Transcript moini_ch09_lecture

Focus on
PHARMACOLOGY
ESSENTIALS FOR HEALTH PROFESSIONALS
CHAPTER
9
Nutritional
Aspects of
Pharmacology
and Herbal
Substances
Organizations are Structured
to Provide Safe Patient Care
• Chain of Command
• Interdisciplinary Team
• Rules and Policies
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Nutrition
• Nutrition: how the body takes in and
uses food and other sources of
nutrients for growth and repair of
tissues
• A five-part process: intake, digestion,
absorption, metabolism, elimination
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Nutrients
• Nutrient: element or compound from
diet that supports normal metabolism,
growth, reproduction, or other
functions
– Essential nutrient: needed by body for
normal functioning
– Nonessential nutrient: can be synthesized
by body from other compounds; may also
be derived from diet
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Seven Nutrients
•
•
•
•
•
•
•
Proteins
Fatty acids (also called lipids or fats)
Carbohydrates
Fiber
Vitamins
Minerals
Water
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Macronutrients
• Needed by body in large amounts for
energy
– Carbohydrates
– Fats
– Proteins
– Macrominerals (dietary minerals needed in
high quantities: grams)
– Water
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Macronutrients Are Energy
• Macronutrients: interchangeable as
sources of energy
– Fats yield 9 kilocalories of energy per 1 g
consumed (9 kcal/g)
– Proteins and carbohydrates yield 4 kcal/g
• Water requirements: 1 mL/kcal of
energy expended or about 2,500
mL/day
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Essential Amino Acids
• Components of proteins that cannot be
synthesized by the body and must be
provided by diet
• Nine of the 20 amino acids are
essential
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Essential Fatty Acids
• Required in amounts equaling 6% to
10% of fat intake (5–10 g/day)
• Appear to play a role in decreasing
triglyceride levels and the growth rate
of atherosclerotic plaque
• Required for the formation of
prostaglandins and thromboxanes
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Types of Fatty Acids
• Saturated
– Dense, heavy, and solid at room
temperature
– Found in dairy products and meats
• Unsaturated
– Usually liquid at room temperature
– From vegetables and legumes: corn, soy,
peanuts, safflower
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Cholesterol
• A natural lipid found in cell membranes
• Found in highest concentrations in
animal muscles and organs
• Essential for certain cell structures
• Excess cholesterol can form
atherosclerotic plaque, leading to
cardiovascular disease
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Carbohydrates
• Provide about two-thirds of daily
energy needs
• Aid in fat metabolism and help reserve
protein for uses such as repairing and
building tissues
• Daily requirement 50% to 60% of total
caloric intake
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Two Types of Carbohydrates
• Simple sugars
– Quickly absorbed
– Found in fruits, some vegetables, milk, and
table sugar
• Complex carbohydrates
– Must be processed by the body before
absorption
– Found in grain, fruits, and vegetables
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Storage of Carbohydrates
• Glucose (a sugar) is stored in the liver
and muscles as glycogen (starch).
– Available to supplement dietary supplies of
carbohydrates
• Excess amounts of carbohydrates are
stored in the body as adipose tissue
(fat).
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Blood Glucose Levels
• The central nervous system (CNS)
requires a constant supply of glucose to
function properly.
• Sustained low blood glucose levels,
which can be caused by an excessively
low intake of carbohydrates, can result
in brain damage and death.
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Lactose Sensitivity
• Lactose is a sugar in human and animal
milk that must be broken down by the
enzyme lactase to be digested.
• Many infants and children have trouble
digesting foods that contain lactose.
• Lactose-free milk can be substituted.
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Fiber: A Complex Carbohydrate
• Soluble fiber: absorbs water and swells
when eaten; found in oats, fruits, and
vegetables
• Insoluble fiber: not absorbed by body;
found in bran of whole wheat and
brown rice
• Provides stool bulk, which stimulates
peristalsis
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Micronutrients
• Vitamins and essential trace nutrients
needed in very small quantities.
• Insufficiencies cause biochemical
alterations (such as changes in the
structure and function of tissues and
organs) and diseases.
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Vitamins
• Organic compounds needed for normal
human growth, development, and
maintenance of normal body function.
• Classified by solubility
– Water soluble: B and C vitamins
– Fat soluble: A, D, E, and K vitamins
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Table 9-1
Water-Soluble Vitamins
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Table 9-1 (continued)
Water-Soluble Vitamins
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Table 9-1 (continued)
Water-Soluble Vitamins
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Table 9-1 (continued)
Water-Soluble Vitamins
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B Vitamins: Thiamine (B1)
• Sources: whole grains (especially
wheat germ), lean meats, fish,
soybeans, and other beans
• Important in carbohydrate metabolic
processes
• Deficiency leads to beri-beri (edema,
cardiovascular abnormalities, and
neurologic symptoms).
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B Vitamins: Riboflavin (B2)
• Sources: dairy, yeast, and liver
• Important in metabolism of fats,
carbohydrates, and proteins
• Deficiency causes cheilosis, stomatitis,
glossitis, and seborrheic dermatitis.
• No danger of excessive consumption
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B Vitamins: Nicotinamide (B3)
• Also called niacin
• Sources: liver, yeast products, peanuts,
whole grain cereals, and fish
• Large doses lower cholesterol,
triglycerides, free fatty acids
• Deficiency causes pellagra (dementia,
dermatitis, diarrhea, and death).
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B Vitamins:
Nicotinamide (B3)
• Toxicity includes hepatic impairment,
severe hypotension, and various skin
conditions.
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Pharmacologic Doses of Niacin
• At high doses, niacin decreases blood
levels of low-density lipoprotein (LDL)
cholesterol and triglyceride levels,
which are linked to cardiovascular
disease, and increases high-density
lipoprotein levels (good cholesterol).
• Niacin is used under physician's
supervision for this purpose.
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B Vitamins:
Pantothenic Acid (B5)
• Sources: whole grain cereals, legumes,
meat, eggs
• Needed for formation of coenzyme A
• Deficiency is rare
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B Vitamins: Pyridoxine (B6)
• Sources: animal and plant products
• Used to prevent neuritis in patients on
isoniazid (INH) therapy and to treat
hyperemesis gravidarum (nausea
during pregnancy)
• Deficiency is rare
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B Vitamins: Biotin
• Sources: widely available in foods and
made by natural flora in intestines
• Deficiency is almost unknown
• No known toxicities
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B Vitamins: Folate
• Sources: dark green, leafy vegetables
• Aids creation of DNA; essential to
hemoglobin formation and amino acid
synthesis
• Deficiency causes anemia
• Increased folic acid recommended in
pregnancy to prevent spina bifida.
• No known toxicity
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B Vitamins: Cobalamin (B12)
• Sources: fish, dairy, organ meats, eggs
• Promotes normal cell function,
especially blood formation and nerve
cell function
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B Vitamins: Cobalamin (B12)
• Lack of intrinsic factor in GI tract
(caused by certain GI disorders) can
block absorption of B12, leading to
pernicious anemia
– More common in elderly patients
• No known toxicity
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Vitamin B Factors (Choline)
• Sources: milk, eggs, liver, and peanuts
• Needed to produce acetylcholine
(neurotransmitter involved in memory
and muscle control)
• Deficiency linked to Huntington’s
chorea, Parkinson’s disease, and
Alzheimer’s disease
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Vitamin B Factors (Choline)
• Excess doses may lower blood
pressure; cause fishy body odor,
sweating, and excessive salivation; and
reduce growth rate.
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Vitamin C: Ascorbic Acid
• Sources: capsicums, guavas, kiwi,
citrus
• Aids wound healing, tissue repair,
infection resistance, iron bioavailability,
and calcium absorption
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Vitamin C: Ascorbic Acid
• Antioxidant role: may reduce cancer
risk and lower cholesterol levels
• Deficiency causes scurvy
• Excess may cause diarrhea and
gastritis.
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Vitamin C and Cataracts
• Vitamin C may protect against
cataracts because the body
concentrates it in the lenses of the eye.
• The use of vitamin C for 10 or more
years is associated with 77 to 83%
lower prevalence of early to moderate
cataracts.
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Fat-Soluble Vitamins
•
•
•
•
•
•
Vitamin
Vitamin
Vitamin
Vitamin
Vitamin
Vitamin
A (retinol)
D3 (cholecalciferol)
D2 (ergocalciferol)
E (alpha tocopherol)
K1 (phylloquinone)
K2 (menaquinone)
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Retinol (Vitamin A)
• Sources: fish-liver oils, butter, egg
yolk, liver
– All milk is fortified with vitamin A
– Carotene is converted to vitamin A in body
• Aids tissue maintenance, skeletal and
soft-tissue growth, protein synthesis,
vision
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Retinol (Vitamin A)
• Mild deficiency may cause night
blindness
• Toxicity (hypervitaminosis A) marked
by hair loss, jaundice, joint pain, liver
injury, ascites
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Vitamin A Deficiency
• Dietary vitamin A deficiency is the
number one cause of blindness in
children worldwide.
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Overconsumption of
Vitamins or Minerals
• If overconsumption of vitamin or
mineral occurs, patients should cut
back, but not stop immediately, to
allow the body to adjust.
• Stopping immediately can trigger a
deficiency.
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Cholecalciferol (Vitamin D3)
• Sources: yeast, fish-liver oils
• Cholecalciferol (vitamin D3), made by
the body in response to UV light; then
activated by cholesterol to become
calcitriol.
• Stimulates calcium and phosphorus
absorption
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Cholecalciferol (Vitamin D3)
• Deficiency causes rickets, osteomalacia,
osteoporosis.
• Toxicity can occur, especially in
children.
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Tocopherol (Vitamin E)
• Sources: vegetable oils, nuts, fortified
cereals
• Protects breakdown of red blood cells
(RBCs)
• Deficiency can occur in premature
infants who miss final 1-2 months of
gestation.
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Tocopherol (Vitamin E)
• Deficiency in adults disrupts myelin
production, affecting physical activity
and vision.
• Excess intake may interfere with
vitamin K and blood clotting.
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Vitamin K
• Phylloquinone (K1) is dietary form;
menaquinone (K2) is synthesized by
intestinal bacteria.
• Sources: green leafy vegetables
• Aids blood clotting and bone
development
• Antidote for overdose of anticoagulants
• Deficiency is rare.
• No known toxicity
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Vitamin K
• Phylloquinone is routinely given to
newborns to prevent hemorrhage when
the umbilical cord is cut.
• Trade names of this “vitamin K shot”
are AquaMephyton, Mephyton, or
Phytonadione.
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Mineral and Vitamin Interactions
• Insufficient vitamin D intake hinders
the uptake of calcium.
• High amounts of supplemental vitamin
C reduce copper levels.
• Vitamin C can increase iron absorption
as much as 30%.
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Mineral and Vitamin Interactions
• Excessive amounts of vitamin E
interfere with iron absorption.
• Vitamin B6 is required to metabolize
magnesium and zinc.
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Proper Dosage of Vitamins
• Advise patients about the proper dose
of vitamins that are needed to maintain
metabolic control and prevent disease.a
• Warn patients that certain health
problems are related to inadequate or
excessive intake.
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Minerals
• Major: daily requirements more than
100 mg/day
– Calcium, phosphorus, sodium, potassium,
magnesium, and chlorine
• Minor (essential trade minerals): daily
requirements less than 100 mg/day
– Iron, iodine, fluoride, zinc, chromium,
selenium, manganese, molybdenum, and
copper
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Calcium
• Sources: milk, cheese, salmon, green
leafy vegetables, whole grains
• Aids bone formation, nerve conduction,
myocardial and skeletal muscle
contractions
• Absorption dependent on vitamin D.
• Deficiency causes rickets, osteomalacia,
osteoporosis.
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Calcium
• Excess may cause constipation, nausea,
hypotension, vomiting, kidney stones,
cardiac arrhythmias.
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Phosphorus
• Sources: milk, cheese, legumes, beef,
fish, pork
• Needed for bone and tooth formation,
energy, storage of fats, metabolism of
other nutrients
• Deficiency can cause anemia, bone
brittleness, confusion, and weakness.
• Toxicity may cause hypocalcemia and
kidney stones.
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Sodium
• Source: table salt
• Needed for body fluid balance and acidbase balance; regulates nerve
transmission and cell membrane
irritability.
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Sodium
• Deficiency may cause headache,
confusion, nausea, weakness, anxiety,
muscle spasms, hypotension.
• Toxicity produces hypertension and
edema.
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Potassium
• Sources: oranges, bananas, red meats,
vegetables, yams, milk products, coffee
• Helps maintain normal cardiac and
muscle function
• Deficiency can cause weakness,
paralysis, cardiac arrhythmias, digitalis
toxicity.
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Potassium
• Excessive intake may produce muscle
weakness, diarrhea, severe
dehydration, abdominal pain,
hypotension, cardiac arrest.
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Magnesium
• Magnesium is required to form
proteins.
• It stimulates muscle contraction and
nerve transmission, activates enzymes,
and aids in bone formation.
• Sources: green leafy vegetables, whole
grains, and legumes
• Excess or deficit may cause tetany,
convulsions, or muscle spasms.
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Chlorine
• Sources: table salt, meat, milk,
processed foods
• Major electrolyte that aids acid–base
balance and fluid balance
• Deficiency is rare.
• No known toxicity
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Essential Trace Minerals
• Essential trace minerals are also called
microminerals.
• Less than 100 mg per day are required
• They include: iron, iodine, fluoride,
zinc, chromium, selenium, manganese,
molybdenum, and copper.
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Iron
• Sources: meat, eggs, vegetables,
cereals
• Aids in synthesis of hemoglobin and
general metabolism
• Deficiency causes anemia.
• Toxicity can be fatal.
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Iron Toxicity
• In the United States, iron overdose
from supplements is leading cause of
poisoning in young children.
• Symptoms: nausea, vomiting, diarrhea
• If not treated immediately, can result in
brain, kidney, liver, and heart damage
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Iodine
• Sources: iodized table salt, seafood
• Helps synthesize thyroxine to control
body’s basal metabolic rate
• Deficiency can cause goiter, cretinism,
and myxedema.
• Excess intake causes acne-like skin
lesions or worsen acne.
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Cretinism
• Cretinism occurs in children born to
mothers who had limited iodine intake
during adolescence and pregnancy.
• Children with cretinism have retarded
physical and mental development.
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Zinc
• Source: meat
• Important during growth periods
• Deficiency may cause retarded physical
growth (such as dwarfism) and
retarded sexual maturation, poor
wound healing, hair loss, diarrhea, skin
irritation.
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Zinc
• Excess intake can inhibit copper
absorption or cause nausea, vomiting,
and decreased immune function.
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Fluoride
• Sources: fish, tea
• Prevents dental caries by strengthening
tooth's ability to withstand bacterial
erosion
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Copper
• Sources: organ meats (liver), seafood,
nuts, seeds, legumes, grains
• Aid energy production and hemoglobin
synthesis
• Deficiency is rare; increased intake is
recommended for pregnant or lactating
women to meet increased needs.
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Copper
• Toxicity: Wilson’s disease is genetic
disorder causing excess storage of
copper in body that can result in liver
and nerve damage.
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Nutritional Requirements
• Nutritional needs of infants in 1st year
of life are increased.
• Breast milk and commercially prepared
formula contain the correct balance of
nutrients.
• Cow’s milk does not meet these
standards.
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Nutritional Requirements
• Food and Nutrition Board issues
recommended dietary allowances
(RDAs) every 5 years.
• Body composition requires balancing
energy intake with energy expenditure.
• Nutrition during pregnancy: 25–30
pound weight gain recommended.
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Cachexia
• A profound syndrome caused by
malnutrition and a disturbance in
glucose and fat metabolism.
• Occurs in patients with terminal cancer
or AIDS and in patients who are in
generally poor health
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Nutritional Support
• Enteral nutrition: used in patients with
a functioning GI tract to supplement or
completely replace oral feeding;
administered through a tube
• Parenteral nutrition: indicated for
patients who require intensive protein
and caloric support and who are unable
or unwilling to take oral
supplementation; administered IV
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Nutrient–Drug Interactions
• Food affects drug absorption by slowing
gastric emptying, by binding with a
drug, decreasing the access of drugs to
sites of absorption, altering the
dissolution rate of drugs, or altering the
pH of the GI contents.
• Drugs can affect mineral or vitamin
metabolism or absorption, and also
suppress appetite.
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Table 9-2
Drugs That Affect Appetite, Absorption, and Tissue Metabolism
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Food Additives
and Contaminants
• Benefits of additives
– Facilitate food processing and preservation
– Enhance restorative or stimulating
properties of foods
– Control natural contaminants
• Additives are strictly regulated.
• Reported health problems related to
additives have been trivial and largely
anecdotal
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Herbal Supplements
• An herbal supplement may be defined
as any mixture of ingredients based on
plant sources and designed for the
improvement of health or treatment of
certain conditions.
• They are considered by the FDA to be
food products, and not drugs.
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Use of Herbal Supplements
• Patients must understand that the
taking of herbal supplements should
not occur without consulting their
physician.
• These substances are not regulated by
the FDA and there is no verification of
their quality, effectiveness, or quantity
of ingredients they contain.
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Complementary and
Alternative Medicine (CAM)
• CAM involves different healing systems
and therapies, which include:
– Herbal therapies
– Nutritional supplements
– Special diets
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The Dietary Supplement
Health and Education Act
• DSHEA (1994) attempted to regulate
herbal supplements.
• This act requires manufacturers to label
these products as dietary supplements.
• Dietary supplements are defined as
products that are intended to enhance
or supplement the diet.
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The Dietary Supplement and Nonprescription
Drug Consumer Protection Act
• This 2007 act required that
manufacturers must include contact
information on product labels for
consumers so that they can report
adverse effects of products.
• Manufacturers must inform the FDA of
such occurrences within 15 days after
receiving a consumer complaint.
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Table 9-3
Top-Selling Herbal Supplements
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Table 9-3 (continued)
Top-Selling Herbal Supplements
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Table 9-3 (continued)
Top-Selling Herbal Supplements
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Table 9-3 (continued)
Top-Selling Herbal Supplements
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