Episode 7: Nutritional Deficiencies and Dietary Supplements

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Episode 7: Nutritional Deficiencies and Dietary Supplements

• Public Interest in Nutritional Supplementation
  • 50% of the U.S. adult population uses dietary supplements
  • 1990-1997 400% growth in dietary supplement sales for humans
  • Currently growing at 15% per year
  • $37 billion annually
  • 85% of regular supplement users believe that dietary supplements are good for health
  • 82% of Americans would try herbs for terminal illness

{ http://www.cfsan.fda.gov/~dms/fdsupp.html; Boothe DM. 2004 Vet Clin Small Anim 34:7-38 ; Blendon RJ. 2001 Arch Intern Med 161:805-810 }

 

• Similar interest in supplement use for pets
  • 30% of pet owners have used or have considered using dietary supplements
  • 90% of veterinarians sell some type of herbs or nutraceuticals
  • $20-50 million in annual sales

{Boothe DM. 2004 Vet Clin Small Anim 34:7-38}

 

• Important Questions Concerning Nutritional Supplements
  • What are nutritional supplements?
  • Terminology, Definitions, Contents
  • Why do we need nutritional supplements?
  • Evidence for nutritional deficiencies – When should we use nutritional supplements?
    • How do we recognize/suspect the need?
  • What nutritional supplements should we use? – What kind of nutritional supplement is best?
    • How do we use nutritional supplements?

 

• Conventional Thinking About Nutritional Supplementation
  • “The proper role of a supplement is to correct a diagnosed nutrient deficiency”

{Small Animal Clinical Nutrition 4th Ed p. 116}

• However, diagnosis is difficult with current tools and difficult to recognize based on conventional definitions of deficiency
• “ The most common form of veterinary supplements is a wide variety of vitamin and vitamin-mineral combinations that are used by 10% of animal owners”

{Small Animal Clinical Nutrition 4th Ed p. 116}

• Predominantly consist of isolated, or synthetic, vitamins
• “Routine use of vitamin mineral supplements is not needed when a dog or cat eats typical commercial pet food”
• “…dogs and cats consuming commercial dry rations were ingesting from two to five times the daily allowance of vitamins”

{Small Animal Clinical Nutrition 4th Ed p. 116}

• They are already receiving potentially excessive amounts of isolated, or synthetic vitamins
• The conventional approach to nutritional supplementation is to provide more of the same isolated and synthetic nutrients that are already present in high amounts in the pet foods, expecting a better outcome
  • It has been claimed that insanity is continuing to do the same thing, expecting a different result

 

• Confusion in Terminology: What Are Nutritional Supplements?
• Food: (according to section 201(f) of the Food, Drug, and Cosmetic Act)
  • “a raw, cooked, or processed edible substance, ice, beverage, or ingredient used or intended for use or for sale in whole or in part for human consumption”
  • “articles used for food or drink for man or other animals, chewing gum, and articles used for components of any such articles.”
  • This includes “dietary supplements and dietary ingredients”

{ http://www.cfsan.fda.gov/~dms/fsbtac13.html http://www.cfsan.fda.gov/~dms/fc01-1.html1  http://www.cfsan.fda.gov/~ear/ims-a-30.html}

• Drugs:
  •  “articles [food or non-food] intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease in man or other animals”
  • “ articles (other than food) intended to affect the structure or any function of the body of man or other animals”

{ http://www.cfsan.fda.gov/~dms/fsbtac13.html   http://www.cfsan.fda.gov/~dms/fc01-1.html1

http://www.cfsan.fda.gov/~ear/ims-a-30.html}

 

• “Medical Food” originally applied to humans
  • For dietary management of a disease or health condition
  • Under the direction of a physician
  • Label must state that the product is to be used to manage a specific medical disorder or condition
  • Term adopted/applied to veterinary medicine
  • Why a “Medical” food?
  • “…the scientific community generally believes that foods and ingredients play a role in prevention and treatment of certain diseases and that claims to that effect on food labels should not render those products as drugs”

{http://cfsan.fda.gov/~dms/ds-medfd.html }

•  “Specific requirements for the safety or appropriate use of medical foods have not yet been established. Medical foods do not have to include nutrition information on their labels, and their claims do not need to meet specific standards.”
• Veterinary medical foods do not require pre-market submission of safety or efficacy data for their intended use.
  • “Unfortunately, a product could be exempt from fulfilling any requirements for labeling (including submission of data to support a health message) simply by meeting category definition of a medical food.”

{Dzanis D, McGovern L.  The CVM’s role in the practice of small animal medicine.  Kirk’s Current Veterinary Therapy XI Small Animal Practice, 1992, pp. 64-66}

 

 

 

 

• Terminology of Nutritional Supplements
  • “A nutrient is any food constituent that helps support life”
  • FDA’s traditional definition of dietary supplement consisted of only ‘essential’ nutrients – vitamins, minerals, and proteins

 

• “Herbs, or similar nutritional substances” were added in the Nutrition Labeling and Education Act of 1990

{Small Animal Clinical Nutrition 4th Ed p. 21

{http://www.cfsan.fda.gov/~dms/dietsupp.html}

{Dietary Supplement Health and Education Act of 1994 (DSHEA)}

• Amended the Federal Food, Drug, and Cosmetic Act to include provisions specific to dietary supplements and dietary ingredients to dietary supplements
• Recognition that there is:
  • “a relationship between sound dietary practice and good health”
  • “a connection between dietary supplement use, reduced health-care expenses, and disease prevention.”

{http://www.cfsan.fda.gov/~dms/dietsupp.html}

{http://www.cfsan.fda.gov/~dms/ds-oview.html}

• “A dietary supplement is a product taken by mouth that contains a ‘dietary ingredient’ intended to supplement the diet.”
• “A product that is intended to supplement the diet that bears or contains one or more of the following dietary ingredients : a vitamin, a mineral, an herb or other botanical, an amino acid, a dietary substance for use by man to supplement the diet by increasing the total daily intake, or a concentrate, metabolite, extract, or combinations of these ingredients”

{http://www.cfsan.fda.gov/~dms/dietsupp.html}

{http://www.cfsan.fda.gov/~dms/ds-oview.html}

• “Is intended for ingestion in pill, capsule, tablet, or liquid form.”
• “Is not represented for use as a conventional food or as the sole item in a meal or diet.”
• “Is labeled as a ‘dietary supplement’.”
• “Includes products such as an approved new drug, certified antibiotic, or licensed biological that was marketed as a dietary supplement or food before approval, certification, or license.”

{http://www.cfsan.fda.gov/~dms/dietsupp.htm}

 

• ‘Nutraceuticals’
  • “a substance that is produced in purified or extracted form and administered orally to patients to provide agents required for normal body structure and function and administered with the intent of improving the health and well-being of animals.”
  • “Any substance that may be considered food or part of a food and provides medical or health benefits, including the prevention and treatment of disease.”

{Small Animal Clinical Nutrition 4th Ed pp.114-115}

 

 

• Nutraceuticals may contain
  • Isolated nutrients
  • EFA’s, vitamins, chondroprotective agents, DMG, CoQ10, individual phytochemicals
  • Functional foods
  • “Any modified food or food ingredient that may provide a health benefit beyond the traditional nutrients it contains”
  • Designer (genetically-engineered) foods , hypernutritious foods, pharmafoods, processed human foods
  • “Foods or nutrients that claims medical or health benefits, including the prevention and treatment of disease”
  • Herbs

{Small Animal Clinical Nutrition 4th Ed pp.114-115}

 

• Nutritional/Dietary Supplements:  The Key Distinctions
  • What nutritional supplements should we use?
  • What kind is best?
    • Synthetic?
      • Chemically-synthesized single substance either duplicates or approximates naturally occurring vitamin substance and has vitamin-like activity
  • Natural?
    • Single vitamin compound extracted or isolated from food source
• Isolated components (alone or in combination)?
  • Macronutrients
  • Vitamins
  • Minerals
  • Amino acids/proteins
  • Fatty acids
  • Carbohydrates
  • “Trace” minerals
  • “Phytochemicals” (“non-nutrients”)
• Whole-food based supplements  (including botanicals)
  • Whole-food concentrates
  • Contains naturally-occurring substances as found in food
  • Complete vitamin complexes
  • Synergistic combination of phytochemicals
  • Proteins (nucleic acids)
  • Fatty acids
  • Minerals
  • Food concentrate produced from  specific nutrient-dense food
  • Not isolated single constituent
  • “The best way to get vitamins is from whole foods.”

{Stevens L. Nutrition: Vitamins A to K. JAMA Patient Page JAMA Vol. 287, No. 23 June 19, 2002}

 

• Why Do We Need Nutritional Supplementation?
  • Provide vital factors lost during processing
  • Increase specific nutrients and “non-nutrient” factors
  • Manage biochemical individuality
  • Manage periods of increased tissue stress or demand
  • Inherent deficiencies of commercially produced vegetables, fruits, and animal products
  • Recognize importance of partial or “subclinical” nutritional deficiency

 

 

 

• Nutrients serve as metabolic substrates  – enter cell and enter into cellular metabolic functions to produce outputs of proteins, enzymes, neurotransmitters, fats, hormones, etc.
  • Deficient input = deficient output
  • Garbage In – Garbage Out
  • Affects potentially any cells in the body: examples –
    • Immune
      • Nutrition provides the components needed by the immune system to generate an effective immune response
      • Leukocyte proliferation and phagocytic activity
      • Oxidant balance
      • Protein activity
      • Antibody production
      • Cytokine balance
      • Acute phase proteins
      • Complement pathways
      • Transcription factors
      • Enzymes
      • Nutrition and Immunology: Principles and Practice Gershwin, German, Keen Eds. 2000
      • Range of immune problems associated with nutritional deficiencies
      • Increased opportunistic infections
      • Increased risk of cancer development
      • Suboptimal response or adverse response to vaccinations
      • Allergies/autoimmune disease
      • Nutrition and Immunology: Principles and Practice Gershwin, German, Keen Eds. 2000
  • Nervous
  • Endocrine
  • GI