CPhA05 Nutrition05 W

CPhA Professional Advancement
2005
Learning Series
Nutrition and Health
The Role of Vitamin and Mineral Supplements

Theresa Glanville, PDt, PhD (Nutritional Sciences)
This program has been approved for 1.5 CEUs by the Canadian Council on Continuing Education in Pharmacy CCCEP #202-1204 This lesson is valid until December 31, 2007
This lesson has been sponsored with an unrestricted educational grant from
EP
Suggested retail price: $15 plus GST for CPhA members, $25 plus GST for non-members. This lesson is available from the CPhA Online Learning Centre, with online marking at www.pharmacists.ca. If online access is not available to you, contact CPhA at 1-800- 917-9489.
All material 2005 MediResource Inc.
Disclaimer
Lesson description
Learning objectives
e have done our best to produce an accurate, timely, and educational Learning Series. However, MediResource Inc., the Canadian Pharmacists Association, the authors, the reviewers, and the editors assume no responsibility for any errors or consequences arising from the use of information contained within this program. With the constant changes in practice and regional differences, it remains the responsibility of the readers as professionals to interpret and apply this lessons information to their own practices. All rights reserved. For this lesson, in compliance with sections 10.2 and 10.3 of the Guidelines and Criteria for CCCEP Accreditation, Theresa Glanville, Tom Smiley, and MediResource Inc. report no real or potential conflict of interest in relation to the sponsor of the CE lesson. Zubin Austin has previously received an honorarium from the sponsor for a past presentation.
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lmost 40% of the Canadian population uses a vitamin and/or mineral supplement on a regular basis. All Canadians should be encouraged to follow Canadas Food Guide to Healthy Eating as a source of these essential nutrients. However, at some stages of the lifecycle, it is difficult to meet nutrient needs from food alone either because the need is too great, food intake is inadequate, or because physiological changes in the body lead to inefficient nutrient utilization. Because vitamins and minerals are natural constituents of food, the possibility that taking a large amount could have a negative impact on health is often not appreciated. This continuing education lesson will use the newly established Dietary Reference Intakes as a framework for assessing nutrient needs throughout the lifecycle. Most of those taking a supplement do so because they believe it will reduce risk of chronic disease. This continuing education lesson will review some of the key findings of research on vitamins and minerals in relation to cardiovascular disease and cancer. Finally, it will also examine the basis for drug-nutrient interactions that could come to play with supplement use or consumption of fortified food.
pon completion of this lesson, pharmacists should be able to: describe the relationship between the Recommended Dietary Allowance, Adequate Intake, and Estimated Tolerable Upper Level as a basis for evaluating a supplement describe the differences in metabolism of nutrients from supplements and nutrients from food identify the stages of the lifecycle that would benefit from supplement usage describe the major outcomes of research on supplement use and chronic disease prevention use the dietary reference intakes to direct clients on appropriate selection of a vitamin and/or mineral supplement

cpha.learning.mediresource.com All material 2005 MediResource Inc.
Author
Theresa Glanville, PDt, PhD (Nutritional Sciences) Theresa Glanville is a Professor of Nutrition in the Department of Applied Human Nutrition at Mount Saint Vincent University, Halifax, NS. The department offers undergraduate and graduate programs in nutrition and dietetics with an integrated dietetic internship. Dr. Glanville teaches introductory nutrition, undergraduate and graduate research methods, medical nutrition therapy, and nutritional epidemiology. She is a Registered Dietitian and past-member of the Board of Directors of Dietitians of Canada. Dr. Glanville has an active research program with a particular emphasis on assessment of dietary and health practices of at risk population groups. She is currently a member of the Expert Advisory Committee convened by Health Canada to guide implementation of the new Dietary Reference Intakes and at the request of Health Canada, Dr. Glanville served as an external reviewer for the Panel Report on Folate and Other B Vitamins. Dr. Glanville is also a member of the Expert Advisory Committee convened by Dietitians of Canada to guide development of web-based education modules for health professionals on the Dietary Reference Intakes, and she has authored a module on vitamin and mineral supplementation. Dr. Glanville has written articles and presented papers on the impact of food fortification policy in Canada with a particular emphasis on folic acid fortification.
Expert reviewers
Tom Smiley, BScPhm., PharmD Tom Smiley is a pharmacist consultant who remains active in community practice with Dell Pharmacy in Brantford, Ontario. In addition to his clinical experience with patients over the past 24 years, Tom has written many CE Lessons and workshops for pharmacists on topics including nutrition (including Women and Nutrition), management of obesity, cardiovascular disease, dyslipidemia, and diabetes education. Tom has also developed educational material for the general public on the topics of nutrition, vitamins and minerals, weight management, cardiovascular disease and diabetes. Tom continues to develop and write workshops for pharmacists in the area of general pharmaceutical patient care concepts and disease state/medication management. Zubin Austin, BScPhm, MBA, MIS, PhD Zubin Austin is OCP Professor in Pharmacy at the Leslie Dan Faculty of Pharmacy, University of Toronto. Zubin has taught the Vitamins/Mineral Supplementation lectures in the undergraduate program for the past six years (in 1st and 3rd year). As well, he has worked with Whitehall Robbins on a live CE presentation for pharmacists on the topic of vitamin and mineral supplementation, and delivered this across the country for three years. Additionally, Zubin is currently principal investigator in the International Pharmacy Graduate Program and co-investigator in several interprofessional education and practice research projects. He continues to practice as a clinical pharmacist at Mount Sinai Hospital in Toronto, with particular interest in psychiatry and family medicine. Zubin has published extensively in the areas of pharmacy education and practice, and is an award-winning educator, having received the BristolMyers Squibb National Award for excellence in pharmacy education.

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Contents
page 1 1. Introduction 1 Table 1. Common reasons for taking a vitamin and mineral supplement 1 2. Dietary Reference Intakes 1 Table 2. Dietary Reference Intakes (DRIs) 2 Figure 1. Conceptual relationship between the dietary reference intakes 2 3. Food versus supplements 2 Table 3. Comparison of B-100 vitamin supplement formulation to the RDA (AI) and UL 3 Table 4. Food sources of nutrients of concern throughout the lifecycle 3 4. Vitamin and mineral nutrition throughout the lifecycle 4 Table 5. Nutrients of concern by life stage and age group 4 4.1 Reproductive-age women 5 Figure 2. Folate and homocysteine and methionine metabolism 5 Table 6. Behaviours that increase iron requirements 5 4.2 Pregnancy 6 Table 7. Select nutrients from five prenatal products available in Canada 6 4.3 Lactation 6 4.4 Breast-fed infants 7 4.5 Effect of aging on bone health 8 4.6 Vitamin B12 and folate status with advancing age 8 5. Relationship of vitamin and mineral nutrition to chronic disease 9 5.1 Cardiovascular disease (CVD) 9 5.2 Cancer 10 5.3 Immune function 10 6. Drug-nutrient interactions 11 Table 8. Examples of drug-nutrient interactions 11 7. Conclusions 12 References 16 Appendix 1. Dietary Reference Intake Tables 16 Table 8. Dietary Reference Intakes (DRIs): Recommended Intake for Individuals, Vitamins 17 Table 9. Dietary Reference Intakes: Tolerable Upper Levels (ULs), Vitamins 18 Table 10. Dietary Reference Intakes: Recommended Intakes for Individuals, Elements 19 Table 11. Dietary Reference Intakes: Tolerable Upper Levels, Elements 20 Questions

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1. Introduction
n increasing number of Canadians are using dietary supplements on a regular basis.1,2,3 A recent survey reports that 46% of women and 33% of men use at least one natural health product, with 38% of them taking a vitamin and mineral supplement.1 Supplement users tend to be older, to be less likely to smoke, and to perceive their health as better than non-users. In the United States (US), 40% of the population over 2 months of age use dietary supplements, with typical users being 15 years of age or middle-aged and older.4 While most take only one supplement per day, the number taking two or more supplements per day increases with age. The supplements used most frequently are multivitamin, multivitamin and mineral, and single nutrient supplements containing vitamin C, vitamin E, calcium, or iron.4 Consumers are exposed to messages that promote a belief that supplements are necessary.5,6 Table 1 highlights some common notions underpinning supplement use. Obviously, if dietary intake is poor, supplements can be beneficial. However, research clearly shows that those most likely to use dietary supplements are those who already consume an adequate diet.611 The pharmacist can play an important role in guiding clients to select vitamin and mineral supplements that they clearly should be taking for optimum health, and on how to use products in the marketplace in a safe and efficient manner.12 The focus of this continuing education lesson will be on recommendations for use of vitamin and mineral supplements throughout the lifecycle with an emphasis on health promotion and chronic disease prevention.
Table 1. Common reasons for taking a vitamin and mineral supplement

to fill a gap between dietary intake and actual need a belief that more is better to make up for nutrients missing from the food supply to make up for poor absorption of vitamins and minerals from food to increase energy or boost performance to decrease susceptibility to or severity of chronic disease
Table 2. Dietary Reference Intakes (DRIs)15

Estimated Average Requirement (EAR) is the average daily nutrient intake level estimated to meet the requirement, as defined by the specific indicator or criterion of adequacy, of half of the healthy individuals in a particular life stage and gender group. Recommended Dietary Allowance (RDA) is the average daily dietary nutrient intake level sufficient to meet the nutrient requirement of nearly all (9798%) healthy individuals in a particular life stage and gender group. The RDA is derived from the EAR (EAR 1.2 to adjust for biological variability). Adequate Intake (AI) is the recommended average daily intake level based on observed or experimentally determined approximations or estimates of nutrient intake by a group (or groups) of apparently healthy people that are assumed to be adequate. This value is used when an EAR and hence RDA cannot be established. Tolerable Upper Intake Level (UL) is the highest average daily nutrient intake level that is likely to pose no risk of adverse health effects to almost all individuals in the general population. The goal in establishing the DRIs was to achieve optimal health through diet, not merely the prevention of nutritional deficiency. Since true individual nutrient requirements are unknown, the DRIs are based on probability assumptions that intake will or will not be adequate (Figure 1). As habitual intake of a nutrient by an individual decreases progressively below the recommendation, the probability that intake is inadequate to meet individual needs increases. Likewise, as individual intake increases, the probability that intake is adequate to meet individual needs increases. When habitual intake meets the RDA or AI, the individual will derive no further benefit from consuming more of the nutrient. If intake exceeds the UL, a negative health effect may occur.15
2. Dietary Reference Intakes

The Dietary Reference Intakes (DRIs) are nutrient recommendations established for all age categories through a partnership between the US Institute of Medicine and Health Canada (Table 2). The four recommendations correspond to a continuum of nutrient adequacy. The Estimated Average Requirement (EAR) is used to assess the prevalence of inadequate nutrient intake within populations. The Recommended Dietary Allowance (RDA) is derived from the EAR and can be used to set targets for nutrient intake by healthy individuals. The Adequate Intake (AI) is less precise than the RDA but can also be used to set targets for nutrient intake by healthy individuals. The Tolerable Upper Intake Level (UL) is the point beyond which risk of toxicity must be considered. To date, the DRI expert panels have set dietary recommendations for 14 vitamins and 12 minerals (see Appendix 1, DRI tables).1318

Pharmacists can use the DRIs to guide clients in selecting a supplement. The compositions of vitamin and mineral supplements are quite variable, with some being formulated to approximate RDAs while others contain several-fold more than the RDAs. Table 3 provides a comparison of a B-100 vitamin supplement formulation relative to the RDA and UL.17 Note that the product provides most B vitamins far in excess of the RDA, except for folic acid, which meets the recommendation. The amount of choline in the product is considerably less than the AI. This product clearly exceeds the UL for niacin. The criterion used to establish the UL for niacin was onset of flushing, and although niacin as niacina-
mide does not cause flushing, the same UL applies to this form of niacin.17 The high level of vitamin B6 could be a concern if the client routinely takes more than the recommended dose of this product (containing 100 mg/tab), as prolonged excessive intake of vitamin B6 can lead to irreversible peripheral neuropathy. Keep in mind intake from a supplement will be in addition to the vitamins and minerals provided by the diet. Table 4 provides an example of the nutrient contribution of different foods. 20
3. Food versus supplements
The UL for most nutrients considers intake from food, fortified food, water and supplements. While all sources impact on total available nutrient, it is Figure 1. Conceptual relationship between virtually impossible to exceed the UL from food the dietary reference intakes alone (unless the food is fortified). The UL for magnesium and niacin is based solely on intake from EAR UL RDA 1.0 1.0 supplements. A UL was established only for nutrients where there was sufficient research to apply a risk assessment analysis. When insufficient evi0.5 0.5 dence was available, the UL is considered to be Non-Determinable (ND see Table 3). In no way does absence of a UL imply a low level of 0 0 risk.14,1618 Observed level of intake Because vitamins and minerals are natural conThe Estimated average requirement (EAR) is the intake at which stituents of food, consumers may not appreciate the the risk of inadequacy to an individual is 50%. The Recommended potential risk associated with use of supplements, Dietary Allowance (RDA) is the intake at which the risk of inadand the need to follow product directions. When equacy is 23%. The Adequate Intake (AI) does not bear a consistent relationship to the EAR or RDA because it is set without being ingesting vitamins and minerals as part of food, able to estimate the average requirement. It is assumed that the intake is distributed throughout the day, and the AI is at or above the RDA if one could be calculated. At intakes nutrients are integrated within the organic matrix between the RDA and the Tolerable Upper Level (UL), the risks of of food. In contrast, a supplement presents a bolus inadequacy and excess are both close to zero. At intakes above the dose whether taken with meals or not. With a bolus UL, the risk of adverse effect may increase.15 dose, carrier proteins become saturated and the fractional absorption rate decreases. However, even though fractional uptake is lower, total Table 3. Comparison of B-100 vitamin supplement absorption is higher than from food alone formulation to the RDA (AI) and UL because more is present to be absorbed. As dose increases, some nutrients will also Nutrient Amount/serving RDA (AI) UL be absorbed by passive diffusion because Thiamin (as thiamin mononitrate) 100 mg 1.1 mg ND of the extreme concentration gradient. This Riboflavin 100 mg 1.1 mg ND dose effect can override regulation of minNiacin (as niacinamide) 100 mg 14 mg* 35 mg eral transport leading to expansion of Vitamin B6 (as pyridoxine HCl) 100 mg 1.3 mg 100 mg body stores. For vitamins, the impact on Folic acid 400 g 400 g 1000 g body stores will depend on the post-absorpVitamin B12 (as cyanocobalamin) 100 mg 2.4 mg ND tive capacity for degradation and excreBiotin 100 mg 30 mg ND tion, with water-soluble vitamins having a Pantothenic acid lower degree of risk relative to fat-soluble (as D-calcium pantothenate) 100 mg 5 mg ND vitamins.14,1618 Choline (as choline bitartrate) 50 mg 425 mg 3500 mg Absorption efficiency of vitamins and Inositol 100 mg NE NE minerals from food is factored into the DRIs. Paba (para-aminobenzoic acid) 100 mg NE NE Approximately 4090% of ingested vitamins * As niacin equivalents are absorbed, while absorption of minerals Non-essential nutrient is inefficient and inversely related to body Non-determinable stores. Since it is very difficult to remove Nutrition and Health
Risk of adverse evetns
Risk of inadequacy
Table 4. Food sources of nutrients of concern throughout the lifecycle

Nutrient Vitamins Vitamin A & Beef liver, sweet potatoes, spinach, -carotene mango, carrots, kale, broccoli, margarine, fortified milk, fortified soy beverage Vitamin C Oranges, grapefruit, strawberries, red and green peppers, kiwi, tomatoes, broccoli, kale, potatoes Eggs, oily fish with edible bones, cod liver oil, fortified milk, fortified soy beverage Vegetable oils, salad dressings, wheat germ, nuts, seeds Examples of food sources
tive abundance of calcium will out-compete iron for absorption. The DRI committees developed new terms to account for efficiencies of nutrient absorption and metabolism. These include: Dietary Folate Equivalent (DFE): This term was developed to quantitate the difference in absorption efficiency between food folate (pteroylpolyglutamate) and synthetic folic acid (pteroylmonoglutamate) found in supplements and fortified food.17,21 1 DFE = 1 g naturally occurring food folate or 0.6 g synthetic folic acid consumed as fortified food or a supplement taken with food or 0.5 g of synthetic folic acid taken on an empty stomach. For example, a supplement containing 400 g of folic acid taken on an empty stomach provides 800 g DFE. Retinol Activity Equivalent (RAE): This term was developed to account for new information on the conversion efficiency of carotenes to vitamin A.14 1 RAE = 1 g retinol or 12 g all-trans-carotene or 24 g all other provitamin A carotenoids. 1 IU vitamin A = 0.3 g of all-trans retinol or 3.6 g all-trans--carotene or 7.2 g of all other provitamin A carotinoids. For example, a supplement containing 3500 IU of vitamin A (29% -carotene) would provide 745 g RAE as retinol and 304 g RAE as -carotene.
Vitamin D
Vitamin E
Vitamin B12 Animal products such as beef, chicken, fish, shell fish, eggs, milk Folate Asparagus, spinach, dried peas and beans, lentils, romaine lettuce, strawberries, oranges and orange juice, peanut butter, wheat germ, fortified foods including flour, corn meal, pasta, and bread Milk, cheese, yogurt, tofu (processed with calcium), fortified orange juice, fortified soy beverage, fish with edible bones, spinach, broccoli
Minerals Calcium
Magnesium Spinach, squash, wheat germ, dried beans and peas, seeds, whole grain products Iron Zinc Meat, poultry, fish, dried beans and peas, products made with enriched flour Oysters, meats, peanuts, wheat germ, dried peas and beans, cheeses
4. Vitamin and mineral nutrition throughout the lifecycle

In the ideal situation, healthy people will meet nutrient needs by consuming a variety of foods selected from grains, fruits and vegetables, milk, and meat/meat alternatives in amounts that maintain normal body weight. Canadas Food Guide to Healthy Eating is designed to guide individual food choice by providing recommendations for number and size of servings for different age groups. However, compliance with the Food Guide is poor, with most Canadians meeting the minimum serving recommendations for only two or three food groups, with intake of milk and fruits and vegetables being most limiting.8,2226 Despite this, overt nutritional deficiency in Canada is rare because food is abundant and enrichment and fortification policies are in place to provide extra nutrients even with poor dietary habits. However, while deficiency may be rare, those with poor eating habits will not be deriving optimal health benefits from the diet. Also, nutrient needs change as we age. In the early
Adapted from Perspectives in Nutrition19
minerals from the body once they are absorbed, low absorption efficiency is an essential aspect of regulation. Chelated mineral supplements are promoted as a way to enhance absorption by accessing paracellular transport in addition to transcellular transport, but there is little evidence to support that this type of presentation makes a difference in total uptake.14,20 Minerals of similar valence compete for common transport sites, which can be of practical significance when counseling clients. For example, the effectiveness of an iron supplement containing 10 mg of elemental iron will be reduced if taken at the same time as a calcium supplement providing 500 mg of elemental calcium because the rela-

Randomized clinical trials, observational cohort follow-up and casecontrol studies provide unequivocal Population group Nutrients evidence that increased folic acid Exclusively breast-fed infants vitamin D, iron intake decreases both recurrent and occurrent cases of NTDs.28,29 Folate Teenagers with irregular functions in one-carbon transfer eating habits calcium, iron (females) reactions and as such plays a role Reproductive-age women iron, folic acid in protein synthesis, homocysteine Post-menopausal women calcium, vitamin D metabolism and DNA synthesis. Figure 2 shows the role of folate in the Vegetarians who eat methionine/homocysteine pathway. absolutely no animal products iron, zinc, vitamin B12 It is proposed that a genetic defect Dieters and people who depends on total energy intake in folate metabolism affects neural avoid entire food groups and food group(s) avoided tube closure.3032 Mothers and affected Men and women over age 50 vitamin B12, folic acid, calcium, infants have a higher frequency of vitamin D, magnesium gene mutations, and it is proposed that heterogeneity of gene mutations People with deficiency diseases, may account for variation in NTD absorptive disorders or nutritionphenotypes.33,34 A recent report sugrelated genetic disorders depends on medical condition gests that women with an affected People who smoke at any age Vitamin C pregnancy may have decreased transport of folate into cells secondary to years, nutrients are required to support growth and auto-antibodies against folate receptors suggestdevelopment. With the onset of puberty, nutrient ing another possible mechanism for folate to affect needs will change to support reproductive func- birth outcome.35 tions. Finally, with advancing age, nutrient needs The RDA for folate, based on the amount required change to reflect metabolic inefficiency and loss of to sustain folate-dependent metabolism and to reproductive capacity. Table 5 highlights nutrient ensure body stores, is 400 g DFE/day for both concerns at different stages of the lifecycle. men and women.17 All women of reproductive age are advised to consume an additional 400 g/day 4.1 Reproductive-age women of synthetic folic acid either as a supplement or as All women who are capable of becoming pregnant part of fortified food whether they are contemplatshould be mindful that nutrient intake could impact ing a pregnancy or not (total food and supplement on pregnancy outcome with folate and iron being = 10001200 g DFE). In 1998, Health Canada introthe nutrients of greatest concern. In the case of folate duced mandatory fortification of flour to provide intake, the window of opportunity to affect preg- 150 g of folic acid per 100 g of flour and 100 g nancy outcome has passed before many women are of folic acid per 100 g serving of bread. Based on aware they are pregnant. Iron is a concern because population modeling, this level of folic acid addiof loss of iron through menstruation and low dietary tion was projected to increase folic acid intake by intake. Without adequate intake of iron prior to ~150 g/day (240 g DFE), which, when combined pregnancy, women will enter pregnancy with low with food intake, yields a typical daily intake of iron stores. 500800 g DFE. 3638 Food fortification affects all members of the pop4.1.1 Folic acid and neural tube defects ulation, so fortification additions must be conservaNeural tube defects (NTDs), including spina bifida, tive. In the case of folic acid, two population sectors anencephaly, meningomyelocele, meningocele, and were considered to be at risk: young males with craniorachischisis, are birth defects resulting from high energy intake from grains (intake above the UL improper development and closure of the neural of 1000 g/day) and elderly Canadians in the event tube during the third and fourth week of gestation. that folic acid could mask vitamin B12 deficiency. The incidence rate in Canada is ~1 in 1000 live Since implementation of folic acid fortification, probirths, with the incidence being higher in New- vincial reports of birth outcomes indicate a signiffoundland and Quebec and lower in Ontario and icant decrease in the incidence of NTDs.3941 Since British Columbia.27 Regional variation could be due birth surveys are retrospective, it is possible that to genetic predisposition in some population groups, improved birth outcomes are related to better prenaenvironmental factors such as dietary intake, and/or tal screening rather than improved folic acid nutriother factors related to socioeconomic status. tion.
Table 5. Nutrients of concern by life stage and age group

Figure 2. Folate and homocysteine and methionine metabolism
Cystathionine -synthase Cystathionine
Table 6. Behaviours that increase iron requirements42
ment, deposition of nutrient stores in the fetus, loss of maternal tissues at birth, and prepaMethionine synthase ration for lactation. Canadas Homocysteine Methionine Food Guide to Healthy Eating B12 recommends that pregnant women select more servings B6 from all food groups to meet the additional nutrient require5-methyl Tetrahydrofolate ments. Considering the energy tetrahydrofolate cost of pregnancy (~100 kcal/d during 1st trimester; 300 kcal/ 5,10-methylene d during 2nd and 3rd trimestetrahydrofolate Dihydrofolate ters), women will have to make reductase nutrient-dense food selections to meet the increased needs and Dietary folate/ 5,10-methylene not gain excess body weight.42 folic acid tetrahydrofolate While all nutrients are of concern, most attention is focused on folate, iron, and calcium. 4.2.1 Folate In contrast to pre-pregnancy, when folate was required for prevention of a potential birth defect, after pregnancy has occurred, folate is required to support increased nucleotide synthesis associated with growth of the uterus, placenta, maternal red blood cells and fetal tissue. Folate is actively transported from the mother to the fetus, suggesting that maternal folate is sacrificed to support fetal development. The RDA for folate during pregnancy is 600 g DFE/day.17 While it may be possible to achieve this level of intake from a varied diet that includes foods fortified with folic acid, most women will benefit from a vitamin supplement containing folic acid. 4.2.2 Iron Although menstrual loss of iron ceases during pregnancy, iron is required to support on-going basal losses, iron deposited in the fetus and placenta, plus iron used to support expansion of maternal hemoglobin. Using factorial modeling, the net iron cost of pregnancy is estimated to be ~700800 mg in total, which represents the amount of iron that must be absorbed from the diet over the entire gestational period, with the need being greatest in the 2nd and 3rd trimesters.14,42 In response to this, efficiency of iron absorption increases from the non-pregnant level of 18% to as high as 25%. The RDA for iron during pregnancy is 27 mg/d.14 The DRI report on iron recommends that intake be increased throughout gestation, while the current Canadian guidelines recommend that iron intake be increased during the 2nd and 3rd trimesters, when the need for iron is greatest.14,42 In theory, women should be able to meet the iron requirements for pregnancy without taking
consuming diets low in heme iron from meat, fish, and poultry (e.g., vegetarian diets) consuming a diet low in vitamin C (ascorbate increases solubility of non-heme iron in the intestinal lumen) consumption of coffee and tea close to meals (phytates and oxalates bind iron and decrease absorption) regular use of acetylsalicylic acid (increase likelihood of gastric blood loss) three or more blood donations in a year multiple gestations over a short interval 4.1.2 Iron deficiency In the early 1990s, Health Canada implemented a program to enrich white flour with iron, and grain products now provide ~50% of dietary iron intake, whereas it was less than 30% from grain products before enrichment.26 Assessment of adequacy of dietary iron intake suggests that ~11% of women do not consume enough iron.8,9 However, even though total consumption is adequate, net uptake may be lower because non-heme iron is not absorbed as efficiently as heme iron.14 Table 6 identifies some behaviours that can predispose to increased iron need. If a woman decides to take an iron supplement, it should provide no more than the RDA for non-pregnant women unless she has been diagnosed with iron deficiency.
4.2 Pregnancy
Once a woman becomes pregnant, extra nutrients are required to support expansion of maternal blood volume, growth of maternal tissues, fetal develop-

a supplement. However, this assumes adequate iron stores prior to pregnancy, which is not often the case, and as a result, most women will benefit from a supplement that contains the RDA for iron. 4.2.3 Calcium During pregnancy, calcium is required to support calcification of the fetal skeleton. Most of the transfer from the mother to the fetus occurs in the 3rd trimester, but the maternal skeleton starts to accrue calcium very early in gestation.18,42 To accommodate the need for calcium, efficiency of intestinal absorption increases secondary to an increase in total and free 1,25(OH)2D, the active form of vitamin D. The increased efficiency of calcium absorption offsets the increased need, and the AI is 1000 mg/d (1300 mg/d for adolescent females), the same as that for non-pregnant women. Although a pregnant woman does not need extra calcium, she does need to at least meet the recommendations for healthy women by consuming milk and calciumfortified orange juice and soy beverages or by taking a calcium supplement.18 The formulation of prenatal vitamin supplements can be quite variable. Table 7 shows the content of folic acid, iron and vitamin A (as retinol) in five different pre-natal products. When recommending a product, the pharmacist should first focus on vitamin A (as retinol), since excess intake during early pregnancy has been linked to increased risk of fetal malformations.14,42,43 Supplements providing vitamin A (as -carotene) are safe because the conversion of -carotene to retinol is tightly regulated. Vitamin A in prenatal supplements is usually provided as both retinol and -carotene. Intake from a supplement will be in addition to dietary intake, so one containing less than the RDA combined with healthy food choices is also appropriate. Unless there is a reason (more than one fetus, short interval between gestations, diagnosed iron deficiency), the product should not provide more than the RDA for iron.14,42 If a supplement contains a therapeutic dose of iron, supplemental zinc (15 mg) and copper (2 mg) should also be taken to offset competition for absorption.42,44
Prenatal supplements provide <20% of the AI for calcium. A calcium supplement and a prenatal supplement should not be ingested together because calcium will out-compete iron and other trace minerals for absorption.45
4.3 Lactation
Table 7. Select nutrients from five prenatal products available in Canada

Product A B C D E RDA Folic acid 1000 g 1000 g 1000 g 500 g 400 g 600 g DFE Elemental iron 60 mg 35 mg 30 mg 15 mg 15 mg 27 mg Vitamin A 1667 IU 1667 IU 2500 IU 10,000 IU 2000 IU 2567 IU
The composition of breast milk is ideally suited to meet the nutrient needs of healthy term infants. Although the mother requires more of all nutrients to support her own needs plus transfer of nutrients to the baby, these can usually be met by eating a well-balanced diet that follows Canadas Food Guide to Healthy Eating. The effect of maternal diet on milk composition depends on the nutrient. The mineral content of breast milk varies with the stage of lactation and bears little relationship to the mothers intake, while the vitamin content of breast milk is directly related to maternal vitamin status. When vitamin intake is chronically low, the level in breast milk is low; as intake increases, the content in breast milk increases until a plateau is reached corresponding to transport saturation.14,1618,42 While the vitamin content of breast milk is affected by maternal vitamin status, with the exception of early reports of vitamin B6 deficiency in breast-fed infants,17 there is no literature to support that poor maternal diet is a risk factor for breast-fed infants. A common, but unsubstantiated, practice for babies experiencing colic is for the mother to avoid milk and milk products, the principal dietary sources of calcium and vitamin D.46 During pregnancy, maternal bones deposit calcium for mobilization during lactation through bone resorption. Bone calcium is mobilized regardless of dietary intake. While dietary calcium will not spare bone calcium, mothers should at least meet the AI for calcium, which will be difficult when avoiding dairy products. Women who avoid dairy products should consider an alternative source of calcium such as fortified soy beverage (contains vitamin D) and fortified orange juice (does not contain vitamin D) or a calcium supplement with vitamin D. Mothers who want to take a multivitamin/mineral supplement during lactation should avoid those containing iron because iron requirements remain low until menstruation is reestablished.14
4.4 Breast-fed infants
With birth, the infant moves from the steady supply of nutrients provided by placental blood flow to intermittent provision of nutrients via the gut as breast milk or formula. While breast milk provides all essential nutrients for healthy full-term infants, iron and vitamin D status need to be considered.

4.4.1 Iron A normal-term infant should have sufficient iron stores to last until 4 to 6 months of age.14,42,46 The Guidelines for Feeding Healthy Term Infants recommend that breast-fed infants be provided with a source of iron beginning between 4 and 6 months of age either as iron-fortified cereal or as an iron supplement.46 Formula-fed infants should receive an iron-fortified formula from birth, which is a departure from earlier recommendations to use iron-fortified formula beginning after 4 months.46 The concern over iron relates to research showing that low iron stores can impact on cognitive development. 4.4.2 Vitamin D Early humans lived and evolved in regions around the equator, so vitamin D needs were met through conversion of 7-dehydrocholesterol to vitamin D in response to UVB rays from the sun.18 As a result of this evolutionary niche, breast milk does not contain enough vitamin D to meet needs in the absence of exposure to sunlight. Babies born to mothers who do not consume foods fortified with vitamin D, do not take a vitamin D supplement during pregnancy, and have limited exposure to sunlight will have limited stores of vitamin D at birth.18 The Guidelines for Feeding Healthy Term Infants recommend that all breast-fed infants be given a supplement that provides 400 IU (10 g/d) of vitamin D. Infants living in northern communities should receive twice this amount (800 IU (20 g/d)).46 4.4.3 Vitamin B12 Infants born to mothers with a long history of veganism may be at risk of deficiency due to low stores at birth and low vitamin B12 content in breast milk. Infants of vegan mothers should be supplemented with vitamin B12 from birth (AI: birth6 mo: 0.4 g/d; 712 mo: 0.5 g/d).46
4.5.1 Calcium The effect of calcium from food or supplements on bone loss depends on whether it is due to hormonal or age-related factors. During early post-menopause the loss of bone is related to hormonal factors, and extra calcium will have little effect on loss of trabecular bone, but cortical bone may retain some responsiveness. Women who are taking hormone replacement therapy during early post-menopause will achieve optimal benefit for osteoporosis prevention if calcium intake meets the AI.18 After 5 years post-menopause, loss of bone slows and is related to age factors, and increasing calcium intake can slow the rate of loss in both men and women.47,48 To account for decreased efficiency of calcium metabolism with age, the AI for calcium for older men and women is 1200 mg/d. Most older men and women will require a supplement to meet this level of intake. Of the supplements available on the market, when taken on an empty stomach, calcium citrate is absorbed 2227% better than calcium carbonate, while there is little difference in absorption efficiency when taken with food. Since calcium carbonate costs less, this form may be preferable for practical reasons. Also, to increase absorption efficiency, it is preferable to take a small dose twice a day (500 mg or less) rather than a large dose once per day.4951 4.5.2 Vitamin D In addition to calcium intake, older men and women need to be concerned about vitamin D intake, as this vitamin is essential for efficient calcium metabolism. With advancing age, the efficiency of vitamin D3 synthesis from 7-dehydrocholesterol is reduced such that longer exposure to UVB rays is required for endogenous synthesis. At the same time, poor mobility, institutional living, and wearing multiple layers of clothing often limit exposure to sunlight. Consequently, older men and women are much more dependent on a dietary source of vitamin D.18,5256 The AI is increased from the young adult level of 5 g/d (200 IU) to 10 g/d (400 IU) for those in the 51 to 70 age category and 15 g/d (600 IU) for those over 71. Milk is fortified to provide 10 g/L (400 IU) of vitamin D; however, recent evidence suggests that the fortification program is not affecting those in need 57. Considering the limited number of dietary sources of vitamin D, it will be virtually impossible for older adults to achieve the AI without taking a vitamin D supplement. 4.5.3 Magnesium With advancing age, magnesium absorption is decreased and urinary excretion is increased, indicating a loss of metabolic efficiency. Magnesium is found in many foods, with the richest sources
4.5 Effect of aging on bone health
Both men and women progress through the young and middle age adult years in a relative state of balance (1930 years; 3150 years). In the late middle and early older adult years (5170 years), the consequences of aging begin to show, especially with respect to bone health. Both men and women experience age-related bone loss, but it is more apparent in women because of the rate at which calcium is lost and their smaller skeletal mass. With the onset of menopause, decreased estrogen production initiates accelerated bone loss, particularly from trabecular bone of the lumbar spine. For the first 5 years after menopause, women lose 3% of skeletal mass per year on average. As estrogen levels decrease, calcium absorption efficiency decreases and bone resorption increases, likely due to a specific effect of estrogen on osteoblast/osteoclast cycling.18

being green leafy vegetables, whole grains, and legumes (see Table 4). Magnesium intake from dietary sources by older men and women is typically inadequate, with over a 50% prevalence of inadequate intake.8,9 While there is little research to suggest that intake of magnesium above the RDA is beneficial, older men and women should at least meet the RDA. This could be achieved by taking a supplement in addition to dietary intake, but the effectiveness of magnesium supplementation is limited by osmotic diarrhea at higher levels of intake.18 4.5.4 Vitamin A Vitamin A (as retinol) can have a negative effect on bone density and fracture risk. In both men and post-menopausal women, the fracture rate increases as vitamin A intake and blood retinol levels increase. The level of intake associated with decreased bone density is approximately two to three times the RDA.58,59 This level of intake could be achieved by taking twice the recommended dose in a typical multivitamin and mineral preparation or by taking two or three different preparations with each one containing vitamin A.
4.6 Vitamin B12 and folate status with advancing age
Vitamin B12 is present only in foods of animal origin. Typically, the Canadian diet provides enough of these foods to meet needs, yet the risk of deficiency increases with age because efficiency of digestion and absorption decreases. The stomach plays a key role in vitamin B12 absorption through release of acid to break down the food matrix for release of the vitamin, and secretion of intrinsic factor necessary for vitamin B12 absorption. 1020% of adults over age 50 have inefficient vitamin B12 absorption secondary to atrophic gastritis.17 With atrophic gastritis, absorption of food-bound vitamin B12 is decreased but uptake of crystalline vitamin B12 from supplements is not altered. The RDA for men and women older than age 50 is not increased but the recommendation stipulates that vitamin B12 should be taken as crystalline vitamin B12 either as a supplement or through fortified foods (current food policy in Canada does not permit the addition of crystalline vitamin B12 to food although this will likely change as food policies are revised to be consistent with the DRIs).17 Of the supplemental forms of vitamin B12, methylcobalamin is better absorbed than cyanocolbalamin.60 As shown in Figure 2, metabolic functions of vitamin B12 and folate are inter-related and deficiency of either one will cause megaloblastic cell changes. The majority of individuals with clinical vitamin B12 deficiency also present with irreversible neurological symptoms (motor dysfunction and cognitive
changes ranging from loss of concentration to disorientation and frank dementia) related to the function of vitamin B12 in organic acid metabolism.61,62 Approximately 25% of cases of vitamin B12 deficiency do not present with symptoms of anemia, which is probably related to the ability of folate to mask the hematological signs of vitamin B12 deficiency.18 Current research provides preliminary evidence that vitamins involved in one-carbon transfer may affect depressive symptoms in older adults and in those prone to depression.6367 Hyperhomocysteinemia and the mutated methylenetetrahydrofolate reductase genotype are associated with depression. Folate levels are low in subjects recently recovered from depression, and subjects with low vitamin B12 status are two times more likely to suffer from depression than those with normal nutrition status. A recent meta-analysis of three clinical trials on folate and depressive disorders suggests that folic acid supplementation may have a potential role as a supplement to other treatments for depression.68 Further, recent evidence suggests that elevated homocysteine may be an early marker of dementia in elderly patients.69,70 While there is insufficient evidence to indicate that folic acid and vitamin B12 supplementation will improve cognitive function in the absence of deficiency, there is good evidence to indicate that elderly men and women need to meet the RDA for these vitamins.
5. Relationship of vitamin and mineral nutrition to chronic disease

The most common reason given by consumers for taking a vitamin and mineral supplement is a belief that doing so will reduce risk of chronic diseases, including cardiovascular disease and cancer.14,71 Epidemiological, observational studies consistently demonstrate a lower incidence of chronic disease in populations that consume diets rich in fruits and vegetables.6,7,7174 However, randomized clinical trials assessing the effectiveness of vitamin and mineral supplementation on disease risk are equivocal in showing both negative and positive outcomes.71 Some of the disparity may be related to aspects of design such as dose, length of treatment, population characteristics, and definition of endpoints. Also, diets rich in fruits and vegetables differ in ways other than the provision of more vitamins and minerals.6,7,16 For example, this dietary pattern is likely to contain less fat and energy and more fibre. Fruits and vegetables also provide a source of phytochemicals, plant constituents with potent antioxidant properties.6 In the majority of supplementation trials, the dose is far in excess of what would

normally be consumed from dietary sources, implying that outcomes are pharmacological rather than physiological.71
5.1 Cardiovascular disease (CVD)

5.1.1 Antioxidant vitamins A considerable body of research has examined the affect of antioxidant vitamins, including -carotene, vitamin C, and vitamin E on cardiovascular disease risk. This research question is based on the observation that aerobic metabolism produces a small but steady stream of reactive by-products capable of interacting with cellular constituents to produce oxidative damage.75 Further, it is known that oxidation of low-density lipoprotein (LDL) particles leads to accumulation of cholesterol-laden foam cells beneath the endothelial lining of major arteries as the precursor event in the progression of atherosclerosis. Of the antioxidant vitamins, most interest has focused on vitamin E. Research using cell culture and animal models demonstrates that vitamin E can reduce risk of a myocardial event by blocking progression of a fatty streak to a plaque, and by blocking formation of a blood clot should a plaque be present. However, research outcomes in human populations are much less clear for many reasons7577: Observational studies show a reduction in risk when consuming diets rich in vitamin E. Intervention trials have shown no positive effect using dose levels ranging from 268 mg/d to as much 567 mg/d, many-fold higher than the RDA of 12 mg/d. Vitamin E is consumed as a component of vegetable oils, so diets rich in vitamin E also contain more mono- and polyunsaturated fatty acids, both of which have a positive effect on cardiovascular status. The degree of risk of suffering a myocardial event is a confounding variable. Based on an evidenced-based review of the literature, the Canadian Task Force on Preventive Health Care concluded that there was insufficient evidence to recommend for or against vitamin E supplementation for the primary prevention of a cardiovascular event and there was good evidence against recommending vitamin E supplementation for secondary prevention in those with established CVD.76 Similar results on the effect of vitamin E for secondary prevention of CVD were observed in the HOPE study.77 Population-based observational studies indicate an inverse relationship between plasma vitamin C and -carotene and risk of cardiovascular disease,
which would be expected when consuming diets rich in fruits and vegetables. Intervention trials with vitamin supplements have for the most part not shown a reduction in risk of CVD.16,71 5.1.2 B vitamins Hyperhomocysteinemia as an independent risk factor for CVD occurs in 1015% of the general population and 40% of those with established vascular disease.78 It is hypothesized that homocysteinemediated oxidative stress stimulates proliferation of smooth muscles and formation of atherosclerotic lesions as well as inducing a procoagulant environment. Under normal conditions, homocysteine accumulation is prevented by efficient remethylation to methionine or degradation to cystathionine (Figure 2). It is proposed that hyperhomocysteinemia can be attributed to the same genetic polymorphisms that predispose to NTDs, although not all research supports this assumption.79 As folate intake increases, homocysteine levels decrease with the greatest response in those with higher blood levels at the outset. Maximum effect is achieved with a folic acid intake of 300 g/d.8083 Recent research suggests that folate has pleiotropic effects on the vascular other than related to homocysteine lowering. In vitro evidence demonstrates that 5-methyltetrahydrofolate can increase nitric oxide production and directly scavenge superoxide radicals.84,85 While it is clear that folic acid supplementation can reduce hyperhomocysteinemia, there is insufficient evidence to date to show that taking a folic acid supplement will reduce risk of a cardiac event in the general population.86 Nonetheless, in those with a family history of premature cardiovascular disease and/or laboratory evidence of hyperhomocysteinemia, the American Heart Association recommends ingestion of 400 g/d of synthetic folic acid plus a diet providing 400 g DFE/d. Further, they recommend supplementation with vitamin B12 and vitamin B6, since these vitamins also play a role in homocysteine metabolism.87 As shown in Figure 2, each nutrient functions in a different step in homocysteine metabolism. However, a meta-analysis of vitamin supplementation trials on homocysteine metabolism demonstrated that folic acid (0.55 mg) lowered plasma levels by 25%, vitamin B12 (0.5 mg) by 7% with no additional effect when vitamin B6 (mean intake of 16.5 mg) was factored in, indicating that supplements containing only folic acid will be as effective as combination products.17
5.2 Cancer
Involvement of dietary factors in both the etiology and prevention of cancer has been extensively studied. Work in animal models suggests that dietary

factors act as tumour promoters in cells where a mutation has occurred. Dietary factors that have a preventative effect may do so by blocking the promoter role or by preventing the initial mutagenic event.16 Similar to CVD, it has been exceedingly difficult to demonstrate a protective effect of vitamin supplementation even when intakes have been several times the recommended amount. This relates to the use of observational rather than intervention designs for ethical reasons, the length of time between exposure and disease outcome, and the likelihood that response will vary by site and cellular pathology. The only consistent observation is that diets rich in fruits and vegetables are associated with a lower incidence of cancer at several sites including oral cavity, pharynx, larynx, prostate, breast, cervical, and colorectal. 6,7,16 Research on vitamin supplementation and cancer risk has focused on the antioxidant vitamins (-carotene vitamin C, vitamin E) and vitamins that play a role in DNA synthesis (folate). While the results are inconclusive, it is possible to make some general statements.8891 While research for the most part does not support a protective effect of pharmacological doses of vitamins, it is important to at least meet the RDA preferably from a variety of fruits and vegetables, but a multivitamin preparation formulated to provide the RDA would also be useful. Special consideration should be given to people who smoke. Evidence suggests that smokers may be at higher risk of lung cancer if taking large doses of -carotene. Other research has suggested that vitamin E may reduce risk of prostate cancer in heavy smokers. The RDA for vitamin C in smokers is increased by 35% to account for accelerated turnover rate. These observations imply that smokers differ from non-smokers in complex ways and this should be considered when making an assessment. The effectiveness of supplements differs based on alcohol consumption. For example, dietary folate has been shown to protect against colon and breast cancer in those with moderate alcohol consumption. The effect was strongest when blood folate level was low to begin with. This could be due to inadequate dietary intake since alcohol can displace food; alternatively, since alcohol is a toxin, it could increase the requirement for folate. In either case, a means to increase nutrient intake would be useful. Very little work has examined the role of vitamins and minerals as an adjuvant to cancer treatment. When food intake is limited during treatment, a supplement will help to replenish nutrient stores.92
Many clients turn to supplements at this very difficult time as part of the coping process.93 The most appropriate guidance will be to take a supplement that supports good health and does not exceed the UL.
5.3 Immune function

5.3.1 Vitamin C Vitamin C is important for optimum functioning of the immune system. Leukocytes use active, energydependent transport to concentrate vitamin C so as to protect the cell from oxidative damage secondary to the respiratory burst generated to neutralize pathogens. Saturation of the intracellular pool is projected to occur with an intake of 100 mg/d, which is within the range of the RDA for non-smoking men and women.16 Megadoses of vitamin C (200 mg/d to 6 g/d) have been proposed as treatment for the common cold, with outcomes showing reduced symptoms and recovery time in some studies and not in others. Since a functional basis for prevention of the common cold is within the range of dietary intake, megadoses of vitamin C likely trigger a non-specific antihistamine response.9497 5.3.2 Zinc Zinc, another essential nutrient for optimum immune function, has also been investigated for treatment of the common cold, but the results are inconclusive. Clinical trials using different formulations of zinc lozenges have shown both shorter duration of cold symptoms and no effect on duration of symptoms. Inability to show a relationship may be related to aspects of study design, including small sample size, inadequate blinding, and subjective reporting to symptoms. It is proposed that zinc in the lozenges blocks binding of virus particles to receptor sites in the oral mucosa.98
6. Drug-nutrient interactions
Interactions between drugs and food/nutrients are common and affect pharmacokinetic properties of drugs and nutrients. The likelihood of interactions increases with the number of medications taken.100 Clients may need to be advised to take medications and food/ supplements separately, to increase amount of nutrient ingested, or to alter types of foods consumed when on medication. Food fortification can change the nutrient composition of the food supply in unanticipated ways. For example, we now consume substantial amounts of iron and calcium from bread and orange juice as forticants, rather than as natural constituents of meat and dairy products. Pharmacists need to consider

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this when providing guidance to clients. For example, a drug may carry a directive to avoid milk because chelation with calcium in the gut will limit absorption.101 Now that orange juice is a significant source of dietary calcium for many Canadians, the directive may also need to include avoidance of calcium-fortified orange juice. The likelihood of this type of unanticipated drug-food interaction will increase as the number of fortified foods in the marketplace increases, which is likely to occur as food fortification guidelines are liberalized to be more consistent with consumer expectations.102
7. Conclusions
Vitamins and minerals are essential for health and well-being. Consuming a varied diet that meets the recommendations outlined in Canadas Food Guide to Healthy Eating will provide food sources of nutrients that will meet the needs of most healthy Canadians. With advancing age and at some stages of the lifecycle, vitamin and mineral supplements will be necessary to meet the dietary requirements. While the most common reason for taking a supplement is for chronic disease prevention, research suggests there will be little gain from taking more of a nutrient than is required to meet basic health needs. The role of the pharmacist is to recommend the supplements that will be of optimum benefit and to discourage use of those that will have negative consequences. While there are many positive aspects of taking a supplement, this should be in addition to, not as a replacement for, healthy foods, since foods contain many other compounds that promote health.
Table 8. Examples of drug-nutrient interactions

decreased absorption from the gut secondary to chelation and formation of insoluble complexes, e.g., binding of minerals to antacids (aluminum hydroxide) decreased absorption from the gut secondary to sequestration or solubility in the lipid phase, e.g., binding of fat-soluble vitamins to cholestyramine, solubility of fat-soluble vitamins in mineral oil decreased absorption from the gut secondary to competition for binding sites, e.g., complexing of drug to calcium reduces uptake of trace minerals decreased absorption from the gut secondary to drug-induced fat malabsorption, e.g., inhibition of pancreatic lipase reduces fat-soluble vitamin absorption decreased release of nutrient from food matrix secondary to changes in the pH of the stomach, e.g., proton-pump inhibitors and absorption efficiency of food-bound vitamin B12 metabolism of drug decreasing conversion to the active form, e.g., phosphorylation of pyridoxine during treatment with isoniazid metabolism of drug increasing degradation of the vitamin, e.g., oxidation of vitamin D during treatment with some types of anti-convulsants; vitamin B6 during use of high-dose oral contraceptives nutrient increasing rate of drug metabolism, e.g., vitamin B6 and L-DOPA metabolism nutrient interfering with drug action, e.g., foods rich in vitamin K interfering with warfarin
Adapted from Drugs-Nutrients: An Interaction Guide99

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ulatory activities of ascorbic acid. Subcell Biochem. 1996; 25: 213231. 97. Johnston CS, Martin LJ, Cai X. Antihistamine effect of supplemental ascorbic acid and neutrophil chemotaxis. J Am Coll Nutr. 1992; 11: 172176. 98. Hulisz D. Efficacy of zinc against common cold viruses: an overview. J Am Pharm Assoc. 2004; 44:594603. 99. Locong A, Ruel D, Tessier V. Drugs-Nutrients: An Interaction Guide. Les Presses de lUniversit Laval, 2000. 100. McCabe BJ. Prevention of food-drug interactions with special emphasis on older adults. Curr Opin Clin Nutr Metab Care. 2004; 7: 2126. 101. Wallace AW, Victory JM, Amsden GW. Lack of bioequivalence when levofloxacin and calcium-fortified orange juice are coadministered to healthy volunteers. J Clin Pharmacol. 2003; 43: 539544. 102. Health Canada. The Addition of Vitamins and Minerals to Foods: Proposed Policy Recommendations. Ottawa: Bureau of Nutritional Sciences, Food Directorate, Health Protection Branch, 1999.

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Table 8. Dietary Reference Intakes (DRIs): Recommended Intake for Individuals, Vitamins Food and Nutrition Board, Institute of Medicine, The National Academies
Vit. A (g/d) 400* 500* 300 400 600 00 00 00 00 00 600 700 700 700 700 700 750 770 770 1200 1300 1300 115 120 120 5* 5* 5* 1 1 1 75* 90* 90* 80 85 85 5* 5* 5* 15 15 15 75* 90* 90* 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.4 1.6 1.6 1.6 18 18 18 17 17 17 45 65 75 75 75 75 5* 5* 5* 5* 10* 10* 11 15 15 15 15 15 0. 1.0 1.1 1.1 1.1 1.1 0. 1.0 1.1 1.1 1.1 1.1 12 14 14 14 14 14 60* 75* 90* 90* 90* 90* 1.0 1.2 1.3 1.3 1.5 1.5 1. 1. 1. 2.0 2.0 2.0 300 400 400 400 400 400 600 600 600 500 500 500 45 75 0 0 0 0 5* 5* 5* 5* 10* 10* 11 15 15 15 15 15 0. 1.2 1.2 1.2 1.2 1.2 0. 1.3 1.3 1.3 1.3 1.3 12 16 16 16 16 16 1.0 1.3 1.3 1.3 1.7 1.7 300 400 400 400 400 400 60* 75* 120* 120* 120* 120* 1.8 2.4 2.4 2.4 2.4 2.4 1.8 2.4 2.4 2.4 2.4 2.4 2.6 2.6 2.6 2.8 2.8 2.8 15 25 5* 5* 6 7 0.5 0.6 0.5 0.6 6 8 0.5 0.6 150 200 0. 1.2 30* 55* 2* 3* 4* 5* 5* 5* 5* 5* 4* 5* 5* 5* 5* 5* 6* 6* 6* 7* 7* 7* 40* 50* 5* 5* 4* 5* 0.2* 0.3* 0.3* 0.4* 2* 4* 0.1* 0.3* 65* 80* 0.4* 0.5* 2.0* 2.5* 1.7* 1.8* 5* 6* 8* 12* 20* 25* 30* 30* 30* 30* 20* 25* 30* 30* 30* 30* 30* 30* 30* 35* 35* 35* 125* 150* 200* 250* 375* 550* 550* 550* 550* 550* 375* 400* 425* 425* 425* 425* 450* 450* 450* 550* 550* 550* Vit. C (mg/d) Vit. D (g/d) Vit. E (mg/d) Vit. K (g/d) Thiamin (mg/d) Vit. B6 (mg/d) Biotin Choline (g/d) (mg/d) Riboflavin Niacin (mg/d) (mg/d) PantoFolate Vit. B12 thenate (g/d) (g/d) (mg/d)
Life Stage Group
Infants
06 mo 712 mo
Children
13 y 48 y
Appendix 1. Dietary Reference Intake Tables
Males
913 y 1418 y 1930 y 3150 y 5170 y >70 y
16
Females
913 y 1418 y 1930 y 3150 y 5170 y >70 y
Pregnancy
18 y 1930 y 3150 y
Lactation
18 y 1930 y 3150 y
The table presents the Recommended dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*) RDAs and AIs may both be used as goals for individual intake. RDAs are set to meet the needs of almost all (9798%) individuals in a group. For healthy infants, the AI is the mean intake. The AI for other life stage and gender groups is believed to cover needs of all individuals in the group, but lack of data or uncertainty in the data prevent stating with confidence the percentage of individuals covered by the intake.
Table . Dietary Reference Intakes: Tolerable Upper Levels (ULs), Vitamins Food and Nutrition Board, Institute of Medicine, The National Academies
Vit. A (g/d) 600 600 600 900 400 650 50 50 200 300 ND ND ND ND ND ND 10 15 30 40 300 400 ND ND ND ND 25 25 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND Vit. C (mg/d) Vit. D (g/d) Vit. E (mg/d) Vit. K Thiamin Ribo- Niacin flavin Vit. B6 (mg/d) Folate Vit. B12 Panto(mg/d) (g/d) thenate Biotin Choline (mg/d) (g/d) ND ND ND ND ND ND 1.0 1.0 Carotenoids (mg/d) ND ND ND ND
Life Stage Group
Infants
06 mo 712 mo
Children
13 y 48 y
Males, Females 1700 2800 3000 3000 2800 3000 2800 3000 1800 2000 50 50 800 1000 ND ND ND ND ND ND 1800 2000 50 50 800 1000 ND ND ND ND ND ND 30 35 30 35 80 100 80 100 1200 1800 2000 2000 50 50 50 50 600 800 1000 1000 ND ND ND ND ND ND ND ND ND ND ND ND 20 30 35 35 60 80 100 100 600 800 1000 1000 800 1000 800 1000 ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND 2.0 3.0 3.5 3.5 3.0 3.5 3.0 3.5 ND ND ND ND ND ND ND ND
17
913 y 1418 y 1970 y >70 y
Pregnancy
18 y 1950 y
Lactation
18 y 1950 y
Uls = The maximum level of daily nutrient intake that is likely to pose no risk of adverse effects. Unless otherwise specified, the UL represents total intake from food, water, and supplements. Due to lack of suitable data, ULs could not be established for vitamin K, thiamin, riboflavin, vitamin B12, pantothenate, biotin, or carotenoids. In the absence of Uls, extra caution may be warranted in consuming levels above recommended intakes. The ULs for vitamin E, niacin, and folate apply to synthetic forms obtained from supplements, fortified foods, or a combination of both. ND = Not determinable due to lack of data of adverse effects in this age group and concerns with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake.
Table 10. Dietary Reference Intakes: Recommended Intakes for Individuals, Elements Food and Nutrition Board, Institute of Medicine, The National Academies
Life Stage Ca Group (mg/d) Infants 06 mo 712 mo Children 13 y 48 y Males 913 y 1418 y 1930 y 3150 y 5170 y >70 y Females 913 y 1418 y 1930 y 3150 y 5170 y >70 y Pregnancy 18 y 1930 y 3150 y Lactation 18 y 1930 y 3150 y 1300* 1000* 1000* 44* 45* 45* 1300 1300 1300 3* 3* 3* 20 20 20 10 360 310 320 2.6* 2.6* 2.6* 50 50 50 1250 700 700 70 70 70 13 12 12 1300* 1000* 1000* 29* 30* 30* 1000 1000 1000 3* 3* 3* 220 220 220 27 27 27 400 350 360 2.0* 2.0* 2.0* 50 50 50 1250 700 700 60 60 60 12 11 11 1300* 1300* 1000* 1000* 1200* 1200* 21* 24* 25* 25* 20* 20* 700 80 00 00 00 00 2* 3* 3* 3* 3* 3* 120 150 150 150 150 150 8 15 18 18 8 8 240 360 310 320 320 320 1.6* 1.6* 1.8* 1.8* 1.8* 1.8* 34 43 45 45 45 45 1250 1250 700 700 700 700 40 55 55 55 55 55 8 8 8 8 8 1300* 1300* 1000* 1000* 1200* 1200* 25* 35* 35* 35* 30* 30* 700 80 00 00 00 00 2* 3* 4* 4* 4* 4* 120 150 150 150 150 150 8 11 8 8 8 8 240 410 400 420 420 420 1.9* 2.2* 2.3* 2.3* 2.3* 2.3* 34 43 45 45 45 45 1250 1250 700 700 700 700 40 55 55 55 55 55 8 11 11 11 11 11 500* 800* 11* 15* 340 440 0.7* 1* 0 0 7 10 80 130 1.2* 1.5* 17 22 460 500 20 30 3 5 210* 270* 0.2* 5.5* 200* 220* 0.07* 110* 0.5* 130* 0.27* 11 30* 75* 0.003* 0.6* 2* 3* 100* 275* 15* 20* 2* 3 Cr (g/d) Cu F (g/d) (mg/d) I (g/d) Fe (mg/d) Mg (mg/d) Mn (g/d) Mo (g/d) P (mg/d) Se (g/d) Zn (mg/d)
The table presents the Recommended dietary Allowances (RDAs) in bold type and Adequate Intakes (AIs) in ordinary type followed by an asterisk (*) RDAs and AIs may both be used as goals for individual intake. RDAs are set to meet the needs of almost all (9798%) individuals in a group. For healthy infants, the AI is the mean intake. The AI for other life-stage and gender groups is believed to cover needs of all individuals in the group, but lack of data or uncertainty in the data prevent stating with confidence the percentage of individuals covered by the intake. Ca = calcium; Cr = chromium; Cu = copper; F = fluoride; I = iodine; Fe = iron; Mg = magnesium; Mn = manganese; Mo = molybdenum; P = phosphorus; Se = selenium; Zn = zinc

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Table 11. Dietary Reference Intakes: Tolerable Upper Levels, Elements Food and Nutrition Board, Institute of Medicine, The National Academies
Ca (g/d) ND ND 2.5 2.5 ND ND 1000 3000 1.3 2.2 200 300 40 40 65 110 2 3 300 600 0.2 0.3 ND ND ND ND 0.7 0.9 ND ND 40 40 ND ND ND ND ND ND ND ND ND ND 3 3 45 60 90 150 Cr Cu (g/d) F (mg/d) I (g/d) Fe (mg/d) Mg (mg/d) Mn (mg/d) Mo (g/d) Ni (mg/d) P (g/d) Se (g/d) Si V (mg/d) ND ND ND ND ND ND ND ND Zn (mg/d) 4 5 7 12
Life Stage Group ND ND 3 6
As
B (mg/d)
Infants
06 mo 712 mo
ND ND
Children
13 y 48 y
ND ND
Males, Females 11 17 20 20 17 20 17 20 2.5 2.5 ND ND 8000 10000 10 10 900 1100 45 45 2.5 2.5 ND ND 8000 10000 10 10 900 1100 45 45 350 350 350 350 9 11 9 11 2.5 2.5 2.5 2.5 ND ND ND ND 5000 8000 10000 10000 10 10 10 10 600 900 1100 1100 40 45 45 45 350 350 350 350 6 9 11 11 1100 1700 2000 2000 1700 2000 1700 2000 0.6 1.0 1.0 1.0 1.0 1.0 1.0 1.0 4 4 4 3 3.5 3.5 4 4 280 400 400 400 400 400 400 400 ND ND ND ND ND ND ND ND ND ND 1.8 1.8 ND ND ND ND 23 34 40 40 34 40 34 40
1
913 y 1418 y 1970 y >70 y
ND ND ND ND
Pregnancy
18 y 1950 y
ND ND
Lactation
18 y 1950 y
ND ND
ULs = The maximum level of daily nutrient intake that is likely to pose no risk of adverse effects. Unless otherwise specified, the UL represents total intake from food, water and supplements. Due to lack of suitable data, Uls could not be established for arsenic, chromium, and silicon. In the absence of ULs, extra caution may be warranted in consuming levels above recommended intakes. The ULs for magnesium represent intake from a pharmacological agent only and do not include intake from food and water. ND = Not determinable due to lack of data of adverse effects in this age group and concerns with regard to lack of ability to handle excess amounts. Source of intake should be from food only to prevent high levels of intake. As = arsenic; B = boron; Ca = calcium; Cr = chromium; Cu = copper; F = fluoride; I = iodine; Fe = iron; Mg = magnesium; Mn = manganese; Mo = molybdenum; Ni = nickel; P = phosphorus; Se = selenium; Si = silicon; V = vanadium; Zn = zinc
Questions
According to CCCEP guidelines, participants have two attempts to achieve a score of 70% on the post-test questions. Successful participants will receive a certificate documenting their completion of the course. While not required to do so, participants are encouraged to use the feedback form to provide comments and suggestions about the course.
1. Which of the following is not among the most common reasons for taking a vitamin and/or mineral supplement? a. to make up nutrients missing from the food supply b. to reduce amount of money spent on food c. to fill a gap between need and what is actually consumed d. to boost energy 2. Most commonly, vitamin and mineral supplement users are a. older and in good health b. in need of supplementary nutrients because they eat poorly c. diagnosed with a nutrient deficiency d. taking a supplement as self-medication for a perceived illness The following scenario applies to questions 38: Lauren is a 21-year-old woman in the third year of a Bachelor of Arts program. She works as a clerk at a retail store two evenings a week and on Saturday, and she usually goes to the gym for a workout at least three times a week. Lauren likes to cook, but she does not have much time to spend preparing foods and she does not like to eat alone. Because money is tight, she doesnt buy much meat. Lauren likes milk and she usually manages to drink at least three glasses a day. Lauren was talking to some of her friends at school about what to eat and they mentioned that carbs cause you to gain weight and they have stopped eating bread and pasta. Lauren was thinking she would give this a try. She read an article in the student newspaper about ways to deal with stress and it mentioned that taking a supplement containing B vitamins could help. Lauren has come into the pharmacy and has asked you for advice. 3. Lauren is typical of young women of university age in that she is responding to media messages and peer influences regarding use of supplements and food choices. Considering her lifestyle and age, Lauren would benefit by taking a supplement providing a. calcium and vitamin D b. folate and vitamin B12 c. iron and vitamin C d. folic acid and iron
4. If Lauren were to consume 230 g of food folate, 110 g of folic acid from fortified bread, and a supplement containing 400 g of a folic acid taken with breakfast, what would this yield as Dietary Folate Equivalents? a. 740 g DFE b. 1080 g DFE c. 1280 g DFE d. 1520 g DFE 5. Lauren is contemplating avoidance of carbs in the form of bread and pasta from her diet. What effect will this have on her intake of vitamins and minerals? a. could lead to inadequate intake of thiamin b. could lead to inadequate intake of riboflavin c. could lead to inadequate intake of zinc d. could lead to inadequate intake of iron 6. There is no UL for vitamin B12. This could be interpreted to mean a. there is no potential risk of taking an excessive dose b. there was not enough evidence to establish a UL and it is safe to take any amount of the vitamin c. there was not enough evidence to establish a UL but it is not advisable to take excessive amounts of the vitamin d. it is better to take a high dose because more is better 7. Lifestyle behaviours that Lauren should consider to optimize absorption of dietary iron include a. avoiding drinking tea with meals b. avoiding adding cream sauces to vegetable dishes c. avoiding drinking orange juice with meals d. consuming calcium-fortified orange juice whenever possible 8. What product would you recommend to Lauren? a. mineral supplement containing iron, zinc and copper b. B-complex with C c. folate, vitamin B12, vitamin B6 d. multivitamin and mineral e. calcium with vitamin D

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The following scenario applies to questions 912: Amanda is a healthy 32-year-old woman in the first trimester of her first pregnancy. She has been experiencing considerable nausea and this has affected what she is able to eat. At her first prenatal visit, the doctor recommended that she take a vitamin supplement but did not give her any direction on which one to use. Amanda is overweight and her doctor has already spoken to her about weight gain. Her sister gained 22 kg with her first pregnancy and she has never been able to lose the extra weight. 9. Because nutrient requirements increase relatively more than the need for energy, Amanda will need to make nutrient-dense food choices during pregnancy. For some nutrients, it will be very difficult to meet recommendations without taking a supplement. Current Canadian guidelines for iron intake during pregnancy recommend that a. only women with inadequate iron stores should take an iron supplement during pregnancy b. all women should take an iron supplement during the 2nd and 3rd trimester c. only women following a vegetarian diet should take a supplement during pregnancy d. iron supplements are not necessary because storage iron will be mobilized to meet needs 10. Current recommendations for calcium intake during pregnancy are that a. extra dietary calcium should be taken in late gestation when fetal bones are mineralized b. extra dietary calcium should be taken in early gestation when calcium is deposited in the maternal skeleton c. extra dietary calcium is not necessary d. extra dietary calcium is necessary because efficiency of calcium absorption is decreased 11. Women who drink a litre of milk containing 10 g (400 IU) of vitamin D and who take a prenatal supplement containing 10 g (400 IU) of vitamin D a. are at risk of developing hypercalcemia b. are at risk of developing hypocalcemia c. should avoid taking other supplements containing vitamin D d. should also take a calcium supplement
12. Amanda asks for advice on which product to use. Which of the following criteria will guide your decision? a. The product should contain more than the RDA for all nutrients because intake from diet is unreliable and it is better to have more than not enough. b. The product should contain at least 30 mg of iron with or without zinc and copper. c. The product should not contain more than the RDA for vitamin A with or without -carotene. d. The product should contain both folic acid and vitamin B12 at twice the RDA. The following scenario applies to questions 1315: Charles was born after an uneventful full-term pregnancy. Amanda made the decision to breast feed the baby before he was born. Amanda is concerned about whether she should take a supplement, and she decided to continue to use the one she took while she was pregnant. 13. The amount of vitamins in breast milk a. will be inversely related to dietary intake b. plateaus when transport sites become saturated c. remains constant and is independent of intake from either food or supplements d. will be deficient if intake is inadequate because mothers needs take priority 14. During lactation, the predominant source of calcium in breast milk is from a. maternal bones b. calcium supplements c. fortified foods d. improved efficiency of calcium absorption from the gut 15. During lactation, if Amanda takes a supplement, it should a. contain vitamin D to make up for the low vitamin D content of breast milk b. contain iron to make up for blood loss at birth c. not contain iron because iron requirements are low d. not contain vitamin A because of potential risk of toxicity

21
The following scenario applies to questions 16 & 17: Charles continued to grow and develop normally. Amanda took a year of maternity leave, and she is intent on exclusively breast-feeding Charles until he is at least 8 months old, maybe even longer if all goes well. She was speaking to some women she met in the park and they said this was not a good idea and that she should start Charles on solid foods right away. 16. While breast milk is ideal for infants, iron stores can be depleted if breast-feeding is prolonged. A normal full-term infant who is exclusively breastfed will require an exogenous form of iron at a. 2 months of age b. 6 months of age c. 8 months of age d. 10 months of age 17. The AI for vitamin D was assumed to be sufficient to meet needs in the absence of exposure to sunlight. To account for climatic conditions, the vitamin D recommendation for healthy term infants living in Canada is a. 5 g (200 IU/d) b. 10 g (400 IU/d) c. 15 g (600 IU/d) d. 25 g (1000 IU/d) The following scenario applies to questions 1822: Gloria is a 55-year-old female who has been post-menopausal for three years. She tries to watch what she eats, but she doesnt care for dairy products and is concerned about whether she is getting enough calcium. Gloria has started to use the calcium-fortified orange juice available in the grocery store. Gloria tries to stay active. She walks in the evening with some of her friends and they get out at least four times a week regardless of the weather. Gloria wants to know if she should be taking a supplement in addition to the calcium-fortified orange juice. 18. Gloria is correct in thinking she needs to ensure she has adequate calcium intake now that she is post-menopausal. During the first 3 years after menopause, Gloria will lose a. ~9% of skeletal mass b. ~15% of skeletal mass c. ~3% of skeletal mass d. skeletal mass at the same rate as men
19. One litre of calcium fortified orange juice will provide about the same amount of total calcium as a litre of milk. Will this food source be sufficient to meet Glorias needs for bone health in the absence of dairy products? a. Yes, because it will provide enough calcium when combined with other dietary sources. b. No, because it will not provide enough phosphorus. c. Yes, because the vitamin C in orange juice will improve calcium absorption. d. No, because she still needs a source of vitamin D. 20. If Gloria were to take a calcium supplement, which one of the following dosing methods would lead to optimal calcium absorption? a. 500 mg of elemental calcium twice daily as calcium lactate with a meal b. 1000 mg of elemental calcium once daily as calcium citrate with a meal c. 500 mg of elemental calcium twice daily as calcium carbonate with a meal d. 1000 mg of elemental calcium once daily as calcium gluconate with a meal 21. Gloria should ask her health care professional about a vitamin B12 supplement because a. it is required to balance the effects of low dietary folate intake b. with advancing age vitamin B12 gets trapped as methyl vitamin B12 c. absorption of vitamin B12 decreases due to presence of atrophic gastritis d. vitamin D and vitamin B12 compete for transport across the gut 22. What supplement would you recommend for Gloria to take? a. multi-vitamin/mineral supplement with high-dose iron b. multi-vitamin/mineral complex without iron c. B-complex d. vitamin E

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The following scenario applies to questions 2325: Harold is an 84-year-old man who lives in a seniors residence in a small town north of Toronto. He pays a monthly rent for a room and three meals a day. Harold moved into the residence four years ago after his wife died. He lived alone for the first year but his daughter was concerned because he had slipped cognitively and he lost weight when he suddenly had to prepare meals for himself, and he did not like to eat alone. Harold used to work in his garden everyday; now he is content to sit inside and look out at the flowers. On her last visit, Harolds daughter noticed that he was walking with a shuffling gait and seemed to be a little unsteady on his feet and he was confused. She is concerned that he might fall and break his hip. Harold likes most of the food they offer at the residence because it is like the foods his wife used to make plain foods made without a lot of fuss and tea with milk. Harold has been in good health. He takes medication to regulate blood pressure and has been managed successfully since entering the residence. 23. Which of the following nutrients is a potential concern for Harold? a. riboflavin b. vitamin C c. vitamin E d. vitamin D 24. If Harold were to have a blood test that indicated no evidence of megaloblastic anemia, does this mean he does not have vitamin B12 deficiency? a. Yes, because anemia is always present with vitamin B12 deficiency. b. No, because anemia never occurs with vitamin B12 deficiency. c. No, because folic acid can mask anemia in the presence of vitamin B12 deficiency. d. Yes, because iron can mask vitamin B12 deficiency. 25. Which of the following supplements would come closest to meeting Harolds nutritional needs? a. multi-vitamin/mineral complex formulated with no iron b. B-complex with C c. calcium and zinc d. phosphorous
The following scenario applies to questions 2630: Dave is a 47-year-old truck driver who does long-haul runs from the container port in Halifax to Toronto. He usually does two up-and-back trips in a week and then has a few days off. He doesnt get much exercise and he smokes about a pack of cigarettes a day. Daves father died of a heart attack when he was 48. Recently his 52-year-old brother (who does not smoke) was hospitalized with chest pains and ended up having quadruple bypass surgery. Dave is tall and slim and doesnt have much trouble with his weight. When he is on the road, Dave eats mostly fast foods. When at home Dave eats what his wife prepares, which are usually meat and potato-type meals with bread. He does eat some vegetables, mainly turnip, carrots, corn, and peas. He also likes to drink orange juice. Dave does not drink much alcohol, as it doesnt fit with his work schedule. He might have a drink of rye on a special occasion. Dave has been having problems with heartburn and the doctor prescribed esomeprazole magnesium, which has provided relief. 26. What type of preventive CVD benefit would Dave be likely to achieve if he were to take a supplement providing ~300 mg/d of vitamin E? a. some benefit because this is a pharmacological dose b. no benefit unless it is also combined with -carotene c. no benefit has been identified d. some benefit because it will offset his poor dietary habits 27. A factor confounding epidemiological research on the relationship between dietary antioxidants and folate and cancer risk is a. age of the subjects b. intake of alcohol c. intake of other micronutrients, especially iron d. intake of meat 28. Hyperhomocysteinemia is a risk factor for cardiovascular disease and has a higher prevalence in families with a history of premature onset such as in Daves family. The vitamin with the greatest effect on homocysteine metabolism is a. vitamin B6 b. folate c. riboflavin d. vitamin B12

23
29. Dave is taking esomeprazole magnesium for treatment of heartburn. This drug acts as proton pump inhibitor to reduce gastric acidity. What could be a potential drug-nutrient interaction? a. decreased vitamin A absorption b. decreased vitamin E absorption c. decreased vitamin C absorption d. decreased vitamin B12 absorption 30. What supplement would you recommend for Dave to take? a. multi-vitamin/mineral supplement without iron b. calcium and phosphorous supplement c. vitamin E providing 10 times the RDA d. calcium and zinc supplement To earn CEUs associated with this CE program, you must complete the online post-test available at cpha.learning.mediresource.com.

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CPhA05 Nutrition05 W

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CPhA Professional Advancement

Nutrition and Health

The Role of Vitamin and Mineral Supplements

All material 2005 MediResource Inc.

Nutrition and Health

Nutrition and Health

Nutrition and Health

Table 1. Common reasons for taking a vitamin and mineral supplement

Table 2. Dietary Reference Intakes (DRIs)15

2. Dietary Reference Intakes

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3. Food versus supplements

Risk of adverse evetns

Table 4. Food sources of nutrients of concern throughout the lifecycle

4. Vitamin and mineral nutrition throughout the lifecycle

Adapted from Perspectives in Nutrition19

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Table 5. Nutrients of concern by life stage and age group

Nutrition and Health

Figure 2. Folate and homocysteine and methionine metabolism

Cystathionine -synthase Cystathionine

Table 6. Behaviours that increase iron requirements42

Nutrition and Health

Table 7. Select nutrients from five prenatal products available in Canada

4.4 Breast-fed infants

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4.5 Effect of aging on bone health

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4.6 Vitamin B12 and folate status with advancing age

5. Relationship of vitamin and mineral nutrition to chronic disease

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5.1 Cardiovascular disease (CVD)

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5.3 Immune function

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Table 8. Examples of drug-nutrient interactions

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60. 61. 62. 63.

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Life Stage Group

Appendix 1. Dietary Reference Intake Tables

913 y 1418 y 1930 y 3150 y 5170 y >70 y

Nutrition and Health

cpha.learning.mediresource.com All material 2005 MediResource Inc.

913 y 1418 y 1930 y 3150 y 5170 y >70 y

Life Stage Group

Nutrition and Health

cpha.learning.mediresource.com All material 2005 MediResource Inc.

913 y 1418 y 1970 y >70 y

Nutrition and Health

Life Stage Group ND ND 3 6

Nutrition and Health

cpha.learning.mediresource.com All material 2005 MediResource Inc.

913 y 1418 y 1970 y >70 y

Nutrition and Health

Nutrition and Health

Nutrition and Health

Nutrition and Health

Nutrition and Health