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

• Undernutritionprotein-energy – low BMI, malnutritionanaemia – iron, folate, vitamins B12, B2, C, A and copperosteoporosis – calcium, vitamin D, physical activitymicronutrient deficiencies - many

• Overnutritionenergy – obesity, high BMI and disease riskprotein (animal) – osteoporosis, renal diseasesodium – high BP/stroke, heart failure and osteoporosismicronutrient excess – diet, supplement use or disease

• Poor Food Choiceslack of protective foods – vascular disease, cancer and others intolerance/allergy – eczema, IBS, migraine, arthritisfoods with therapeutic effects – ginger - migraine, sugar - pain

All-cause mortality and BMIdata from 900,000 people Europe and N. America

15 20 25 30 35 40 504

8

16

32

64

Annual deaths

per 1000

Baseline BMI (kg/m2)

Adjusted for age, smoking and study; 1st 5 years of follow-up excluded

Male

Female

Fig 2, Lancet 2009; 373: 1083-96

& 95% CI (floated so matches PSC rate at ages 35-

79)

All-cause mortality and BMI by smoking status

15 20 25 30 35 50

5

10

15

20

0

Male (35-69 years)

15 20 25 30 35 50

5

10

15

20

0

Female (35-69 years)

Baseline BMI (kg/m2)

Current cigarette smoker

Never smoked regularly

Current cigarette smoker

Never smoked regularly

Adjusted for age and study; 1st 5 years of follow-up excluded Webfig 7a & b, Lancet 2009; 373: 1083-96

Annual deaths

per 1000& 95% CI (floated so matches EU rate at ages 35-

69)

BMI and Cause-Specific MortalityProspective Studies Collaboration Lancet 2009;373:1083-1096

BMI kg/m2 Survival Effect Change in Disease Risk

35-45 -5 to -10 years Overall mortality +30%

Vascular +40%

Diabetic +120%Renal + 60%

Hepatic +80%

Cancer +10% or more

Respiratory +20% or ? protection

30-35 -2 to -4 years

25-30 0 to -2 years

22.5-25.0 Healthy norm Ideal is perhaps 21-27.5 kg/m2

<22.5 0 to -5 years 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

• 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:

• UnderweightA body mass index (BMI) of less than 18.5kg/m2

• Unintentional Weight LossGreater 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 Signs3. 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 Diet + supplements2. Reduced Absorption Coeliac, IBD & diet factors3. Increased Losses Diarrhoea, menstruation4. Increased Demand Pregn’cy, illness + recovery5. Altered Metabolism Alcohol, drugs, illness, age

genetic factors

• Decline in Tissue Stores• Loss of Function:

1. Symptoms 2. Physical Signs3. Organ Failure

• Death

Nutritional Excesses Develop in a Similar Way

• Adequacy• State of Positive Balance:

1. High Intake Diet + supplements2. Increased Absorption Haemochromatosis3. Reduced Losses Post-menopause4. Reduced Demand Elderly5. Altered Metabolism Alcohol, drugs, illness,

age genetic factors

• Increase in Tissue Stores• Loss of Function:

1. Symptoms 2. Physical Signs3. Organ Failure

• Death

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 Diet 4-7 days + Supplement use 2. Reduced absorption 3. Increased losses 4. Increased requirement 5. Altered metabolism Alcohol intake and drugs

• Decline in Tissue Stores Tests – blood and urine

• Loss of Function:1. Symptoms NDNS 65+ Depression2. Physical Signs BMI, NDNS 4-18 Growth3. Organ Failure NDNS 65+ Renal and Liver

• Death NDNS 65+ only

Prevalence of Inadequate Micronutrient Intakes<Lower Reference Nutrient Intakes – NDNS x 4

0%

3%

6%

9%

12%

15%

18%

21%

24%

27%

30%

33%

36%

39%

Infants Children Adults F-LivingElderly

InstitutionElderly

Calcium

Potassium

Magnesium

Iron

Zinc

Vitamin A

Vitamin B12

Folate

Vitamin C

• “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

0%

5%

10%

15%

20%

25%

30%

1.5-2.5yr 4-6yr 15-18yr 35-49yr 75-84yr Institution85+yr

Male

Female

• 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

0%

5%

10%

15%

20%

25%

30%

1.5-2.5yr 4-6yr 15-18yr 35-49yr 75-84yr Institution85+yr

Male

Female

Poor Diet Poor Diet Poor Diet Reduced Absorption Menstrual Losses GI Blood Loss

- diet – tea/tannins Reduced Absorption Disease/ Unknown - disease - diet and disease Mixed Deficiencies

Diagnosing Malnutrition

1. History

2. Physical Examination

3. Laboratory Investigation

Diagnosing Malnutrition

1. History Intake: diet + supplements Risk Factors for deficiencySymptoms of deficiency

2. Physical Anthropometric MeasuresExamination (Body Mass Index - kg/m2)

Signs of Deficiency Signs of Underlying

Disease

3. Laboratory Blood and Urine TestsInvestigation 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 Nutritional Dietary Targets 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, I2 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 TargetsWHO/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 CarbohydrateTarget 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. PotatoPercentage of adult female Estimated Average Requirement by 120 g

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

Protein Pot'm Mag'm Iron Vit B1 Vit B3 Folate Vit C

White PastaWhite RicePizza MargharitaJacket Potato

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

0%

10%

20%

30%

40%

50%

60%

15-18yr 19-24yr 25-34yr 35-49yr 50-64yr 65-74yr 75-84yr 85+yr

Male >3u

Female >2u

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

• 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 effectsincreased risk of obesity increased health risks

• Considerable individual variation in effect

Nutritional Assessment - Risk FactorsNICE 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 FactorsNICE 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 IntakePercentage of Male Population 19-64 yrs with deficient intake, <LRNI*

0%3%6%9%

12%15%18%21%24%27%30%33%36%39%42%45%48%51%

Vit A B1 B2 B3 B6 B12 Fol Vit C Fe Ca P Mg K Zn I

Men No Benefits n=724

Men Benefits n=110

• 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 IntakePercentage of Female Population 19-64 yrs with deficient intake, <LRNI*

0%3%6%9%

12%15%18%21%24%27%30%33%36%39%42%45%48%51%

Vit A B1 B2 B3 B6 B12 Fol Vit C Fe Ca P Mg K Zn I

Women No Benefits n=741

Women Benefits n=150

• 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

• ReferencesHampton JR et al. BMJ. 1975;2:486-9Peterson 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) Lifestyle, vit B1• Hypertension (3) Lifestyle, vit B2• Stroke and TIA (8)• Depression (3) Folate• Mental Health (6) Folate• Dementia (2) Folate + vit B12• Chronic Kidney Disease (5) Many• Cancer (2) Caution with vitamins• Osteoporosis (? in 2013) Ca + vit D, avoid vit A XS• Maternity (1) Lifestyle, folic acid, vit D• Child Health Surveillance (1) Healthy diet, surestart, Zn• Anaemia (0) • Low BMI/Wt Loss (0)

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 FailureSoukoulis 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 failureDr 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 effectsperipheral neuropathycardiac failure + tachycardiacalf muscle tenderness

• No oral/skin signs• Test: RBC transketolase

activation coefficient

Prevalence of Vitamin B1 DeficiencyErythrocyte Transketolase Activation Coefficient >1.25 NDNS

0%

5%

10%

15%

20%

25%

30%

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

Inst85+yr

Male

Female

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

• Supplement with appropriate amounts of nutrientSevere 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 nutrientsAssess 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 correctedTreat >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 HypertensionWilson 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 BPSys -9.2 + 12.8 mmHgDias -6.0 + 9.9 mmH

Riboflavin Supplementation and Haematological StatusPowers 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 Advicehealthy eating – milk, full-fat cheese, eggs, wholemeal breadfortified foods – some breakfast cereals

• Supplement with appropriate amounts of nutrientNo separate supplement use vit.B Co Forte X 3 = 6 mg Yellow discolouration of urine is expected and harmless

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

• Once main deficiency correctedTreat >2 monthsClearance of angular stomatitis within 4 weeks is expectedCaution if cancer especially if rapid growing

Angular Stomatitis/Cheilitis a Common Problemsee 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 DeficiencyHerbert V. Trans Assoc Am Phys.1962:75:307

• 35 year old healthy maleAll 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

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

1.5-2.5yr 4-6yr 15-18yr 35-49yr 75-84yr Institution85+yr

MaleFemale

• 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 Advicehealthy eating – green leafy vegetables, potatoes, orangesfortified foods – some breakfast cereals

• Supplement with appropriate amounts of nutrientFolic acid 5 mg x 1-3/day for proven deficiency; x1/wk if MTXPregnancy 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 nutrientsOther deficiencies - vitamin B if alcohol, zinc if malabsorptionpoor diet in pregnancy consider prenatal multivit/multimineral

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

Folate/Folic Acid and Cancer RiskUlrich 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):279-85Hultdin J et al Int J Cancer 2004;113:819-24

• Thiamin - vit B1 is growth-promoting for some cancersLangbein et al

Risk Management: Cancer WarningRoyal 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

0%

5%

10%

15%

20%

25%

30%

1.5-2.5yr 3.5-4.5yr 7-10yr 15-18yr 25-34yr 50-64yr 75-84yr Institution65-84yr

Male

Female

• 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 Advicehealthy eating – protein, meat, milk, fish, eggsfortified foods some soya milks b’fast cereals, Flora Proactive

• Supplement with appropriate amounts of nutrientParenteral 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 nutrientsVegetarian/vegans – iron, zinc, calcium: elderly Ca/vit D

• Once main deficiency correctedMalabsorption/severe deficiency parenterally - 2-3 monthsUse 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 Deficiencyplasma Vit. C<11.0umol/l - NDNS data

0%

10%

20%

30%

40%

50%

60%

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 Inst65-

84yr

Inst85+yr

Male

Female

• 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 Advicehealthy eating – fresh vegetables, fruit/juice, potatoes + skins

• Supplement with appropriate amounts of nutrientAscorbic acid 200 – 500 mg/day for 8 weeksAdverse effects rare: Safe Upper Levels 1000 mg

• Consider need for other nutrientsAnaemia (iron) and folate lack are possible/likely

• Once main deficiency correctedIf 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 - NDNSLow Plasma Ferritin: Range < 10-20ug/l

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

1.5-2.5yr 3.5-4.5yr 7-10yr 15-18yr 25-43yr 50-64yr 75-84yr Institution65-84yr

Male

Female

• 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 DeficiencyPrevalence of self-reported symptoms in 11,561 white female US college entrants Hb >12.0 g/dl

0.00%

5.00%

10.00%

15.00%

20.00%

25.00%

30.00%

35.00%

40.00%

45.00%

50.00%

Fatigue Irritabilty FrequentHeadache

Not Deficient

Deficient

• All Hb >12.0g/dl

• Iron Deficient 616serum ferritin <21ug/l

• Not iron deficient 10,945

• Analysis by Chi squared:Fatigue p= 0.0026Irritability p= 0.003Headache p= 0.0004

• BMJ on line 28/6/2003Waalen 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 Advicehealthy eating – red meat, liver, beans, eggs, green veg; fortified foods - white bread and some breakfast cereals

• Supplement with appropriate amounts of nutrientFerrous 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 nutrientsVit B2 lack and rarely vits C, A and copper cause iron lackGive Vit. B Co Strong x 2/day or Forceval x 1/day as needed

• Once main deficiency correctedRetest (Hb and ferritin) after 2 monthsContinue supplements for 3 months to replenish storesChronic 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 theirprevention in those at significant risk of undernutrition (see BNF)

• Vitamin Tabletsvitamins 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 Strongvitamins B1, B2, B3, (B6 – strong only)

• Liquid ABIDEC and DALIVIT dropsvitamins 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 JuniorRDA amounts of vitamins and trace elementsUseful but avoid in cholestatic liver disease (Mn XS) and caution in osteoporosis (vit A XS)

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

• Children’s Vitamin Dropswould 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 Womenwould 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 - NDNSPercentage of Population with a plasma Retinol < 0.7/75 umol/l

0%2%4%6%8%

10%12%14%16%18%20%

1.5-3.5yr

4-6yr 11-14yr

19-24yr

35-49yr

65-74yr

85+yr Inst85+yr

Male

Female

Statement of Professor Bloch Danish PaediatricianWorld 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 BoysIncrease in Height in Inches in One Year

Mann H C Corry (1926) Sp. Rep Ser Med Res Coun. London No. 105.

0

0.5

1

1.5

2

2.5

3

BasicDiet

Water-Cress

Casein VegetMarg

Sugar N-ZButter

Milk

HeightIncrease• 219 Institutionalised orphaned boys many of whom were considered to be

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

0%3%6%9%

12%15%18%21%24%27%30%33%36%39%

1.5-2.5yr

2.5-3.5yr

3.5-4.5yr

4-6yr 7-10yr 11-14yr

15-18yr

19-24yr

25-34yr

35-49yr

50-64yr

65-74yr

75-84yr

85+yr

Male

Female

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 babiesLancet 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 Advicehealthy eating – red meat, cheese, eggs, nuts and seeds

• Supplement with appropriate amounts of nutrientZinc 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 nutrientsIf malabsorption/underweight consider multivitamins and if alcohol XS Vit. B Co Strong x 3/day

• Once main deficiency correctedReassess/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/daynone 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

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1.5 - 4.5 yrs 4 - 18 yrs 19 - 64 yrs F-L 65+ yrs Inst 65 + yrs

Deficient <0.7/0.75 umol/lBorderline 0.75-1.0 umol/lAdequate 1.0-2.8 umol/lMild Excess 2.8-3.5 umol/lSignificant excess >3.5 umol/l

Vitamin D Prevalence of Deficiency - NDNS% Plasma 25-hydroxyvitamin D <25nmol/l NDNS

0%5%

10%15%20%25%30%35%40%45%50%

1.2-2.5yr

2.5-3.5yr

3.5-4.5yr

4-6yr 7-10yr 11-14yr

15-18yr

19-24yr

25-34yr

35-49yr

50-64yr

65-74yr

75-84yr

85+yr Inst65-

84yr

Inst85+yr

Male

Female

• 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

0%

5%

10%

15%

20%

25%

30%

35%

40%

45%

50%

1.5-3.5yr

3.5-4.5yr

4-6yr 7-10yr 11-14yr

15-18yr

19-24yr

25-34yr

35-49yr

50-64yr

65-74yr

75-84yr

85+yr Inst65-

84yr

Inst85+yr

MaleFemale

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

• Supplement with appropriate amounts of nutrientCa +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 nutrientsCalcium if low intake, young/old or osteoporosis + extra vit D

• Once main deficiency correctedRe-measure 25OH D after 3-6 monthsTarget >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 lineClinicians involved in NDNS planning and interpretationAction group – respond rapidly to NDNS findings

• Education:Books to include NDNS dataBasic principles to be taught from GCSE to academia

• Clinical Practice:Targets – for screening for undernutrition in primary care Dietary assessment – deficiency and excessEmphasise food-based dietary targets, therapeutic dietsBetter availability of tests with clear indicationsMore appropriate and safer NHS nutritional supplements