Guidance in the Guidelines: Looking at Your Nutritional Needs after Bariatric Surgery

Transcription

1 Guidance in the Guidelines: Looking at Your Nutritional Needs after Bariatric Surgery Presented by: Nina Crowley, PhD, RDN, LD; Christopher D. Still, DO, FACN, FACP, Cassie I. Story, RDN LET S TAKE A LOOK AT THE ASMBS NUTRITIONAL GUIDELINES NINA CROWLEY, PHD, RDN, LD MEDICAL UNIVERSITY OF SOUTH CAROLINA METABOLIC & BARIATRIC SURGERY PROGRAM COORDINATOR & REGISTERED DIETITIAN 1

2 GLOSSARY OF TERMS ASMBS American Society of Metabolic and Bariatric Surgery Educational professional medical society for bariatric surgeons and integrated health Registered Dietitian Food and nutrition experts who completed bachelors in dietetics curriculum, supervised practice dietetic internship, and passed national exam to earn the RD/RDN credential, and maintain continuing education Clinical Practice Guidelines Statements that include recommendations intended to optimize patient care that are informed by a systematic review of evidence and an assessment of the benefits and harms of alternative care options Systematic Review Critically analyzes and summarizes the results of available carefully designed studies and provides a high level of evidence on the effectiveness of healthcare interventions Grading of evidence Grade A Strong Grade B Intermediate Grade C Weak Grade D No evidence Evidence Based Practice Interdisciplinary approach to clinical practice integrating best available research evidence on treatments, clinical expertise and client preferences and values GLOSSARY OF TERMS Nutrients Macronutrients provide energy and include carbohydrate, protein and fat) & Micronutrients Micronutrients Essential nutrient as a trace mineral or vitamin that is required in minute amounts Vitamins Organic compounds required by humans in small amounts from the diet water soluble vit C, thiamin, riboflavin, niacin, vitamins B6 and B12, folate, biotin, and pantothenic acid fat soluble vitamins A, D, E, K Minerals Elements that originate in the Earth and cannot be made by living organisms Calcium, magnesium Trace: Iron, zinc, copper, chromium, selenium 2

3 HISTORY OF NUTRITION GUIDELINES FOR BARIATRIC SURGERY 2008 ASMBS (Bariatric) Allied Health Nutritional Guidelines for Surgical Weight Loss Patient 2009 AACE (Endocrine), TOS (Obesity), ASMBS (Bariatric) Medical Guidelines for the Clinical Practice for Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient 2010 Endocrine Society Clinical Practice Guideline: Endocrine/Nutritional Management of the Post Bariatric Surgery Patient 2013 AACE/TOS/ASMBS Guidelines Update 2016 ASMBS Integrated Health Nutritional Guidelines for the Surgical Weight Loss Patient 2016 Update: Micronutrients WHY ARE THERE DIFFERENCES IN RECOMMENDATIONS? Similarities Screening prior to surgery Prevention recommendations for everyone Follow up with bariatric professionals forever Check in with labs/providers annually You change, science changes, and evidence/guidelines change! Differences Individualized care based on available labwork, tolerance, personal preferences Provider experience and knowledge of guidelines Treatment or repletion based on identified deficiencies 3

4 PREOPERATIVE CLINICAL NUTRITION EVALUATION Medical Nutrition Therapy (MNT) by Registered Dietitian Nutritionist (RDN) as part of the interdisciplinary team 1. nutrition assessment 2. nutrition diagnosis 3. nutrition intervention 4. monitoring and evaluation Assessment (preop and postop screening), supplementation, and repletion of micronutrient deficiencies Optimize preoperatively Education on expected deficiencies associated with anatomy PREOP SCREENING WATER SOLUBLE B VITAMINS Vitamin B1 (thiamin) Whole blood thiamin (TDP), red blood cell (RBC) thiamin Transketolase concentration, erythrocyte transketolase activity (ETKA) activity coefficient, plasma thiamin Vitamin B12 (cobalamin) Serum vitamin B12, Serum methylmalonic acid (MMA) Homocysteine Folic acid (folate) Red blood cell (RBC) folate Homocysteine, serum MMA 4

5 PREOP SCREENING FAT SOLUBLE VITAMINS Vitamin D Vitamin D, 25 OH, serum parathyroid hormone (PTH) Serum alkaline phosphatase (Alk Phos) Vitamin A Plasma retinol Retinol binding protein Vitamin E Plasma alpha tocopherol Plasma lipids Vitamin K Prothrombin time (PT) Des gamma carboxy prothrombin (DCP), plasma phylloquinone, PREOP SCREENING MINERALS Calcium Serum parathyroid hormone (PTH), Vitamin D, 25 OH DXA scan Iron serum iron, transferrin, serum transferrin saturation (TF), total iron binding capacity (TIBC), ferritin, complete blood count (CBC) Soluble transferrin receptor (stfr) Zinc Serum zinc, plasma zinc Red blood cell (RBC) zinc Copper Serum copper, ceruloplasmin Erythrocyte superoxide dismutase, plasma copper 5

6 POSTOP SCREENING Frequency Within first 3 months (iron) Every 3 6 mo then annually (iron, B1, B12, folate, vitamin D) Annually (vitamin B1, B12, folate, vitamins ADEK, iron, zinc, copper) Type of surgery More frequent, more labs with greater intestinal manipulation (AGB<LSG<RYGBP<BPDDS) Symptoms Nausea, vomiting, cardiac failure, small bowel bacterial overgrowth (B1) Chronic use of meds exacerbating low B12 (ppi, metformin, seizure meds) (B12) Chronic diarrhea (Zinc) SUPPLEMENT RECOMMENDATIONS TO PREVENT DEFICIENCY Vitamin/Mineral Minimum to prevent deficiency Higher risk groups to prevent deficiency Vitamin B mg mg Vitamin B mcg Folate mcg mcg childbearing women Vitamin A IU IU BPDDS Vitamin D 3000 IU Vitamin E 15 mg (22 IU) Vitamin K mcg 300 mcg BPDDS Calcium mg mg BPDDS Iron 18 mg men, non menstruating women/agb mg menstruating women/sg/gbp/bpdds Zinc 8 22 mg mg BPDDS Copper 1 2 mg 2 mg GBP/BPDDS 6

7 STRONG (GRADE A) RECOMMENDATIONS Routine pre WLS Calcium/Vitamin D screening is recommended for all patients A 70 90% lower vitamin D3 bolus dose is needed (compared to vitamin D2) to achieve the same effects as those produced in healthy non bariatric surgical patients Repletion: Vitamin D3 at least 3000 IU/d and as high as 6000 IU/d, or 50,000 IU vitamin D2 1 3 times weekly Vitamin D3 is recommended as a more potent treatment than vitamin D2 when comparing frequency and amount needed for repletion. However, both forms can be efficacious, depending on the dosing regimen NEW TO YOU? Vitamin B1 increase to 12 mg (preferably mg) Vitamin B mcg for all procedures Folate increase to mcg for childbearing age women Vitamin A 5,000 10,000 mg (10,000 for BPDDS) Vitamin D 3,000 IU Both D2/D3 can replete deficiency Vitamin E 15 mg (22 IU) Vitamin K mcg (300 for DS) Calcium decrease to mg ( for BPDDS) can be taken as carbonate with meals, citrate with or without Iron increase for most to mg Zinc increase to 8 22 mg Copper increase to 1 2 mg 7

8 TAKE HOME MESSAGES Commit to yearly visit with bariatric specialist/interdisciplinary team Utilize nutrition focused physical assessment in addition to labwork Keep up to date on guidelines/research (or be sure your provider is) New guidelines support additional labwork to be checked If you stop taking something due to high levels, check next year There may be many pathways to getting in recommended nutrients Don t rely on someone checking all your labs Don t take complete at face value Your insides are not normal after surgery you need long term supplementation REFERENCES 1. ASMBS: Allied Health Nutritional Guidelines for the Surgical Weight Loss Patient (2008) 2. AACE / TOS / ASMBS Medical Guidelines for Clinical Practice for the Perioperative Nutritional, Metabolic, and Nonsurgical Support of the Bariatric Surgery Patient (2009) 3. Endocrine Society Clinical Practice Guideline: Endocrine and Nutritional Management of the Post bariatric Surgery Patient (2010) 4. AACE / TOS / ASMBS (2013 Update) 5. ASMBS Integrated Health Micronutrients (2016 Update) 8

9 Recognizing Deficiencies: Signs, Symptoms, & What Your Annual Labs Tell You Christopher D. Still, DO, FACN, FACP, FTOS Medical Director, Center for Nutrition & Weight Management Director, Geisinger Obesity Research Institute Medical Director, Employee Wellness Geisinger Health Care System Danville, Pennsylvania Vitamin and minerals at risk preoperative deficiency Vitamin D 60-70% Iron (9-16%) menstruating women Thiamine (B1) 15-30% African Americans/Hispanics B12 (cobalamin) 10-13%-vegans/lack of dietary meat, older patients, patients taking H2 blockers or PPIs Zinc 9% Schweiger C, Weiss R, et al. Nutritional deficiencies in Bariatric Surgery Candidates. Obes Surg 2010; 20: Flancbaum L, Belsley S, Drake V et al. Preoperative nutritional status of patients undergoing Roux-en-Y gastric bypass for morbid obesity. J Gastrointest Surg 2006; 2: Forrest KY, Stuhldreher WL. Prevalence and correlates of vitamin D deficiency in US adults. Nutr Res 2011; 31:48 9

10 Post operative Micronutrient Deficiencies Lower Risk Higher Risk 10

11 Post-operative Data 1. Adherence rates to directives from HCP s as patients progress from surgery¹ 2. Risk of nutrition deficiencies as patients progress from surgery² 3. Nutritional deficiencies can lead to irreversible consequences³ 1. Larjani S, et al. 2. Matrana M, et al. 3. Gletsu Miller N, et al Post- op Micronutrient Deficiencies Research shows: Nutrition related deficiencies are high data suggests nutrient deficiencies are increasing ¹ˉ⁴ Adherence to micronutrient supplementation is low⁵ˉ⁶ 10 year data found 33% adherence; 8% never taking supplements⁷ 1. Gudzune KA, et al. 2. Gehrer S, et al. 3. Bal BS, et al. 4. Peterson LA, et al. 5. Nadkarni et al 6.. Avani et al 7. Brolin, et al. 11

12 Nutrition related deficiencies may be prevented with appropriate supplementation, follow-up care, and adequate monitoring of nutrition status. ¹ˉ² 1.Pournaras D, et al 2. Saltzman E, et al Bariatric Advantage Signs, symptoms and history that may be precursor to deficiency Persistent nausea/vomiting Excessive/++ rapid weight loss Fear of eating/gaining weight combined w/suboptimal oral intake Non-compliance w/vitamin and mineral supplementation Other medical conditions that predispose to vit/mineral deficiency-renal dz, liver dz (excessive diarrhea, excessive bleeding with menses, non-healing wounds, alcoholism) Absorption interference with other medications Pregnancy Overall poor self care and compliance Others? 12

13 Most Common Deficiencies Calcium Vit D Iron Vitamin B12 Folate Zinc Selenium Copper Vitamin A Vitamin and Mineral Deficiencies Assess Signs and Symptoms Laboratory work up If labs are low normal and sign/symptoms present may need to do laboratory assessment of more sensitive markers Collaborate with PCP 13

14 Nutrient Screening Time Points X = ALL PROCEDURES Adapted from: 1. Stein et al 2. Parrot et al Nutrient Pre-op 3 mo. 6 mo. Annually Vitamin B1 X X X X Vitamin B12 X RYGB VSG BPD/DS RYGB VSG BPD/DS X Folate X X X X Vitamin A X RYGB BPD/DS X Vitamin D X X X X Vitamin K / E X X Iron X X X X Zinc X RYGB VSG BPD/DS Copper X RYGB VSG BPD/DS ipth X X X X Calcium X X X X DEXA X q 2-5 yrs Altered Absorption of Micronutrients Vitamin/Mineral Lab Monitoring BPD/DS RYGB SG LAGB Calcium Bone Density* Iron Fe panel, Ferritin, TIBC Vitamin B12 Vitamin B 12, MMA Folate RBC Folate Thiamin Serum Thiamin Vitamin D** 25-OH-Vitamin D & Serum PTH Zinc Serum or Plasma Zinc Copper Serum Copper and Ceruloplasmin Vitamin A, E, and Plasma Retinol, K Plasma Alpha Tocopherol, and Prothrombin Time (PT) *In peri or post menopausal women Aarts et al. Obes Surg. 2011; Aills, et al. SOARD, 2008; Gehrer, et al. Obes Surg. 2010; Mechanik, et al. SOARD. 2013; Moize, et al. JAND, **Often low in obese patients and should be assessed and repleted prior to surgery 14

15 Nutrition Focused Physical Assessment Hydration Status Mucous Membranes Mouth and Tongue Eyes Skin Level of consciousness Capillary refill Urine output and color of urine Labs associated with dehydration BUN, Na, Osm, BUN:Cr ratio Prolonged vomiting Nutrition Focused Physical Assessment Tongue Glossitis Atrophied papillae Dehydration Potential Deficiencies: Anemias Vitamin B12 Iron Riboflavin Niacin Tryptophan 15

16 Nutrition Focused Physical Assessment Teeth, Gums, Mouth, Lips Swollen gums (Vitamin C) Hypogeusia and / or Dysgeusia (Zinc) Angular stomatitis (Lesions/fissures) (Vitamins B2, B3, B6) Pallor, inflamed mucosa (Iron) Mouth Dermatitis (Vitamins B2, B3, B6, Folate) Cheilosis (cracks, lesions, fissures) (Vitamins B2, B3, B6, Folate) Nutrition Focused Physical Assessment Ears and Nose Acrodermatitis Enteropathica (zinc) Nasolabial Seborrhea (Vitamin B2, Vitamin A) 16

17 Nails and Hands Koilonychia or pallor Spoon-shaped nails Thin nails Vertical vs. horizontal ridges Normal aging Curved nail ends, dark nails, dry Iron or protein Iron or protein Iron Vitamin B12 Hair Alopecia Hair loss Corkscrew hairs Hair depigmentation Follicular Hyperkeratosis Scaly scalp Zinc, iron, copper, protein, biotin Vitamin C Copper Vitamins A and C, essential fatty acids 17

18 Anemias Iron, Vitamin B12, Folate, Zinc, Copper Pre-op Def. Rate Post-op Def. Rate S/S Iron 8-18% 17-45% (3mo-20 yr) Fatigue, low productivity, spoon shaped nails / vertical ridges, glossitis B12 18% 4-62% (>2 yr) Numbness / tingling fingers and toes, glossitis, fatigue, depression, dementia, gait ataxia Folic Acid 2-10% 9-38% Palpitations, fatigue, Neural Tube Defects, changes in skin pigmentation Zn Up to 30% SG: 12%; RYGB 21-33%; BPD / DS 74-91% Skin lesions, poor wound healing, hair loss, taste changes Cu ND RYGB: 2% BPD/DS: 10-24% Unsteady gait, tingling in hands / feet, poor wound healing, paralysis Stein J, et al. 18

19 Serum Markers * Cummings S, et al. # Mechanick, J. et al. ^ Bays H, et al. ~Stein J, et al. Parrot J, et al. Repletion (per day unless indicated) Iron B12 Folate Iron: <60 µg/dl (critical <50µg/dL) TIBC: >450 µg/dl Transferrin Saturation: <20% Ferritin: <20 µg/l ( H/H MCV TSAT stfr ZPP) Serum MMA >0.56 mmol/l Serum B12 (may miss 30%-50% of def) <400pg/mL suboptimal <200pg/mL deficiency Homocysteine, H/H MCV Serum Folate <340 ng/ml RBC Folate, Homocysteine H/H MCV (Normal serum MMA) mg of elemental iron to 300 mg BID-TID Oral supplementation should be taken in divided doses separately from calcium supplements, acid-reducing medications, and foods high in phytates or polyphenols. If iron deficiency does not respond to oral therapy, intravenous iron infusion should be administered. 1,000-2,000 mcg~ OR 1000 mcg / wk IM 1 mg oral until serum levels wnl Zn Plasma Zinc < 60 µg/dl RBC or WBC zinc Urinary zinc 60 mg BID until wnl ^ Cu Serum Copper: 11 µmol/l Serum Ceruloplasmin : <75µg/dL Mild Mod 3-8 mg until wnl Severe IV 2-4 mg x 6 days # Bone Disorders Vitamin D, Calcium, Magnesium (Vitamin K) 19

20 Pre-op Deficiency Rate Post-op Deficiency Rate S/S Vitamin D 25-68% 25-80% Depression, muscle pain, involuntary muscle movements, osteoporosis Calcium % ~ 10% Low bone density, osteoporosis, muscle contractions, spasms, pain Mg 35% 32% Muscle contractions, pain, spasms, osteoporosis Stein J, et al. Vitamin D Calcium Serum Markers 25 (OH)D <20ng/mL (def); 20-30ng/mL (ins) Alk Phos ipth DEXA Ionized Ca <4.48 mg / dl Alk Phos ipth DEXA Urinary N and C telopep de Urinary crosslinks type 1 collagen telopeptides (indicator of bone resorption) Repletion (per day unless indicated) 50k / wk x 8-12 weeks *^ 50k 1-3 x wk 2,000-6,000 IU / day Severe: 50k-150k / day ; calcitriol mcg /day ~ 1,200-2,000 mg~ (w/specific instruction) Bisphosphonates if T-score <2.5~ Mg Serum Mg <1.5 (1.8?) urinary Mg ND * Cummings S, et al. # Mechanick, J. et al. ^ Bays H, et al. ~Stein J, et al. Parrot, J et al. 20

21 Neuro Thiamin (Vitamin B1), B-vitamins, Essential Fatty Acids, Trace Minerals Pre-op Deficiency Rate Post-op Deficiency Rate S/S Thiamin 15-29% Up to 49% Nutrition Focused Physical Assessment: Numbness, tingling in extremities, gait ataxia, convulsions, edema, vomiting, confusion Dry Beriberi: convulsions, muscle weakness, pain of lower/ upper extremities, brisk tendon reflexes Wet Beriberi: tachycardia or bradycardia, lactic acidosis, dyspnea Neuropsychiatric: confusion, ataxia, paralysis Wernicke encephalopathy: ophthalmoplegia, ataxia, confusion, hallucinations, psychosis * Cummings S, et al. ~Stein J, et al. 21

22 Serum Markers Repletion (per day unless indicated) Thiamin Plasma Thiamin by HPLC: < 4 nmol / L Serum Thiamin (whole blood by HPLC) <80 µg/l * TPP ETKA urinary thiamin excretion RBC transketolase Lac c acid or pyruvate Oral therapy: 100 mg orally two-to -three times daily until symptoms resolve IV therapy: 200 mg, three times daily to 500 mg once or twice daily for 3-5 days followed by 250 mg/day for 3-5 days or until resolutions of symptoms, then consider treatment with 100 mg/day orally, usually indefinitely or until risk factors have been resolved IM therapy: 250 mg once daily for 3-5 days or mg monthly Note: Simultaneous administration of magnesium, potassium and phosphorus should be given in patients at risk for refeeding syndrome. * Cummings S, et al. # Mechanick, J. et al. ^ Bays H, et al. ~Stein J, et al., Parrot J, et al. Fat soluble vitamins 22

23 Pre-op Deficiency Rate Post-op Deficiency Rate S/S Vitamin A Up to 17% RYGB 8 11% BPD 61 69% Loss of nocturnal vision, itching, dry hair, xerophthalmia, decreased Immunity / poor wound healing Vitamin K Uncommon ND Easy bruising Vitamin E Uncommon ND Hyporeflexia/ weakness, gait ataxia Stein J, et al. Vitamin A Serum Markers Plasma retinol <.70 micromoles/l (20 mcg/dl) Inadequacy micromoles/l Serum vitamin A lmol/l Retinol binding protein Repletion (per day unless indicated) Without corneal changes: 10,000-25,000 IU (until clinical improvement) With corneal changes: 50, ,000 IU IM x 3 days followed by 50,000 IU IM x 2 weeks Note: evaluate for iron and/or copper deficiencies - can impair resolution of vitamin A deficiency. Vitamin K Plasma vit K DCP Acute malabsorption: parenteral dose of 10 mg Vitamin K Chronic malabsorption: either 1-2 mg/d orally or 1-2 mg/week parenterally. Vitamin E Plasma alpha tocopherol < 5 µg/ml IU * Cummings S, et al. # Mechanick, J. et al. ^ Bays H, et al. ~Stein J, et al. Parrot J, et al. 23

24 Muscle Health Pre-op Deficiency Rate Post-op Deficiency Rate S/S Protein 5% 3-18% Weakness; decreased muscle mass, brittle hair, edema Serum Markers Albumin <4.0 Pre-albumin <20 mg/dl DEXA (fat free mass)~ Protein intake at 12 months: 37 61% patients consume <60 gm / day ¹,² Pts with inadequate protein intake lost more FFM than pts with sufficient protein intake.³ 1. Andreu A, et al. 2. Verger, E, et al. 3. Moize, V, et al. 24

25 Body Comp Prevention AGB (per day) Prevention RYGB/SG (per day) Repletion (per day unless indicated) Protein mg 1.2 gm / kg IBW mg 1.2 gm /kg IBW Studies suggest higher protein levels gm more favorable on body composition. # Studies suggest that reaching 60 gm protein intake per day post operatively through food alone is challenging for most patients.¹ Studies also suggest that a relationship between poor dietary adherence (including low protein intake) are associated with inadequate weight loss 2 years after surgery.² 1. Beckman L, et al. 2. Hood, M et al. Summary Understand what type of surgery you had, or going to have, will affect nutrient absorption Know what labs you need to have checked EDUCATE your PCP on the type of surgery you had and what labs need to be check Take responsibility for your PCP to check your labs annually A birthday present to you! 50 25

26 How to Select a Supplement? Cassie I. Story, RDN Clinical Science Liaison Bariatric Advantage Private Practice Dietitian Network Director Weight Management Dietetic Practice Group of the Academy of Nutrition and Dietetics Scientific Advisor Apollo EndoSurgery Peer Reviewer Obesity Surgery Content Provider Your Weight Matters Magazine (OAC) Photo credit: 26

27 Forms, Quality, Dosing oh my! Quality Dose Dissolution Claims Timing Willingness to take! 27

28 Quality Dietary Supplement Regulation Since 1994 the FDA has regulated dietary supplements Which include: vitamins, minerals, botanicals, amino acids, enzymes, microbial probiotics, and metabolites FDA established current Good Manufacturing Practice (cgmp) regulations For companies to ensure their: identity, purity, strength, and composition 28

29 Here s the catch. The FDA is required to take action if a supplement is misbranded or adulterated products AFTER it comes to market Anyone can produce a dietary supplement and sell it There is no premarket approval it is the company's responsibility to make sure the product is safe and that its claims are true Trusted Brands Manufactured in GMP facility Third-party oversight R & D team Reputable Company 29

30 Quality does it need a seal? 1 st Ensure the company is following cgmp Companies may elect to pay for additional seals: The United States Pharmacopeia (USP) NSF International (NSF) Consumer Labs Dose How to Read the Label 30

31 What s in this thing? Complete Multivitamin? 13 essential vitamins A, C, D, E, K, B1, B2, B3, B5, B6, B7, B9, B12 Minerals Calcium, Magnesium, Phosphorous, Sodium, Potassium, Chloride, Sulfur Trace minerals Iron, Zinc, Iodine, Selenium, Copper, Manganese, Fluoride, Chromium, Molybdenum 31

32 More on Minerals Minerals are naturally bound to other substances The substance a mineral is bound to impacts its absorption (or bioavailability) Forms & Dissolution 32

33 Forms of Supplements Tablets Cost effective, higher potency, may be too large, may not break down in low acid environment Capsules Disintegrate quickly, can be opened Softgels Designed to hold liquid Chewables More expensive (cost more to produce) Lozenges Can stain teeth Powders Used for larger quantity nutrients, can add to food (high temperatures will destroy water soluble vitamins) Liquids Easy to drink, more expensive, shorter shelf-life Topicals / Patches???? NOT considered dietary supplements Is this thing working? (Tablet Edition) Place the tablet in a cup filled with 98 (ish) degree water Periodically stir the water After 30 minutes the tablet should be disintegrated 33

34 Bioavailability Ability to Absorb Form of nutrient Natural vs. synthetic Depends. Synthetic vitamin E (dl-alpha tocopherol) is half as biologically active as natural vitamin E (d-alpha tocopherol) Synthetic vitamin C is as biologically active as natural vitamin C Bioavailability Ability to Absorb Digestive Juices Stomach acid Plays a role in absorption of calcium, magnesium, iron, and B12 Reminder calcium carbonate requires stomach acid in order to be absorbed Pancreatic enzymes Needed to absorb vitamins A, D, E, K 34

35 Claims Purchase Supplements Wisely Work with a health care provider NOT google WebMD or your best friend Don t believe the headlines (most of the time) Be cautious with quick fixes Sound health advice is based on research over time More is not necessarily better Spot false claims! Quick Totally safe no side effects cures X 35

36 Timing In general. Take multivitamin and fat soluble vitamins with largest meal of the day Separate large amounts of calcium from other minerals as they compete for absorption by at least 2 hours If you have certain existing nutrient deficiencies you will need to be even more cautious with timing (ie: iron, bone disorders) 36

37 Typical Routine Ideal 1 serving high potency multivitamin (w/ iron) with breakfast Calcium citrate mid-morning Calcium citrate mid-afternoon 1 serving high potency multivitamin (w/ iron) with evening meal (If needed) calcium citrate evening Any other nutrients (ie: probiotics, fish oil, CoQ10, etc. can be taken at anytime of day / evening) Willingness to take 37

38 Dietitians Favorite Quote The best vitamin is the one you are willing to take Kind of.. Feeling better? If any confusion ask yourself: 1. Does this contradict what the majority of people are saying? 2. Does what they re claiming make sense? 3. Was there a meta-analysis? 4. How similar were the study subjects to me? 5. What nutrient was being studied? 6. How long was the study? 38

39 Take your vitamins! 39