed to assess improvement in nutrient levels
Evaluation of symptom resolution
Adherence assessment to dietary supplementation plans
What are the magnesium salts used for supplementation
Magnesium aspartate
Magnesium bisglycinate
Magnesium carbonate
Magnesium Chloride
Magnesium glucoheptonate
Magnesium Gluconate
What is the indications for supplementation (magnesium) and the potential causes of deficiency
- Average health adult does not need supplementation with magnesium
- malnutrition, chronic diarrhea, IBD, Diuretics, Critically ill
Adverse effects of magnesium supplementation
Diarrhea
Nausea
Toxicity: Hypotension,N/V, facial flushing, muscle weakness, arrhythmia, cardiac arrest
Measuring Vitamin D levels
25-hydroxyvitamin D - best biomarker of nutritional vitamin D status (Half -life of 2 weeks)
Generally not required prior to or after intitating vitamin D supplementation
Indicated in high risk pt: malabsorption syndromes, significant liver disease, CKD, unexplained bone pain, unusual fractures
What is the preferred test for Vitamin D levels and numbers associated
25-hydroxyvitamin D is preferred test
<30 nmol/l- risk of deficiency
30-50 nmol/l clinical features of inadequacy in some individuals
> 50nmol/l - adequate for bone health in practically all individuals
> 125nmol/l- potential for adverse effects
What are some Vitamin D sources
Food sources: Fatty fish, egg yolks, fortified foods
Exposure to sunlight, BUT increased risk of skin cancer
On average, Canadian adults do not obtain sufficient vitamin D from dietary sources to meet the RDA of …..
RDA: 600-800IU
TUL : 4000IU
What are the vitamin D dosage forms
Vitamin D2 - Ergocalciferol
Vitamin D3 - cholecalciferol
Vitamin D3 is recommended over vitamin D2 as it has been show to be 3x more effective than D2 at increasing 25-hydroxyvitamin D levels
High dose vitamin D once/year not recommended- increase risk of fracture
What are some potential indication for higher doses of D2/D3
Malabsorption, obesity, meds that affect metabolisms of VitD
- 5000U daily or 50,000u weekly
- maintancene: 1500-2000u/day
Vitamin D-resistant rickets
- 12,000-500,000U daily
Hypoparathyrodism
-50,000-200,000 daily
Vitamin D toxicity (>250nmol/l)
Hypercalceima
-Confusion, depression, psychosis
-vomiting, abdominal pain, anorexia, constipation
-hypertension, arrhythmias,
Vitamin B12 testing
Recommend?
Not recommended
1150-220pmol/l
Test if clinically symptomatic patient with specific features of B12 deficiency
What is the recommendation in all Canadians over the age of 50 in terms of vitamin D
Take 400IU of vitamin D per day in addition to consuming vitamin D rich food
Risk factors for Vitamin B12 low levels
Diet
Medical hx
Medications
Diet: Vegetarian, vegan, chronic excessive alcohol use
Medical Hx: increasing age, pernicious anemia, crohns, celiac disease
Medications: Metformin, PPI, H2 receptor antagonists
Treatment recommendations for vitamin B12 deficiency
1.Adults with normal absorption
2.Adult with impaired absorption
3.Adults with dietary deficiency
4.Pernicious anemia
5.Altered GI anatomy
6.Adults anemia or neurological symptoms or pregnancy
1 - 1000mcg daily orally
2- high doses 1000-2000mcg daily
3- 500-2000 mcg orally
4- IM/deep SC, 1000mcg once per week for 4 weeks, then once per month. Can do high dose oral
5- IM/Deep SC, 1000mcg once per week x4 then once per month
- IM/Deep SC, 1000mcg daily or every other day for 1-2 weeks then once month. Trial oral 1000-2000 mcg based on preference
Following and monitor for VitaminB12
Hematologic parameters should resolve within weeks
Neurological/neuropsychaitric within months
B12 levels every 3-6 months
Celiac disease
Deficient nutrients and supplement recommendation
- iron, folate, B12, Fat-soluble vitamin, calcium
- iron 325mg daily, folate 1mg, B12 1000mcg, vitamin D 1000-2000 IU daily
Crohn’s disease, deficient nutrients and supplement recommendations
- Deficient nutrient - B12, Iron, Zinc, Fat soluble vitamins
- B12 1000mcg IM monthly, zinc 10-40mg daily, iron 325 mg daily
Short bowel syndrome deficient nutrients and supplement recommendations
B12, Fat soluble vitamins, iron, calcium, Zinc
B12 1000mcg IM monthly, High dose fat soluble vitamins, zinc 10-40 mg daily
Chronic pancreatitis deficient nutrients and supplement recommendations
Deficient nutrients- Fat soluble vitamins, B12, Calcium
Enzyme replacement, vitamin B12 1000mcg daily, Calcium 1000-1500 mg daily
Thiamine- Alcohol disorder
Increased risk of …….
Treatment dose
Increased risk of wernicke-korsakoff syndrome
200-500mg IM/IV 3 times daily for 2-7 days, followed by 250mg once daily for 3-5 days
Thiamine Deficiency = Beriberi
“Wet”- high output cardiac failure
Dry - peripheral neuropathy, absent knee jerk and deep tendon reflexes, progressive weakness and muscle atrophy
Thiamine supplementation, initial - IM/IV, or oral : 100-200mg 3x daily for 2-3 days. Maintenance : 5-100mg once daily until no longer at risk of deficiency
Cancer prevention
Breast cancer
B vitamins- limit supplementation for primary prevention of breast cancer
Vitamin D- Not recommended for prevention
Vitamin E - Limit or avoid Vitamine E supplementation
Cardiovasculate disease prevention ( primary)
Limit supplementation of the following
- Vitamin C, Multivitamins
- Vitamin D
- Omega-3-fatty acids
CVD- secondary prevention
Avoid routine use of - antioxidants
Omega-3fatty acids
- unlikely benefit, but minimal risk
- high dose supplementation with icosapent ethyl may reduce elevated triglycerides
Absorption Interactions
Mechanism : Chelation, PH changes, alterations in gastrointestinal motility or enzyme activity
Examples: calcium, iron, zinc, magnesium ( bind to tetracyclines and fluoroquinolones reducing absorption). Antacids ( calcium carbonate, aluminum hydroxide), reduce absorption of iron and B12 due to increased gastric PH
Management: separate administration times
Metabolism interaction
Mechanism: enzyme inhibition or induction, nutrients affecting drug metabolism
Examples: Vitamin K + warfarin = reduce effectiveness of warfarin. Grapefruit inhibits CYP3A4 - potential to increase concentration of some statin and CCB
Management: patient education on consistent vitamin K intake, avoidance of grapefruit with certain medication
Distribution and protein binding
Mechanism : completion between drug and nutrient for plasma protein binding sites
Examples: vitamin A and warfarin - displacement of warfarin from protein binding sites, increasing bleeding risk
Management: monitor INR and adjust doses as necessary
Symptoms of low Vitamin B12
Fatigue, weakness, pallor, numbness tingling, cognitive difficulties, depression
What are some nutrient deficiency induced by drugs
Vitamin B12 - long term use of PPI or Metformin
Folic acids - methotrexate,phenytoin
Calcium and Vitamin D - corticosteroids
What are some nutrient affecting drug efficacy and monitoring and management
Iron and calcium- reduces efficacy of levothyroxine
Managementz; adjust timing, seperate administration
T/F loop diuretics may increase excretion of potassium,magnesium,calcium
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