Supplementation Guidelines Research Articles

Do health visitors advise mothers about vitamin supplementation for their infants in line with government recommendations to help prevent rickets?

Increasing numbers of children are presenting with nutritional rickets. Rickets affects mainly dark-skinned infants being breastfed for prolonged periods without vitamin supplementation. The main aim of this study was to assess health visitors' (HV) knowledge of the government guidelines for vitamin supplementation for infants and children and the advice given to mothers. Questionnaires were sent to all HV in Brent, Harrow and Westminster Primary Care Trusts (PCT). Information received was collated and used to assess HV knowledge. A total of 98 (69%) questionnaires were returned from HV. Seventy-nine HV (81%) recommend vitamins for the breastfed infant at 6 months or younger, 18 of which would recommend at 1 month of age. Fifty-six HV (57%) recommend vitamins until 5 years of age. Seventy-nine HV correctly identified Asians to be at risk of developing rickets. However, only 28 and 16 HV, respectively, identified Black Africans and Black Caribbeans to be at risk. Rickets has become a national public health issue. The majority of HVs is advising vitamin supplements according to government guidelines for breastfeeding infants and the age to which children should continue vitamin supplements. However, ethnic minority groups are at increased risk of vitamin D deficiency. Consequently, greater awareness needs to be raised about the government guidelines for vitamin D supplementation for ethnic minorities to ensure all HVs are imparting consistent, correct advice to these families.

Effects of routine prophylactic supplementation with iron and folic acid on admission to hospital and mortality in preschool children in a high malaria transmission setting: community-based, randomised, placebo-controlled trial

Anaemia caused by iron deficiency is common in children younger than age 5 years in eastern Africa. However, there is concern that universal supplementation of children with iron and folic acid in areas of high malaria transmission might be harmful. We did a randomised, placebo-controlled trial, of children aged 1-35 months and living in Pemba, Zanzibar. We assigned children to daily oral supplementation with: iron (12.5 mg) and folic acid (50 mug; n=7950), iron, folic acid, and zinc (n=8120), or placebo (n=8006); children aged 1-11 months received half the dose. Our primary endpoints were all-cause mortality and admission to hospital. Analyses were by intention to treat. This study is registered as an International Standard Randomised Controlled Trial, number ISRCTN59549825. The iron and folic acid-containing groups of the trial were stopped early on Aug 19, 2003, on the recommendation of the data and safety monitoring board. To this date, 24 076 children contributed a follow-up of 25,524 child-years. Those who received iron and folic acid with or without zinc were 12% (95% CI 2-23, p=0.02) more likely to die or need treatment in hospital for an adverse event and 11% (1-23%, p=0.03) more likely to be admitted to hospital; there were also 15% (-7 to 41, p=0.19) more deaths in these groups. Routine supplementation with iron and folic acid in preschool children in a population with high rates of malaria can result in an increased risk of severe illness and death. In the presence of an active programme to detect and treat malaria and other infections, iron-deficient and anaemic children can benefit from supplementation. However, supplementation of those who are not iron deficient might be harmful. As such, current guidelines for universal supplementation with iron and folic acid should be revised.

Knowledge and use of folic acid in Croatian pregnant women—a need for health care education initiative

Adequate periconceptional folic acid (FA) intake reduces the risk of neural tube defects. There are still no official FA supplementation guidelines, FA fortification policies or larger studies of awareness regarding FA or number of planned pregnancies in Croatia. This study assesses the knowledge and practice regarding FA supplementation and reports the trends in pregnancy planning in Croatia. A total of 569 pregnant women completed an anonymous questionnaire and about 72% of them were aware of the benefits of FA. Despite 75.53% of planned pregnancies, only 14.41% of all women took FA appropriately. Croatian women get information about FA from the media, health professionals and friends, but 63.77% got this information too late. The present study showed low percentage of appropriate FA intake despite high number of planned pregnancies in Croatia. It emphasizes the need for immediate and continuous public health education initiative about FA intake targeted to the women of childbearing age before their pregnancies have occurred.

Cortisol Levels and Corticosteroid Administration Fail to Predict Mortality in Critical Illness

Corticosteroid supplementation based on plasma cortisol measurement was reported to decrease mortality in vasopressor-dependent critical illness. Random levels or maximal increments of plasma cortisol measured after short adrenal stimulation may predict mortality independent of concurrent organ dysfunction or sex, and corticosteroid supplementation may decrease mortality in vasopressor-dependent critical illness. An observational descriptive study. Critically ill patients receiving vasopressors for treatment of hemodynamic instability. Random levels (n = 522 patients) and maximal increments (n = 282 patients) of plasma cortisol were measured after 250 microg of adrenocorticotropic hormone was administered for short stimulation tests before patients received corticosteroid supplementation. The severity of acute illness was measured by sequential organ failure assessment. Hospital mortality. The overall mortality was 24%. A random plasma cortisol level of 15 microg/dL or less was associated with lower mortality than a random plasma cortisol level greater than 15 microg/dL in men (12% vs 26%, respectively; P<.01) and women (13% vs 31%, respectively; P<.01). A maximal plasma cortisol increment of 9 microg/dL or less increased mortality as compared with an increment greater than 9 microg/dL in men (31% vs 11%, respectively; P<.01) but not in women (30% vs 29%, respectively; P = .8). Random levels and maximal increments of plasma cortisol did not influence hospital mortality predicted by the sequential organ failure assessment score. Corticosteroids were given to 244 patients (47%) without an effect on mortality (mortality rate of 27% for patients given corticosteroids vs mortality rate of 22% for patients who did not receive corticosteroids; P = .6). Corticosteroids did not influence mortality when plasma cortisol was a random level of 15 microg/dL or less (mortality rate of 14% for patients who received corticosteroids vs mortality rate of 10% for those who did not receive corticosteroids; P = .4) or when plasma cortisol was a maximal increment of 9 microg/dL or less (mortality rate of 30% for patients who received corticosteroids vs mortality rate of 31% for patients who did not receive corticosteroids; P = .9). Remote organ dysfunction and sex influenced mortality associated with cortisol levels measured in critical illness. Corticosteroid supplementation guided by arbitrary levels or increments of plasma cortisol in critical illness did not improve survival. Better guidelines for corticosteroid supplementation in critical illness should be developed to avoid potential adverse effects from unwarranted treatment.

Effects of standardized care plan on length of stay in patients undergoing laparoscopic Roux-en-Y gastric bypass for morbid obesity

tients and observed nutritional deficiencies. Methods: A survey was conducted via e-mail of ASBS surgeons who perform the DS procedure and of surgeons who attended the DS meeting of the 2004 ASBS conference in San Diego. The survey addressed nutritional guidelines given to patients, nutritional parameters measured postoperatively and nutritional deficiencies observed. Results: There were seventeen responses to the survey. Percent of the respondents recommending supplements ‘below’ RDI values were as follows: 44% recommended less than the RDI for calcium; 76% for iron; 24% for vitamins D and A (water-soluble); and 71% for vitamins E and K. More than half of respondents failed to recommend adequate fluid intake ( 64 oz) and only 29% recommended protein in amounts 80 g. Among the respondents, 27% reported vitamin D deficiencies post-DS; 18% reported vitamin A deficits; 41% low calcium; 29% low iron; and 35% protein deficiencies. Conclusions: Inadequate nutritional guidelines provided to patients undergoing the DS procedure may account for some of the nutritional deficiencies of the procedure. Standard nutritional supplementation guidelines should be developed for the DS procedure. PII: S1550-7289(05)00231-5

Nutritional Deficiencies following Bariatric Surgery: What Have We Learned?

Deficiencies in vitamins and other nutrients are common following the Roux-en-Y gastric bypass (RYGBP), biliopancreatic diversion (BPD) and biliopancreatic diversion with duodenal switch (BPDDS), and may become clinically significant if not recognized and treated with supplementation. This paper presents a review of the current literature and evidence of the most commonly deficient vitamins and minerals following weight loss surgery, including protein, iron, vitamin B12, folate, calcium, the fat-soluble vitamins (A, D, E, K), and other micronutrients. The deficiencies appear to be more substantial following malabsorptive procedures such as BPD, but occur with restrictive procedures as well. The review suggests that further studies are needed to evaluate the clinical significance of the nutritional deficiencies, and to determine guidelines for supplementation.

In vitro clearance of trace elements via continuous renal replacement therapy

Trace element loss during continuous renal replacement therapy in patients with acute renal failure has not been quantified sufficiently. Trace element loss was quantified using an in vitro model of continuous venovenous hemofiltration. Bovine blood was used for the experiment, and the plasma was analyzed for its chromium, copper, selenium, manganese, and zinc content. Two different polysulfone hemodiafilters, a low-flux F8 and high-flux F70 were used, and tested at two different ultrafiltrate flow rates of 1 L/hr and 2 L/hr, respectively. Trace element concentrations in the plasma and ultrafiltrate were analyzed using inductively coupled plasma mass spectrometry. The sieving coefficient and clearance of each trace element were calculated and compared between the two hemodiafilters. In vitro bovine model of continuous venovenous hemofiltration. Not applicable. Mean sieving coefficients of both F8 and F70 hemodiafilters were similar for each trace element. Copper, chromium, manganese, selenium, and zinc all were detected in the ultrafiltrate. Estimated trace element loss using typical trace element blood concentrations and study-derived sieving coefficients suggest that daily losses of selenium are greater than what is replenished with a standard daily trace element supplement in total parenteral nutrition. These data suggest that the degree of continuous venovenous hemofiltration clearance chromium, copper, selenium, manganese, and zinc differ between elements and that selenium and copper might need to be replaced with doses that exceed typical supplementation guidelines.

Guidelines for iron supplementation in pregnancy: compliance among 431 parous Scandinavian women.

The need for iron in pregnancy is rarely met by dietary food intake alone. Therefore, guidelines on iron supplementation have been developed to ensure optimal maternal and foetal iron provision. Today, the World Health Organization recommends iron supplementation during the second half of pregnancy. Our aim was to study compliance to these guidelines among 431 parous Scandinavian women. In addition, the association between maternal socio-demographic and lifestyle factors, maternal haemoglobin (Hb) values and non-compliance was assessed. The women were interviewed about iron use at gestational weeks 25, 33 and 37 at the three Scandinavian study sites, Trondheim, Bergen and Uppsala. In all, 27% of the women used iron supplements continuously during the second half of pregnancy, hence complying with the guidelines. Further, 41% of the women reported periodical and 32% no use of iron supplementation during the second half of pregnancy. In the multivariable analyses, high Hb-concentration, living in Uppsala [OR: 3.1 (1.6-6.0)] or Bergen [OR: 4.7 (2.4-9.3)] as opposed to Trondheim, and smoking during pregnancy [OR: 2.0 (1.1-3.5)] were associated with non-compliance to guidelines. We conclude that maternal Hb values, demographic factors and smoking during pregnancy are among the factors associated with non-compliance to guidelines on iron supplementation during pregnancy.

International Discussions on Guidelines for Dietary Supplements

International Discussions on Guidelines for Dietary Supplements

Dual Diagnosis Motivational Interviewing: A modification of Motivational Interviewing for substance-abusing patients with psychotic disorders

Motivational Interviewing (MI) is a brief treatment approach for helping patients develop intrinsic motivation to change addictive behaviors. While initially developed to target primary substance using populations, professionals are increasingly recognizing the promise this approach has for addressing the motivational dilemmas faced by patients who have co-occurring psychiatric and psychoactive substance use disorders. Unfortunately, this recognition has not lead to a clear explication of how MI might be adopted for specific diagnostic populations of dually diagnosed patients. In this article we describe how we have applied the principles and practices of MI to patients who have psychotic disorders and co-occurring drug or alcohol use problems. Specifically, we provide two supplemental guidelines to augment basic MI principles (adopting an integrated dual diagnosis approach, accommodating cognitive impairments and disordered thinking). We present recommended modifications to primary MI skill sets (simplifying open-ended questions, refining reflective listening skills, heightening emphasis on affirmations, integrating psychiatric issues into personalized feedback and decisional balance matrices). Finally, we highlight other clinical considerations (handling psychotic exacerbation and crisis events, recommended professional qualifications) when using MI with psychotic disordered dually diagnosed patients.

Is Milk Best for Infants and Toddlers

Tower Hamlets is a deprived inner city area with a high level of ethnic minority groups, and has many nutritional problems. Iron deficiency and rickets are among the commonest seen. One of the main causes remains late or inappropriate weaning, as indicated in research carried out 15 years ago in Tower Hamlets and, as a result, an undue reliance on unmodified cow's milk, usually given in a bottle, for the first 2-3 years of life. Late weaning results in difficulties with chewing and swallowing, and as a direct consequence speech and language therapy is often needed to help overcome the problem. The danger of drinking excessive amounts of unmodified cow's milk is discussed, together with the controversies surrounding the possible long-term consequences of iron deficiency. Rickets continues to occur, and much of this stems from ignorance on the part of both parents and health professionals about current Department of Health guidelines for vitamin supplementation, and a prolonged exposure to unmodified cow's ...

REVIEW: Update on Vitamin Nutrition and Fortification in Dairy Cattle

Abstract Vitamins are essential to the health and well-being of commercial livestock and contribute to the nutritional value of animal products to humans. In the last 10 yr, a number of studies have been published in which varying levels of supplemental vitamins have been fed to dairy cattle, and the effects on health, reproduction, and overall performance were compared. In many cases, the results indicate that optimal levels of dietary vitamin supplementation exceed what have been considered minimal or adequate levels. Other studies have revealed previously unrecognized effects of certain vitamins, fed at levels above minimal requirements, on immune function, milk production, and in the alleviation of some toxicosis. The purpose of this paper is to review recent studies of the effects of vitamin supplementation on health and performance of dairy cattle and to provide supplementation guidelines to support optimal performance of dairy cattle under commercial conditions.

Parenteral selenium supplementation in extremely low birth weight infants: inadequate dosage but no correlation with hypothyroidism.

Selenium is an essential trace element, known to be important in thyroid metabolism. We speculated that parenteral selenium supplementation is inadequate in preterm infants and may contribute to the development of hypothyroidism. Serum selenium and thyroid function were evaluated on day 10 of life in extremely low birth weight infants. Selenium intake provided by parenteral nutrition was prospectively evaluated. Selenium intake was close to the recommended 2 micrograms/kg per day. Serum selenium values were 0.54 +/- 0.13 microM (mean +/- SD, n = 29). Selenium serum levels were low in 26 of 29 infants. In infants with subnormal serum selenium levels, free T4 was transiently low in 10 of 26 infants but was normal in 16 of 26 infants. No significant correlation was found between serum selenium levels and hypothyroidism. Current selenium supplementation guidelines may be inadequate in extremely low birth weight infants. However, selenium deficiency does not seem to play a major role in neonatal hypothyroidism.

An overview of state efforts to improve transfusion medicine. The New York state model.

New York State must provide effective oversight for more than 400 facilities that provide blood services, ensuring the safety of transfusion recipients. PROGRAM STRUCTURE: Oversight is based on educated, trained program staff; a council of transfusion medicine experts; regulations governing laboratories and blood banking services; proficiency testing; requirements for reporting transfusion-related errors and incidents; tracking collection, testing, and disposition of all blood; inspections; partnership with the Food and Drug Administration; and investigation of incident reports. Policy letters and guidelines (eg, umbilical cord blood, transfusion-associated infections, intraoperative blood recovery) supplement regulations. Standards are maintained through education by a responsive, proactive oversight program. Areas warranting stricter regulation or supplemental educational guidelines are identified by periodic assessment of standards of practice and review of reported information. The multifaceted oversight program contributes to efforts to improve transfusion medicine.

Methotrexate in Rheumatoid Arthritis

Methotrexate is now the disease-modifying antirheumatic drug prescribed most frequently for the treatment of rheumatoid arthritis. Methotrexate is an antifolate that inhibits methylation reactions and reactions of amino acid, purine and pyrimidine metabolism. Toxic manifestations of methotrexate administration for rheumatoid arthritis (at relatively low doses compared with those used in cancer chemotherapy) include cytopenias, gastrointestinal intolerance, liver disease, pulmonary injury, central nervous system dysfunction, skin rashes and nodulosis. Delayed wound healing and increased risk for infections with opportunistic organisms also occur. Some of these toxic manifestations respond to supplementation with folates [folic acid or folinic acid (calcium folinate)]. The folate status of patients has been shown to be impaired after prolonged treatment with methotrexate, and poor baseline folate status is an independent risk factor for subsequent toxicity. Numerous studies have now documented that folic acid, even in high doses, and moderate doses of folinic acid are beneficial in preventing methotrexate toxicity without affecting efficacy. In this article we present guidelines and rationale for monitoring methotrexate therapy, and guidelines for folate supplementation during methotrexate therapy for rheumatoid arthritis. It is our recommendation that folic acid should be empirically supplemented in all patients at the initiation of methotrexate therapy. This regimen is associated with a high benefit : risk ratio and is likely to be cost effective.

The Impact of R.D.'s Screening Ambulatory Patient Prescriptions for a Nutritional Supplement

LEARNING OUTCOME: To describe a successful model for controlling use of nutritional supplements in a hospital ambulatory care program. In an urban public teaching hospital's Ambulatory Care Center (that treats over 2000 clients daily)the use of a liquid caloric / protein nutritional supplement by MD prescription was a source of concern to the dietitians on staff, as well as hospital medical & executive staff. The reason for the concern was the misuse and frequent illegal resale of this product by clients as well as illegal exportation to Central & South America. The product, while obtainable in the retail market without a prescription, was distributed via prescription in the hospital in an effort to control quantities and efficacy. In 1996 78,000 cases were distributed. An interdisciplinary project team consisting of an MD, RN, RD and hospital Executive staff was organized to address the issue and develop a protocol. The protocol was comprised of the following steps: 1) Conversion from liquid to powdered supplement. 2) R.D.'s reviewed prescriptions (prior to filling) for client's eligibility for current state Medicaid guidelines for nutritional supplementation. 3) Prescriptions must be renewed every 30 days. 4) RD / MD signature required on letter of medical necessity needed to fill prescription. In the first 30 days of protocol, usage declined 30 for a cost saving of $14,500.00 in the first 60 days of protocol, total $ savings amounted to $64,350.00 with an annualized projected savings of over $500,000

Reply: Vitamin E Supplementation in Cystic Fibrosis

To the Editor: We are grateful for the opportunity to respond to Dr. Winklhofer-Roob's detailed critique of our article, which was, as described in our introduction, a study around normal clinical practice in the setting of a children's cystic fibrosis (CF) clinic. In our study, conducted between 1989 and 1991, we were able to exploit the fact that measurement of erythrocyte α-tocopherol levels was being undertaken before the implementation throughout our clinic population of current supplementation guidelines, affording an invaluable opportunity to study steady-state α-tocopherol concentrations at various levels of supplementation, as opposed to Dr. Winklhofer-Roob's study of short-term changes in erythrocyte α-tocopherol response to a single dose of the vitamin (1). As we state, many patients were, at the beginning of the study, receiving no supplementation, or daily Ketovite, which contains 15 mg of vitamin E, hence data for this dosage. In our experience, RRR-α-tocopherol alone is used in the United Kingdom, so the racemic form of the vitamin is not an issue in this study. Recent work has shown that the free phenol and esterified forms of α-tocopherol (α-tocopherol and α-tocopherol acetate, respectively) have similar bioavailabilities (2). As Dr. Winklhofer-Roob points out, the association between erythrocyte and tissue α-tocopherol concentrations have not been measured in patients with CF. In light of this, and as the α-tocopherol is bound in the membrane with polyunsaturated fatty acids, we believe that erythrocyte levels are more representative of tissue levels than the more commonly used plasma levels. In our article, some measurements are shown in graphic form only because, for clarity, we chose to tabulate only the most common supplementation regimens. Dr. Winklhofer-Roob attempts to comment on the numbers of subjects in each group when, unfortunately, tight clustering of α-tocopherol concentrations makes counting of subjects on the graphs impossible, particularly at 100 mg/day. As shown in Table 1, there were in fact 46 measurements at this dosage, and only 8 of these were below the reference range. Likewise, the distribution of data cannot be inferred from this graph. We appreciate Dr. Winklhofer-Roob's concerns regarding statistical validity where data from the same patient are used twice; this study gathered all available data on α-tocopherol concentrations within a population of patients receiving a variety of supplements, prescribed independently of α-tocopherol level, during a 2-year period. In no case were data for the same patient entered twice less than 1 year apart. The results of our study confirm and complement those carried out by Dr. Winklhofer-Roob in indicating that relatively large α-tocopherol supplements (100 mg/day) are required by most CF patients to normalise plasma levels (at this time we do not know about tissue levels directly). There are a number of variables that may have an impact on the response of a CF patient to a particular α-tocopherol supplement, and studies on the magnitude of these responses are currently under way in our group. Given the lack of understanding of the positive role that reactive oxygen species may play in cell metabolism, caution should be exercised before prescribing very large α-tocopherol supplements to all CF patients. Until we have this information, we recommend normalisation only. S. A. Peters; F. J. Kelly Children's Unit; St. Mary's Hospital; Portsmouth, England

Compliance with the peri-conceptional folic acid supplementation guidelines

Summary This audit of peri-conceptional folic acid use in early pregnancy demonstrates inadequacies in both awareness of and compliance with the Department of Health guidelines. If the benefits of folic acid are to be fulfilled then additional efforts to improve public awareness are required.

Guidelines for dietary supplementation of pregnant women in a Rwandan refugee camp.

Units deployed on humanitarian aid may have little experience of the most appropriate interventions which can be expected to produce the most favourable population outcomes. Guidelines produced by UNICEF and the International Dispensary Association (IDA) can be used as a basis for planning. These guidelines were previously untested in Rwanda. This report focuses on iron and folate supplementation for pregnant women suggested by the IDA. The high levels of anaemia in pregnancy would suggest that supplementation is appropriate. However, before fully embracing the full set of recommendations, further field testing would be sensible.

Advice from a teratology information service may not be enough to ensure compliance with folic acid supplementation guidelines

Advice from a teratology information service may not be enough to ensure compliance with folic acid supplementation guidelines