NURSING NR 228 Nutrition Week 4 edapt - Introduction to Vitamins, - Chamberlain College of Nursing

Introduction to Vitamins Vitamins play a vital role in health and wellness and perform specific metabolic functions. From previous foundational courses, you have learned the function of these organic molecules (i.e. vitamins), to include their requirements in small amounts to support body functions.

As a health care provider, it is vital to understand the role of vitamins; how the body uses each, deficiencies, and use through supplementation. The controversies surrounding vitamins hold interest as well. Are fresh fruits better than sun-dried? Are frozen vegetables better than steamed? Am I supposed to supplement my diet? The answers to these questions varies, depending on who you ask and if any deficiencies exist.

In this learning module, you will gain knowledge of vitamin use for personal health and for educating clients about the essential need for vitamins to support optimal health and wellness. This introduction to vitamins includes:  Defining vitamins  Exploring vitamins role in health and wellness  Identifying vitamin categories and supplementation

Vitamins Which vitamins cannot be stored by the body, requiring individuals to ingest them each day?

Water-soluble vitamins Fat-soluble vitamins Nutrient-rich vitamins B complex vitamins Fat-soluble vitamins are vitamins are stored in fat cells. Water-soluble vitamins are vitamins that pass through the body's water supply. The body cannot keep these vitamins, so they must be ingested for the body to maintain an appropriate level.

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Fat-soluble vitamins include Vitamin A, D, E, and K. Water-soluble vitamins include thiamin, riboflavin, niacin, pyridoxine, folate, cobalamin, biotin, pantothenic acid, choline, and vitamin C.

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Vitamins How can individuals ensure their vitamin intake meets their body requirements?

Have labs drawn monthly to check therapeutic levels.

Ensure your diet includes a variety of foods from all of the food groups.

Take a vitamin supplement.

Rely on food purchases being fortified with vitamins.

The best way to ensure optimal vitamin intake is to eat nutrient-rich foods, which includes a diet with a variety of foods from all the major food

groups. Reliance on supplements and fortification of foods does not result in a therapeutic diet. Supplement use may be used to accompany primary or secondary vitamin deficiencies, but are for primary use.

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What Are Vitamins, Anyway?

Vit amins are nutrients; essential noncaloric, organic molecules needed in the diet. Often, they are referred to as micronutrients, since only small amounts are needed in the body to perform specific metabolic functions.

Vitamins act as helpers to get chemical processes done. They are essential for our bodies, and because we cannot produce them on our own, we must consume them. After vitamins are ingested, they act as precursors and turn vitamins into active chemicals. Vitamins are divided into two categories:  Fat-soluble vitamins: These are stored in fat cells, in the liver, and near the liver for 3—6 weeks.

 Water-soluble vitamins: These pass through the body's water supply.

The body cannot keep these vitamins, so they must be ingested for the body to maintain an appropriate level.

Vitamins often act as a buffer in many chemical reactions; they aid other nutrients in the digestion and absorption processes. Some vitamins can act as a precursor molecule in foods where, once ingested, they chemically rearrange into their active form. For example, the precursor of vitamin A is beta-carotene, and the active form is called retinol.

To promote health and wellness, vitamins and minerals are considered essential nutrients; and in acting together, they carry out hundreds of functional roles within the body. For example, they help with growth and development, strong bones, heal wounds, and strengthen your immune system.

Function of Vitamins What functions within the body are supported by vitamins? Select all that apply.

Vitamins often act as a buffer in many chemical reactions; they aid other nutrients in the digestion and absorption processes. Some vitamins can act as a precursor molecule in foods where, once ingested, they chemically rearrange into their active form.

Minerals help the body maintain fluid balance (sodium) and create gastric acids (chloride).

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Vitamin Intake Dietary Reference Intakes (DRIs) offer quantitative estimates of nutrient intakes to be used for planning and assessing diets applicable to healthy individuals in the United States and Canada (National Academies of Sciences, Engineering, & Medicine, 2020).

DRIs include Recommended Dietary Allowances (RDAs) for vitamin intake, which provides a standard of care for good nutrition.

RDAs represent the average daily dietary intake sufficient to meet the nutrient requirements of nearly all (97%-98%) healthy individuals in a particular life-stage or gender group.

Dietary Reference Intakes Review the infographic on DRIs to gain a better understanding of nutrient reference values.

Dietary Reference Intakes

Vitamins - Role in Health You have previously learned the Introduction to Nutrition, Health, and Wellness module about the six dimensions of health and their defining characteristics that support nutrition.

Now, let’s take a look in how vitamins play a vital role in the health dimensions to support physical, intellectual, emotional, social, spiritual, and environmental health.

References

Vitamins and Health Vitamins play a vital role in the health dimensions to support our physical, intellectual, emotional, social, spiritual, and environmental health.

Match the definition and image to the type of health dimension it represents.

Intellectual health 1 Social health 2 Spiritual health 3 Emotional health 4 Physical health 5 Environmental health 6

1. intellectual health 2. Social health 3. Spiritual health 4. Emotional health 5. Physical 6. Environmental

Physical health: Without vitamins the body can not continue to function.

They play an active role in cellular metabolism and metabolic functions.

Dietary recommendations include eating a variety of foods from the food groups – paying particular attention to fruits and vegetables which are packed with vitamins.

Intellectual health: Food choices can effect future abilities. For example, lack women of childbearing age who lack folate can lead to fetal growth and development problems, to include neural tube defects.

Emotional health: Vitamin B deficiencies can cause irritability and confusion, which effect mental health.

Social health: Older adults can be at-risk if they have mobility issues, and are not able to get to the grocery store. They may have to rely of family or friends to help with shopping needs.

Spiritual health: Cultural beliefs or religious teachings about specific foods may prevent clients from following dietary guidelines, therefore could pose a risk to vitamin deficiencies.

Environmental health: The best sources of vitamins are through a variety of healthy food, therefore if clients live in community with “food deserts” they may not have access to healthy food options. Also, the socioeconomic impact to be able to purchase healthy food options. Just think, it is often cheaper to buy processed, unhealthy foods, such as a pack of potato chips, then to purchase a bag of potatoes. When it comes to feeding one’s family, the limited financial means to purchase healthy foods impacts health.

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Vitamin Categories Vitamins are sorted into two (2) separate nutrient categories. Let’s take a look at the micronutrients that fall within their nutrient categories.

Transcript Link In your learning resources, review each of the vitamins to gain a clearer understanding of their function(s) within the body. In future learning modules, you will explore each vitamin in more depth.

Fat-Soluble Vitamins Vitamins are classified as fat-soluble or water-soluble. Which of the following are fat-soluble vitamins? Select all that apply.

Fat-soluble vitamins include vitamins A,D, E, and K. Vitamin C is a watersoluble vitamin.

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Vitamins - Role in Wellness Our primary source of vitamins should come from eating a variety of foods in multiple food groups. Following the recommended dietary standards, as learned in previous modules, will support receiving the essential vitamins needed to support overall health and wellness.

A healthy body includes following the Dietary Reference Intake (DRI), which provides nutrient requirements. Following the DRI guidelines is also to prevent deficiencies and toxicity from overdoses, and accounting for the value of nutrient intake as a means of reducing disease risk.

Recommendations include the use of fortified foods or supplements, such as folic acid for women of childbearing age, to support the health of the baby during pregnancy. Review the evidence-based recommendations.

Take the time to review the DRI table per life stage group and recommended vitamin dosages (National Academy of Sciences, 2011). Pay close attention to dietary recommendations for not only age-appropriate groups, but also for gender, pregnancy, and lactation.

Daily Recommended Intake (DRI) A health care provider is providing education to a 17-year-old mother about the recommended daily dosage of vitamin C and folate during lactation. What is the recommended daily dose for vitamin c and folate?

Review the DRIs to answer the following questions.

Question 1 / 2

What is the recommended daily intake of vitamin C for this lactating mother?

1300 mg/dL 120 mg/dL 115 mg/dL 15 mg/dL According to the summary table, a 17-year old female needs 115 mg/d of vitamin C Life StagVita Vita Vita Vita Vita Vita Vita Pantot Thia Ribofl Nia Fol Bio Chol e min min min min min min min henic min avin cin ate tin ine Gro A C D E K B6 B12 Acid up Lactation ★1 17 2.0 500 2.8 7* 35* 550* 4– 1,200115 15 19 75* 1.4 1.6 18 y 19– 1,300120 15 30 y

19

90* 1.4

1.6

17 2.0

500 2.8

7*

35* 550*

31– 1,300120 15 50 y

19

90* 1.4

1.6

17 2.0

500 2.8

7*

35* 550*

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Daily Recommended Intake (DRI) A health care provider is providing education to a 17-year-old mother about the recommended daily dosage of vitamin C and folate during lactation. What is the recommended daily dose for vitamin c and folate?

Review the DRIs to answer the following questions.

Question 2 / 2

What is the recommended daily intake of folate for this lactating mother?

500 ug/dL 600 ug/dL 700 ug/dL 800 ug/dL According to the summary table, a 17-year old female needs 500 μg/d of Folate.

Life Vitamin Vitamin Vitamin Vitamin Vitamin Vitamin Stage Thiamin (mg/d)Riboflavin (mg/d)Niacin (mg/d) F A (μg/d) C (mg/d) D (μg/d) E (mg/d) K (μg/d) B6 (mg/d) Group Lactation ★14– 1,200 115 15 19 75* 1.4 1.6 17 2.0 5 18 y 19– 1,300 120 15 19 90* 1.4 1.6 17 2.0 5 30 y 31– 1,300 120 15 19 90* 1.4 1.6 17 2.0 5 50 y

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Vitamin Deficiencies – At Risk Certain subgroups are at risk for vitamin deficiencies. According to the National Health and Nutrition Examination Survey (NHANES) significantly higher deficiency risk was seen in women (37%), non-Hispanic blacks (55%), individuals from low income households (40%), or without a high school diploma (42%), and underweight (42%) or obese individuals (39%) (Bird et al., 2017).

Subgroup populations at risk for vitamin deficiencies also include older adults (i.e. elderly) because of decreased vitamin absorption, limited physical abilities, and financial resources to purchase and prepare food.

Active adults, to include middle-aged, generally consume enough foods to ensure adequate vitamin intake.

Primary verses Secondary Deficiencies A primary vitamin deficiency occurs when the vitamin is not consumed in sufficient amounts to meet physiologic needs.

A secondary deficiency develops when absorption is impaired or excess excretion occurs, limiting bioavailability.

Individuals consuming an adequate diet based on the estimated average requirement had a lower risk of any deficiency (16%) than those with an inadequate diet (57%) and nearly one-third of the U.S. population is at risk of deficiency in at least one vitamin (Bird et al., 2017).

Think about your own personal health – Are you making healthy food choices, with a variety of vitamin-packed foods to support your health? If lacking, what foods and vitamins do you think your body may be needing?

Take the time to reflect on personal health as well as the dietary needs of your clients. Ask questions within the dimensions of health to identify if any vitamin deficiencies exist.

Malnutrition According to the Centers for Disease Control & Prevention (CDC, 2020), people most likely to be affected by micronutrient malnutrition are women, infants, young children, and adolescents. In 2000, the CDC established the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) program aimed to improve micronutrient nutrition globally for vulnerable populations. Take the time to review program details, to include micronutrient facts, global health and nutrition resources, and strategies and guidelines.

Strategies and Guidelines These strategies and guidelines support dietary guidelines and public health approaches to improve nutrition. Examples include:  Increase consumption of fruits and vegetables  Support breastfeeding mother and babies  School health guidelines to promote health eating and physical activity  Dietary guidelines  Workplace health promotion

Health Strategies According to the Centers for Disease Control & Prevention (CDC), what public health approaches aim to improve nutrition? Select all that apply.

Increase saturated and healthy fats Support breastfeeding mother and babies Health promotion in the workplace Support school health guidelines to promote health eating and physical activity Increase consumption of fruits and vegetables Strategies to support dietary guidelines and public health approaches to improve nutrition include: 1) Increase consumption of fruits and vegetables, 2) Support breastfeeding mother and babies, 3) Support school health guidelines to promote health eating and physical activity, and 4) Health promotion in the workplace.

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What are Vitamin Supplements?

The Federal Food, Drug, and Cosmetic Act defines a dietary ingredient as a “vitamin; mineral; herb or other botanical; amino acid; dietary substance for use by man to supplement the diet by increasing the total dietary intake; or a concentrate, metabolite, constituent, extract, or combination of the preceding substances and unlike drugs, “supplements are not intended to treat, diagnose, prevent, or cure diseases,” (U.S. Food & Drug Administration, 2020).

That means supplements, which include vitamins, should not make statements, such as “decreases cholesterol,” “prevents heart disease,” or “treats depression.” Statements like these can only justifiably be made for drugs, not dietary supplements.

Dietary supplements include such ingredients as vitamins, minerals, herbs, amino acids, and enzymes. Dietary supplements are marketed and sold in a variety of forms (i.e. capsules, tablets, liquids, etc.)

Take the time to review the vitamin supplemental fact sheets for health professionals.

References U.S. Food and Drug Administration. (2020, February 5). Dietary supplements. https://www.fda.gov/food/dietary-supplements National Institutes of Health, Office of Dietary Supplements. (2020). Vitamin and mineral supplement fact sheets. https://ods.od.nih.gov/factsheets/listVitaminsMinerals/

Do I Need Supplements?

Do you or your client take a multivitamin supplement? Why or why not?

Address the underlying reason for supplementation:  Primary or secondary deficiency  Considerations through all the dimensions of health (i.e. cultural considerations, food insecurities, etc.), not solely physical.  Consider which populations are at-risk for vitamin deficiencies, and whether supplementation is recommended for each group.

If adequate levels are not consumed as a result of social, cultural, or economic reasons, then it is the role of health professionals to provide guidance as to how to achieve these levels.

Supplements “More” does not always mean better.

Overuse of vitamin supplements is equivalent to a pharmacologic effect, with potential drug-like side effects. Vitamins can reach toxic levels in the body with overuse, especially with fat-soluble vitamins. Review the DRI recommendations for life stages and populations, and educate clients on taking the RDAs.

Remember, supplements may be necessary; however compare specific supplementation with functional foods for an individualized approach to nutritional therapy.

For some clients, taking vitamin supplements rather than making dietary and behavioral modifications for adequate nutrient seems easier. Client education is essential.

Interprofessional collaboration with a registered dietitian may be needed, to include social service support to help with nutrient intake when challenges are faced.

Deficiencies The nurse is educating older adults on the importance of vitamins for health and wellness. What is the best response by the nurse when someone asks why the might have a vitamin deficiency when their eating habits have not changed during the last 20 years?

“You are older and vitamins don’t work well in your body.”

“With age, absorption becomes impaired therefore older adults are at a higher risk for vitamin deficiencies.”

“You need more vitamins as you age due to absorption and excess excretion issues.”

“As you age, absorption may become increased therefore older adults are at a lower risk for a vitamin deficiency.”

A primary vitamin deficiency occurs when the vitamin is not consumed in sufficient amounts to meet physiologic needs. A secondary deficiency develops when absorption is impaired or excess excretion occurs, limiting bioavailability. Populations at risk for vitamin deficiencies include older adults because of decreased vitamin absorption with aging.

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Deficiencies Which vitamin is most likely to quickly deplete if dietary intake decreases?

K C D A Vitamin C is water soluble; vitamins A, D, E, and K are fat soluble.

Deficiencies of water-soluble vitamins develop more quickly because they are not stored in the body. They are absorbed and excreted more rapidly.

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At-Risk Populations Which client is at highest risk for vitamin deficiency?

18 year old college male living in a dorm 85 year old man living alone 24 year old soccer player 2 month old breastfed infant Populations at risk for vitamin deficiencies include older adults because of decreased vitamin absorption and limited physical and financial resources to purchase and prepare food. Active adults and college students generally consume enough foods to ensure adequate vitamin intake.

Vitamin deficiencies are rare among breastfed infants.

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Vitamins & Health Vitamins play a vital role in the health dimensions to support our physical, intellectual, emotional, social, spiritual, and environmental health.

Match the definition to the type of health dimension it represents.

Physical health

Children who don’t get the necessary vitamins in nutrient-rich foods can lead to deficiencies in learning and cognitive deficits.

Intellectual health

Cultural beliefs or religious teachings about specific foods.

Emotional health

Older adults may have to rely of family or friends to help with shopping needs.

Social health

Dietary recommendations include eating a variety of foods from the food groups – paying particular attention to fruits and vegetables which are packed with vitamins.

Spiritual health

The best sources of vitamins are through a variety of healthy foods, therefore if clients live in community with “food deserts” they may not have access to healthy food options.

Environmental health

Vitamin B deficiencies can cause irritability and confusion, which effects mental health.

 Physical health: Dietary recommendations include eating a variety of foods from the food groups – paying particular attention to fruits and vegetables which are packed with vitamins.  Intellectual health: Children who don’t get the necessary vitamins in nutrient-rich foods can lead to deficiencies in learning and cognitive deficits.  Emotional health: Vitamin B deficiencies can cause irritability and confusion, which effects mental health.  Social health: Older adults may have to rely of family or friends to help with shopping needs.  Spiritual health: Cultural beliefs or religious teachings about specific foods.

 Environmental health: The best sources of vitamins are through a variety of healthy foods, therefore if clients live in community with “food deserts” they may not have access to healthy food options.

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Vitamin Characteristics Identify the distinguishable characteristics of water-soluble verses fatsoluble vitamins.

Distinguishable Characteristics

Water-Soluble Vitamins

Fat-Soluble Vitamins

Not stored in the body Greater risk of deficiencies Excreted easily Deficiencies develop quickly B-complex Low risk of toxicity

Less likely to develop deficiencies High risk of toxicity Absorbed with lipids Excess stored in the body Vitamins A, D, E, & K

Water-soluble — B complex, absorbed and then excreted easily, minimal to no storage capabilities, deficiencies develop quickly, & and low risk for toxicity.

Fat soluble — Vitamins A, D, E and K, absorbed with fat (lipids), excess stored in the body, deficiencies take longer to develop, & greater risk of toxicity.

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Women who may become pregnant need to ensure adequate intake of folic acid to prevent neural tube defects. The neural tube forms in a fetus before many women know they are pregnant, and so it is important to

ensure adequate intake of folic acid before pregnancy. Riboflavin and vitamins C and K are all essential vitamins, but folate takes priority.

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Toxicity What is the most likely cause of vitamin toxicity?

Prescription medication use.

Eating too many fruits and vegetables.

Long-term, high-dose use of supplements.

Intake of fortified cereals and bread products.

Vitamin toxicity is usually caused by overuse; high-dose supplements over a long period of time. Fat-soluble overuse is especially concerning as the body will store the excess amounts. Levels of vitamins in fortified foods are not likely to be toxic, and very few foods contain high enough levels to cause toxicity. Most medications do not cause significant increases in vitamin absorption, so most likely not the cause.

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Vitamin Supplements What is the primary reason many individuals give for using vitamin supplements?

Not having time to prepare healthy meals.

It is easier than making dietary and behavioral modifications.

Taste better than nutritious foods They are cheaper than buying fruits and vegetables.

It is often easier to take vitamin supplements than to make dietary and behavioral modifications. Supplements do not necessarily taste good.

Preparing healthy meals may be an obstacle, however not a primary reason to use vitamin supplements. Supplements can be expensive, and are also not always cheaper than foods containing a variety of nutrients.

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Fat-Soluble Vitamins Vitamins are essential nutrients for our bodies, and because we cannot produce them on our own, we must consume them. Fat-soluble vitamins are one of the two major categories of vitamins.

Fat-soluble vitamins are absorbed along with fats in the diet and can be stored in the body’s fatty tissue. They come from plant and animal foods or dietary supplements. Vitamins A, D, E, and K are the specific fat-soluble vitamins we will explore through this learning module.

Take the time to review the vitamins module and function of fat-soluble vitamins prior to proceeding with this learning module.

Fat-Soluble Vitamins Fat-soluble vitamins are dependent on dietary fat for which process that supports health?

transportation metabolization absorption elimination Fat-soluble vitamins are dependent upon dietary fat for absorption. They can be stored in the body’s fat cells and are not excreted as easily as water-soluble vitamins. Transportation, metabolization, and elimination, are all steps of the process to get fat-soluble vitamins to the cells, only absorption from the digestive tract is dependent on dietary fat.

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Vitamin Differences There are distinct differences in fat-soluble vitamins verses water-soluble vitamins. Which of the following characteristics are unique to fat-soluble vitamins? Select all that apply.

High risk of toxicity Excreted easily Less risk of toxicity Deficiencies develop quickly Absorbed with lipids Fat soluble vitamins are A, D, E and K, absorbed with fat (lipids), excess stored in the body, deficiencies take longer to develop, & greater risk of

toxicity. Water soluble vitamins include B complex, absorbed and then excreted easily, minimal to no storage capabilities, deficiencies develop quickly, & and low risk for toxicity.

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Recommended Daily Allowances (RDAs) When discussing RDA with a group of young adults, the nurse uses which statement to best describe what they are?

“Least needed daily intake in a specified life stage group.”

“Guideline that sets the maximum intake of a nutrient that is unlikely to pose a risk of toxicity.”

“Daily intake that meets the nutrition needs of almost all individuals in a specified life stage groups.”

“Daily intake that meets the nutrition needs of the individuals who have a deficiency.”

Recommended Dietary Allowances (RDAs) are levels of intake of essential nutrients that are to meet the known nutrient needs of practically all healthy persons. The RDAs are recommended by the on the basis of scientific knowledge of different populations , as specified by life stage groups.

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Fat-Soluble Vitamins Fat-soluble vitamins are dependent upon dietary fat for absorption. They can be stored in the body’s fat cells and are not excreted as easily as water-soluble vitamins. These vitamins do not need to be eaten as often as water-soluble vitamins, although adequate amounts are still needed to maintain body functions.

Fat-soluble vitamins include:    

Vitamin A Vitamin D Vitamin E Vitamin K

A healthy, balanced diet from all of the major food groups usually provides enough fat-soluble vitamins for optimal health.

Let’s take a closer look at each vitamin.

Vitamin A

Th e active form of vitamin A is called retinol. Retinol has a yellowish-color pigment. The precursor, beta carotene, has an orange-colored pigment.

Vitamin A also helps with the growth of teeth and bone, boosts the immune system, keeps skin cells healthy, helps the rods and cones in the eyes stay healthy, helps with night vision, and may help decrease the probability of skin cancer and any cancer with the epithelial cells.

Therapeutic uses:  Maintains epithelial tissues (skin & mucous membranes)  Formation of rhodopsin (purplish-red, light-sensitive pigment present in the retina) for vision  Bone growth and reproduction Deficiency causes:  Night blindness (1st indication of deficiency)  Xerophthalmia (dry, thickened condition of the conjunctiva)  Keratomalacia (deterioration of the cornea)

 Blindness (Severe deficiency) Vitamin A can be absorbed in the form of topical solutions, such as soaps, creams, and lotions. Often you see it as an added ingredient to cosmetic products but it is also found in nonnutritive sources (i.e. medications). It can be ingested and absorbed more easily by eating green, yellow, and orange fruit and vegetables, such as broccoli and carrots, and animal fat sources, such as whole milk and liver.

In excess, vitamin A may cause weakness, anorexia, vomiting, and an enlarged spleen and liver, however toxicity is rare with healthy food consumption.

Vitamin A Deficiency Signs and Symptoms Review the top foods with vitamin A, and deficiency signs and symptoms below.

Transcript Link

Vitamin D Have you noticed the label on a gallon of milk? Often commercial milk and non-dairy products, such as orange juice, are fortified with vitamin D. There is truth to the common catch-phrase “Milk does a body good.”

Vitamin D is an essential vitamin that supports strong bones and growth and development. It is also one of the few vitamins that can be made by the body, as it is manufactured with the help of the sun.

Therapeutic uses:  Regulates calcium and phosphorus  Assists with bone mineralization & regulation of blood calcium levels

Deficiency causes:  Rickets in children  Osteomalacia in adults Vitamin D toxicity manifests as hypercalcemia and hypercalciuria.

A healthy diet, consuming animal sources: butter, egg yolks, fatty fish, liver, and fortified milk.

Sunlight & Sunscreen Let’s take a look at why sunlight is important. Watch the video below to learn more.

Vitamin D Aiding Growth and Development Review facts about Vitamin D below.

Transcript Link

Unique Features of Vitamin D Which feature of fat-soluble vitamins is unique to vitamin D? When exposed to sunlight, the skin can make vitamin D. It is a unique feature to this fat-soluble vitamin. Vitamin K is produced in the intestinal tract and the active form of Vitamin A is retinol. The other option does not apply.

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Vitamin E Vitamin E exists within nature in eight different forms: four from the tocopherol family and four from the tocotrienol family. Alpha-tocopherol is typically the most active form in humans and is the form of vitamin E that can be found in the largest quantities in our blood and tissue.

Therapeutic uses:  Protects cell walls  Antioxidant properties Deficiency causes:  Primary deficiencies are rare  Secondary deficiencies cause metabolic & neurological deficits Toxicities are rare; however, supplement use is contraindicated with anticoagulation drugs (risk for bleeding) Vitamin E can be found in such foods as plant-based vegetable oils, whole grains, seeds, nuts, and green, leafy vegetables.

Vitamin E Deficiency Signs and Symptoms Let’s review signs and symptoms of Vitamin E deficiency.

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Vitamin K Vitamin K is involved with blood clotting and keeps the thrombocytes (platelets) healthy. Scientists are still researching the cellular processes related to Vitamin K. Therapeutic uses:  Required for synthesis of prothrombin and other clotting factors (VII, IX, and X)  Formation of protein  Produced in the intestinal tract by bacteria  Warfarin overdose (reversal agent used) Deficiency causes:  Bleeding – note that newborns receive some vitamin K from their mother at birth (they just can't produce it yet due to sterile gut).

Once newborns have received milk for couple of weeks, there will be enough intestinal flora to produce their own vitamin K. During the interim, newborns receive a vitamin K injection after delivery to help prevent bleeding.

Toxic levels of Vitamin K are most often from injection reactions in infants, causing hemolytic anemia and hyperbilirubinemia.

Vitamin K is most abundant in green, leafy vegetables such as kale, collard greens, and spinach; green vegetables such as broccoli, brussels sprouts, and asparagus; also produced in the intestinal tract by bacteria.

Vitamin K Benefits and Sources Review the benefits and sources of Vitamin K.

Transcript Link

Reversal Agent Vitamins may have unique characteristics for therapeutic use. Which of the following vitamins is a reversal agent for warfarin?

Vitamin E Vitamin D Vitamin K Vitamin A Vitamin K is involved with blood clotting and keeps the thrombocytes (platelets) healthy. For warfarin overdoses, the reversal agent to prevent

further blood clotting is an injection of vitamin K. The other vitamins are not reversal agents for warfarin.

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Vitamin K Which of the following statements is true about sources of vitamin K?

Vitamin K is found in a wide variety of foods, so no deficiency can occur.

Vitamin K is produced by our own intestinal bacteria and is required for metabolic needs.

Vitamin K is easily absorbed, so we absorb all of the nutrient that we consume into our bodies.

Vitamin K is found in limited food sources, so a deficiency could occur.

Vitamin K is produced by our own intestinal bacteria and is required for our metabolic needs often in adequate amounts, therefore supplement use is rarely needed. It is most abundant in green, leafy vegetables and available in many food sources. We don’t necessarily absorb all of the nutrients we consume, especially with malabsorption issues. Deficiencies can occur with vitamin K, most likely from lack of a healthy diet, malabsorption issues, or with neonates/infants.

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Fat-Soluble Vitamins Let’s take a quick review of the fat-soluble vitamins.

Vitamin A Vitamin D Vitamin E Vitamin K

Sources of Fat-Soluble Vitamins Match the vitamin to its sources.

Nutrient Sources Fortified milk, cheese, cream, butter, fortified margarine, eggs, liver Vitamin A Leafy, dark green vegetables; dark orange fruits (apricots, cantaloupe) and vegetables (carrots, winter squash, sweet potatoes, pumpkin) Vitamin Egg yolks, liver, fatty fish, fortified milk; exposure to sunlight D Polyunsaturated plant oils (soybean, corn, cottonseed, Vitamin E safflower); green, leafy vegetables; whole-grain products; nuts and seeds

Nutrient Sources Green, leafy vegetables; green vegetables such as broccoli, Vitamin K brussels sprouts, and asparagus; also produced in intestinal tract by bacteria

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Recommended Dietary Allowances (RDAs) A healthy body includes following the Dietary Reference Intake (DRI), which provides recommended dietary allowances (RDA) and adequate intakes for vitamin to meet nutrient requirements.

Following the DRI guidelines is used to prevent deficiencies and toxicity from overdoses, and accounting for the value of nutrient intake as a means of reducing disease risk.

Review the RDAs for fat-soluble vitamins.

As a health care provider you may need to provide patient education on the daily recommendations for nutritional support.

RDAs According to the dietary reference intake guide, what is the recommended dietary allowance (RDA) for vitamin D in a 65 year old female?

5 ug/d 10 ug/d 15 ug/d 20 ug/d

According to the dietary reference intake guide, the recommended dietary allowance (RDA) of vitamin D in a 65 year old female is 15 ug/d. 5-10 ug/d is too low and 20 ug/d is the recommendation for females > 70 years old.

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Lifespan & Cultural Considerations Any individual across the lifespan that has malabsorption issues are atrisk of having a vitamin deficiency. In particular to fat-soluble vitamins are those clients who experience chronic fat malabsorption. Let’s review other special considerations.

Pharmacological Considerations Remember, vitamins are medications and are common supplements (either prescribed or over the counter (OTC)). Review possible food-drug or drug-drug interactions. For example, clients taking sotretinoin (Accutane) and isotretinoin (oral forms) are at risk for vitamin A toxicity as those medications contain vitamin A. Women of childbearing age who take either of these drugs should be counseled to use an alternative, reliable method of birth control. Use of these medications during pregnancy can cause birth defects.

The effectiveness of anticoagulant medications and other “blood-thinning” drugs can be decreased by high intakes of vitamin K from either foods or supplements. Clients on these types of medications should be educated on vitamin K food sources, and to watch their consumption of foods containing this essential vitamin.

Pharmacological Considerations Remember, vitamins are medications and are common supplements (either prescribed or over the counter (OTC)). Review possible food-drug or drug-drug interactions. For example, clients taking sotretinoin (Accutane) and isotretinoin (oral forms) are at risk for vitamin A toxicity as those medications contain vitamin A. Women of childbearing age who take either of these drugs should be counseled to use an alternative,

reliable method of birth control. Use of these medications during pregnancy can cause birth defects.

The effectiveness of anticoagulant medications and other “blood-thinning” drugs can be decreased by high intakes of vitamin K from either foods or supplements. Clients on these types of medications should be educated on vitamin K food sources, and to watch their consumption of foods containing this essential vitamin.

Vitamin E A health care provider is providing discharge teaching on medication and nutritional therapy needs. The client’s medication history includes apixaban, insulin, acetaminophen, and bupropion and with fat malabsorption issues, has a vitamin E deficiency.

First, the provider explains a diet rich in vitamin E that includes plantbased vegetable oils, whole grains, seeds, nuts, and green, leafy

vegetables. The client states “Can I just purchase a vitamin E supplement to make sure I get enough in my body.”

For what potential complication is the client at risk?

Risk for aspiration Risk for infection Risk for noncompliance Risk for bleeding Toxicities are rare; however, supplement use is contraindicated with anticoagulation drugs (risk for bleeding). The client is on apixaban, an anticoagulant, which is contraindicated with supplement use. Educate the client that vitamin E can found with a healthy diet that includes plantbased vegetable oils, whole grains, seeds, nuts, and green, leafy vegetables. The other risks do not apply.

Your response is correct!

Vitamin K Deficiency An individual on long-term antibiotic therapy is at risk for vitamin K deficiency for which reason?

Antibiotics kill gut bacteria Limits the ability to stimulate production of vitamin D Causes kidney damage Lack of intrinsic factors Antibiotics kills healthy gut bacteria that help synthesize vitamin K, therefore long-term use of antibiotics may cause a vitamin K deficiency.

Intrinsic factor is required for absorption of vitamin B12, not vitamin K. Skin exposure to sunlight stimulates production of vitamin D, not vitamin K. Kidney damage is less likely from antibiotic use.

Your response is correct!

1. Exposure to sunlight produces vitamin D from a cholesterol precursor in the skin.

2. Vitamin D and sufficient levels of calcium and phosphorus can prevent rickets in children and osteomalacia in adults.

3. Good sources of vitamin K are found in green, leafy vegetables such as kale and spinach.

4. A large portion of the amount of vitamin K that is required for metabolic purposes is produced by our own intestinal bacteria.

5. Older adults need more vitamin D from foods because their skin manufactures less.

6. In excess, vitamin A may cause weakness, anorexia, vomiting, and an enlarged spleen and liver.

7. Newborns are deficient in vitamin K, therefore receive an injection after delivery.

8. Supplements of vitamin E are contraindicated with anticoagulation drugs due to the risk for bleeding.

9. The effectiveness of anticoagulant medications and other “bloodthinning” drugs can be decreased by high intakes of vitamin K from either foods or supplements.

10.

Clients taking sotretinoin (Accutane) and isotretinoin (oral forms) are at-risk of vitamin A toxicity as those medications contain vitamin A.

Your response is incorrect!

Vitamin D What is the main reason that the recommended daily allowance (RDA) for vitamin D increases in older adults?

They need more vitamin D for bone growth.

Their inability to absorb vitamin D and convert to its active form.

Their skin is less efficient in synthesizing vitamin D during sun exposure.

To prevent bone loss due to low levels of calcium and phosphorus.

Older adults need more vitamin D from foods because their skin manufactures less. Older adults need more dietary vitamin D because their skin is less effective in synthesizing vitamin D during sun exposure to meet their nutritional needs. Their ability to absorb and convert vitamin D to its active form has a lesser effect on vitamin D needs. They do not necessarily require more vitamin D than do younger adults for bone health.

Your response is correct!

Nutrient Functions Match the vitamins below to their proper functions.

Nutrient Function Regulates calcium and phosphorus; Assists with bone mineralization & Vitamin D regulation of blood calcium levels.

Vitamin E Antioxidant; protects cell walls.

Vitamin K Needed for proper blood clotting.

Needed for vision, healthy skin and mucous membranes, vision, bone growth Vitamin A and development.

Your response is correct!

Toxicity A female client presents to their primary care provider’s office for a follow-up visit due to a recent diagnosis malabsorption issues. She is taking vitamin A supplements. The health care provider is reviewing the medication history with the client.

What finding in the client’s medication history is most concerning to the health care provider?

Clients taking sotretinoin (Accutane) and isotretinoin (oral forms) are at risk for vitamin A toxicity as those medications contain vitamin A. Women of childbearing age who take either of these drugs should also be counseled to use an alternative, reliable method of birth control too. Use of these medications during pregnancy can cause birth defects. The other medications are not a known drug-drug interaction with vitamin A.

Your response is correct!

Sources of Nutrients You are providing client teaching on food sources for fat-soluble vitamins.

Identify the nutrient and food source in which the specific vitamin can be found.

Vitamin D

Vitamin A

Vitamin E

Nutrient Food Sources Vitamin A from animal sources (retinol): fortified milk, cheese, cream, butter, fortified margarine, eggs, liver Vitamin ABeta-carotene (from plant sources): Leafy, dark green vegetables; dark orange fruits (apricots, cantaloupe) and vegetables (carrots, winter squash, sweet potatoes, pumpkin)

Nutrient Food Sources Vitamin Egg yolks, liver, fatty fish, fortified milk.

D Polyunsaturated plant oils (soybean, corn, cottonseed, Vitamin E safflower); green, leafy vegetables; whole-grain products; nuts and seeds Vitamin K

Green, leafy vegetables; green vegetables such as broccoli, brussels sprouts, and asparagus.

Your response is correct!

Vitamin K Which meal will provide the highest levels of vitamin K?

Stir-fried beef with broccoli Tilapia and fresh fruit Cereal and milk Liver and onions The best source of vitamin K is green leafy vegetables, such as broccoli.

Dairy products, meats, cereals, and fruits provide smaller amounts. Liver is high in vitamin A.

Your response is correct!

Water Soluble Vitamins Water-soluble vitamins are one of the two major categories of vitamins.

Just like fat-soluble vitamins they are essential nutrients for our bodies,

and because we cannot produce them on our own, we must consume them.

After ingestion, water-soluble vitamins are dissolved in water and as a result are easily absorbed into the tissues of the body. Most vitamins are water-soluble and include the B complex group; thiamin (B1), riboflavin (B2), niacin (B3), pyridoxine (B6), folate, cobalamin (B12), biotin, and pantothenic acid. Other water-soluble vitamins include choline and vitamin C. We will explore each of these vitamins throughout this learning module.

Take the time to review the vitamins module and function of watersoluble vitamins prior to proceeding with this learning module. Also, think through various deficiencies and differences between fat verses watersoluble vitamins.

Vitamin Differences

There are distinct differences in fat-soluble vitamins verses water-soluble vitamins. Which of the following characteristics are unique to watersoluble vitamins? Select all that apply.

Deficiencies develop quickly Excreted easily Less risk of toxicity High risk of toxicity Absorbed with lipids Water-soluble vitamins are absorbed and then excreted easily, minimal to no storage capabilities, deficiencies develop quickly, & and low risk for toxicity. Fat-soluble vitamins are absorbed with fat (lipids), excess stored in the body, deficiencies take longer to develop, & have a greater risk of toxicity.

Your response is correct!

A health care provider would need to know whether the individual smokes cigarettes because smokers require more vitamin C than nonsmokers. A vegan diet raises concerns about intake of vitamin B12, as this vitamin is not found in plants; found only in animal foods. Regular exposure to sunlight and milk intake affect vitamin D status but not vitamin C status.

Drinking fruit juice is a source of vitamin C, however the higher risk is cigarette smoking.

Your response is incorrect!

Nutritional Deficiencies Identify the correct water-soluble vitamin with its deficiency. 

Thiamine

— Beriberi which effects the nervous and circulatory systems.



Riboflavin

— Ariboflavinosis is the group of symptoms of swollen lips, cheilosis, glossitis, and seborrheic dermatitis. 

Niacin

— Pellagra is deficiency disorder, which includes dermatitis, dementia and diarrhea (three D’s). 

Folate

— May cause neural tube defects in children. 

Vitamin C

— Scurvy, disease that causes inflammation and weakening of connective tissue.

Your response is correct!

Water-Soluble Vitamins As the name suggest, water-soluble vitamins dissolve in water. They metabolize quicker than fat-soluble vitamins, are easily absorbed through the small intestine, and then travel through the blood to various tissues within the body. Any excess are excreted through urination. Let’s look at the water-soluble vitamins.  B-Complex Vitamins:  Thiamin (B1)  Riboflavin (B2)  Niacin (B3)  Pyridoxine (B6)  Folate (B9)

 Cobalamin (B12)  Biotin (B7)  Pantothenic acid (B5)  Choline (B4)  Vitamin C A healthy, balanced diet from all the major food groups usually provides enough water-soluble vitamins for optimal health. Supplementation is not needed in healthy individuals. In general, if supplementation is needed then the individual often has an underlying cause. Nutrient deficiencies are most often secondary to the effects of illness, treatment, socioeconomic factors, age, and/or lifestyle choices.

Water-Soluble Vitamins Now, let’s look at the individual water-soluble vitamins. Use your learning resources as you review the nutrient, its function, deficiency , toxicity, and

food sources for each vitamin-type. Note any special considerations for vitamin-types.

Click on each vitamin below to learn more.  Thiamine (vitamin B1)         

Riboflavin (vitamin B2) Niacin (vitamin B3) Pyridoxine (vitamin B6) Folate (folic acid, B9) Cobalamin (vitamin B12) Biotin (vitamin B7) Pantothenic acid (vitamin B5) Choline (vitamin B4) Vitamin C (ascorbic acid)

Function

Deficiency

Toxicity

Supplementation

Sources

Coenzyme (substance that activates an enzyme) needed for energy metabolism; important for nerve function related to the action of muscles

Muscle weakness, loss of coordination, and tachycardia. Alters nervous system, muscle activity, GI and CV systems, known as Beriberi. Still occurs in some areas of the world (i.e. Asia) where white rice is the major food source.

Rice is a lowin thiamin.

Excess is excreted in urine.

Toxicity is not common.

Recommended for individuals with underlying nutrient deficiency, chronic excessive alcohol consumption and those with thiamine deficiencies.

Lean po wholegrain or enriched breads a cereals, legumes nuts and seeds.

Recommended for individuals during treatments or disorders that effect insufficient nutritional intake.

Severe deficiency leads to WernickeKorsakoff Syndrome which is a cerebral form of beriberi. Neurotoxic effects such as loss of memory, mental confusion, ataxia occurs and often displayed by individuals with chronic alcohol use.

1.

2.

3.

Vitamin B Complex Health Benefits

Review the overall health benefits of Vitamin B complex.

Vitamin C Health Benefits Let’s review Vitamin C health benefits.

Cobalamin Which is the most likely reason an individual would require regular injections of vitamin B12 (cobalamin)?

Doesn’t supplement as recommended.

Has malabsorption issues.

Does not produce intrinsic factor.

Drinks excessive amounts of alcohol.

Vitamin B12 injections are necessary for patients who do not produce intrinsic factor, which is essential for absorption of vitamin B12 from the gut. A vegan diet needs vitamin B12 supplements because this vitamin is found only in animal foods. However, they can use oral supplements because they are still able to absorb the vitamin; they do not need injections. Alcoholism does not affect absorption of vitamin B12.

Malabsorption syndromes may decrease absorption of vitamin B12, but with adequate dietary intake and supplements, affected patients may still be able to absorb enough from the gut.

Your response is correct!

Riboflavin Intake When speaking with a group of older adults, the health care professional recommends which lifestyle change to increase intake of riboflavin?

replace romaine lettuce salad with spinach salad. eat cereal with skim milk for breakfast instead of toast and coffee. drink orange juice instead of coffee. make sandwiches with whole grain bread instead of white bread.

The most significant source of riboflavin in the United States is milk & milk products, and so switching to cereal with milk for breakfast would increase riboflavin intake. Replacing romaine lettuce with spinach would increase intake of folate. Replacing coffee with orange juice would increase vitamin C intake. Whole grains are all good but lesser sources of riboflavin than milk or milk products.

Your response is correct!

Biotin Which lunch supplies the highest amount of biotin?

Roast beef and swiss sandwich with salad Peanut butter and jelly sandwich with chips Cheeseburger and french fries Egg whites and fresh fruit

The richest sources of biotin include liver, peanut butter, egg yolks, and yeast.

Your response is correct!

Water- Verses Fat-Soluble Differences How are water-soluble vitamins different than fat-soluble vitamins?

Let's compare. Main differences between water-soluble vitamins and fatsoluble vitamins is how they are absorbed and function within the body.

One major benefit to water-soluble vitamins is that it is less likely for them to build up in the body, even in large amounts. Any excess will exit the body when you urinate. This also means that because water-soluble vitamins are either used or excreted so quickly, you’ll need to consistently get them into your body through nutrient-rich foods and supplements that help fill nutritional gaps.

Fat-soluble vitamins don’t immediately leave the body and, instead, are stored in fatty tissue and in the liver. Because fat-soluble vitamins are stored in the body, excess is more likely—and that’s not necessarily a good as toxicity can occur.

Toxicity is less likely with water-soluble vitamins. Regardless of the vitamin-type, it is important to follow recommended dietary guidelines and collaborate with the health care team, to include dietitians, for nutritional guidance and support.

Water vs. Fat-Soluble Vitamins Main difference between water-soluble vitamins and fat-soluble vitamins is how they are absorbed and function within the body. One major benefit to water-soluble vitamins is that it is less likely for them to build up in the body, even in large amounts. Any excess will exit the body when you urinate (sweat). This also means that because water-soluble vitamins are either used or excreted so quickly, you’ll need to consistently get them into your body through nutrient-rich foods and supplements that help fill nutritional gaps.

Remember from previous learning that fat-soluble vitamins don’t immediately leave the body and, instead, are stored in fatty tissue and in the liver. Because fat-soluble vitamins are stored in the body, excess is more likely—and that’s not necessarily a good thing.

Remember, toxicity can occur.

Toxicity is less likely with water-soluble vitamins. Regardless of the vitamin-type, it is important to follow recommended dietary guidelines and collaborate with the health care team, to include dietitians, for nutritional guidance and support.

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Recommended Dietary Allowances A healthy body includes following the Dietary Reference Intake (DRI), which provides recommended dietary allowances (RDA) and adequate intakes for vitamins to meet nutrient requirements.

Following the DRI guidelines is used to prevent deficiencies and toxicity from overdoses, and accounting for the value of nutrient intake as a means of reducing disease risk.

Review the RDAs for water-soluble vitamins.

As a health care provider you may need to provide patient education on the daily recommendations for nutritional support. As you review the RDAs for water-soluble vitamins, pay special attention to any high-risk groups.

Lifespan Considerations Certain individuals may be at-risk of having a water-soluble vitamin deficiencies. Let’s review these special considerations.  Chronic alcohol consumption can cause a multitude of nutritional deficiencies. Nutritional support generally includes supplementation of B-complex vitamins and vitamin C.  Folate supplementation is needed for childbearing women, during pregnancy and lactation.  Older adults at higher risk of cobalamin (vit. B12) deficiency due to reduction of intrinsic factor by stomach mucosa. Deficiency in this population results in psychiatric symptoms; delusions and hallucinations. It could mimic a mental health disorder, when in fact, the underlying problem is a vitamin deficiency.  Chronic antibiotic use and long-term intravenous feedings (IV) are known to decrease the number of biotin-producing “good” bacteria to support GI health. Supplementation of biotin may be needed.

Vitamin Deficiency A homeless man presents to the community health clinic with muscle weakness, loss of coordination, and tachycardia. An alcohol-odor was noted on his breath. The man may be suffering fr Alcoholism increases the body’s need for thiamin and may contribute to a secondary thiamin deficiency. Severe deficiency leads to WernickeKorsakoff Syndrome which is a cerebral form of beriberi. Neurotoxic effects such as loss of memory, mental confusion, ataxia and tachycardia occurs and often displayed by individuals with chronic alcohol use.

Symptoms of riboflavin deficiency include cheilosis, glossitis, and dermatitis. Niacin deficiency causes pellagra, characterized by dermatitis, dementia, and diarrhea. Symptoms of folate deficiency include megaloblastic anemia, glossitis, diarrhea, irritability, depression, and anxiety.

Your response is correct!

Disease Prevention – Folic Acid

Let’s look at public health in action. This video documents the story of how fortification of folic acid has become vital and instrumental in the lives of women of child-bearing age to; 1) protect their babies from developing major birth defects such as spina bifida and anencephaly, and 2) how spina bifida could be the next major health problem eliminated due to the use of folic acid.

Climate & Scurvy In which area of the country is a person most likely to experience scurvy?

In Florida close to the ocean.

In an Appalachian village in southern Ohio.

In California wine country.

On the east coast, one of the New England states.

Scurvy is caused by vitamin C deficiency. Both Florida and California produce a multitude of citrus fruits and vegetables, which are excellent sources of vitamin C. A community on the coast of Maine does not necessarily produce good sources of vitamin C locally, but it is connected to commercial transportation, and so a variety of foods are likely available.

A remote village in southern Appalachian Ohio may not have good access to fresh fruits and vegetables during the winter months, and so scurvy could potentially develop.

Your response is correct!

Older Adults Which vitamin level is most important to assess when an older adult develops delusions and hallucinations?

Iron Folate

Vitamin C Vitamin B12 Delusions and hallucinations may be signs of vitamin B12 deficiency.

Intrinsic factor is produced by the stomach and is vital for absorption of vitamin B12. Loss of intrinsic factor in older adults contributes to vitamin B12 deficiency. Vitamin C deficiency causes scurvy. Folic acid deficiency may cause irritability, depression, and anxiety, and thiamin deficiency causes memory loss and confusion, but neither of these is associated with delusions and hallucinations.

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Types of Anemia The type of anemia associated with folate deficiency is megaloblastic anemia. Microcytic anemia is associated with iron deficiency. Pernicious anemia is associated with vitamin B12 deficiency. Iron-deficiency anemia is associated with deficiency of iron, not of folate.

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Metabolic Need Which individual has the greatest need for thiamin?

A pregnant woman.

A professional cyclist.

A young adult who lifts weights for recreational use.

An older adult who walks 1 mile a daily.

Thiamine needs are related to metabolic rate (i.e., energy expenditure) because thiamine is a coenzyme in energy metabolism and important for nerve function related to the action of muscles. Therefore, the

professional cyclist needs the most thiamin because they have the greatest energy needs. Pregnancy, walking, and weightlifting all increase energy needs, but less than professional athletic training.

Your response is correct!

Meal Planning – Vitamin C You are providing patient education in ways to increase the vitamin C content for a healthy diet. Which of the following foods would you recommend choosing in larger amounts?

Green peppers, strawberries, and oranges Milk, cheese, and eggs Liver, other organ meats, and seafood Enriched cereals and fortified margarine Found only in fruits and vegetables, especially citrus fruits, vegetables in the cabbage family, cantaloupe, strawberries, peppers, tomatoes, potatoes, lettuce, papayas, mangoes, kiwifruit. Some foods and drinks are fortified with vitamin C (i.e. cereal and juice). Meats, or animal products, do not include vitamin C. Cereals may be fortified with vitamin C but not an original source.

Your response is correct!

Case Study - Pregnancy

Susan and her partner are about to have their first consultation with Dr. Jones, obstetrician,. Susan is pregnant with their first child.

“We’re so excited about this pregnancy and want to do things right,” as stated by the partner.

“We’re both healthy, walk daily, and try to eat the right foods. We want to know if there’s anything we should do differently while I’m pregnant.”

The obstetrician has recommended vitamin supplements and provides further education on _________ to help prevent neural tube defects.

Identify the supplement that Susan should take during her pregnancy to help prevent neural tube defects?

Zinc Vitamin C Folate Vitamin D Folate has a role in the proper formation of fetal neural tubes. Folate is most important vitamin to prevent neural tube defects in the fetus. She should make certain she is getting an increased amount of folate. Rich

sources of folate are in vegetables; spinach, broccoli, asparagus, dark leafy greens, and whole grains.

Your response is correct!

Nutrients During Pregnancy

Susan states that she is drinking only whole, organic milk from a dairy known for its clear glass bottles.

“These keep in flavor so much better and keep the milk colder than plastic,” she says, “so it stays fresher.”

What education would you provide Susan about maximizing the nutrients in milk during her pregnancy?

Organic milk can be purchased but purchase it only in glass containers.

Glass containers will help preserve the riboflavin in milk.

Organic milk is great, but purchase milk in containers that do not use clear glass bottles. A nontransparent, opaque bottle, whether glass or plastic, will help preserve the riboflavin in milk.

Organic milk is not pasteurized and can introduce unnecessary bacteria into your body. Drink pasteurized milk in containers that do not use clear glass bottles.

Organic milk is great, but purchase milk in containers that do not use clear glass bottles. A glass or plastic container will help preserve the vitamin C in milk.

Riboflavin is sensitive to ultraviolet rays in sunlight and artificial light; most of the riboflavin is destroyed if milk, an excellent source of riboflavin, is sold in clear glass or clear plastic containers. Organic milk is great, but purchase milk in containers that do not use clear glass bottles. A nontransparent, opaque bottle, whether glass or plastic, will help preserve the riboflavin in milk. Milk does not have vitamin C. Nothing in the scenario suggests the milk is unpasteurized.

Your response is correct!

1. Vitamin C provides support for the immune system and protects memory.

2. Chronic alcohol consumption can cause a multitude of nutritional deficiencies. Nutritional support generally includes supplementation of B-complex vitamins and vitamin C. 3. Folate supplementation is needed for childbearing women, during pregnancy and lactation to prevent neural tube defects.

4. Older adults at higher risk of cobalamin deficiency due to reduction of intrinsic factor by stomach mucosa. Deficiency in this population results in psychiatric symptoms; delusions and hallucinations. It could mimic a mental health disorder, when in fact, the underlying problem is a vitamin deficiency.

5. Chronic antibiotic use and long-term intravenous feedings (IV) are known to decrease the number of bacteria in the intestinal tract.

Supplementation of biotin may be needed, which assists in good bacteria production to support GI health.

6. Cigarette smokers have lower levels of vitamin C (metabolic use is increased), therefore supplementation is recommended.

7. Numerous medications may decrease folate absorption; oral contraceptives, anticonvulsants, aspirin, chemotherapy, NSAIDS and antacids.

8. Toxicity of niacin produces a “flushing” effect throughout the body effects the vascular system. Often the face will feel warm and have a reddish-appearance.

9. Severe thiamine deficiency leads to Wernicke-Korsakoff Syndrome which is a cerebral form of beriberi. Neurotoxic effects such as loss of memory, mental confusion, ataxia occurs and often displayed by individuals with chronic alcohol use.

10.

Milk is sold in nontransparent containers to protect riboflavin (i.e. cardboard and/or opaque plastic). This vitamin is sensitive to sunlight’s UV rays and artificial light. Loss of this vitamin occurs with use of glass or clear plastic containers.

Your response is correct!

Minerals Minerals play an important physiologic role in achieving nutritional wellness. They circulate in our body fluids to help facilitate biochemical reactions to support optimal health. These inorganic substances are found naturally within the earth but have a critical role in maintaining homeostasis as they interact with other elements in our body to support our health.

With a healthy diet, you will have an adequate amount of these minerals to support health, however fortification and supplementation may be necessary in certain health conditions. This module will provide an overview of the essential major minerals and trace minerals that support our health and wellness.

Public Health Strategies Which strategies and public health approaches are aimed to prevent mineral malnutrition? Select all that apply.

Increase consumption of processed foods.

Support breastfeeding mother and babies.

School health guidelines to promote health eating and physical activity.

Dietary guidelines.

Workplace health promotion.

These strategies and guidelines support dietary guidelines and public health approaches to improve nutrition. Examples include:  Increase consumption of fruits and vegetables

 Support breastfeeding mother and babies  School health guidelines to promote health eating and physical activity  Dietary guidelines  Workplace health promotion Increased consumption of processed foods are not recommended as they are not nutrient-rich food sources.

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Minerals Minerals are obtained from both plant and animal foods. Which of the following foods are good sources of dietary minerals? Select all that apply.

Fish Whole grains Beef Legumes Chicken Minerals are obtained from both plant and animal foods. Legumes, whole grains, beef, chicken, and fish are good sources of dietary minerals.

Your response is correct!

Electrolytes are key minerals, but not all minerals are electrolytes.

Electrolytes are best defined as specific minerals in the body that contain an electric charge. They are found in blood, urine, and other body fluids.

Maintaining a precise electrolyte balance keeps the body's blood chemistry, muscle action, and other processes running smoothly. Sodium is a major extracellular electrolyte for fluid regulation, body fluid levels and acid-base balance. Potassium works in conjunction with sodium and

chloride. Potassium is the major intracellular electrolyte for fluid regulation.

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Adding Minerals to Food What is the process in which minerals are added to food to supplement mineral content?

Homeostasis Fortification Glycogen Gluconeogenesis Food fortification is the process by which vitamins and minerals are added to food to supplement mineral content. Breakfast cereal is a common food item that is fortified with vitamins and minerals.

Homeostasis mean balance or equilibrium. Glycogen is the process by which fat is used as energy and Gluconeogenesis is the process in which glucose is stored as fat.

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What Are Minerals?

Minerals are crucial for proper body growth and good health. Minerals are inorganic substances that are found naturally within the earth. They have a critical role interacting synergistically with other elements and body systems to support health in our bodies.

Minerals the body needs are classified into two categories called: Major Minerals

Major minerals must be consumed in the amount of 100 mg or higher daily. These are often referred to as macrominerals.

Major minerals include: Sodium, Chloride, Potassium, Calcium, Phosphorus, Magnesium and Sulfur Trace Minerals These minerals are required in the daily amount of 20 mg or less and are often referred to as microminerals.

Trace minerals include: Iron, Zinc, Iodine, Selenium, Copper, Manganese, Fluoride, Chromium and Molybdenum

Comparing Major and Trace Minerals Minerals are obtained from both plant and animal foods. Legumes, whole grains, beef, chicken, and fish are good sources of dietary minerals.

Minerals do not break down in heat and will remain intact while

Mineral

Function

Sources

Iron

Part of a molecule (hemoglobin) found in red blood cells that carries oxygen in the body; needed for energy metabolism

Organ meats; red meats; fish; poultry; shellfish (especially clams); egg yolks; legumes; dried fruits; dark, leafy greens; iron-enriched breads and cereals; and fortified cereals

Zinc

Part of many enzymes; needed for making protein and genetic material; has a function in taste perception, wound healing, normal fetal development, production of sperm, normal growth and sexual maturation, immune system health

Meats, fish, poultry, leavened whole grains, vegetables

Iodine

Found in thyroid hormone, which helps regulate growth, development, and metabolism

Seafood, foods grown in iodine-rich soil, iodized salt, bread, dairy products

Selenium

Antioxidant

Meats, seafood, grains

Copper

Part of many enzymes; needed for iron metabolism

Legumes, nuts and seeds, whole grains, organ meats, drinking water

Manganese

Part of many enzymes

Widespread in foods, especially plant foods

Fluoride

Involved in formation of bones and teeth; helps prevent tooth decay

Drinking water (either fluoridated or naturally containing fluoride), fish, and most teas

Chromium

Works closely with insulin to regulate blood sugar (glucose) levels

Unrefined foods, especially liver, brewer's yeast, whole grains, nuts, cheeses

Molybdenu m

Part of some enzymes

Legumes; breads and grains; leafy greens; leafy, green vegetables; milk; liver

cooking. A good example of this is intentional mineral “leaching”. For example, chicken bones are boiled to where the minerals are leached into the fluid for a nutrient-rich broth. It is important to note that minerals do not provide energy once they are absorbed, however minerals are the catalyst for many metabolic processes.

Here is a list of major and trace minerals, their functions, and commonly found food sources.  Major Minerals  Trace Minerals

Minerals as Electrolytes Some minerals, called electrolytes, dissolve in water and can hold an electric charge. All electrolytes are minerals, but not all minerals are electrolytes. Electrolytes are best defined as specific minerals in the body that contain an electric charge. They are found in blood, urine, and other body fluids. Maintaining a precise electrolyte balance keeps the body's blood chemistry, muscle action, and other processes running smoothly.

Sodium is a major extracellular electrolyte for fluid regulation, body fluid levels and acid-base balance.

Potassium works in conjunction with sodium and chloride. Potassium is the major intracellular electrolyte for fluid regulation.

You would have learned more about these important minerals in foundational learning courses. Take the time to re-review.

Transcript Link Sodium is a major extracellular electrolyte for fluid regulation, body fluid levels and acid-base balance.

Potassium works in conjunction with sodium and chloride. It is the major intracellular electrolyte for fluid regulation.

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Mineral

Function

Chloride

Needed for proper fluid balance, stomach acid

Calcium

Important for healthy bones and teeth; helps muscles relax and contract; important in nerve functioning, blood clotting, blood pressure regulation, immune system health

Phosphorus

Important for healthy bones and teeth; found in every cell; part of the system that maintains acid-base balance

Magnesium

Found in bones; needed for making protein, muscle contraction, nerve transmission, immune system health

Sulfur

Found in protein molecules

Your response is correct!

Mineral

Sources

Iron

Organ meats; red meats; fish; poultry; shellfish (especially clams); egg yolks; legumes; dried fruits; dark, leafy greens; iron-enriched breads and cereals; and fortified cereals

Zinc

Meats, fish, poultry, leavened whole grains, vegetables

Iodine

Seafood, salt, bread, dairy products

Selenium

Meats, seafood, grains

Copper

Legumes, nuts and seeds, whole grains, organ meats, drinking water

Manganese Widespread in foods, especially plant foods Fluoride

Drinking water, fish, and most teas

Mineral

Sources

Chromium

Unrefined foods, especially liver, brewer's yeast, whole grains, nuts, cheeses

Molybdenum

Legumes; breads and grains; leafy greens; leafy, green vegetables; milk; liver

Your response is correct!

Mineral Bioavailability Heat from cooking does not affect the minerals in the food we eat.

However, the way food is prepared can affect mineral availability.

Bioavailability is the absorption of consumed nutrients. A factor that can affect mineral absorption is food processing. Milling or blanching of food can cause removal of minerals during processing.

Food Fortification Often, it is difficult to obtain all the minerals necessary from our diets.

This is where food fortification processing helps. Food fortification is when minerals are added with food to help supplement an adequate intake of the essential minerals.

Cereal, milk, flour and rice are commonly fortified food items.

Transcript Link

Food Fortification Which statement best describes food fortification?

When foods are blanched or milled to extract mineral content.

When supplements are added to food to help increase their calories.

When food binders are added to the products for the purpose of improving the texture.

When minerals are added with food to help supplement an adequate intake.

Food fortification is when minerals are added with food to help supplement an adequate intake of the essential minerals. In some areas, it is difficult to obtain all the minerals necessary from our diets so supplementation may be needed. This is where food fortification processing helps. The other options are not relevant to food fortification.

Your response is correct!

Hidden Hunger “Micronutrient deficiency is often called ‘hidden hunger’. It attracts less attention than the obvious starvation of people who are unable to get enough food to survive. It refers instead to the sickness that affects people who can only afford cheap, filling food that is deficient in essential vitamins and minerals” (Copenhagen Consensus Center, n.d.).

You will see food fortification as a public health effort to prevent mineral deficiencies. Watch the video below to learn more.

Micronutrient Malnutrition According to the World Health Organization (WHO), iron deficiency is the most common form of micronutrient malnutrition globally, and in the United States, one of every six women is iron deficient during pregnancy;

deficiency is higher among non-Hispanic blacks and Hispanics (WHO, 2020). Severe anemia during pregnancy can result in poor fetal growth, preterm birth, low birth weight, and increased risk of death for the mother and the baby.

According to the Center’s for Disease Control & Prevention (CDC, 2020), people most likely to be affected by micronutrient malnutrition are women, infants, young children, and adolescents. In 2000, the CDC established the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) program aimed to improve micronutrient nutrition globally for vulnerable populations.

Micronutrient Malnutrition Take the time to review the IMMPaCt program details, to include micronutrient facts, strategies, and guidelines.

These strategies and guidelines support dietary guidelines and public health approaches to improve nutrition. Examples include:  Increase consumption of fruits and vegetables  Support breastfeeding mother and babies  School health guidelines to promote health eating and physical activity  Dietary guidelines  Workplace health promotion As a health care provider, you will care for clients with micronutrient deficiencies. Understanding their role in health and wellness will help improve growth and development, disease prevention, and well-being.

Recommended Dietary Allowances Minerals A healthy body includes following the Dietary Reference Intake (DRI), which provides recommended dietary allowances (RDA) and adequate intakes for minerals to meet nutrient requirements.

Following the DRI guidelines is used to prevent deficiencies and toxicity from overdoses, and accounting for the value of mineral intake as a means of reducing disease risk.

Mineral RDAs Review the RDAs for minerals.

As a health care provider you may need to provide patient education on the daily recommendations for nutritional support. As you review the RDAs for minerals, pay special attention to any high-risk groups.

Water is Important!

As previously discussed, major minerals are needed by the body in the amounts of 100mg or higher. Trace minerals are needed in the amounts of 20mg or less. Often, minerals can be obtained from consuming water.

Major minerals are needed by the body in the amounts of 100mg or higher. Trace minerals are needed in the amounts of 20mg or less. Often, minerals can be obtained from water. Hard water contains a large amount of mineral deposits. Soft water is water that has had its minerals removed and replaced with sodium. It’s important for the nurse to carefully assess clients who consume large amounts of soft water and who are sodium sensitive.

Your response is correct!

Fortified Verses Unfortified Which foods below are fortified? Select all that apply.

Peaches Milk Apples Flour Cereal Lemons Salt

Processed foods, including cereal, flour, milk, and salt are often fortified with minerals. Fresh foods, such as peaches, lemons, and apples are not processed to add minerals.

Your response is correct!

Anemia in Pregnancy Iron-deficiency anemia during pregnancy can result in which of the following health conditions? Select all that apply.

Preterm birth.

Poor fetal growth.

Low birth weight.

Increased risk of death for the mother and the baby.

High blood glucose levels.

According to the World Health Organization (WHO), iron deficiency is the most common form of micronutrient malnutrition globally, and in the United States, one of every six women is iron deficient during pregnancy; deficiency is higher among non-Hispanic blacks and Hispanics (WHO, 2020) Severe anemia during pregnancy can result in poor fetal growth, preterm birth, low birth weight, and increased risk of death for the mother and the baby. High blood glucose levels are not a result of severe anemia.

Your response is correct!

Sodium is in table salt.

Bananas are high in potassium (fresh fruit) Milk is high in calcium.

Phosphorus is in processed foods, to include soda pop (i.e. soft drinks).

Limit intake of soda, which is also high in sugar.

Your response is correct!

Mineral

Function

Sodium

Promotes acid-base balance, blood volume, and extracellular fluid balance

Chloride

Needed for proper fluid balance, stomach acid

Potassium

Needed for proper fluid balance, nerve transmission, and muscle contraction

Calcium

Important for healthy bones and teeth; helps muscles relax and contract; important in nerve functioning, blood clotting, blood pressure regulation, immune system health

Phosphorus

Important for healthy bones and teeth; found in every cell; part of the system that maintains acid-base balance

Magnesium

Found in bones; needed for making protein, muscle contraction, nerve transmission, immune system health

Sulfur

Found in protein molecules

Your response is correct!

According to the Center’s for Disease Control & Prevention (CDC) (2020), people most likely to be affected by micronutrient malnutrition are women, infants, young children, and adolescents. In 2000, the CDC established the International Micronutrient Malnutrition Prevention and Control (IMMPaCt) program aimed to improve micronutrient nutrition globally for vulnerable populations. As a health care provider, you will care for clients with micronutrient deficiencies. Understanding their role in health and wellness will help improve growth and development, disease prevention, and well-being.

Women Infants Adolescents Young children Your response is correct!

Trace Minerals Match the trace mineral with its food sources.

Meats; shellfish (esp. clams); egg yolks; legumes; dried fruits; dark, leafy greens Iron

Meats, leavened whole grains, vegetables Zinc

Seafood, foods grown in iodine-rich soil, iodized salt, bread, dairy products Iodine

Legumes, nuts and seeds, whole grains, organ meats, drinking water Copper

Widespread in foods, especially plant foods Manganese

Your response is correct!

Milk, salmon, and tuna will increase calcium absorption. All of these items are ways to increase vitamin D intake which will promote calcium absorption. It is important to mention vitamin D is important for the absorption of calcium. Based on the National Institute of Health data, cod liver oil, trout, and salmon are the highest in vitamin D (NIH, 2020).

Remember, vitamin D is a fat- soluble vitamin, therefore clients who have

alterations in absorbing fat soluble vitamins will have alterations in absorbing calcium.

Your response is correct!

Minerals Identify each mineral as a Major or Trace mineral.

Major Sodium

Trace

x

Iron

x

Folic Acid

x

Chloride

x

Potassium

x

Iodine Calcium

Neither

x

x

Tocopherol

x

Fluoride

x

Chromium

x

 Major Minerals include:  Sodium, Chloride, Potassium, Calcium  Trace Minerals include:  Iron, Iodine, Fluoride, Chromium  Both folic acid and tocopherol are vitamins.



Your response is correct!

Antioxidants Antioxidants are substances that can prevent or slow damage to cells caused by free radicals. Free radicals are waste substances produced by cells as the body processes food, reacts to internal forces and the environment. Antioxidants are known to help counteract free radicals in our body and are believed to help decrease risk of certain diseases, enhance our health, and promote overall wellness.

In this learning module, you will learn about select antioxidants and health effects of oxidative stress. The vitamins and/or minerals that are suggested to have antioxidant properties include Vitamin A, Vitamin C, Vitamin E, and Selenium.

Antioxidants

Which of the following antioxidants may decrease the risk of some cancers and cardiovascular (CV) disease? Select all that apply.

Vitamin A Vitamin B Vitamin C Vitamin D Vitamin A and Vitamin C antioxidant functions may decrease the risk of some cancer-types and cardiovascular disease. Vitamin B and Vitamin D are not known to have antioxidant properties.

Your response is correct!

Antioxidants Which statements are true regarding antioxidants? Select all that apply.

Protect against cell damage Increase risk of disease Decrease risk of disease Work against free radicals Work for free radicals Antioxidants work against free radicals in our body and are believed to help decrease risk of certain diseases, enhance our health, and promote overall wellness. Antioxidants can protect against the cell damage that free radicals cause, known as oxidative stress.

Your response is correct!

High-Risk Use Which vitamin, taken in large amounts as a nutritional supplement, increases risk for severe liver damage?

Selenium Vitamin A Vitamin E Iron High levels of selenium is toxic and can cause severe liver damage (Grodner, et. al., 2020). High-dose vitamin A supplements increased the risk of lung cancer in smokers and use of high-dose vitamin E supplements increased the risk of hemorrhagic stroke and prostate cancer (NCCIH, 2013). Iron is not an antioxidant.

Your response is correct!

Why are Antioxidants Important?

Antioxidants work against free radicals in our body and are believed to help decrease risk of certain diseases, enhance our health, and promote overall wellness. Antioxidants can protect against the cell damage that free radicals cause, known as oxidative stress.

Factors that can lead to oxidative stress (i.e. cellular damage) include: Mitochondrial activity Excessive exercise Tissue trauma, due to inflammation and injury Ischemia and reperfusion damage Consumption of certain foods, especially refined and processed foods, trans fats, artificial sweeteners, and certain dyes and additives  Smoking     

 Environmental pollution  Radiation  Exposure to chemicals, such as pesticides and drugs, including chemotherapy  Industrial solvents  Ozone

References Healthline Media, Medical News Today. (2018). How can antioxidants benefit our health? https://www.medicalnewstoday.com/articles/301506

Antioxidants

Antioxidants work against free radicals in our body and are believed to help decrease risk of certain diseases, enhance our health, and promote overall wellness. Antioxidants can protect against the cell damage that free radicals cause, known as oxidative stress.

Your response is correct!

What is Oxidative Stress?

Antioxidants are said to be the body’s defense mechanism against free radicals and oxidative stress. If you don’t eat a healthy diet and/or the body can’t remove these free radicals efficiently, then oxidative stress can result.

Oxidative Stress Let’s take a closer look at oxidative stress.

Importance of Antioxidants Remember, free radicals are waste substances produced by cells as the body processes food (i.e. diet), reacts to internal forces (i.e. inflammation or injury) and the environment (i.e. ultraviolet light exposure, cigarette smoke, etc.). They cause cellular damage. An overabundance of these

“harmful” free radicals may increase the risk of certain diseases. Eating a healthy diet, rich in antioxidants, is believed to help reduce these risks.

Now, let’s review the various antioxidants, their function in reducing oxidative stress, and major food sources. Some of these will look very familiar as they are vitamins and/or minerals with antioxidant properties too.

Vitamin A Vitamin C Vitamin E Selenium

Antioxidant Function Identify the antioxidant with its function by selecting the correct responses from the drop down menu.

Vitamin A, not vitamin E or selenium, may decrease the risk of various cancer-types and cardiovascular disease.

Use of vitamin E, not vitamin C or vitamin A, may prevent or delay cataracts.

Selenium, not vitamin E or vitamin C, functions to help prevent cellular and lipid damage.

Vitamin C plays a role in decreasing risks of various cancer-types and cardiovascular disease, similar to vitamin A.

Your response is correct!

Recommended Dietary Allowances (RDAs) A healthy body includes following the Dietary Reference Intake (DRI), which provides recommended dietary allowances (RDA) and adequate intakes for vitamin and minerals to meet nutrient requirements.

Following the DRI guidelines is used to prevent deficiencies and toxicity from overdoses, and accounting for the value of nutrient intake as a means of reducing disease risk.

Antioxidant RDAs Review the RDAs for antioxidants.

Selenium RDA for an adult is 55ug. Daily recommended supplementation is no more than 200ug (Grodner et al., 2020). This antioxidant is one not listed on the DRI list.

As a health care provider you may need to provide patient education on the importance of antioxidants and daily recommendations to nutritional support.

References Grodner, M., Escott-Stump, S., & Dorner, S. (2020). Nutritional foundations and clinical applications: A nursing approach (7th ed.). Elsevier.

National Academy of Sciences. (2011). Dietary reference intakes (DRSs): Recommended dietary allowances and adequate intakes, vitamins. https://www.ncbi.nlm.nih.gov/books/NBK56068/table/summaryt ables.t2/?report=objectonly

Selenium RDA With a recommended daily allowance of 55 micrograms (ug), the daily recommendation for selenium is no more than which amount?

600ug 300ug 900mg 200ug The recommended supplementation of selenium to prevent cellular membrane damage is no more than 200ug a day. The other levels are high-dose and put the client at risk for severe liver damage.

Your response is correct!

Antioxidants & Evidence-Based Practice Antioxidants can be man-made through supplements or ingested as a natural substance within a healthy diet. Diets high in antioxidant properties may decrease the risk or delay some types of cellular damage, however not enough research has shown that antioxidant supplementation supports disease prevention (NCCIH, 2013). Preference is obtaining the necessary dietary recommendations through a healthy

diet, which includes nutrient-rich fruits and vegetables. Supplementation may be necessary with malabsorption issues or through other primary disease-types that effect absorption.

Antioxidant Supplementation Antioxidants can be man-made through supplements or ingested as a natural substance within a healthy diet.

Diets high in antioxidant properties may decrease the risk or delay some types of cellular damage, however not enough research has shown that antioxidant supplementation supports disease prevention (NCCIH, 2013).

Your response is correct!

Is More Better?

“More must be better!”

Have you heard this statement before? Some clients may feel that taking more (high-dose supplemental use) than the recommended daily amount (RDA) is a healthier option to prevent disease.

Research on antioxidant supplements has not found that high dose antioxidant supplementation prevents disease and is a safety concern. For example, studies have linked the use of high-dose vitamin A supplements to an increased risk of lung cancer in smokers, and the use of high-dose vitamin E supplements to an increased risk of hemorrhagic stroke and prostate cancer (NCCIH, 2013). High levels of selenium is toxic and can cause severe liver damage whereas high levels of vitamin C cause gastrointestinal problems, such as diarrhea (Grodner et al., 2020).

High-Dose Antioxidant Supplements Research has shown that high-dose antioxidant supplement use can cause more harm than good. Match the antioxidant to the high-dose risk image. You may use an antioxidant more than once.

Antioxidant

Vitamin A

Vitamin e

High-Dose Risk

Antioxidant

Vitamin e

Vitamin selenium

High-Dose Risk

Antioxidant

High-Dose Risk

Vitamin c

High-dose vitamin A supplements increased the risk of lung cancer in smokers and use of high-dose vitamin E supplements increased the risk of hemorrhagic stroke and prostate cancer (NCCIH, 2013). High levels of selenium are toxic and can cause severe liver damage (Grodner et al., 2020). High levels of vitamin C may cause gastrointestinal (GI) upset, including diarrhea. Iron is not an antioxidant.

Your response is incorrect!

Nursing Considerations Please remember to obtain a thorough medical history that includes diet and medication use (prescription and over-the-counter). Some foods and medications may interact with antioxidants, therefore pay close attention to possible drug-drug or food-drug interactions.

For example, toxicities of Vitamin E are rare; however, supplement use is contraindicated with anticoagulation drugs (risk for bleeding)

High-Dose Supplementation Research has shown that high-dose use of antioxidant supplements can cause more harm than good. Match the antioxidant to its high-dose, supplemental risk. You may use an antioxidant more than once.

High-dose vitamin A supplements increased the risk of lung cancer in smokers and use of high-dose vitamin E supplements increased the risk of hemorrhagic stroke and prostate cancer (NCCIH, 2013). High levels of vitamin C may cause gastrointestinal (GI) upset, including diarrhea. High levels of selenium is toxic and can cause severe liver damage (Grodner et al., 2020).

Your response is correct!

Nutritional Therapy

The health care provider is providing nutritional therapy and a diet rich in vitamin A. Which breakfast recommendation would you educate the client that provides the richest sources of vitamin A.

Fried eggs, bacon, and strawberries Cereal topped with blueberries and low-fat milk Oatmeal with brown sugar and coffee Scrambled eggs with green and yellow peppers and an orange A mixture of colorful vegetables (green and yellow peppers), eggs (animal source) and orange-colored fruits are options rich in vitamin A. Fried eggs and bacon are animal fat sources with Vitamin A but higher in fat content.

Strawberries and blueberries only contain a small amount of vitamin A. Fortified cereal has vitamin C and vitamin E. Oatmeal has vitamin E.

Your response is correct!

Supplementation The health care provider is reviewing discharge instruction with a client who has been recommended antioxidant supplementation. The client verbalized, “Can I just take more than the recommended dose to prevent cardiovascular disease?” What is the health care provider’s best response.

Taking more than the recommended daily allowance will not prevent cardiovascular disease and is a safety concern.

Let me review your medication history to see if you are at risk for any drug interactions with an increased dose.

Taking more than your daily allowance will prevent cardiovascular disease and is recommended.

I will go ask the prescribing provider if you can double your dose.

Some clients may feel that taking more (high-dose use through supplements) than the RDA is a healthier option to prevent disease.

Research on antioxidant supplements has not found that high dose antioxidant supplementation prevents disease and is a safety concern.

Taking the RDA may decrease the risk of CV disease; however will not prevent it.

Your response is correct!

Sources of Antioxidants You are providing client teaching on antioxidant food sources. The client states that the family will be eating fish, sweet potatoes , cantaloupe, and whole grain bread for dinner tonight. Which antioxidant(s) can be found in the following food source(s). You can select more than one antioxidant for each source, as needed.

selenium

Vitamin A & C

Vitamin a and c

Vitamin E & Selenium

Selenium is in fish, vitamin A & C in sweet potatoes, and vitamin A & C in cantaloupe. Vitamin E and Selenium are both in whole grain foods. The family will be consuming rich sources of antioxidants in this dinner.

Your response is correct!

Oxidative Stress Which factors can lead to oxidative stress? Select all that apply.

processed foods environmental pollution ischemia exposure to drugs walking smoking Factors that can lead to oxidative stress (i.e. cellular damage) include:     

     

Mitochondrial activity Excessive exercise (not walking) Tissue trauma, due to inflammation and injury Ischemia and reperfusion damage Consumption of certain foods, especially refined and processed foods, trans fats, artificial sweeteners, and certain dyes and additives Smoking Environmental pollution Radiation Exposure to chemicals, such as pesticides and drugs, including chemotherapy Industrial solvents Ozone

Walking improves circulation and promotes health of the cells.

Your response is correct!

Drug-Drug Interaction Which antioxidant is contraindicated for use by clients on anticoagulant therapy?

Vitamin B Vitamin C Vitamin E Iron Vitamin E supplement use is contraindicated with anticoagulation drugs (risk for bleeding). The other vitamins do not pose a risk for bleeding with supplemental use.

Your response is correct!

Older Adults A diet rich in which antioxidant can help delay cataracts in older adults?

Vitamin C Selenium Vitamin E Vitamin A Vitamin E may decrease risk of various cancer-types, decrease risk or delay cataracts; Vitamin A may decrease risk of various cancer-types and cardiovascular disease; Vitamin C may decrease risk of various cancertypes and cardiovascular disease and Selenium prevents cellular and lipid membrane damage.

Your response is correct!

At-Risk Research suggests that high levels of which antioxidant increases the risk of hemorrhagic stroke?

Selenium Iron Vitamin E Vitamin C High-dose vitamin A supplements increased the risk of lung cancer in smokers and use of high-dose vitamin E supplements increased the risk of hemorrhagic stroke and prostate cancer (NCCIH, 2013). High levels of selenium is toxic and can cause severe liver damage (Grodner et. al, 2020).

Iron is not an antioxidant and vitamin C has gastrointestinal problems at high levels.

References

Your response is correct!

Nursing Application: Vitamins, Antioxidants, and Minerals Vitamins, minerals and antioxidants play an important role in maintaining good health. Teaching clients how to consume foods with ample amounts of these nutrients and eating a healthy well-balanced diet is critical in meeting the physiological needs of the body. This lesson will review major vitamins, minerals and antioxidants, and reflect on why consuming the recommended dietary allowances are important in keeping us healthy.

As you complete the concept, you will gain the nursing knowledge and skills needed to:

   

Explain the use of vitamins, antioxidants, and minerals.

Identify factors that affect nutrient absorption.

Describe lifespan and cultural considerations.

Differentiate food sources that contain the major vitamins, antioxidants, and minerals.

Minerals Identify the minerals with its food source image.

Iron Zinc

Iodine Fluoride

Iron is high in red meats, such as steak.

Zinc is found in whole grain food, such as whole grain bread.

Iodine is rich in seafood.

Flouride can be found in drinking water.

Your response is correct!

Vitamins

Choose the vitamin that best completes the sentence. 

Vitamin A

supports healthy eyesight and immune system functions. Children with a deficiency of this vitamin face an increased risk of blindness. 

Vitamin D

deficiency causes bone diseases, including rickets in children and osteomalacia in adults. 

Folate

is essential in the earliest days of fetal growth for healthy development of the brain and spine. 

Iron

is critical for motor and cognitive development. Children and pregnant women are especially vulnerable to the consequences of this deficiency.

Vitamin A supports healthy eyesight and immune system functions.

Children with vitamin A deficiency face an increased risk of blindness.

Vitamin D deficiency causes bone diseases, including rickets in children and osteomalacia in adults. Folate is essential in the earliest days of fetal growth for healthy development of the brain and spine. The other options do not apply.

Your response is correct!

Antioxidants Antioxidants work against free radicals in our body and are believed to help decrease risk of certain diseases, enhance our health, and promote

overall wellness. Antioxidants can protect against the cell damage that free radicals cause, known as oxidative stress.

Your response is correct!

What Are Vitamins Again?

Vitamins are nutrients; essential noncaloric, organic molecules needed in the diet. Often, they are referred to as micronutrients, since only small amounts are needed in the body to perform specific metabolic functions.

Vitamins act as helpers to get chemical processes done. They are essential for our bodies, and because we cannot produce them on our own, we must consume them. After vitamins are ingested, they act as precursors and turn vitamins into active chemicals. Vitamins are divided into two categories: Fat-Soluble Vitamins These are stored in fat cells, in the liver, and near the liver for 3—6 weeks.

Water-Soluble Vitamins These pass through the body's water supply. The body cannot keep these vitamins, so they must be ingested for the body to maintain an appropriate level.

To promote health and wellness, vitamins and minerals are considered essential nutrients; and in acting together, they carry out hundreds of functional roles within the body.

Vitamin Deficiencies – Clinical Considerations Certain subgroups are at risk for vitamin deficiencies.

Vitamins – Clinical Considerations It is important to recall the clinical manifestations seen with fat-soluble vitamins. Let’s review from previous learning.

 Vitamin A  Vitamin D  Vitamin E  Vitamin K Deficiency Causes    

Night blindness (1st indication of deficiency) Xerophthalmia (dry, thickened condition of the conjunctiva) Keratomalacia (deterioration of the cornea) Blindness (Severe deficiency)

Toxicity Weakness, anorexia, vomiting, and an enlarged spleen and liver, however toxicity is rare with healthy food consumption.

Vitamin Review Identify the vitamin that completes the sentence.  Vitamin D and sufficient levels of calcium and phosphorus can prevent rickets in children and osteomalacia in adults.  Older adults need more vitamin D from foods because their skin manufactures less.

 In excess, vitamin A may cause weakness, anorexia, vomiting, and an enlarged spleen and liver.  Newborns have a decreased vitamin K level at birth, therefore receive an injection after delivery.  The effectiveness of anticoagulant medications and other “bloodthinning” drugs can be decreased by high intakes of vitamin K from either foods or supplements.  Clients taking sotretinoin (Accutane) and isotretinoin (oral forms) are at-risk of vitamin A toxicity as those medications contain vitamin A.

Your response is correct!

At-Risk Populations - Vitamins Certain conditions may place clients at-risk of having a vitamin deficiency.

Let’s review these special considerations.  Chronic alcohol consumption can cause a multitude of nutritional deficiencies. Nutritional support generally includes supplementation of B-complex vitamins and vitamin C.  Folate supplementation is needed for childbearing women, during pregnancy and lactation.  Older adults at higher risk of cobalamin (vit. B12) deficiency due to reduction of intrinsic factor by stomach mucosa. Deficiency in this population results in psychiatric symptoms; delusions and hallucinations. It could mimic a mental health disorder, when in fact, the underlying problem is a vitamin deficiency.  Chronic antibiotic use and long-term intravenous feedings (IV) are known to decrease the number of biotin-producing “good” bacteria to support GI health. Supplementation of biotin may be needed.

References Grodner, M., Escott-Stump, S., & Dorner, S. (2020). Nutritional foundations and clinical applications: A nursing approach (7th ed.). Elsevier.

Lifespan & Cultural Considerations Any individual across the lifespan that has malabsorption issues are atrisk of having a vitamin deficiency. In particular to fat-soluble vitamins are those clients who experience chronic fat malabsorption. Let’s review other special considerations.

Reversal Agent Which vitamin has a therapeutic use to reverse the effects of warfarin?

Vitamin A Vitamin D Vitamin E Vitamin K Vitamin K is involved with blood clotting and keeps the thrombocytes (platelets) healthy. For warfarin overdoses, the reversal agent to prevent further blood clotting is an injection of vitamin K. The other vitamins are not reversal agents for warfarin.

Your response is correct!

Antioxidant Review Antioxidants are substances that can prevent or slow damage to cells caused by free radicals.

Free radicals are waste substances produced by cells as the body processes food, reacts to internal forces and the environment. Antioxidants are known to help counteract free radicals in our body and are believed to help decrease risk of certain diseases, enhance our health, and promote overall wellness.

You have learned that:    

Vitamin A Vitamin C Vitamin E Selenium

All have antioxidant properties. Antioxidants can protect against the cell damage that free radicals cause, known as oxidative stress. Be sure to review potential health problems with highdose antioxidant supplement use in previous learning.

High-Dose Antioxidant Supplements Research has shown that high-dose antioxidant supplement use can cause more harm than good. Identify the health problem associated with high-dose use.

High-dose vitamin A supplements increased the risk of lung cancer in smokers and use of high-dose vitamin E supplements increased the risk of hemorrhagic stroke and prostate cancer (NCCIH, 2013). High levels of

selenium is toxic and can cause severe liver damage (Grodner et al., 2020). High levels of vitamin C may cause gastrointestinal (GI) upset, including diarrhea. Iron is not an antioxidant.

Your response is incorrect!

Review of Minerals Minerals are also crucial for proper body development and health.

Minerals are inorganic substances that are found naturally within the earth. They play a critical role interacting synergistically with other elements and body systems to support and maintain good health.

Minerals do not provide energy to the body; however, they are a catalyst to many body processes.

Let’s look at some of the essential minerals and clinical considerations.

Essential Minerals Review the essential minerals below.

Calcium Phosphorus Magnesium References

Essential Minerals Review the essential minerals below.

Calcium Phosphorus Magnesium References

Sodium Sodium The one mineral that is most present in the body is sodium. You may know that sodium is one half of table salt (sodium chloride). Sodium helps maintain fluid balance by being present in blood to maintain a certain concentration (or osmolality). Water is drawn to sodium through osmosis. Therefore, wherever sodium goes, water follows.

When sodium levels are too low (hyponatremia), the kidneys and other organs get rid of extra water. We can help by restricting someone's fluid intake. When sodium levels are too high (hypernatremia), the kidneys and other organs retain water. This can lead to other complications (i.e. fluid overload, swelling, hypertension) depending on the any underlying health problems.

Sodium Review the questions below on sodium and select the correct answer(s).

Question 1 / 3 The primary functions of sodium include major positively charged electrolyte in extracellular fluid; maintains proper acid-base balance; assists with transmission of nerve signals; aids muscle contraction (not relaxation): and assists in the absorption of glucose and other nutrients.

Your response is incorrect!

Sodium Review the questions below on sodium and select the correct answer(s).

Question 2 / 3 What are some clinical manifestations of hypernatremia? Select all that apply.

Fluid overload Water retention High blood pressure

Hypernatremia is high levels of sodium in the body. Signs of hypernatremia include water retention, swelling, fluid overload, and high blood pressure (not low blood pressure).

Your response is correct!

Sodium Review the questions below on sodium and select the correct answer(s).

Question 3 / 3 What are some clinical manifestations of hyponatremia? Select all that apply.

Mental confusion Mental alertness Increased appetite Dizziness Fatigue Loss of appetite Muscle cramps Nausea

Clinical manifestations of hyponatremia (low levels of sodium) include muscle cramps, loss of appetite (not increased appetite), dizziness, fatigue, nausea/vomiting, and mental confusion (not mental alertness).

Your response is correct!

Potassium Potassium is one of the most important minerals in the body. Like all the other electrolytes, there is a certain amount of potassium inside and outside the cells of the body. Fluctuations in these levels can be caused by many things and can have disastrous consequences if the body is unable to achieve homeostasis with or without help.

If potassium gets too high or too low, it is life-threatening. Potassium is the main cation (positive ion) in intracellular fluid. Potassium regulates cell excitability. In addition, it moves out of the cell to let Hydrogen in to help with acid-base balance. Potassium is also responsible for excitability and nerve impulse conduction particularly in the heart. Levels that are too high or two low can cause cardiac (heart) arrest and death.

Too high or too low, potassium can cause bad heart electrical rhythms.

When potassium gets too low (hypokalemia), people get weakness, paresthesia (numbness and tingling), loss of reflexes, and rarely muscle weakness. Their heart rate may go up, and the heart rhythm will appear abnormal. Medications can cause low potassium. When potassium gets too high (hyperkalemia), similar symptoms occur in the muscles and reflexes. In addition a slow heart rate and blood pressure may also occur.

Chloride Chloride is the good neighbor of the body. Because it is negatively charged ion, it combines with all the positively charged ions including hydrogen, sodium, potassium, and calcium. There are also high levels of chloride in cerebral spinal fluid as well as gastric and pancreatic juices.

The brain uses sodium and chloride together to attract water to make the cerebral spinal fluid. Hydrogen combines with chloride in the digestive process to make hydrochloric acid. Chloride even helps transport carbon dioxide (waste product from the cells) through the blood to the lungs.

Chloride is also important in acid base balance by opposing bicarbonate (an alkaline).

Some facts about Chloride:

     

Good neighbor except for bicarbonate Helps regulate osmotic pressure and osmolality Negatively charged to attract others Helps maintains fluid balance (with Sodium) Helps regulate acid-base balance (scares bicarbonate) Chloride and bicarbonate both anions (negatively charged)

Foods with lots of Chloride:  Anything with salt

Calcium Absorption The nurse must recognize factors that may alter the absorption of calcium. Insufficient calcium absorption can lead to osteoporosis, which is a preventable diet-related disease.

Factors that affect calcium absorption or lactose intolerance, acidity of the digestive system, food binders and high fiber intake.  Food binders – Phytates (found in whole-grains, legumes (dried beans)and oxalic acids ( found in beet greens, rhubarb) reduce the absorption of calcium.  Medications – Diuretics can cause the excess excretion of calcium (National Institute of Health, 2020) Genetic determinants that affect the absorption of calcium are:  Race – White and Asian woman are more susceptible to osteoporosis.  Gender – Men have greater bone density then women.  Family history- Predisposition to lower bone density may be genetically passed between generations.

Calcium Absorption Physical activity and antacids affect calcium absorption. Physical activity has a big impact on calcium absorption. The more active the client the more calcium will be absorbed in the body (Grodner et al., 2019). Clients that are less active will absorb less calcium. Also, calcium absorption is dependent on the acidity of the food in the stomach. Antacids alter the acidity and therefore alter calcium absorption. The other options do not apply to calcium absorption.

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Client Teaching — Calcium The nurse is to carefully assess the client’s diet, family history and lifestyle for conditions that may alter nutrient absorption.

Client Teaching — Iron

Increased absorption of iron occurs when dietary sources are consumed with foods containing ascorbic acid (vitamin C). For example, drinking orange juice helps your body better absorb iron from other foods.

Educate clients to:  Avoid taking calcium and iron supplements together (Cleveland Clinic, 2019). Milk, calcium and antacids should not be taken at the same time as iron supplements. You should wait at least 2 hours after having these foods before taking your iron supplements to prevent absorption issues.  Consuming iron from meat and plant sources increases the absorption of iron.  Cooking food in a cast-iron skillet. Iron that leaches from the skillet will provide an extra source of iron to food.

Client Teaching — Sodium

It is important for the nurse to prevent clients' overconsumption of sodium. An increase in sodium intake can lead to hypertension and other health issues. Nurses must educate clients about foods that have hidden forms of sodium used to enhance the flavor of foods.

Other forms of sodium used to flavor foods:  Monosodium glutamate [MSG]  Sodium saccharin  Preservative (sodium sulfite) Foods that contain high amounts of sodium:     

Pickled foods Snack foods Deli meat Cheese Condiments

(Cleveland Clinic, 2020)

It is important for the nurse to teach clients how to read food labels for nutrient content. The DASH (Dietary Approaches to Stop Hypertension) diet is a special diet that specifically targets the reduction of high sodium food items. It also encourages the use of seasoning food with natural herbs such as lemon juice, thyme, or oregano. For diet changes to be successful, it is important for the nurse to carefully assess spices and foods the client is familiar with.

Tips for lowering sodium intake when shopping, cooking, and eating out include: References Cleveland Clinic. (2020). Do you know where salt is hiding in your food? Health Essentials from Cleveland Clinic. https://health.clevelandclinic.org/knowsalt-hiding-food/ National Institute of Health. (n.d.). Dash eating plan. https://www.nhlbi.nih.gov/health-topics/dash-eating-plan

Why Vitamins, Antioxidants, and Minerals Matter Good nutrition is crucial in keeping Americans healthy across the lifespan.

People who eat a healthy diet live longer and are at lower risk for serious health problems such as:  Heart disease  Type 2 diabetes  Obesity For people with chronic diseases, healthy eating can help manage these conditions and prevent complications (CDC, 2020).

Making Healthy Eating Easier Take the time to review this fact sheet outlining nutrition, physical activity and obesity in America.

It stresses “Why Nutrition Matters” and efforts to help prevent vitamin and mineral malnutrition.

Community Health — Older Adults

The nurse in the community health clinic is educating older adults on the role of vitamins for health and wellness. One client asks, “Why would I have a vitamin deficiency, I eat lots of fruits and vegetables?”

What is the nurse’s best response.

“You need more vitamins as you age due to absorption and excess excretion issues.”

“You are older and vitamins just don’t work well in your body.”

“As you age, absorption may become increased therefore older adults are at a lower risk for a vitamin deficiency.”

“With age, absorption becomes impaired therefore older adults are at a higher risk for vitamin deficiencies.”

A primary vitamin deficiency occurs when the vitamin is not consumed in sufficient amounts to meet physiologic needs. A secondary deficiency develops when absorption is impaired or excess excretion occurs, limiting bioavailability. Populations at risk for vitamin deficiencies include older adults because of decreased vitamin absorption with aging.

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Water and Sodium A community-based living center had a water softener unit installed.

Which sodium sensitive client would the nurse carefully observe? Select all that apply.

A client with a medical history of pressure ulcers and dry skin.

A client with a medical history of congestive heart failure.

A client with a medical history of diabetes taking insulin.

A client with a medical history of bipolar disorder taking lithium.

Water and Sodium A community-based living center had a water softener unit installed.

Which sodium sensitive client would the nurse carefully observe? Select all that apply.

A client with a medical history of pressure ulcers and dry skin.

A client with a medical history of congestive heart failure.

A client with a medical history of diabetes taking insulin.

A client with a medical history of bipolar disorder taking lithium.

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What Could Be Wrong?

Identify the type of nutrient deficiency or excess described in each scenario.

Potassium

Sodiu m

Chloride

X

I have difficulty paying attention. I have left-sided weakness, difficulty walking due to spatialperceptual deficits, and I am impulsive.

Potassium

Sodiu m

X I have difficulty lifting things because my muscles feel weak. I also have felt my heart beating irregularly.

I know this may sound a little weird, but my bones hurt. Any time I change positions, I get dizzy.

I've also experienced weakness in my arm muscles and can hardly lift this teacup.

X

I know I should eat, but I'm just not hungry. I sit in my wheelchair because my legs feel weak, are

Chloride

Potassium

Sodiu m

swollen, and I get dizzy. My daughter stays here with me because I tend to get confused at times. What's going on with me?  I have difficulty paying attention. I have left-sided weakness, difficulty walking due to spatial-perceptual deficits, and I am impulsive.  Deficiency: Chloride  I have difficulty lifting things because my muscles feel weak. I also have felt my heart beating irregularly.  Deficiency: Potassium  I know this may sound a little weird, but my bones hurt. Any time I change positions, I get dizzy. I've also experienced weakness in my arm muscles and can hardly lift this teacup.  Deficiency: Phosphorus  I know I should eat, but I'm just not hungry. I sit in my wheelchair because my legs feel weak, are swollen, and I get dizzy. My daughter stays here with me because I tend to get confused at times. What's going on with me?  Deficiency: Sodium



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

Pregnancy A female client visiting her primary care provider shares with the nurse her excitement about being pregnant. She should be especially careful to consume adequate amounts of:

Vitamin K Vitamin C

Chloride

Riboflavin Folate Women who may become pregnant need to ensure adequate intake of folic acid to prevent neural tube defects. The neural tube forms in a fetus before many women know they are pregnant, and so it is important to ensure adequate intake of folic acid before pregnancy. Riboflavin and vitamins C and K are all essential vitamins, but folate takes priority.

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Supplement Use Your client is at risk for osteoporosis and calcium supplements. The client asked the nurse the difference between calcium citrate and calcium carbonate and which one is the best to take?

Match the characteristics of calcium carbonate and calcium citrate.

Characteristics

Calcium Citrate

Calcium Carbonate

Less likely to cause constipation.

Best absorbed without food.

Lower dose — may have to take more pills to achieve therapeutic dose.

More expensive.

Best absorbed with food Higher dose — may have to take less pills to reach therapeutic dose.

Constipation is a side effect.

Less expensive.

Calcium carbonate is less expensive than calcium citrate. It is better absorbed with food due to the high acidity of the chyme. In addition, calcium carbonate is available at higher dosages, therefore the client would take less pills to reach therapeutic dose. Calcium citrate is less likely to cause constipation (NIH, 2020) and is best absorbed without food.

Calcium citrate is available at lower doses which means the client will have to take more pills to reach their recommended dose (NIH, 2020).

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Client Teaching The nurse observed the meal tray of a client with hypertension and is on a low sodium diet. Which food items would indicate the client needs additional teaching? Select all that apply.

Strawberries Canned chicken noodle soup Broccoli Saltine crackers Sandwich with bologna and cheese The sandwich with cured meat and cheese, canned soup, and crackers indicate the client requires additional teaching about low sodium food items. These food items are high in sodium and should be avoided or consumed in moderation. Clients that increase their sodium intake are at risk for fluid volume excess. Signs and symptoms of fluid volume excess is swelling, bloating and an increase in blood pressure. Fresh fruits and vegetables are low sodium foods.

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Meal Planning You are providing client education on ways to increase the vitamin C content for a healthy diet. Which of the following foods would you recommend choosing in larger amounts?

Liver, such as organ meats, and seafood Milk, cheese, and eggs Green peppers, strawberries, and oranges

Enriched cereals and fortified juice Found only in fruits and vegetables, especially citrus fruits and colorful vegetables, are rich sources of vitamin C. Some foods and drinks are fortified with vitamin C (i.e. cereal and juice). Meats, or animal products, do not include vitamin C. Cereals may be fortified with vitamin C but not an original source.

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Iron The client’s laboratory findings indicated they are anemic and iron supplements recommended.

Which food item will the nurse recommend the client take with the supplements to increase iron absorption?

Rhubarb Antacids Mineral water Orange juice The nurse would recommend the client take orange juice with the iron supplement as vitamin C in the orange juice will promote the absorption of iron. Mineral water rhubarb an antacids will have no effect on iron absorption. The nurse will teach the client to take their iron supplements with any fruit that contains vitamins C.

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Meal Planning A homeless man presents to the community health clinic with muscle cramps and weakness, loss of coordination, and tachycardia. An alcohol-

odor was noted on his breath. The man may be suffering from which deficiencies? Select all that apply.

Niacin Thiamin Riboflavin Magnesium Folate Alcoholism increases the body’s need for thiamin and may contribute to a secondary thiamin and magnesium deficiency. Neurotoxic effects such as loss of memory, mental confusion, ataxia and tachycardia occurs and often displayed by individuals with chronic alcohol use. Symptoms of riboflavin deficiency include cheilosis, glossitis, and dermatitis. Niacin deficiency causes pellagra, characterized by dermatitis, dementia, and diarrhea. Symptoms of folate deficiency include megaloblastic anemia, glossitis, diarrhea, irritability, depression, and anxiety.

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Iodine Deficiency The client presents to the community health clinic reporting fatigue and weight gain. The physical exam revealed an enlarged thyroid gland. The client lives in the rural mountains of Montana.

What food item will the nurse recommend the client add to their diet?

Eggs Fish Legumes Watermelon

The nurse would advise the client to add fish to their diet to help increase levels of iodine. The client present with signs and symptoms of iodine deficiency. Clients who do not consume fortified salt or have access to fresh seafood can develop a goiter, which is an enlarged thyroid gland.

You can get recommended amounts of iodine by eating a variety of foods, including the following: Fish (such as cod and tuna), shrimp, and other seafood, which are generally rich in iodine.

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