Calcium Potassium Magnesium Iron Zinc Vitamin A Vitamin B12 Folate Vitamin C

Infants Children Adults F-Living Elderly Institution Elderly “LRNI – an amount of the nutrient that is enough for only the few people in a group who have low needs”. <3% of the population Low iron intakes are observed in 33% of women of menstruating age

The Prevalence of Anaemia: NDNS X 4

30% 25% 20% 15% Male Female 10% 5%

• • • •

0% 1.5-2.5yr

4-6yr 15-18yr 35-49yr 75-84yr Institution 85+yr World Health Organisation Normal Ranges; 1.5-6.0 yrs >11.0g/dl, adult women >12.0g/dl, adult men >13.0g/dl. Adult ranges have been adopted from ages 15yrs and upward British laboratories often use a normal range of >11.5g/dl for adult women Levels of 11.5-11.9g/dl in women can indicate symptomatic iron deficiency

The Causes of Anaemia: Age Variations

30% 25% 20% 15% 10% 5% Male Female 0% 1.5-2.5yr

Poor Diet 4-6yr 15-18yr Poor Diet 35-49yr 75-84yr Poor Diet Institution 85+yr Reduced Absorption Menstrual Losses - diet – tea/tannins GI Blood Loss Reduced Absorption Disease/ Unknown - disease - diet and disease Mixed Deficiencies

1. History

Diagnosing Malnutrition

2. Physical Examination 3. Laboratory Investigation

1. History

Diagnosing Malnutrition

2. Physical Examination 3. Laboratory Investigation

Intake: diet + supplements Risk Factors for deficiency Symptoms of deficiency Anthropometric Measures (Body Mass Index - kg/m 2 ) Signs of Deficiency Signs of Underlying Disease Blood and Urine Tests Bone Mineral Density X-Ray

Simple Dietary Assessment – use Food-Based Dietary Guidelines • • • • •

Protein –animal/vegetarian Fish and oily fish Fruit and Vegetables Quality Carbohydrates Dairy or quality substitute

• • • •

Alcohol Salt (sodium) Sugar NMES (non-milk extrinsic sugars) Fat

Simple Dietary Assessment

Assess by interview and description of typical week day’s diet or from dietary questionnaire Five Main Food Groups

• Protein –animal/vegetarian • Fish and oily fish • Fruit and Vegetables • Quality Carbohydrates • Dairy or quality substitute

Four Main Undesirables

• Alcohol • Salt (sodium) • Sugar NMES (non-milk extrinsic sugars) • Fat

Food-Based Dietary Targets Nutritional Significance • • • • •

Protein –animal/veget. - Protein, vit B, Fe, Zn Fish - Protein, vit B12, n-3 EFAs Fruit and Vegetables - Vit C, K, Mg, fibre Quality Carbohydrate - Energy, fibre, vit B, Mg Dairy or substitute - Protein, Ca, I 2 vit B12, B2 A

• • • •

Alcohol <21/14 units/wk Assess units/week Salt (sodium) <6g/day 80% in savoury food Sugar <11% energy 80% in foods & drinks Fat <35% energy Meat, dairy, cakes, pastry biscuits etc

Dietary Assessment – 5 Food-Based Targets WHO/EU/FSA Food-based dietary guidelines

Protein (animal or vegetarian)

7 Good Portions/week

Fish

>2 Portions/week >1 Oily type/week

Fruit and Vegetables Dairy Foods (or soya substitute) Quality Carbohydrate (High Fibre)

>5 Portions/day >1.5-2.5 Portions/day >1-4 Portions/day

12-24g/day

Definition of Quality Carbohydrate Target 1-4 portions/day

Yes

• Wholegrain (wheat, oat or other) breakfast cereal • Wholemeal bread • White bread (UK fortified) • Fresh potato especially with skin • Brown rice or brown pasta • Chappati

No

• White pasta • White rice • Pizza • Noodles

Nutrients in Starchy Foods: “Prizza” vs. Potato Percentage of adult female Estimated Average Requirement by 120 g

70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% White Pasta White Rice Pizza Margharita Jacket Potato 0.00% Protein Pot'm Mag'm Iron Vit B1 Vit B3 Folate Vit C

Alcohol: do doctors know their units?

1 unit = 8g alcohol; ~10 units to a bottle of wine • • • •

Advised Limits Men <21u/wk Women <14 u/wk No alcohol 2-3 days/wk None in pregnancy

Prevalence of High Alcohol Consumption

>21/14 units/week NDNS Data

60% 50% 40% 30% Male >3u Female >2u 20% 10% 0% 15-18yr 19-24yr 25-34yr 35-49yr 50-64yr 65-74yr 75-84yr 85+yr

Alcohol Intake and All Cause Mortality

Alcohol Intake and Stroke Risk

Assessment of Alcohol and Sugar in Adults •

Alcohol - 50% exceed safe limits - suspect if:

- overweight especially abdominal obesity - high blood pressure - raised triglycerides – uncontrolled - depression, mood change, insomnia - abnormal liver function tests - raised uric acid or gout •

Sugar - 50% of adults exceed target - suspect if:

- overweight especially age <30 yrs - poor dental health - poorly controlled diabetic - lower-socioeconomic group - non-alcohol consumer - high intake of sweet foods/added sugar

Simple Assessment of Salt & Fats in Adults •

Salt - 80% of adults exceed target - suspect if:

- high BP - heart failure - fluid retention - high intake of savoury foods/snacks •

Fats - (saturated and trans) 50% exceed - suspect if

- overweight - high cholesterol or vascular disease - high intake of meat, processed meat, butter, full-fat dairy - high intake of hard margarine cakes, pastry (trans fats)

Simple Dietary Assessment: what you learn • • • • •

Protein Fish Fruit and Vegetables Quality Carbohydrate Dairy or substitute

• • • •

Alcohol Salt Sugar Fat (saturates & trans)

• • •

They provide 60-70% of all micronutrients Achieving all targets = good nutrient intake lower health risks But doesn’t guarantee nutritional adequacy

• • •

Displace nutritious foods Excessive Intakes = anti-nutrient effects increased risk of obesity increased health risks Considerable individual variation in effect

Nutritional Assessment - Risk Factors NICE guidelines www.nice.org.uk/cg032 (2006) • Fragile skin • Poor wound healing • Apathy • Wasted muscles • Poor appetite • Altered taste sensation • Impaired swallowing • Altered bowel habit • Loose fitting clothes • Prolonged illness: chronic infection, chest disease, cardiac failure, cancer etc.

Nutritional Assessment - Risk Factors NICE guidelines www.nice.org.uk/cg032 (2006) and others • Fragile skin • Poor wound healing • Apathy • Wasted muscles • Poor appetite • Altered taste sensation • Impaired swallowing • Altered bowel habit • Loose fitting clothes • Prolonged illness: chronic infection, chest disease, cardiac failure, cancer etc.

• • • • • • • •

Life Stage:

- extremes of age - adolesence - pregnant/breastfeeding

Social Circumstances:

- in receipt of benefits - living alone – especially men

Medical History:

- chronic illness/organ failure - heavy periods

Family History/Genetic Factors Medical Drug Use Poor mobility/lack of sun Smoking Symptoms and Physical Signs

Benefit Status and Micronutrient Intake

Percentage of Male Population 19-64 yrs with deficient intake,

51% 48% 45% 42% 39% 36% 33% 30% 27% 24% 21% 18% 15% 12% 9% 6% 3% 0% Vit A B1 Men No Benefits n=724 Men Benefits n=110 B2 B3 B6 B12 Fol Vit C Fe Ca P Mg K Zn I

Data from

National Diet and Nutrition Survey British Adults. TSO 2003/4

Dietary Reference Values for Food Energy and Nutrient for the UK. HMSO 1991

Benefit Status and Micronutrient Intake

Percentage of Female Population 19-64 yrs with deficient intake,

51% 48% 45% 42% 39% 36% 33% 30% 27% 24% 21% 18% 15% 12% 9% 6% 3% 0% Vit A B1 Women No Benefits n=741 Women Benefits n=150 B2 B3 B6 B12 Fol Vit C Fe

Data from Ref:

Ca P Mg K

National Diet and Nutrition Survey British Adults. TSO 2003/4

Zn I

Dietary Reference Values for Food Energy and Nutrient for the UK. HMSO 1991

Low Income Diet and Nutrition Survey (2006/7) • •

Sample of ~2000 people aged 2 to 85+ yrs

• Household where >1adult in receipt of one or more benefits

Increased risks of:

- obesity - physical inactivity - smoking - alcohol excess – slightly in women only but not men • •

Poorer intakes and status of:

- folate - vitamin C - vitamin D - not iron and anaemia • Causative factor: more lack of

education

rather than money

Dietary solution costs ~ £7:00/week:

fresh potatoes, DGLV (see lecture – dark green leafy vegetables, fruit, eggs and tinned oily fish www.stewartnutrition.co.uk

for detail)

Nutritional Assessment: the Whole Picture history is the most informative element Element

History Examination Investigation Nottingham 1975 82.5% W. Virginia 1992 76%

8.75% 12% 8.75% 11% • Both studies assessed new patients, with no clear diagnosis, who were referred to a medical clinic • Studies assessed what key element was required to reach the final diagnosis • References Hampton JR et al. BMJ. 1975;2:486-9 Peterson MC et al. West Med J. 1992;156(2):163-5

Common Nutritionally-Related Problems (QOF Clinical Domain and Additional Services Points) • • Heart Disease Prevention (2) • Coronary Heart Disease (10)

Heart Failure (4)

• Hypertension (3) • • • • • Stroke and TIA (8)

Depression (3) Mental Health (6) Dementia (2) Chronic Kidney Disease (5)

• •

Cancer (2) Osteoporosis (? in 2013)

• •

Maternity (1) Child Health Surveillance (1)

• Anaemia (0) • Low BMI/Wt Loss (0)

Lifestyle, vit B1 Lifestyle, vit B2 Folate Folate Folate + vit B12 Many Caution with vitamins Ca + vit D, avoid vit A XS Lifestyle, folic acid, vit D Healthy diet, surestart, Zn

Heart Failure: Nutrition and Lifestyle

• Sodium restriction if oedema, unintentional wt gain • Alcohol restriction – cardiac depressant • Optimum weight • • Regular exercise • Diet – adequate protein, easy to digest, • Good intakes of K and Mg – potato, vegetable soup • Correct anaemia and iron deficiency

Correct thiamin deficiency

Micronutrient Deficiencies in Heart Failure Soukoulis V. et al. J ACC 2009;54:1660-73 • Some micronutrient deficiencies are common • Some nutrients are important for energy production and muscle function • Thiamin - vit B1, n-3 EFAs, CoQ10, L-carnitine amino acids, taurine, Fe, K and Mg • Trials of some show benefit • Further trials of targeted appropriate nutrition support needed

Thiamin deficiency and heart failure Dr Paul Wood: UK Cardiologist 1968 •

“Here is one of the fatal forms of heart disease which is curable”

• Foods: bread, meat, breakfast cereals • Clinical Features: alcohol XS – CNS effects peripheral neuropathy cardiac failure + tachycardia calf muscle tenderness • No oral/skin signs • Test: RBC transketolase activation coefficient

Prevalence of Vitamin B1 Deficiency

Erythrocyte Transketolase Activation Coefficient >1.25 NDNS

30% 25% 20% Male Female 15% 10% 5%

• • •

0% 4-6yr 7-10yr 11-14yr 15-18yr 19-24yr 25-34yr 35-49yr 50-64yr 65-74yr 75-84yr 85+yr Inst 65 84yr Inst 85+yr ETKAC - measures the increase in stimulation of a vitamin B1 dependent enzyme following the addition of vitamin B1 in the laboratory A high level ( >1.25) indicates pre-existing biochemical deficiency ETKAC was not measured in infants age 1.5 to 4.5 yrs

Treating Patients with Vitamin B1-Thiamin Deficiency

• • • • •

Address the Cause(s)

very poor diet reliant upon white rice and sugar, alcohol XS,, persistent vomiting, unintentional weight loss >5%

Dietary Advice

healthy eating – wholegrain cereals, pork, eggs, fish, nuts fortified foods – UK white flour/bread, some breakfast cereals

Supplement with appropriate amounts of nutrient

Severe deficiency (confusion, ataxia, neurological signs, heart failure) especially if alcohol XS – parenteral injections (BNF) Mild deficit/poor diet oral B1 25-100ug X 3 /day for >2 months

Consider need for other nutrients

Assess folate, zinc and other nutrients if alcohol XS, wt loss Many will also need vit B Co Forte x 3/day or multivitamins

Once main deficiency corrected

Treat >2 months or until full neurological/cardiac recovery Many need long-term vit. B (thiamin >5 mg/day) /multivitamin Caution if cancer especially if rapid growing

Vitamin B2 – Riboflavin and Hypertension Wilson CP et al Am J Clin Nutr 2012:95;766-772 • 83 patients with three genotypes for MTHFR enzyme (folate metabolism) • Increased cardiovascular risk homozygous for 677C >T polymorphism • 31 with TT genotype had higher systolic BP, unresponsive to drug treatment • Given riboflavin 1.6 mg/day 2004 & 2008 • Fall in BP Sys -9.2 + 12.8 mmHg Dias -6.0 + 9.9 mmH

Riboflavin Supplementation and Haematological Status

Powers HJ et al. Am J Clin Nutr 2011;93:1274-84 • Several studies in pregnant women and children in developing countries have shown enhanced response to iron deficiency when riboflavin is given with iron supplements • In a trial in Sheffield involving 123 women age 19-25 yrs who were biochemically riboflavin deficient the three groups received placebo or 2 mg or 4 mg per day for 8 weeks • Both doses resulted in a modest rise in Hb with a dose response effect • Those with the poorest status (found in 20% of UK) experienced a rise of ~0.4g/dl in Hb • There was no observed increase in iron absorption and improved mobilisation from tissues is considered a possibility

Treating Patients with Vitamin B2- Riboflavin Deficiency

• • • • •

Address the Cause(s)

poor diet low in dairy foods especially full-fat, alcohol XS, unintentional weight loss >5%

Dietary Advice

healthy eating – milk, full-fat cheese, eggs, wholemeal bread fortified foods – some breakfast cereals

Supplement with appropriate amounts of nutrient

No separate supplement use vit.B Co Forte X 3 = 6 mg Yellow discolouration of urine is expected and harmless

Consider need for other nutrients

Assess anaemia and iron (reduced absorption) Dairy-free diet consider calcium + multivit/multimineral Consider folate, zinc and other nutrients if alcohol XS

Once main deficiency corrected

Treat >2 months Clearance of angular stomatitis within 4 weeks is expected Caution if cancer especially if rapid growing

Angular Stomatitis/Cheilitis a Common Problem see BNF for further detail • Redness, cracking and soreness at mouth corners • Causes: - nutritional deficiency • Assessment: - dietary history • Investigation: - Full blood count - other nutrients • Nutritional Treatment – iron, riboflavin possibly other B vits.

- candida or mixed bacterial infection - poorly fitting dentures or dribbling - risk factors for nutrient lack - unilateral = mechanical; bilateral = infection/nutritional - failure to clear with antifungal/bacterial = nutrient deficiency – iron, folate as indicated, vit B12 in elderly - Vit B Co Forte x 3 per day for 8 weeks and healthy diet - other supplements as indicated - expect clearance in 4-8 weeks if not reassess

Effect of methylfolate 5 mg x 3/day in psychiatric in-patients with proven folate deficiency

Experimentally-Induced Folate Deficiency Herbert V. Trans Assoc Am Phys.1962:75:307 • 35 year old healthy male All vegetables were triple-boiled in large amount of water • Intake estimated. <25 ug/day vs. requirement of 200ug/day • Supplements of all other B vitamins • 3 weeks – fall in serum folate • 7 weeks – white cells neutrophil hypersegmentation • 16 weeks -

depression & irritability

• 17 weeks - fall in erythrocyte folate • 18-20 weeks - macrocytic red blood cells, fall in haemoglobin, bone marrow – megaloblastic anaemia

Prevalence of low Red Cell Folate: NDNS • • •

50% 45% 40% 35% 30% Male Female 25% 20% 15% 10% 5% 0% 1.5-2.5yr

4-6yr 15-18yr 35-49yr 75-84yr Institution 85+yr

The normal ranges for red cell folate and method of analysis varied with each study; infants > 400nmol/l, children and adults > 350nmol/l and the elderly > 345nmol/l Folate status is influenced by alcohol excess and altered metabolism in the elderly Pregnant or breast feeding women were excluded from the adult NDNS

Treating Patients with Folate Deficiency • • • • •

Address the Cause(s)

poor diet, alcohol XS, malabsorption, elderly, blood disorders

Dietary Advice

healthy eating – green leafy vegetables, potatoes, oranges fortified foods – some breakfast cereals

Supplement with appropriate amounts of nutrient

Folic acid 5 mg x 1-3/day for proven deficiency; x1/wk if MTX Pregnancy 400 ug/day but high NTD risk 5 mg/day (see BNF) Caution if cancer – may promote tumor growth ask oncologist

Consider need for other nutrients

Other deficiencies - vitamin B if alcohol, zinc if malabsorption poor diet in pregnancy consider prenatal multivit/multimineral

Once main deficiency corrected

Retest rbc folate (better than serum folate) after 2-3 months High daily folic acid may reduce zinc absorption long-term Consider long-term 400ug/day or 5mg/wk if status is poor

Folate/Folic Acid and Cancer Risk

Ulrich CM.

Editorial

Am J Clin Nutr 2007;86:271-3 • Low dietary intakes increase the risk of alcohol-associated breast cancer • High intakes of folic acid from supplements

may

increase the growth of an existing tumor • High serum vitamin B12 level associated with increased risk of advanced prostate cancer Johansson M et al Cancer Epidemiol Biomarkers Prev 2008;17(2):279-85 Hultdin J et al Int J Cancer 2004;113:819-24 • Thiamin - vit B1 is growth promoting for some cancers Langbein et al

Risk Management: Cancer Warning Royal College of Radiologists/CR-UK [2006] www.rcr.ac.uk/docs/oncology/pdf/HerbalSupplementsFINALVERSION.pdf

Cancer Treatment, Herbal and Nutritional Supplements

• Ask patients what they are taking before commencing treatment • Urge patients to seek

professional

supplements advice on diet and • If patients are keen take a good quality one-a-day multivitamin and mineral; do not exceed the dose • Antioxidants may reduce the effectiveness of chemotherapy; avoid their use especially high doses • Monitor and report any adverse interaction through the Yellow Card Scheme ( www.mhra.gov.uk

)

Prevalence of Vitamin B12 Deficiency

Plasma <118 pmol/l - NDNS 30% Male Female 25% 20% 15% 10% 5%

• • •

0% 1.5-2.5yr

3.5-4.5yr 7-10yr 15-18yr 25-34yr 50-64yr 75-84yr Institution 65-84yr A serum vitamin B12 of 118pmol/l is equivalent to 154pg/ml Macrocytosis (MCV >101fl) was seen in: 1-3% of teenagers, 9% of adults, 2% of free-living elderly and 3% of elderly in institutions. Macrocytosis is often due to alcohol excess and not vitamin B12 deficiency

Treating Patients with Vitamin B12 Deficiency • • • • •

Address the Cause(s)

vegetarian/vegans, malabsorption, poor gastric acid (now the commonest cause - reduces absorption of food-derived but not supplemental forms), PPIs, pernicious anaemia - rare

Dietary Advice

healthy eating – protein, meat, milk, fish, eggs fortified foods some soya milks b’fast cereals, Flora Proactive

Supplement with appropriate amounts of nutrient

Parenteral Injections for severe deficiency (signs, anaemia or mental symptoms) or malabsorption (see NHS Direct) Mild deficit/poor diet oral B1210-50ug/day - 2 months + retest

Consider need for other nutrients

Vegetarian/vegans – iron, zinc, calcium: elderly Ca/vit D

Once main deficiency corrected

Malabsorption/severe deficiency parenterally - 2-3 months Use multivitamin if poor diet, elderly, some pregnant/lactating Caution if cancer especially prostate – reassess need

Vitamin C and Health

• Scurvy is rare and occurs when plasma level is <3umol/l • Mild deficit, <11 umol/l, may cause depression and mood change; in the UK 25% of men and 16% of women with a low income are deficient – Mosdol A et al J Pub Hlth 2008;30:456-60 (see presentation on LIDNS on www.stewartnutrition.co.uk

) • Levels >50 umol occur as a result of eating >5 portions of fruit and vegetables daily • Good vitamin C status is associated with a lower risk of: - heart failure - Pfister R et al Am Ht J. 2011:162:246-53 - stroke - Kurl S et al Stroke 2002;33:1568-73 • The results of trials of vitamin C supplements show no reduction in such diseases but those most at risk of deficit groups were not especially targeted – males, elderly, poor diet, smokers and lower socio-economic • Consider assessing status in high risk individuals

Vitamin C Prevalence of Deficiency plasma Vit. C<11.0umol/l - NDNS data

60% 50% 40% 30% Male Female 20% 10%

• • •

0% 1.5 3.5yr

2.5 4.5yr

4-6yr 7-10yr 11 14yr 15 18yr 19 24yr 25 34yr 35 49yr 50 64yr 65 74yr 75 84yr 85+yr Inst 65 84yr

Approx. 20% of adults and 12% of the elderly took supplements of vitamin C

Inst 85+yr

Approx. 25% of British adults smoke and this declines after the age of 65 years Aspirin was taken by 20% of free-living elderly and 24% of institutionalised elderly

Treating Patients with Vitamin C Deficiency • • • • •

Address the Cause(s)

poor diet – lack of fruit, vegetables, potato and XS of pasta & rice, poor teeth/chewing, heavy smoking and asprin/NSAIDs

Dietary Advice

healthy eating –

fresh

vegetables, fruit/juice, potatoes + skins

Supplement with appropriate amounts of nutrient

Ascorbic acid 200 – 500 mg/day for 8 weeks Adverse effects rare: Safe Upper Levels 1000 mg

Consider need for other nutrients

Anaemia (iron) and folate lack are possible/likely

Once main deficiency corrected

If healthy diet cannot be guaranteed long term supplement 200mg/day may be needed by a few elderly, heavy smokers High doses

may

increase risk of cataract in steroid users, increase breast cancer risk and rarely oxalate renal stones (see Safety of Supplements www.stewartnutrition.co.uk

)

• •

Prevalence of Iron Deficiency - NDNS

Low Plasma Ferritin: Range < 10-20ug/l 50% 45% 40% 35% Male Female 30% 25% 20% 15% 10% 5% 0% 1.5-2.5yr

3.5-4.5yr

7-10yr 15-18yr 25-43yr 50-64yr 75-84yr Institution Normal ranges: infants age 1.5-4.5yrs > 10.0ug/l, females age >4yrs-adult > 15.0ug/l, males age >4yrs-adult > 20.0ug/l 65-84yr Plasma ferritin can be elevated by acute or chronic inflammation, infection or liver disease and is not a reliable measure of iron status in ill and elderly people

Symptoms of Non-anaemic Mild Iron Deficiency Prevalence of self-reported symptoms in 11,561 white female US college entrants Hb >12.0 g/dl

50.00% 45.00% 40.00% 35.00% 30.00% 25.00% 20.00% 15.00% 10.00% 5.00% 0.00% Fatigue Not Deficient Deficient Irritabilty Frequent Headache

• All Hb >12.0g/dl • Iron Deficient serum ferritin <21ug/l • Not iron deficient 616 10,945 • Analysis by Chi squared: Fatigue p= 0.0026

Irritability p= 0.003

Headache p= 0.0004

• BMJ on line 28/6/2003 Waalen J, Felitti V and Beutler E

Treating Patients with Iron Deficiency • • • • •

Address the Cause(s)

vegetarian/vegan diet, XS tea, heavy periods, GI bleeding

Dietary Advice

healthy eating – red meat, liver, beans, eggs, green veg; fortified foods - white bread and some breakfast cereals

Supplement with appropriate amounts of nutrient

Ferrous Sulphate 200 mg 1-2/day

always

with fruit/juice Iron supplements

must

be taken 2 hrs away from tea/coffee GI upset likely if dietary advice not followed or high doses Prolonged use may reduce zinc absorption

Consider need for other nutrients

Vit B2 lack and rarely vits C, A and copper cause iron lack Give Vit. B Co Strong x 2/day or Forceval x 1/day as needed

Once main deficiency corrected

Retest (Hb and ferritin) after 2 months Continue supplements for 3 months to replenish stores Chronic menorrhagia -iron x 1/day for 7 days/cycle with period

NHS Multi-vitamins/minerals: not a great choice Prescribable for the treatment of proven deficiencies or their prevention in those at significant risk of undernutrition (see BNF) • • • • •

Vitamin Tablets

vitamins A, D, C, B1, B3, B2 v. low doses, (no folic acid/B12) Based on formulation from 1940s of a free sample from US govt.

see Bransby ER BMJ 15 th Jan 1944 p77.

Vit B Tablets Compound and Compound Strong

vitamins B1, B2, B3, (B6 – strong only)

Liquid ABIDEC and DALIVIT drops

vitamins A,D, C and some B suitable for some infants

Ketovite

tablet - vitamins C, B, E, K; liquid vitamins A, D 2 and B12

Forceval Adult and Junior

RDA amounts of vitamins and trace elements Useful but avoid in cholestatic liver disease (Mn XS) and caution in osteoporosis (vit A XS)

Healthy Start Vitamins: a step in the right direction see www.healthystart.nhs.uk

• •

Children’s Vitamin Drops

would help address poor vitamin status in infants; does not contain iron but iron absorption will be enhanced by vitamin C. Daily dose of 5 drops provides:

- vitamin A 233 ug

(for growth and immunity)

- vitamin C 20 mg

(for bones, immunity and iron)

- vitamin D 7.5 ug

(for bones, teeth and immunity) Take from 6 months until their 4 th birthday. Not needed if consuming 500 ml of formula milk per day

Vitamins for Women

would help fulfil increased needs in pregnancy. Contains

- folic acid 400 ug

(fetal nervous system development)

- vitamin D 10 ug

(calcium absorption, skeletal development)

- vitamin C 70 ug

(healthy tissues and aids iron absorption) For pregnant women until their child is 1 yr old

Vitamin A Prevalence of Deficiency - NDNS

Percentage of Population with a plasma Retinol < 0.7/75 umol/l

20% 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 1.5 3.5yr

4-6yr 11 14yr Male Female 19 24yr 35 49yr 65 74yr 85+yr Inst 85+yr

Statement of Professor Bloch Danish Paediatrician World Dairy Congress Washington DC Oct 3 rd 1923

Retinol – vitamin A Content of Dairy Foods per 100 g: Whole Milk 55ug Semi Skimmed Milk 23ug Yakult None

“No other article can replace milk. Absence of milk from the diet or inclusion of unfavourably modified milk is the origin of most serious diseases. By ordering milk, and especially cream and butter, not only is this terrible eye disease cured for infectious disease.” – which I believe will be discovered in every country when it is looked – but these dairy products are of the greatest importance for growth and development and the cure of our greatest

Supplemental Milk and Growth in Orphan Boys Increase in Height in Inches in One Year Mann H C Corry (1926)

Sp. Rep Ser Med Res Coun.

London No. 105.

3 2.5

2 1.5

1 0.5

• • •

0 Basic Diet Water Cress Casein Veget Marg Sugar N-Z Butter Milk

219 Institutionalised orphaned boys many of whom were considered to be Increase below the standard for height and weight despite the diet being “adequate” 41 Boys were given 1 pint of whole pasteurised milk per day Additional margarine, sugar and butter were isocaloric

Zinc: Prevalence of Low Intake (Diet and Supplements)

< LRNI NDNS x 4

39% 36% 33% 30% 27% 24% 21% 18% 15% 12% 9% 6% 3% 0% 1.5 2.5yr

2.5 3.5yr

3.5 4.5yr

4-6yr 7-10yr 11 14yr Male Female 15 18yr 19 24yr 25 34yr 35 49yr 50 64yr 65 74yr 75 84yr 85+yr

Adjusted final length (cm) by length-for-age Z-score categories at baseline and by treatment.

Rivera J A et al. J. Nutr. 1998;128:556-562

©1998 by American Society for Nutrition

Zinc with antibiotics for babies

Lancet 2012: doi:10.1016/SO140-6736(12060477-2 • • • • • •

Infants age 7-120 days in India with bacterial infection (pneumonia, sepsis, meningitis) Rx Antibiotics or Antibiotics + Zn 10 mg/day Outcome – treatment failure (change of Ab, intensive care or death) Treatment Failure Antibiotics alone Antibiotics + Zn 17% 10% 44% of babies had serum Zn <9.2 umol/l – marked deficiency Similar benefits in other studies in pneumonia and diarrhoea

Treating Patients with Zinc Deficiency • • • • •

Address the Cause(s)

vegetarian/vegan diet, alcohol XS, malabsorption, diarrhoea

Dietary Advice

healthy eating – red meat, cheese, eggs, nuts and seeds

Supplement with appropriate amounts of nutrient

Zinc Sulphate (Solvazinc 125 mg (45 mg Children <10kg ½ tablet/day (see BNF) – elemental) 1-3/day after food away from tea/coffee, bran/chapatti GI upset more likely if taken on an empty stomach

Consider need for other nutrients

If malabsorption/underweight consider multivitamins and if alcohol XS Vit. B Co Strong x 3/day

Once main deficiency corrected

Reassess/retest after 8 weeks; target plasma Zn >10.0umol/l Sample protocol follow guidelines www.izincg.org

Prolonged use (>25 mg/day) may cause Cu lack + anaemia

Osteoporosis - Definitions

• Loss of bone

architecture mass

that leads to an increased risk of

fracture

and • WHO - A bone mineral density measured by DEXA scan that is >2.5 SD (standard deviations)

below

the peak BMD in young normal adults in the lumbar spine or femoral neck, T Score • Osteopenia 1.5 – 2.5 SD below peak BMD

Safety of Vitamin A: SACN Sept 2005 • • Retinol Total Safe Intake, TSI = 1500 ug/day

Risk: Osteoporosis Birth Defects

- common - v. rare • UK adult diet ~700 ug/day • Supplements Safe Upper Level <800 ug/day none in pregnancy • High intakes from: - food – liver, very high dairy - supplements multivits and CLO • TSI is exceeded by: - adults (19-64yrs) 6% - elderly (65+ yrs) 11% • Raised Serum Retinol: - renal impairment - alcohol excess - abdominal obesity

Serum Retinol and the Risk of Fracture [Swedish men aged 49-51 yrs, 30 year cohort study] Michaelsson K et al NEJM 2003:348:287-294

Retinol Status of the British Population (estimates) Plasma Retinol Levels NDNS Data Collected 1990-2001

Deficient <0.7/0.75 umol/l Borderline 0.75-1.0 umol/l Adequate 1.0-2.8 umol/l Mild Excess 2.8-3.5 umol/l Significant excess >3.5 umol/l 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1.5 - 4.5 yrs 4 - 18 yrs 19 - 64 yrs F-L 65+ yrs Inst 65 + yrs

Vitamin D Prevalence of Deficiency - NDNS %

Plasma 25-hydroxyvitamin D <25nmol/l NDNS

• • •

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 1.2 2.5 3.5 4-6yr 7-10yr 11 15 19 25 35 50 65 75 85+yr Inst Inst 2.5yr

3.5yr

4.5yr

14yr 18yr 24yr 34yr 49yr 64yr 74yr 84yr 65 85+yr 84yr

Plasma 25-hydroxyvitamin D levels show considerable seasonal variation with mild deficiency being commonplace in late winter and spring and rare in summer Dietary sources provide approximately 10% of the body’s content of vitamin D Some laboratories adopt a lower end of normal range of 50nmol/l 25-OH D

Male Female

Vitamin D Prevalence of Deficiency - LIDNS Low Income Diet and Nutrition Survey Plasma 25 OH Vit D <25.0nmo/l

50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% 1.5 3.5yr

3.5 4.5yr

4-6yr 7-10yr 11 14yr 15 18yr 19 24yr Male Female 25 34yr 35 49yr 50 64yr 65 74yr 75 84yr 85+yr Inst 65 84yr Inst 85+yr

• • • • • Treating Patients with Vitamin D Deficiency

Address the Cause(s)

lack of sun and inactive; diet – lacking eggs/oily fish, obesity, malabsorption, renal and liver disease

Dietary Advice

healthy eating – eggs, meat, oily fish: wt loss if obese fortified foods – margarine, some b’fast cereals and soya milk

Supplement with appropriate amounts of nutrient

Ca +vit D x 1-2/day for osteoporosis (x2/day if poor diet) Vit. D 1000 iu (25 ug) OTC x 1-4/day for >3months Severe deficiency or renal disease parenteral or specialist supplements (see NHS Direct and BNF) Avoid cod liver oil/vitamin A if osteoporosis

Consider need for other nutrients

Calcium if low intake, young/old or osteoporosis

+

extra vit D

Once main deficiency corrected

Re-measure 25OH D after 3-6 months Target >50 nmol/l but >75 if osteoporosis Long-term oral vit D 1000 iu/day is safe and suitable for many

Short Life Expectancy: Associated Nutritional Factors

NDNS 65+ 17 year follow-up (60% died) Bates CJ et al 2010/11 • • • • • • •

Poor grip strength (men) Low food/protein intake Poor renal function: raised Pl. HCys and Retinol Raised Hb A1c prediabetes/diabetes Inflammatory disease: raised Pl. copper (infection, cancer, liver dis) Low plasma nutrients: vit C, Alpha-carotene, B6, D (men), zinc and selenium Not Cholesterol, vit B12, folate, Hb or Beta-carotene

Supplements: Who needs them?

Department of Health 2011 July Version 2 (14 amendments): Revised following correspondence between Dr S and Paul Gingell DoH • all pregnant or breastfeeding women ( 5 years (

vitamin D

their pregnancy ( ) • women trying to conceive and in the first 12 weeks of

folic acid vitamins A, C & D

) • all children aged 6 months to ) • people aged 65 and over (

vitamin D

much sun ( ) • people with darker skin or who are not exposed to

vitamin D

) • Those diagnosed with a deficiency by their doctor

Nutritional Medicine: Messages and Solutions

• • •

Department of Health:

Publish all previous NDNS on line Clinicians involved in NDNS planning and interpretation Action group – respond rapidly to NDNS findings

Education:

Books to include NDNS data Basic principles to be taught from GCSE to academia

Clinical Practice:

Targets – for screening for undernutrition in primary care Dietary assessment – deficiency and excess Emphasise food-based dietary targets, therapeutic diets Better availability of tests with clear indications More appropriate and safer NHS nutritional supplements