Nutrition - Minerals

Calcium Drug-Nutrient Interactions

*Calcium decreases absorption of: - Fluroqunolones, tetracyclines, iron supplements; Separate by 2hrs - Levothyroxine; Separate by 4hrs

Calcium: Clinical Pearls

*Most common adverse effects: - Constipation - Gastro-intestinal irritation - Flatulence *Be aware of products containing dolomite, bonemeal, or oyster shell may contain high levels of lead (FDA warning 1981)

Calcium: Label Reading

- If labels do not express calcium as "elemental" assume calcium is available dependent on the salt form - A label that states it supplies 1,000mg calcium carbonate actually contains 400mg elemental calcium

What Foods Provide Calcium?

- Milk, yogurt, Cheddar cheese, cooked kale, cooked broccoli, cooked spinach *Bioavailability is dependent on 1,25-OH vitamin D*

Chromium Sources

- Mineral found in brewer's yeast, meat, potato skins, cheese, molasses, breads and cereals, fruits and vegetables - Also found in stainless steel cookware

Copper

- Mineral needed for iron storage, wound healing, and bone strength - Part of cocktail to treat macular degeneration

Conclusions

- Minerals are important to proper biological functioning - Mineral supplementation, aside from calcium, are seldom needed can correct deficiencies and alleviate symptoms - Mineral deficiency is rare aside from poor diet, malabsorption syndromes, drug interactions, and certain diseases - Excessive amounts of mineral intake can be harmful and should be avoided

Zinc deficiency is rare in the US

- Patients with malabsorption syndromes (Crohn's, short gut, etc.) alcoholism, kidney failure are most at risk

Dietary iron has two main forms, heme and nonheme

- Plants and iron-fortified foods contain nonheme iron only, whereas meat, seafood, and poultry contain both heme and nonheme iron - Heme iron is formed when iron combines with protoporphyrin IX, contributes about 10% to 15% of total iron intakes in western populations - Nonheme iron requires adequate Vitamin C for absorption*

Zinc deficiency can cause:

- Slowed growth, hair loss, poor taste and smell, loss of appetite, retinal dysfunction, increased risk of infection, and dry rough skin

Elemental Calcium From Supplements

*Patients who have achlorhydria, on H2 antagonists or PPI - Take a soluble salt (calcium citrate, lactate, gluconate) - Calcium carbonate and phosphate salts are insoluble and should be taken with meals to enhance absorption, which is optimal in a low pH

Calcium Requirements in Elderly

*Postmenopausal women and men age 71 and older* - At least 1200mg/day of calcium and 900 IU/day of Vitamin D - Calcium supplementation delays bone mineral density loss and reduces the risk of hip fractures by 25% to 70%

Thiazide Diuretics and Calcium

*Thiazides decrease renal calcium excretion - Milk Alkali Syndrome (hypercalcemia, metabolic alkalosis, renal failure) - Severity: Moderate - Onset: Delayed *Avoid excessive ingestion of calcium - May need to monitor serum calcium level

Hemochromatosis

- A disease caused by a mutation in the hemochromatosis (HFE) gene, is associated with an excessive buildup of iron in the body - Without treatment by periodic chelation or phlebotomy, people with hereditary hemochromatosis typically develop signs of iron toxicity by their 30s - Liver cirrhosis and carcinoma, heart disease, and impaired pancreatic function

Minerals covered

- Calcium - Zinc - Copper - Chromium - Selenium - Iron

Copper Drug-Nutrient Interactions

- Copper can reduce penicillamine absorption (used in rheumatoid arthritis)

Great Iron Sources

- Fortified cereal - Beans - Red meat (chicken and eggs are ok sources) - Seafood - Tofu - Tomatoes - Potatoes (with skin) - Green leafy vegetables: while has the most iron in them, they have low bioavailability do to iron absorption inhibitors in products - Cashews

Copper Deficiency is rare

- Too much zinc, hemodialysis, intestinal bypass surgery, and malabsorption syndromes can lead to defiency

Zinc supplement adverse effects

- Zinc coexists with cadmium, a heavy metal which can cause kidney failure; Zinc gluconate has the lowest cadmium concentrations - Zinc nasal spray can cause permanent smell loss - Topical zinc (zinc oxide) can cause burning and itching - N/V/D, metallic taste, and kidney damage in overdose - Too much zinc can reduce copper and iron absorption

Zinc

- Zinc is needed for wound healing, immune function, blood clotting, eyesight, and proper growth

Iron Toxicity

1) Acute intakes of more than 20 mg/kg iron from supplements can lead to gastric upset, constipation, nausea, abdominal pain, vomiting, and faintness 2) Taking supplements containing 25 mg elemental iron or more can reduce zinc absorption 3) Ingestions of 60 mg/kg can lead to multisystem organ failure, coma, convulsions, and death - Between 1983 and 2000, at least 43 US children died from ingesting supplements containing high doses of iron (36-443 mg/kg body weight) - Accidental ingestion of iron supplements caused about a third of poisoning deaths among children reported in US between 1983 and 1991

Chromium Quick Facts

1) Chromium is added to steel to create stainless steel - Industrial exposure can lead to chromium excess with kidney damage, lung cancer, and eczema 2) Chromium supplements have few side effects 3) Calcium supplements decrease chromium absorption, space >2hrs

When is Calcium Supplement Needed?

1) FDA approved for treatment and prevention of calcium deficiency 2) Renal failure associated hyperphosphatemia - Calcium binds phosphorous 3) Treatment of acid indigestion 4) Osteoporosis

Iron Supplement-Drug Interactions

1) Iron (like any secondary or tertiary cation (Mg, Al, Ca)) prevents flouroquinolone and tetracycline absorption - Space 2 hours from each other 2) Iron reduces the absorption of levodopa (Parkinson's disease drug) and levothyroxine (thyroid disease drug) - Space 4 hours from each other 3) Proton pump inhibitors - Gastric acid plays an important role in the absorption of nonheme iron from the diet - Patients with iron deficiency taking proton pump inhibitors can have suboptimal responses to iron supplementation - Treatment with proton pump inhibitors for up to 10 years is not associated with iron depletion or anemia in people with normal iron stores

Iron

1) Iron needed for oxidative processes: - Hemoglobin in RBCs - Myoglobin in muscle cells - Cytochrome P450 system - Cellular respiration/energy production 2) Iron is necessary for: - Growth, development, normal cellular functioning, and synthesis of some hormones and connective tissue

Too Much Calcium

1) Maximum dose (UL) - 2500mg/day 2) Excessive doses can lead to toxic effects: - Hypercalcemia - Kidney stones - Milk-Alkali Syndrome

Iron depletion and deficiency progresses through several stages:

1) Mild: Serum ferritin concentrations and levels of iron in bone marrow decrease - Plasma transferrin saturation and hematocrit not reduced 2) Moderate: Iron stores are depleted, ferritin and transferrin saturation reduced - Hemoglobin still not reduced 3) Severe: Iron stores are exhausted, ferritin and transferrin saturation reduced, hematocrit and levels of hemoglobin decline - Microcytic, hypochromic anemia characterized by small red blood cells with low hemoglobin concentrations

Mineral: Calcium

1) Most abundant cation in the body - 99% of body calcium stored in bones & teeth - 1% is extracellular and supports critical metabolic functions, including: Muscle contraction, blood vessel contraction, nerve transmission, secretion of hormones and enzymes* 2) When intake is inadequate, bone is resorbed to maintain serum calcium 3) Needed for: strong bones and teeth 4) Food Sources - Dairy products, vegetables (kale, broccoli, Chinese cabbage)

Copper Dosing Information

1) RDA is 1mg/day 2) UL is 10mg/day - Likely safe supplements are <10mg/day - Higher doses can cause N/V/D, anemia, and hypotension*

Zinc Requirements

1) RDA is 8-14mg/day 2) Normal diet provides 13mg/day 3) UL without medical indication is 40mg/day

Selenium Uses/Sources

1) RDA= 55-70mcg/day ; UL = 400mcg/day 2) Average dietary intake is 125mcg/day - Almost no one needs supplements 3) Foods with selenium: - Meat, fish, nuts, whole grain 4) HIV, Crohn's, TPN patients increased risk of deficiency - Deficiency = issues with macronutrient metabolism

Estimating calcium intake from calcium rich foods (NOF)

1) Step 1 - Estimate calcium intake from calcium-rich foods 2) Step 2 - Add 250mg for nondairy sources to subtotal above

Chromium Uses/Needs

1) Turns macronutrients (fat, protein, carbs) to energy - Adequate intake: 25-35mcg/day 2) Decrease blood glucose levels in Type-2 DM 3) Slows loss of calcium during menopause 4) Low chromium linked to glaucoma 5) Food provides 23-29mcg/day in normal diet - Chromium deficiency is rare, pregnant and alctating women more at risk (higher needs) - Starvation, TPN without minerals at higher risk (lower intake)

Optimal Daily Calcium Requirements

1) Women - 19 to 50 y/o: 1000mg/day - >51 y/o: 1200mg/day 2) Men - 19 to 70 y/o: 1000mg/day - >71 y/o: 1200mg/day 3) Young Adults (9-18y/o) - 1300mg/day

Zinc Dosing in Disease

1) Zinc supplements have been used in: - Common cold, sickle cell, osteoporosis, wound healing, abnormal growth 10-15mg/day 2) Abnormal taste: 25mg/day 3) Macular degeneration 80mg/day - Macular degeneration is slowed by zinc 80mg, copper 2mg, lutein 10mg, zeaxanthin 2mg, vitamin E 400IU, vitamin C 500mg - No extra benefit in macular degeneration from omega-3 or beta-carotene