Principles of Nutritional Assessment Audis Bethea, Pharm.D. Assistant Professor Therapeutics I. December 5 & 9, 2003

Transcription

1 Principles of Nutritional Assessment Audis Bethea, Pharm.D. Assistant Professor Therapeutics I December 5 & 9, 2003 Required Reading Teasley-Strausburg KM, Anderson JD. Assessment of nutrition status and nutrition requirements. Dipiro JT, Talbert RL, Yee CG, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 4 th ed. Appleton and Lange, Stamford, Connecticut, ; Chessman KH, Anderson JK. Pediatric and geriatric nutrition support. Dipiro JT, Talbert RL, Yee CG, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 4 th ed. Appleton and Lange, Stamford, Connecticut, ; Objectives 1. Demonstrate the significance of malnutrition as it relates to patient outcome. 2. Review the effects of malnutrition on the anatomy and physiologic function of the major organ systems. 3. Differentiate between marasmus and kwashiorkor in terms of etiology, laboratory parameters, and physical characteristics. 4. List physical features suggestive of malnutrition. 5. Identify important parameters to consider in the evaluation of a patient s actual body weight (ABW). 6. Calculate ideal body weight (IBW) and identify patient populations in which it is used to assess a patient s nutritional status. 7. Define the differences between albumin, prealbumin, transferrin in terms of biological half-life, serum measurements, and their usefulness in assessing nutritional status. 8. Review the use of nitrogen balance in nutritional assessment. 9. Utilize various assessment methods to evaluate a patient s nutritional status. 1

2 Significance of nutritional assessment Nutritional assessment is the first step in the treatment of malnutrition. An optimal scheme of nutritional assessment enables the clinician to quickly detect the presence of malnutrition and provides guidelines for nutritional therapy. Although advanced cases of malnutrition are often obvious to inspection, nutritional assessment provides an objective characterization for the detection of premorbid states. (Blackburn, 1977) Goal of nutrition support 1. Promote positive clinical outcomes due to an illness and/or improve a patient s quality of life Malnutrition 1. Significance a. Morbidity and mortality (M & M) i. Changes in weight reflecting significant loss of body mass have been shown to correlate with an increased risk in M & M Time Significant wt. loss (%) Severe wt. loss (%) 1 week 1-2 > 2 1 month 5 > 5 3 months 7.5 > months 10 > Risk factors a. Underlying disease states b. Altered dietary intake c. Altered nutrient metabolism/absorption enzyme deficiency, short gut syndrome, critical illness, inflammatory bowel disease, etc d. Socioeconomic factors 3. Clinical manifestations a. Impaired cellular immunity b. Impaired wound healing due to deficiency in arginine, copper, vitamin C, vitamin A, zinc, and protein c. End organ dysfunction 2

3 Organ Anatomical changes Physiologic changes Lung Heart Emphysematous changes, pulmonary infarcts, muscle atrophy, reduced bacterial clearance Dilation of chambers, myocardial degeneration w/ necrosis and fibrosis, disruption of myofibrils Pneumonia, decreased pulmonary functional capacity, depressed hypoxic/hypocarbic drives QT prolongation, bradycardia, decreased contractility and CO, preload intolerance, decreased responsiveness to drugs Hematologic system Stem cell failure, decreased chemotaxis Anemia, increased cardiac workload Kidneys Cortical calcification, epithelial swelling, depressed Reduced GFR, polyuria, metabolic acidosis erythropoietin synthesis GI Atrophic changes, decreased mucosal height/secretion Suppressed enzymatic activity, decreased transit time, bacterial overgrowth, impaired motility, malabsorption/digestion Liver Atrophy, fat accumulation Decreased protein synthesis, depressed hepatocellular metabolism and synthetic function Terminology of malnourishment Deficiency states (3 types) 1. Kwashiorkor a. Rapidly developing condition in response to metabolic stress, i.e. burns, trauma, critical illness (catabolic state) b. Adequate calorie intake w/ relative protein deficiency c. Characterized by a depletion of visceral proteins (albumin/transferrin) and preservation of adipose tissue d. Hypoalbuminemia often results in edema and impaired immune function e. Patients may remain normal in appearance with the exception of edema 2. Marasmus a. Chronic condition b. Deficiency in intake and/or utilization of nutrients c. Reduction and wasting of somatic proteins (skeletal muscle) and adipose tissue (fat stores) d. Visceral proteins are preserved (albumin/transferring) e. > 10% loss of total body weight f. Impaired functioning of the musculoskeletal and immune system g. Patients appear thin and cachetic 3. Mixed marasmus-kwashiorkor a. Associated with chronically ill, metabolically stressed patients b. Characterized by wasting of somatic proteins, adipose tissue and decreased synthesis of visceral proteins c. Patients are immunocompromised and have poor wound healing 3

4 Nutritional assessment 1. History Social Medical/Surgical Dietary Income Surgical procedures Ingested nutrients Living situation Chronic disease Food/drug interactions Religious/cultural limitations Sensory systems Alcohol/drug abuse Activity level Altered metabolic needs Food allergies/intolerance Genetic disorders Anorexia and associated disorders Endocrine disorders Dietary supplements/herbal medications 2. Physical exam General Skin / mucous membranes Musculoskeletal Neurologic Hepatic Ascites / edema Decubitus ulcers Retarded growth Ataxia Jaundice Obesity Dermatitis Bone pain/tenderness Nystagmus Hepatomegaly Cachexia Ecchymoses Muscle atrophy Encephalopathy Loss of SQ tissue Poorly healing wounds Paralysis Alopeica Poor skin turgor Night blindness Anthropometrics 1. Height a. Primarily affected by chronic malnutrition, genetics and endocrine disorders (growth hormone deficiency) 2. Weight a. Representation of body fat, skeletal mass, and lean body mass b. Lean body mass or Ideal body weight (IBW) population standard based on height that correlates with maximum longevity i. Males: IBW (kg) = 50 + (2.3 x # inches over 5 feet) Females: IBW (kg) = 45 + (2.3 x # inches over 5 feet) c. Recent weight changes i. Time period of gain/loss ii. Unintentional vs. intentional iii. Amount of gain/loss Overnutrition 200% IBW = Morbidly obese 150% IBW = Obese 120% IBW = Overweight % IBW = Normal 4

5 Under nutrition (Malnutrition) % of IBW = Weight x 100 IBW 80-90% = Mild malnutrition 70-79% = Moderate malnutrition 0-69% = Severe malnutrition % of recent wt. changes = Usual wt. curr wt. x 100 Usual wt. Rules for Nutrition Calculations 1. If actual weight is > 120% of IBW, use adjusted IBW 2. If actual weight < IBW, use actual weight IBW adj = [(Actual wt. IBW) x 0.3] + IBW 3. Populations in which IBW must be used with caution a. Amputees b. Patients with ascites or edema c. Obesity d. Elderly e. Patients shorter than 5 ft. tall Body Mass Index 1. Additional method to categorize obesity and malnutrition by comparing weight to height in adults years of age. 2. BMI = Weight (kg) OR Weight (lb) x 703 Height 2 (m 2 ) Height 2 (in 2 ) 3. Populations in which BMI must be used with caution a. Geriatric patients BMI increases with age (Avg. BMI for 65 y.o. = 27 kg/m 2 ) b. BMI in muscular patient may overestimate total percentage of body fat 5

6 BMI < 18.5 kg/m 2 underweight, malnutrition = kg/m 2 normal, lowest risk of death = kg/m 2 overweight, excessive nutrition = kg/m 2 Class I obesity = kg/m 2 Class 2 obesity = 40 kg/m 2 Class 3 obesity Estimation of adipose stores (subcutaneous fat) 1. Greater than ½ of total body fat is subcutaneous a. Mid-arm skinfold thickness triceps skinfold thickness (TSF) b. Mid-arm muscle circumference measured circumference of the mid-arm 2. Both values are measured, calculated and compared with population-based standards 3. Limitations a. Standards do not account for variations in bone size, large muscle mass, or hydration status b. Standards do not account for obesity, ethnicity, age, or illness c. Technique may cause up to 30% variability in measurements d. Measured parameters are slow to change e. Measurements may vary between dominant vs. non-dominant sides of the body Laboratory and biochemical assessments 1. Visceral proteins a. Albumin (Alb) reference range g/dl i. Function transport molecule, plasma oncotic pressure ii. Half-life 20 days iii. Large body pool size (4-5 g/kg) and large extravascular distribution iv. Advantages: 1. Low levels correlate with chronic malnutrition 2. Provides a baseline marker of nutritional status 3. Commonly used laboratory test 6

7 v. Disadvantages: 1. Long half-life 2. Affected by comorbid diseases hepatic disease, renal disease, infection, fluid status, caloric and zinc deficiency Causes of Hyperalbuminemia Dehydration Steroid use Anabolism Hyperinsulinemia Causes of Hypoalbuminemia Poor protein intake Overhydration, edema Renal insufficiency / nephritic syndrome Cirrhosis Impaired digestion b. Transferrin (Tfn) reference range ( mg/dl) i. Function Binds and transports ferric iron to the liver for storage ii. Half-life 8 days iii. Smaller body pool size (100 mg/kg) vs. albumin iv. Advantages: 1. Reflective of acute protein deficiency due to relatively short half-life and small body pool 2. Commonly used laboratory test; can be calculated using Total Iron Binding Capacity (TIBC) a. TIBC reference range = mcg/dl Tfn = (TIBC x 0.8) - 43 v. Disadvantages: 1. Affected by comorbid states critical illness, hydration status, and iron stores Causes of low transferring levels Iron deficiency Pregnancy Hypoxia Chronic blood loss Causes of high transferring levels Cirrhosis Renal insufficiency / Nephrotic syndrome Steroids Chronic / critical illness c. Prealbumin (transthyretin) reference range (20-40 mg/dl) i. Function Transports thyroxine and retinol-binding protein ii. Half-life 1-2 days iii. Small total body pool size (10 mg/kg) vs. albumin and transferring 7

8 iv. Advantages: 1. Most useful of all parameters in detecting short-term effects of nutritional changes 2. Reflective of nutritional changes within 3 days of altered nutrient intake v. Disadvantages: 1. Rapidly declines in response to acute stress or illness Causes of low prealbumin levels Renal dysfunction Causes of high prealbumin levels Cirrhosis Critical illness Hyperthyroidism d. Creatinine-Height Index (CHI) i. Comparison of 24-hour creatinine measurement vs. the expected excretion by a healthy gender-matched individual of similar height and weight 1. Indirect measure of muscle mass vs. predicted value Predicted Creatinine excretion: M: 23 mg Cr/kg/d F: 18 mg Cr/kg/d CHI = actual 14-hr Cr excretion x 100 Predicted 24-hr Cr excretion Mild depletion 80% Moderate depletion 60-80% Severe depletion < 60% ii. Questionable clinical utility due to inability to account for effects of impaired renal function, hydration status, age, and protein intake 2. Immunologic markers Nonspecific markers of nutritional status 8

9 Non-nutritional factors affecting Immunologic profile Malignancy Chronic disease Critical illness Drugs Immunocompromised states a. Total lymphocyte count (TLC) i. Reflective of total number of circulating lymphocytes TLC (cells/mm 3 ) = WBC (cells/mm 3 ) x (%lymphocytes/100) Mild depletion Moderate depletion Severe depletion < 800 ii. Affected by immunosuppressive agents and critical illness b. Delayed cutaneous hypersensitivity (skin test) i. Evaluates cellular immunity ii. Antigen injected under skin No response = anergy correlating to malnutrition iii. Skin tests Candida albicans, mumps, PPD iv. No longer used as an assessment of nutritional status due to propensity to cause scarring at the injection site 3. Nitrogen balance a. Theory: N balance = N intake N output N intake protein intake (g) / 6.25 * N output 24 hr UUN + 4g ** *6.25g protein provides 1g N in a standard diet **Standard fudge factor for normal losses. (Losses may be increased patients with fistulae, ostomies, large stool output, burns in such cases N losses in the drainage should be measured) b. Interpretation: N balance (value) Nutritional state 0 Healthy, normal > 0 Anabolic < 0 Catabolic 9

10 c. Advantages: i. Allows for baseline assessment of patient s metabolic state ii. Provides means for acute assessment of nutritional supplementation. d. Disadvantages: i. Potential for unmeasured losses ii. Requires 24 hour urine collection iii. Unclear relationship to caloric intake iv. Requires adjustment for changing BUN 1. in BUN of 10 mg/dl, subtract 2.3g N from intake 2. in BUN of 10 mg/dl, add 2.3g N to intake 10

11 Assessment of Nutritional Requirements Audis Bethea, Pharm.D. Assistant Professor Therapeutics I December 5 & 9, 2003 Required reading Teasley-Strausburg KM, Anderson JD. Assessment of nutrition status and nutrition requirements. Dipiro JT, Talbert RL, Yee CG, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 4 th ed. Appleton and Lange, Stamford, Connecticut, ; Chessman KH, Anderson JK. Pediatric and geriatric nutrition support. Dipiro JT, Talbert RL, Yee CG, et al., eds. Pharmacotherapy: A Pathophysiologic Approach, 4 th ed. Appleton and Lange, Stamford, Connecticut, ; Objectives 1. Review the requirements for energy and protein as provided in recommended daily allowances (RDAs). 2. Demonstrate the ability to calculate basal energy expenditure for a given patient. 3. Identify substrate utilization patterns using respiratory quotient (RQ) values. 4. Identify the significance of the ratio of non-protein calories to protein calories when providing nutritional supplementation. 5. Review protein, fat, and carbohydrate requirements for patients given various clinical conditions. 6. Define principles governing vitamin supplementation and identify symptoms of deficiency. 7. Characterize the physiologic function of various trace elements and symptoms of deficiency. 11

12 Nutritional requirements 1. Nutritional requirements vary with age, size, gender, physical activity, disease state, and clinical condition 2. Assessments of nutritional requirements must be made by applying available guidelines to patient-specific factors 3. Recommended daily allowances (RDAs) general reference developed by the FDA indicating the levels of intake of essential nutrients that are judged to be adequate to meet the known nutrient needs of practically all healthy persons 4. Recommended values are set 2 standard deviations above the mean so that 2/3 of intake would be sufficient 5. RDAs see Appendix 1 Energy and protein recommendations 1. Energy allowances: Men: Women: kcal/day kcal/day a. Factors influencing energy requirements and expenditure i. Physical activity ii. Stress / illness iii. Basal metabolic expenditure iv. Environment v. Maintenance vs. anabolism vs. catabolism 2. Energy requirements determined by: a. Basal metabolic rate (BMR) b. Energy expenditure rate of activity (EEA) c. Specific dynamic/thermic action of food (SDA) Total daily requirement (TDR) = BMR + EEA + SDA 12

13 Terminology describing energy requirements Term Characteristics Basal metabolic rate (BMR) At complete rest Basal energy expenditure (BEE) Shortly after awakening; considers physiologic functions only; varies with age, body size, and sex Resting metabolic rate (RMR) BMR plus increases that occur after awakening Resting energy expenditure (REE) At rest with minimal activity; approx. 10% greater than BMR Total energy expenditure (TEE) Total energy required per day; including: BMR, activity, disease related increases in energy demands, effects of starvation 3. Daily energy requirements calculations a. Weight-based methods i. Simplest method ii. Population based estimations iii. Do not account for differences in energy expenditure due to age and gender Metabolic expenditure Total kcal/kg/day Non-protein calories (NPC/kg/day) Healthy, maintenance Mild stress, malnourished Hypermetabolic, critically ill Major Burn injury b. Harrison-Benedict equation (HBE) i. Considered to be a more accurate assessment vs. weightbased methods ii. Incorporates height, age, gender, and clinical condition of patient iii. Calculates basal energy expenditure (BEE) energy required to perform basic physiologic processes such as breathing, metabolic processes, and circulating blood iv. BEE is modified (multiplied) by factor representative of a patients clinical condition (stress factor) Patients < 60 years old BEE (male) = (wt) + 5 (ht) 6.8 (age) BEE (female) = (wt) (ht) 4.7 (age) -weight = weight in kilograms (may be actual or ideal body weight), height = height in centimeters, age = age in years 13

14 Patients > 60 years old BEE (males) = (8.8 x wt * ) + (1128 x ht ** ) 1071 BEE (females) = (9.2 x wt * ) + (637 x ht ** ) 302 *Always use actual weight **Height in meters Stress factors used to modify BEE to determine adult energy requirements Clinical condition Increase above BEE Activity factors Paralyzed, sedated 1.0 Confined to bed 1.2 Out of bed 1.3 Stress factors Mild moderate (maintenance, minor surgery) Moderate severe (infection, surgery, multiple trauma) Severe (burns) c. Indirect calorimetry i. Most accurate method for estimating energy requirements ii. Measures actual REE and provides information on substrate utilization iii. Represents energy expenditure at the point in time the test is performed and is extrapolated to represent a 24 hour period of energy requirements iv. Uses measurement of oxygen and carbon dioxide content in expired air Metabolic expenditure REE = [(3.9 x VO 2 ) + (1.1 x VCO 2 )] x 1.44 VO 2 VCO 2 REE = oxygen consumption (ml/min) = carbon dioxide production (ml/min) = kcal/day Determination of energy requirements via indirect calorimetry Baseline status Energy requirements Maintenance (wt % IBW) x REE Repletion (wt < 90%) x REE Depletion < 1.0 x REE 14

15 d. Respiratory quotient (substrate utilization ) RQ allows nutrient administration to be tailored to meet patient needs RQ = VO 2 = CO 2 produced VCO 2 O 2 produced *On a Kcal per Kcal basis carbohydrates (CHO) produce 21% more CO 2 than fat RQ values and interpretation RQ value Substrate utilization < 0.7 Ketogenic diet, fat gluconeogenesis, ethanol oxidation 0.71 Fat oxidation 0.82 Protein oxidation 0.85 Mixed substrate oxidation 1.0 CHO oxidation Lipogenesis or patient hyperventilation <0.67 or >1.3 Invalid test result *values >1.0 are associated with hyperventilation or over supplementation Protein Utilization 1. Adult protein requirements are based on baseline nutritional status, clinical condition, and concomitant disease states a. Unlike energy requirements protein requirements do not decrease with age b. Metabolism of protein is dependent upon kidney and liver function c. Critical illness results in a hypermetabolic state resulting in elevated protein requirements Clinical condition Healthy, maintenance Mild moderate stress Moderate severe stress Renal failure No dialysis Dialysis Cirrhosis Anabolic (repletion) Daily requirements g/kg/d g/kg/d g/kg/d g/kg/d g/kg/d g/kg/d g/kg/d 15

16 Optimizing protein utilization 1. Protein should be used for maintenance of physiologic structure and function NOT FOR ENERGY a. Tissues require glucose for metabolic function b. Sufficient non-protein calories (NPC) must be provided to minimize the conversion of protein into glucose c. Minimum amount of glucose required to prevent gluconeogenesis Brain 120 g/d Blood g/d Wound tissue g/d d. Minimum amount of glucose required per day to maintain basal metabolic function and prevent protein degradation 200g e. Stressors (critical illness, trauma, etc.) promote increased protein utilization f. Supplementation of protein may be limited in patients with renal dysfunction and cirrhosis Non-protein to protein calorie ratio (NPC:N) NPC:N = fat calories + CHO calories protein (g) 6.25 Desired NPC:N ratio Maintenance 150:1 Stress :1 Fat requirements 1. Fats (lipids) are required to provide essential fatty acids a. Essential fatty acids are involved in the formation of cell membranes, prostaglandins, immune mediators i. Omega-6 fatty acids (Linoleic acid) ii. Omega-3 fatty acids (Linolenic acid) 16

17 Fluid and electrolyte requirements 1. Fluids Holliday-Segar method 1500 ml + 20 ml/kg/d (each kg > 20) OR ml/kg/d a. Increased fluid supplementation may be required in patients with increased sensible losses (excessive sweating, fever, vomiting, diarrhea, high-output fistula) 2. Electrolytes a. Amount of supplementation is dependent upon route by which it is ingested (see Appendix 2) a. Intravenous administration 100% absorption b. Enteral administration variable absorption b. Sodium, phosphorus, potassium, and magnesium supplementation may be limited in the setting of renal dysfunction or failure c. Increased electrolyte supplementation is required for severely malnourished patients during refeeding (Refeeding Syndrome) d. Excessive fluid and electrolyte losses may influence supplementation Fluid Volume/day (ml) Na K Cl HCO3 Saliva Gastric juice Bile Illeal fluid Cecal fluid Sweat Drug induced electrolyte depletion Drug Amphotericin B Antacids Aminoglycosides Cisplatinum Cyclosporin Diuretics (thiazide) Diuretics (loop) Glucocorticoids Laxatives Electrolyte Potassium, magnesium, zinc Phosphorus Magnesium Magnesium, zinc, sodium Magnesium Potassium, magnesium, zinc Potassium, calcium, magnesium, zinc Potassium, calcium Potassium, calcium 17

18 Refeeding syndrome 1. Life threatening complication of prolonged malnutrition 2. Pathophysiologic process a. BMR and intracellular concentrations of phosphorus, potassium, and magnesium are extremely low due to prolonged malnutrition b. Refeeding promotes rapid increase in BMR c. CHO load stimulates insulin secretion which promotes an intracellular shift of electrolytes resulting in an extracellular depletion d. Extracellular depletion of electrolytes results in an inability to produce ATP which may lead to respiratory failure e. Patients at risk anorexic, chronic alcoholism, kwashiorkor, prolonged IV hydration, obese patients with massive weight loss Vitamin and trace elements 1. Vitamins a. Most people who eat a well balanced diet do not need vitamin supplementation i. Inadequate intake alcoholics, elderly, severe calorierestricted diets ii. Increased metabolic requirements severe injury, trauma, surgery, severe infection, pregnancy or lactation, burns iii. Poor absorption chronic diarrhea, GI malignancy, short bowel syndrome, biliary atresia, cystic fibrosis iv. Iatrogenic INH, laxatives, bile acid sequestrates b. Supplements that supply 100% of RDA are sufficient in most cases. i. Supplements containing > 150% of RDA are prescription only c. Vitamin classification i. Fat soluble A,D,E, and K ii. Water soluble all others Drug induced vitamin deficicency Drug Clinical effect Anticonvulsants Impaired absorption of Vitamin D and folic acid Antibiotics Vitamin K deficiency Antacids Thiamin deficiency Antineoplastics Antagonism and malabsorption of folic acid Cathartics Increased requirements of Vitamin B6, C, and D Isoniazid (INH) Vitamin B6 deficiency 18

19 Vitamin deficiencies Vitamin Niacin (B5) Folic acid Cyanocobalamin (B12) Thiamine (B1) Riboflavin (B2) Pyridoxine (B6) Pantothenic acid (B3) Biotin Vitamin C Vitamin D Vitamin E Vitamin K Clinical manifestation(s) Pellagra, dermatitis, dementia, glossitis, diarrhea, memory loss, headaches Megaloblastic anemia, diarrhea, glossitis Pernicious anemia, glossitis, spinal cord degeneration, peripheral neuropathy Parathesias, nystagmus, impaired memory, CHF, lactic acidosis, Wernicke-Korsakoff syndrome Mucositis, dermatitis, cheilosis, vascularization of cornea, photophobia, lacrimation, decreased vision, impaired wound healing, anemia, lethargy, depression, bleeding, ecchymosis Dermatitis, night blindness, keratomalacia, xerophthalmia Fatigue, malaise, headache, insomnia, vomiting, abdominal cramps Dermatitis, depression, lassitude, somnolence Enlargement and keratosis of hair follicles, impaired wound healing, anemia, lethargy, depression, bleeding, ecchymosis Dermatitis, night blindness, keratomalacia, xerophthalmia Hemolysis, bleeding Bleeding 2. Trace elements a. Serve as co-ezymes in hormonal metabolism, function, and in erythropoiesis Trace Elements *Chromium *Iodine *Selenium Gallium *Cobalt *Iron Silicon Nickel *Copper *Manganese Tin *Zinc Fluorine *Molybdenum Vanadium *Documented clinical deficiency syndrome Trace element deficiencies Trace element Clinical symptoms Chromium Glucose intolerance, peripheral neuropathy, increase free fatty acid levels, low respiratory quotient Copper Hypochromic anemia, osteoporosis, decreased hair and skin pigmentation, dermatitis, anorexia, diarrhea Iodine Hypothyroid goiter, hypothyroidism Manganese Nausea, vomiting, dermatitis, color changes in hair, hypocholesterolemia Molybdenum Tachycardia, tachypnea, altered mental status, visual changes, headache, nausea, vomiting Selenium Muscle weakness, cardiomyopathy Zinc Dermatitis, hypogeusia, alopecia, diarrhea, depression b. Elimination of trace elements i. Bile CU, Mn ii. Feces Se, Fe, Zn iii. Renal Zn, Se, Cr 19

20 c. Conditions increasing trace element requirements i. Small bowel fistulas Zn, Cr ii. Burns Zn, Fe iii. Alcoholism Zn iv. Malabsorption syndromes Zn, Cu d. Conditions decreasing trace element requirements i. Renal failure Zn, Mo, Se, Cr ii. Cholestatis Mn, Cu 20

21 1. Appendix 1 United States Recommended Dietary Allowances (RDA) Recommended Dietary Allowances: National Academy of Sciences;10th ed., 1989 Dietary Reference Intakes: National Academy of Sciences, 1997 Dietary Reference Intakes: National Academy of Sciences, 1998 Compound units/day Adult Males Adult Females Children Infants Pregnant and lactating women yr yr 4-8 Years 7-12mths Protein g Vitamin A RE* Vitamin D IU 200* 200* 200* 200* 200* Vitamin E mg alphate* Vitamin K ug Vitamin C mg Folate ug 400** 400** 200** 80* ** Thiamin(B1) mg 1.2** 1.1** 0.6** 0.3** 1.4** Riboflavin (B2) mg Niacin mg Pyridoxine (B6) mg Cyanocobalamine (B12) ug Biotin ug Pantothenic Acid mg Choline mg Calcium (Ca) mg 1000* * 1000* Phosphorus (P) mg 700** 700** 500** 275* 700** Iodine (I) ug Iron (Fe) mg Magnesium (Mg) mg * Copper (Cu) mg Zinc (Zn) mg Selenium (Se) ug

22 Chromium (Cr) ug Molybdenum (Mo) ug Manganese (Mn) mg Fluoride (F) mg 4.0* 3.0* 1.0* 0.50* 3.0* Sodium (Na) mg Chloride (Cl) mg Potassium (K) mg g = grams mg = milligrams (0.001 g) ug = micrograms ( g) IU = International Units RE = Retinol Equivalent Alpha TE = alpha Tocopherol equivalent + Generally the higher number was reported. * AI (Adequate Intake) from the new Dietary Reference Intakes, 1997: Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. Dietary Reference Intakes, 1998: Thiamin, Riboflavin, Niacin, B6, Folate, B12, Pantothenic Acid, Biotin and Choline. Values have changed from previous RDA. ** RDA (Recommended Dietary Allowance) from the new Dietary Reference Intakes, 1997: Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. Dietary Reference Intakes, 1998: Thiamin, Riboflavin, Niacin, B6, Folate, B12, Pantothenic Acid, Biotin and Choline. Values have changed from previous RDA. Numbers in black indicate 1989, 10th edition RDA values or suggested intakes, which have not been revised. Other intake levels are still being reviewed. 22

23 Appendix 2 23