VITAMINS AND MINERALS:
WHAT, WHEN AND HOW MUCH
TO SUPPLEMENT
Elin Zander, RD, CD, CNSD
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.
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.
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
Recommended Dietary Allowance
• Serves as intake goals for healthy
individuals
• Meets or exceeds the estimated
requirements of 97-98% of the
population
Adequate Intake
• Used when data is insufficient to
determine an RDA
• Likely to exceed the actual requirements
of almost all healthy people
Estimated Average Requirement
• The amount estimated to meet the
needs of 50% of individuals
• RDA = 2 standard deviations above EAR
Upper Tolerable Intake Level
• Above which toxicity is likely to occur
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.
ADA Position Paper
A healthy diet that provides adequate
nutrients is more likely to promote
healthy outcomes than will
supplementation of individual nutrients.
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.
Most Likely Deficiencies in US Diets
•
•
•
•
•
Calcium
Potassium
Magnesium
Vitamins A, C, D & E
Vitamin B-12 in older adults
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
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
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
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
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.
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
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
Pop Quiz!
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.
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
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
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
Geriatrics
• Common micronutrient deficiencies in
the elderly
• Vitamins A, B12, C, D
• Folate
• Calcium
• Magnesium
• Zinc
Consequences of Deficits:
• Poor wound healing
• Impaired vision
• Increased risk for diseases:
–Certain cancers
–Osteoporosis
–Heart disease
–Hypertension
Consequences of Deficits
•
•
•
•
•
•
Impaired immune function
Altered glucose and lipid metabolism
Decreased mental acuity/dementia
Depression
Bone fractures
Declining muscle function
Consequences of Deficits
•
•
•
•
•
Reduced ability to taste
Anemia
Poor appetite
Fatigue
Insomnia
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.
Pop Quiz!
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
Consequences of Fe Deficiency
•
•
•
•
•
Diminished work capacity
Impaired thermoregulation
Immune dysfunction
GI disturbances
Neurocognitive impairment in children
Consequences of Fe Deficiency
• In pregnancy increased risk for:
–LBW
–Preterm delivery
–Perinatal mortality
–Infant & young child mortality
–Maternal mortality
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
Risk for Iron Deficiency
• Premenopausal women
• Young children
• Elderly hospitalized patients requiring
frequent lab draws
• GIB or any blood loss (including blood
donation)
• Malabsorption
Risk for Iron Deficiency
•
•
•
•
•
•
•
Gastric cancer
Gastric resection & bariatric surgery
Celiac disease
Poor intake/vegetarianism
IBD
CHF
Chronic use of NSAIDS
Risk for Iron Deficiency
•
•
•
•
•
•
CKD
Athletes
Low income pregnant women
African American & Hispanic females
Elderly
Chronic illness (ACD)
Risk for Iron Deficiency
• H Pylori infection
• Use of H2 blockers, proton pump
inhibitors or antacids
• Altered hepatic function & protein
malnutrition (altered absorption)
Stages of Fe Deficiency
• Negative iron balance
• Iron depletion
• Iron deficient RBC synthesis – only after
stores are completely depleted
• IDA
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
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
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
Indications for Parenteral Fe
• High iron requirements
• Iron malabsorption
• Intolerance to oral therapy
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])
Pop Quiz
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
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.
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.
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
Pop Quiz
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
Calcium
• Absorption increased by:
– Adequate vitamin D
– Higher BMI
– Fat intake
• Absorption decreased by:
– High dietary Ca++ intake
– Dietary fiber
– Alcohol intake
– Physical activity
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.
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
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
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++
Pop Quiz!
Vitamin D
•
•
•
•
•
Promotes Ca++ absorption
Maintains ser Ca++ and Phos levels
Enables normal bone mineralization
Prevents hypocalcemic tetany
Promotes bone growth & bone
remodeling
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
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.
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)
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%
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.
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.
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.
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.
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%.
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
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
Pop Quiz!
Micronutrients in CPN
ASPEN recommendations:
Magnesium 8-24mEq/Day
Potassium 1-2mEq/kg/Day
Sodium 1-2mEq/kg/Day
Phosphorus 15-30mMole/Day
Calcium 10-20mEq/Day
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.
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 .
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
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
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 (60100ug)
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
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
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.
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.
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
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.
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.
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.
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 Cufree CPN even in cases of cholestasis
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.
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
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.
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!
Conclusions
• Helpful websites:
http://ods.od.nih.gov/Health_Information/Vitami
n_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
Conclusions
• More Websites:
http://www.mypyramidtracker.gov/
– Compares food intake to DRI’s for most
micronutrients
http://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)
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
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
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
Conclusions
• As RD’s we should own micronutrient
management in ANS!
Questions?