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Valerie Dzubur EdD APRN FNP – BC Samuel Merritt University PHC I Vitamins and Minerals • Growth maintenance and repair • Non-energy producing nutrients Vitamins - organic Fat – soluble A D E K Water soluble B complex & C Minerals - inorganic Major Trace Deficiency • Inadequate dietary intake • Increased metabolism • Poor absorption • Medications $7.5 billion spent annually However Vitamins and minerals are best obtained from foods not pills Dietary Reference Intakes (DRI) • Replaced Recommended Daily Allowance Food Labels • % Daily Values Based on the DRI Vitamin A - Fat Soluble • Retinal & retinoic acid • Carotenoids • Stored in the Liver • Required for bone growth, immune function, gene expression, vision, integrity mucosal & epithelial surfaces Vitamin A deficiency • Visual disturbances • Respiratory infections • Dryness • Keratinization of the skin • Genitourinary disturbances • Faulty bone formation Green and yellow vegetables Cancer risk reduction unclear Vitamin A Toxicity • Acute N/V, blurred vision, lack of muscle co- ordination • Long term - large doses Fatigue, irritability, hepatic abnormalities, Anorexia, depression, nausea, vomiting, reduced bone density Vitamin A • Use with caution in pregnancy • Accutane is a Vitamin A analog • Drugs that decrease absorption – separate doses by two hours Cholestyraine ( Questran) Colestipol (Colestid) Orlistat (Zenical) Mineral Oil Vitamin D • Synthesized in the skin • Calciferol, ergocalciferol, cholecalciferol • Ultraviolet triggers the synthesis • Stored in Fat • Needed for calcium and phosphorus homeostasis Vitamin D Deficiency caused by • Inadequate dietary intake of calcium • Limited sun exposure • Use of sunscreen • Obesity • Renal & Liver disease • Inability of the skin to synthesize Fortified Foods Fish liver oils, liver and Eggs Lab – Serum 25(OD) levels • Level 30 – 60 ng/ml Rx Ergocalciferol l50,000 IU once per week 6 – 8 weeks than 1,000 IU vit D 3 q day Vitamin E • Tocopherols and tocotrienols • Stored in the Liver • Deficiency Peripheral neuropathy, dry skin & hair, poor wound healing, bruising, anemia, ataxia, muscle weakness, reproduction failure Vitamin E • An antioxidant & may prevent Select cancers Cardiovascular disease Age-related macular degeneration Visual acuity loss Muscle injury Further decline in Alzheimer Vitamin E • Toxicity Headache GI disturbances, diplopia, muscle weakness • Found in nuts soy beans, green leafy vegetables, wheat germ oil, whole wheat, whole grain cereals Vitamin K • Quinones or naphthoquinoine • Fat soluble • Coenzyme for the synthesis and activation of clotting factors • Creation of proteins in the plasma, kidney and bone Vitamin K • Deficiency caused by inadequate nutrition • Relatively non-toxic • Bile acid sequestrants, mineral oil, orlistat can interfere with absorption • Separate dose by 2 hours Thiamin – Vitamin B 1 • Water soluble • Energy metabolism nerve conduction and aerobic metabolism • Sources Enriched fortified cereal grains, organ meats, lean cuts of pork, legumes, seeds and nuts Vitamin B 1 deficiency – Berriberi • Cardiac failure, muscle weakness, peripheral and central neuropathy, gastrointestinal malfunction High risk • Alcoholics • Adults with high carbohydrate intake White rice – Asian Countries • Dialysis patients • Parental nutrition • Hypermetabolic states Vitamin B 2 – Riboflavin • Facilitates metabolism, energy production • Sources Milk, eggs, cheese, organ meats, green leafy vegetables, whole grains, enriched cereals & breads Little is stored - need daily intake Niacin – Vitamin B 3 • Nicotinic acid & nicotinamide & tryptophan • Lipid metabolism, tissue respiration, glycogenolysis • Causes peripheral prostaglandin- mediated vasodilatation and increased histamine-mediated gastric motility Affects fibrinolytic system, glucose intolerance, synthesis of VLDL –C and LDL – C Used to treat • Hypercholesterolemia, mixed dyslipidemia, hypertriglyceridemia Lowers LDL-C & Triglycerides Increases HDL – C Pre-medication with ASA may help flushing Can exacerbate gout Increased LFT may result long term use Discontinue if LFT > 3 x normal Contraindicated in patients with liver disease Cholestyraine and Colestipol can decrease absorption Niacin • Increased insulin resistance • Hypoglycemic medications may need to be increased • Enhance effects of hypotensive effect of ganglionic- blocking agents Niacin • Sources Red meats Beans Fortified foods Milk and eggs contain Tryptophan Vitamin B 5 – Pantothenic acid • Acetylcholine synthesis Metabolism of fats carbohydrates and proteins Deficiency treated with Pantothenic acid Also good for pruritis and mild eczema Vitamin B5 • Deficiency Somnolence, fatigue headache tingling (burning feet syndrome) Muscle weakness Increased susceptibility to infection Vitamin B5 • Sources Widespread in many foods Eggs Liver fish poultry Whole grain breads cereals legumes Dexpanthenol is also available over the counter as Panthoderm 2% Vitamin B 6 Pyridoxine • Metabolism of Fats Proteins Carbohydrates • Deficiency Alcoholism Malabsorption Drug interactions INH hydralazine penicillamine cycloserine S/S seborrheic dermatosis glossitis cheilosis, irritability depression Vitamin B 6 - Pyridoxine • INH Prophylaxis with Vitamin B 6 • May be helpful for PMS • Sources Brewer’s yeast wheat germ liver peanuts Legumes potatoes, bananas Vitamin B 6 - Pyridoxine • High does may be toxic • S/S Tingling Decreased coordination Stumbling gait Folate Vitamin B 9 • Also known as Folic acid and pteroylglutamic acid • Production of new cells – pregnancy • DNR RNA and Production of RBC • Supplements provide more available Folate than foods however degraded so a daily source is needed Folate Deficiency • Megaloblastic anemia • Neural tube defects • S/S Diarrhea, loss of appetite Weight loss weakness glossitis Headache heart palpitations irritability Folate Deficiency • Adults – anemia • Child – grow slow • Increase in homocysteine levels • Folate Supplementation recently used to decrease homocysteine levels to reduce cardiac risk Folate – Pregnancy • A deficiency occurs in 1/3 pregnancies world wide • High Risk Multiple gestations Teen pregnancy Closely spaced pregnancies Folate replacement in anemia • Diagnosis first • Folate will mask the diagnosis of pernicious anemia • But without Vitamin B 12 will not prevent neurologic damage Folate Drug Interactions • Oral contraceptives • Sulfasalazine • Trimethoprim • Methotrexate • Phenytoin Decreased blood level of Phenytoin Decreased absorption of Folate Folate • Non toxic water soluble • Rapid excretion • Folate Acid 1 mg Q D • Sources Fortified cereal grains organ meats Green vegetables, eggs fresh fruits Vitamin B 12 – Cyanocobalamin • Normal blood cell formation • Neurologic function • Metabolism Fats Protein Carbohydrates • Binds to gastric intrinsic factor • Stored in the liver Vitamin B 12 • Deficiency Pernicious Anemia Malabsorption Decreased secretion of intrinsic factor after gastric by-pass surgery Vegan diet Pernicious anemia • Fatigue loss of appetite • Peripheral neuropathy • Poor blood clotting • Easy bruising When beginning replacement Vitamin B 12 • monitor electrolytes • consider potassium replacement • Can give it PO IM or Nasal Vitamin B 12 • Sources Organ meats, liver eggs milk Chicken cheese Fortified cereals Biotin • Readily available in most foods • Deficiency Hair loss exfoliative dermatitis anorexia nausea Numbness of the extremities muscle pain At Risk Eat a lot of raw eggs prevents absorption Vitamin C – Ascorbic Acid • Water- Soluble daily replacement • When does > 1000 mg absorption < 50 % • Collagen synthesis integrity of connective tissue Vitamin C • Deficiency Scurvy Myalgia weakness irritability anemia Hemorrhage Hyperkeratotic follicles Corkscrew hairs Gingivitis Loose teeth Vitamin C • Deficiency risk Gastrointestinal diseases Acute and chronic inflammatory diseases Patients undergoing surgery Prolonged use of a high dose may increase metabolism causing deficiency when intake reduced Vitamin C in Pregnancy & Lactation • S/S diarrhea cold or heat intolerance • May need supplementation • Large doses during pregnancy can cause scurvy in neonates Vitamin C • In general non toxic Cholestyramine and Vitamin C dose should be separated Large doses may reduce anticoagulant action of Warfarin Use Vitamin C with FeSO4 > Iron absorption Smokers require more vitamin C False positive Occult Blood Buyer Be Ware • Have the potential to unexpected or unwanted effects and toxicity • Also ask people what herbs they use in the history Ginkgo – memory • Hypersensitivity GI disturbance bleeding • Discontinue before surgery 36 hours • Children - seizures Echinacea – Prevention URI • Anti viral activities GI disturbances fever unpleasant taste dizziness Allergic reactions High risk if allergic to ragweed daisies marigolds May interfere with immune-suppression Tx May exacerbate MS Use no more than 8 weeks Discontinue before surgery Garlic - • hypercholesterolemia hypertension and diabetes • GI disturbances odor sweating allergic • Increase risk for bleeding if taking Warfarin • Discontinue 1 -2 weeks before surgery • Hypoglycemia when taking hypoglycemic agents Asian or Oriental Ginseng • Stress enhance immune function • Memory Physical endurance • Insomnia mastalgia palpitations headache • Decreased appetite hypotension and hypertension edema hypoglycemia • Increased risk of bleeding Pt on anti platelet drug • Discontinue 7 days prior to surgery Soy Phytoestrogens Isoflavones • To manage post menopausal symptoms • Prevent Osteoporosis and cardiovascular disease • May be effective in lowering total cholesterol • GI disturbances Nausea Bloating Constipation • Allergic reactions • Use with caution history of Breast Cancer Risk unknown Saw Palmetto • To Tx symptoms of BPH Does not effect PSA or size of prostate • Headache GI disturbances • May interfere with hormonal and contraceptive pharmacotherapy • Decreased ejaculatory volume • Cholestatic hepatitis St. John’s Wart – Hypericum perforatum To Tx Depression and anxiety Insomnia restlessness irritability GI upset Dizziness vivid dreams paresthesias photosensitivity hypomania and mania An inducer of P-450 many drug interactions Discontinue prior to surgery Avoid St. John’s Wart with • Sumatriptan • Other 5-hydroxytryptamine agonists • Zoloft and other SSRIs • Ultram and Serzone • Quinolones Sulfonamides Tetracyclines Valerian • For insomnia or anxiety Chronic use not recommended due to hepatotoxicity Many products also contain alcohol Use caution with driving or operating machinery Black Cohosh • Used to tx premenstrual symptoms • Avoid in Pregnancy Estrogen receptive Breast Cancer Uterine Cancer Thromboembolic disorders Kava • Used for anxiety stress and sleep disorders Use caution driving & operating machinery Stop 24 hours prior to surgery Hepatotoxicity has been reported Short term use only Long term use Pellagra-like syndrome known as kava dermopathy Dry flaky skin reddened eyes discoloration of skin and nails Milk thistle • to relieve gastrointestinal complaints help with liver disease • Antioxidant and hepato protective properties • Laxative effect • Allergic reactions Evening Primrose Oil • PMS & Menopause • Mastalgia and rheumatoid arthritis • S/S soft stools headache • Avoid in pregnancy • Avoid in Schizophrenic patients on phenothiazine , blood levels Grape Seed • Management of venous insufficiency varicose veins peripheral vascular disease wound healing • Antioxidant properties • High in essential fatty acids Bilberry taken as a tea for many conditions • GI, Visual, CV, Diabetes, Arthritis • If taking hypoglycemic Rx monitor Glucose • Avoid long term use risks unknown • May effect platelet function avoid with antiplatelet or anticoagulant medications Coenzyme Q found in oily fish • CHF Angina HTN • Improving immune function May slow the decline in Parkinson’s Disease Melatonin • Management of sleep disturbances • Jet lag • No driving 4 -5 hours after taking • Contraceptive effect – avoid if attempting pregnancy • Avoid with Liver disease • May alter immune function Flaxseed • Constipation • Hypercholesterolemia Arthritis wt loss • Maintain adequate hydration Intestinal blockage Separate from other medications 2 hours High fiber content < absorption Fish Oils Omega 3 Fatty acids • Hypertension • Hyperlipidemia • Hypertriglyceridemia • Coronary Heart Disease • > HDL < triglycerides Fish Oils • Decrease pulmonary function Use in caution with Pt on antihypertensive meds Prone to hypotension ASA sensitive Pt on anticoagulant or antiplatelet meds Glucosamine Sulfate • Used to tx osteoarthritis Often combined with chondroitin No evidence to support Long term use risks unknown Diabetics should monitor for hyperglycemia S-adenosyl-Lmethionin • Depression osteoarthritis liver disorders • Migraines fibromyalgia sleep modulation • May exacerbate hyperhomocystinemia and increase risk for thrombosis • Avoid use with bi-polar disorders May precipitate mania Caffeine • A stimulant and a diuretic • Contained in many supplements • Avoid doses in excess of 250 mgs/d Medical Foods Regulated by FDA • As an orphan drug • May not be covered by health insurance • Requires a prescription • Consider when people have not responded to • • • • conventional therapy Can be used as an augmentation therapy For Depression HIV Alzheimer's, Parkinson’s, age related memory loss Medical Foods Deplin 7.5 mg ($30.00 a month) • L-methylfolate • Regulations the synthesis of serotonin, nor-epinephrine and dopamine • Boosting levels of Folate in the brain • Which in turn helps to activate neurotransmitters in the brain that are associated with mood Medical Foods Axona • Improves cognitive function & memory • As body digests Axona the liver produces extra ketones • • • • which provide an alternative energy source for the brain Ketones have a neuro protective property Comes in the form of a sweet drink packet $80.00 - $100 per month 218 calories in a packet Medical Foods Cerefolin • May help age associated memory impairment • Patients with elevated homocysteine level • www.pamlabs.com • $50.00 for 30 tablets Medical Foods Metanx • Reduce pain in diabetic neuropathy • Numbness • Common Problem with a Gene MTHSR See research by NIH • Results in decreased ability to process folic acid in foods • This medical food provides folic acid in a more bio- available form than is found in food