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FUNCTIONAL NUTRITIONAL ASSESSMENT: AN OPPORTUNITY NANCY M. STRANGE, RD, CNSD, CD CLINICAL NUTRITION SPECIALIST GENERAL SURGICAL OUTPATIENT SERVICES INDIANA UNIVERSITY HOSPITAL APRIL 12, 2012 FUNCTIONAL NUTRITIONAL ASSESSMENT OBJECTIVES Following the completion of this presentation the participant will be able to identify: DIET HISTORY TECHNIQUES THAT CONTRIBUTE TO IDENTIFICATION OF VITAMIN AND MINERAL DEFICIENCIES SUBJECTIVE SIGNS AND SYMPTOMS OF VITAMIN MINERAL DEFICIENCIES PHYSICAL SIGNS OF VITAMIN AND MINERAL DEFECIENCIES FUNCTIONAL NUTRITION ASSESSMENT TRADITIONAL NUTRITIONAL ASSESSMENT COMPONENTS INCLUDE: – – – – – – – ANTHROPOMETRIC MEASUREMENTS MEDICAL HISTORY SOCIAL HISTORY MEDICATION HISTORY DIET HISTORY PHYSICAL EXAM SUBJECTIVE STATEMENTS FUNCTIONAL NUTRITIONAL ASSESSMENT COMPONENTS OF ANY NUTRITIONAL ASSESSMENT ALL ARE IMPORTANT PIECES TO THE PUZZLE ALL HAVE VARYING LEVELS OF IMPORTANCE AND APPLICATION BASED ON THE AREA OF NUTRITION PRACTICE ALL COMBINE TO PROVIDE A NUTRITIONAL “PICTURE” FUNCTIONAL NUTRITIONAL ASSESSMENT WHAT IS IMPORTANT ABOUT THESE COMPONENTS? – DIET HISTORY – SUBJECTIVE SYMPTOMS – PHYSICAL EXAM FUNCTIONAL NUTRITIONAL ASSESSMENT USE OF DIET HISTORY, SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM TOGETHER CAN IDENTIFY SIGNIFICANT PROBLEMS THAT IMPEDE AN INDIVIDUAL’S FUNCTIONAL CAPACITY. COMBINATION WILL RESULT IN A HIGH RATE OF IDENTIFICATION OF MICRONUTRIENT DEFICIENCIES IDENTIFY METHODS FOR IMPROVED OUTCOMES FUNCTIONAL NUTRITIONAL ASSESSMENT IMPORTANCE OF USE AND INTEGRATION OF THIS KNOWLEDGE: – PROVIDES A SERVICE TO THE MEDICAL TEAM THAT IS NOT PROVIDED IN ANY OTHER DISCIPLINE. NUTRITION COMPONENTS OF A PHYSICAL EXAM ARE NOT TAUGHT IN MEDICAL SCHOOLS IMPROVEMENT IN OUTCOMES: – FOR THE PATIENT – REDUCTION IN INSTITUTIONAL EXPENDITURES FUNCTIONAL NUTRITIONAL ASSESSMENT – IF YOU ARE ABLE TO IMPROVE OUTCOMES? PHYSICIANS CHANGE THEIR OPINIONS ABOUT NUTRITION, INCLUDE RD MORE FREQUENTLY ADMINISTRATION LISTENS RD JOB SATISFACTION IS WONDERFUL FUNCTIONAL NUTRITIONAL ASSESSMENT FUNCTIONAL NUTRITIONAL ASSESSMENT “WE STOPPED BY TO SAY THANK YOU FOR THE EXCELLENT CARE YOU PROVIDE FOR OUR PATIENTS. WHAT IS YOUR NEXT PROJECT YOU ARE WORKING ON? HOW CAN WE HELP? ” “WE ONLY SAW DIETITIANS GIVING BOOST AND SNACKS SO WE DECIDED THAT WE COULD DO THAT AND STOPPED CALLING THEM. I CAN’T DO THAT FOR WHAT YOU DO. ” VICE PRESIDENT OF NURSING AND MEDICAL DIRECTOR @ IU HOSPITAL ON ROUNDS – 3/27/2012 25 YEAR SURGICAL RN, IU HOSPITAL, 6/2011 “I HAVE LEARNED MORE FROM YOU IN 15 MINUTES THAN I EVER HAVE IN THE PAST. “ PATIENT WITH CHRONIC NON HEALING WOUND, 11/2011 FUNCTIONAL NUTRITIONAL ASSESSMENT “THE MORE INFORMED YOU ARE, THE MORE LIKELY YOU ARE TO BE PERFORMING A NUTRITION FOCUSED PHYSICAL EXAM. THIS REAFFIRMS THE DIETITIAN’S ROLE, AREA OF EXPERTISE AND ADVANCED LEVEL OF PRACTICE” MP Kelly, 2005 FUNCTIONAL NUTRITIONAL ASSESSMENT START WITH THE BASICS – A KNOWLEDGE BASE OF HOW TO USE ALL COMPONENTS OF A NUTRITIONAL ASSESSMENT IS ESSENTIAL DIET HISTORY, SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM WORK BEST IN THE CONTEXT OF A FULL ASSESSMENT – NUTRITION PLAN OF CARE THAT IS CONCISE AND CLEAR FUNCTIONAL NUTRITIONAL ASSESSMENTS –COMMUNICATE – DEVELOP RELATIONSHIPS WITH NURSES, PHARMACISTS, PHYSICIANS, PHYSICIAN ASSISTANTS, PT, OT, SPEECH THERAPIST – INCLUDE THE NURSE IN YOUR SUGGESTED PLAN OF CARE – TAKE THE TIME TO COMMUNICATE FUNCTIONAL NUTRITIONAL ASSESSMENT DIET HISTORY – GIVES YOU A CURRENT PICTURE OF THE PATIENT – INCLUDE SUPPLEMENT USE IN THE DIET HISTORY – KNOW THE KEY NUTRIENTS IN FOOD GROUPS EFFICIENT- WHAT FOOD GROUP HAS TO BE THERE FOR SUFFICIENCY TO HAPPEN USE USDA.GOV NUTRIENT CONTENT OF FOOD GROUPS. – WHAT FOODS HAVE TO BE PRESENT FOR INTAKE TO BE SUFFICIENT? EXAMPLE: RIBOFLAVIN – IF DAIRY OR FORTIFIED PRODUCTS ARE NOT USED IN DIET THEN IT IS VERY DIFFICULT TO OBTAIN SUFFICIENT RIBOFLAVIN IN THE DIET FUNCTIONAL NUTRITIONAL ASSESSMENT DIET HISTORY – IMPORTANT FOR THE PATIENT TO UNDERSTAND WHY YOU ASK THE QUESTIONS. REMOVE THE “MORAL” VALUE OF FOOD FROM THE CONVERSATION FUNCTIONAL NUTRITIONAL ASSESSMENT DIET HISTORY – – FOCUS TO SPECIFIC POPULATIONS WOUND HEALING WIC LONG TERM CARE – COMPLETE AT ANY POINT IN THE INTERVIEW PROCESS – USE A SIMPLFIED FORM YOU ARE ONLY LOOKING FOR TRENDS QUANTIFY WHAT PATIENT STATES FUNCTIONAL NUTRITIONAL ASSESSMENT SUBJECTIVE SYMPTOMS – ARE KEY IN HELPING TO IDENTIFY NUTRITIONAL ISSUES RELATED TO VITAMIN AND MINERAL DEFICIENCIES PATIENT’S GAIN CONFIDENCE IN THE SKILLS OF THE RD WHEN SUBJECTIVE SYMPTOMS CAN BE RELATED TO NUTRITION. PATIENT’S ARE YOUR BEST ADVOCATES, ESPECIALLY WHEN RELATIVELY SIMPLE MEASURES IMPROVE THEIR SYMPTOMS AND QUALITY OF LIFE FUNCTIONAL NUTRITIONAL ASSESSMENT MOST NUTRIENT DEFICIENCIES HAVE A: – LOOK – SOUND – FEEL SOUND AND FEEL - ARE SUBJECTIVE SYMPTOMS THAT WILL BE EXPRESSED WHEN A DEFICIENCY IS PRESENT USUALLY YOU WILL “HEAR” THE SYMPTOMS BEFORE YOU SEE THE DEFICIENCIES FUNCTIONAL NUTRITIONAL ASSESSEMENT EXAMPLES: FATIGUE- VITAMIN C, A, IRON, B12, B COMPLEX BURNING MOUTH: B12, THRUSH, B COMPLEX SHORT TERM MEMORY ISSUES: B12, B1, IRON, IODINE FOOD CRAVINGS: WHAT IS FOOD GROUP CRAVED? CHOCOLATE, SALTY, STARCHY? TIME OF DAY THE FOOD CRAVING OCCURS? FUNCTIONAL NUTRITIONAL ASSESSMENT NUTRITION PHYSCIAL EXAM STARTING THE PROCESS Routinely check for: - Protein Calorie Malnutrition - Muscle Tissue - Adipose Tissue - Vitamin Deficiencies - Scurvy, Beri-Beri, Pellegra, B 12, Riboflavin, B6 - Mineral Deficiencies - Zinc, Iron, Iodine IF YOU ARE NOT LISTENING AND LOOKING FOR SOMETHING, YOU WILL LIKELY NOT SEE IT. FUNCTIONAL NUTRITIONAL ASSESSMENT PHYSICAL EXAM – GETTING STARTED – LOOK AT THE AVAILABLE PICTURES OF NUTRIENT DEFICIENCIES – KNOW WHAT OTHER DIAGNOSIS’ RESULT IN SIMILAR SKIN CHANGES MEDSCAPE HAS MULTIPLE EDUCATION TOOLS TO HELP WITH THIS YOU WILL HAVE TO DEFEND WHAT YOU ARE DESCRIBING – IT IS JUST PART OF THE PROCESS – LEARN WHAT AN EARLY OR LATE DEFICIENCY CAN LOOK LIKE FUNCTIONAL NUTRITIONAL ASSESSMENT PHYSICAL EXAM – TAKE THE NUTRITION TEXT BOOKS LITERALLY – KNOW “TIME TO DEFICIENCY” – DON’T ASK FOR LABS WITHOUT THE DIET HISTORY, SUBJECTIVE INFORMATION AND THE PHYSICAL EXAM – IT IS WASTEFUL AND UNDERMINES YOUR CREDIBILITY WITH THE MEDICAL TEAM – PRACTICE ON YOURSELF, FAMILY OR YOUR PEERS THIS IS TO BECOME COMFORTABLE WITH TOUCHING, LOOKING AT SOMEONE ELSE – UNDERSTAND THE PROCESS OF DIFFERENTIAL DIAGNOSIS FUNCTIONAL NUTRITIONAL ASSESSMENT VITAMIN C/ASCORBIC ACID DISEASE: SCURVY PRIMARY ROLES IN THE BODY – ANTIOXIDANT THAT IS REQUIRED FOR THE SYNTHESIS OF NOREPINEPHRINE – REGENERATION OF VITAMIN E – COLLAGEN SYNTHESIS – CARNITINE SYNTHESIS – HISTIDINE SYNTHESIS – ADRENAL STEROID SYNTHESIS – FUNCTIONS IN TYROSINE AND FOLATE METABOLISM FUNCTIONAL NUTRITIONAL ASSESSMENT VITAMIN C DEFICIENCY IDENTIFIED – NHANES, 1994 10-14% – NHANES, 2003-2004 7.1% - SMOKERS AND LOWER INCOME AT SIGNIFICANT RISK FUNCTIONAL NUTRITIONAL ASSESSMENT VITAMIN C DEPLETION – GENERAL OUTPATIENT POPULATION 6% OF GENERAL POPULATION 51% OF DIABETIC POPULATION 40% OF CARDIAC/HLD PATIENTS Journal of American College of Nutrition; 1998 FUNCTIONAL NUTRITIONAL ASSESSMENT RENAL FAILURE ON RRT – 20-25% RATE OF VITAMIN C DEFICIENCY HOSPITALIZED PATIENTS – MULTIPLE SINGLE CASE REPORTS SURGICAL OUTPATIENT POPULATION AT IU: – SCURVY SEEN IN ~ 40% OF PATIENTS SEEN BY RD – ALL AGE GROUPS, DIFFERING SOCIAL ECONOMIC STATUS, NOT ALWAYS POST SURGICAL OR HIGHER RISK CATEGORIES FUNCTIONAL NUTRITIONAL ASSESSMENT VITAMIN C DEFICIENCY – DIET HISTORY FRUITS AND VEGETABLES – NEED TO BE SPECIFIC FORTIFIED FOODS -CEREALS, JUICES, DRINKS, PROTEIN BARS SOUR CANDIES FUNCTIONAL NUTRITIONAL ASSESSMENT SUBJECTIVE SYMPTOMS OF SCURVY – – – – – – – – – – FATIGUE LOWER EXTREMITY PAIN ARTHRALGIAS MYALGIAS LASSITUDE DEPRESSED MOOD/DEPRESSION EASILY BRUISED BLEEDING TENDER GUMS DIARRHEA TOBACCO USE FUNCTIONAL NUTRITIONAL ASSESSMENT HOW DO YOU CORRELATE THE SUBJECTIVE SYMPTOMS WITH THE FUNCTION OF VITAMIN C IN THE BODY? – ASK THIS QUESTION WITH EACH FUNCTION OF THE NUTRIENT EXAMPLE: FATIGUE WITH SCURVY – BLOOD LOSS FROM CAPILLARY BLOOD LOSS WITH LOSS OF COLLEGEN SYNTHESIS; – UNABLE TO SYNTHESIZE CARNITINE – DECREASED ADRENAL HORMONE SYNTHESIS FUNCTIONAL NUTRITIONAL ASSESSMENT PHYSICAL ASSESSMENT – FOLLICULAR PETECHIEA EARLIER- BECOMES DARKER MORE PRONOUNCED AS DEFICIENCY CONTINUES CAN BE MASKED BY VITAMIN A HYPERKERATOSIS EMBEDDED CORKSCREW HAIR IN THE HAIR FOLLICLE – LATER APPEARANCE – BRUISING/PURPURA EARLY AND ONGOING – PEDAL EDEMA LATER, NON RESPONSIVE TO DIURETICS – OFTEN SEEN WITH LOWER EXTREMITY CELLULITIS – JOINT SWELLING USUALLY MID TO LATE MANIFESTATION FUNCTIONAL NUTRITIONAL ASSESSMENT FUNCTIONAL NUTRITIONAL ASSESSMENT PURPURA FUNCTIONAL NUTRITIONAL ASSESSMENT FOLLICULAR SWAN PETECHIEA HAIR DX: WOUND HEALING FAILURE FUNCTIONAL NUTRITIONAL ASSESSMENT SERUM VITAMIN C LEVEL: UNABLE TO BE MEASURED DX: SEVERE MALNUTRITION WITH H/O R-N-Y 25 YEARS PRIOR; HAD NOT BEEN ABLE TO WALK FOR 6 MONTHS DUE TO SCURVY FUNCTIONAL NUTRITIONAL ASSESSMENT ZINC DEFICIENCY – NHANES III –35-45% RATE OF DEFICIENT INTAKE IN INDIVIDUALS >60 YEARS OF AGE – DEFICIENCY RATE OF 20-25% AFTER ADJUSTING FOR SUPPLEMENT INTAKE FUNCTIONAL NUTRITIONAL ASSESSMENT ZINC DEFICIENCY HIGHER RISK POPULATIONS – > 50 YEARS OF AGE – GASTROINTESTINAL DISEASES – – – – – – – – – – MALABSORPTION, CHRONIC DIARRHEA, SBS, CELIAC, IFBD LIVER DISEASE ALCOHOLICS HIV/AIDS SICKLE CELL DISEASE DIABETES PREGNANCY VEGETARIANS FOOD INSUFFICIENT POPULATIONS EATING DISORDERS USE OF GASTRIC ACID REDUCTION MEDICATIONS FUNCTIONAL NUTRITIONAL ASSESSMENT – FUNCTIONS OF ZINC NEUROPEPTIDE FORMATION IMMUNE FUNCTION CATALYTIC ROLE – ~ 100 ZINC DEPENDANT ENZYMES – EXAMPLES: CARBONIC ANHYDRASE; SUPEROXIDE DISMUTASE REGULATORY ROLE – REGULATION OF GENE EXPRESSION STRUCTURAL ROLE – ZINC FINGER, STABILIZES THE STRUCTURE – LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE SUSEPTTIBILITY TO OXIDATIVE DAMAGE, IMPAIRING THEIR FUNCTION – HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINC ZINC DEPLETION RESULTS IN ESTROGEN SYNTHESIS – CELL SIGNALING HORMONE RELEASE NERVE IMPULSE INNERVATION – APOTOSIS FUNCTIONAL NUTRITIONAL ASSESSMENT FUNCTIONS OF ZINC STRUCTURAL ROLE – ZINC FINGER, STABILIZES THE STRUCTURE – LOSS OF ZINC INCREASES BIOLOGICAL MEMBRANE SUSEPTTIBILITY TO OXIDATIVE DAMAGE, IMPAIRING THEIR FUNCTION – HORMONE STRUCTURE; TESTOSTERONE SYNTHESIS REQUIRES ZINC ZINC DEPLETION RESULTS IN ESTROGEN SYNTHESIS – CELL SIGNALING HORMONE RELEASE NERVE IMPULSE INNERVATION – CELLULAR APOTOSIS FUNCTIONAL NUTRITIONAL ASSESSMENT ZINC ASK DEFICIENCY THE QUESTION: – HOW ZINC – HOW – HOW DOES EACH FUNCTION DIFFER IF DEFICIENCY EXISTS? DOES IT LOOK? DOES IT SOUND? FUNCTIONAL NUTRITIONAL ASSESSMENT ZINC DEFICIENCY – EXAMPLE: IMMUNE FUNCTION INCREASED CIRCULATING CORTICOIDSTEROIDS DECREASED LYMPHOCYTES THYMIC ATROPHY INDIVIDUAL REFERRED TO YOU BECAUSE OF DESIRE TO LOSE WEIGHT, DIFFICULTY MANAGING GLUCOSE LEVELS; ABDOMINAL OBESITY; FREQUENT INFECTIONS HOW WOULD THE PHYSICAL EXAM HELP? FUNCTIONAL NUTRITIONAL ASSESSMENT ZINC DEFICIENCY – EXAMPLE: GYNOMASTICA, MALE DECREASED TESTOSTERONE SYNTHESIS WITH INCREASED ESTROGEN SYNTHESIS COMPLAINT EXAMPLE: “I CAN’T LOSE WEIGHT OR BUILD MUSCLE.” FUNCTIONAL NUTRITIONAL ASSESSMENT ZINC DEFICIENCY – DIET HISTORY VEGETARIAN W/O USE OF LEAVENED GRAINS ELIMINATION OF ZINC RICH FOODS FROM DIET (CRUSTATIONS/BEEF/PORK) INFREQUENT USE OF BEAN, LEGUME, NUT FAMILY HIGH INTAKE OF PHYTATES AND DAIRY FUNCTIONAL NUTRITIONAL ASSESSMENT ZINC DEFICIENCY – SUBJECTIVE SYMPTOMS BLAND TASTE CHANGES EARLY SATIETY ANOREXIA/NO INTEREST IN FOOD LIGHT ADAPTATION ISSUES DIARRHEA HAIR LOSS NIGHT BLINDNESS DEPRESSION, WITH INADEQUATE RESPONSE TO MEDICATION ACUTE ONSET? LOOK FOR PRECIPITATING EVENT FUNCTIONAL NUTRITIONAL ASSESSMENT ZINC DEFICIENCY PHYSICAL EXAM – – – – – – – – DRY FLAKY SKIN- LOWER EXTREMITIES NASOLABIAL SEBORRHEA DRY, REDDENED KNUCKLES LEUKONYCHIA MALE GYNOMASTICA HAIR LOSS ECCHYMOSIS FRAGILE SKIN DUE TO POOR SYNTHESIS OF COLLEGEN, POOR PROTEIN SYNTHESIS FUNCTIONAL NUTRITIIONAL ASSESSMENT DRY RED KNUCKLES FUNCTIONAL NUTRITIONAL ASSESSMENT LEUKONYCHIA FUNCTIONAL NUTRITIONAL ASSESSMENT SEVERE ZINC DEFICIENCY FUNCTIONAL NUTRITIONAL ASSESSMENT CASE STUDY – 56 YR OLD FEMALE WITH HISTORY OF BREAST CANCER 3 MONTHS OUT OF TREATMENT FAILURE TO THRIVE NO DISEASE RECURRENCE FUNCTIONAL NUTRITIONAL ASSESSMENT CASE STUDY 1 – MEDICAL HISTORY HTN BREAST CANCER HYPOTHYROID – SOCIAL HISTORY SINGLE, LIVES ALONE CHILDREN LIVING WITH HER CURRENTLY DUE TO HER INABILITY TO CARE FOR HERSELF WHEEL CHAIR BOUND FUNCTIONAL NUTRITIONAL ASSESSMENT CASE STUDY 1 – ANTHROPOMETRICS BMI: 32 CBW: STABLE – DIET HISTORY DRINKS ONE STEAK AND SHAKE MILKSHAKE PER DAY OCCASIONALLY EATS A FEW BITES OF SOUP FUNCTIONAL NUTRITIONAL ASSESSMENT CASE STUDY 1 – SUBJECTIVE SYMPTOMS FATIGUE TASTE CHANGES, DRY, SAWDUST UNABLE TO MAINTAIN BALANCE PAINFUL FEET NO DESIRE TO EAT BLOATING DIARRHEA HAIR LOSS NIGHT VISION ISSUES FAMILY REPORTS DECREASED ABILITY TO PROCESS INFORMATION DEPRESSED AFFECT FUNCTIONAL NUTRITIONAL ASSESSMENT PHYSICAL EXAM – THRUSH – FRAGILE SKIN WITH CELLOPHANE APPEARANCE – BRUISING – FOLLICULAR PETECHIEA – 3+ LOWER EXTREMITY EDEMA – ECCHYMOSIS – DRY FLAKY SKIN – ATAXIA – ANGULAR STOMATITIS – CHEILOSIS FUNCTIONAL NUTRITIONAL ASSESSMENT CASE STUDY 1 LABS: ANEMIA WITH MACROCYTIC PARAMETERS ALBUMIN: 2.7 GM/DL FUNCTIONAL NUTRITIONAL ASSESSMENT ASSESSMENT: – INADEQUATE ORAL INTAKE DUE TO MICRONUTRIENT DEFICIENCIES AS EVIDENCED BY TASTE CHANGES, SUBJECTIVE SYMPTOMS AND PHYSICAL EXAM RESULTS FUNCTIONAL NUTRITIONAL ASSESSMENT PLAN OF CARE – – – – – – – TREATMENT OF THRUSH THIAMINE 100 MG/DAY X 7 MVI WITH MINERALS Q DAY WITH FOOD B COMPLEX 1X/DAY ZINC 25 MG BID X 2 WEEKS VITAMIN C 500 MG TID X 2 WEEKS EDUCATION ON USE OF ORAL SUPPLEMENTS, FRUIT SMOOTHIES WITH PROTEIN, HYDRATION ADEQUACY – CHECK B12, VITAMIN D LEVEL – USE OF ACTIVE CULTURE YOGURT Q DAY FUNCTIONAL NUTRITIONAL ASSESSMENT MONITORING AND EVALUATION – RETURN TO CLINIC IN 2 WEEKS – CALL RD IF ANY ISSUES OUTCOME – RETURNED TO CLINIC, DRIVING HERSELF – NO LONGER REQUIRED HELP FROM FAMILY MEMBERS – LOST 20. ALL OF FLUID FROM HER LOWER EXTREMITIES IS GONE. SHE WAS ABLE TO USE HER NORMAL SHOES INSTEAD ONLY HOUSE SLIPPERS. – HAS RETURNED TO EATING 3 MEALS/DAY WITH NORMAL VARIETY/VOLUME OF FOOD – PATIENT WAS CONTINUED ON MVI WITH MINERALS, REDUCED DOSE OF VITAMIN C TO 200 MG/DAY, ZINC CONTINUED FOR ADDITIONAL 14 DAY, B COMPLEX DISCONTINUED – MD INCREASED REFERRALS – RD HAD A REALLY GOOD DAY REFERENCES Gropper, S.; Advanced Nutrition and Human Metabolism, Fourth Edition, 2005 Schleicher,R.;Carroll,M.; Serum Vitamin C and the prevalence of Vitamin C deficiency in the United States; 2003-2004 NHANES Schectman, G.; Byrd, J.; Gruchow, H. The Influence of Smoking on Vitamin C Status in Adults. Am J Pub Health,1989 Johnston, C.; Thompson, L.; Vitamin C Status of an Outpatient Population. J AM Col Nutr, 17, No. 4, 366-370 Olmedo, J.; Yiannias, J.; Scurvy: a Disease Almost Forgotten. Int J Derm 2006, 45, 909-913 REFERENCES Mahan, K.L.; Escott-Stump, S.; Krause’s Food, Nutrition and Diet Therapy Prasad, A.; Beck, F.; Bao, B.; Zinc Supplementation decreases incidence of infections in the elderly; effect of zinc on generation of cytokines and oxidative stress. Am J Clin Nutr, 2007, 85, No.3, 837844 NIH Office of Dietary Supplements, Dietary Supplement Fact Sheet Fraker, Pamela J.; King, L.; Reprogramming of the Immune System During Zinc Deficiency. Annu Rev Nutr 2004, 24:277-298 Mohammad, M., et al; Zinc in Liver Disease Nutr Clin Pract 2012, 27: 8-20
