20. SUPPLEMENTS Flashcards
THIS MODULE COVERS: • Supplements: Why use them, legislation, manufacturing, administration, cost excipients, dosages and absorption. • Natural v. synthetic supplements. • Different types and forms of nutritional supplements. • Mineral, vitamin and EFA supplements.
1
Q
What is a food supplement defined as?
A
A concentrated source of a vitamin, mineral or other substance with a nutritional or physiological effect, alone, or in combination, sold in dose form.
2
Q
Do herbal products have food supplement status?
A
Herbal products do not have food supplement status since they are classed as medicines.
3
Q
Why use supplements?
A
- For deficiency states: Deficiency symptoms are end-stage symptoms associated with an extended lack of a particular vitamin, mineral or other nutrient.
- For therapeutic uses: Insufficiency can be identified when there is under-functioning of certain biochemical pathways, by nutritional evaluation, or by identification of other symptoms. Most disease starts and progresses due to an insufficiency of specific vitamins or minerals.
- For preventative health: Supplements are used to address any nutrient insufficiencies in order to maintain optimal health and wellness.
4
Q
Name FIVE causative factors for supplements being needed.
A
- Food processing reduces nutrient content: best to eat whole organic food, locally sourced, in season and minimally processed.
-
Food additives deplete nutrients:
Many food additives are toxic, depleting the body of essential nutrients and impairing nutrient absorption. -
Weakened digestion:
Due to refined, low-quality food and medications. -
Stressful lifestyles:
Depletes nutrients including calcium, magnesium and zinc. -
Nutrient depletion at birth: Potential heavy
metal and chemical toxicity of the parents. - Soil is depleted: Zinc, manganese, chromium, molybdenum, calcium and magnesium.
-
High-yield crops are deficient in certain
nutrients: After years of intensive cultivation. - Fertilisers: Do not supply enough trace minerals to plants.
- Pesticides deplete soil: Kill soil microorganisms needed to create nutrients for plants, thereby causing lower nutrient content.
- Long-distance transportation: Crops lose much of their nutritional value.
5
Q
Where can we find what vitamin and mineral substances are permitted for use in food supplements?
A
The EU Food Supplements Directive gives a list of the vitamins and minerals, including the form in which they may be used, in the manufacture of food supplements.
It contains a legal requirement for the setting of maximum and minimum levels for vitamins and minerals in food supplements.
New sources of vitamins and minerals may be added to these lists if safety information is submitted and approved by the European Food Safety Authority (EFSA).
6
Q
How is food supplements regulated in Ireland?
A
Ireland is regulated by EU legislation on food supplements.
The Food Safety Authority of Ireland (FSAI) oversees the implementation of all relevant legislation for food supplements.
7
Q
How are food supplements regulated in the US?
A
All prescription and non-prescription drugs are regulated in the United States by the Food and Drug Administration (FDA).
In the US, dietary supplements are treated as a special category of food with different regulations to drugs. They are considered safe until proven otherwise.
8
Q
Which organisation is responsible for licensing medicines in the UK?
A
The Medicines and Healthcare Products Regulatory Agency (MHRA).
9
Q
What regulates medicinal products, medical devices and cosmetics?
A
The Health Products Regulatory Authority (HPRA).
10
Q
What has the responsibility for national and EU legislation on food supplements in:
- England
- Wales
- Scotland and Northern Ireland?
A
- The Department of Health in England.
- The Welsh Assembly in Wales
- the local Food Standards Agencies in Scotland and Northern Ireland.
Compliance is monitored and enforced by local trading standards authorities but if pharmacologically-active substances or herbs are part of the product they will be sent to the MHRA for assessment.
11
Q
How are herbal products regulated?
A
Many herbal ingredients are classified as medicines. Herbal products are regulated by the Traditional Herbal Medicines (THM) Directive, which is administered in the UK by the MHRA.
12
Q
What claims are prohibited on the labels?
A
- Medicinal claims.
- Presentation or labelling that infers that a supplement can prevent, treat or cure human disease.
- Reference to the rate or amount of weight loss.
- Reference to recommendations of individual doctors or health professionals.
- Health claims on alcoholic beverages.
- Claims which suggest that health could be affected by not consuming the food.
13
Q
What checks are involved for animal-based supplements?
A
Any facility involved in the manufacture of animal-based supplements such as fish oils and glucosamine needs to be registered and approved by the European Commission.
Checks include where the animal was caught, farmed, handled, manufactured, extracted and packaged and the approval
number must be displayed on the label.
Contaminants such as PCBs, dioxins and heavy metals must be within EU ‘acceptable levels’ for supplements.
14
Q
Are genetically modified (GM) ingredients allowed in supplements?
A
Ingredients from GM organisms are only permitted for use in supplements if authorised under the Regulation on genetically modified food and feed.
This regulation requires companies to declare the presence of GM materials on food product and supplement labels.
The accidental presence of GM material may still occur in a non-GM crop via transference in nature; e.g. via windborne pollen.
15
Q
What does GMP stand for? Are companies required to be GMP-approved?
A
Good Manufacturing Practice.
In the UK, supplement companies are required to manufacture with ‘due diligence’. There is a legal requirement that all products must be ‘fit for purpose’.
Many companies are GMP compliant (self-regulated) but not GMP approved. This means that supplements may be produced
to GMP standard with rigorous quality control, production and distribution procedures but without having actual GMP approval.
Few companies in the UK are GMP approved - most of these are Australian or American companies as they have to meet the standards set by the Therapeutics Goods Act (TGA) or Food and Drug Administration (FDA) in their respective countries.
16
Q
What do tests carried out by the regulatory agencies check in supplements?
A
High or unacceptable levels of heavy metals, solvent residue, aflatoxins, or herbicides and pesticides.
UK law limits contaminants such as arsenic; EU legislation limits amounts of materials such as mercury, lead and cadmium.
17
Q
What is overage?
A
Ingredients may degrade over a supplement’s shelf life. Reputable supplement companies will add extra so that the amount left at the end of its shelf life still meets the label claim. This is called overage.
18
Q
eg. fish oil, whey protein
How the way certain ingredients are processed can affect their quality?
A
Fish oil and omega plant oils need to be cold-pressed to minimise oxidation; whey protein needs to be specially filtered to remove lactose, hormones, etc.
Cheaper extraction and processing methods reduce the effectiveness of the supplement and affects its safety profile.
19
Q
Compare tablets to capsules supplementation.
A
Tablets: Cheaper, easier to produce large quantities. Generally contain more excipients so try to avoid.
Capsules: Fewer excipients but not efficient for large doses.
20
Q
Compare powders to liquids supplementation.
A
Powders: Good for bigger doses; e.g. glutamine. Not suitable for sticky ingredients, ones that attract moisture, e.g. phosphatidyl serine or fruit powders, where there is a toxicity risk, or where ingredients are unstable.
Liquids: Excellent absorption but more expensive and less stable. Many, such as fish oils, need antioxidants such as vitamin E added to prevent oxidation.
21
Q
What are the advantages of enteric formulations?
A
Excipients, such as shellac or cellulose acetate phthalate (CAP) ensure tablets survive stomach acid so that they don’t release contents until the small intestine. Commonly used for good garlic capsules.
22
Q
Name a good form of supplements to enable probiotics to survive the stomach acid and reactivate in the intestines.
A
Spore form
23
Q
Why do we need chewable formulations of supplements?
A
As vitamins and minerals may taste unpleasant, most vitamin and mineral powders are coated before they are compressed into tablets.
24
Q
Cheaper slow-release tablets contain ______________ to hold the tablets together longer.
A
hydrogenated fats
25
What are liposomal supplements and their advantages?
Liposomal supplements have a protective phospholipid bilayer protecting the active ingredients.
- High bioavailability and absorption.
- Increased oral uptake in the mouth.
- Increased uptake into target cells.
- Easier to take than large tablets.
- Suitable for water- and fat-soluble nutrients.
26
What are excipients and why are they used in a supplement?
Excipients are additives used in forming tablets and capsules to bind active ingredients together and keep them active (potentially harmful).
27
Give FIVE examples of excipients in supplements.
- *Capsule shells*: Made from gelatine or from plant cellulose.
- *Flow agents*: Help formulations flow easily through machinery but no nutritional benefit. Avoid magnesium stearate.
- *Binding agents*: Help to bind ingredients together to make a tablet; e.g. maltodextrin.
- *Fillers*. Help to fill capsules, particularly when small amounts of an active nutrient is needed e.g. B12 or vitamin D.
- *Natural fillers*: lithothamnion calcareum from fossilised seaweed; vegetable powder; new form of rice flour that is inert.
- *Emulsifiers*. Used to mix oily and watery ingredients together.
- *Flavours*. Avoid MSG.
- *Colours*: riboflavin, beet extract, turmeric.
- *Sweeteners*: glycerine.
- *Preservatives*: vitamin E, ascorbic acid.
28
What does the naturopathic approach to supplementing involve?
- Addressing the underlying cause of any dysfunction and treating the whole person, rather than the disease.
- It is vital that supplements are taken underthe best conditions to achieve maximum absorption, assimilation and utilisation.
- A naturopathic nutritionist understands that everyone is unique and that many factors must be considered to ensure that appropriate supplements are used in the correct dosage for optimal efficacy.
29
Where does absorption occur?
Absorption mostly occurs in the *duodenum* and *jejunum* but chemical bonds are broken in the stomach.
30
Give THREE examples of the nutrients absorbed in the duodenum and jejunum. What nutrient is absorbed in the ileum?
*Duodenum*: Calcium, selenium, magnesium, chromium, iron, manganese, zinc.
*Jejunum*: B vitamins, biotin, vitamin C, choline, inositol, calcium, magnesium.
*Ileum*: Vitamin B12.
31
# B vitamins and vitamin C
Best way to take water-soluble vitamins.
When is it best to avoid taking B vitamins and why?
Most B vitamins and vitamin C: Take with food.
B vitamins: Contraindicated in the evening as they may trigger or exacerbate insomnia (B6 is the exception).
32
Best way to take fat-soluble nutrients.
Vitamins A, D, E, K and CoQ10: Take with food containing fat.
Essential fatty acids: Take with food. It is preferable not to take with high amounts of their opposing fat; if taking omega-3 then
avoid high amounts of omega-6 in the same meal.
33
Best way to take amino acids
* Ideally with carbohydrate food / drink or on an empty stomach.
* Protein shakes: take any time of day. Often used post-surgery or after extreme exercise to restore energy and rebuild muscle.
Protein shakes take about 30 minutes to reach the muscle after ingestion so are quicker to digest than solid food.
Absorption of amino acids in liquid shakes depends on transit time through gut, stomach acid, proteolytic enzymes, etc.
34
Best way to take minerals. What is needed for mineral digestion? What time would you recommend taking Ca, Mg and Zn?
Minerals: Take with food. Adequate stomach acid is needed for digestion.
* Calcium and magnesium: Take in the evening to aid restful sleep.
* Zinc: Take on an empty stomach before bed. Caution: Some people may suffer stomach discomfort after taking zinc.
35
What should we consider to work out the dosage for a client?
* Age of the client: May need a higher dose with increasing age.
* Digestive capability: Ability to absorb and excrete? Constipated?
* State of health: Dosing for optimum health or for disease state?
* Therapeutic doses: Evidence of dosages that are shown in clinical trials to be effective for certain disease states.
* Dietary deficiency or insufficiency: What symptoms are there?
* Lab test results: What do these indicate?
* Safe therapeutic range: Age group of client?
36
What is an 'elemental mineral' in a supplement?
Labels in the UK / IRL state the elemental amount of minerals - the amount of mineral available for absorption when it has been freed from its carrier molecule.
The 'elemental mineral' is the amount of the mineral that is actually used by the body.
37
What is a natural supplement?
The term ‘natural’ can be used even if only 10% of the product is natural. The other 90% could be synthetic.
Depending on the manufacturing process, natural supplements may actually contain synthetic nutrients added to a food paste and grown into a more nutritious food matrix.
Some methods involve synthetic nutrients being biochemically incorporated into yeast or algae.
38
Why is it better to choose the vitamins from whole foods over manufactured synthetic isolates?
The body recognises when nutrients are derived from food and includes the necessary co-factors. It may not recognise isolates.
Natural supplements usually have better bowel tolerance than synthetic ones so they are retained longer in the body.
39
Give an example of a supplement from a natural source.
Nutrients from vegetable, animal or mineral sources.
- Vitamin D from fish liver oils,
- vitamin E from vegetable oils,
- natural betacarotene.
- Vitamin K.
40
Give an example of a supplement from a synthetic source.
Manufactured with identical molecular structure to the same natural nutrients. Most standard vitamin supplements are this type. Sometimes used preferentially by practitioners when trying to use higher doses.
Vitamin C: As this is a weak acid, many supplements use salt forms (calcium ascorbate, magnesium ascorbate) to decrease acidity.
41
Give an example of a supplement from a food cultured source.
Whole food multivitamins, minerals and other nutrients.
It is thought culturing makes nutrients that are more bioavailable. Nutrient supplements are often grown in *yeast* or *algae* and contain the nutrients they are fed in a whole food complex form.
This involves the same process behind cultured foods like yoghurt, kefir, miso, and sauerkraut.
42
What is hydroponics?
Growing of plants in nutrient solutions with or without an inert medium (such as soil).
43
What is a supplement from a food based source?
This is a physical mix of isolated nutrients within a food base but there may not always be bonding at a cellular level. However, the metabolic outcome may be the same as food-cultured as the body recognises these two forms as food.
Made by enzymatically reacting synthetic and natural vitamins with extracts containing vegetable proteins and then making this into a supplement. This is not food cultured, because the nutrients are not grown into a whole food, as in yeast / algae suspensions.
44
Give an example of when a synthetic form of a supplement can be more useful or / and a natural form cannot be used.
If you use *ascorbic acid*, the most common synthetic form of vitamin C, it will be rapidly excreted from the body but will take a significant amount of free radicals with it. This is ideal if detoxification is the desired outcome.
*Vitamin B9* - labelling laws insist that companies use folic acid or methylfolate as the product descriptor. Food state folate is not the same as traditional folic acid. It’s not methylfolate either as this does not occur in plants. Methylation only takes place in the human body or in a laboratory process - hence methylfolate, although the most bio-effective form of folate, cannot be natural or from food sources.
45
Name TWO reasons why synthetic supplements may be preferential to food-state.
Food-state supplements may not be enough to supply the optimal dosage when someone has a *high nutritional requirement* due to:
- poor dietary habits and lifestyle
- environmental factors
- chronic health conditions.
*Sensitivities* to foods or fillers in food-based products, such as gluten or nightshades can cause mild to severe reactions. Isolated, synthetic nutrient products may work better for some sensitive people.
46
What is a naturopathic approach to supplementation?
Naturopaths embrace a philosophy of using formulations that have a scientific, but holistic approach to supplementation.
- favour the use of whole, unadulterated botanicals and phytonutrient-rich foods optimally combined with vitamins, minerals, enzymes, coenzymes and amino acids.
- try to avoid preservatives, colourants, fillers or binding agents to allow the activity of, and synergy between, vitamins, minerals, plant enzymes, phytonutrients without physiological or biochemical interference.
- avoid GMO and irradiated products.
47
Why is it better to avoid irradiated supplements? Is there an alternative?
* High doses of radiant energy are used to destroy pathogens.
* Destroys delicate nutrients and disrupts their natural frequencies.
* Less damaging technologies include *dry steam sterilisation*.
48
Give THREE examples of what may contain genetically modified organisms in supplements.
Low-quality supplements are often filled with GMOs - often added to compensate for poor-quality ingredients.
May be GMO:
- citric acid,
- corn syrup or corn starch,
- maltodextrin,
- MSG (monosodium glutamate),
- soy lecithin,
- xanthan gum.
49
What is the difference between organic and inorganic acid salts? Give THREE examples of each.
**Organic**- natural, found in living organisms.
The bond between a mineral and an organic acid is generally weak. It is, therefore, more effectively absorbed than inorganic salts; the body can also use the carrier molecule.
Eg. citrate, fumarate, malate, ascorbate, gluconate, glycinate, acetate, lactate, picolinate, aspartate, succinate, orotate (some feed into the Krebs cycle so can be used by the body).
**Inorganic** - simple mineral compounds important for electrolyte balance. Inorganic supplement forms tend to cause more adverse effects (esp. GI).
Eg. oxide, sulphates, chloride, phosphates, nitrates, carbonates.
50
What is the best form for mineral absorption?
Amino acid chelates. Specific minerals chelate best with specific amino acids.
51
Mineral carriers: citrate. Name benefits in practice.
Excellent carrier as bound to citric acid (Krebs cycle); Ca2+, Zn 2+, Mg2+
* More bioavailable: The + acidic form requires less stomach acid to break bonds and free the mineral for absorption.
* Absorption of calcium citrate 2.5 times better than calcium carbonate.
52
What mineral carrier would be preferable for zinc and chromium?
Picolinates: Organically bound to picolinic acid (a metabolite of tryptophan).
* Natural chelator for absorption of certain minerals in the small intestine.
* High absorption in gut giving high serum levels.
53
What are amino acid chelates?
Chelator + mineral atom = chelate.
Chelator: Substance that binds tightly to mineral atoms and forces the mineral to go wherever the chelator goes.
Mineral ion attached by covalent bonds to two or more amino acids in the same molecule.
54
What are the advantages of amino acid chelates? Name THREE minerals that are available in chelated form.
- Bypasses competitive absorption that can occur between different minerals (amino acid disguise); absorbed as a protein instead of as a mineral.
- Body treats it as a peptide and is efficient at absorbing amino acids.
- Extends length of absorption sites to large portion of small intestine.
Most minerals are available in chelated form, typically using an amino acid or organic acid. Examples include: Calcium, zinc, iron, copper, magnesium, potassium, cobalt, chromium, molybdenum.
55
Amino acid chelates limitations.
- Amino acid complexes may be too tightly bonded.
- Minerals may not be released from this tight bond with the carrier if cellular energy is poor.
- Amino acid chelate complexes may often be too large for capsules so dosage can end
up too low; it is beneficial to combine with
other forms of minerals.
- Quality and price limitations as amino acids chelates may be too expensive for clients.
56
Name the nutrients best taken at the same time if supplementing Calcium.
Magnesium and vitamin D3 / K2
57
What might be the side effects of calcium supplementation?
Calcium supplementation may be ineffective at preserving bone density when dietary intake is sufficient; it can cause kidney stones and soft tissue calcification, especially if low vitamin D / K.
58
What form of calcium is commonly recommended? Is there another form that is easier to absorb?
Calcium carbonate is commonly recommended but calcium citrate is easier to absorb.
59
What is the maximum absorption of calcium?
Maximum absorption of calcium is usually 500 mg at one time.
60
Name FOUR organic forms of calcium supplements. Which would you recommend to your clients and why?
Calcium aspartate - a new type of calcium, is being marketed as having a higher absorption rate than other calcium supplements. Lacks scientific studies to support this or any of the other claims made for this form of calcium.
Calcium glycinate - is presently regarded as the most bio-available and most soluble form of supplemental calcium.
Calcium citrate - is easily assimilated by the body; most nutritional companies tend to use this form.
Calcium gluconate - low elemental level of calcium in this salt; 1 g contains only 93 mg of calcium.
61
Inorganic calcium forms: which ones you would NOT recommend and why?
Calcium carbonate (Calcium bound with
carbonic acid).
* Most cost-effective form.
* It is usually derived from coral or limestone.
* Used by the pharmaceutical industry.
* Can cause adverse effects (nausea, gas, constipation).
* Requires more HCl for absorption than other forms.
Calcium oxalate - Calcium bound to oxalic acid (oxalate).
* Never use as a supplement ― may lead to the formation of calcium oxalate kidney stones.
62
Inorganic calcium forms: which ones you would recommend and why?
Calcium ascorbate - Used as buffered source of vitamin C (gentle on GIT).
Calcium pantothenate - Is a supplemental form of pantothenic acid (vit. B5).
Calcium citrate malate (new form) - Exceptional absorption; can be consumed with or without food (other forms should be taken with food).
63
Name THREE Calcium Nutrient Interactions.
Magnesium - Competes for the same absorption pathway as calcium.
Separate by two hours to achieve the highest serum levels.
Zinc and iron - May reduce absorption.
Lysine - Enhances intestinal absorption and reduces excretion.
Excess intake of phosphorus (soft drinks),
caffeine and dietary fat will increase calcium excretion if supplements are taken.
Excess fibre - May slow absorption. Leave two hours apart.
Salt overload - Ca binds with excess sodium; excreted when the body’s Na levels must be lowered. Ingesting too much sodium through table salt or processed foods could result in losing calcium as the body rids itself of the surplus sodium.
64
Name THREE Calcium Drug Interactions.
Corticosteroids - Long-term use can lead to reduced absorption, increased secretion and inhibition of osteoblasts.
Levothyroxine - Competes for absorption; separate doses by >four hours.
Oestrogen and progesterone therapy - Increases absorption; may be a beneficial
interaction.
Quinolone - Antibiotics bioavailability hindered by calcium supplements. Take two hours before, or four to six hours after calcium supplementation.
Tetracyclines - Separate from supplements by at least two hours.
Other: Cardiac glycosides and calcium channel blockers.
65
What other nutrients are required for Magnesium absorption?
Selenium, vitamin B6 and D.
66
Magnesium absorption is inhibited by:
- Phytates, fibre, alcohol, excess saturated fat.
- High levels of zinc, calcium and phosphorus taken concurrently or within two hours of each other.
67
TRUE or FALSE:
The different forms of magnesium supplements have varying clinical applications.
True
68
Magnesium adverse reactions:
Diarrhoea. Possible gastric irritation. Less
common side effects with the organic form.
69
What form of Magnesium would you recommend for insomnia?
Magnesium glycinate
70
What form of Magnesium would you recommend for use in the bath?
- Magnesium sulphate (Epsom salts) - Osmotic laxative
- Magnesium chloride - Transdermal form, higher absorption than oral.
71
What form of Magnesium would you recommend for energy production, particularly in fibromyalgia?
Magnesium malate: Malic acid is an intermediary in the Krebs cycle.
72
What form of Magnesium would you recommend for cardiovascular support?
Magnesium orotate: orotic acid enhances energy production in the heart.
73
TRUE or FALSE
Magnesium aspartate, Magnesium citrate, Magnesium gluconate and Magnesium oxide - all provide good absorption by the body.
FALSE.
All except Magnesium oxide - the cheapest form available / commonly used. An osmotic laxative.
74
Magnesium drug interactions and contraindications. Name TWO.
Antibiotics - Taking magnesium supplements may reduce the absorption of some antibiotics. Supplements should be taken one hour before, or two hours after these.
Blood pressure medications, calcium
channel blockers - Magnesium may increase the risk of negative adverse effects.
HRT, OCP, diuretics and penicillamine - May decrease magnesium levels; concomitant
supplementation may be beneficial.
Contraindications:
* Heart block (unless there is a pacemaker present).
* Renal failure.
75
What are the best absorbed iron supplements?
Ferrous salts (ferrous fumarate, ferrous sulphate, and ferrous gluconate).
76
Discuss the most studied orthodox version of iron. Would we recommend this form of iron to clients? What are the alternatives?
Ferrous sulphate
* Can cause nausea and constipation.
* May interfere with vitamin E absorption.
* Higher dosages may be given than other forms.
Instead
Ferrous citrate: Well absorbed and generally tolerated well.
Ferrous fumarate: Well absorbed but may inhibit the absorption of vitamin E.
Ferrous bisglycinate: Chelated iron that is claimed by its manufacturers to be highly
bioavailable and without the adverse effects of ferrous sulphate.
Ferrous lactate (Iron II lactate): Derived from the action of lactic acid on iron fillings; can be vegan or animal derived. In fortified foods and baby formula.
77
Why should we always check serum ferritin and transferrin levels before supplementing?
* Overdosing iron is toxic in children; can be fatal.
* Has pro-oxidant effects - can cause free radical damage.
It also feeds bacteria - avoid in GI bacterial overgrowth.
* With males, beware of haemochromatosis.
* A minor overload of manganese can exacerbate iron deficiency. Having too little can also cause problems.
Consider levels of other minerals before supplementing.
78
Name TWO drug interactions with iron supplements.
Thyroxine, levodopa, tetracyclines, fluoroquinolones, penicillamine.
79
What are the adverse reactions of iron supplementation?
* Nausea, diarrhoea, constipation, heartburn, upper gastric pain.
* Taking with food seems to decrease adverse effects.
* Toxicity: Organ damage and death.
* Toxicity is more common in conditions such as:
- Haemosiderosis: Overload of iron in organs or tissues.
- Haemochromatosis (iron overload) - often genetic condition causes the body to absorb more than normal.
- Thalassaemia and sideroblastic anaemias.
80
What form(s) of chromium supplementation would you consider for T2DM?
Chromium picolinate: Readily absorbed with high serum levels.
Chromium polynicotinate: Claimed to be a safer long-term option than chromium picolinate but is not currently listed on the EU safe list.
Chromium malate: Animal studies indicate that chromium malate exhibits greater benefits in treating Type 2 diabetes and, its curative effect of, is superior to chromium trichloride and chromium picolinate.
81
What is hexavalent form of chromium?
is from industry and is associated with toxicity (ref: Erin Brockovich). It is not used in nutritional supplements.
82
Chromium interactions and contraindications.
- Some diabetes drugs may have an additive effect. Careful monitoring is required.
- Oral corticosteroids may deplete chromium levels.
83
What form of zinc is one of the most common over-the-counter forms; often used in cold remedies, such as lozenges and nasal spray?
Zinc gluconate. Widely available and cost-effective form.
84
What form of zinc is often added to lozenges to reduce cold symptoms and speed up the rate of recovery?
Zinc acetate
85
What form(s) of zinc would you recommend in the clinic?
Zinc picolinate: Best assimilation and absorption but more expensive than citrate or gluconate.
Zinc citrate: Absorbed as well as gluconate
form but less bitter, with a more appealing taste.
86
What form of inorganic zinc may cause
stomach irritation and nausea?
Zinc sulphate. Absorption is better in liquid form and for less adverse effects.
87
How is it best to take zinc supplementation?
Zinc is best taken at night on an empty stomach, or at least one hour before, or two hours after meals. If zinc supplements cause stomach upset, they may be taken with a meal
88
Zinc interaction with other minerals
High doses of zinc (100-150 mg daily) will inhibit copper metabolism and cause low copper levels. Some zinc supplements include copper to counteract this effect.
89
Zinc adverse reactions
Nausea, vomiting, diarrhoea.
Nasal sprays may be linked with loss of smell (anosmia).
90
Zinc drugs interactions
Antibiotics (take the antibiotic at least two hours before or four–six hours after taking zinc), and penicillamine.
Aspirin (3 grams per day) and PPIs reduce zinc absorption.
Thiazide diuretics increase the excretion of zinc by at least 60%.
91
What is the readily absorbed and most commonly found form of potassium in supplements?
Potassium citrate
92
What inorganic form of potassium increases HCl production?
Potassium chloride. Only found in tissue salts and celloids (inorganic mineral compounds in cation:anion forms)
93
What form of potassium is found in nature e.g. fruit, vegetables?
Potassium bicarbonate
94
Potassium supplementation toxicity
Tachycardia: In doses greater than 15 g daily.
Cardiac arrest: In doses greater than 18 g per day. It is still given as the lethal injection in some parts of America.
95
What factors increase our need for vitamin C?
pollution exposure, chronic stress,
illness and infection.
96
What are less desirable forms of vitamin C supplementation and why? What would be a preferred form?
Tablets, chewables, fizzy powders / tablets
which can contain sweeteners, artificial colourings / additives.
Instead: Capsules, liposomal vit C, powders.
97
What forms of vitamin C would you choose for:
- health maintenance
- detoxification
* For health maintenance: Use low-dose food forms, such as rose hip and acerola; the body recognises these as food.
* Detoxification: High dose ascorbic acid acts as an antioxidant; is quickly excreted from the body but takes free radicals with it.
98
What are the positives and negatives of the ascorbic acid form of vitamin C supplementation?
Found naturally in food with good bioavailability. Acidic so may be harsh on the GIT.
99
Vitamin C: Bioflavonoids
Beneficial plant compounds such as hesperidin, quercetin and rutin, often added; work synergistically to deliver
extra immune benefits and may help to increase bioavailability.
100
Vitamin C: Liposomal
Increased bioavailability due to phospholipid outer casing protecting the vitamin C inside from damage.
101
Benefits of time-release vitamin C
Better bioavailability when taken in
smaller doses throughout the day; time-release formulas maximise total absorption of vitamin C over a prolonged period.
102
What is 'buffered’ vitamin C, and what are its benefits?
Mineral ascorbates: Such as calcium, magnesium, sodium, potassium ascorbate are often called ‘buffered’ vitamin C (Ester-C®)
- Joined to alkaline mineral to cause less GI upset. Gentler forms of vitamin C; better tolerated by the gut.
- Body absorbs carrier molecule as well as ascorbate.
Important to consider the accompanying dose of mineral (calcium, magnesium, etc.) when taking higher levels.
103
Vitamin C adverse reactions
* Bowel tolerance: Can cause diarrhoea in high doses.
* Haemochromatosis: Sufferers should not supplement high-dose vitamin C as it may increase iron absorption; pro-oxidant effect.
* Lab tests: Can alter results; e.g. bilirubin, glucose, nitrites, leukocytes. Don’t take for at least 10 hours before testing.
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Vitamin C interactions
- Cancer: Safety and efficacy during treatment is controversial; clients should consult their oncologist before supplementing.
- Statins: May affect lipid levels in individuals taking statins.
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Who can benefit from vitamin A supplementation?
Oral vitamin A supplements mainly benefit those with poor or limited diet, or with conditions where there is increased need
such as pancreatic disease, eye disease or measles
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What forms of vitamin A can be found in supplementation?
Multivitamin supplements often contain both provitamin A (beta-carotene) and pre-formed vitamin A.
Pre-formed vitamin A:
Retinol acetate or retinyl palmitate - both stable and highly bioavailable.
Provitamin A:
Beta-carotene - most common synthetic form. Converted in body as needed; prevents vitamin A toxicity.
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Vitamin A caution.
- Not recommended for current or previous smokers (synthetic form especially) - shown to accelerate lung cancer growth. High dietary intake does not have the same effect.
- Taking doses greater than 100,000 IU long term may be toxic.
- High-dose therapy is only recommended short term; caution with doses over 10,000 IU - especially with liver or renal disease, alcoholism or pregnancy.
- Vitamin A is recycled / stored in the liver; liver toxicity is possible.
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Why many groups of people are Vitamin D deficient?
Only small amounts are available from food. A lack of sunlight exposure, excessive sunscreen use and genetic polymorphisms increase the risk of deficiency.
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Name TWO forms of vitamin D. What form is suitable for vegans?
Vitamin D3: Cholecalciferol (active form). Most effective form.
Vitamin D2: Ergocalciferol (inactive vegetarian form).
Vegan form of D3 from lichen is suitable for vegetarians / vegans.
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Preferable ways to administer vitamin D in supplementation.
Oral spray forms an effective method of delivering active D3 directly into the bloodstream, bypassing the digestive system.
Supplement vitamin D3 alongside vitamin K2.
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Name TWO forms of vitamin E as supplements.
Natural form: D-alpha-tocopherol is most commonly used.
1.4 times more biologically active than the synthetic form and retained in the body more efficiently.
Synthetic form: DL or dl-alpha-tocopherol (petrochemical source).
Synthetic dl form may inhibit the natural d form from entering cells.
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Selenium supplementation uses
Selenium supplements are used for immune system health and supporting T3 production in cases of hypothyroidism.
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Name TWO forms of supplemental selenium. Which form is the most bioavailable?
Food form: L-selenomethionine; selenium chelated to methionine.
Supplement forms: Inorganic selenite and selenate; organic selenomethionine, selenocysteine and selenium-enriched yeast.
Higher bioavailability of selenium in selenomethionine (90%) compared to about 50% from selenite. Most bioavailable and easily assimilated form of selenium.
Optimal form of supplemental selenium: Combination of selenomethionine, selenodiglutathione and sodium selenate.
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Vitamin B1 supplemental forms and risk factors.
Thiamine hydrochloride, thiamine mononitrate.
Stable and water-soluble.
Deficiency is rare; thiamine deficiency is usually easy to reverse with supplementation.
Risk factors: Alcoholism or advanced age.
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Vitamin B2 supplemental forms. Advise for best bioavailability and absorption.
Riboflavin, riboflavin 5'-phosphate (FMN).
Modified-release capsules may be best for
bioavailability. High doses have lower bioavailability.
Colours urine bright yellow.
Riboflavin is absorbed best if taken between meals.
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Vitamin B3 supplemental forms. Adverse effects and use in practice.
Niacin, niacinamide (nicotinamide) and nicotinic acid.
Nicotinic acid can cause non-allergic flushing and prickly heat sensation. Tolerance to flushing develops quickly.
Niacin: Cholesterol and triglyceride levels. Raynaud's disease.
Niacinamide: Diabetes and blood sugar control.
Niacin and niacinamide: Cognitive and mental health uses; to combat deficiency (pellagra).
Take niacin with meals to avoid irritation of
the stomach.
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Vitamin B12 supplemental forms.
Methylcobalamin and adenosylcobalamin.
Methyl form used for methylation; adenosyl form in mitochondria.
Most B12 supplements are cyanocobalamin; this inactive form needs to be converted to the active form in the body.
Hydroxycobalamin: Also inactive but with a high affinity for plasma proteins; indicated for those who don’t tolerate methyl groups, or to start B12 supplementation if both folate and B12 deficiency.
B12 supplements do not need stomach acid
or digestive enzymes to release it from protein but absorption still requires intrinsic factor.
The sublingual form is beneficial if digestive issues are present.
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Essential Fatty Acids: supplemental forms.
- What caution should be taken with supplementation?
- What form is more efficiently absorbed?
- What form would you offer to a vegan client? Name ONE good plant source of omega-3.
EPA / DHA
Relatively high levels are needed for therapeutic effect.
Check if fish oils are from the body or liver of fish: Pollutants may be present in oils made from fish livers.
Omega-3s in krill oil are more efficiently absorbed in the body as they are carried into the cells in phospholipid form.
Vegan forms are now available derived from plant marine algae.
Flaxseed oil is a good plant source of omega-3 (high in ALA).
