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

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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 DRIs?

• Dietary Reference Intakes are the best available
  evidenced-based nutrient standards for estimating
  optimal intakes.
• 4 DRIs
• 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 individuals 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, Wernickes
  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 gt200ng/dL suggests Inflammation
• Ferritin lt40ng/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 dentition
• Oral lesions/infections
• Periodontal disease
• Neurological 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
• lt25ug/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 gt30
• 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 RDAs
• 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 (gt1500mg/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 gt20

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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 DRIs 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 (25OH gt30ng/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/Day
• Potassium 1-2mEq/kg/Day
• Sodium 1-2mEq/kg/Day
• Phosphorus 15-30mMole/Day
• Calcium 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 gt3.5

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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 gt 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_a
  nd_Mineral_Supplement_Fact_sheets.aspx
• Up to date information on micronutrients
• http//fnic.nal.usda.gov/interactiveDRI/
• Individuals DRIs based on age, gender and
  weight

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Conclusions

• More Websites
• http//www.mypyramidtracker.gov/
• Compares food intake to DRIs for most
  micronutrients
• http//www.ars.usda.gov/Services/docs.htm?docid18
  877
• 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 RDs we should own micronutrient management in
  ANS!

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Questions?