Nutritional assessment and therapies

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Chapter 2 Nutritional assessment and therapies

With contribution from Dr Antigone Kouris-Blazos

Introduction

The importance of nutrition in general medical practice has paralleled the increasing prevalence of lifestyle related disorders such as obesity, diabetes, and heart disease. In fact, alongside dermatology and psychological disorders, nutritional disorders are among the most common problems encountered by doctors and there is pressure for the general practitioner to provide competent nutritional assessment, diagnosis and therapy.¹ It has been estimated that over 70% of patients seen in general practice are at high risk of having or developing a nutritional deficiency and many patients will exhibit symptoms suggestive of nutritional inadequacy or imbalance which is contributing to their illness.^2,³

The Australian National Health Survey in 2004–5 reported that 86% of Australians between 18–64 years do not consume the recommended 5 serves of vegetables each day and 46% do not consume the recommended 2 serves of fruit each day.⁴ In 2008 rising petrol and food prices (especially for fresh produce but not for processed/take away foods) were reported to potentially affect shopping trends with less fresh produce being purchased.⁵ Furthermore, the costs of healthy foods such as bread and milk is rising far greater than the cost of nutrient poor energy dense foods (such as cakes, soft drinks and biscuits), which will impact on food choices and the diet in lower socioeconomic groups.⁶

This may be further compounded by emerging evidence from the UK and US (Australian data lacking) that there has been declining levels of minerals in our fruit and vegetables over the last 50 years, especially for magnesium dropping by about 45% (see page 23 ‘Dietary history and assessing food and nutrient intake’). Markovic and Natoli report paradoxical nutrient deficiencies such as zinc, iron, vitamin C and D and folate in the obese and overweight due to eating high-energy foods that are also high in saturated fats, salt and sugar, with poor nutrient content.⁷ The authors note that this condition is under-recognised and therefore not treated. The Public Health Association of Australia released a report in 2009 ‘A Future for our Food: addressing public health, sustainability and equity from paddock to plate’ outlining the urgent need for Australian food policy to encourage food choices that are environmentally sustainable and address the re-emergence of nutrient-deficiency related diseases.⁸

The Australian dietary guidelines and core food groups are currently undergoing revision. The Public Health Association of Australia would like to see the new guidelines address the re-emergence of nutrient-deficiency related disease and food sustainability. Specific recommendations include: reduced total intake of animal products; reduced reliance on ruminant meat; promotion of sustainable proteins, especially legumes, nuts, eggs and chicken; promotion of seasonal fruit and vegetables, legumes and grains that are grown using production methods appropriate to the region. The report highlights that shifting less than 1 day per week’s worth of calories from red meat and dairy products to chicken, fish, eggs, or legume-based diet achieves more green house gas reduction than buying all locally sourced food. In addition, consuming less meat and more plant-based foods may be 1 type of measure that will lead to increased sustainability and reduced environmental costs of food production systems.⁸

The Australian National Children’s Nutrition and Physical Activity Survey also highlights the growing epidemic of obesity in children — estimated at 17% of children considered overweight and 6% obese in Australia — with poor quality diets with significant nutritional shortfalls, particularly vitamin D, E, iodine and iron.⁹

Suboptimal intake of vitamins from diet is common in the general population, particularly children and the elderly, and a risk factor for chronic diseases such as cardiovascular disease, neural tube defects, colon and breast cancer, osteopenia and fractures.¹⁰

Other risk groups identified include vegans, drug and alcohol-dependent individuals, hospitalised patients and patients with malabsorption.

If these trends continue nutritional deficiencies may become more commonplace in the community. Doctors, dietitians, nurses and other allied health professionals may need to become more active and skilled at detecting signs and symptoms of nutritional deficiencies/insufficiencies. Improving the nutritional status of patients will help improve clinical outcomes/wellness and reduce morbidity and mortality and is thus of increasing importance to comprehensive medical care. In order to determine whether a patient’s nutritional status needs improving, a nutritional assessment is required.

Nutritional assessment will identify the high-risk patient (see Table 2.1) for nutrient inadequacies or excesses which in turn will contribute to a nutritional diagnosis. Once the diagnosis is made it is then possible to put in place the nutritional therapy of the patient.

Table 2.1 Identifying patients at high risk of nutrient deficiency or insufficiency

• Patients with chronic illnesses (especially bowel problems, other functional disorders, such as chronic fatigue, psychiatric illness).

• Patients on certain and many medications (poly-pharmacy).

• Senior patients, recent surgery, injured/severe trauma, burns, sepsis, protracted fever, recent discharge from hospital.

• Crash dieters or patients on chronic low calorie diets (<1300kcal/day).

• Poor/altered food intake (e.g. due to restricted food budget, food supply, rising food prices, food storage, poor cooking skills).

• Some vegetarians, some athletes and those with food allergies or sensitivities to particular foods.

• Sedentary patients, especially those who are office/housebound (with little sun exposure or opportunity for incidental activity); the elderly.

• Pregnant/breastfeeding women and those who excessively bleed during menstruation.

• Women with young children.

• Excess alcohol (more than 1 drink per day for women and 2 drinks per day for men), smoking or illegal drug users.

• Disabled patients, dental/chewing problems, widowers, socially isolated/living alone.

(Source: adapted from Wahlqvist M, Kouris-Blazos A. Nutrition — is diet enough? J Comp Med 2002: 46)¹¹

Nutritional assessment is based on information gathered from:

1. medical history and genetic predisposition (see Table 2.3)

2. examination for nutrition-related signs and symptoms (see Table 2.2)

3. anthropometry (weight history, BMI, waist circumference, body composition using electrical impedance or skinfold measurements)

4. socioeconomic history (living arrangements, financial problems) and lifestyle history (physical activity, alcohol, smoking, stress, gambling, sleep)

5. medication (potential adverse or beneficial effects on nutritional status (see also Chapter 37, Herb–nutrient–drug interactions)

6. vitamin and herbal supplement use — potential adverse effects (especially if far exceeding the recommended dietary intakes) or beneficial effects on nutritional status and interaction with medications (see also Chapter 37, Herb–nutrient–drug interactions)

7. dietary history (food pattern, cuisine/culture, food variety, intake and frequency of specific foods like fish, nuts, legumes)

8. laboratory tests (see Table 2.5).

Table 2.2 Presentations and signs (can include) to consider with specific vitamin deficiencies (rare or sub-clinical deficiency in Western populations)

Micronutrient	Signs
Vitamin A	Conjuctival xerosis Bitot spot Perifollicular hyperkeratosis
Vitamin B1	Peripheral neuropathy Cardiac arrythmias Cardiac failure
Vitamin B2	Magenta tongue (Glossitis) Angular stomatitis ‘Shark skin’
Vitamin B3	Strawberry tipped tongue (Glossitis) Swollen gums Dermatitis Peripheral neuropathy Hyperpigmentation
Vitamin B6	Glossitis, seborrhoea Peripheral neuropathy Symmetrical sensory and motor deficits
Vitamin B12	Glossitis Angular stomatitis Hyperpigmentation Peripheral neuropathy and sub–acute combined degeneration
Vitamin B complex/folate	Glossitis Angular stomatitis and hyperpigmentation
Vitamin C	Bleeding and swollen gums Swollen eyelids Perifollicular petechiae Follicular hyperkeratosis Scorbutic rosary and joint pain
Vitamin D	Rickets–bowing of long bone and rachitic rosary Osteoporosis
Calcium (Ca) and/or magnesium (Mg)	Positive Chvostek sign
Iron (Fe)	Koilonychia, leucoplakia, Plummer–Vinson syndrome
Zinc (Zn)	Acne, stretch marks, white spots on nail
Iodine (I)	Weight gain

Medical history

The medical history may reveal a disease that interferes with the patient’s ability to eat (e.g. Cerebrovascular accident and Parkinson’s disease) or the body’s use of nutrients (increased excretion of magnesium and chromium in diabetes or reduced absorption of several nutrients in Crohn’s disease). The genetic predisposition may also provide clues e.g. reported weight loss or diarrhoea could be due to coeliac disease which runs in the family.

Signs and symptoms of nutritional deficiencies

Clinical symptoms and anthropometric measurements will provide further clues to the nutritional puzzle. However, symptoms (manifestations reported by the patient) and signs (observations made by a clinician) can occur late in the development of the nutritional problem. Thus diagnosis of a nutritional deficiency cannot usually be made solely on the basis of a clinical examination. This is mainly because many nutrition-related signs and symptoms are non-specific and can occur for non-nutritional reasons. Usually the presence of a group of related clinical signs and symptoms is a better indication than a single sign or symptom.¹² For example, the finding of follicular hyperkeratosis isolated to the back of a patient’s arms is a fairly common, normal finding. On the other hand if it is widespread on a person who consumes little fruit and vegetables and smokes regularly (increasing vitamin C requirements) vitamin C deficiency is a possible cause. Not surprisingly, the tissues with the fastest turnover rates are the most likely to show signs of nutrient deficiencies or excesses e.g. hair, skin and lingual papillae (an indirect reflection of the status of the villae of the gut)¹³ (see Tables 2.2 and 2.3 for clinical signs and symptoms of possible nutritional deficiencies).

A thorough medical and nutritional history, together with a thorough physical examination is necessary to detect nutrient deficiencies (occasionally this may be subtle i.e. nutritional insufficiency). When taking a nutritional history, if limited by time, ask patients to recall what they ate and drank in the last 24–48 hours and/or ask them to bring a 1-week food diary at their next consultation. If time permits, then a more extensive dietary assessment would be helpful as discussed under Dietary history and assessing food and nutrient intake in this chapter. Examples of symptoms suggestive of nutrient deficiencies include gum bleeding (vitamin C), numbness of feet (folic acid and B1 deficiency), night blindness (vitamin A), poor immunity and recurrent infections (vitamins A, C, D and zinc), poor appetite (B group vitamins and zinc), muscle cramps (calcium, magnesium), tremor (magnesium), poor memory (B group vitamins, folic acid and various minerals e.g. magnesium), loss of libido (B group vitamins, folic acid), tiredness (any nutrient), mood disorders (B group vitamins, vitamin C and zinc), poor wound healing (protein, zinc, vitamin C), sore tongue (several B group vitamins) and loss of taste (zinc). Physical examination of the patient may identify a number of signs suggestive of nutrient deficiency (see Tables 2.2 and 2.3).

Table 2.3 Clinical symptoms and signs of nutrient deficiencies/insufficiencies

Clinical symptoms and signs	Consider low intake/deficiency (may warrant blood/urine/faeces testing)
HEAD
appetite poor	Znⁱ, ^v, Mgⁱⁱⁱ, Feⁱⁱⁱ, B1^vi, B3^vi, folate^vi, excess vit Aⁱ
nausea (esp with fatty foods)	B3^vi
fatigue/tiredness/irritable	B6^vi, B12^vi, folate^vi, Zn^{i, v, vi}, vit C^vi, Fe^{iii, vi}, chromium (Cr)^vi, thyroid, excess vit A^v, protein^vi
sugar cravings/hyperglycaemia	insulin resistance, Mg, Cr^{iii, v, vi}, Zn, vit E
moody/depressed	protein^vi, B1^vi, B3ⁱⁱⁱ, B6^{iii, vi}, B12^vi, vit C^vi, Mg^vi, Znⁱⁱⁱ, iodine, thyroid, vit D
anxiety/agitation	Cr^vi, Mg^vi, vit D^vi
migraine	B2^vi, coenzyme Q₁₀ (CoQ₁₀)
headache	B3ⁱⁱⁱ, B12^vi, folate^vi, Feⁱⁱⁱ, Mg if cervicocranial, excess vit A^{i, iii}
sleep disturbance	B6^vi, Mg^vi, vit C^vi
sleep onset delay	vit D^vi
poor dream recall	B6^vi
insomnia/restless sleep	vit D^vi, Ca^vi, B3ⁱⁱⁱ
non-refreshing sleep	Mg^vi
night sweats-back of head/scalp	vit D^vi
low libido	Fe (women) ⁱⁱⁱ, Zn (men), low testosterone, thyroid
impaired memory/cognition/dementia	B1^{iv, vi}, B12^{iii, iv, vi}, B3^{iii, iv, v}, folate^{iv, vi}, Fe^vi, Zn^vi, iodine
HAIR/SCALP
hair thinning/loss/alopecia	protein^iv, B2^vi, EFA^vi, Zn^{iii, vi}, Fe^vi, Biotin^{i, iii, v, vi}, excess vit Aⁱⁱⁱ, excess selenium (Seⁱⁱⁱ) thyroidⁱ, iodine
dry dull hair	essential fatty acid (EFA)^vi, vit A^vi
easily plucked hair	protein^iv
dry coarse/brittle hair	protein^iv, biotin^iv, Fe^vi, Zn^{i, vi}, Iodine, hypothyroid, EFA^vi, excess vit A^{i, iii}
depigmentation/dyschromotrichia	copper (Cu)ⁱ, Seⁱ
hair growth arrest	Znⁱ
diaphoresis of scalp (night)	vit D^vi
dry flaking hair and scalp	vit A, Zn, Se
dandruff	Zn^vi, Mg^vi, biotin^vi, Se
prematurely graying hair	Cu^vi, Biotin^vi, vit B12^{iii, vi}
coiled/cork screw hairs	vit Cⁱⁱⁱ (hair shaft flat instead of round in cross section)
EYES
tearing/burning/itching	vit B2^v
dark/crimson under eye circles	Fe, allergy^vi, liver problems
dry thickened conjunctiva xerophthalmia/xerosis

vit A^{i, vi}, Znⁱ, Biotinⁱⁱⁱ (conjunctivitis) pale conjunctiva Feⁱⁱⁱ muddy sclera vit C^vi yellow sclera liver function^{i, vi} photosensitivity vit B2^{iii, vi}, Znⁱⁱⁱ bitot spots/white thick patches vit Aⁱ, Znⁱ impaired night vision vit A^{iii, vi}, Znⁱⁱⁱ long sightedness vit D^vi impaired visual acuity/blurred EFA^vi, xs vit Aⁱ pterygium (thickness) vit C^vi, B3^vi, EFA^vi twitching eye/spasms facial muscles Mg^{i, iii, vi}, Ca^{i, iii}, Kⁱ macular/retinal degeneration age, lutein, zeaxanthin, excess blood sugar NOSE scaling/red folds nasolabial seborrhea vit B2^{iii, vi} (red greasy folds), B6ⁱⁱⁱ, omega-6ⁱⁱⁱ (dry folds) poor smell/anosmia Zn^{v, vi}, vit A^v EARS noise intolerance Mg^vi post aural flush Zn^vi, EFA^vi tinnitus Feⁱⁱⁱ TONGUE/MOUTH

dark red raw/swollen/glossitis

painful ‘raw beef’ appearance

vit B3^{i, iii, iv, v}, B12^{i, iii, iv, v}, folate^{i, iv, v}, Fe^{i, iv, v, vi} bright red smooth/glossitis vit B2^{i, iv}, B6^{i, iii, iv, v}, B12^{i, iv}, folate^{i, iv, v}, Fe^{i, iv, v, vi}, biotin^{i, v} large beefy tongue hypothyroidⁱ, iodineⁱ magenta/blue tongue vit B2^{i, iii, v}, Biotinⁱ white/pale smooth Feⁱ yellow/brown tongue bowel dysfunction/dysbiosis^vi, low HCL^vi berry like red tongue vit B complexⁱ fissured/creviced tongue vit B3^{iv, v} scalloped tongue Mg^vi, vit B3^vi strawberry tip/cherry tip tongue vit B3^vi, B6^vi burning sensation of mouth/throat D^vi lips cheilosis (burning/soreness) vit B2^{iii, iv, v}, B3^{iii, iv}, B6^{iv, v} angular stomatitis vit B1ⁱ, B2^{i, iii, iv, v}, B3^{i, iii, iv}, B6^{iii, iv}, folate^v, B12^{i, v}, Feⁱ halitosis vit B3^vi, low HCL, dysbiotic bacteria, hypothyroid; liver problems periodontal disease/loose teeth vit C^vi, CoQ₁₀^vi, Ca^vi bleeding gums/gingivitis vit C^{i, iii, iv}, B2^iv, vitK^vi, xs vit A (red gingiva around teeth)^{i, iii} gum recession protein^vi, CoQ₁₀^vi mouth ulcers vit B12^vi, vit A^vi, folate^vi crimson crescents back of mouth food sensitivies^vi intense thirst xs vit D^vi, B1/wet beri beriⁱⁱⁱ impaired taste Zn^{i, v}, vit Aⁱⁱⁱ loss of tooth enamel Ca^iv HANDS/NAILS finger pulp atrophy protein^vi cold hands Feⁱⁱⁱ, Mg^vi, vit E^vi, EFA^vi, thyroid vertical corrugations — pronounced (beaded nails) vit Bⁱⁱ, protein^vi, Zn^vi, diabetesⁱⁱ, thyroidⁱⁱ, Addisonsⁱⁱ vertical corrugations — unpronounced Ageⁱ, RAⁱ, PVDⁱ, Lichen planusⁱ pronounced central ridge Feⁱ, folateⁱ, proteinⁱ horizontal grooves/Beau’s lines protein^vi, past severe illness/surgeryⁱⁱ, MIⁱⁱ, Znⁱ, Seⁱ, Caⁱⁱ leukonychia (white spots) Zn^vi half moons base of nails vit B6^vi dry thin brittle nails protein^vi, malnutritionⁱⁱ EFA^vi, Fe^vi, Ca/osteopeniaⁱⁱ, thyroidⁱⁱ peeling/splitting nails Ca^vi protein^vi spoon shaped/brittle nails Fe^{i, iii, vi}, low cysteine/methionineⁱ, diabetesⁱ soft/papery/bitten nails Zn^vi, protein^vi growth arrest/thickened nails protein^vi, Znⁱ yellow nails vit E^vi black/red thickened nails xs Seⁱ egg shell nails vit A^vi clubbed nails lung problemsⁱⁱ, IBDⁱⁱ, coeliacⁱⁱ, hyperthyroidⁱⁱ brown nail beds or skin creases vit B12ⁱⁱⁱ white nail beds Seⁱⁱⁱ paronychia excess Seⁱⁱⁱ, Znⁱⁱⁱ MUSCLE generalised muscle pain/ache tender muscles

B1 ^iv, vit E^v, Ca^{i, v}, Mg^{i, vi}, potasium (K)^{i, v}, Se^{i, iii}, vit D^{v, vi}, coma, iodine

CoQ₁₀ (if on statins), vit C ⁱⁱⁱ

cramps Ca^{iii, v}, Mg^vi, vit B5^vi, Feⁱⁱⁱ, K, Na, vit Cⁱⁱⁱ, vit D^vi muscle twitching/spasms (hyper-reflexia) B6^v, Mg^{i, iii, v, vi}, Ca^{i, iii}, Kⁱ, vit D^vi muscle atrophy face, hands, chest, loss of tissue recoil back of hand protein^vi, B1^vi calf/muscle tenderness vit E^v (intermittent claudication), B complex^{iv, vi} muscle weakness/wasting (difficulty up/down stairs)iii protein^iv, vit D^v, K^v, Ca, thiamin decreased muscle reflexes B complex^vi, vit E^vi SKIN excessive ageing of skin/wrinkles vit E^vi perifollicular hyperkeratosis (toad skin) commonly seen on upper arms/thighs vit A^{i, iv, vi}, Znⁱ, B complexⁱⁱⁱ, vit C^{iii, v}, EFAⁱⁱⁱ perifollicular petechiae/haemorrhages vit C^{i, iii, v}, vit K^{i, iii} (causes petechiae unrelated to hair; sometimes seen with prolonged antibiotic treatment) shark skin/dyssebacea (sebum plugs in follicles/face/body) vit B2ⁱⁱⁱ

oily scaly seborrheic dermatitis

esp nasolabial folds/eyebrows/forehead

vit B2^{iii, v}(nasolabial/scrotum), vit B3ⁱⁱⁱ, vit B6^{i, iii, v}, Biotin^vi, Cuⁱ, EFA^vi dry scaly/coarse dermatitis Zn^{iii, v}, Iodineⁱ, vit B3ⁱⁱⁱ, omega-6^{i, iii}, omega-3^vi, vit C^v, vit E, biotin^{i, v}, vitA^v, vit A excess^{i, iii, v} dry ‘fish scale’, ‘flaky paint’ vit A^iv, Zn^{iv, v} especially on the legs hyperpigmentation non scaly macules/patches insulin resistance^vi, vit A, Zn^{iii, v}, vit C, vit B12ⁱⁱⁱ, vit B6^vi, folateⁱⁱⁱ, EFA, evening primrose oil (EPO), vit B3^iv (see also dermatitis) hyperpigmented scaly dermal patches on face/limbs (pellagra) vit B1, vit B3ⁱ, biotin^{i, v}, Zn^{iii, v}, EFA unusual skin rash vit B6 or excess supplement use spider veins vit C^vi liver spots (ceroid accumulation) vit E^vi eczema biotin^vi, Znⁱⁱⁱ, omega-3^vi, omega-6/EPO^{i, iii}, glutenⁱ rosacea vit B2, hypochlorhydria/gastric dysfunction^vi, dysbiotic bacteria/H pylori infection^vi psoriasis vit D^vi, EFA^vi, vit A^iv, Znⁱⁱⁱ acne EFA^vi, Zn^vi, vit A^vi, vit Cⁱⁱⁱ, dysbiotic bacteria, bowel dysbiosis^vi, high GI diet/insulin resistance^vi stretchmarks Zn^vi, vit E^vi, Bvi^vi wound healing/lesions on pressure areas vit A, B6^vi, vit C^{v, vi}, Zn^{i, iii, v}, EFA^vi, protein^vi, biotin^vi easy bruising vit K^{iv, vi}, dysbiotic bacteria^vi, protein, vit C^{iv, vi}, blood thinning medication blood mottling arms/legs vit B6^vi itchy skin/rashes liver problems NERVES/PAIN/BONES impaired coordination/balance, disorientation/ataxic gait vit B1^{i, vi}, B12^{iii, v} (neurological changes can occur without haematologic changes), B3^iv, vit E^{iv, vi} neuropathy (weakness, ataxia, pins/needles, parasthesia, foot/wrist drop, reduced tendon reflexes, numbness of fingers/feet/lips/tongue fine tactile sense, vibratory sense, position sense) vit B1^{i, iv, vi}, B2^{iii, vi}, B6^{iii, iv}, B12^{iv, v}, carnitine, EPO, vit B6 toxicityⁱⁱⁱ, folateⁱⁱⁱ, Mgⁱ, Caⁱ, Kⁱ, omega-3ⁱⁱⁱ, Cr^{iii, v} Fe^vi, vit E^{iv, v}, lipoic acid neuralgia/paralysis/paresthesia vit B1^iv, B3ⁱⁱⁱ, B12^{iii, iv, v} Mg^{iv, v} tetany Ca^{iv, v}, Mg^iv, K^v diminished reflexes Iodine^iv postural hypotension vit B6/B complex^vi, Fe^vi (general hypotension) bone/joint pain vit C^{iv, v, vi}, xs vit A^{iv, v}, vit D^{iv, v}, Ca^v, omega-3^vi, Zn^vi, Boron^vi low bone density excess vit A^v Ca^v, Mg^v, vit D^v, Ca^v, Zn, vit K DIGESTION constipation/bloating Feⁱⁱⁱ, B3^vi, low HCL/enzymes, gluten, food intolerances, dysbiosis, candida management, vit D excess diarrhoea Feⁱⁱⁱ, excess Mg/vit Cⁱ, Znⁱ, B3^{iii, vi}, B12ⁱⁱⁱ folate^v, biotin^v, fructose, fructans belching/flatulence/reflux vit B12ⁱⁱⁱ, low hydrochloric acid (HCL), H Pylori, allergen, lactose, fructose poor digestion vit B3^vi, low stomach acid (HCI)^vi MENSTRUAL delayed/<flow periods/irregular oligomenorrhoea/sub-fertility Feⁱⁱⁱ, vit E^vi, EFAs^vi, insulin resistance^vi, Zn^vi mastalgia vit E^vi, vit A^vi, omega-3^vi/EFA imbalance^vi PMS vit B6^vi, Ca^vi, Mg^vi, EFA^vi dysmennorrhoea/menorrhagea Ca^vi LEGS/FEET heels — hyperkeratosis/dry/cracked vit E^vi, EFA^vi soles — hyperkeratosis vit A^vi cold feet/<peripheral perfusion vit E^vi, EFA^vi, Mg^vi, vit B6, thyroid (vit A, Zn, I, Fe) burning paresthesias in feet vit B5ⁱⁱⁱ, B1ⁱⁱⁱ arch collapse protein^vi calf muscle tenderness vit E^vi, B1ⁱⁱⁱ oedema K, Mg, vit B1^{i, iii}, Feⁱⁱⁱ, protein^iv, quercetin GROWTH poor Feⁱ, Zn^{i, vi}, Iodine^{i, iii}, proteinⁱ, energyⁱ, vit Dⁱ, Ca, omega-6ⁱⁱⁱ, vitA^v IMMUNITY/INFECTIONS/CANCER immuno-dysfunction Znⁱⁱⁱ Se^vi, vit C^vi, vit E^vi, vit D

Important note: The list in Table 2.3 is not definitive and is based on combined clinical experience and scientific evidence. Assessment and treatment should be based on your own clinical judgment (i.e. dietary history and physical examination) and confirmed with pathology testing. Symptoms may also occur from other non-nutritional related diseases.

i McLaren DS. A Colour Atlas and Text of Diet-Related Disorders. 2nd edn. London England: Wolfe & Mosby — Year book Europe Ltd, 1992.

ii Medscape. Examining the Fingernails When Evaluating Presenting Symptoms in Elderly Patients. Online. Available: www.medscape.com (accessed 7 Aug 2008).

iii McLaren DS. Clinical manifestations of human vitamin and mineral disorders: a resume. In: Shils M, Olson JA, Shike M, Ross C. Modern Nutrition in Health and Disease. 9th edn. Williams & Wilkins, 1999;485–503.

iv Newton MJ, Halsted CH. Clinical and functional assessment of adults. In: Shils M, Olson JA, Shike M, Ross C. Modern Nutrition in Health and Disease. 9th edn. Williams & Wilkins, 1999;895–902.

v Heimburger DC, Ard JD. Handbook of Clinical Nutrition. 4th edn. Mosby Elsevier 2006.

vi Sydney-Smith M. Nutritional Assessment. J Comp Medicine 2006; Jan-Feb 28–40; and Nutritional Assessment Workshop Seminar slides, March 2008.

1. Food distribution across the day and if patients have a high protein food at every meal. A study in 867 of free-living individuals ¹⁷ reported that food intake in the morning created better satiety and was linked to a reduced total amount of food ingested for the day; on the other hand intake in the late night appeared to lack satiating value and resulted in greater overall daily intake. Consuming low energy dense high protein foods throughout the day can reduce overall intake by increasing satiety. In other words, this study suggests that it is not wise to under eat during the first part of the day and appears to be linked to circadian and diurnal rhythms.

2. Food intake frequency and food portions; for example, how many times a week do you consume red meat (Figure 2.1) and how large are the food portions — for example, is the meat serve the size of a deck of cards (= 100g) or is the cheese serve the size of a matchbox (= 30g) (Figure 2.2)? Another way to look at portion sizes is to use your hand. One serving of protein should be about the size of the palm of your hand or about ¼ plate. The recommended serving of green vegetables and salad greens could be the size of 2 fists (½ plate), while starchy items like potatoes or pasta should be served in a portion about the size of 1 tightly clenched fist (¼ plate). Finally, how closely do the patient’s food servings resemble the recommended ‘plate’ servings (Figure 2.3).

Figure 2.1 Taking a dietary history from your patient ¹⁸

Copyright: Kouris-Blazos A 2010; adapted from Kouris-Blazos A & Wahlquist ML, HEC Healthy Eating Pyramid 2001, www.healthyeatingclub.org, 2001

Figure 2.2 Estimating portion sizes ¹⁹

Figure 2.3 Recommended ‘plate’ servings

Servings: ½ plate of vegetables (1 cup cooked or 2 cups raw); ¼ plate starchy food (1/2 cup pasta or 1/3 cup rice or 1 slice bread or 2 small potatoes); ¼ plate high protein food (100g cooked red meat/chicken/pork or 150g cooked fish fillet or 250g whole fish or 1 cup legumes or 1 large egg); 1–2 tablespoons unsaturated oil; season food with vinegar or lemon juice as this helps to lower the glycaemic index of the meal and flavour with herbs/spices (if using salt prefer iodised salt).

Photo: Antigone Kouris-Blazos

A general dietary history from a patient can be obtained within 5–10 minutes. A more detailed dietary history using the information as in Figure 2.1.

Note: Serving food from a smaller plate (e.g. from a 30cm plate to a 25cm plate) can result in about 22% fewer calories being served as long as vegetable intake is not reduced (www.smallplatemovement.org).

Assessing food intake and nutrient intake

Various models and guides have been developed over the years to assess adequacy of food intake — not only with respect to obtaining an adequate intake of nutrients but also for health protection and promotion. Models and guides have been developed by:

• the Australian Government Department of Health (5 food groups in 1940s, food plate 1998)

• Nutrition Australia (formerly known as Australian Nutrition Foundation — Healthy Eating Pyramid 1980s)

• The National Health and Medical Research Council (NHMRC) core food groups (1995) currently being revised for a new food guidance system for Australia, (to be released in 2011)

• nutrition scientists developing their own tools, such as:

• the food variety checklist by Australian Professor Mark Wahlqvist (1989)

• the Mediterranean diet pyramid developed in 1995 by American Professor Walter Willet²⁰

• the Healthy Eating Pyramid developed by the Department of Nutrition, Harvard School of Public Health, Harvard College (Figure 2.4) which is similar to the Mediterranean food pyramid but emphasises foods known to have healing benefits, plant-based choices, variety and balance, support of a healthful environment and mindful eating.

The interest in the Mediterranean diet was reignited in the 1990s when a Greek-Australian team of researchers showed that adhering to the principals of a Mediterranean food pattern conferred longevity in people aged over 70,²¹ especially when legumes were consumed.²² The Mediterranean diet represents the dietary pattern that has been widely reported to be a model of healthy eating²³ that contributes significantly to a favourable health status²⁴, including prevention of diabetes,²⁵ cancer,²⁶ cardiovascular and heart disease²⁷ and even obesity/weight loss.²⁸

Figure 2.4 The Healthy Eating Pyramid ²⁹

Copyright © 2008. For more information about The Healthy Eating Pyramid, please see The Nutrition Source, Department of Nutrition, Harvard School of Public Health, http://www.thenutritionsource.org, and Eat, Drink, and Be Healthy, by Walter C Willett, MD and Patrick J Skerrett (2005), Free Press/Simon & Schuster Inc.

The food serves calculated from the dietary history can be compared to the recommended food serves (shaded boxes in Fig 2.1). The closer the patient’s intake is to the recommended daily servings for meat and alternatives, fruit, dairy, cereals, and vegetables the more nutritionally adequate it will be. To investigate the intake of particular nutrients, food composition tables or lists of good food sources of nutrients can be used (see Appendix 1). The adequacy of energy and nutrient intakes can then be compared to the recommended dietary intake (see Table 2.4 and Figure 2.5).

Table 2.4 Recommended dietary intakes per day for men and women aged >19 years, 2006

Figure 2.5 Calculating energy and protein requirements

When the food and nutrient data is combined with other sources of information (e.g. clinical signs, laboratory tests) it can help confirm or rule out the possibility of suspected nutritional problems. A sufficient intake of a nutrient does not guarantee adequate nutrition status for an individual (e.g. medication or chronic diarrhoea may be increasing excretion of minerals) and an insufficient intake does not always indicate a deficiency, but such findings warn of possible problems. A variety of computer programs and patient questionnaires are available that permit rapid estimation of nutrient intake. These can be completed before or after the consultation, with the aid of practice staff. However, many of these nutrient analysis programs are based on food composition tables that have been periodically updated for some foods but not all foods. For instance, the nutrient composition data for Australian fruits and vegetables is over 20 years old in the Australian food composition tables, therefore calculated nutrient intakes using these programs may not reflect actual intake.

There is emerging evidence from the UK and USA that there have been declining levels of many nutrients in fruit and vegetables over the last 50 years with magnesium levels dropping by 45%, calcium and iron levels dropping by 20%, copper by 80%, vitamin C by 20% and riboflavin by 40%. These changes have been linked to changes in soil quality and plant cultivars having a higher water content (referred to as the dilution effect) suggesting that crop yield may have been favoured over nutrient content.^30,^{31, 32} Many Australians are not eating the recommended amount of fruit and vegetables and these data suggest we may need to eat even larger serves of fruit and vegetables!

Laboratory tests

The laboratory test will, to some extent, help the clinician confirm their suspicions and assist them in reaching a nutritional diagnosis. Sample nutritional testing may include those tests detailed in Table 2.5.^3,³⁴

Table 2.5 Sample nutritional tests ^3,³⁴

Protein

serum albumin, TIBC, transferrin, urinary excretion 3–methylhistidine;

Urea mmol/l: Creatinine umol/l ratio (the average urea/creat ratio is around 0.08 and the majority of results tend to be less than 0.15; values lower than 0.08 suggest low protein intake and values higher than 0.15 are associated with dehydration, high protein meals, excessive protein tissue catabolism, upper gastrointestinal tract (GIT) bleeds etc.)

Fatty acids plasma and erythrocyte essential fatty acids Carbohydrate fasting insulin/hyperinsulinaemia, glucose tolerance test (GTT) (with insulin and C-peptide), HbA1c, fructosamine Vitamins Vitamin A plasma retinol/carotene Thiamin (B1) whole blood thiamin (preferred), plasma thiamin, erythrocyte transketolase activity before or after stimulation with thiamine pyrophosphate, erythrocyte thiamin diphosphate, urinary thiamin Riboflavin (B2) whole blood riboflavin, urinary riboflavin, percentage activation of erythrocyte glutathione reducatse by flavinadenine dinucleotide (FAD) Niacin (B3) urinary N1–methyl-nicotinamide or erythrocyte NAD:NADP ratio Pyridoxine (B6) erythrocyte pyridoxal and pyridoxine Folate erythrocyte folate Cobalamin (B12) serum B12 (does not pick up all cases of deficiency), urinary methylmalonic acid or holotrans-cobalamine or active B₁₂ (more accurate) Biotin whole blood biotin, urinary biotin (more accurate) Homocysteine serum homocysteine Vitamin C plasma vitamin C, urinary vitamin C Vitamin D serum 25–OH vitamin D (preferred), serum 1,25 OH vitamin D Vitamin E serum tocopherol Vitamin K prothrombin time CoQ₁₀ serum coenzyme Q₁₀ Antioxidants serum or plasma total antioxidant status Minerals Calcium 24–hour urinary calcium excretion, plasma ionised calcium, serum PTH, 25-OH vit D, bone mineral densitometry (DEXA) Chromium serum and urine chromium used clinically only to detect toxic levels Copper erythrocyte copper, serum copper, urine copper Iodine urine iodine/creatinine ratio (consistent hydration required to compare iodine in different urine samples); repeated urine samples (at least 2–3 samples) are needed to diagnose iodine status preferably taken at the same time e.g. morning urine, first void; iodine supplements need to be stopped at least 24 hrs before urine collection Iron serum iron, TIBC, ferritin, transferrin saturation Zinc 24–hour urinary zinc excretion which allows some assessment of turnover, erythrocyte/leucocyte zinc, serum zinc (unreliable measure), plasma zinc (more reliable than serum zinc) together with serum albumin (an important zinc-binding protein which may affect values) Magnesium low serum Mg usually indicates a true magnesium deficiency but a normal serum Mg does not rule out a deficiency — up to 20% depletion without change in serum Mg (unreliable measure); erythrocyte/leucocyte Mg and 24–hour urinary magnesium excretion possibly better than serum Mg as it reflects intracellular Mg but normal or even elevated levels may occur in frank deficiency states; 24-hour urinary magnesium excretion after intravenous loading is the most accurate with an excretion level 80% of the infused amount being indicative of deficiency Selenium serum or whole blood selenium Food intolerances^∗ no reliable blood test currently available to identify food intolerances — elimination diet currently best tool to identify foods/chemicals causing symptoms Food allergy^∗ blood IgG levels for 40–93 foods — this is not a reliable test Zinc 24–hour urinary zinc excretion which allows some assessment of turnover, erythrocyte/leucocyte zinc, serum zinc (unreliable measure), plasma zinc (more reliable than serum zinc) together with serum albumin (an important zinc-binding protein which may affect values) Magnesium low serum Mg usually indicates a true magnesium deficiency but a normal serum Mg does not rule out a deficiency — up to 20% depletion without change in serum Mg (unreliable measure); erythrocyte/leucocyte Mg and 24–hour urinary magnesium excretion possibly better than serum Mg as it reflects intracellular Mg but normal or even elevated levels may occur in frank deficiency states; 24-hour urinary magnesium excretion after intravenous loading is the most accurate with an excretion level 80% of the infused amount being indicative of deficiency Selenium serum or whole blood selenium Food intolerances^∗ no reliable blood test currently available to identify food intolerances — elimination diet currently best tool to identify foods/chemicals causing symptoms Food allergy^∗ blood IgG levels for 40–93 foods — this is not a reliable test

∗ Skin prick for allergies and elimination diet and oral re-challenging test for food intolerances are considered gold standard.

There are limitations in using plasma, serum or cellular conentrations of nutrients as these are subject to homeostatic control, tend to reflect very recent uptake or supplementation and not longer term nutritional status. Supplements should be ceased a few days before blood testing.³⁴

Nutritional therapy and micronutrients

Recommended daily intake

Micronutrients are nutrients, such as vitamins, minerals and essential fatty acids that are required by the body in small quantities (usually less than 1g/day),³⁵ as opposed to macronutrients that include proteins, carbohydrates and fats. This topic has been a controversial and highly debated area amongst leading nutritionists, but there is an increasing body of scientific evidence to support the use of micronutrients as therapeutic agents. There is no doubt in anybody’s mind that our natural source of micronutrients should be from food. A diet of fresh fruit, vegetables, whole-grains, meats, legumes, raw nuts and seeds, and dairy foods (if tolerant to cow’s, goat’s or sheep’s milk) should provide all of the necessary nutrients. However, as discussed, it is not always possible for individuals to obtain their required daily allowance of nutrients from food.

The National Health and Medical Research Council (NHMRC) updated its recommended daily intake of nutrients in 2006; the first time in 15 years.^39,³³ The update brings with it a new set of definitions. The recommended intakes are now referred as ‘Nutrient Reference Values’ (NRV). ‘Estimated Average Requirements’ (EAR) was established for all nutrients, which is the level estimated to meet the requirements of half of the healthy individuals in a particular life stage and gender group. If the data were normally distributed and sufficiently robust to calculate an EAR then a Recommended Dietary Intake (RDI) was defined as the EAR plus 2 standard deviations; that is, most EAR values are 20% less than the RDIs. When there were insufficient or inconsistent data to calculate an EAR, an Adequate Intake (AI) was set. The AI is defined as the median intake of a given nutrient as obtained from the National Nutrition Surveys of Australia and New Zealand. Furthermore, an Upper Limit (UL) was set for the first time for all nutrients that included intake from all sources and was based on the possibility of adverse effects. The NRVs also include a recommendation for an Acceptable Macronutrient Distribution Range or AMDR expressed in terms of total energy consumed. The AMDR for protein has increased allowing for a higher intake than previously recommended (up to 25% energy intake). There is also the Suggested Dietary Target (SDT) for chronic disease prevention for many micronutrients, fibre and omega-3 fatty acids for which there is evidence that intakes higher than EAR, RDI or AI may confer a health advantage. In the revised NRVs, the RDIs for the following nutrients increased: iron (for women only); calcium, zinc (for men only); magnesium; and B group vitamins. The RDI for vitamin E was changed to AI (and an SDT was set) because the key evidence, published in the early 1960s, does not allow for a valid analysis of the vitamin E dose-response curve.

A number of population studies and surveys have shown that the majority of people in the community fail to meet RDI levels for many common nutrients.^43,⁴¹ For instance, the Commonwealth Department of Health, ^43,⁴¹ following a national dietary survey in 1983 on adults and in 1985 on children, concluded that there were problems of excess in the average Australian diet, particularly of sugar and fat intake, and a high prevalence of obesity. The studies indicated that a significant proportion of the population did not reach RDI levels. This was seen mostly in females, and in the Asian and Southern European population. Micronutrients that these populations were mostly deficient in included vitamins A, calcium, zinc iron, and calcium.

A survey of children and teenagers in 2007 continues to highlight the nutritional shortfalls of the diets of Australian children and teenagers, with less than 5% meeting the guideline for recommended vegetable intake and only 1% of teenagers consuming 3 serves of fruit daily when fruit juice was excluded (24% met the recommendation when juice was included) and egg intake was low at less than 2 eggs per week.⁴² The study also reported the following average percentages of children aged 9–16 years not achieving the minimal EARs for key nutrients: calcium (60%); folate (15%); vitamin A (12%); magnesium (30%); zinc (10%); iodine (10%); and iron (3%). However, when intakes were compared to RDIs (or optimal intake) the percentage of children not achieving RDIs was much higher than those for EARs (since RDIs are about 20% higher than EARs).

Nutrient deficiency

There are various reasons for nutrient deficiencies occurring. One factor is over-consumption of processed and packaged foods, causing:⁴⁰

1. destruction of the nutrient balance often inherent from the ‘whole’ food

2. loss of essential nutrients and bulk, especially complex carbohydrates and fibre

3. excess intake of total calories in the form of fats and refined sugars.

Nutritional deficiencies are becoming more common because of emerging food insecurity and the changing quality of the food supply, especially iodine, selenium, magnesium, zinc, and vitamin D. Special cultivars of plants that can absorb and bind organically greater amounts of these nutrients might be the answer in addressing nutrient deficiencies in plants rather than food fortification with micronutrients. Apart from food processing, risk factors for micronutrient deficiency also includes the following:⁴³

• Decreased nutrient intake — stress, psychiatric disorders (e.g. anorexia, depression), crash dieters or people on chronic low energy diets for weight loss, poor appetite, food processing and lack of nutritious food, diseases of the mouth and chewing, chronic illness, sedentary lifestyle, alcohol and drug abuse. Decreased nutrient intake is found particularly in population groups such as: teenagers; vegetarians; those with allergies or sensitivities to particular foods; indigenous peoples; and the homeless and elderly, especially if institutionalised or in those that are house bound.

• Decreased absorption — chronic illness, thyroid disorders, gastrointestinal tract illness (virtually all, including irritable bowel syndrome), medication, alcohol and drug abuse.

• Decreased storage — liver disease, alcohol and fat storage disorder, chronic illness.

• Increased utilisation — a number of illnesses (e.g. recurrent infections), catabolic stress (trauma, major infection, surgery), chronic illness (cancer, HIV etc.), pregnancy and lactation, very heavy exercise, a number of medications (eg. anti-neoplastic drugs, colchicine, oral contraceptive pill, anticonvulsants, tetracyclines — see Chapter 37, Herb–nutrient–drug interactions), smoking, alcohol and drug abuse.

• Increased excretion — medication such as laxatives, anticonvulsants, diuretics (see Chapter 37, Herb–nutrient–drug interactions). Dietary fibre can bind minerals and increase their excretion.⁵

The problem with RDI levels is that it is based on the ‘healthy’ population. It does not take into consideration the ‘unwell or sick’ individual who requires significantly higher levels of micronutrients than the suggested RDI figures, and it is not designed to apply to individual needs (e.g. at times of stress, ill health, lifestyle factors etc.) that may vary with changing lifecycle patterns.

When there is disturbance of more than 1 of the above mechanisms together with a processed diet, there is an even greater risk of deficiency of nutrients in individuals.

Megadoses versus multivitamins

A Cochrane review based on a meta-analysis of 68 randomised primary and secondary prevention trials (n = 232 606) that tested antioxidant supplements concluded that high doses of vitamins A, E and b-carotene (but not vitamin C or selenium) can significantly increase all-cause mortality when given singly or with other antioxidant supplements.⁴⁴ This review, however, focused on antioxidant vitamins used at high doses rather than lower dose multivitamins. Furthermore, the review looked at 815 antioxidant trials but included only 68 of them in its analysis. Two excluded from this review (published in the Journal of the National Cancer Institute and the Lancet) found substantial benefits and reduced mortality from intake of antioxidant supplements. If these 2 large studies had been included, none of the reported effects on increased mortality would have been significant, with the exception of the effects of beta-carotene.

The research on multivitamin supplement usage is more positive and has prompted many nutrition experts to rethink their stance on this issue (see below). Several studies have shown taking low dose multivitamins can reduce health risks such as all-cause mortality, ischaemic heart disease and cancer in men but not in women (RR 0.63 in men versus RR 1.03 in women, in 13 000 French adults taking a single capsule daily multivitamin over a 7.5 year period), especially where the diet is of poor quality and lacking in nutrient-dense foods.⁴⁵ A study on people (n = 1056) using (1) multiple supplements (2) a single multivitamin supplement and (3) non-users of multivitamins produced some interesting findings. More than 50% of the multiple supplement users took a multivitamin, B complex, vitamin C, carotenoids, vitamin E, calcium/vitamin D, fish oil, flavonoids, lecithin, alfalfa, CoQ₁₀ with resveratrol, glucosamine, and a herbal immune supplement. The majority of women also took evening primrose oil and probiotic and men took zinc, garlic, saw palmetto and a protein soy supplement. A greater degree of supplement use was associated with more favourable concentrations of serum homocysteine, C-reactive protein, high density lipoprotein cholesterol, triglycerides as well as lower risk of prevalent elevated blood pressure and diabetes even when confounders were controlled, such as education, income, BMI.⁴⁶ Another study on 8555 women from the US Nurses Health study showed that regular use of multivitamin supplements may decrease the risk of ovulatory infertility.⁴⁷

Farvid et. al.⁴⁸ randomised 69 people with type 2 diabetes to 4 groups to receive 1 of the following daily supplements for 3 months: Group 1 200mg Mg, 30mg Zn; Group 2 200mg vitamin C and 100IU vitamin E; Group 3 minerals plus vitamins; Group 4: placebo. After 3 months Group 2 (vitamins) and Group 3 (vitamins and minerals) had improved glomerular (but not tubular) kidney function with reduced excretion of urinary albumin. Group 3 experienced additional benefits: reductions in systolic and diastolic blood pressure, fasting serum glucose and malondialdehyde concentration, increases in HDL cholesterol and apolipoprotein A1 levels. This study not only supports the use of multivitamins in diabetes but suggests a synergistic action of vitamin and mineral therapy with the combination achieving better results than vitamins or minerals alone.

Harvard University Healthy Eating Pyramid

Nutrition scientists at Harvard University School of Public Health developed their own version of a Healthy Eating Pyramid in 2006 ⁴⁹ based upon the best available scientific evidence linking diet and health independent of businesses and organisations with vested interests (see Figure 2.4). The Harvard University experts agreed that there was enough evidence to recommend a multivitamin daily (which appears alongside their pyramid). However, some scientists believe there is not enough scientific evidence to recommend either for or against taking a daily multivitamin.⁵⁰ The Harvard scientists argue this is a short-sighted point of view⁴⁹ since it may never be possible to conduct randomised trials that are long enough to test the effects of multiple vitamins on risks of cancers, Alzheimer’s disease, and other degenerative conditions. They conclude that, balancing the weight of all of the evidence — from epidemiological studies on diet and health, to biochemical studies on the minute mechanisms of disease — the potential health benefits of taking a standard daily multivitamin far outweigh the potential risks.⁵¹

Prescribing micronutrient supplements

How can micronutrients be of help?

1. Micronutrients may be used to correct deficiencies in the unwell for relief of symptoms (Table 2.6).

2. Micronutrients have a therapeutic action as evidenced by increasing studies and are effective in the treatment of a number of diseases (Table 2.7).

Table 2.6 Circumstances that place patients at risk of nutrient deficiency and suggested supplementation

Food habits	Consider short-term (or long-term if food habits cannot be altered) low-dose supplementation with:^∗
At risk individuals (see Table 2.1), especially patients following reduced energy diets (<1500kcal/day) for several months, elderly, polypharmacy, GI disorders	Multivitamin, Ca, Mg, Fe, Zn, B complex, fibre
Not eating recommended number of food serves (but if eating vegemite will not need B complex) (see Table 2.4)	Multivitamin, Ca, Mg, Fe, Zn, B complex, fibre
High intake of sugar, refined carbohydrates/white flour, processed foods, pre-cooked meals, take away food	Multivitamin, Mg, Chromium, Zn, fibre
Excess alcohol	Multivitamin, Ca, Mg, K, Fe, Zn, Se, folate, thiamin and other B vitamins, vit C/D/E
Eating out more than twice a week for dinner, especially at fast food restaurants	Multivitamin, fibre
Fatty fish consumed less than 3 times a week	Omega-3 EPA/DHA
Low intake of animal foods (if 2 brazil nuts consumed daily Se intake adequate; if vegemite or bananas/walnuts/pecans/potatoes consumed daily then B6 may be adequate)	Fe, Zn, Se, B12, B6
Total avoidance of animal foods and fish (vegan diet)	B12, Iodine, Fe, Zn, Ca, omega-3, vit D, vitamin A (some medical conditions affect conversion of beta carotene from plant foods to vitamin A)
Low intake of dairy or calcium fortified soy foods (<3 serves/day) For food cultures that do not habitually consume milk products, a low intake of certain soup broths (soups made form bones can be high in calcium, especially if acid ingredients such as vinegar or lemon are used, which facilitate dissolution of bones), prawns, fish with soft bones, tofu Chinese cabbage, broccoli, and bok choy may suggest inadequate calcium intake)	Ca, B2
Low intake of dairy, eggs, carrots, sweet potato, dark green leafy vegetables and avoidance of organ meats (e.g. liver)	Vitamin A
Reduced carbohydrate diets or low intake of wholegrain cereals/breakfast cereals (<3 serves/day), not compensated by adequate meat, fish, legumes, nuts	B1, Mg, Zn, Cr
Low intake of fish/seaweed (less than once a week), iodised bread, or use of un-iodised salt or un-iodised milo or multivitamin not containing iodine (especially important for pregnant/lactating women and children)	Iodine
Low intake of dark green leafy vegetables (<3 times a week) e.g. spinach, endives, kale, chickory, Chinese greens, nuts (<3 times a week), wholegrain cereals/breakfast cereals (<3 serves/day), legumes (<once a week)	Mg, Zn, folate, fibre
Low intake of fruit and vegetables	Vit C, folate, b carotene, Mg, fibre
Low intake of flax seeds, chia seeds, canola/soybean oil or spreads, walnuts, pumpkin seeds, tofu	Omega-3 linolenic
Low intake of unsaturated oils/spreads (<1 tbs/day) and nuts/seeds (whole/spread) or fatty fruit (avocado) or sweet potato	Vit E, omega-6 linoleic Omega-3 linolenic

Low intake of eggs, fatty fish, sun exposed mushrooms, vitamin D fortified foods (milk, oil spreads), inadequate sun exposure (more important) Vit D (deficiency can lead to reduced absorption of Mg, Ca, and Zn)

Note: use this table in conjunction with Appendix 1 ‘Food sources of macronutrients, micronutrients, phytonutrients and chemicals’.

∗ Ideally, it is best to do blood/urine tests to check levels before supplementation is commenced but this may not be possible for some nutrients (because they may not be covered by public medical system or tests may not accurately measure nutrient levels in body). In this situation supplementation (with fortified drinks or capsules) should be low dose, around the RDI levels or below the upper tolerable level (Table 2.4). However, if blood/urine tests show deficiency, a much higher dose above the RDI will be needed.

(source: www.healthyeatingclub.com)

Table 2.7 Some conditions(s) that may be prevented or improved with nutrient administration

Conditions	Supplementation
Prevention of neural tube defects in ongoing pregnancies^53,^{54, 55}	B12, folate
Mood disturbance/insomnia,⁵⁶ depression, affective disorder^57,⁵⁸ Psychiatric disorders⁵⁸	Vitamin C, E, folic acid B group vitamins (B1,B2, B6, B12) Biotin, nicotinamide Tryptophan, magnesium, vitamin D

Atherosclerosis, coronary artery disease, cardiovascular disease, stroke⁵⁹^–⁶⁸

Omega-3 fatty acids (fish oils)

Vitamins A, C, E

Folate, vitamin D

HIV, AIDS^69,⁷⁰ (Improving T cell levels)

Vitamin A, Zinc micronutrients

Cervical cancer^71,⁷²

Carotenoids, vitamins C and possibly E and D

Folate and vitamin B12

Oral cavity and pharyngeal cancers⁷² Carotenoids, vitamins C and possibly E

Gastric cancer ⁷³

Gastrointestinal cancer ^74,⁷⁵

Vitamins A, C, E

Selenium, B6, vitamin D

Prevention of bronchial squamous metaplasia in smokers⁷⁶

Folate

Vitamin B12

Common cold⁷⁷^–⁸⁰ Vitamin C, zinc Respiratory infections in hospitalised elderly⁷⁹ Vitamin C

Diabetes ⁸¹^–⁸⁵

Diabetic neuropathy ^85,⁸⁷

Vitamin C, E, magnesium

Chromium, evening primrose oil, omega-3 fatty acids

Gestational vitamin B6

Lipoic acid

Vitamin B12, vitamin D

Infantile atopic dermatitis^88,⁸⁹ Evening primrose oil (omega-6–GLA) Hypercholesterolaemia^90,^{91, 92} Vitamin C, garlic Acute measles^93,⁹⁴ Vitamin A Thyroid (low T3/4 ratio)⁹⁵ Selenium, iodine, Zn, Fe Miscarriage⁹⁶

Selenium

Zinc

Myocardial infarction⁹⁷^–¹⁰² Vitamins A, C, E magnesium, coenzyme Q10 Angina^101,^{103, 104} Beta–carotene, magnesium, vitamin E Arrhythmia^105,^{109, 110}

Selenium, magnesium, vitamin C

Coenzyme Q₁₀

Autism^106,¹⁰⁷

Tardive Dyskinesia¹⁰⁸ Vitamin E Nausea/vomiting and vertigo during pregnancy^111,¹¹²

Vitamin B6

Multivitamin

Multimineral

Chemotherapy-induced neuropathy¹¹³ Vitamin E Parkinson’s disease^114,¹¹⁵ Coenzyme Q₁₀ Bladder cancer¹¹⁶

Vitamins A, C, E

Vitamin B6

Zinc, selenium

Poor sperm quality (esp. in smokers)¹¹⁷ Vitamin C, zinc, selenium The elderly^117,¹¹⁸

Multivitamin

Beta–carotene

Vitamins C, E

Age–related macular degeneration¹²¹ Beta–carotene, vitamins C, E Atopic eczema¹²² Evening primrose oil Preterm delivery^123,¹²⁴ Zinc Short stature in infants, children and adolescents¹²⁴^–¹²⁶ Zinc Smoking¹²⁷ Vitamin C Iron deficiency¹²⁸ Vitamin C ↓ risk of basal cell carcinoma¹²⁹ Vitamin A, E Fibromyalgia¹³⁰ Magnesium, malic acid Hypertension¹³¹^–¹³⁶

Fish oil (omega–3 fatty acids), coenzyme Q₁₀, magnesium, garlic

Vitamin D

Preeclampsia/pregnancy induced hypertension¹³⁷^–¹³⁸ Magnesium, calcium Mastalgia¹³⁹ Evening primrose oil, vitamin E Hip fracture prevention^140,¹⁴¹

Calcium

Vitamin D3

Osteoporosis¹⁴² Magnesium, calcium, vitamin D3 (>400IU/day) Muscle soreness¹⁴³ Vitamin C, vitamin D, magnesium, thiamin Immune function¹⁴⁴^–¹⁴⁶

Garlic, vitamin D, Zn

Vitamin A

Multivitamin/multimineral

Asthma^147,¹⁴⁸ Vitamin C, antioxidants Status Asthmaticus¹⁴⁹ Magnesium (iv) Hearing loss¹⁵⁰ (noise induced) Magnesium, vitamin B12 Tinnitus¹⁵¹ Vitamin B12 Multiple sclerosis¹⁵² Vitamin D Pulmonary function¹⁵³ (asthma, COAD, ARF) Magnesium Pulmonary hypertension in newborn¹⁵⁴ Magnesium Convulsions in preeclampsia¹⁵⁵ Magnesium Cataract¹⁵⁶ Vitamin C Acute pancreatitis^157,¹⁵⁸ Sodium Selenite Rheumatoid arthritis¹⁵⁹ Omega-3 fatty acid (fish oils) Coronary artery bypass graft^160,¹⁶¹ Vitamin E, A Favourable lipoprotein profiles¹⁶² Vitamin C Growth of infants small for gestational age¹⁶³ Zinc Tardive Dyskinesia¹⁶⁴ Vitamin E Lipoprotein profile (favourable)¹⁶⁵ Vitamin c, fish oils Recurrent herpes labialis¹⁶⁶ Vitamin C, bioflavanoids Mortality reduction¹⁶⁷ Vitamin D

Note: For more detail see chapters in this book regarding specific conditions.

When a plant is looking unwell, amongst other ways, we improve the quality of the soil by changing the soil (analogous to improving the food source) and adding fertiliser rich in micronutrients. We can use this concept as an analogy for improving human health.

What if a patient presents with vague symptoms such as ‘tiredness’ and their dietary history reveals that their diet could be improved although a specific vitamin deficiency cannot be identified? What if the clinician feels they do not have time to provide dietary counselling and the patient can’t afford a dietitian? Is it acceptable to use a multivitamin supplement or fortified protein drink instead of, or in addition to, dietary counselling? The answer is yes but the clinician ought to solve the problem with food as often as possible. Some patients may need long-term supplementation if they are unable to improve their diet or if they have certain conditions or take certain medications.¹¹

Cautions when prescribing supplements

One must be cautious when prescribing nutrients, especially in the presence of kidney and/or liver disease. In most cases, there are minimal side-effects. Table 2.4 provides upper safe levels for each nutrient.

In general, avoid mega-dose vitamins and mega-fortified foods (e.g. folate — see below) as these may have adverse effects. Vitamin D, vitamin B12 and iron are an exception, as many people need more than the RDA due to deficiencies identified in blood tests. Also avoid ‘super’ supplements which tend to have wild health claims — if they sound too good to be true, they probably are. Many vitamins and minerals operate in a synergistic fashion so it is best they are taken together rather than individually. Unless the diet is very poor, a low dose multivitamin can be taken intermittantly (a few times a week as a top-up) and it is probably prudent to take a break from a daily mutivitamin for a while. Long-term high-dose individual supplementation is not advised and it is preferable to increase patient’s consumption of nutrient-dense foods before instituting long-term supplement therapy.

Vitamin E

The adult safe upper intake level (UL) for vitamin E is set at 400IU/300mg daily. Vitamin E has a blood thinning effect. In 1 study of 28 519 men, vitamin E supplementation at the low dose of about 50IU synthetic vitamin E per day caused an increase in fatal hemorrhagic strokes.⁵² Based on its blood thinning effects, there are concerns that vitamin E could cause problems if it is combined with blood thinning medications, such as warfarin (Coumadin), heparin, clopidogrel (Plavix), ticlopidine (Ticlid), pentoxifylline (Trental), and aspirin. However, a study has shown that Vitamin E does not interfere with the anticoagulation response of warfarin.¹⁶⁶

A study that evaluated vitamin E plus aspirin did in fact find an additive effect.¹⁶⁷ There is also at least a remote possibility that vitamin E could also interact with supplements that possess a mild blood thinning effect, such as garlic, policosanol, and ginkgo. Individuals with bleeding disorders, such as haemophilia, and those about to undergo surgery or labour and delivery should also approach vitamin E with caution. In addition, vitamin E might temporarily enhance the body’s sensitivity to its own insulin in individuals with type 2 diabetes¹⁶⁸ but may raise blood pressure in people with diabetes.¹⁶⁹ Some evidence suggests that long-term usage of vitamin E at high doses (>400IU/day) might increase overall death rate, for reasons that are unclear.¹⁷⁰ Vitamin E may help to prevent heart disease in people with diabetes.¹⁷¹ A number of these studies have used synthetic vitamin E and this may explain differences in safety between the studies. Also, ideally vitamin E should be given with vitamin C in order to allow vitamin E to function most effectively.¹⁷²

Folate

A standard multivitamin usually has the RDI for folic acid, so one may need to avoid foods that have high amounts of folic acid added to them.

The US Institute of Medicine ¹⁷³ recommends against obtaining more than 1000mg per day of folic acid from supplements or fortified food; folate intake from food is not a concern.¹⁷⁴ Excess folic acid supplementation can mask the signs of a vitamin B12 deficiency (up to 1 in 6 older people either don’t get enough vitamin B12 or don’t absorb it efficiently). Too much folic acid can hide the signs of anaemia, an early warning of a vitamin B12 deficiency. This could allow the problem to progress to the point of causing confusion, dementia, and/or severe and irreversible damage to the nervous system. There is some concern that too much folic acid can accelerate the growth of existing tumours and may increase the risk for colorectal, breast¹⁷⁵ and prostate cancer.¹⁷⁶ It is thought that folate can protect against colorectal cancer if commenced earlier in life.¹⁷⁷ Although these studies are limited, and other, similar studies have shown no association between folic acid and increased cancer risk, they sound a warning about consuming too much folic acid supplementation that deserves further investigation.

Vitamin C

The safe tolerable upper intake level for vitamin C from supplements and diet is 2000mg. Even within the safe intake range for vitamin C, some individuals may develop diarrhoea and abdominal discomfort which resolves on dose reduction. Long-term high dose vitamin C intake has not been linked with kidney stone formation but there may be certain individuals who are particularly at risk for vitamin C-induced kidney stones.¹⁷⁸ People with a history of kidney stones and those with kidney failure and who have a defect in vitamin C or oxalate metabolism should probably restrict vitamin C intake to approximately 100mg daily. High-dose vitamin C should also be avoided in glucose-6–phosphate dehydrogenase deficiency, iron overload, or a history of intestinal surgery.

Weak evidence suggests that vitamin C, when taken in high doses, might reduce the blood thinning effects of warfarin (Coumadin) and heparin. Heated disagreement exists regarding whether it is safe or appropriate to combine antioxidants such as vitamin C with standard chemotherapy drugs. The reasoning behind the concern is that some chemotherapy drugs may work in part by creating free radicals that destroy cancer cells, and antioxidants might interfere with this beneficial effect. However, there is no good evidence that antioxidants actually interfere with chemotherapy drugs, but there is growing evidence that they do not.¹⁷⁹

However, new research on stem cells suggests that high (but not low) doses of antioxidants such as vitamins C and E can increase DNA damage, increasing potentially the risk of developing cancer.¹⁸⁰

The maximum safe dosages of vitamin C for people with severe liver or kidney disease have not been determined. Large doses of oral or intravenous vitamin C in patients with renal impairment should be avoided.

Vitamin A, β−carotene

Nutrient toxicity, especially with prolonged use, is a concern. Most supplements in Australia have warnings of this on their labels. For instance, signs of vitamin A toxicity include skin dryness. Vitamin A supplementation in excess of 2500IU per day in pregnant women is associated with fetal teratogenicity.¹⁸¹ Beta–carotene is a safer form of vitamin A. However, beta–carotene in high doses should be avoided in smokers and asbestos-related lung disease as it may increase the risk of lung cancer in these situations.¹⁸² This study has been criticised because synthetic β-carotene rather than the natural form was used.

Vitamin B6

High prolonged doses of vitamin B6 (>50mg/day) can cause headache, epistaxis and peripheral neuropathy (usually reversible, upon withdrawal of vitamin B6 although in some cases can cause permanent damage).

Zinc

The safe tolerable upper intake level for zinc from supplements and diet is 40mg. Long-term use of oral zinc at dosages of 100mg or more daily can cause a number of toxic effects, including severe copper deficiency and reduced iron absorption leading to anaemia, impaired immunity and heart problems. Zinc at a dose of more than 50mg daily might reduce levels of HDL cholesterol. In addition, very weak evidence hints that use of zinc supplements might increase risk of prostate cancer in men.¹⁸³

Magnesium

The safe tolerable upper intake level for magnesium from supplements is 350mg. This level of daily supplemental magnesium intake is not likely to pose a risk of diarrhoea or gastrointestinal disturbance in almost all individuals. The initial symptom of excess magnesium supplementation is diarrhoea — a well-known side-effect of magnesium that is used therapeutically as a laxative. Individuals with impaired kidney function are at higher risk for adverse effects of magnesium supplementation, and symptoms of magnesium toxicity have occurred in people with impaired kidney function taking moderate doses of magnesium-containing laxatives or antacids. Elevated serum levels of magnesium (hypermagnesemia) may result in a fall in blood pressure (hypotension). Some of the later effects of magnesium toxicity, such as lethargy, confusion, disturbances in normal cardiac rhythm, and deterioration of kidney function, are related to severe hypotension. As hypermagnesemia progresses, muscle weakness and difficulty breathing may occur. Severe hypermagnesemia may result in cardiac arrest. However, there are some conditions that may warrant higher doses of magnesium under medical supervision.¹⁸⁴

Selenium

The tolerable upper intake level for selenium is 400mcg/day based on the prevention of hair and nail brittleness and early signs of chronic selenium toxicity. Highly excessive selenium intake, beginning at about 900mcg daily, can cause selenium toxicity. Signs include skin rashes, a garlic breath odour, fatigue, depression, nervousness, emotional instability, nausea, vomiting, gastrointestinal disturbances and in some cases loss of hair and fingernails. Maximum safe doses of selenium for individuals with severe liver or kidney disease have not been established. There is some evidence that supplementing selenium over the long-term in areas where selenium is already adequate in the diet may increase the risk of diabetes and perhaps hypercholesterolemia.

Chromium

The tolerable upper intake level for chromium is 300μg/day. There is some evidence that if chromium is taken in high enough amounts, it may be converted from its original safe form (chromium 3) into a known carcinogen, chromium 6.¹⁸⁵ The risk of chromium toxicity (kidney, liver, bone marrow damage) is believed to be higher in individuals who already have liver or kidney disease. There are also several concerns about the picolinate form of chromium in particular. Picolinate can alter levels of neurotransmitters. This has led to concern among some experts that chromium picolinate might be harmful for individuals with depression, bipolar disease, or schizophrenia. Finally, there are also concerns, still fairly theoretical and uncertain, that chromium picolinate could cause adverse effects on DNA.¹⁸⁶