YR1 Lecture 1H - Micronutrition 2021 PDF

9/04/2021 MICRO NUTRITION Leanne Venkat Senior Critical Care Dietitian Liverpool Hospital 1 LEARNING OUTCOMES Contrast the consequences of energy deprivation and those arising from deficiencies of essential nutrients, especially vitamins and minerals Identify the deficiency symptoms of micronutrie...

9/04/2021 MICRO NUTRITION Leanne Venkat Senior Critical Care Dietitian Liverpool Hospital 1 LEARNING OUTCOMES Contrast the consequences of energy deprivation and those arising from deficiencies of essential nutrients, especially vitamins and minerals Identify the deficiency symptoms of micronutrients Identify the different forms of micronutrients, their main function and the food sources that they come from 2 1 9/04/2021 SESSION OUTLINE Part 1 Part 2 Macronutrients versus Micronutrients History of micronutrients Vitamins: fat soluble & water soluble: Functions and sources Deficiencies Minerals: macro & micro-minerals (trace elements): Functions and sources Toxicities Dietitian role Physician role - Summary 3 MACRONUTRIENTS VS MICRONUTRIENTS 4 2 9/04/2021 Vitamins & Minerals Carbohydrates Protein Fat Fibre 5 NOT containing micronutrients in proportion to macronutrient content Water 6 3 9/04/2021 7 CASE EXAMPLE: SUBJECTIVE MICRONUTRIENT ASSESSMENT  Referral from medical team re: ? malnutrition  Diagnosis- Severe Community Acquired Pneumonia (CAP) secondary to poor nutritional status  PMHx: Childhood leukemia age 4 (+ RadioRx/ chemoRx), asthma, seizures, malnutrition, Osteoporosis, ?Developmental Delay  Nil known food allergies 8 4 9/04/2021 INFORMATION GATHERING Pt alone all day, nil visitors Pt vague historian- unwell, drowsy + dehydrated Developmental delay How will we assess the patient’s nutrition status/ nutrition issues? 9 PHYSICAL EXAMINATION  Subcutaneous fat + muscle wasting evident in all areas- minimal stores remaining Incidental findings:  Extremely dry, discoloured flaky skin  Pt had “sore” on foot reportedly from 2 years ago – not yet healed  Tingling in extremities during examination 10 5 9/04/2021 ANTHROPOMETRY Available info: Weight- 21.5kg (emergency department data) Height- Pt unsure. Dietitian Est 130cm BMI- 12.7kg/m2 (n= 18.5-25) Healthy Weight Range= 31.6- 42.3kg Weight History- pt unsure of history of weight loss Info in old notes- mother reported 24kg weight loss over 2 months (=53%) 11 PHYSICAL EXAMINATION- INCIDENTAL FINDINGS Top- toe: Hair thinning/ loss Eyes- difficult to ax, pt unco-operative Scaling around nostrils Lesions in corner of lips/ on lips Mouth ulcers Deep tongue fissuring Bright red/ swollen tongue appearance 12 6 9/04/2021 PHYSICAL EXAMINATION- INCIDENTAL FINDINGS No teeth “dentures hurt so don’t wear them” Spoon-shaped nails Clubbing of fingers 13 POSSIBLE NUTRITIONAL ISSUES FROM THESE FINDINGS Physical sign Possible disorders/ nutrient deficiency Possible non-nutrition problem Nasolabial seborrhoea (scaling around nostrils) Niacin, riboflavin, pyridoxine Angular stomatitis Riboflavin, Iron Excessive salivation from improper fitting dentures- possible Niacin, pyridoxine, B12, riboflavin, folate Periodontal disease Zinc, Vitamin A, EFA, protein, niacin, riboflavin, vit C, energy Environmental exposure Zinc, vitamin C, selenium, arginine, protein, energy Poor vascular supply - pt does not have acne (lesions at corners of mouth) Glossitis + tongue fissuring Xerosis (dry skin), subcut fat loss Poor wound healing Acne Vulgaris - Nil dentition - Pt indoors most days Poor glycaemic control 14 7 9/04/2021 POSSIBLE NUTRITIONAL CONCERNS FROM THESE FINDINGS Physical sign Possible disorders/ nutrient deficiency Koilonychia (spoon shaped nails) Iron Brittle, ridged nails Protein, energy Mental confusion Niacin, thiamine Possible non-nutrition problem ? ? Developmental delay ? Dehydration Motor weakness Thiamine ? Muscle tenderness + pain, muscle wasting Thiamine, vit C ? Bone tenderness Vit D, Vit C, calcium, phosphorus Burning and tingling Protein, energy 15 SESSION OUTLINE Part 1 Part 2 Macronutrients versus Micronutrients History of micronutrients Vitamins: Fat soluble & water soluble: Functions and sources Deficiencies  Minerals: macro & micro-minerals (trace elements): Functions and sources Toxicities Dietitian role Physician role - Summary 16 8 9/04/2021 VITAMINS: DEFINITION A group of essential micronutrients that:  Are organic  Natural components of foods not synthesized by the host  Essential (even if in minute amounts)  Insufficiency or absence leads to a specific deficiency syndrome 17 VITAMINS FAT SOLUBLE VITAMINS  A (retinol)  D (cholecalciferol)  E (α- tocopherol)  K (phylloquinones) Only soluble in non-polar solvents Absorption reliant on fat absorption Stored in the body and when necessary, excreted via the faeces Essential in:        Cell membranes Anti-oxidant activity Calcium and bone metabolism Visual pigmentation Gene regulation Cell differentiation Blood clotting 18 9 9/04/2021 VITAMIN A: RETINOL FUNCTIONS Reproduction Vision Immune function SOURCES  Yellow, orange, dark green veg/ fruits  “Eat your carrots so you can see in the dark’’  Dairy products  Egg yolk  Liver 19 VITAMIN D: CHOLECALCIFEROL FUNCTIONS  Bone health  Teeth health  Maintain calcium levels  Other benefits? SOURCES  Sunlight main source Depends on time of year/ skin type  Some oily fish  Fortified products e.g. margarine  Liver  Egg yolks 20 10 9/04/2021 VITAMIN E: ALPHA- TOCOPHEROL FUNCTIONS  Antioxidant SOURCES  Vegetable oils (canola, sunflower)  Protect polyunsaturated fatty  Nuts, seeds acids (PUFA) from oxidation.  Green leafy vegetables  Located in cell membranes  Fortified cereals 21 VITAMIN K: PHYLLOQUINONES FUNCTIONS  Blood coagulation- clotting factors  Moderate intake (not avoid) when requiring warfarin/ anticoagulation  Possibly bone health? SOURCES  Green, leafy vegetables: kale, spinach, salad greens, cabbage, broccoli, brussel sprouts  Soybean, canola oils  Bioavailability may increase when taken with fat e.g. butter 22 11 9/04/2021 VITAMINS WATER SOLUBLE VITAMINS  B1 (thiamine)  B2 (riboflavin)  B3 (niacin)  B5 (pantothenic acid)  B6 (pyridoxine)  B7 (biotin)  B9 (folate)  Absorbed directly from the gut (jejunum) either by simple diffusion or a carrier mechanism  Not stored in the body and excreted in the urine  Essential as coenzymes in: Amino acid, fatty acid and glucose metabolism Metabolism of toxins and drugs B12 (cobalamin)  C- ascorbic acid 23 VITAMIN B1: THIAMINE FUNCTIONS  Delivery of energy to body tissues  Carbohydrate metabolism  Metabolic links between macronutrients SOURCES  Kidney  Lean pork - richer than beef or chicken  Green peas SOURCES continued  Bread/ wheat flour products  Yeast extract e.g. Vegemite, Promite  Malted milk powders e.g. Milo, Ovaltine  Wheat germ  Cashews, peanuts, Brazils, pistachios and pine nuts  Sunflower and sesame seeds  Breakfast - 25% of the RDI 24 12 9/04/2021 VITAMIN B2: RIBOFLAVIN FUNCTIONS SOURCES  Catabolism  Dairy products  Cofactor in conversion of  Fortified bread + cereals other vitamins to active form 25 VITAMIN B3: NIACIN FUNCTIONS SOURCES  Energy metabolism  Beef, pork  DNA repair  Wholegrain cereals  Calcium mobilisation  Eggs  Cows milk 26 13 9/04/2021 VITAMIN B5: PANTOTHENIC ACID FUNCTIONS SOURCES  Component of coenzyme Q  Chicken, beef  Fatty acid metabolism  Potatoes  Oats/ wholegrains  Tomato products  Liver  Kidney  Egg 27 VITAMIN B6: PYRIDOXINE FUNCTIONS SOURCES  Amino acid, carbohydrate and fat metabolism  Organ meat  Meat  Cereals  Vegetables  Fruit 28 14 9/04/2021 VITAMIN B7: BIOTIN FUNCTIONS SOURCES  Co-factor in metabolism  Liver  Protein/ gluconeogenesis, fatty acid synthesis  Meats  Cereals  Bioavailability not known  Raw egg whites may bind/prevent absorption 29 VITAMIN B9: FOLATE FUNCTIONS  DNA synthesis incl foetal development  RBC maturation SOURCES  Fortified bread/ cereals  Green leafy vegetables  Fruit  Legumes  Bioavailability higher in fortified foods 30 15 9/04/2021 VITAMIN B12: COBALAMIN FUNCTIONS SOURCES  Blood function  Animal foods  Neurological function  Some algae and plants exposed to bacterial action or contaminated by soil/insects  Can be stored in the liver many years  Dairy products 31 VITAMIN C: ASCORBIC ACID FUNCTIONS SOURCES  Some animals make themselves!  Fruits  Anti-oxidant  Vegetables  Repair of skin cells 32 16 9/04/2021 SESSION OUTLINE Part 1 Part 2 Macronutrients versus Micronutrients History of micronutrients Vitamins: Fat soluble & water soluble: Functions and sources Deficiencies  Minerals: macro & micro-minerals (trace elements): Functions and sources Toxicities Dietitian role Physician role - Summary 33 MINERALS  Calcium  Chloride  Magnesium  Sodium MACRO MINERALS  Bone and muscle formation/function  Intra/extracellular fluids balance  Enzyme activity  pH regulation  Potassium  Phosphate  Usually required in doses >100mg/ day 34 17 9/04/2021 CALCIUM FUNCTIONS SOURCES  Development and maintenance of skeleton  Milk products  Neuromuscular function  Legumes- chickpeas  Cardiac function  Fortified soy products  Bony fish- salmon, sardines  Almonds  Dried figs, apricots  Some green vegetables  Note bioavailability may vary 35 MAGNESIUM FUNCTIONS SOURCES  Co-factor to >300 enzyme systems  Green vegetables  Energy generation  Legumes  Electrolyte balance- K+/Ca2+  Peas, beans  Nuts  Shellfish  Spices 36 18 9/04/2021 PHOSPHORUS FUNCTIONS SOURCES  Systemic acid/ base balance  Animal products  Acts as store/ transport mechanism for energy  Nuts  Activates catalytic proteins  Legumes  Processed meats  Dairy products 37 POTASSIUM FUNCTIONS SOURCES  Major cation of intracellular fluids  Leafy green vegetables  Maintained by Na+/K+ ATPase pump  Tomatoes  Muscle/ nerve functionality  Avocados  Potatoes  Eggplant  Pumpkin  Dairy products  Fruits 38 19 9/04/2021 SODIUM FUNCTIONS SOURCES  Maintain extracellular volume and serum osmolality  Lower content in unprocessed, fresh foods (but sufficient)  Active transport of molecules across cell membranes  Processed foods- most things in a packet e.g. sauces, cheese, chips, cold meats, cakes/ biscuits  Most individuals consume in excess of needs  Elevated blood pressure  Takeaway foods  Includes MSG 39 MINERALS  Iron  Selenium  Zinc  Copper  Iodine  Manganese  Fluoride  Molybdenum  Cobalt  Chromium Micro-minerals- TRACE ELEMENTS      Bone and muscle formation/function Intra/extracellular fluids balance Enzyme activity pH regulation Co-enzymes for metabolism Usually required in doses 100% estimated needs’, trial of Creon (25,000 TDS)  Difficult IV access (delayed micronutrient supplementation, requiring central line secondary to poor skin integrity hence difficult vascular access)  Team aiming for ward discharge – per team, IV micronutrient supplementation = barrier to discharge home  3/7 acute progressive neurological decline  MET for reduced GCS  ICU 80 40 9/04/2021 CASE EXAMPLE #3 ICU admission – 28 days  On admission: GCS 6 – CTB negative, ammonia >250 (although not cirrhosis; hepatic microsteatosis) - ? Cause of hyperammonia nutritional  Severe impairments in skin integrity, dressings to all limbs, wounds oozing ++ , sacral excoriation, BMS inserted  Derm consult – ‘mixed nutritional deficiency (including pellagra)’ underlying skin changes – treatment = nutrition optimisation  ?Sepsis driven encephalopathy 81 CASE EXAMPLE #3 Initiation of nutrition support: Macronutrients: Semi elemental, trophic NJ feeding Initiation and slow progression of TPN (minimal nutrition reserve + ? Absorption of enteral nutrition; monitoring ammonia + electrolytes with progression) Micronutrients:         IV thiamine 300mg TDS IV cernevit 1 vial, IV ADTE (adult dose trace elements) 1 vial Vitamin K 10mg weekly (initially daily – elevated INR (nutritional) Thyroxine (iodine deficiency-induced hypothyroidism) Vitamin B3 (enteral) IV selenium, IV copper, IV zinc Vitamin D (enteral) Creon once commenced oral intake (medical management of suspected fat malabsorption via pancreatic enzyme replacement therapy) 82 41 9/04/2021 CASE EXAMPLE #3 Progress:  Cognition/ mood/ alertness  Skin integrity - 4x full limb dressings, oozing wounds for 5 weeks  no dressings, healed wounds  Function – bedbound/ severe weakness  full power, self mobility in bed, steps with physio, sitting on edge of bed, self feeding  walked out of hospital  Diarrhoea – resolved, 2 formed motions/d 83 SESSION OUTLINE Part 1 Part 2 Macronutrients versus Micronutrients History of micronutrients Vitamins: Fat soluble & water soluble: Functions and sources Deficiencies  Minerals: macro & micro-minerals (trace elements): Functions and sources Toxicities Dietitian role Your role 84 42 9/04/2021 TOXICITIES: VITAMINS VITAMIN A VITAMIN C  Excessive amounts stored in the liver  ‘Mega’ doses  Dry mucous membranes, peeling, hair loss, headache, nausea and vomiting  Can cause diarrhoea  Liver disease in severe cases  May interact with other medications e.g. chemotherapy- reduce effectiveness  High amounts of liver, cod liver oils  Safe upper limit not clear  Vitamin preparations containing vitamin A  Caution with renal failure  Especially careful in pregnant women and children 85 TOXICITIES: MINERALS SODIUM IRON  Hypertension – debatable  Haemochromatosis  Limit in patients with organ diseaseliver, kidney, heart failure  Genetic deposition of iron in the liver and other organs Sources:  Dietary iron does not influence levels  Processed foods/ takeaway foods  Including meats/ cheeses  Adding to meal 86 43 9/04/2021 SESSION OUTLINE Part 1 Part 2 Macronutrients versus Micronutrients History of micronutrients Vitamins: Fat soluble & water soluble: Functions and sources Deficiencies  Minerals: macro & micro-minerals (trace elements): Functions and sources Toxicities Dietitian role Your role 87 ROLE OF THE DIETITIAN  Consider all information regarding medical diagnosis, blood tests from medical practitioner, medications prescribed  Physical examination  Thorough review of eating habits  Thorough review of possible contributing factors to deficiencies  Consider psycho-social aspects of diet- food security/ access, cultural beliefs, ethical beliefs etc.  Make recommendations to improve dietary balance within any limitations, respecting beliefs/ preferences 88 44 9/04/2021 SUMMARY: ROLE OF THE PHYSICIAN  Adequate macronutrients may not equate to adequate micronutrients - be aware of food sources for micronutrient balance  Be aware of role of a ‘balanced diet’ other than weight control  Be mindful of ‘at risk’ groups  Don’t rely on tests- look at the patient (Physical examination)  Be mindful of potential serious consequences of macro and micronutrient deficiencies when planning resumption of nutrition provision (such as refeeding syndrome)  If concerned about diet- refer to Accredited Practising Dietitian 89 WHAT BALANCED MACRO/MICRONUTRIENTS LOOKS LIKE 90 45 9/04/2021 This presentation is adapted from previous presentations by Dr Sharon Carey (RPAH) and Ms Marianne Acosta (Liverpool Hospital) My contact information: [email protected] Useful resources: Clinical Review: Refeeding syndrome: what it is, and how to prevent and treat it BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.a301 Australian New Zealand Nutrient Reference Values (NRVs) https://www.nrv.gov.au/home Food standards Australia http://www.foodstandards.gov.au/Pages/default.aspx Australian Guide to Healthy eating https://www.eatforhealth.gov.au/guidelines Your hospital ward/ medical practice dietitian RESOURCES 91 46