|
|
||||||||||||||||||||||||||||||||||||
|
Modular
Nutrition
Vitamins
Publications Nutritional Rescue, Starter Packs
|
When I was a medical student learning therapeutics, our assignments were exclusively to write the admission orders on patients coming into hospital with a variety of diseases. There was a standard routine -activity level, nursing orders, diet, investigations, and medications. Since I was in a downtown teaching hospital in a big city, a disproportionate number of patients were alcoholics, poor or elderly and infirm - malnutrition was common, if not assumed. It was permissible to include an order for B-vitamins - added to the intravenous, if you had one, or taken orally. Big drug companies had established the hospital market for B- complex vitamins both injected and oral. nj limo bus One popular oral B complex included Vitamin C in a bright capsule. No one complained if you routinely ordered this supplement. On the other hand, no one complained if you failed to order the B complex. Thiamin was given to alcoholics and vitamin B12 only to patients with laboratory-proved deficiency. Vitamin C was not prescribed alone but was permissible in a B-complex tablet. We seldom saw scurvy or did not recognize it if we did. Other vitamins, were ignored or some, such as Vitamin E, were taboo because only "fringe' practitioners used such things. Oral mineral supplements were rare except for iron and potassium. Iron deficiency was well recognized as an anemia and iron supplements were popular. Potassium supplementation was commonplace because we were taught to prescribe potassium-wasting diuretics and replace potassium by prescribing tablets or powders added to juice. Magnesium supplementation was usually not considered. The admission MD always wrote diet instructions to be carried out by the hospital dietitians. These were rudimentary diet prescriptions - food was often by-passed completely with the order NPO (nothing by mouth) or "clear fluids only "and a prescription for intravenous solutions replaced oral nutrition with salt water, and glucose. It was perfectly permissible to starve patients for many days if their disease or our investigations made eating difficult or inconvenient. Often, a patient progressed directly from NPO to DAT (diet as tolerated) and the physician had no idea what the hospital was feeding his patients. I found out later that there were hidden benefits to NPO - the benefits of fasting; many patients got better NPO because they stopped eating their usual diet that had been making them ill. It is surprising how little has changed in hospital nutrition since I interned in a teaching hospital. Although a whole technology of intravenous feeding has emerged the benefits are doubtful and oral feeding has taken last place, overwhelmed by the more glamorous technologies that often fail when nutrition is neglected. The human body needs a steady supply of 40 nutrients or it doesn't work. Some institutions have made improvements in the nutritional care of patients in critical care situations. The literature which supports this effort has expanded rapidly with the result that it is an esoteric field only understood by a small number of physicians The commercial development of infant feeding formulas and hospital nutritional products has added to nutritional knowledge. Meanwhile in the community at large, a revolution in thinking has occurred over the past 30 years and nutritional approaches to disease prevention and treatment have become increasingly popular. In the community, there is an overabundance of products and claims for products that greatly exceed the evidence at hand. It is estimated that up to 70 to 100 million North American take routine vitamin and or mineral supplements; while this is about 40% of the population, the vitamin-takers are better educated, more affluent, and tend to be healthier. In the scientific literature, there have been literally thousands of new studies which reveal new indications for nutrient supplementation and/or nutrient therapeutics in a wide variety of disease states. Among all the claims of benefit, the strongest evidence suggests the need for more folic acid in the diet of mothers-to-be and the elderly, the benefits of vitamin E in cardiovascular and eye disease, the general benefits of antioxidants in a variety of states, the need of alcoholics for extra thiamine, of vegetarians for Vitamin B12, of Vitamin D supplements in all northerly and indoor-living populations, the need for extra calcium in osteoporosis- prone women, and the need for consideration of trace mineral deficiencies especially selenium and chromium. There are roles for each of the B vitamins in therapeutic applications and since they are cheap and safe to take at 2 or 3 times the RDA doses, there are reasonable arguments to include the B-complex in routine supplementation. There is little evidence to support the use of "megadoses" of the B complex vitamins, with the exception of niacin in fat transport disorders. B vitamins in larger therapeutic doses are desirable in many situations; whenever intake is reduced or need is increased. Thiamine, folic acid, pyridoxine can be supplemented in higher doses for brief periods. High doses (about 10 to 20 times RDA) of vitamin C and E can be supported by scientific studies but there is little convincing evidence that routine doses of vitamin C above 1 gram per day are beneficial, although brief intakes of higher doses to treat tissue inflammation and injury may prove to be a good idea. Some Vitamins are toxic in high dose; Vitamins A, D and B6 are the leading offenders. Vitamin C is remarkably safe in extreme doses up to 150 grams intravenously per day (the RDA is .060 grams). In spite of the persisting popularity of supplements and increasing scientific evidence of benefits, some dietitians and MDs still declare that vitamin-mineral supplements are unnecessary if you have a "well-balanced diet". Other scientific evidence reveals that the "well-balanced" diet may be a idealized and uncommon version of life anywhere in the world and total fiction when talking about poor people both in affluent countries and in the third world. There is evidence in many directions that many groups of people have nutrient deficiencies. In the USA, for example, an ambitious one-day survey of 12,000 people (Second National Health and Nutrition examination) showed that 41% ate no fruit and only 25% reported eating a fruit of vegetable that contained vitamin C or A. A US study showed that: " adolescents consumed diets that were low in several essential vitamins and minerals and high in some nutrients related to increased incidence of chronic disease. There were groups of teens who had dietary patterns that placed them at especially high risk, in particular the black and Southern females. Vitamin A, vitamin E, calcium, magnesium, and zinc were the nutrients most often consumed below recommended levels. In addition the females consumed low levels of phosphorus and iron. Percent calories from total fat and saturated fat and mean sodium intakes were above recommended levels for the majority of the sample. Another US report concluded: that 5% of Americans over age 65, or 1.5 million individuals, currently reside in the nation's 20,000 nursing homes; that nutritional deficiencies are common, frequently not recognized. and that opportunities for preventing or correcting under-nutrition exist. Another study concluded: despite eating supervision and assistance, the majority of eating-dependent nursing home residents (EDR) have inadequate intakes of numerous essential macro- and micronutrients. The deficient micronutrient intakes could be normalized by administration of a multivitamin/trace mineral supplement daily. Nevertheless, a minority of patients in nursing homes currently receive such a supplement. In the care of critically injured or ill patients improved nutrition through the use of supplements and enteral nutrient formulas is seen to be important. "Micronutrients play a key role in many of the metabolic processes that promote survival from critical illness. For vitamins, these processes include oxidative phosphorylation, which is altered in the patient with systemic inflammation, and protection against mediators, in particular oxidants. Trace elements are essential for direct antioxidant activity as well as functioning as cofactors for a variety of antioxidant enzymes. Wound healing and immune function also depend on adequate levels of vitamins and trace elements Of extreme importance is the ease with which a deficiency state can develop in the critically ill because of decreased nutrient intakes and increased requirements. Daily intakes up to or exceeding many times the RDA usually are required. Attention to micronutrients is paramount both in optimizing the nutritional management of the critically ill and in the overall management of these patients. It also is essential in promoting positive outcomes and decreasing complications." A paradox has emerged, many health professionals take supplements themselves but do not recommend them to their patients. Their better-informed and more affluent patients take the supplements anyway, and the patients who miss out are the most likely to be malnourished. Various studies have polled different populations to define the prevalence of supplement use. In the USA The FDA Vitamin and Mineral supplement use survey in 1980 found that 42% of adults use some supplement. A repeat of this survey on 1896 showed that 38% were users. Subsequent studies show supplement use hovering at about the same incidence; infrequent or occasional users always out-number regular users. Supplement Use Surveys
1. National Center for Disease Prevention and Health Promotion: Medical Tribune April 29 1993:5 2. Vitamin and Mineral Supplemental Use and Mortality in a US Cohort. American Journal of Public Health 1993;83(4):546-550. (Mortality rates were similar in vitamin-users and non-users) 3. Medeiros Dm Long-term supplement Users and Dosages Among Adult Westerners. J. Amer dietetic Ass'n 1991:91(8):980-982 4. Bender M. Trends in Prevalence and Magnitude of Vitamin and Mineral Supplement Use. Jour Am Dietetic Assn 1992;92(9):1096-1101 5. Fernandez-Banares F. et al Suboptimal vitamin status widespread. Nutr (Health Media of America Inc.) report May 1994; 36 and International Journal of Vitamin and Nutrition Research 1994:63:68-74
|