Vitamin supplementation

SUPPlemeNtAry qUeStioNS

ursula arens writer; nutrition & dietetics

Ursula has spent most of her career in industry as a company nutritionist for a food retailer and a pharmaceutical company. She was also a nutrition scientist at the british Nutrition Foundation for seven years. Ursula helps guide the NHD features agenda as well as contributing features and reviews.

the use of dietary supplements in the us has increased strongly over the past two decades. the latest industry data (5) states that 68 percent of all us adults reported taking dietary supplements. Figures show, as they have done consistently in the past that usage rates are slightly higher in women, in older adults, in the better off and the better qualified.

Nearly twice as many supplement takers trust doctors (56 percent) rather than nutritionists as a reliable source of information, and supplement takers all score higher for other healthy habits (better diets/less smoking/ more exercise). One very interesting observation is that supplement taking is especially high amongst health professionals. So it seems that most American doctors and nurses are not confident that they either 1) have wellbalanced healthy diets and/or 2) that such diets contain adequate amounts of particular nutrients. In any case, the data on the use of micronutrient supplements demonstrates that most American health professionals view their use as an essential tool to support their own good health (whatever they tell their patients).

Analysis by Hyun Ja Kim and colleagues (3), from the prolific gift-thatkeeps-on-giving, the long-term prospective Harvard cohort studies of Health Professionals, documents the use of dietary supplements over the 20 year period 1986 to 2006. The headline statement is that more than 88 percent of the women and 80 percent of the men reported some use of dietary supplements. But, within the massive swell of increased usage, there are some astonishing sub-plots. A specific contrast figure for the prevalence of use of at least one supplement in the general US population (National Health Interview Survey 2000 and NHANES 2003-2006), is 50 to 65 percent.

The average age of the subjects in the 75,000 strong female-only Nurses’ Health Study was 53 years; for the 50,000 strong male-only Health Professionals Follow-Up Study, it was slightly higher, at 55 years. In the 20-year period from 1986, the use of micronutrient supplements, i.e. excluding herbs or botanicals, blossomed by 17 percent in women and by an even greater amount of 25 percent in men. The hardy minority of health experts not taking any supplements crashed by more than 40 percent to the year 2006, to only 20 percent of the health professionals and 12 percent of the nurses.

When comparing the trend data, there are clear winners and losers. Out-of-favour in 2006 is the antioxidant triad of beta-carotene, vitamins C and E and also down are vitamin A and iron. Considerable disappointment in some of the intervention trials looking at the use of antioxidant nutrients to reduce the risk of heart disease and some cancers is a clear explanation for these shifts. It is probable that health professionals would be the first to know of trial outcomes, and would be more sensitive to the fine-tuning of information of the effects of individual micronutrients compared to the general population.

In contrast, there are strong gains in the use of other vitamins. Folic acid supplement use is up more than 13fold in women and more than 12-fold in men. Darling of the moment, vitamin D, is up more than14-fold in wom-

en and six-fold in men. Fish oil supplements are up 11-fold in women and nearly seven-fold in men. Figures for general all-in-one multivitamins show less spectacular growth, but the high base rates in 1986 of about 43 percent usage, makes current figures of about 72 percent astonishing.

Further general observations by Kim and colleagues were that supplement taking was higher in non-smokers (compared to smokers) and increased with age. Secular trend analysis showed that the increased use of many of the supplements was a result of real changes in practice and could not be explained by the ageing of the cohort population.

Several previous studies have reported on the intakes of micronutrient supplements in health professionals, although the data all relates to the US (1). Published data on use by dietitians is rarefied. A survey of 900 dietitians carried out in 1981 reports that 37 percent claimed to use supplements regularly. A later survey in 2001 amongst 676 student dietitians reports that 43 percent took supplements frequently/daily; of the 68 supervisory dietitians questioned, the figure was higher, at 53 percent. A survey of 300 dietitians published in 2012 (2), reports that 74 percent were regular users of dietary supplements.

There is not much information of the use of vitamin supplements by UK health professionals, but there are endless facts and figures on UK consumer practices (which of course, includes health professionals within this data). The most recent four-year NDNS survey issued in May 2014 reported that 17 percent of adult men and 27 percent of women had taken a nutrient supplement in the four-day survey period. These figures were significantly higher in those over the age of 65 years (35 percent/47 percent). The trade association Propriety Association of Great Britain (PAGB) reports stagnant retail sales in the year to December 2013, with an annual value of over £350 million (so annual per person spend of about £6). But strong growth areas in vitamin supplements are for products distributed via internet orders, where data is less available.

Industry experts planning UK supplement distribution will all have purchased the latest 130-page review of the sector by the market intelligence company Mintel (4). Published in September 2014, it is available for £1,750 + tax! The vitamin supplements report describes trends and predicts future developments: essential information to have before the investment of £££s in the production and marketing of these products. What does Mintel predict for the vitamin supplements market in the UK?

There are three strong themes that are likely to steer activity. Consumers want more personalisation of supplements, with the change in focus of communications. Instead of, for example, messages that vitamin x is good for tall red-haired women, the messages will target tall red-haired women with information on requirements for vitamin x. Market opportunities are particularly identified in the youngest and the oldest consumers. Secondly, in relation to the robust published opinions on health claims from the European Food Safety Authority (EFSA), there will be more muscular clamp-down on

incorrect or misleading labelling claims by the Advertising Standards Association. For example another negative verdict from ASA on a vitamin supplement product marketed at women planning pregnancy (Viabiotics product Pregnacare - conception), was issued in February 2015. This will put a tighter leash on some of the more excitable marketing promotions that can be made to develop the sales of supplements.

Thirdly, motivations to take supplements seem to have developed particularly in relation to appearance benefits, in women and in the young adults. It is a disappointment that being healthy is less the issue for this supplement-taking group, however having smooth skin, strong nails and glossy hair is vital. Other general themes identified as focus areas by the Mintel report are for women = weight gain/fatigue and healthy bones, and for men = healthy heart. The young (under 30s?) are in desperate want of ‘energy’, although the meaning of this is the consumer interpretation of vibrancy and vigour and not the dietitian’s meaning of calories from foods. The two meanings for the same word are an endless joy for marketers, especially those promoting particular drinks.

The use of dietary supplements can have very potent effects on nutrient intakes, and their use is so widespread and common that they must increasingly be the default assumption in assessments and discussions about nutrient intakes in populations. Clearly, dietitians are the experts in nutrition knowledge, but supplements sometimes seem to be part of the section: ‘non-diet, other’ in health assessments and many alternative health nutrition therapists claim this territory as their own. If patients need advice on supplements, then dietitians should be their first go-to, (and perhaps ask, “Which ones do you take?”).

Information sources 1 arens U (2001) News and Views: Expert practice. british Nutrition

Foundation Nutrition bulletin 26, 311-312 2 Dickinson a, bonci L, boyon N, Franco JC (2012). Dietitians use and recommend dietary supplements: report of a survey. Nutrition Journal 14, 11, 11-14 3 Kim HJ, Giovannucci E, rosner b, willett wC, Cho E (2014). Longitudinal and Secular trends in Dietary Supplement Use: Nurses’ Health Study and Health Professionals Follow-Up Study, 1986-2006. Journal of the academy of Nutrition and Dietetics, 114, 3, 436-443 4 Mintel (www.mintel.com) Vitamins and supplements UK report. September 2014 5 CrN consumer survey 2014 at www.crnusa.org

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REFERENCE:

1 Department of Health (1991) Dietary Reference Values for Food Energy and Nutrients for the United Kingdom. Report of the Panel on Dietary Reference Values of the Committee on Medical Aspects of Food Policy. HMSO, London. NHD0315

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Issue 102 March 2015

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DIET AND KIDNEY TRANSPLANTATION

Liz Rai p25

INTENSIVE CARE NUTRITION . . . p8

Emma Copeland Senior Dietitian

EARLY YEARS NUTRITION VITAMIN SUPPLEMENTATION IMD WATCH IRRITABLE BOWEL SYNDROME

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Liz Rai, Renal dietitian, newcastle upon tyne hospitals nhs Foundation trust

liz has worked as a renal dietitian at the freeman hospital since 2001. She works with patients with CKd and those receiving dialysis and also supports patients following a kidney transplant.

diet ANd KidNey trANSPlANtAtioN: dietetiC iNPUt Pre- ANd PoSt-KidNey trANSPlANt

a kidney transplant is considered the renal replacement method of choice for patients with end stage renal disease (esrD) (1). this article explores the dietetic challenges presented both pre- and post-transplant.

pRe-Kidney tRanspLant The patient awaiting a kidney transplant is usually receiving renal replacement therapy in the form of haemodialysis or peritoneal dialysis. A small number of patients may receive a pre-emptive renal transplant prior to requiring dialysis. The challenges in all groups are the same.

obesity Current guidelines state that patients with a BMI>30kg/m2 are at higher risk of perioperative complications and this risk increases in patients with a BMI >40kg/m2 (1). For this reason, a weight reducing diet may be required to enable a patient to lose the necessary weight to be listed for transplant. Dietetic advice can be similar to that given to a non-renal patient but within the context of a renal diet.

There is some evidence to suggest that bariatric surgery may be beneficial in reducing body weight prior to transplantation (2). There is also work that suggests the risks of performing bariatric surgery in patients with CKD outweighs the benefits and that this area requires further research (3). Orlistat may also have a role to play when combined with a low fat, low energy diet and exercise (4, 5).

Various studies have assessed the outcome of transplanting obese patients compared with non-obese. Outcomes considered included delayed graft function, acute rejection and graft and patient survival. A recent systematic review of 21 such studies published from 1990-2013 suggests that although delayed graft function may be more likely to occur in obese patients, there was no evidence of an association with longterm graft and patient survival (6). This suggests that a high BMI alone may not be an accurate indicator of a successful outcome post kidney transplant and patients should be assessed in the context of other comorbidities.

malnutrition Poor nutritional status may prevent a renal transplant taking place. In addition to delayed wound healing and increased risk of infection, there is evidence to suggest that very low BMI is associated with significantly worse graft and patient survival (17). Promotion of adequate nutrition to sustain a healthy BMI is, therefore, appropriate pre transplant and the use of oral nutritional supplements may be appropriate.

cardiovascular and bone health Effective control of serum phosphate, calcium and parathyroid hormone (PTH) levels in patients with ESRD is well documented in reducing the risk of long-term health problems, including cardiovascular disease (8) and vascular calcification (9). Although a successful kidney transplant normalises serum phosphate, effects of previous damage remain. Poor phosphate control prior to a kidney transplant has been shown to delay graft function and increase risk of graft failure (10). Pre transplant dietary support should therefore put high priority on promoting a low phosphate diet and adherence with phosphate binders.

post Kidney tRanspLant Adequate nutritional intake is essential for wound healing and recovery posttransplant. If necessary, nutritional supple-

ments and NG feeding should be initiated but in most cases these are not required.

Promotion of a healthy lifestyle is recommended for long-term good health and graft survival (11). Promoting maintenance of a healthy weight, avoiding hyperlipidaemia and advising on a healthy diet is part of this. Prior to their transplant, most patients have had their dietary choices limited by a low potassium, low phosphate, reduced salt and fluid restricted diet. On receiving a successful transplant, these restrictions are relaxed. Combined with improved appetite and steroids taken for immunosuppression, weight gain is likely. This increases the risk of cardiovascular complications. Dietetic advice should focus on promoting a balanced diet low in saturated fat and rich in fruit and vegetables centred on the Eat Well plate (12). A reduced salt diet is still applicable to aid blood pressure control (13), essential for prolonging transplant function (14) and reducing the risk of cardiovascular complications.

Additional dietetic challenges may also present post-transplant and these will now be discussed in more detail.

diabetes Diabetes or impaired glucose tolerance post-transplant is common and has been reported to affect 15 to 30 percent of patients in the first year (15). It is widely documented that steroids and the immunosuppressive agent Tacrolimus have a significant role to play in this (16). Relaxed dietary restrictions and weight gain may also play a part, as well as age and genetic background. Advice should be given to limit sugar and sugary foods, encourage regular meals containing carbohydrate and to follow a healthy diet as discussed above. For patients on steroids, blood sugar levels may return to normal as steroid dose is reduced.

hypophosphataemia The effect of a new kidney is to increase urinary excretion of phosphate. Hypophosphataemia is, therefore, common in the early postoperative period. A high dietary phosphate intake should be encouraged until levels improve to normal. Phosphate supplements may also be required. Care should be taken to inform patients that this a shortterm dietary intervention and that eating large quantities of high phosphate foods, such as cheese and milk, will also lead to a high fat intake. hyperkalaemia Despite a well-functioning kidney transplant, hyperkalaemia may still occur. This is usually caused by the immunosuppressive agents Tacrolimus and Cyclosporin. A low potassium diet is, therefore, necessary to keep levels within normal range and prevent hyperkalaemia. In some patients, this can be relaxed as immunosuppression is adjusted, but others may require a restriction long term.

other considerations Grapefruit and grapefruit juice affect the absorption of the immunosuppressive drugs Cyclosporin, Tacrolimus and Sirolimus. Patients should, therefore, be advised to avoid these. Adequate calcium intake should be encouraged for patients on longterm steroids to reduce the risk of steroid induced osteoporosis.

Food hygiene advice The use of immunosuppressive drugs may increase the risk of food born infections, although there is limited evidence to support this in renal transplant patients. One case-control study (17) found an incidence of listeria in only 0.12% of solid organ transplant recipients (of theses 26 percent were kidney transplant patients). However, of those who did contract the infection, a 30-day mortality rate of 26.7% was reported. In many units food hygiene advice is given which includes the avoidance of undercooked eggs and meat and avoidance of unpasteurized cheeses. Good hygiene practises in food preparation and storage are also essential.

concLusion Good nutrition has an important role to play in the health of renal patients’ pre- and post-renal transplant. There is good evidence to suggest that outcome can be affected if this is not achieved. Dietitians are best placed to provide nutritional advice and support to these groups of patients.

CASE STUDY

Mr F, aged 57, was first seen by the dietitian in predialysis clinic in October 2010. He weighed 138kg, BMI=49kg/m2, but did not have diabetes or evidence of cardiovascular disease. Advice on a low potassium, low phosphate and weight-reducing diet was provided.

pre-transplant

short term

post-transplant

Long term

achieve and maintain a healthy bmi promote adequate nutrition for wound healing maintain a healthy bmi

maintain phosphate, calcium and parathyroid hormone levels within target (18) promote a high dietary phosphate intake

advise on a low potassium diet if potassium levels >5.5mmol/L encourage an adequate phosphate and calcium intake for healthy bones continue a low potassium diet if levels remain raised

advise on a low sugar diabetic diet if raised blood sugars maintain a diabetic diet if ongoing impaired glucose tolerance or diabetes encourage a healthy, no added salt diet for long-term cardiovascular health

On starting dialysis in September 2011, his dry weight had reduced to 118kg (BMI=42kg/m2), phosphate control ranged from 1.9-2.3mmmol/L. He was assessed for a live donor kidney transplant in 2013 and a target weight of 98kg (BMI=35kg/m2) was stipulated prior to transplantation. Further dietetic input was provided to help with this.

Mr F completed a four-day diet diary, which revealed a high fat, high sugar diet. Advice on reducing his intake of these was given, along with reducing overall calorie intake. Mr F was keen to lose weight and also started swimming three times a week. By August 2014 his dry weight had reduced further to 108.5kg (BMI=39kg/m2). As a result of the changes to his diet, phosphate control had also improved to 0.93-1.53mmol/L (within target (18)). The transplant team were happy to proceed with the transplant, which was successfully performed in November 2014.

Following renal transplant, Mr F recovered quickly and had immediate graft function. Phosphate levels dropped to 0.46mmol/L, but returned to normal within four days. Potassium levels were within normal range. Healthy eating advice was provided on discharge. Two months post-transplant his weight had risen to 117kg (BMI 42). He, therefore, requires ongoing dietetic support to encourage weight loss and prevent cardiovascular complications.

references 1 Dudley C, Harden P (2011). assessment of the potential kidney transplant recipient. Clinical practice guideline. the renal association 2 Modanlou Ka, Muthylal U et al (2009). bariatric surgery among kidney transplant recipients: analysis of the United States renal Data System and literature review. transplantation 87 (8) 1167-1173 3 MacLaughlin H, Macdougall IC et al (2013). Safety and efficacy of bariatric surgery in obese patients with CKD: the London renal Obesity Network (LonrON) experience. abstract: meeting of Journal of american Society of Nephrology tH-Or111 4 Cook Sa, MacLaughlin H, Macdougall IC (2007). a structured weight management programme can achieve improved functional ability and significant weight loss in obese patients with chronic kidney disease. Nephrology Dialysis transplantation 23: 293-268 5 MacLaughlin HL, Cook Sa et al (2010). Non randomised trial of weight loss with Orlistat, nutrition education, diet and exercise in obese patients with CKD: two-year follow-up. american Journal of Kidney Diseases, 55/1(69-76) 6 Nicoletto bb, Fonseca NK et al (2014). Effects of obesity on kidney transplantation outcomes: a systematic review and meta-analysis. transplantation 98 (2) 167-175 7 Meier-Kriesche HU, andorfer Ja, Kaplan b (2002). the impact of body mass index on renal transplant outcomes: a significant independent risk factor for graft failure and patient death. transplantation 73 (1) 70-74 8 Covic a, Kothawala P et al (2008). Systematic review of the evidence underlying the association between mineral metabolism disturbances and risk of all-cause mortality, cardiovascular mortality and cardiovascular events in chronic kidney disease. 24:1506-1523 9 London GM, Guerin aP et al (2003). arterial media calcification in end-stage renal disease: impact on all cause and cardiovascular mortality. Nephrology Dialysis transplantation 18 (9) 11737-1740 10 Sapir-Pichhadze r, Parmar K, Kim SJ (2012). Pre transplant serum phosphate levels and outcomes after kidney transplantation. Journal of Nephrology 25 (06) 1091-1097 11 baker r, Jardine a, andrew P (2011). Post-operative care of the renal transplant patient. Clinical practice guideline. the renal association 12 the Eat well Plate. Crown copyright (2011). Department of Health in association with the welsh assembly Government, the Scottish Government and the Food

Standards agency in Northern Ireland 13 Sacks FM, Svetkey LP et al (2001). Effects on blood pressure of reduced dietary sodium and the dietary approaches to stop hypertension (DaSH) diet. New England

Journal of Medicine 344 (1) 3-10 14 Opelz G, Dohler b (2005). Improved long-term outcomes after renal transplantation associated with blood pressure control. american Journal of transplantation 5:2725-31 15 Chakkera Ha, weil EJ et al (2013). Can new-onset diabetes after kidney transplant be prevented? Diabetes Care 36:1406-1412 16 rodrigo E, Fernandez-Fresnedo G et al (2006). New onset diabetes after kidney transplantation: risk factors. Journal of american Society of Nephrology 17:S291-295 17 Fernandez-Sabe N, Cervara C et al (2009). risk factors, clinical features, and outcomes of listeriosis in solid-organ transplant recipients: a matched case control study.

Clinical Infectious Diseases 49:1153-1159 18 Steddon S, Sharples E (2010). CKD Mineral and bone disease. Clinical practice guideline. the renal association