Download Nutritional Medicine

Nutritional Medicine for NHS Practitioners
Dr Alan Stewart MRCP
www.stewartnutrition.co.uk
What I will address
• Some basic concepts
• How deficiencies develop
• Making a nutritional diagnosis
• Simple dietary assessment
• Common health problems: - undernutrition and
overnutrition
• Correcting micronutrient deficiencies using BNF
listed supplements
The Three Types of Nutrition-Related Disease
• Undernutrition
protein-energy – low BMI, malnutrition
anaemia – iron, folate, vitamins B12, B2, C, A and copper
osteoporosis – calcium, vitamin D, physical activity
micronutrient deficiencies - many
• Overnutrition
energy – obesity, high BMI and disease risk
protein (animal) – osteoporosis, renal disease
sodium – high BP/stroke, heart failure and osteoporosis
micronutrient excess – diet, supplement use or disease
• Poor Food Choices
lack of protective foods – vascular disease, cancer and others
intolerance/allergy – eczema, IBS, migraine, arthritis
foods with therapeutic effects – ginger - migraine, sugar - pain
All-cause mortality and BMI
data from 900,000 people Europe and N. America
64
Annual
deaths
per 1000
32
Male
Female
16
& 95% CI (floated
so matches PSC
rate at ages 35-79)
8
4
15 20 25 30 35 40
50
Baseline BMI (kg/m2)
Adjusted for age, smoking and study; 1st 5 years of follow-up excluded
Fig 2, Lancet 2009; 373: 1083-96
All-cause mortality and BMI by smoking status
Male (35-69 years)
20
Female (35-69 years)
20
Current
cigarette
smoker
Annual
deaths
per 1000
15
15
Never
smoked
regularly
10
Current
cigarette
smoker
10
& 95% CI (floated
so matches EU
rate at ages 35-69)
5
Never
smoked
regularly
5
0
15 20 25 30 35
50
Baseline BMI
Adjusted for age and study; 1st 5 years of follow-up excluded
0
15 20 25 30 35
(kg/m2)
50
Webfig 7a & b, Lancet 2009; 373: 1083-96
BMI and Cause-Specific Mortality
Prospective Studies Collaboration Lancet 2009;373:1083-1096
BMI kg/m2 Survival Effect Change in Disease Risk
35-45
-5 to -10 years
30-35
-2 to -4 years
25-30
0 to -2 years
22.5-25.0
<22.5
Healthy norm
0 to -5 years
Overall mortality +30%
Vascular +40%
Diabetic +120%
Renal + 60%
Hepatic +80%
Cancer +10% or more
Respiratory +20% or ? protection
Ideal is perhaps 21-27.5 kg/m2
Smoking related illness
Respiratory ++
Micronutrient deficiencies
Undernutrition Syndromes
•
•
•
•
•
•
•
•
•
•
Protein-energy deficiency
Anaemia and associated nutrients
Iron: fatigue and minor symptoms, cardiac and renal failure
Vitamin B12: neurological health
Vitamin B1 (alcohol XS): neurological problems/cardiac failure
Vitamin B2: anaemia and hypertension
Vitamin C (smoking): increased stroke risk
Vitamin D: musculo-skeletal health, immunity, major illness
Zinc: poor growth, reduced immunity, poor wound healing
Other nutrients: pregnancy, anaemia, immunity, mental health
Undernutrition and Life Functions: MRSNERG-D
• Movement
Bone Fracture
• Respiration
Anaemia, muscle fatigue
• Sensitivity
Neuropathy, visual loss, mood
• Nutrition
Loss of appetite
• Excretion
Liver/Renal Disease
• Reproduction
Miscarriage, NTD pregnancy
• Growth
Low birth weight, infant stunting
• Defence
Infection – respiratory, GI, GU
Overnutrition Syndromes
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•
•
•
•
•
•
•
•
•
Energy (CHO, fats and alcohol): obesity
Energy-Protein (hospital): re-feeding syndromes - various
Sugars: dental caries, irritable bowel syndrome, gout
Animal Protein: gout, osteoporosis, renal disease
Iron: haemochromatosis, liver disease
Vitamin A: osteoporosis
Vitamin A/beta-carotene: cancer risk in smokers and asbestos
Vitamin B: cancer growth
Vitamin C: oestrogen metabolism
Trace element excess: fatigue, CNS problems, poor immunity
Nutritional Support in Adults
[www.nice.org.uk/CG032 February 2006]
Screen all patients to identify those most at risk of being deficient:
• Underweight
A body mass index (BMI) of less than 18.5kg/m2
• Unintentional Weight Loss
Greater than 10% within the last 3 – 6 months
or
• Combination of:
- BMI of less than 20kg/m2 and
- Unintentional weight loss >5% within the last 3 – 6 months
Others at risk:
• Eaten little or nothing (or likely to) for more than 5 days
• Poor absorption, vomiting, high losses, increased need - catabolic
• Already identified with one deficiency e.g. anaemia or osteoporosis
How Do Nutritional Deficiencies Develop?
Adapted from Brin M 1964
• Adequacy
• State of Negative Balance
• Decline in Tissue Stores
• Loss of Function:
1. Symptoms
2. Physical Signs
3. Organ Failure
• Death
Develop over variable amount of time in a recognizable sequence
Why Do Nutritional Deficiencies Develop?
Adapted from Brin M 1964
• Adequacy
• State of Negative Balance:
1. Poor Intake
2. Reduced Absorption
3. Increased Losses
4. Increased Demand
5. Altered Metabolism
• Decline in Tissue Stores
• Loss of Function:
1. Symptoms
2. Physical Signs
3. Organ Failure
• Death
Diet + supplements
Coeliac, IBD & diet factors
Diarrhoea, menstruation
Pregn’cy, illness + recovery
Alcohol, drugs, illness, age
genetic factors
Nutritional Excesses Develop in a Similar Way
• Adequacy
• State of Positive Balance:
1. High Intake
2. Increased Absorption
3. Reduced Losses
4. Reduced Demand
5. Altered Metabolism
• Increase in Tissue Stores
• Loss of Function:
1. Symptoms
2. Physical Signs
3. Organ Failure
• Death
Diet + supplements
Haemochromatosis
Post-menopause
Elderly
Alcohol, drugs, illness, age
genetic factors
Nutrition Surveys in UK 1980-present
(years surveys were conducted)
• Diet and Nutrition Survey of British Adults (16-64yr)
1986/7
• National Diet and Nutrition Surveys x 4 (1.5 – 85+yr)
1990-2004
• Low Income Diet and Nutrition Survey (1.5 – 85+yr)
2006/7
• NDNS Rolling Programme (1.5 – 85+yr)
2010 - present
• NDNS Young People (6-18 mo)
2013?
What do National Nutritional Surveys Survey?
http://www.food.gov.uk/science/dietarysurveys/
Stage
Survey Component
• State of Adequacy
• State of Negative Balance
1. Poor intake
2. Reduced absorption
3. Increased losses
4. Increased requirement
5. Altered metabolism
• Decline in Tissue Stores
Diet 4-7 days + Supplement use
Alcohol intake and drugs
Tests – blood and urine
• Loss of Function:
1. Symptoms
2. Physical Signs
3. Organ Failure
• Death
NDNS 65+ Depression
BMI, NDNS 4-18 Growth
NDNS 65+ Renal and Liver
NDNS 65+ only
Prevalence of Inadequate Micronutrient Intakes
<Lower Reference Nutrient Intakes – NDNS x 4
39%
36%
Calcium
33%
Potassium
30%
27%
Magnesium
24%
Iron
21%
Zinc
18%
15%
Vitamin A
12%
Vitamin B12
9%
6%
Folate
3%
Vitamin C
0%
Infants
•
•
Children
Adults
F-Living Institution
Elderly
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%
Male
Female
25%
20%
15%
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%
Male
Female
25%
20%
15%
10%
5%
0%
1.5-2.5yr
4-6yr
Poor Diet
Reduced Absorption
- diet – tea/tannins
- disease
15-18yr
35-49yr
Poor Diet
Menstrual Losses
Reduced Absorption
- diet and disease
75-84yr
Institution
85+yr
Poor Diet
GI Blood Loss
Disease/ Unknown
Mixed Deficiencies
Diagnosing Malnutrition
1. History
2. Physical
Examination
3. Laboratory
Investigation
Diagnosing Malnutrition
1. History
Intake: diet + supplements
Risk Factors for deficiency
Symptoms of deficiency
2. Physical
Examination
Anthropometric Measures
(Body Mass Index - kg/m2)
Signs of Deficiency
Signs of Underlying Disease
3. Laboratory
Investigation
Blood and Urine Tests
Bone Mineral Density
X-Ray
Simple Dietary Assessment – use Food-Based
Dietary Guidelines
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•
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•
•
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
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Protein –animal/vegetarian
Fish and oily fish
Fruit and Vegetables
Quality Carbohydrates
Dairy or quality substitute
Four Main Undesirables
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Alcohol
Salt (sodium)
Sugar NMES (non-milk extrinsic sugars)
Fat
Food-Based
Dietary Targets
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•
Protein –animal/veget.
Fish
Fruit and Vegetables
Quality Carbohydrate
Dairy or substitute
•
•
•
•
Alcohol <21/14 units/wk
Salt (sodium) <6g/day
Sugar <11% energy
Fat <35% energy
Nutritional
Significance
- Protein, vit B, Fe, Zn
- Protein, vit B12, n-3 EFAs
- Vit C, K, Mg, fibre
- Energy, fibre, vit B, Mg
- Protein, Ca, I2 vit B12, B2 A
Assess units/week
80% in savoury food
80% in foods & drinks
Meat, dairy, cakes, pastry
biscuits etc
Dietary Assessment – 5 Food-Based Targets
WHO/EU/FSA Food-based dietary guidelines
Protein
7 Good Portions/week
(animal or vegetarian)
Fish
>2 Portions/week
>1 Oily type/week
Fruit and Vegetables
>5 Portions/day
Dairy Foods
>1.5-2.5 Portions/day
(or soya substitute)
Quality Carbohydrate
>1-4 Portions/day
(High Fibre)
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%
White Pasta
White Rice
Pizza Margharita
Jacket Potato
50.00%
40.00%
30.00%
20.00%
10.00%
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
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•
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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%
Male >3u
Female >2u
50%
40%
30%
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 – uncontrolled
- depression, mood change, insomnia
- abnormal liver function tests
- raised triglycerides
- 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
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Protein
Fish
Fruit and Vegetables
Quality Carbohydrate
Dairy or substitute
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•
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)
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•
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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
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•
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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, <LRNI*
51%
48%
45%
42%
39%
36%
33%
30%
27%
24%
21%
18%
15%
12%
9%
6%
3%
0%
Men No Benefits n=724
Men Benefits n=110
Vit A B1
•
•
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
<Lower Reference Nutrient Intakes are likely to be adequate for <3% of the population.
Ref: 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, <LRNI*
51%
48%
45%
42%
39%
36%
33%
30%
27%
24%
21%
18%
15%
12%
9%
6%
3%
0%
Women No Benefits n=741
Women Benefits n=150
Vit A B1
•
•
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
<Lower Reference Nutrient Intake are likely to be adequate for <3% of the population.
Ref: 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 – dark green leafy vegetables, fruit,
eggs and tinned oily fish
(see lecture www.stewartnutrition.co.uk for detail)
Nutritional Assessment: the Whole Picture history is the most informative element
Element
Nottingham 1975 W. Virginia 1992
History
82.5%
76%
Examination
8.75%
12%
Investigation
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)
•
•
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•
•
•
•
•
•
•
•
•
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%
Male
Female
25%
20%
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 6584yr
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 doseresponse 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 – iron, riboflavin possibly other B vits.
- candida or mixed bacterial infection
- poorly fitting dentures or dribbling
• Assessment:
- dietary history
- risk factors for nutrient lack
- unilateral = mechanical; bilateral = infection/nutritional
- failure to clear with antifungal/bacterial = nutrient deficiency
• Investigation:
- Full blood count
- other nutrients – iron, folate as indicated, vit B12 in elderly
• Nutritional Treatment
- 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
Male
Female
50%
45%
40%
35%
30%
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 growthpromoting 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 advice on diet and
supplements
• 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 –
males, elderly, poor diet, smokers and lower socio-economic
groups were not especially targeted
• Consider assessing status in high risk individuals
Vitamin C Prevalence of Deficiency
plasma Vit. C<11.0umol/l - NDNS data
Male
Female
60%
50%
40%
30%
20%
10%
0%
1.52.53.5yr 4.5yr
•
•
•
4-6yr 7-10yr
1114yr
1518yr
1924yr
2534yr
3549yr
5064yr
6574yr
7584yr
85+yr
Inst
6584yr
Inst
85+yr
Approx. 20% of adults and 12% of the elderly took supplements of vitamin C
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%
Male
45%
Female
40%
35%
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
65-84yr
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
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%
Not Deficient
45.00%
Deficient
40.00%
35.00%
30.00%
25.00%
20.00%
• All Hb >12.0g/dl
• Iron Deficient
616
serum ferritin <21ug/l
• Not iron deficient
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
15.00%
10.00%
5.00%
0.00%
Fatigue
Irritabilty
Frequent
Headache
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 15th 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, D2 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 4th 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%
Male
Female
1.53.5yr
4-6yr
1114yr
1924yr
3549yr
6574yr
85+yr
Inst
85+yr
Statement of Professor Bloch Danish Paediatrician
World Dairy Congress Washington DC Oct 3rd 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 – which I
believe will be discovered in every country when it is looked
for – but these dairy products are of the greatest importance
for growth and development and the cure of our greatest
infectious disease.”
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- Casein
Cress
Veget
Marg
Sugar
N-Z
Butter
Milk
Height
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
Male
39%
36%
33%
30%
27%
24%
21%
18%
15%
12%
9%
6%
3%
0%
Female
1.5- 2.5- 3.5- 4-6yr 7-10yr 112.5yr 3.5yr 4.5yr
14yr
1518yr
1924yr
2534yr
3549yr
5064yr
6574yr
75- 85+yr
84yr
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
17%
Antibiotics + Zn
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 – elemental) 1-3/day
after food away from tea/coffee, bran/chapatti
Children <10kg ½ tablet/day (see BNF)
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 and
mass that leads to an
increased risk of fracture
• 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 - common
Birth Defects - 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%
•
•
•
Male
Female
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
Vitamin D Prevalence of Deficiency - LIDNS
Low Income Diet and Nutrition Survey Plasma 25 OH Vit D <25.0nmo/l
Male
50%
Female
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
1.53.5yr
3.5- 4-6yr 7-10yr 114.5yr
14yr
1518yr
1924yr
2534yr
3549yr
5064yr
6574yr
75- 85+yr
84yr
Inst
Inst
65- 85+yr
84yr
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 (vitamin D)
• women trying to conceive
and in the first 12 weeks of
their pregnancy (folic acid)
• all children aged 6 months to
5 years (vitamins A, C & D)
• people aged 65 and over
(vitamin D)
• people with darker skin or
who are not exposed to
much sun (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