NS 220 Unit 5 Seminar Vitamins and Health Brooke Benton MS, RD, LDN, CDE

Overview Vitamin Supplementation Vitamin deficiency diseases & food fortification Beneficial vitamins for specific populations Vitamin toxicities Multivitamins Today, we will discuss vitamins with specifics on supplementation, vitamin deficiency diseases & food fortification, beneficial vitamins for specific populations, vitamin toxicities, and multivitamins. According to the National Institutes of Health, annual sales of supplements to Americans are reported at about $23 billion with a substantial share of that being spent on vitamins and minerals. Today, the supplementation industry is a big business making and selling many different types of dietary supplements that have vitamins, minerals, fiber, amino acids, herbs, or hormones in them. Supplemental vitamins are common worldwide. They come in the form of pills, capsules, powders, gel tabs, extracts, or liquids. Sometimes you find them added to drinks or energy bars. They might be used to add nutrients to your diet or to prevent health problems. Since you don’t need a prescription from your doctor to buy vitamins some people may be taking megadose levels which may be toxic to the body or some people may be taking vitamins that they don’t really need. Some vitamins may be required to treat certain disease states and vitamin deficiencies. How many of you take some type of vitamin supplementation? If so, what do you take, if you don’t mind sharing?

Position of American Dietetic Assoc. To promote health and reduce risk of chronic disease, choose variety of foods. Food provides all vitamins you need. Fortified foods and supplements can help some meet their nutrition needs. According to the American Dietetic Association, the best nutritional strategy for promoting optimal health and reducing the risk of chronic disease is to wisely choose a wide variety of foods. So, you can obtain all the vitamins you need from food. Additional nutrients from fortified foods and/or supplements can help some people meet their nutritional needs as specified by the DRI’s (Dietary Reference Intakes).

What are vitamins? Essential organic substances needed daily in very small amounts to perform a specific function Essential for growth and health - an absence or deficiency of vitamins creates specific disorders Interact with other vitamins and/or nutrients to enhance absorption Can function as coenzymes Help release energy from biological reactions during metabolism but they do not provide energy Vitamins are essential organic substances needed daily in very small amounts to perform a specific function in the body. Vitamins are essential for growth and health. An absence or deficiency of vitamins creates specific disorders – we will be talking about some of these later today In the digestive process, vitamins interact with other vitamins and/or nutrients to enhance absorption. Vitamins can function as coenzymes; that is, they can work with enzymes to speed body chemical reactions. They are used up in the reactions, whereas the enzymes remain unchanged. Vitamins help release energy from biological reactions during metabolism. They do not provide energy. Vitamins are not a structural part of the body.

Vitamin Types Water-Soluble Fat-Soluble Vitamin C B Vitamins: Folate B12 Thiamin Riboflavin Niacin Biotin Pantothentic Acid Vitamin A Vitamin D Vitamin E Vitamin K Vitamins are classified into groups with regard to their solubility in either fat or water

Water Soluble Vitamins Water soluble vitamins are lost into cooking water To prevent this lose: Use only a small amount of cooking water Use leftover cooking water to make sauces Minimize cutting food into pieces Use the shortest cooking times and with the lid when possible to shorten cooking time

Water Soluble Vitamins The body does not store excess water soluble vitamins Excess are excreted in urine Supplementation does not provide extra benefits if the person is consuming an adequate amount – excess will be excreted Vitamins deficiencies usually appear only a few weeks later Vitamins need to be consumed daily

Fat Soluble Vitamins Not affected by cooking and preparation in water Can be destroyed by high cooking heat, sun drying, forms of dehydration Oxidations that accompanies rancidity in fat

Fat Soluble Vitamins Excess fat soluble vitamins are stored in body fat and organs, especially the liver Can delay deficiency for several months Need to supplement every other day instead of daily Not immune to large doses – megadoses are toxic to the body

Vitamin Deficiencies Vitamin A: may result in xerophthalmia Vitamin D: rickets and osteomalacia Vitamin K: deficiency in newborns; made in intestines by good bacteria Vitamin C: scurvy; delayed wound healing; decrease in iron absorption; capillary bleeding Thiamin: beriberi; heavy alcohol consumption can lead to poor absorption of thiamin These are some of the vitamin deficiency diseases. Vitamin A deficiency may result in xerophthalmia (final question). Vitamin D deficiency= Rickets and Osteomalacia Vitamin K deficiency= newborns are born deficient in vitamin K so a shot of vitamin K is given at birth; vit K is synthesized in the intestines by good bacteria and at birth newborns have not yet produced the good bacteria and vit K, so supplement is required (final questions). Vitamin C: scurvy; delayed wound healing; decrease in iron absorption; capillary bleeding (final question). Thiamin: beriberi; heavy alcohol consumption can lead to poor absorption of thiamin Vitamin deficiency diseases such as scurvy (deficiency of vitamin C) and rickets (vitamin D deficiency) and many others are all linked to health conditions, but these diseases have mostly been eradicated with the fortification of many food items. Now, the focus of vitamins has shifted from nutrient deficiency diseases to chronic disease prevention.

Dietary Guidelines Nutrients consumed should come primarily from food. Beneficial Vitamins for Specific Populations: Which populations?? According to the Dietary Guidelines, there are Beneficial Vitamins for Specific Populations: certain vitamins that may benefit certain populations of people. The Dietary Guidelines promote health and reducing the risk of chronic diseases through diet and exercise. So, according to the Dietary Guidelines for Americans, nutrients consumed should come primarily from foods since foods contain not only the vitamins and minerals that are often found in supplements, but also hundreds of naturally occurring substances, including carotenoids and flavonoids that may protect against chronic health conditions. There are specific instances when supplements may be useful. What type of instances would a vitamin supplement be useful? Supplements may be useful when they fill a specific identified nutrient gap that cannot or is not otherwise being met by the individual’s food intake. Supplements are not a substitute for a healthy diet. Let’s review a few vitamins that may be beneficial for specific populations of people.

Women and Folic Acid Necessary for all women of childbearing age and women who are pregnant. Reduces the risk of neural tube defects and Spina Bifida. Food fortification & food sources (green leafy vegetables) RDA: 400 mcg (adults/women childbearing age); 600 mcg (pregnancy) Folate is the natural form of the vitamin and folic acid is the synthetic form that is found in supplements and added to fortified foods. One of the functions of folate is that it helps produce and maintain new cells, so this is especially important during periods of rapid cell growth such as during pregnancy and infancy. Do you know why folic acid is so important for women of childbearing age as well as pregnant women? Folic acid is one of the necessary vitamins for all women of child bearing age and women who are pregnant since folic acid reduces the risk of the neural tube defects and spina bifida. This is when the neural tube doesn’t close all the way & results in an incompletely formed spinal cord. Now, the incidence of spina bifida can be decreased up to 70 percent when daily folic acid supplements are taken prior to conception. To help reduce the incidence of neural tube defects, the FDA in 1998 required the addition of folic acid to breads, cereals, flours, pastas, rice, and other grain products. These products have become an important source of folic acid in the US and most people are consuming the recommended amounts of folate because of this. RDA: For women who are of child bearing age who may or could become pregnant, a daily intake of 400 μg/day of synthetic folic acid (from fortified foods or supplements in addition to food forms of folate from a varied diet) is recommended. Pregnant women should consume a higher amount of 600 μg/day of synthetic folic acid (from fortified foods or supplements) in addition to food forms of folate from a varied diet. CDC Podcast: http://www2a.cdc.gov/podcasts/player.asp?f=7552

Special Groups & Vitamin D Fat-soluble; obtain from food and sun Sun source activated in liver & kidney Deficiency diseases: Rickets & Osteomalacia Food sources: fortified milk most reliable source High risk of deficiency: Breastfed infants Older adults Limited sun exposure Individuals with dark skin A fat-soluble vitamin that is naturally present in only a few foods, is added to some foods, and can be produced in the body from exposure to the sun. Adequate vitamin D status is important for optimal calcium absorption, and it can reduce the risk for bone loss leading to osteoporosis. Both calcium and vitamin D in combination help to prevent rickets (final question) in kids and osteomalacia (soft bones resulting in bone pain and muscle weakness) in adults. (Rickets: http://familydoctor.org/online/famdocen/home/children/parents/special/bone/902.printerview.html) Which food sources contain vitamin D? Food sources: very few foods naturally contain vitamin D…fish (salmon, tuna, mackerel; cod liver oil). Fortified foods consist of milk (100 IU/cup; fortified to prevent rickets), cereals, some orange juice, yogurts, and margarines. The sun source of vitamin D is produced by sun exposure to the skin that is then converted to the active form of vitamin D in the body. Season, geographic latitude, time of day, cloud coverage, smog, and sunscreen >SPF of 8 are all factors that affect vitamin D synthesis. A latitude north of Boston is insufficient for vitamin D synthesis from November through February. Cloud coverage reduces UV energy by 50% and shale reduces it by 60%. Exposure to sunshine through a window does not produce vitamin D. Optimal amount of sun exposure is 5-30 mins b/t 10 am – 3 pm at least 2x/week w/o sunscreen…this amount can lead to sufficient vitamin D production. What do you think some of the limitations may be to obtaining adequate vitamin D intake and production from the sun? Obtaining sufficient vitamin D from food sources can be difficult as well as adequate sun exposure (less in winter months vs. summer in some climates). What groups of people might be at risk or insufficient vitamin D? Breastfed infants: breastmilk alone does not provide adequate vitamin D (supplement with 400 IU per day). Older Adults (ages 50 and over) are at risk because as people get older their skin cannot synthesize vitamin D as efficiently so housebound individuals and nursing home residents are at risk and they also get limited sun exposure as well. Jail; daycare People living in northern climates Individuals with dark skin because the pigment reduces the skin’s ability to produce vitamin D from the sun Milk allergy/lactose intolerance Fat malabsorption: fat-soluble vitamins require dietary fat in the gut for absorption; fat malabsorption conditions include Crohn’s disease, cystic fibrosis, celiac disease, surgical removal of part of the stomach or intestines, and some forms of liver disease. Obesity: does not affect the skin’s capacity to synthesize vitamin D, but the greater amount of fat sequesters more of the vitamin and alter it’s release into the circulation. For individuals within the high risk groups, substantially higher daily intakes of vitamin D, up to 1,000 International Units (IU) of vitamin D per day has been recommended to reach and maintain serum vitamin D values. Three cups of vitamin D fortified milk (7.5 μg or 300 IU), 1 cup of vitamin D fortified orange juice (2.5 μg or 100 IU), and 15 μg (600 IU) of supplemental vitamin D would provide 25 μg (1,000 IU) of vitamin D daily. AI: current levels are 200 IU (birth to 50 yo + pregnancy/lactation); 400 IU (adults 51-70 yo); 600 IU (71+ yo). Recent increase recommendation by American Academy of Pediatrics (2008) for infants/children/adolescents to 400 IU per day. A lot of researchers think the recommended levels for vitamin D are too low due to recent research results and an increased incidence of vitamin D deficiency, so these levels are currently being reviewed by the IOM. Look for new recommended levels in the next year or two. Toxicities are more likely to occur from high intakes of supplements; excessive sun exposure does not result in toxicity because the sustained heat on the skin is thought to degrade it.  

People >50 & Vitamin B12 Most adults meeting recommended amounts Deficiency most likely to occur as a result of an inability to absorb B12 from food. B12 needs stomach acid & Intrinsic Factor to be absorbed; less gastric secretions over age 50, so decrease in absorption. Recommend for >50 years old to eat fortified B12 foods or take supplement. Natural source B12 only in animal foods. Most children and adults are consuming the recommended amounts of vitamin B12, however a deficiency is most likely to occur as a result of an inability to absorb B12 from food. HCL in stomach releases B12 in foods during digestion. Once released, B12 combines with intrinsic factor (secreted by gastric cells) and is then absorbed in the GI tract. There is a substantial proportion (~30%) of individuals over age 50 that have decreased gastric acid secretions, so they are unable to absorb vitamin B12 from food (naturally occurring). They are, however able to absorb the synthetic form of B12 that is added to fortified foods and vitamins. Thus, all individuals over the age of 50 should be encouraged to meet their Recommended Dietary Allowance (RDA) (2.4 μg/day) for vitamin B12 by eating foods fortified with vitamin B12 such as fortified cereals, or by taking vitamin B12 in the form of a supplement. Only natural source of B12 comes from animal foods…who might be at risk of B12 defic?

Toxicities >100% of RDA could be harmful to health for specific vitamins, esp from supplements. Fat-soluble more risk of toxicity than water- soluble. Vit. A toxicity more likely from high dosage vit A supplements. UL’s established. Some people might think that if a little is good, a lot must be better. But, that doesn’t necessarily apply to vitamins and minerals. Depending on the supplement, your age, and your health, taking more than 100% DV could be harmful to your health. So, more is not necessarily better with supplements, especially the fat-soluble vitamins. Fat-soluble vitamins have a higher potential for toxicity due to their capability to accumulate in the body whereas water-soluble vitamins are excreted in the urine if excess amounts are consumed. Which fat-soluble vitamins are more likely to be toxic? Vit. A toxicity more likely from high dosage vit A supplements (final question). High storage levels of vitamin A can lead to toxic symptoms which are birth defects, liver abnormalities, reduced bone mineral density that may result in osteoporosis and central nervous system disorders. . Vitamin D toxicity can lead to high blood calcium levels and even kidney damage. UL’s are established for some vits/mins that should not be exceeded per day. There is more of a risk if someone is supplementing with vitamins and consuming a high amount of fortified foods. For example, a supplement of vitamin A intake of 100% DV (Daily Value) means the supplement is giving you the full amount of vitamin A you need each day. This is in addition to what you are getting from your food.

Multivitamins NIH Consensus and State-of-the-Science Conference on Multivitamin/Mineral Supplements and Chronic Disease Prevention (2006) with results indicating: There is not strong evidence for beneficial health- related effects of supplements. There is insufficient evidence to recommend either for or against the use of multivitamin/mineral supplements by the American public to prevent chronic disease. NIH State-of-the-Science Conference Statement on Multivitamin/Mineral Supplements and Chronic Disease Prevention. Ann Intern Med. 2006;145:364–371. Use of multivitamins/minerals has grown rapidly over the past several decades, and dietary supplements are now used by more than half of the adult population in the United States. What are your reasons for taking MVM supplements? POLL: Do you take a multivitamin/mineral supplement? Despite the widespread use of MVMs, we still have insufficient knowledge about the actual amount of total nutrients that Americans consume from diet and supplements. This is at least in part due to the fortification of foods with these nutrients, which adds to the effects of MVMs or single-vitamin or single-mineral supplements. With such widespread use of MVM, increasing public and medical confusion over apparently contradictory results from studies… Office of Dietary Supplements and the Office of Medical Applications of Research of the National Institutes of Health convened a State-of-the-Science Conference on Multivitamin/Mineral Supplements and Chronic Disease Prevention, (May 15-17, 2006) in Bethesda, Maryland. The goal of the conference was to assess the evidence available on MVM use and outcomes for chronic disease prevention in the generally healthy population of adults and to make recommendations for future research. Most of the studies they examined did not provide strong evidence for beneficial health-related effects of supplements taken singly, in pairs, or in combinations of three or more. Within some studies or subgroups of the study populations, there is encouraging evidence of health benefits, such as increased bone mineral density and decreased fractures in postmenopausal women who use calcium and vitamin D supplements. However, several other studies also provide disturbing evidence of risk, such as increased lung cancer risk with β-carotene use among smokers. The concensus concluded that the present evidence is insufficient to recommend either for or against the use of MVMs by the American public to prevent chronic disease. There may be some cases where specific vitamins or even a MVI may be warranted. The may be in cases of: Health conditions such as malabsorption syndromes, celiac disease Unbalanced diet such as typically in the cases of chronic alcoholics and possibly older adults Pregnant or breastfeeding Anorexia Nervosa or very low calorie intake Historically, fortification of foods has led to the remediation of vitamin and mineral deficits, but the cumulative effects of supplementation and fortification have also raised safety concerns about exceeding upper levels. Thus, there is a national need to improve the methods of obtaining accurate and current data on the public’s total intake of these nutrients in foods and dietary supplements.

Questions???

Let’s Play Vitamin Trivia!

Vitamin Trivia Which of the following vitamins has a requirement based on the amount of carbohydrate in the diet? Riboflavin Thiamin B6 B12 Niacin Thiamin

Vitamin Trivia Which of the following vitamins may be synthesized from the amino acid tryptophan? Riboflavin Thiamin B6 B12 Niacin Niacin

Vitamin Trivia Which of the following vitamins has a deficiency that causes cracked skin around the mouth, inflamed lips, and a sore tongue? Riboflavin Thiamin B6 B12 Niacin Riboflavin

Vitamin Trivia Which of the following vitamins helps change one amino acid into another? Riboflavin Thiamin B6 B12 Niacin B6

Vitamin Trivia Which of the following vitamins is a cobalt containing vitamin needed for red blood cell formation? Riboflavin Thiamin B6 B12 Niacin B12

Vitamin Trivia True or False Synthetic vitamins are nutritionally equivalent to naturally occurring vitamins. True

Vitamin Trivia True or False Vitamin losses from fruits and vegetables can occur as a result of poor conditions of harvesting and storing. True

Vitamin Trivia True or False Natural and synthetic vitamins are used by the body the same way. True

Vitamin Trivia True or False Vitamin K is required for the synthesis of blood- clotting factors. True

Vitamin Trivia True or False B vitamins serve as co-enzymes in metabolic reactions in the body. True

Vitamin Trivia True or False There is no RDA/DRI for Vitamin K because it is produced by the body. True

Vitamin Trivia Is the following phrase true of a Water Soluble or Fat Soluble vitamin? These are excreted in urine. Water

Vitamin Trivia Is the following phrase true of a Water Soluble or Fat Soluble vitamin? These require regular consumption in the diet because storage in the body is minimal. Water

Vitamin Trivia Is the following phrase true of a Water Soluble or Fat Soluble vitamin? These have deficiencies that are slow to develop. Fat

Vitamin Trivia Is the following phrase true of a Water Soluble or Fat Soluble vitamin? These include the vitamin B complex and vitamin C. Water

Vitamin Trivia Is the following phrase true of a Water Soluble or Fat Soluble vitamin? The include vitamins A, D, E, and K. Fat

Vitamin Trivia Is the following phrase true of a Water Soluble or Fat Soluble vitamin? These are stored in appreciable amounts in the body. Fat

Vitamin Trivia Which of the following food preparation methods is most likely to cause large losses of vitamins? Cooking fruits and vegetables whole and unpared Dicing fruits and vegetables into small pieced Cutting fruits and vegetables into medium, chunky pieces Cutting just before serving time B

Vitamin Trivia When cooking vegetables to conserve vitamins, which is preferred? Small amounts of water Large amounts of water No water Addition of baking soda A

Vitamin Trivia Which vegetable preparation method tends to conserve the most vitamins? Boiling Simmering Stir-frying baking C

Vitamin Trivia Excessive vitamin intake has: Not been demonstrated to be beneficial in humans Been shown to cause toxicity by some vitamins Been shown to cause increased excretion of the water-soluble vitamins All of the above D

Vitamin Trivia An important role of the water-soluble vitamins is to serve as: Enzymes Hormones Electrolytes coenzymes D

Vitamin Trivia Vitamin/mineral supplements are generally recommended for ______ because they are at higher risk for developing deficiencies? Infants Pregnant and lactating women Strict vegetarians Persons with malabsorption diseases A

Vitamin Trivia One should avoid taking vitamin pills unless especially prescribed by one’s doctor because: They are too expensive Fat-soluble vitamins are stored in the body and can build up to toxic levels Water-soluble vitamins in excess of daily requirements become toxic to the liver Edema can result from high blood levels of water soluble vitamins B

Vitamin Trivia Good food sources of thiamin include all except: Lean pork, beef, liver Citrus fruits Green leafy vegetables Sunflower and sesame seeds B

Reference Hui, Y.H. & Stanfield, P. (2010). Nutrition and Diet Therapy: Self-Instructional Approaches, 5th edition. Sudbury, Massachusetts: Jones and Bartlett Publishers