Canadian Clinicaldrugtherapyf 27

CHAPTER
57
KEY TERMS

Nutritional Support Products, Vitamins, and MineralsElectrolytes

OBJECTIVES
After studying this chapter, you will be able to:
Chelating agent Electrolytes Enteral nutrition Fat-soluble vitamins Hyperkalemia Hypokalemia Malabsorption Megaloblastic anemia Megavitamins Parenteral nutrition Water-soluble vitamins
1. Assess patients for risk factors and manifestations of protein-calorie

undernutrition.
2. Identify patients at risk for development of vitamin and/or mineral

electrolyte deciency or excess. 3. Describe the adverse effects associated with overdoses of vitamins. 4. Discuss the rationale for administering vitamin K to newborns. 5. Describe the signs, symptoms, and treatment of sodium, potassium, magnesium, and chloride imbalances. 6. Describe the signs, symptoms, and treatment of iron deciency anemia. 7. Discuss the chelating agents used to remove excessive copper, iron, and lead from body tissues. 8. Apply nursing process skills to prevent, recognize, or treat nutritional imbalances. 9. Monitor laboratory reports that indicate nutritional status.
Applying Your Knowledge

Jane Farber is a 91-year-old woman who suffers from heart failure, osteoarthritis, and Parkinsons disease. Upon evaluation, you nd that Mrs. Farber is undernourished and slightly dehydrated.
Introduction
Water, carbohydrates, proteins, fats, vitamins, and minerals are required to promote or maintain health, to prevent illness, and to promote recovery from illness or injury. Water is required for cellular metabolism and excretion of metabolic waste products; 2,000 to 3,000 mL is needed daily. Proteins are structural and functional components of all body cells and tissues; the recommended amount for adults is 50 to 60 g daily. Carbohydrates and fats mainly provide energy for cellular metabolism. Energy is measured in kilocalories (kcal) per gram (g) of food oxidized in the body. Carbohydrates and proteins supply 4 kcal per g; fats supply 9 kcal per g. Vitamins are required for normal body metabolism, growth, and development. They are components of enzyme systems that release energy from proteins, fats, and carbohydrates. They also are required for formation of red blood cells (RBCs), nerve cells, hormones, genetic material, and bone and other tissues. Minerals and electrolytes are essential constituents of bone, teeth, cell membranes, connective tissue, and many essential enzymes. They function to maintain uid, electrolyte, and acidbase balance; maintain osmotic pressure; maintain nerve and muscle function; assist in
902
Chapter 57 Nutritional Support Products, Vitamins, and MineralsElectrolytes
903
transfer of compounds across cell membranes; and inuence the growth process. For all of these nutrients, patients requirements vary widely, depending on age, sex, size, health or illness status, and other factors. This chapter discusses products to improve nutritional status in patients with deciency states and excess states of selected vitamins and mineralelectrolytes.
contain 1 kcal per mL. Additional products are formulated for patients with special conditions (eg, renal or hepatic failure, malabsorption syndromes) or needs (eg, high protein, increased calories).
IV Fluids
IV uids are used when oral or tube feedings are contraindicated. Most are nutritionally incomplete and used short term to supply uids and electrolytes. Dextrose or dextrose and sodium chloride solutions are often used. When nutrients must be provided parenterally for more than a few days, a special parenteral nutritional formula can be designed to meet all nutritional needs or to supplement other feeding methods.
Nutritional Deciency States

Nurses encounter many patients who are unable to ingest, digest, absorb, or use sufcient nutrients to improve or maintain health. Debilitating illnesses such as cancer; acquired immunodeciency syndrome; and chronic lung, kidney, or cardiovascular disorders often interfere with appetite and gastrointestinal (GI) function. Therapeutic drugs often cause anorexia, nausea, vomiting, diarrhea, or constipation. Nutritional deciencies may impair the function of essentially every body organ. Signs and symptoms include unintended weight loss; increased susceptibility to infection; weakness and fatigability; impaired wound healing; impaired growth and development in children; edema; and decreased hemoglobin.
Pancreatic Enzymes
Pancreatic enzymes (amylase, protease, lipase) are required for absorption of carbohydrates, protein, and fat. Pancrelipase (Cotazym, Ultrase, Pancrease, Viokase, others) is a commercial preparation used as replacement therapy in deciency states, including cystic brosis, chronic pancreatitis, pancreatectomy, and pancreatic obstruction. Dosage ranges from one to three capsules or tablets with each meal or snack.
Vitamins
Vitamins are obtained from foods or supplements. Although foods are considered the best source, studies indicate that most adults and children do not consume enough fruits, vegetables, cereal grains, dairy products, and other foods to consistently meet their vitamin requirements. In addition, some conditions increase requirements above the usual recommended amounts (eg, pregnancy, lactation, various illnesses). Historically, the major concern about vitamins was sufcient intake to promote health and prevent deciency diseases. To this end, the Food and Nutrition Board of the National Academy of Sciences, an independent, non-governmental body, in association with Canadian and American scientists, established recommendations for daily vitamin intake (Dietary Reference Intakes [DRIs]; see Box 57-1). The DRIs provide
Nutritional Products
Various products are available to supplement or substitute for dietary intake. These may consist of liquid enteral formulas, intravenous (IV) uids, pancreatic enzymes, vitamins, and minerals.
Liquid Enteral Products

Numerous liquid enteral formulas are available over-thecounter (OTC) or in health care settings for oral or tube feedings. Many are nutritionally complete, except for water, when given in sufcient amounts (eg, Ensure, Isocal, Sustacal, Resource). Additional water must be given to meet uid needs. Most oral products are available in a variety of avours and
Box 57-1
Dietary Reference Intakes

healthy children and adults in a specic age and gender group. The RDA is used to advise various groups about nutrient intake. It should be noted, however, that RDAs were established to prevent deciencies and that they were extrapolated from studies of healthy adults. Thus, they may not be appropriate for all groups, such as young children and older adults. 3. Adequate Intake (AI) is the amount thought to be sufcient when there is not enough reliable, scientic information to estimate an average requirement. The AI is derived from data that show an average intake that appears to maintain health. 4. Tolerable Upper Intake Level (UL) is the maximum intake considered unlikely to pose a health risk in almost all
(continued on page 904)
DRIs are the recommended amounts of vitamins (see Table 57-1) and some minerals (see Table 57-3). The current DRIs were established in 1997, 1998, and 2000 by the Food and Nutrition Board of the National Academy of Sciences in association with Canadian and American scientists in an effort to streamline standards between countries, and are intended to replace the RDAs and RNIs (Canada) used since 1989. DRIs consist of four subtypes of nutrient recommendations as follows: 1. Estimated Average Requirement (EAR) is the amount estimated to provide adequate intake in 50% of healthy persons in a specic group. 2. Recommended Dietary Allowance (RDA) is the amount estimated to meet the needs of approximately 98% of
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Section 9 Drugs Affecting the Digestive System
Box 57-1
Dietary Reference Intakes (continued)

There are inadequate data for establishing ULs for biotin, cyanocobalamin (B12), pantothenic acid, riboavin, and thiamine. As a result, consuming more than the recommended amounts of these vitamins should generally be avoided. With minerals, ULs have been established for calcium (2.5 g), phosphorus (34 g), magnesium (350 mg), uoride (10 mg), and selenium (400 mcg). The UL should not be exceeded for any mineralelectrolyte because all minerals are toxic in overdose. Except for magnesium, which is set for supplements only and excludes food and water sources, the stated UL amounts include those from both foods and supplements.
healthy persons in a specied group; it is not intended to be a recommended level of intake. With vitamins, the ULs for adults (1970 y and older) are D, 50 mg; E, 1,000 mg; C, 2,000 mg; folate, 1,000 mcg; niacin, 35 mg; and pyridoxine, 100 mg. With vitamins C and D and pyridoxine, the UL refers to the total intake from food, fortied food, and supplements. With niacin and folate, the UL applies to synthetic forms obtained from supplements, fortied foods, or a combination of the two. With vitamin E, the UL applies to any form of supplemental alpha-tocopherol. These ULs should not be exceeded.
a set of dietary standards agreed upon by health professionals in both countries to replace the RNIs (Recommended Nutrient Intakes) in Canada and the RDAs (Recommended Dietary Allowances) in the United States. Currently, concern extends to excessive vitamin intake, which may also cause disordered body metabolism and may be detrimental to health. Vitamin supplements are widely promoted to increase health and prevent or treat illness. However, the supplements can be harmful if overused. As a result, the DRIs include the maximum Tolerable Upper Intake Levels (ULs) of some vitamins. These amounts should not be exceeded. Vitamins are classied as fat-soluble (A, D, E, K) and water-soluble (B complex, C). Fat-soluble vitamins are absorbed from the intestine with dietary fat, and the absorption requires the presence of bile salts and pancreatic lipase. Vitamin D is discussed mainly in Chapter 25 because of its major role in bone metabolism. Vitamin deciencies occur with inadequate intake or disease processes that interfere with absorption or use of vitamins. Excess states occur with excessive intake of fat-soluble vitamins because these vitamins accumulate in the body. Excess states do not occur with dietary intake of watersoluble vitamins, but may occur with vitamin supplements that exceed recommended amounts. Vitamins are described further in Table 57-1, and recommended dosages of vitamin preparations are listed in Table 57-2.
Vitamin products vary widely in number, type, and amount of specic ingredients. Preparations should not contain more than recommended amounts of vitamin D, folic acid, and vitamin A. Synthetic vitamins have the same structure and function as natural vitamins derived from plant and animal sources and are less expensive. Multivitamin preparations often contain minerals as well. Large doses of all minerals are toxic. Vitamins are often marketed in combination products with each other (eg, anti-oxidant vitamins) and with herbal products (eg, B-complex vitamins with ginseng, for energy). Research studies are being done to determine the support for the use of such products. Vitamin E contains four compounds of which alpha-tocopherol is the most active and is expressed as alpha-tocopherol equivalents (-TE), as mg, and as International Units (IU). One -TE is equivalent to 1 mg of active vitamin E. One IU of vitamin E is equal to 0.67 mg of -TE.
MineralElectrolytes
There are 22 minerals considered necessary for human nutrition. Some (calcium, phosphorus, sodium, potassium, magnesium, chlorine, sulphur) are required in relatively large amounts. Calcium and phosphorus are discussed mainly in Chapter 25 because of their major roles in bone metabolism. Sulphur is a component of cellular proteins, several amino acids, B vitamins, insulin, and other essential body substances. No recommended intake has been established; it is obtained from protein foods. Other minerals are required in small amounts and are often called trace elements. Eight trace elements (chromium, cobalt, copper, uoride, iodine, iron, selenium, and zinc) have relatively well dened roles in human nutrition. Others (manganese, molybdenum, nickel, silicon, tin, and vanadium) are present in many body tissues and may be necessary for normal growth, structure, and function of connective tissue. However, requirements are unknown and states of deciency or excess have not been identied in humans.
Vitamin Supplements
Dietitians generally recommend people meet their vitamin needs through making choices from Canadas Food Guide. Health care providers may prescribe vitamin supplements, but most supplements are self-prescribed. Because vitamins are essential nutrients, some people believe that large amounts (megadoses) promote health and provide other benecial effects. However, excessive intake may cause harmful effects, and megavitamins should never be self-prescribed. Additional characteristics include the following:
Vitamins from supplements exert the same physiologic effects as those obtained from foods. Most vitamin supplements do not require a prescription.
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Table 57-1
Vitamins
SIGNS AND SYMPTOMS OF DEFICIENCY
Night blindness; xerophthalmia, which may progress to corneal ulceration and blindness; changes in skin and mucous membranes that lead to skin lesions and infections, respiratory tract infections, and urinary calculi
VITAMIN/ FUNCTION
Fat-Soluble Vitamins Vitamin A (retinol) Required for normal vision, growth, bone development, skin, and mucous membranes
RDA
RDAsa Females: 14 y and older, 700 mcg; in pregnancy, 750770 mcg; lactation, 1,2001,300 mcg Males: 14 y and older, 900 mcg Children: 13 y, 300 mcg; 48 y, 400 mcg; 913 y, 600 mcg Infants (AIs): 06 mo, 400 mcg; 612 mo, 500 mcg
FOOD SOURCES
Preformed vitamin A: liver, fortied dairy products (eg, milk and margarine), and egg yolk Carotenoids: turnip and collard greens, kale, spinach, carrots, sweet potatoes, squash, oranges, mangos, apricots, peaches, and cantaloupe
SIGNS AND SYMPTOMS OF EXCESS

Anorexia, vomiting, irritability, skin changes (itching, desquamation, dermatitis); pain in muscles, bones, and joints; gingivitis; enlargement of spleen and liver; increased intracranial pressure; and other neurologic signs Congenital abnormalities in newborns whose mothers took excessive vitamin A during pregnancy Acute toxicity, with increased intracranial pressure, bulging fontanels, and vomiting, may occur in infants who are given vitamin A
Vitamin E Anti-oxidant in preventing destruction of certain fats, including the lipid portion of cell membranes; may increase absorption, hepatic storage, and use of vitamin A
RDAsb Females: 14 y and older, 15 mg; in pregnancy, 15 mg; lactation, 19 mg Males: 14 y and older, 15 mg Children: 13 y, 6 mg; 48 y, 7 mg; 913 y, 11 mg Infants (AIs): 06 mo, 4 mg; 712 mo, 5 mg
Fortied cereals, green leafy vegetables, egg yolk, milk fat, butter, meat, vegetable oils (eg, corn, safower, soybean), wheat germ, and nuts (eg, almonds, pecans, sunower seeds)
Deciency is rare
Fatigue, nausea, headache, blurred vision, and diarrhea
Vitamin K Essential for normal blood clotting. Activates precursor proteins, found in the liver, into clotting factors II, VII, IX, and X
Females (AIs): 1418 y, 75 mcg; 1970 y and older, 90 mcg; in pregnancy, 7590 mcg; lactation, 7590 mcg Males (AIs): 1418 y, 75 mcg; 1970 y and older, 120 mcg Children (AIs): 13 y, 30 mcg; 48 y, 55 mcg; 913 y, 60 mcg Infants (AIs): 06 mo, 2 mcg; 712 mo, 2.5 mcg
Dark green leafy vegetables (spinach, kale, cabbage, lettuce), cauliower, wheat bran, egg yolk, and liver
Abnormal bleeding (melena, hematemesis, hematuria, epistaxis, petechiae, ecchymoses, hypovolemic shock)
Clinical manifestations rarely occur. However, when vitamin K is given to someone who is receiving warfarin (Coumadin), the patient can be made warfarinresistant for 23 weeks
Vitamin D (see Chap. 25)

906
Table 57-1
Vitamins (continued)
Anorexia, nausea, depression, muscle pain, and dermatitis
VITAMIN/ FUNCTION
RDA
FOOD SOURCES
Meat, poultry, sh (eg, salmon, trout, tuna), egg yolk, nuts, whole grains, cereals, legumes (garbanzo beans and lima beans), bananas, and potatoes

Not established
Water-Soluble Vitamins B-Complex Biotin Females (AIs): 1418 y, Essential in fat 25 mcg; 19 y and and carbohydrate older, 30 mcg; in metabolism pregnancy, 30 mcg; lactation, 35 mcg Males (AIs): 1418 y, 25 mcg; 19 y and older, 30 mcg Children (AIs): 13 y, 8 mcg; 48 y, 12 mcg; 913 y, 20 mcg Infants (AIs): 06 mo, 5 mcg; 712 mo, 6 mcg Cyanocobalamin (B12) Essential for normal metabolism of all body cells; normal RBCs; normal nerve cells; growth; and metabolism of carbohydrate, protein, and fat Females: 14 y and older, 2.4 mcg; in pregnancy, 2.6 mcg; lactation, 2.8 mcg Males: 14 y and older, 2.4 mcg Children: 13 y, 0.9 mcg; 48 y, 1.2 mcg; 913 y, 1.8 mcg Infants (AIs): 06 mo, 0.4 mcg; 712 mo, 0.5 mcg
Meat, eggs, sh (haddock, salmon, tuna), dairy products (cheese, milk, yogurt), and fortied cereals
Pernicious anemia: decreased numbers of RBCs; large, immature RBCs; fatigue; and dyspnea Severe deciency: leukopenia, infection, thrombocytopenia, cardiac dysrhythmias, and heart failure Neurologic signs and symptoms: paraesthesias in hands and feet, unsteady gait, and depressed deeptendon reexes Severe deciency: loss of memory; confusion; delusions; hallucinations; and psychosis may occur. Nerve damage may be irreversible
Not established
Folic acid (folate) Essential for normal metabolism of all body cells; normal RBCs; and growth
Females: 14 y and older, 400 mcg; in pregnancy, 600 mcg; lactation, 500 mcg Males: 14 y and older, 400 mcg
Liver, kidney beans, fresh green vegetables (spinach, broccoli, asparagus), and fortied grain products (eg, breads, cereals, rice)
Megaloblastic anemia that cannot be distinguished from the anemia produced by B12 deciency; impaired growth in children;
Not established
907
VITAMIN/ FUNCTION
RDA
Children: 13 y, 150 mcg; 48 y, 200 mcg; 913 y, 300 mcg Infants (AIs): 06 mo, 65 mcg; 712 mo, 80 mcg
FOOD SOURCES

glossitis; and GI problems
Niacin (B3) Essential for glycolysis, fat synthesis, and tissue respiration. It functions as a coenzyme in many metabolic processes (after conversion to nicotinamide, the physiologically active form)
Females: 14 y and older, 14 mg; in pregnancy, 18 mg; lactation, 17 mg Males: 14 y and older, 16 mg Children: 13 y, 6 mg; 48 y, 8 mg; 913 y, 12 mg Infants (AIs): 06 mo, 2 mg; 712 mo, 4 mg
Meat, poultry, sh (cod, halibut, salmon), peanuts, dairy products, eggs, whole grains, and enriched our and cereals
Pellagra: erythematous skin lesions, GI problems (stomatitis, glossitis, enteritis, diarrhea), and central nervous system problems (headache, dizziness, insomnia, depression, memory loss) Severe deciency: delusions, hallucinations, and impairment of peripheral motor and sensory nerves
Flushing; pruritus; hyperglycemia; hyperuricemia; and increased liver enzymes
Pantothenic acid (B5) Essential for metabolism of carbohydrate, fat, and protein (eg, release of energy from carbohydrate; fatty acid metabolism; synthesis of cholesterol, steroid hormones, and phospholipids) Pyridoxine (B6) A coenzyme in metabolism of carbohydrate, protein, and fat; required for formation of tryptophan and conversion of tryptophan to niacin; helps release glycogen from the liver and muscle tissue; functions in metabolism of the central nervous system; helps maintain cellular immunity
Females (AIs): 14 y and older, 5 mg; in pregnancy, 6 mg; lactation, 7 mg Males (AIs): 14 y and older, 5 mg Children (AIs): 13 y, 2 mg; 48 y, 3 mg; 913 y, 4 mg Infants (AIs): 06 mo, 1.7 mg; 712 mo, 1.8 mg Females: 1418 y, 1.2 mg; 1950 y, 1.3 mg; 5170 y and older, 1.5 mg; in pregnancy, 1.9 mg; lactation, 2.0 mg Males: 1450 y, 1.3 mg; 5170 y and older, 1.7 mg Children: 13 y, 0.5 mg; 48 y, 0.6 mg; 913 y, 1.0 mg Infants (AIs): 06 mo, 0.1 mg; 712 mo, 0.3 mg
Eggs, liver, salmon, yeast, cauliower, broccoli, lean beef, potatoes, tomatoes, whole-grain cereal and bread, avocados, and milk
No deciency state established
Not established
Yeast, wheat germ, liver and other glandular meats, fortied whole grains and cereals, potatoes, poultry, sh (salmon, trout, tuna), legumes (garbanzo beans and lima beans), and bananas
Skin and mucous membrane lesions (seborrheic dermatitis, intertrigo, glossitis, stomatitis) and neurologic problems (convulsions, peripheral neuritis, mental depression)
Not established
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Table 57-1
Vitamins (continued)
Glossitis, stomatitis, seborrheic dermatitis, eye disorders (burning, itching, lacrimation, photophobia, vascularization of the cornea)
VITAMIN/ FUNCTION
Riboavin (B2) A coenzyme in metabolism; necessary for growth; may function in production of corticosteroids and RBCs and gluconeogenesis
RDA
Females: 1418 y, 1.0 mg; 19 y and older, 1.1 mg; in pregnancy, 1.4 mg; lactation, 1.6 mg Males: 14 y and older, 1.3 mg Children: 13 y, 0.5 mg; 48 y, 0.6 mg; 913 y, 0.9 mg Infants (AIs): 06 mo, 0.3 mg; 712 mo, 0.4 mg
FOOD SOURCES
Dairy products (milk, cheddar and cottage cheeses), meat, eggs, green leafy vegetables, mushrooms, salmon, organ meats (liver and kidney), and wholegrain and enriched cereals and breads

Not established
Thiamine (B1) A coenzyme in carbohydrate metabolism; essential for energy production
Females: 1418 y, 1.0 mg; 19 y and older, 1.1 mg; in pregnancy, 1.4 mg; lactation, 1.4 mg Males: 14 y and older, 1.2 mg Children: 13 y, 0.5 mg; 48 y, 0.6 mg; 913 y, 0.9 mg Infants (AIs): 06 mo, 0.2 mg; 712 mo, 0.3 mg
Meat (especially pork), dried beans, wholegrain and enriched cereals and breads, peanuts, Brazil nuts, and brewers yeast
Mild deciency: fatigue, anorexia, retarded growth, mental depression, irritability, apathy, and lethargy Severe deciency (beriberi): peripheral neuritis; personality disturbances; heart failure; edema; and WernickeKorsakoff syndrome in alcoholics
Not established
Vitamin C (ascorbic acid) Essential for formation of skin, ligaments, cartilage, bone, and teeth; required for wound healing and tissue repair, metabolism of iron and folic acid, synthesis of fats and proteins, preservation of blood vessel integrity, and resistance to infection
Females: 1418 y, 65 mg; 19 y and older, 75 mg; in pregnancy, 8085 mg; lactation, 115120 mg Males: 1418 y, 75 mg; 19 y and older, 90 mg Children: 13 y, 15 mg; 48 y, 25 mg; 913 y, 45 mg Infants (AIs): 06 mo, 40 mg; 712 mo, 50 mg
Fruits (cantaloupe, kiwi fruit, mangos, papaya) and vegetables (sweet green, red, and yellow peppers), especially citrus fruits (oranges and grapefruit) and their juices
Mild deciency: irritability, malaise, arthralgia, and increased tendency to bleed Severe deciency: scurvy and adverse effects on most body tissues (gingivitis; bleeding of gums, skin, joints, and other areas; disturbances of bone growth; anemia; and loosening of teeth). If not treated, coma and death may occur
Renal calculi
RDAs for vitamin A are expressed in retinol activity equivalents (RAEs), which include both preformed vitamin A and carotenoids. 1 RAE = 1 mcg retinol or 12 mcg beta carotene. Vitamin E activity is expressed in milligrams of alpha-tocopherol equivalents (a-TE). AIs, adequate intakefor all healthy infants, the AI is used and is based on estimated mean intakes of human milk; GI, gastrointestinal; RBCs, red blood cells; RDAs, recommended dietary allowances.
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Table 57-2
Drugs at a Glance: Vitamin Drug Preparations

ROUTES AND DOSAGE RANGES
GENERIC/TRADE NAME
FAT-SOLUBLE VITAMINS Vitamin A (also called retinol)
Adults
Deciency, Children >8 y and adults, PO, IM 150,000 RE (500,000 IU) daily for 3 d, then 15,000 RE (50,000 IU) daily for 2 weeks, then 3,0006,000 RE (10,00020,000 IU) daily for another 2 mo
Children
Kwashiorkor, Retinol 30 mg IM followed by intermittent oral therapy Xerophthalmia (>18 y), 1,500 3,000 RE (5,00010,000 IU)/kg for 5 d or until recovery
COMMENTS
IM administration indicated when oral not feasible, as in anorexia, nausea, vomiting, preoperative and postoperative conditions, or malabsorption syndromes With xerophthalmia, vitamin E 40 IU should be co-administered to increase effectiveness of the retinol
Vitamin E Vitamin K (Phytonadione, Mephyton)
PO 6075 IU daily If INR > 5 but <9 with no signicant bleeding give <5 mg PO, hold warfarin, give <5 mg PO if INR is still elevated, can give 12 mg PO; if INR > 9 with no signicant bleeding, hold warfarin and give 510 mg PO; if serious bleeding and elevated INRs, give 10 mg by slow IV infusion and repeat in 12 h as needed
PO 1530 IU daily Older children, same as adults Newborns, prevention of hemorrhagic disease, IM 1 mg within 1 h after birth; if birth weight > 500 g and 0.5 mg if birth weight < 1,500 g; may be repeated after 23 weeks if the mother received anticoagulant, anti-convulsant, anti-tubercular, or recent antibiotic drug therapy during pregnancy Treatment of hemorrhagic disease, subcutaneous/IM 1 mg For non-life-threatening bleeding, 0.52 mg subcutaneous or IV, if lifethreatening bleeding, 5 mg IV over 1020 min Do not give IV; serious, anaphylaxis-like reactions have occurred
WATER-SOLUBLE VITAMINS B-COMPLEX VITAMINS Calcium pantothenate Total parenteral nutrition, IV (B5) (Pantothenic acid, 15 mg daily Penta/3b) Cyanocobalamin (B12) PO 1,0002,000 mcg daily, then 1,000 mcg daily IM 30100 mcg daily for 510 d, then 100200 mcg monthly Folic acid (Apo-folic) Deciency, megaloblastic anemia, PO, Subcutaneous, IM, IV 0.251 mg daily until symptoms decrease and blood tests are normal, then maintenance dose of 0.4 mg daily
Total parenteral nutrition, >11 y, IV 15 mg daily; 111 y, IV 5 mg daily IM, deep subcutaneous 100 mcg daily until total dose of 15 mg is given, then 60 mcg monthly
Deciency states seen only with severe, multiple B-complex deciency states Oral drug, alone or in multivitamin preparations, is given for nutritional deciencies. Deciencies more common in the elderly Oral administration preferred unless severe intestinal malabsorption is present
PO, subcutaneous, IM, IV up 0.251 mg daily until symptoms decrease and blood tests are normal, then a daily maintenance dose as follows: infants, 0.1 mg; <4 y, up to 0.3 mg; >4 y, 0.4 mg
910
Table 57-2
Drugs at a Glance: Vitamin Drug Preparations (continued)

ROUTES AND DOSAGE RANGES
GENERIC/TRADE NAME
Niacin (nicotinic acid) (Niaspan)
Adults
Deciency, PO 50100 mg daily Pellagra, PO 300500 mg daily in divided doses; maximum dose 500 mg daily Dyslipidemia, PO 26 g daily, 50 mg TID initially, may double the dose every 5 d to 1.52 g/d (maximum dose, 4 g/d) Niaspan:500 mg/d for 4 weeks, then 1,000 mg/d for 4 weeks, then increase up to 2,000 mg if necessary
Children
100300 mg daily in divided doses
COMMENTS
To reduce ushing with larger doses, start with smaller doses and gradually increase them or administer ASA 325 mg 1 h prior to niacin
Pyridoxine (Vitamin B6)
Deciency, PO, IM, IV 210 mg daily, once corrected, give 25 mg daily Anemia, peripheral neuritis, 50200 mg daily
525 mg daily for 3 weeks then 1.52.5 mg daily
Usually given with INH, an anti-tubercular drug, to prevent peripheral neuropathy Deciency rarely occurs alone; more likely with other vitamin deciency states Deciency is common in alcoholics
Riboavin (Vitamin B2)
Deciency, PO 530 mg daily in divided doses
In total parenteral nutrition, IV 310 mg daily in divided doses 1050 mg daily in divided doses
Thiamine hydrochloride (Vitamin B1) Vitathion-ATP
Deciency, PO 530 mg daily or in divided doses for 1 mo; IM 1030 mg three times daily for 2 weeks, supplemented with 510 mg orally for 1 mo; IV 50100 mg/d until able to take orally Deciency, PO, IM, IV 100250 mg once or twice daily for 2 weeks
VITAMIN C Vitamin C (ascorbic acid)
100300 mg in divided doses
Excessive doses (eg, 2,000 mg or more daily) cause adverse effects and should be avoided
IM, intramuscular; IV, intravenous; PO, oral; RDA, recommended dietary allowance; TID, three times a day.
Minerals occur in the body and foods mainly in ionic form. Ions are electrically charged particles. Metals (eg, sodium, potassium, calcium, magnesium) form positive ions or cations; nonmetals (eg, chlorine, phosphorus, sulphur) form negative ions or anions. These cations and anions combine to form compounds that are physiologically inactive and electrically neutral. When placed in solution, such as a body uid, the components separate into electrically charged particles called electrolytes. At any given time, the body must maintain an equal number of positive and negative charges. Therefore, the ions constantly combine and separate to maintain electrical neutrality or electrolyte balance. These electrolytes also maintain the acidbase balance of body uids. When foods are digested, they produce mineral residues that react chemically as acids or bases. Acids are usually
anions (eg, chloride, bicarbonate, sulphate, phosphate). Bases are usually cations (eg, sodium, potassium, calcium, magnesium). If approximately equal amounts of cations and anions are present in the mineral residue, the residue is essentially neutral and the pH of body uids does not require adjustment. If there is an excess of cations (base), the body must draw on its anions (acid) to combine with the cations, render them physiologically inactive, and restore the normal pH of the blood. Excess cations combine with anions (eg, phosphate) and are excreted in the urine; excess anions combine with hydrogen ions or other cations and are excreted in the urine. Mineralelectrolytes are obtained from foods or supplements. Although most minerals are supplied by a well-balanced diet, studies indicate that most adults and children do not ingest
911
sufcient dietary calcium and that iron deciency anemia is common in some populations. In addition, some conditions increase requirements (eg, pregnancy, lactation, various illnesses) and some drugdrug interactions decrease absorption or use of minerals. As with vitamins, goals for daily mineral intake have been established as DRIs. Thus far, DRIs and ULs have been established for calcium, phosphorus, magnesium, iron, uoride, and selenium. The UL should not be exceeded for any mineral electrolyte. Except for magnesium, which is set for supplements only and excludes food and water sources, the stated amounts include those from both foods and supplements. Mineral electrolytes are described further in Table 57-3.
Mineral Supplements
Many people take mineral preparations as dietary supplements, usually in a multivitaminmineral combination. Health care providers and patients should consider the following factors in relation to mineral supplements.
Nutritionists usually recommend dietary intake of nutrients rather than pharmaceutical supplements and emphasize that supplements do not compensate for an inadequate diet. In general, recommended daily doses should not be exceeded because all minerals are toxic at high doses. Multivitaminmineral combinations recommended for age and gender groups contain different amounts of some
Table 57-3
Minerals and Electrolytes

RECOMMENDED LEVELS OF INTAKE SIGNS AND SYMPTOMS OF DEFICIENCY SIGNS AND SYMPTOMS OF EXCESS
MINERAL/ FUNCTION
Macro Minerals Sodium Assists in regulating osmotic pressure, water balance, conduction of electrical impulses in nerves and muscles, and electrolyte and acidbase balance Inuences permeability of cell membranes and assists in movement of substances across cell membranes Participates in many intracellular chemical reactions
FOOD SOURCES
(AIs) Females: 1450 y, 1.5 g; 5170 y, 1.3 g; 71 and older, 1.2 g; in pregnancy, 1.5 g; lactation, 1.5 g Males: 1450 y, 1.5 g; 5170 y, 1.3 g; 71 and older, 1.2 g Children: 13 y, 1 g; 48 y, 1.2 g; 912 y, 1.5 g Infants: 06 mo, 0.12 g; 712 mo, 0.37 g
In most foods. Proteins contain large amounts, vegetables and cereals contain moderate to small amounts, fruits contain little or no sodium Major source in the diet is table salt added to food in cooking, processing, or seasoning. One teaspoon contains 2.3 g of sodium Water in some areas may contain signicant amounts of sodium Present in most foods, including meat, wholegrain breads or cereals, bananas, citrus fruits, tomatoes, and broccoli
Serum sodium <35 mmol/L (mEq/L); anorexia, nausea, and vomiting; ataxia; confusion; delirium; hypotension and tachycardia; muscle tremors; oliguria and increased BUN; seizures; and weakness
Serum sodium >145 mmol/L (mEq/L); disorientation; dry skin and mucous membranes; fever; hyperactive reexes; hypotension; muscle rigidity; tremors and spasms; irritability; cerebral hemorrhage; coma; oliguria, concentrated urine, and increased BUN
Potassium Within cells, helps maintain osmotic pressure, uid and electrolyte balance, and acidbase balance In extracellular uid, is required for conduction of nerve impulses and contraction of skeletal and smooth muscle (especially important in myocardium) Helps transport glucose into cells and is required for glycogen formation and storage Required for synthesis of muscle proteins
(AIs) Females: 1470 y and older, 4.7 g; in pregnancy, 4.7 g; lactation, 5.1 g Males: 1470 y and older, 4.7 g Children: 13 y, 3 g; 48 y, 3.8 g; 913 y, 4.5 g Infants: 06 mo, 0.4 g; 712 mo, 0.7 g
Serum potassium <3.5 mmol/L (mEq/L); dysrhythmias and electrocardiographic changes; cardiac arrest; confusion; delirium; hyperglycemia; postural hypotension; muscle weakness; abdominal distention, constipation, paralytic ileus; polyuria, polydipsia, and nocturia Prolonged deciency may increase serum creatinine and BUN
Serum potassium >5 mmol/L (mEq/L); muscle weakness; cardiotoxicity, with dysrhythmias or cardiac arrest Cardiac effects are not usually severe until serum levels are 7 mmol/L (mEq/L) or above
912
Table 57-3
Minerals and Electrolytes (continued)

RECOMMENDED LEVELS OF INTAKE
Adults (RDAs): Females 1930 y, 310 mg; 3170 y and older, 320 mg; in pregnancy, 350 400 mg; lactation, 310360 mg. Males 1930 y, 400 mg; 3170 y and older, 420 mg. Upper Level (UL) or maximum intake from pharmaceutical preparations, 350 mg (does not include intake from food and water) Children (RDAs): 13 y, 80 mg; 48 y, 130 mg; 913 y, 240 mg; 1418 y, 410 mg Infants (AIs): 06 mo, 30 mg; 712 mo, 75 mg
MINERAL/ FUNCTION
Magnesium Required for conduction of nerve impulses and contraction of muscle (especially important in functions of cardiac and skeletal muscles) Serves as a component of many enzymes Essential for metabolism of carbohydrate and protein
FOOD SOURCES
Present in many foods; diet that is adequate in other respects contains adequate magnesium. Good food sources include nuts, cereal grains, dark green vegetables, and seafoods

Serum magnesium < 1.5 mmol (mEq/L); ataxia; confusion; dizziness; irritability; muscle tremors, carpopedal spasm, nystagmus, generalized spasticity; seizures; tachycardia, hypotension, and premature atrial and ventricular beats

Serum magnesium > 2.5 mmol (mEq)/L; skeletal muscle weakness; cardiac dysrhythmias, hypotension; respiratory insufciency; and coma
Chloride Helps maintain osmotic pressure and electrolyte, acidbase, and water balance Forms hydrochloric acid (HCl) in gastric mucosal cells
(AIs) Females: 1350 y, 2.3 g; 5170 y, 2.0 g, 71 y and older, 1.8 g; in pregnancy and lactation, 2.3 g Males: 1350 y, 2.3 g; 5170 y, 2.0 g; 71 y and older, 1.8 g Children: 13 y, 1.5 g; 48 y, 1.9 g; 913 y, 2.3 g Infants: 06 mo, 0.18 g; 712 mo, 0.57 g
Most dietary chloride is ingested as sodium chloride (NaCl), and foods high in sodium are also high in chloride
Serum chloride < 95 mmol/L (mEq/L); arterial blood pH > 7.45; dehydration; hypotension; low, shallow respirations; paraesthesias of face and extremities; and muscle spasms and tetany, which cannot be distinguished from the tetany produced by hypocalcemia
Serum chloride > 103 mmol/L (mEq/L); arterial blood pH < 7.35; increased rate and depth of respiration; lethargy, stupor, disorientation, and coma if acidosis is not treated
Trace Elements Chromium Aids glucose use by increasing effectiveness of insulin and facilitating transport of glucose across cell membrane
(AIs)
Brewers yeast and
whole-wheat products Females: 913 y, 21 mcg; 1418 y, 24 mcg; 1950 y, 25 mcg; 5170 and older, 20 mcg; in pregnancy, 2930 mcg; lactation, 4445 mcg Males: 913 y, 25 mcg; 1450 y, 35 mcg; 5170 y and older, 30 mcg Children: 13 y, 11 mcg; 48 y, 15 mcg Infants: 06 mo, 0.2 mcg; 712 mo, 5.5 mcg
Impaired glucose tolerance (hyperglycemia, glycosuria); impaired growth and reproduction; and decreased life span
Not established
913
MINERAL/ FUNCTION
Cobalt A component of vitamin B12 that is required for normal function of all body cells and for maturation of RBCs Copper A component of many enzymes Essential for correct functioning of the central nervous, cardiovascular, and skeletal systems Important in formation of RBCs, apparently by regulating storage and release of iron for hemoglobin

Approximately 1 mg in the form of vitamin B12
FOOD SOURCES
Animal foods, including liver, muscle meats, and shellsh. Fruits, vegetables, and cereals contain no cobalt as vitamin B12 Many foods, including liver, shellsh, nuts, cereals, poultry, and dried fruits

Deciency of vitamin B12 produces pernicious anemia

Not established
(RDAs) Females: 913 y, 700 mcg; 1418 y, 890 mcg; 1970 y and older, 900 mcg; in pregnancy, 1,000 mcg; lactation, 1,300 mcg Males: 913 y, 700 mcg; 1418 y, 890 mcg; 19 y and older, 900 mcg Children: 13 y, 340 mcg; 48 y, 440 mcg Infants (AIs): 06 mo, 200 mcg; 712 mo, 220 mcg
Decreased serum levels; decreased iron absorption; anemia from impaired erythropoiesis; and leukopenia. Death can occur. In infants, anemia, chronic malnutrition and diarrhea, or Menkes syndrome (retarded growth and progressive mental deterioration) can occur
Increased serum levels; Wilsons disease (a rare disorder characterized by accumulation of copper in brain, liver, and kidneys). Signs and symptoms vary according to affected organs
Fluoride A component of tooth enamel Strengthens bones Adequate intake before ages 5060 y may decrease osteoporosis and fractures during later years
Adults (AIs): Females 1970 y and older, 3 mg; in pregnancy and lactation, 3 mg. Males 1970 y and older, 4 mg. Children (AIs): 13 y, 0.7 mg; 48 y, 1 mg; 913 y, 2 mg; 1418 y, 3 mg Infants (AIs): 06 mo, 0.01 mg; 712 mo, 0.5 mg
Beef, canned salmon, Dental caries and and eggs. Very little in possibly a greater milk, cereal grains, incidence of fruits, and vegetables. osteoporosis Fluoride content of foods depends on uoride content of the soil where they are grown
Mottling of teeth and osteosclerosis
Iodine Essential component of thyroid hormones
Adults (RDAs): males and females 1451 y and older, 150 mcg; in pregnancy, 220 mcg; lactation, 290 mcg
Seafood is the best source. In vegetables, iodine content varies with the amount of iodine in the soil where they are grown. In milk and eggs, Children: 18 y, 90 mcg; males 913 y, content depends on the amount present in 120 mcg; females animal feed 913 y, 120 mcg Infants: 06 mo, 110 mcg; 612 mo, 130 mcg
Thyroid gland enlargement; possible hypothyroidism
Iodism, with coryza, edema, fever, conjunctivitis, lymphadenopathy, stomatitis, and vomiting
914
Table 57-3
Minerals and Electrolytes (continued)

Adults (RDAs): Females 1950, 18 mg; 51 y and older, 8 mg; in pregnancy, 27 mg; lactation, 910 mg Males 1951 y and older, 8 mg. Children: 13 y, 7 mg; 48 y, 10 mg; males 913 y, 8 mg; 1418 y, 11 mg; females 913 y, 8 mg; 1418 y, 15 mg Infants (AIs): 06 mo, 0.27 mg; (RDA) 712 mo, 11 mg
MINERAL/ FUNCTION
Iron Essential component of hemoglobin, myoglobin, and several enzymes: hemoglobin is required for transport and use of oxygen by body cells; myoglobin aids oxygen transport and use by muscle cells; enzymes are important for cellular metabolism
FOOD SOURCES
Liver and other organ meats, lean meat, shellsh, dried beans and vegetables, egg yolks, dried fruits, molasses, whole-grain and enriched breads. Milk and milk products contain essentially no iron

Iron deciency anemia: with gradual development of anemia, minimal symptoms occur; with rapid development or severe anemia, dyspnea, fatigue, tachycardia, malaise, and drowsiness occur

Acute iron intoxication: vomiting, diarrhea, melena, abdominal pain, shock, convulsions, and metabolic acidosis. Death may occur within 24 h if treatment is not prompt Chronic iron overload (hemochromatosis): cardiac dysrhythmias, heart failure, diabetes mellitus, bronze pigmentation of skin, liver enlargement, arthropathy, and others
Selenium Important for function of myocardium and probably other muscles
Adults (RDAs): males and females 1970 y and older, 55 mcg; in pregnancy, 60 mcg; lactation, 70 mcg Children (RDAs): 13 y, 20 mcg; 48 y, 30 mcg; 913 y, 40 mcg; 1418 y, 55 mcg Infants (AIs): 06 mo, 15 mcg; 712 mo, 20 mcg
Fish, meat, breads, and cereals
Deciency most likely with longterm IV therapy. Signs and symptoms include myocardial abnormalities and other muscle discomfort and weakness
Highly toxic in excessive amounts. Signs and symptoms include fatigue, peripheral neuropathy, nausea, diarrhea, and alopecia
Zinc A component of many enzymes that are essential for normal metabolism (eg, carbonic anhydrase, lactic dehydrogenase, alkaline phosphatase) Necessary for normal cell growth, synthesis of nucleic acids (RNA and DNA), and synthesis of carbohydrates and proteins
Adults (RDAs): Females 1951 y and older, 8 mg; in pregnancy, 1112 mg; lactation, 1213 mg Males 1451 y and older, 11 mg. Children: 13 y, 3 mg; 48 y, 5 mg; males 913 y, 8 mg; females 913 y, 8 mg
Animal proteins, such as meat, liver, eggs, and seafood. Wheat germ is also a good source
Most evident in growing children and include impaired growth, hypogonadism in boys, anorexia, and sensory impairment (loss of taste and smell). Also, if the patient has had surgery, wound healing may be delayed
Unlikely with dietary intake but may develop with excessive ingestion or inhalation of zinc. Ingestion may cause nausea, vomiting, and diarrhea; inhalation may cause vomiting, headache, and fever
Infants (AIs): 06 mo, May be essential for use 2 mg; (RDA) 612 mo, 3 mg of vitamin A
AIs, adequate intakesfor all healthy infants, the AI is used and is based on estimated mean intakes of human milk; BUN, blood urea nitrogen; DRIs, dietary reference intakes; RBCs, red blood cells.
915
minerals (eg, post-menopausal women need less iron than younger women). This should be considered in choosing a product.
heart failure, severe hypertension, edema, or renal failure. Calcium polystyrene sulfonate (Resonium calcium) may be an alternate for these patients.
Iron supplements other than those in multivitaminmineral combinations are usually intended for temporary use in the presence of deciency or a period of increased need (eg, pregnancy). They should not be taken otherwise because of the risk of accumulation and toxicity. Although selenium is promoted as an anti-oxidant that decreases cardiovascular disease and cancer, there is limited evidence of such benets and a selenium supplement is not recommended. Sometimes mineral supplements are listed as the strength of the salt form of the mineral but they may contain a different (usually lesser) amount of the elemental form of the mineral (eg, ferrous sulphate 300 mg = 60 mg elemental iron). Sometimes the elemental amount is listed on the side of the bottle label. Although zinc is promoted for the treatment of the common cold and to promote wound healing, there is insufcient evidence to support such uses. With colds, zinc reportedly helps some people and does not help others. With wounds, zinc is reportedly benecial only if the patient has a zinc deciency. More studies are needed before supplemental zinc can be recommended for general use.
Chelating Agents (Metal Antagonists)

Deferoxamine (Desferal) is used to remove excess iron from the body. When given orally within a few hours after oral ingestion of iron preparations, deferoxamine combines with the iron in the bowel lumen and prevents its absorption. When given parenterally, it removes iron from storage sites (eg, ferritin, hemosiderin) and combines with the iron to produce a water-soluble compound that can be excreted by the kidneys. The drug can remove 10 to 50 mg of iron per day. The urine becomes reddish brown from the iron content. The major indication for use of deferoxamine is acute iron intoxication. The drug may also be used in chronic conditions characterized by accumulation of iron in tissues (eg, hemochromatosis with blood transfusions, hemosiderosis due to certain hemolytic anemias). Penicillamine (Cuprimine) chelates copper, zinc, mercury, and lead to form soluble complexes that are excreted in the urine. It is used mainly to remove excess copper in patients with Wilsons disease, a rare condition characterized by accumulation of copper in vital organs. It also can be used prophylactically, before clinical manifestations occur, in patients in whom this hereditary condition is likely to develop. Penicillamine may be used to treat cystinuria, a hereditary metabolic disorder characterized by large amounts of cystine in the urine and renal calculi. It may be used in lead poisoning and in severe rheumatoid arthritis that does not respond to conventional treatment measures.
Agents Used in Mineral Electrolyte Imbalances

Mineralelectrolyte imbalances include both deciency states and excess states. Most deciency states occur with inadequate intake or excessive losses (eg, vomiting, gastric suction, diarrhea, overuse of laxatives). Most excess states occur with excessive intake or impaired renal excretion. Several pharmacologic agents are used to prevent or treat mineralelectrolyte imbalances. Usually, neutral salts of minerals (eg, potassium chloride) are used in deciency states, and non-mineral drug preparations are used in excess states. These agents are described below; routes and dosage ranges are listed in Table 57-4.
Iron Preparations
Iron preparations are used to prevent or treat iron deciency anemia. For prevention, they are often given during periods of increased need (eg, childhood, pregnancy). Oral ferrous salts (sulphate, gluconate, fumarate) are preferred because they are well absorbed. Action starts in about 4 days, peaks in 7 to 10 days, and lasts 2 to 4 months. The drugs are not metabolized; a portion of a dose is lost daily in feces. Otherwise, the iron content is recycled and its half-life is unknown. Sustained release or enteric-coated formulations are not as well absorbed as other preparations. Available ferrous salts differ in the amount of elemental iron they contain. Adverse effects include nausea and other symptoms of GI irritation. Oral preparations also discolour feces, producing a black-green colour that may be mistaken for blood in the stool. Iron preparations are contraindicated in patients with peptic ulcer disease, inammatory intestinal disorders, anemias other than iron deciency anemia, multiple blood transfusions, hemochromatosis, and hemosiderosis. Ferrous sulphate (Fer-In-Sol), which contains 20% elemental iron (ie, 60 mg per 300 mg tablet), is the prototype and often the preparation of choice. Ferrous gluconate (Apo-ferrous gluconate) may be less irritating to GI mucosa and therefore better tolerated than ferrous sulphate. It contains 12% elemental iron (ie, 36 mg per 325 mg tablet). Ferrous
Cation Exchange Resin

Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia. Given orally or rectally, the resin combines with potassium in the colon. Potassium is then eliminated from the body in the feces. Each gram of resin removes about 1 mmol (mEq) of potassium. Because the resin requires several hours to lower serum potassium levels, it may be used after other measures (eg, IV insulin and glucose infusions) have lowered serum levels. Insulin and glucose lower serum potassium levels by driving potassium into the cells; they do not remove potassium from the body. As the resin works in the intestinal tract, it releases sodium mole for mole with potassium uptake. Caution is advised when it is administered to patients with congestive
916
Table 57-4
Drugs at a Glance: Individual Agents Used in MineralElectrolyte and AcidBase Imbalances

ROUTES AND DOSAGE RANGES Adults
PO powder: 15 g in 100200 mL of water or syrup, one to four times daily; suspension: 60 mL (15 g) one to four times daily Rectally (retention enema) 3050 g in 150200 mL of water or 10% D/W q6h IM 90 mg/kg followed by 45 mg/kg q 412 h up to a maximum of 6 g/24 h; a single injection should not exceed 1 g
DRUG
INDICATIONS FOR USE
Children
Acute hyperkalemia: 1 g/kg body weight daily in divided doses Maintenance therapy: 0.5 g/kg body weight daily in divided doses
CATION EXCHANGE RESIN Sodium polystyrene Treatment of sulfonate (Kayexalate; hyperkalemia PMS-sodium polystyrene sulfonate suspension)
CHELATING AGENTS (METAL ANTAGONISTS) Deferoxamine Acute iron IM 0.51 g initially given in one or (Desferal) intoxication two injections; maintenance dose Hemochromatosis depends on iron excretion rate, maximum dose, 6 g/24 h due to blood transfusions Hemosiderosis due to hemolytic anemia Subcutaneous or IV 14 g (2060 mg/kg depending on iron load) over 12 h IV infusion (for patients in shock) (not to exceed 15 mg/kg/h), then reduce after 46 h so that total IV dose does not exceed 80 mg/kg up to a maximum dose of 6 g/24 h Wilsons disease, 0.251.5 g, increased gradually if necessary, up to 2 g daily Rheumatoid arthritis, PO 125 250 mg/d for 4 weeks, increased by 125250 mg/d at 1- to 3-mo intervals, if necessary usual maintenance dose, 500750 mg/d; maximum dose, 1,0001,500 mg/d PO 320640 mg (4080 mg elemental iron) three times daily
Penicillamine (Cuprimine)
Wilsons disease Rheumatoid arthritis Cystinuria
Older children: same as adults Children: Wilsons disease, PO 250 mg daily, dissolved in fruit juice
IRON PREPARATIONS Ferrous gluconate (Apo-ferrous gluconate)
Iron deciency anemia
PO 100300 mg (12.537.5 mg elemental iron) three times daily Infants: PO 100 mg or 30 drops of elixir initially, gradually increased to 300 mg or 5 mL (1537.5 mg elemental iron) of elixir daily, in divided doses Infants and children: For severe deciency: 46 mg elemental iron/kg/d in three divided doses For mild to moderate deciency: 3 mg elemental iron/kg/d single or divided doses
Ferrous sulphate (Fer-in-sol, Apo-ferrous sulphate)
PO 325 mg1.2 g (60240 mg elemental iron) daily in three or four divided doses Syrup: each 5 mL = 150 mg (equivalent to 30 mg elemental iron) Adults, 1015 mL divided into three doses and give between meals with water or juice
Drops: each mL of liquid contains iron sulphate 75 mg (equivalent to 15 mg elemental iron) Drops: 02 y, 5 mL daily divided into three doses given between meals, with water or juice Syrup: 02 y, 2.55 mL; 26, 5 mL; 612 y, 512 mL; divided into three doses and given between meals with water or juice
917
DRUG
Iron dextran injection (Dexiron, Infufer)
INDICATIONS FOR USE

ROUTES AND DOSAGE RANGES Adults

Dosage is calculated for individual patients according to hemoglobin and weight (see manufacturers literature). A small test dose is required before therapeutic doses are given Hypomagnesemia, PO magnesium oxide 250500 mg three to four times daily, milk of magnesia 5 mL four times daily, or a magnesium-containing antacid 15 mL three times daily; IM (magnesium sulphate) 12 g (24 mL of 50% solution) one to two times daily based on serum magnesium levels Eclampsia, IM 12 g (24 mL of 50% solution) initially, then 1 g q30min until seizures stop Convulsive seizures, IM 1 g (2 mL of 50% solution) repeated PRN IV, do not exceed 150 mg/min (1.5 mL/min of a 10% solution, 3 mL/min of a 5% solution)
Children
Dosage is calculated for individual patients according to hemoglobin and weight (see manufacturers literature). A small test dose is required before therapeutic doses are given
MAGNESIUM PREPARATIONS Magnesium oxide Magnesium hydroxide Magnesium sulphate Prevent or treat hypomagnesemia Treat hypertension or convulsions associated with toxemia of pregnancy or acute nephritis in children Convulsions, IM 2040 mg/kg in a 20% solution; repeat as necessary
POTASSIUM PREPARATION Potassium chloride Prevent or treat (Apo-K; K-Lyte, Slow K, hypokalemia Micro-K, and others)
PO 2040 mmol (mEq)/d IV 40100 mmol (mEq)/24 h, depending on serum potassium levels Potassium chloride must be diluted in dextrose or NaCl IV solution for IV use Maximum for serum K+ >2.5 mmol (mEq): diluted 40 mmol (mEq)/L, infused 10 mmol (mEq)/h to maximum dose of 200 mmol (mEq) in 24 h Maximum for serum K+ <2.5 mmol (mEq): diluted 80 mmol (mEq)/L, infused 40 mmol (mEq)/h to maximum dose of 400 mmol (mEq) in 24 h
IV infusion 23 mmol (mEq)/kg or 40 mmol (mEq)/m2 daily Adjust the amount of uids to body size
SODIUM PREPARATION Sodium chloride Hyponatremia (NaCl) injection
IV 1,5003,000 mL of 0.45% or 0.9% solution/24 h depending on the patients uid needs; approximately 50 mL/h to keep IV lines open
918
Table 57-4
Drugs at a Glance: Individual Agents Used in MineralElectrolyte and AcidBase Imbalances (continued)
INDICATIONS FOR USE
Prevent or treat zinc deciency
ROUTES AND DOSAGE RANGES Adults Children
DRUG
ZINC PREPARATION Zinc sulphate (ADEKs Pediatric drops)
PO 2550 mg elemental zinc Child: 410 y, one tablet daily; >10 y, (eg, zinc sulphate 110220 mg) daily two tablets daily IV, PO, amount individualized according to uid and electrolyte needs (ie, estimated uid loss), age and weight (see manufacturers literature)
MULTIPLE MINERALELECTROLYTE PREPARATIONS Oral solutions Prevent or IV 2,0003,000 mL/24 h, depending (eg, Pedialyte) treat uid and on individual uid and electrolyte electrolyte needs IV solutions deciencies (eg, Normosol, Plasma-Lyte 148, Ringers solution)
IM, intramuscular; IV, intravenous; PO, oral; PRN, as needed.
fumarate (Palafer) contains 33% elemental iron (ie, 33 mg per 100 mg tablet). As with dietary iron, only a portion is absorbed from pharmaceutical preparations and relatively large doses are needed to supply the 10 to 15 mg needed daily by most adults and children. Co-administration with ascorbic acid (vitamin C) may increase absorption as iron is better absorbed in an acidic environment. Small amounts of iron are lost daily (about 0.5 to 1 mg) in urine, sweat, and sloughing of intestinal mucosal cells. Somewhat larger amounts (1 to 2 mg daily) are lost during menstruation. Thus, women of childbearing potential need larger amounts of iron than children, men, and postmenopausal women. Women who are pregnant have the greatest requirement and usually need an iron supplement. Although most iron products are available OTC, their use should be discussed with a health care provider because of the toxicity that may occur with iron accumulation in body tissues. Iron dextran injection (Dexiron, Infufer) is a parenteral form of iron useful in treating iron deciency anemia when oral supplements cannot be used. One millilitre contains 50 mg of elemental iron. Indications for use include peptic ulcer or inammatory bowel disease that is likely to be aggravated by oral iron preparations; the patients inability or unwillingness to take oral preparations; and a shortage of time for correcting the iron deciency (eg, late pregnancy or preoperative status). Contraindications include anemias not associated with iron deciency and patients with hypersensitivity to the drug (fatal anaphylactoid reactions have occurred). The drug is usually given IV. Drug action has a slow onset and peaks in 1 to 2 weeks. Dosage is calculated according to hemoglobin level and weight. A small IV test dose should be given prior to a therapeutic dose. Emergency resuscitation equipment should be available, as fatal anaphylactic reactions have occurred with the use of IV iron. After the test dose is given without problem, at least 1 hour should elapse before the rest of the dose is administered.
Magnesium Preparations
Magnesium oxide or hydroxide may be given orally for mild hypomagnesemia in asymptomatic patients. Magnesium sulphate is given parenterally for moderate to severe hypomagnesemia; convulsions associated with pregnancy; and prevention of hypomagnesemia in total parenteral nutrition. Therapeutic effects in these conditions are attributed to the drugs depressant effects on the central nervous system and smooth, skeletal, and cardiac muscle. Oral magnesium salts may cause diarrhea; their uses as antacids and cathartics are discussed in Chapters 59 and 60, respectively. Magnesium preparations are contraindicated in patients who have impaired renal function or who are comatose. Oral preparations of magnesium oxide or hydroxide act in 3 to 6 hours, are minimally absorbed systemically, and are excreted in urine. With parenteral magnesium sulphate, intramuscular (IM) injections act in 1 hour and last 3 to 4 hours; IV administration produces immediate action that lasts about 30 minutes. The products are excreted in urine.
Potassium Preparations
Potassium chloride (Slow-K, Apo-K, Micro-K, K-Dur) is usually the drug of choice for preventing or treating hypokalemia because deciencies of potassium and chloride often occur together. It may be prescribed for patients who are receiving potassiumdepleting diuretics (eg, hydrochlorothiazide, furosemide); those who are receiving digoxin (hypokalemia increases risks of digoxin toxicity); and those who are receiving only IV uids because of surgical procedures, GI disease, or other conditions. Potassium chloride also may be used to replace chloride in hypochloremic metabolic alkalosis. It is contraindicated in patients with renal failure and in those receiving potassium-sparing diuretics, such as triamterene (Novo-Triamzide), spironolactone (Aldactone), or amiloride (Novamilor).
919
Potassium chloride can be given orally or IV. Oral preparations are available in avoured powders, liquids, effervescent tablets, and controlled- or extended-release tablets or capsules. Most patients prefer tablets or capsules to liquids. These preparations act slowly and peak in 1 to 2 hours. IV preparations act rapidly; IV potassium chloride must be well diluted before administration to prevent hyperkalemia, cardiotoxicity, and severe pain at the injection site. For patient safety, most hospitals restrict access to concentrated forms of potassium for injection. There are a variety of pre-mixed IV solutions containing a range of potassium concentrations (ie, 20 to 40 mmol [mEq per L] of potassium chloride) in several solutions (ie, D5W, normal saline, 2/3, 1/3) that do not require further dilution. Dosage must be individualized according to serum potassium levels; the usual range is 10 to 60 mmol (mEq) in 24 hours.
or chew food). Calculate or estimate the body mass index (BMI); a BMI under 18.5 indicates underweight.
Does the patient have symptoms, disease processes, treatments, medications, or diagnostic tests that are likely to interfere with nutrition? For example, many illnesses and oral medications cause anorexia, nausea, vomiting, and diarrhea.
With vitamins, assessment factors include the following:
Deciency states are more common than excess states and people with other nutritional deciencies are likely to have vitamin deciencies as well. Deciencies of water-soluble vitamins (B complex and C) are more common than those of fat-soluble vitamins. Vitamin deciencies are usually multiple and signs and symptoms often overlap, especially with B-complex deciencies. Vitamin requirements are increased during infancy, pregnancy, lactation, fever, hyperthyroidism, and many illnesses. Thus, a vitamin intake that is normally adequate may be inadequate in certain circumstances. Vitamin deciencies are likely to occur in people who are poor, elderly, chronically or severely ill, or alcoholic. Vitamin excess states are rarely caused by excessive dietary intake but may occur with use of vitamin drug preparations, especially if megadoses are taken.
Zinc Preparations
Zinc sulphate (ADEKs Tablets) is available OTC in various forms and strengths (eg, tablets with 110 mg and capsules with 220 mg of zinc sulphate, equivalent to 25 or 50 mg of elemental zinc). Zinc is also an ingredient in several vitaminmineral combination products. Zinc preparations are given orally as a dietary supplement to prevent or treat zinc deciency. They have a slow onset of action and a delayed peak. They are metabolized in the liver and excreted in feces.
Multiple MineralElectrolyte Preparations

There are numerous electrolyte solutions for IV use to maintain or replace electrolytes when the patient is unable to eat and drink. Oral electrolyte solutions (eg, Pedialyte, Pedialyte Freezer Pops) contain several electrolytes and a small amount of dextrose. They are used to supply maintenance amounts of uids and electrolytes when oral intake is restricted. They are especially useful in children for the treatment of diarrhea and may prevent severe uid and electrolyte depletion. The amount given must be carefully calculated, prescribed, and administered to avoid excessive intake. Oral solutions should not be used in severe circumstances in which IV uid and electrolyte therapy is indicated and they should not be mixed with other electrolyte-containing uids, such as milk or fruit juices. In addition, they must be cautiously used in impaired renal function.
With mineralelectrolytes, assessment factors include the following:
Deciency states are more common than excess states unless a mineralelectrolyte supplement is being taken. However, deciencies and excesses may be equally harmful and both must be assessed. Patients with other nutritional deciencies are likely to have mineralelectrolyte deciencies as well. Moreover, deciencies are likely to be multiple, with overlapping signs and symptoms. Many drugs inuence gains and losses of minerals and electrolytes, including diuretics and laxatives. Minerals and electrolytes are lost with gastric suction, polyuria, diarrhea, excessive perspiration, and other conditions.
Assess laboratory reports when available.
Nursing Process
Assessment
Assess each patient for current or potential nutritional deciencies. Some specic assessment factors include the following:

Check the complete blood count for decreased RBCs, hemoglobin, hematocrit, mean corpuscular volume (MCV), and mean corpuscular hemoglobin concentration (MCHC). Reduced values may indicate a deciency anemia and further assessment is needed. Check serum electrolyte reports for abnormal values. All major minerals can be measured in clinical laboratories. The ones usually measured are sodium, chloride, and potassium; carbon dioxide content, a measure of bicarbonate, is also assessed.
( Nursing Process continues on page 920)
What are the usual eating patterns? Does the patient appear underweight? If so, assess for contributing factors (eg, appetite; ability to obtain, cook,
920
Nursing Diagnoses
Imbalanced nutrition: Less than body requirements related to inadequate intake or impaired ability to digest nutrients Imbalanced nutrition: More than body requirements related to excessive intake of pharmaceutical preparations of vitamins and minerals Risk for injury related to complications of tube or IV feedings Risk for injury related to nutrient deciency or overdose Decient knowledge: Nutritional needs and sources of nutrients
nutrition according to the patients status and whether he or she is hospitalized or at home.
Mineral supplements are recommended only for current or potential deciencies because all are toxic in excessive amounts. For patients who have nasogastric tubes to suction, irrigate the tubes with isotonic sodium chloride solution. The use of tap water is contraindicated because it is hypotonic and would pull electrolytes into the stomach. Electrolytes are then lost in the aspirated and discarded stomach contents. For the same reason, only small amounts of ice chips or water are allowed per hour. Patients often request ice chips or water in larger amounts than desirable; the nurse must explain the reason for the restrictions. Provide appropriate patient teaching regarding nutritional support products, vitamins, and minerals (see accompanying display). Ensure food trays are within reach of the patient and containers are opened.
Planning/Goals
The patient will

Improve nutritional status in relation to body needs Maintain uid and electrolyte balance Ingest appropriate amounts of vitamins and mineral electrolytes Experience no complications of enteral nutrition, including aspiration, diarrhea, and infection Experience no complications of parenteral nutrition Describe the adverse effects of vitamins and minerals and avoid if possible Take no mineralelectrolyte supplements unless recommended by a health care provider Take mineralelectrolyte drugs as prescribed and have appropriate laboratory tests to monitor response
Evaluation
Assess undernourished patients for quantity and quality of nutrient intake, weight gain, and improvement in laboratory tests of nutritional status (eg, serum proteins, blood sugar, electrolytes). Assess children for quantity and quality of food intake and appropriate increases in height and weight. Interview and assess for signs and symptoms of complications of enteral and parenteral nutrition.
Interventions
Promote a well-balanced diet for all patients. Five to ten daily servings of fruits and vegetables provide adequate vitamins unless the patient has increased requirements or conditions that interfere with absorption or use of vitamins. An oral multivitamin may benet some people, but it is not a substitute for an adequate diet. A diet that is adequate in protein and calories usually provides adequate minerals and electrolytes. Exceptions are calcium and iron, which often need to be encouraged in women and children. Treat the symptoms or disorders which are likely to interfere with nutrition, such as pain, nausea, vomiting, or diarrhea. Provide palatable supplements at appropriate times and encourage patients to take them for those who need increased protein-calorie intake. Promote exercise and activity. For undernourished patients, this may increase appetite, improve digestion, and aid bowel elimination. Weigh patients at regular intervals. Calculate or estimate BMI when indicated. Monitor weight, uid intake, urine output, vital signs, blood glucose, serum electrolytes, and complete blood count daily or weekly, for those receiving parenteral
Principles of Therapy
Managing Nutritional Deciencies
When possible, oral administration of liquid formulas, vitamins, and minerals is preferred. With vitamin and mineral supplements, larger doses are needed to treat deciencies than are needed to prevent them. Treatment of deciency states should be cautious, to avoid excess states.
Enteral Nutrition: Oral and Tube Feedings

When the GI tract is functional but the patient cannot ingest enough food and uid, high-protein, high-calorie foods (eg, milkshakes) or nutritionally complete supplements (eg, Ensure) can be given with meals, between meals, and at bedtime. When oral feeding is contraindicated, tube feeding helps to maintain GI tract and immune system functioning. Guidelines for tube feedings include the following:
Several tubes and placement sites are available. For shortterm use (about 4 weeks), a nasogastric tube may be used. For long-term feedings, a gastrostomy tube may be placed percutaneously or surgically. Nasointestinal tubes are
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recommended for patients at risk of aspiration from gastric feedings or with gastric disorders. Except for gastrostomy tubes, the tubes should be soft and small-bore to decrease trauma.
When tube feedings are the patients only source of nutrients, they should be nutritionally complete and given in amounts calculated to provide adequate water, protein, calories, vitamins, and minerals. For feedings that enter the stomach, intermittent administration is often used. For feedings that enter the duodenum or jejunum, a continuous drip method is required because
the small bowel cannot tolerate the larger volumes of intermittent feedings. Continuous feedings require an infusion pump for accurate control of the ow rate. Water can be given with, after, or between regular feedings and with medications, according to the patients uid needs.
A potential complication of tube feeding is aspiration of the formula into the lungs. This is more likely to occur with unconscious patients. The risk can be decreased by correctly positioning the patients, verifying tube placement, and giving feedings slowly.
Nutritional Support Products, Vitamins, and Minerals

General Considerations

Nutrition is extremely important in promoting health and recovery from illness. For people who are unable to take in enough nutrients because of poor appetite or illness, nutritional supplements can be very benecial in improving nutritional status. For example, supplemental feedings can slow or stop weight loss; increase energy and feelings of well-being; and increase resistance to infection. With oral or tube-feeding supplements, choose one or more that the patient is able and willing to take when possible. With vitamins, supplements are often recommended because studies indicate that many adults and children do not ingest sufcient dietary vitamins. Supplements are also usually needed by pregnant women and by people who smoke, ingest large amounts of alcohol, have impaired immune systems, or are elderly. When choosing a vitamin supplement, the following factors should be considered:
Vitamins from supplements exert the same physiologic effects as those obtained from foods. Multivitamin preparations often contain minerals as well, usually in smaller amounts than those recommended for daily intake. Large doses of minerals are toxic.
With minerals, a well-balanced diet contains all the minerals needed for health in most people. Exceptions are calcium and iron, which are often needed as a dietary supplement in women and children. Note that natural health products of chamomile, feverfew, and St. Johns wort may inhibit iron absorption. The safest action is to take mineral supplements only on a health care providers advice, in the amounts and for the length of time prescribed. All minerals are toxic when taken in excess. Additional considerations include
Avoid large doses of vitamins. They will not promote health, strength, or youth. In addition, excessive amounts of B vitamins and vitamin C are eliminated in urine and some can cause adverse effects (eg, large doses of vitamin C can cause kidney stones; niacin [B3] can cause stomach upset, ushing, skin rashes, itching, and aggravation of asthma and gout; pyridoxine [B6] may cause numbness in limbs and difculty in walking). Excessive amounts of vitamins A, D, E, and K are stored in the body and often lead to toxic effects. For example, high doses of vitamin A can result in headaches; diarrhea; nausea; loss of appetite; dry, itching skin; and elevated blood calcium. Excessive doses during pregnancy may cause birth defects. Although natural vitamins are advertised as being better than synthetic vitamins, there is no evidence to support this claim. The two types are chemically identical and used in the same way by the human body. Natural vitamins are more expensive. Sexually active women of childbearing potential need an adequate intake of folic acid to prevent severe birth defects in infants. To help prevent birth defects from folic acid deciency, Health Canadas Food and Drug Regulations requires that folic acid be added to breads and cereal-grain products. This is estimated to add about 100 mcg of folic acid to the daily diet of most people. However, the recommended daily intake for females 14 years and older is 400 mcg, which must be taken prior to becoming pregnant. Folic acid 1 mg tablets are available OTC.
Keep all mineralelectrolyte substances out of reach of children to prevent accidental overdose. Acute iron intoxication is a common problem among young children and can be fatal. Also, supervise children in using uoride supplements (eg, remind them to spit out oral rinses and gels rather than swallow them). Keep appointments with health care providers for periodic blood tests and other follow-up procedures when mineralelectrolyte supplements are prescribed (eg, potassium chloride). This helps prevent ingestion of excessive amounts. Minerals are often contained in multivitamin preparations, with percentages of the RDAs supplied. These amounts differ in various preparations and should be included in the estimations of daily intake. Vitamin or mineral preparations may interact with prescription drugs; check with your doctor or pharmacist.
Self-Administration or Caregiver Administration

For oral supplemental feedings, take or give at the preferred time and temperature, when possible. For tube feedings Use or give with the patient in a sitting position, if possible, to decrease risks of choking and inhaling formula into the lungs. Be sure the tube is placed correctly before each feeding. Ask a health care provider how to check placement with your type of tube.
( continued on page 922)
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Nutritional Support Products, Vitamins, and Minerals (continued)

Be sure the solution is at room temperature. Cold formulas may cause abdominal cramping. Do not take or give >500 mL per feeding, including 6090 mL of water for rinsing the tube. This helps avoid overlling the stomach and possible vomiting. Take or give slowly, over approximately 3060 min. Rapid administration may cause nausea and vomiting. With continuous feedings, change containers and tubing daily. With intermittent feedings, rinse all equipment after each use, and change at least q24 h. Most tube-feeding formulas are milk based, and infection may occur if formulas become contaminated or equipment is not kept clean. Ask a health care provider about the amount of water to take or give. Most people receiving 1,5002,000 mL of tube feeding daily need approximately 1,000 mL or more of water daily. However, patients needs vary. Water can be mixed with the tube-feeding formula, given after the tube feeding, or given between feedings. Be sure to include the amount of water used for rinsing the tube in the total daily amount. Give liquid preparations when available. When not available, some tablets may be crushed and some capsules may be emptied and mixed with 510 mL of water. Ask a health care provider which medications can safely be crushed or altered because some (eg, long-acting or enteric-coated) can be harmful if crushed. Do not mix medications with the tube-feeding formula because some medications may not be absorbed. Do not mix medications; give each one separately. Rinse the tube with water before and after each medication to get the medication through the tube and to keep the tube open.
can also be obtained by eating at least ve to ten servings of fruit and vegetables daily.
Take oral niacin preparations, except for timed-release forms, with or after meals or at bedtime to decrease stomach irritation. In addition, sit or lie down for approximately 30 min after taking a dose. Niacin causes blood vessels to dilate and may cause facial ushing, dizziness, and falls. Facial ushing can be decreased by taking 325 mg of acetylsalicylic acid (ASA) 3060 min before a dose of niacin. Itching, tingling, and headache may also occur. These effects usually subside with continued use of niacin. Swallow extended-release products whole; do not break, crush, or chew them. Breaking the product delivers the entire dose at once and may cause adverse effects. Take prescribed vitamins as directed and for the appropriate time. In pernicious anemia, vitamin B12 injections must be taken for the remainder of life. In pregnancy and lactation, vitamin supplements are usually taken only during this period of increased need. Swallow vitamin E capsules whole; do not crush or chew. Take iron preparations with or after meals, with approximately 240 mL of uid, to prevent stomach upset. Do not take iron with coffee or other caffeine-containing beverages because caffeine decreases absorption (take iron and caffeine preparations at least 2 h apart). Do not crush or chew slow-release tablets or capsules. With liquid preparations, dilute with water or juice, drink through a straw, and rinse the mouth afterward to avoid staining the teeth. Expect that stools will be dark green or black. With potassium preparations, mix oral solutions or effervescent tablets with at least 120 mL of water or juice to improve the taste, dilute the drug, and decrease gastric irritation. Do not crush or chew slow-release preparations. Ensure tablets or capsules are taken with adequate amounts of uid so they do not stick in the esophagus. Take after meals initially to decrease gastric irritation. If no nausea, vomiting, or other problems occur, the drug can be tried before meals because it is better absorbed from an empty stomach. Do not stop taking the medication without notifying the physician who prescribed it, especially if taking digoxin or diuretics. Excessive amounts should also be avoided. Do not use salt substitutes unless they are recommended by a health care provider; they contain potassium chloride and may result in excessive intake. Serious problems may develop from either high or low levels of potassium in the blood.
For giving medications by tube
With supplementary vitamins, preparations differ widely in amounts and types of vitamin content. The product should not contain more than recommended amounts of vitamin D and vitamin A because of possible adverse effects. When choosing a vitamin supplement, compare the ingredients and costs. Store brands are as effective as and less expensive than name brands. Vitamin C supplements are available in various dosages, often in multivitamin and other preparations sold as antioxidants. In 2000, the RDA was increased from 60 mg daily to 75 mg for adult women and 90 mg for adult men. Large doses (eg, 1,000 mg or more daily) may cause adverse effects and should be avoided. An adequate amount of vitamin C
Parenteral Nutrition: IV Feedings

Parenteral feedings are indicated when the GI tract is nonfunctional, when nutritional needs cannot be met by enteral feedings, or when enteral feedings would aggravate conditions such as inammatory bowel diseases or pancreatitis.
used solution is 5% dextrose in 0.22% sodium chloride, 2,000 to 3,000 mL in 24 hours (provides approximately 170 kcal per L, water, sodium, and chloride). Potassium chloride is often added, and vitamins may be added. These solutions are nutritionally inadequate.
Short-Term IV Nutrition
For short-term use (eg, 3 to 5 days), the goal is to provide adequate amounts of uids and electrolytes and enough carbohydrate to minimize oxidation of body protein and fat for energy. The choice of specic solution depends on individual needs, but it should contain at least 5% dextrose. A frequently
Long-Term IV Nutrition
For long-term use (weeks to months), the goal is to provide all nutrients required for normal body functioning, including tissue growth and repair. Basic solutions provide water, carbohydrate, protein, vitamins, and minerals; fat emulsions (eg, Intralipid) are usually given separately to provide additional calories
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and essential fatty acids (500 mL of 10% emulsion provides 550 kcal). Guidelines include the following:
Parenteral nutritional solutions can be administered through central or peripheral IV lines. Some solutions are hypertonic (from high concentrations of glucose) and must be given in a central vein so they can be diluted rapidly. Solutions that contain 5% or 10% dextrose are less hypertonic and can be given in a peripheral vein. However, they are nutritionally incomplete and used for a limited time (about 5 to 7 days). Fat emulsions are isotonic and may be given centrally or peripherally. When given peripherally, they are co-infused with dextroseprotein solution, to help protect the vein from phlebitis. Dextroseprotein solutions are given through an in-line lter. Fat emulsions should not be ltered; they are piggybacked into the IV line beyond the lter. Solutions should be administered with an infusion pump to maintain a steady and accurate ow rate. Sterile technique should be used in all aspects of preparation, administration, and site care. Most agencies have specic protocols for changing solution containers, administration sets, and dressings at the venipuncture site.
until serum prothrombin activity returns to a normal range. In obstructive jaundice, bile salts must be given at the same time as oral vitamin K, or vitamin K must be given parenterally. In malabsorption syndromes or diarrhea, parenteral administration is probably necessary. A single dose of vitamin K may be sufcient. With severe bleeding, vitamin K may be given IV but must be given very slowly to decrease risks of hypotension and shock. Even with IV vitamin K, however, therapeutic effects do not occur for at least 4 hours. For more rapid control of bleeding, transfusions of plasma or whole blood are needed.
B-Complex Disorders
With B-complex vitamins, most deciencies are multiple rather than single and treatment consists of increasing intake of foods containing B-complex vitamins (many foods, including meat, vegetables, and cereal grains) or giving multivitamin preparations. If a single deciency seems predominant, that vitamin may be given alone or in addition to a multivitamin preparation. For example, folic acid deciency may occur with inadequate dietary intake and intestinal disorders that inhibit absorption. In addition, folic acid is depleted by alcohol and several medications, including antibiotics containing trimethoprim (eg, Bactrim), phenytoin, methotrexate, and oral contraceptives. Thiamine deciency is common in alcoholics because of inadequate dietary intake and the use of large amounts of thiamine to metabolize ethanol.
Managing Vitamin Disorders

Early recognition and treatment of vitamin disorders can prevent a mild deciency or excess from becoming severe. For deciency states, oral vitamin preparations are preferred when possible. Multiple deciencies are common and a multivitamin preparation used to treat them usually contains more than the recommended daily amount. These products should be used for limited periods. When fat-soluble vitamins are given to correct a deciency, there is a risk of producing excess states. When water-soluble vitamins are given, excesses are less likely but may occur with large doses. For excess states, the usual treatment is to stop administration of the vitamin preparation. There are no specic antidotes or antagonists.
Anemias Associated With B-Complex Vitamin Deciencies

One type of anemia occurs with pyridoxine deciency and is relieved by administration of pyridoxine. Another type, called megaloblastic anemias (because they are characterized by abnormally large, immature RBCs), occurs with deciency of folic acid or vitamin B12. If megaloblastic anemia is severe, treatment is usually instituted with both folic acid and vitamin B12. In pernicious anemia, vitamin B12 must be given by injection because oral forms are not absorbed from the GI tract. The injections must be continued for life. Vitamin B12 is also given to prevent pernicious anemia in patients who are strict vegetarians, who have had gastrectomy, or who have chronic small bowel disease. Although folic acid relieves hematologic disorders of pernicious anemia, giving folic acid alone allows continued neurologic deterioration. Thus, an accurate diagnosis is required. In other megaloblastic anemias, vitamin B12 or folic acid is indicated. Although both of these are included in many multivitamin preparations, they usually must be given separately for therapeutic purposes. With vitamin B12, doses in excess of 100 mcg are rapidly excreted in urine. With folic acid, doses in excess of 1 mg are excreted in the urine.
Vitamin A Disorders
With vitamin A deciency, assist patients to increase intake of foods containing preformed vitamin A (eg, meat, egg yolk, whole milk) or beta carotene (eg, yellow fruits and vegetables such as cantaloupe, peaches, carrots, sweet potatoes) when feasible. If a supplement is required, vitamin A alone may be preferred over a multivitamin unless multiple deciencies are present. Daily doses should not exceed 9,900 IU (approximately 3,000 mcg RE; 1 mcg RE = 3.3 IU) unless a severe deciency is present. Vitamin A may be given IM if GI absorption is severely impaired or ocular symptoms are severe. With vitamin A excess, immediately stop known sources of the vitamin.
Vitamin K Disorders
With vitamin K deciency, bleeding may occur spontaneously or in response to trauma. Thus, administration of vitamin K and measures to prevent bleeding are indicated. If the deciency is not severe, oral vitamin K may be given for a few days
Ascorbic Acid (Vitamin C) Disorders

Treatment of vitamin C deciency involves increased intake of vitamin C from dietary (eg, fruits and vegetables) or pharmaceutical sources. Vitamin C is available alone for oral, IM, or IV administration. It is also an ingredient in most multivitamin
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preparations for oral or parenteral use. People who smoke need to increase their intake of vitamin C by 35 mg per day to maintain an adequate vitamin C status. In 2000, the DRI for vitamin C was increased to 75 mg for most adult women and 90 mg for most adult men. An additional recommendation is to avoid large doses (ie, >1 g per day). With excessive intake of vitamin C supplements, the main concern is formation of calcium oxalate kidney stones and potential obstruction or other renal damage. There is no known benet of such large amounts, and their use should be discouraged.
Effects of Vitamin E Supplementation Source: Lonn, E., Bosch, J., Yusuf, S., et al. (2005). Effects of long-term vitamin E supplementation on cardiovascular events and cancer: A randomized controlled trial. Journal of the American Medical Association, 293(11), 13381347. Summary: This report is from the Heart Outcomes Prevention Evaluation (HOPE) clinical trial, conducted between December 1993 and April 1999; and its extension (HOPEThe Ongoing Outcomes or HOPE-TOO), continued from April 1999 until May 2003. HOPE involved >9,000 patients and HOPE-TOO involved >7,000 patients 55 years of age or older who had vascular disease or diabetes mellitus. The purpose of the study was to evaluate whether long-term vitamin E supplementation would decrease risks of cancer, cancer death, or major cardiovascular events (ie, myocardial infarction, stroke, or cardiovascular death). The patients took a daily vitamin E supplement of 400 IU or placebo for a median duration of 7 y. Results indicated no differences between the vitamin E group and the placebo group in cancer incidence, cancer deaths, or major cardiovascular events. In addition, the vitamin E group had higher rates of heart failure and hospitalizations for heart failure than the placebo group. The researchers concluded that long-term vitamin E supplementation does not prevent cancer or major cardiovascular events in patients with vascular disease or diabetes mellitus, and may increase the risk for heart failure, and should not be used in this population. Nursing implications: The main implication for the nurse may be to correct a common misconception that high-dose, long-term vitamin supplementation, including vitamin E, is benecial to health, and that even if it does not benet the recipient, it cant hurt. For people 14 years of age and older, the RDA for vitamin E is 15 IU for males and females. Single vitamin E supplements may contain 100 to 1,000 IU per tablet or capsule; multivitamin preparations may contain various amounts but usually contain more than the RDA.
Use of Vitamins in Preventing Cancer and Cardiovascular Disease

Vitamins with anti-oxidant effects (eg, C; E; beta carotene, a precursor of vitamin A) are thought to help prevent heart disease, cancer, and other illnesses. Anti-oxidants inactivate oxygen free radicals, potentially toxic substances formed during normal cell metabolism, and prevent or inhibit them from damaging body cells. In general, however, research studies are inconclusive and vitamin supplementation to prevent cancer and cardiovascular disease is not currently recommended. Clinical trials continue in this area.
Cancer
Vitamin A and beta carotene may reduce cancers of the lung, breast, oral mucosa, esophagus, and bladder. Vitamin A supplements are not recommended, but people are urged to increase dietary intake of fruits and vegetables that contain vitamin A and beta carotene. It is unknown whether anti-cancer effects stem from beta carotene or other components of fruits and vegetables. Vitamin C, in diets with ve or more daily servings of fruits and vegetables, is associated with reduced risk of cancers of the GI tract (eg, oral cavity, esophagus, stomach, colon) and lung. However, in some studies, vitamin C supplements did not decrease the occurrence of stomach or colorectal cancer. Thus, the cancer-preventing effects of fruits and vegetables may be associated with factors other than vitamin C. Vitamin E has also been promoted for cancer prevention, but supplementation to prevent cancer is not recommended (see accompanying Research Brief).
Cardiovascular Disease
Folic acid and vitamin C are thought to have cardioprotective effects. Folic acid is important in the metabolism of homocysteine, a toxic amino acid and a major risk factor for heart disease. Homocysteine is normally produced during metabolism of methionine, another amino acid. Several B vitamins, including folic acid, are required for the metabolism of homocysteine to a non-toxic substance, and an increased blood level of homocysteine occurs with folic acid deciency. Excessive homocysteine damages the endothelial lining of arteries and leads to plaque formation, atherosclerosis, and thrombosis. Folic acid supplements can prevent or delay these effects by lowering blood levels of homocysteine.
Although the Health Canada requirement that folic acid be added to cereal-grain foods may be helpful, the folic acid intake that helps prevent cardiovascular disease is thought to be higher. Vitamin C is thought to help prevent cardiovascular disease by anti-oxidant effects. The atherogenic effects of blood lipids, especially low-density lipoprotein (LDL) cholesterol (see Chap. 55), are attributed to their chemical breakdown or oxidation. Vitamin C may help prevent oxidation of LDL cholesterol. Overall, however, the effects of vitamin C on prevention of coronary artery disease (CAD) are unclear. Some studies indicate an increased risk for CAD only with a severe vitamin C deciency and that vitamin C has little effect on ischemic heart disease and stroke after adjustment for other risk factors. More research is needed before vitamin C supplements are recommended for cardioprotective
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effects, but increased intake of fruits and vegetables may be benecial. Vitamin E has also been promoted for prevention of cardiovascular disease. Although some observational studies report benecial effects of vitamin E supplements, randomized clinical trials do not. A recent meta-analysis concluded that 400 IU per day of vitamin E increased all cause mortality and should be avoided.
chloride per litre of uids at a ow rate of 100 to 125 mL per hour). An infusion pump should be used to control ow rate accurately. Also, serum potassium levels must be checked frequently and dosage adjusted if indicated.
Hyperkalemia
Eliminate any exogenous sources of potassium, such as potassium supplements, penicillin G potassium, salt substitutes, and blood transfusion with old blood. Treat acidosis, if present, because potassium leaves cells and enters the serum with acidosis. Use measures that antagonize the effects of potassium, that cause potassium to leave the serum and re-enter cells, and that remove potassium from the body. Appropriate measures are determined mainly by serum potassium levels and ECG changes. Continuous cardiac monitoring is required. If the following measures fail to reduce hyperkalemia, peritoneal dialysis or hemodialysis may be used.
Managing MineralElectrolyte Disorders

When a mineral is given to correct a deciency state, there is a risk of producing an excess state. Because both deciencies and excesses may be harmful, the amount of mineral supplement should be titrated closely to the amount needed by the body. Larger doses are needed to treat deciency states than are needed to prevent deciencies from developing. When mineralelectrolyte drug preparations are needed, oral products are preferred when possible. They are safer, less likely to produce toxicity, more convenient to administer, and less expensive than parenteral preparations.
Potassium Disorders
Hypokalemia
Assess for conditions contributing to hypokalemia, and attempt to eliminate them or reduce their impact. Assess severity by checking serum potassium levels and clinical manifestations. Serum potassium levels alone are inadequate because they may not accurately reect depletion of body potassium or shifts of potassium into cells. In general, potassium supplements are indicated when serum potassium is below 3 mmol per L (mEq per L); when symptoms or electrocardiographic (ECG) changes indicate hypokalemia; and when patients are receiving digoxin, if necessary to maintain serum potassium above 3.5 mmol per L (mEq per L). Potassium chloride is the drug of choice in most instances. Controlled-release tablets or capsules with potassium chloride in a wax matrix or microencapsulated form are preferred over liquids by most patients; however, they may be more difcult to swallow. IV potassium chloride is indicated when a patient cannot take an oral preparation or has severe hypokalemia. The serum potassium level should be measured and adequate urine output established before IV potassium therapy is started. IV potassium chloride must be well diluted to prevent sudden hyperkalemia, cardiotoxic effects, and phlebitis at the venipuncture site. The usual dilution is potassium chloride 20 to 40 mmol (mEq per L) per 1,000 mL of IV uid. Dosage must be individualized. Patients receiving IV uids only are usually given 40 to 60 mmol (mEq per L) of potassium chloride daily (eg, 20 mmol [mEq per L] potassium
With severe hyperkalemia (serum potassium above 7 mmol per L [mEq per L] and ECG changes indicating hyperkalemia), urgent treatment is required. IV sodium bicarbonate 45 mmol (mEq per L), over a 5-minute period, causes rapid movement of potassium into cells. This can be repeated in a few minutes if ECG changes persist. Calcium gluconate 10%, 5 to 10 mL IV, is also given early in the treatment to decrease the cardiotoxic effects of hyperkalemia. It is contraindicated if the patient is receiving digoxin, and it cannot be added to uids containing sodium bicarbonate because insoluble precipitates are formed. IV glucose and insulin may also be infused. This causes potassium to move into cells, though not as quickly as administration of sodium bicarbonate. With less severe hyperkalemia (or when serum potassium levels have been reduced by other measures), sodium polystyrene sulfonate, a cation exchange resin, can be given orally or rectally to remove potassium from the body. Each gram of the resin combines with 1 mmol (mEq) of potassium, and both are excreted in feces. The resin is usually mixed with water and sorbitol, a poorly absorbed, osmotically active alcohol that has a laxative effect. The sorbitol offsets the constipating effect of the resin and aids in its expulsion. Oral administration is preferred, and several doses daily may be given until serum potassium is normal. When given as an enema, the solution must be retained from 1 to several hours, or repeated enemas must be given for therapeutic effect.
Magnesium Disorders
Hypomagnesemia
For mild hypomagnesemia, oral magnesium preparations may be given. For moderate to severe and symptomatic hypomagnesemia, parenteral (IV or IM) magnesium sulphate may be given daily as long as hypomagnesemia persists or continuing losses occur. Initial dosage may be larger, but the usual maintenance dose is approximately 8 mmol (mEq) daily. A 10% solution is available in 10-mL vials that contain 8 mmol (mEq) of
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magnesium sulphate for adding to IV solutions. A 50% solution is available in 2-mL vials (8 mmol [mEq]) for IM administration. Serum magnesium levels should be measured daily during treatment with a magnesium preparation.
if no therapeutic response is evident within 3 to 4 weeks after drug therapy is begun.
Hypermagnesemia
Stop any source of exogenous magnesium, such as magnesium sulphate or magnesium-containing antacids and cathartics. Have calcium gluconate available for IV administration. It is an antidote for the sedative effects of magnesium excess. Increase urine output by increasing uid intake, if feasible. This increases removal of magnesium from the body in urine. Patients with chronic renal failure (CRF) are the most likely to become hypermagnesemic. They may require peritoneal dialysis or hemodialysis to lower serum magnesium levels.
Parenteral iron is indicated when oral preparations may further irritate a diseased GI tract, when the patient is unable or unwilling to take the oral drugs, or when the anemia must be corrected rapidly. For severe iron deciency anemia, blood transfusions may be most effective.
Iron Excess
Acute iron overdosage requires treatment as soon as possible, even if overdosage is only suspected and the amount taken is unknown. It is unnecessary to wait until the serum iron level is measured. If treatment is begun shortly after oral ingestion of iron, aspiration of stomach contents by nasogastric tube or whole bowel irrigation with a polyethylene glycol solution (eg, Colyte) may be performed. Gastric lavage can be followed by instillation of 1% sodium bicarbonate solution to form insoluble iron carbonate compounds, or 5 to 8 g of deferoxamine (Desferal) dissolved in 50 mL of distilled water to bind the iron remaining in the GI tract and prevent its absorption. Deferoxamine may also be given IM or IV to bind with iron in tissues and allow its excretion in the urine. Throughout the treatment period, supportive measures may be needed for GI hemorrhage, acidosis, and shock.
Iron Deciency and Excess

Iron Deciency Anemia
Anemia is a symptom, not a disease. Therefore, the underlying cause must be identied and eliminated, if possible. Encourage increased dietary intake of foods with high iron content. Ferrous sulphate is usually the drug of choice for oral iron therapy. Slow-release or enteric-coated products decrease absorption of iron, but may cause less gastric irritation. Dosage is calculated in terms of elemental iron. Iron preparations vary greatly in the amount of elemental iron they contain. Ferrous sulphate, for example, contains 20% iron; thus, each 300-mg tablet furnishes about 60 mg of elemental iron. With the usual regimen of one tablet three times daily, a daily dose of 180 mg of elemental iron is given. For most patients, probably half that amount would correct the deciency. However, tablets are not manufactured in sizes to allow this regimen, and liquid preparations are not popular with patients. Thus, relatively large doses are usually given, but smaller doses may be effective, especially if GI symptoms become a problem with higher dosages. Whatever the dose, only about 10% to 15% of the iron is absorbed. Most of the remainder is excreted in feces, which turn dark green or black. Oral iron preparations are better absorbed if taken on an empty stomach. However, because gastric irritation is a common adverse reaction, they are more often given with or immediately after meals. Although normal hemoglobin levels return after approximately 2 months of oral iron therapy, an additional 6-month period of drug therapy is recommended to replenish the bodys iron stores. Reasons for failure to respond to iron therapy include continued blood loss, failure to take the drug as prescribed, or defective iron absorption. These factors must be re-evaluated
For chronic iron overload or hemochromatosis, the rst step in treatment is to stop the source of iron, if possible. Phlebotomy is the treatment of choice for most patients because withdrawal of 500 mL of blood removes about 250 mg of iron. Phlebotomy may be needed as often as weekly and for as long as 2 to 3 years. For patients resistant to or intolerant of phlebotomy, deferoxamine can be given. Ten to 50 mg of iron is excreted daily in the urine with deferoxamine administration.
Effects of Vitamins and Minerals on Other Drugs

Folic acid decreases effects of phenytoin, probably by accelerating phenytoin metabolism, and may decrease absorption and effects of zinc. Niacin may increase the risk of rhabdomyolysis (a life-threatening breakdown of skeletal muscle) with statin cholesterol-lowering drugs. Vitamin A in large doses, and possibly vitamin E, may increase the anti-coagulant effect of warfarin. Vitamin C, 1g daily or more, may decrease metabolism and increase the effects of estrogens and oral contraceptives. It is recommended that the daily dose of vitamin C not exceed 100 mg, to prevent this interaction. Iron salts may decrease absorption of levodopa, levothyroxine, methyldopa, penicillamine, uoroquinolones, and tetracyclines. Magnesium salts may decrease absorption and therapeutic effects of digoxin, uoroquinolones, nitrofurantoin, penicillamine, and tetracyclines. Zinc salts may decrease absorption of uoroquinolones and most tetracyclines (doxycycline is apparently not affected).
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Use in Special Populations

Nutritional Support in Ethnic Populations
Although Canadas Food Guide is inclusive in its diversity of choices related to the four food groups, it is often very difcult for some Aboriginal and Inuit populations to achieve these standards. Recent research has demonstrated that food choices based on traditional foods are more nutritionally adequate, than relying on modern foods. Health Canada has devised a Canadas Food guide, Eating Well with Canadas Food Guide: First Nations, Inuit and Metis, for these populations. Acculturation is also changing food habits for Asian and Indian populations. Reliance on the low fat, high fruit and vegetable intake common in Chinese culture is being replaced by a typical Western diet favoured by younger, more highly educated Chinese who believe it is just as healthy. Difculty obtaining traditional foods is also a problem for some Indian populations who then must change their food preparation methods.
Parenteral nutrition may be indicated in infants and children who cannot eat or be fed enterally (eg, during medical illnesses or in perioperative conditions) to improve or maintain nutritional status. Overall, benets include weight gain, increased height, increased liver synthesis of plasma proteins, and improved healing and recovery. With vitamins, children need sufcient amounts to support growth and normal body functioning. If supplements are given, considerations include the following:
Nutritional Support in Children

Children usually need sufcient water, protein, carbohydrate, and fat in proportion to their size to support growth and increased physical activity. However, reports of childhood obesity and inadequate exercise are steadily increasing. Therefore, the goal of nutritional support is to meet needs without promoting obesity. For children with special needs in relation to nutrients, various enteral formulations are available for use. Some examples include Lofenalac for children with phenylketonuria (a disorder in which the amino acid phenylalanine cannot be metabolized normally); Nursoy and Prosobee, which contain soy protein, for children who are allergic to cows milk; and Nutramigen, Enfalac and Pregestimil, which contain easily digested nutrients for children with malabsorption or other GI problems. With tube feedings, to prevent nausea and regurgitation, the recommended rate of administration is no more than 5 mL every 5 to 10 minutes for premature and small infants and 10 mL per minute for older infants and children. Preparation of formulas, positioning of children, and administration are the same as for adults to prevent aspiration and infection.
Dosages should not exceed recommended amounts. There is a risk of overdosage by children and their parents. Because of manufacturers marketing strategies, many supplements are available in avours and shapes (eg, cartoon characters, animals) designed to appeal to children. Because younger children may think of these supplements as candy and take more than recommended, they should be stored out of reach and dispensed by an adult. Because parents desires to promote health may lead them to give unneeded supplements or to give more than the recommended amounts, parents may need information about the potential hazards of vitamin overdoses. Supplements given to children and adolescents should provide the recommended amounts of vitamins. Except for single supplements of vitamin K and vitamin E in infants, multivitamin products are commonly used. For infants, liquid formulations usually include vitamins A, D, C, and B complex. Folic acid is not included because it is unstable in liquid form. For older children, chewable tablets usually contain vitamins A, D, C, and B complex, including folic acid. A single IM dose of vitamin K is given to newborn infants to prevent hemorrhagic disease of newborns. Preterm infants need proportionately more vitamins than term infants because their growth rate is faster and their absorption of vitamins from the intestine is less complete. A multivitamin product containing the equivalent of DRIs for term infants is recommended. ULs have been established for some vitamins and these maximum daily amounts should not be exceeded. For other children, ULs vary according to age, as listed in Table 57-5.
Table 57-5
VITAMIN
D E C Folate Niacin Pyridoxine
Vitamins: Tolerable ULs for Children

13 Y
50 mcg 200 mg 400 mg 300 mcg 10 mg 30 mg
48 Y
50 mcg 300 mg 650 mg 400 mcg 15 mg 40 mg
913 Y
50 mcg 600 mg 1,200 mg 600 mcg 20 mg 60 mg
1418 Y
50 mg 800 mg 1,800 mg 800 mcg 30 mg 80 mg
928
With mineralelectrolytes, children need sufcient amounts to support growth and normal body functioning. However, iron deciency is common in young children and teenage girls, and teaching about appropriate foods to eat is useful. An iron supplement may be needed. Guidelines include the following:
levels must be monitored. In addition, doses must be carefully measured and given no more often than prescribed to avoid toxicity.
The Canadian Pediatric Society recommends term infants who are not breast-fed receive iron-fortied formula from birth. Breast-fed infants do not need supplemental iron until after 6 months of age. A combined vitaminmineral supplement every other day may be reasonable, especially for children who eat poorly. If supplements are given, dosages should be discussed with a health care provider and usually should not exceed the recommended amounts for particular age groups. ULs for children have been established for some minerals, and these maximum daily amounts should not be exceeded. They are listed in Table 57-6. The ULs for magnesium indicate maximum intake from pharmaceutical preparations; they do not include intake from food and water. All minerals and electrolytes are toxic in overdose and may cause life-threatening adverse effects. All such drugs should be kept out of reach of young children and should never be referred to as candy. In areas where water is not uoridated, a vitaminmineral supplement containing uoride may be indicated for infants and children. Fluoride may be prescribed by a physician, dentist, or nurse practitioner. In many provinces, public health departments provide a uoride rinse program for children who do not have uoride in their drinking water. Children must be guarded against excessive uoride ingestion and possible toxicity. Fluoride supplements are available for oral (tablets, chewable tablets, solutions) or topical (liquid rinse solutions or gels) uses. Supplements used by children or adults should be kept out of the reach of children; supplements prescribed for children should be used only with adult supervision; and children using topical preparations should be reminded to spit them out and not to swallow them. If potassium chloride and other electrolyte preparations are used to treat deciency states in children, serum electrolyte
Accidental ingestion of iron-containing medications and dietary supplements is a common cause of poisoning death in children younger than 6 years of age. To help combat accidental poisoning, products containing iron must be labelled with a warning, and products with 30 mg or more of iron (eg, prenatal products) must be packaged as individual doses. All iron-containing preparations should be stored in places that are inaccessible to young children.
Nutritional Support in Older Adults

Older adults are at risk of undernutrition with all nutrients. Inadequate intake may result from the inability to obtain and prepare food; disease processes that interfere with the ability to digest and use nutrients; and the use of drugs that decrease absorption of nutrients. A decrease in stomach acid in older adults may also reduce the ability to absorb nutrients. When alternative feeding methods (tube feedings, IV uids) are used, careful assessment of nutritional status is required to avoid decits or excesses. With the high incidence of atherosclerosis, cardiovascular disease, and diabetes mellitus in older adults, it is especially important that intake of animal fats and high-calorie sweets be reduced. Vitamin requirements are the same as for younger adults, but deciencies are common, especially of vitamins A and D, cyanocobalamin (B12), folic acid, riboavin, and thiamine. With vitamin B12, for example, it is estimated that those over 50 years only absorb 10% to 30% of the amount found in food. Every older adult should be assessed regarding vitamin intake (from foods and supplements) and use of drugs that interact with dietary nutrients. For most older adults, a daily multivitamin is probably desirable, even for those who seem healthy and able to eat a well-balanced diet. Health Canada recommends that all adults over the age of 50 should take a daily vitamin D supplement (400 IU). In addition, requirements may be increased during illnesses, especially those affecting GI function. Overdoses, especially of the fat-soluble vitamins A and D, may cause toxicity and should be avoided. ULs for older adults have been established for some vitamins (D, 50 mcg or
Table 57-6
MINERAL
Calcium Phosphorus Fluoride Magnesium Selenium
Minerals: Tolerable ULs for Children

BIRTH6 MO
No data No data 0.7 mg No data 45 mcg
712 MO
No data No data 0.9 mg No data 60 mcg
13 Y
2.5 g 3g 1.3 mg 65 mg 90 mcg
48 Y
2.5 g 3g 2.2 mg 110 mg 150 mcg
913 Y
2.5 g 4g 10 mg 350 mg 280 mcg
1418 Y
2.5 g 4g 10 mg 350 mg 400 mcg
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2,000 IU; E, 1,000 mg; C, 2,000 mg; folate, 1,000 mcg; niacin, 35 mg; pyridoxine, 100 mg) and these amounts should not be exceeded.
Applying Your Knowledge 57-1

You recognize that along with being undernourished, Mrs. Farber is also most likely decient in vitamins. You confer with the physician. What will be the likely recommendation for Mrs. Farber?
Mineralelectrolyte requirements are also the same as for younger adults, but deciencies of calcium and iron are common. Excess states also may occur in older adults. For example, decreased renal function promotes retention of magnesium and potassium. Hyperkalemia also may occur with the use of potassium supplements or salt substitutes. All minerals and electrolytes are toxic in overdose. ULs for older adults (>65 years of age) have been established for calcium (2.5 g), phosphorus (3 to 4 g), uoride (10 mg), magnesium (350 mg), and selenium (400 mcg) and these maximum daily amounts should not be exceeded. In general, serum levels of minerals and electrolytes should be monitored carefully during illness, and measures taken to prevent either deciency or excess states.

It is important to assess patients for individual risk factors related to gender, health status, and age. For Mrs. Farber, what particular mineralelectrolyte deciencies would you consider/explore?
Many patients with CRF have hypertriglyceridemia, which is worsened by fat emulsions and may cause pancreatitis. With vitamins, patients with ARF who are unable to eat an adequate diet need a vitamin supplement to meet DRIs. Large doses of vitamin C should be avoided because urinary excretion is impaired. In addition, oxalate (a product of vitamin C catabolism) may precipitate in renal tubules or form calcium oxalate stones, obstruct urine ow, and worsen renal function. Patients with CRF often have deciencies of water-soluble vitamins because many foods that contain these vitamins are restricted due to their potassium content. In addition, vitamin C is reabsorbed from renal tubules by a specic transport protein. When the transport protein becomes saturated, remaining vitamin C is excreted in urine. Vitamin C is removed by dialysis and patients receiving dialysis require vitamin C replacement. The optimal replacement dose is unknown but probably should not exceed 200 mg per day (to avoid increased oxalate and possible stones). Overall, a multivitamin with essential vitamins, including vitamin C 70 to 100 mg, pyridoxine 5 to 10 mg, and folic acid 1 mg, is recommended for daily use. With mineralelectrolyte products, several are contraindicated in patients with renal impairment, including magnesium and potassium chloride, because of potential accumulation and toxicity. Frequent measurements of serum electrolyte levels may be indicated. In patients with CRF who are on hemodialysis and receiving supplemental erythropoietin therapy, two iron preparations have been developed to treat iron deciency anemia. Sodium ferric gluconate complex and iron sucrose may be given IV during dialysis.
Nutritional Support in Patients With Hepatic Impairment

The liver is extremely important in digestion and metabolism of carbohydrate, protein, and fat as well as storage of nutrients. Thus, patients with impaired hepatic function are often undernourished, with impaired metabolism of foodstuffs, vitamin deciencies, and uid and electrolyte imbalances. Depending on the disease process and the extent of liver impairment, these patients have special needs in relation to nutritional support.
Nutritional Support in Patients With Renal Impairment

Patients with impaired renal function usually have multiple metabolic disorders such as hyperglycemia, accumulation of urea nitrogen (the end product of protein metabolism), and increased serum triglyceride levels from disordered fat metabolism. With enteral nutrition, Amin-Aid may be given to provide amino acids, carbohydrates, and a few electrolytes for patients with acute or chronic renal failure. With parenteral nutrition, several amino acid solutions are formulated for patients with renal failure. In addition, patients with acute renal failure (ARF) often have hyperkalemia, hyperphosphatemia, and hypermagnesemia, so that potassium, phosphorus, and magnesium should be omitted until serum levels return to normal. IV fat emulsions should not be given to patients with ARF if serum triglyceride levels exceed 300 mg per dL. With CRF, high-calorie, lowelectrolyte enteral formulations are usually indicated. Nepro is a formulation for patients receiving dialysis; Suplena, which is lower in protein and some electrolytes than Nepro, may be used in patients who are not receiving dialysis. Serum triglyceride levels should be measured before IV fat emulsions are given.
Patients with alcoholic hepatitis or cirrhosis have a high rate of metabolism and therefore need foods to supply extra energy. However, metabolic disorders interfere with the livers ability to process and use foodstuffs. Patients with cirrhosis often have hyperglycemia. Patients with severe hepatitis often have hypoglycemia because of impaired hepatic production of glucose and possibly impaired hepatic metabolism of insulin. Protein restriction is usually needed in patients with cirrhosis to prevent or treat hepatic encephalopathy, which is caused by excessive protein or excessive production of ammonia (from protein breakdown in the GI tract). For patients able to tolerate enteral feedings (usually by GI tube), Hepatic Aid II is formulated for patients with liver failure. When parenteral nutrition is necessary for patients with hepatic
930
failure and hepatic encephalopathy, HepatAmine, a special formulation of amino acids, may be used. Other amino acid preparations are contraindicated in patients with hepatic encephalopathy and coma. Lactulose is also given to treat hepatic encephalopathy.
The usual dose is 2 to 4 mg, but some clinicians give 5 to 10 mg. Vitamin K is included in pediatric parenteral nutrition solutions.
Enteral and parenteral fat preparations must be used very cautiously. Medium-chain triglycerides (eg, MCT oil), which are used to provide calories in other malnourished patients, may lead to coma in patients with advanced cirrhosis. Patients who require parenteral nutrition may develop high serum triglyceride levels and pancreatitis if given usual amounts of IV fat emulsions. Sodium and uid restrictions are often needed to decrease edema. Vitamin deciencies commonly occur in patients with chronic liver disease because of poor intake and malabsorption. With hepatic failure, hepatic stores of vitamin A, pyridoxine, folic acid, riboavin, pantothenic acid, vitamin B12, and thiamine are depleted. Folic acid deciency may lead to megaloblastic anemia. Thiamine deciency may lead to Wernickes encephalopathy. Therapeutic doses of vitamins should be given for documented deciency states. Niacin is contraindicated in liver disease because it may increase liver enzymes (alanine and aspartate aminotransferase, alkaline phosphatase) and bilirubin and cause further liver damage. Long-acting dosage forms may be more hepatotoxic than the fast-acting forms.
Electrolyte and acidbase imbalances often occur in critically ill patients and are usually treated as in other patients, with very close monitoring of serum electrolyte levels and avoiding excessive amounts of replacement products.
Nutritional Support in Home Care

The home care nurse is involved with nutritional matters in almost any home care setting. Because nutrition is so important to health, the home care nurse should take advantage of any opportunity for health promotion in this area. Health promotion may involve assessing the nutritional status of all members of the household, especially children, older adults, and those with obvious deciencies, and providing assistance to improve the nutritional status. For patients receiving tube feedings at home, the home care nurse may teach as well as discuss the goals of treatment, administration, preparation or storage of solutions, equipment (eg, obtaining, cleaning), and monitoring responses (eg, weight, urine output). For patients receiving parenteral nutrition at home, solutions, infusion pumps, and other equipment may be obtained from a pharmacy, home health agency, or independent company. The home care nurse may not be involved in the initial setup but is likely to participate in ongoing patient care, monitoring of patient responses, and supporting caregivers. In addition, the home care nurse may need to coordinate activities among physicians, IV therapy personnel, and other health care providers. With vitamins, the home care nurse needs to assess for indications of vitamin deciencies and discuss the use of supplements, especially megadoses. If difculties are found, the nurse may need to counsel the household members about dietary sources of vitamins and adverse effects of excessive vitamin intake. With mineralelectrolytes, the home care nurse needs to assess for indications of mineralelectrolyte deciency or excess. Depending on the assessment data, teaching and discussion may be needed about dietary sources of these nutrients; when mineral supplements are indicated or should be avoided; and safety factors related to iron supplements or exposure to lead in homes with small children.
Iron dextran must be used with extreme caution in patients with impaired hepatic function. Also, overdoses of chromium and copper are hepatotoxic and should be avoided.
Nutritional Support in Patients With Critical Illness

Critically ill patients often have organ failures that alter their ability to ingest and use essential nutrients. Thus, they may be undernourished in relation to protein-calorie, vitamin, and mineralelectrolyte needs. Some considerations include the following:
With enteral nutrition, adequate calories and DRIequivalent amounts of all vitamins are usually needed. Patients with respiratory impairment may need a formula that contains less carbohydrate and more fat than other products and produces less carbon dioxide (eg, Pulmocare, Nutrivent). Patients with cardiac or renal impairment who require uid restriction may benet from a more concentrated formula (eg, 1.5 kcal per mL). With parenteral nutrition, adequate types and amounts of nutrients are needed. When IV fat emulsions are given, they should be infused slowly, over 24 hours. Those for adults do not contain vitamin K, which is usually injected weekly.

How Can You Avoid This Medication Error? Mrs. Farber is taking an iron supplement. You tell the family to give her the iron supplement with her morning coffee.
931
N u tr i ti on al Products, Vi tami n s, and M i n e ral El e ctrolyte s

NURSING ACTIONS 1. Administer accurately
a. For oral supplemental feedings, chill liquids or pour over ice and give through a straw, from a closed container, between meals. Chilling (or freezing) may improve formula taste and decrease formula odour. A straw directs the formula toward the back of the throat and decreases its contact with the taste buds. A closed container also decreases odour. Giving between meals may have less effect on appetite at mealtimes. To decrease risks of aspirating formula into lungs. To prevent aspiration or accidental instillation of feedings into lungs. Cold formulas may cause abdominal cramping. To avoid gastric distention, possible vomiting, and aspiration into lungs. Rapid administration may cause nausea, vomiting, and other symptoms. Most tube-feeding formulas are milk based and provide a good culture medium for bacteria growth. Clean technique, not sterile technique, is required. To avoid dehydration and promote uid balance. Most patients receiving 1,5002,000 mL of tube-feeding formula daily will need 1,000 mL or more of water daily. To keep the tube patent and functioning. This water is included in the calculation of uid intake. Tablets or powders may stick in the tube lumen. This may mean the full dose of the medication does not reach the stomach. Also, the tube is likely to become obstructed. To be effective, these agents must be in the small intestine when food is present. Mineral oil absorbs the vitamins and thus prevents their systemic absorption. Vitamin K is given to patients with hypoprothrombinemia, which causes bleeding tendencies. Thus, any injection may cause trauma and bleeding at the injection site so is rarely used.
RATIONALE/EXPLANATION
b. For tube feedings (1) Have the patient sitting, if possible. (2) Check tube placement before each feeding. (3) Give the solution at room temperature. (4) If giving by intermittent instillation, do not give >500 mL per feeding, including water for rinsing the tube. (5) Give by gravity ow (over 3060 min) or infusion pump. (6) With continuous feedings, change the containers and tubing daily. With intermittent bolus feedings, rinse all equipment after each use and change at least q24h. (7) Give additional water with, after, or between feedings. (8) Rinse the nasogastric tubes with at least 50100 mL water after each bolus feeding or administration of medications through the tube. (9) When medications are ordered by tube, liquid preparations, when available, are preferred over crushed tablets or powders emptied from capsules. c. With pancreatic enzymes, give before or with meals or food. d. With fat-soluble vitamins (1) Do not give oral preparations at the same time as mineral oil. (2) For subcutaneous or IM administration of vitamin K, aspirate carefully to avoid IV injection, apply gentle pressure to the injection site, and inspect the site frequently. For IV injection, vitamin K may be given by direct injection or diluted in IV uids (eg, 5% dextrose in water or saline). (3) Administer IV vitamin K slowly, at a rate not exceeding 1 mg/min, whether diluted or undiluted. e. With B-complex vitamins (1) Give parenteral cyanocobalamin (vitamin B12) IM or deep subcutaneous. (2) Give oral niacin, except for timed-release forms, with or after meals or at bedtime. Have the patient sit or lie down for about 30 min after administration. (3) Give IM thiamine deeply into a large muscle mass. Avoid the IV route. f. With mineralelectrolyte preparations, give oral drugs with food or immediately after meals; give IV preparations slowly, do not mix with any other drug in a syringe, and dilute as directed with compatible IV solutions.
IV phytonadione may cause hypotension and shock from an anaphylactic type of reaction.
To decrease anorexia, nausea, vomiting, diarrhea, and atulence. Niacin causes vasodilation, which may result in dizziness, hypotension, and injury from falls. Vasodilation occurs within a few minutes and may last 1 h. To decrease pain at the injection site. Hypotension and anaphylactic shock have occurred with rapid IV administration and large doses. Giving oral drugs with or after food decreases gastric irritation. Rapid IV administration may cause cardiac dysrhythmias or other serious problems. Mixing the drugs may cause drug inactivation or precipitation.
932
N u t r i ti onal Products, Vi tami ns, an d Mine ral El e ctrolyte s (cont inu e d)

NURSING ACTIONS
g. For potassium supplements (1) For oral preparations, give with or after meals; do not crush controlled- or extended-release tablets; mix oral liquids, powders, and effervescent tablets in at least 120 mL of juice, water, or carbonated beverage. (2) For IV potassium chloride, never give undiluted drug IV; dilute 2060 mmol (mEq) in 1,000 mL of IV solution, such as dextrose in water; be sure that potassium chloride is mixed well with the IV solution; as a general rule, give potassium-containing IV solutions at a rate that administers approximately 10 mEq/h or less; for life-threatening dysrhythmias caused by hypokalemia, potassium can be replaced with 2040 mmol (mEq)/h with constant electrocardiogram (ECG) monitoring. Use an infusion pump and do not give potassiumcontaining IV solutions into a central venous catheter. A variety of premixed IV solutions containing different amounts of potassium chloride are commercially available. h. For parenteral magnesium sulphate (MgSO4) (1) Read the drug label carefully to be sure you have the correct preparation for the intended use. (2) For IM use, small amounts of 50% solution are usually given (1 g MgSO4 = 2 mL of 50% solution). (3) For IV use, a 5% or 10% solution is used for direct injection, intermittent infusion, or continuous infusion. Whatever concentration is used, administer no >150 mg/min (1.5 mL/min of 10% solution; 3 mL/min of 5% solution). i. For iron preparations (1) Give tablets or capsules before meals, with 240 mL of water or juice, if tolerated. If gastric upset occurs, give with or after meals. Instruct patients not to crush or chew sustained-release preparations. (2) Dilute liquid iron preparations, give with a straw, and have the patient rinse the mouth afterward. (3) To give iron dextran IM, use a 2- to 3-in. needle and Z-track technique to inject the drug into the upper outer quadrant of the buttock. (4) To give iron dextran IV (either directly or diluted in sodium chloride solution and given over several hours), do not use the multi-dose vial. j. Refer to the individual drugs or package literature for instructions regarding administration of deferoxamine, penicillamine, IV sodium bicarbonate, and multiple electrolyte solutions.
Giving with food decreases gastric irritation; crushing extended-release tablets causes the drug to be absorbed immediately rather than over several hours, as intended; mixing dilutes, disguises the taste, and decreases gastric irritation. Concentrated drug and transient hyperkalemia may cause life-threatening cardiotoxicity, severe pain, and vein sclerosis; adequate dilution decreases risks of hyperkalemia and cardiotoxicity and prevents or decreases pain at the infusion site; 10 mmol (mEq) or less per hour is the safest amount and rate of potassium administration and it is usually effective; risks of hyperkalemia and life-threatening cardiotoxicity are greatly increased with high concentrations or rapid ow rates. Constant ECG monitoring can detect hyperkalemia. Infusion pumps can regulate the ow rate accurately. Administration through a central IV line can cause hyperkalemia and cardiac dysrhythmias or arrest. Check carefully to ensure the correct strength of potassium in solution is chosen; errors are potentially fatal.
MgSO4 is available in concentrations of 10%, 25%, and 50% and in sizes of 2-, 10-, and 20-mL ampoules, as well as a 30-mL multi-dose vial.
Iron preparations are absorbed better if taken on an empty stomach. If taken with meals, note that bran, eggs, tea, coffee, and dairy products decrease iron absorption. Crushing or chewing releases all the medication at once, rather than over several hours, as intended. To prevent temporary staining of teeth. To prevent discomfort and staining of subcutaneous tissue and skin. The multi-dose vial contains phenol as a preservative and is not suitable for IV use. Ampoules of 2 or 5 mL are available without preservative.
2. Assess for therapeutic effects

a. With nutritional formulas given orally or by tube feeding, assess for weight gain and increased serum albumin. For infants and children receiving milk substitutes, assess for decreased diarrhea and weight gain. b. With pancreatic enzymes, assess for decreased diarrhea and steatorrhea. c. With vitamins, assess for decreased signs and symptoms of deciency: (1) With vitamin A, assess for improved vision, especially in dim light or at night, less dryness in eyes and conjunctiva (xerophthalmia), and improvement in skin lesions. Therapeutic effects depend on the reason for use (ie, prevention or treatment of undernutrition).
The pancreatic enzymes function the same way as endogenous enzymes to and digestion of carbohydrate, protein, and fat.
Night blindness is usually relieved within a few days. Skin lesions may not disappear for several weeks.
933
NURSING ACTIONS
(2) With vitamin K, assess for decreased bleeding and more nearly normal blood coagulation tests (eg, prothrombin time). (3) With B-complex vitamins, assess for decreased or absent stomatitis, glossitis, seborrheic dermatitis, neurologic problems (neuritis, convulsions, mental deterioration, psychotic symptoms), cardiovascular problems (edema, heart failure), and eye problems (itching, burning, photophobia). (4) With vitamin B12 and folic acid, assess for increased appetite, strength and feeling of well-being, increased reticulocyte counts, and increased numbers of normal RBCs, hemoglobin, and hematocrit. (5) With vitamin C, assess for decreased or absent malaise, irritability, and bleeding tendencies (easy bruising of skin, bleeding gums, nosebleeds, and so forth). d. With mineralelectrolyte preparations, assess for decreased signs of deciency. (1) With potassium chloride or other potassium preparations, assess for decreased signs of hypokalemia and increased serum potassium levels. (2) With MgSO4, assess for decreased signs of hypomagnesemia, increased serum magnesium levels, or control of convulsions. (3) With zinc sulphate (ZnSO4), assess for improved wound healing. (4) With iron preparations, assess for increased vigour and feeling of well-being, improved appetite, less fatigue, and increased RBCs, hemoglobin, and hematocrit. With parenteral iron, assess for an average increase in hemoglobin of 1 g/week.
Blood coagulation tests usually improve within 412 h.
Deciencies of B-complex vitamins commonly occur together and produce many similar manifestations.
Therapeutic effects may be rapid and dramatic. The patient usually feels better within 2448 h, and normal RBCs begin to appear. Anemia is decreased within approximately 2 weeks, but 48 weeks may be needed for complete blood count to return to normal.
Therapeutic effects are usually evident within a month unless other problems are also present (eg, vitamin deciency, achlorhydria, infection, malabsorption).
3. Assess for adverse effects

a. With commercial nutritional formulas (except Osmolite and Isocal), assess for hypotension, tachycardia, increased urine output, dehydration, nausea, vomiting, or diarrhea. b. With vitamin A, assess for signs of hypervitaminosis A (anorexia; vomiting; irritability; headache; skin disorders; pain in muscles, bones, and joints; other clinical manifestations; and serum levels of vitamin A above 752,000 retinol activity equivalent [RAE]/100 mL). c. With vitamin K, assess for hypotension and signs of anaphylactic shock with IV phytonadione. d. With B-complex vitamins, assess for hypotension and anaphylactic shock with parenteral niacin, thiamine, cyanocobalamin, and folic acid; anorexia, nausea, vomiting and diarrhea, and postural hypotension with oral niacin. e. With vitamin C megadoses, assess for diarrhea and rebound deciency if stopped abruptly. f. With mineralelectrolytes, assess for excess states. These adverse reactions are usually attributed to the hypertonicity of the preparations. They can be prevented or minimized by starting with small amounts of formula, given slowly. Severity of manifestations depends largely on dose and duration of excess vitamin A intake. Very severe states produce additional clinical signs, including enlargement of liver and spleen, altered liver function, increased intracranial pressure, and other neurologic manifestations. Vitamin K rarely produces adverse reactions. Giving IV phytonadione slowly may prevent adverse reactions. Adverse reactions are generally rare. They are unlikely with B-complex multivitamin preparations. They are most likely to occur with large IV doses and rapid administration.
g. With potassium preparations, assess for hyperkalemia.
h. With magnesium preparations, assess for hypermagnesemia. i. GI symptomsanorexia, nausea, vomiting, diarrhea, and abdominal discomfort from gastric irritation.
Adverse reactions are rare with usual doses and methods of administration. These are likely to occur with excessive dosages of supplements. They can usually be prevented by using relatively low doses in non-emergency situations and by frequent monitoring of serum levels of electrolytes and iron. This is most likely to occur with rapid IV administration, high dosages or concentrations, or in the presence of renal insufcency and decreased urine output. See potassium preparations, above. Most oral preparations of minerals and electrolytes are likely to cause gastric irritation. Taking the drugs with food or 240 mL of uid may decrease symptoms.
934
N u t r i ti onal Products, Vi tami ns, an d Mine ral El e ctrolyte s (cont inu e d)

NURSING ACTIONS
j. Cardiovascular symptomscardiac dysrhythmias, hypotension, tachycardia, and other symptoms of shock. k. With sodium polystyrene sulfonate, assess for hypokalemia, hypocalcemia, hypomagnesemia, and edema.
Potentially fatal dysrhythmias may occur with hyperkalemia or hypermagnesemia; shock may occur with deferoxamine and iron dextran injections. Although this drug is used to treat hyperkalemia, it removes calcium and magnesium ions as well as potassium ions. Because it acts by trading sodium for potassium, the sodium retention may lead to edema.
4. Assess for drug interactions

a. With fat-soluble vitamins (1) Bile salts increase effects. (2) Laxatives, especially mineral oil, and orlistat decrease effects. (3) Antibiotics may decrease effects. Increase intestinal absorption Mineral oil and orlistat combine with fat-soluble vitamins and prevent their absorption if both are taken at the same time. Excessive or chronic laxative use decreases intestinal absorption. With vitamin K, antibiotics decrease production by decreasing intestinal bacteria. With others, antibiotics may cause diarrhea and subsequent malabsorption. By increasing urinary excretion of vitamin B-complex. INH has an anti-pyridoxine effect. When INH is given for prevention or treatment of tuberculosis, pyridoxine is also usually given. Alcohol alters liver function and leads to poor hepatic storage of folic acid. Methotrexate and phenytoin act as antagonists to folic acid and may cause folic acid deciency. Cholestyramine, oral contraceptives, and sulfasalazine decrease absorption of folic acid. Decreases absorption of B12 from foods.
b. With B-complex vitamins (1) Isoniazid (INH) decreases effect.
(2) With folic acidalcohol, cholestyramine, methotrexate, oral contraceptives, phenytoin, sulfasalazine, and triamterene decrease effects.
(3) With vitamin B12, omeprazole (Losec) decreases effects. c. Drugs that increase effects of minerals and electrolytes and related drugs: (1) Cation exchange resin (Kayexalate): diuretics increase potassium loss; other sources of sodium increase the likelihood of edema. (2) With iron salts (a) Allopurinol (Zyloprim) (b) Ascorbic acid (vitamin C) (3) With potassium salts (a) Angiotensin-converting enzyme (ACE) inhibitors (eg, captopril) (b) Diuretics, potassium-sparing (spironolactone, triamterene, amiloride) (c) Salt substitutes (d) Penicillin G potassium d. Drugs that decrease effects of minerals and electrolytes and related drugs: (1) With oral iron salts (a) Antacids (b) Caffeine (c) Pancreatic extracts (2) With potassium salts (a) Calcium gluconate (b) Sodium polystyrene sulfonate (Kayexalate)
Additive effects
This drug may increase the concentration of iron in the liver. It should not be given concurrently with any iron preparation. Increases absorption of iron by acidifying secretions May increase risks of hyperkalemia These drugs should not be given with a potassium supplement because of additive risks of producing life-threatening hyperkalemia. These contain potassium rather than sodium and may cause hyperkalemia if given with potassium supplements. This potassium salt of penicillin contains 1.7 mmol (mEq) of potassium per 1 million units and increases risks of hyperkalemia.
Decrease absorption. Iron is best absorbed in an acidic environment and antacids increase alkalinity. Decreases absorption. An iron preparation and a caffeinecontaining substance (eg, coffee) should be separated by at least 2 h. Decrease absorption Decreases cardiotoxic effects of hyperkalemia and is therefore useful in the treatment of hyperkalemia Used in the treatment of hyperkalemia because it removes potassium from the body
935
Applying Your Knowledge Answers

57-1
Include the administration of a multivitamin with her daily nourishment. The undernourished frequently have deciencies in vitamins A, D, B12, folic acid, riboavin, and thiamine. In the elderly, the most common mineralelectrolyte deciencies are of calcium and iron. Excess states are also possible. Serum levels of minerals and electrolytes should be monitored carefully and measures taken to prevent both deciency and excess.
57-3
57-2
Iron preparations are to be administered before meals for best absorption. When given with coffee, tea, or dairy products, absorption is decreased.
Key Concepts
Human nutrition for health requires sufcient water, carbohydrates, proteins, fats, vitamins, and minerals. Patients with other health problems often have nutritional deciencies, such as protein-caloried undernutrition and vitamin deciencies. All patients need to be assessed in terms of nutritional status. When problems are assessed, interventions to maintain or improve nutritional status are needed. Fat-soluble vitamins are A, D, E, and K; water-soluble vitamins are B complex and C. Nutrients are best obtained from foods; when they cannot be obtained from foods, they can be provided by oral,
enteral (via GI tubes), or parenteral (IV) feedings to meet a patients nutritional needs. Techniques for safe administration of oral, enteral, and parenteral feedings must be consistently followed because complications and harm to patients may occur with all methods. Adverse effects may occur with large doses of vitamin and mineral supplements; the maximum recommended amounts should not be exceeded. Although most adults and children probably benet from a daily multivitamin, large doses of single vitamins do not prevent cancer or cardiovascular disease and should be avoided.
Review and Application Exercises

Short Answer Exercises
1. For patients who are unable to ingest food, which nutrients can be provided with enteral or IV nutritional formulas? 2. What is the role of lipid emulsions in parenteral nutrition? 3. What roles do vitamins play in normal body functioning? 4. Identify patient populations who are at risk for vitamin deciencies and excesses. 5. Are fat-soluble or water-soluble vitamins more toxic in overdoses? Why? 6. For a patient who asks your advice about taking a multivitamin supplement daily, how would you reply? Justify your answer. 7. How do the vitamin requirements of children, older adults, and critically ill patients differ from those of healthy young and middle-aged adults? 8. What are the major roles of minerals and electrolytes in normal body functioning? 9. When a patient is given potassium supplements for hypokalemia, how do you monitor for therapeutic and adverse drug effects? 10. List the main steps in the treatment of hyperkalemia. Identify patient populations at risk for development of hyperkalemia. 11. What are the advantages and disadvantages of iron supplements? 12. List the measures an adult can take to prevent accidental iron poisoning in small children.
CRNE-Style Questions
13. Mr. H. develops respiratory distress while receiving continuous tube feeding. After stopping the feeding which of the following actions should the nurse take? a. Assess bowel sounds to determine if he has a paralytic ileus. b. Assess breath sounds to determine if he has aspirated tube-feeding formula. c. Perform nasal or tracheal suctioning. d. Aspirate stomach contents.
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14. Which of the following statements by Mr. H.s daughter, who will care for him at home, leads you to believe that she has understood your teaching regarding tube feedings? a. I will store unopened cans of formula in the refrigerator. b. I will stop the feedings if he has >2 stools/d. c. I will place him in a sitting position for his feedings. d. I will give no >50 mL/h. 15. Which of the following is a fat-soluble vitamin that is toxic in overdose? a. Vitamin A b. Vitamin B1 c. Vitamin C d. Folic acid
16. Which of the following statements should be included in teaching a patient who is being started on an iron supplement? a. The preparation may cause diarrhea. b. The preparation may cause stools to be dark green or black. c. The preparation should be taken with an antacid. d. The preparation should not be taken with fruit juice. 17. Which of the following IV electrolytes must be well diluted and never given as a bolus injection because it can cause fatal cardiac dysrhythmias? a. Sodium bicarbonate b. Magnesium sulphate c. Sodium chloride d. Potassium chloride
Selected References
Brophy, D. F., & Gehr, T. W. B. (2005). Disorders of potassium and magnesium homeostasis. In J. T. DiPiro, R. L. Talbert, G. C. Yee, et al. (Eds.), Pharmacotherapy: A pathophysiologic approach (6th ed., pp. 967982). New York: McGraw-Hill. Canadian Pharmacists Association. (2009). Compendium of pharmaceuticals and specialties. Ottawa, ON: Author. Christoes, A., Schauer, C., & Zlotkin, S.H. (2005). Iron deciency and anemia prevalence and associated etiologic risk factors in First Nations and Inuit communities in Northern Ontario and Nunavut. Canadian Journal of Public Health, 96(4), 304307. DeHart, R. M., & Worthington, M. A. (2005). Nutritional considerations in major organ failure. In J. T. DiPiro, R. L. Talbert, G. C. Yee, et al. (Eds.), Pharmacotherapy: A pathophysiologic approach (6th ed., pp. 26352658). New York: McGraw-Hill. Facts & Comparisons. (Updated monthly). Drug facts and comparisons. St. Louis, MO: Author. Giles, H., & Vijayan, A. (2004). Fluid and electrolyte management. In G. B. Green, I. S. Harris, G. A. Lin, et al. (Eds.), The Washington manual of medical therapeutics (31st ed., pp. 3971). Philadelphia, PA: Lippincott Williams & Wilkins. Health Canada. (2007). Eating well with Canadas food guide. Retrieved May 21, 2009, from http://www.hc-sc.gc.ca/fn-an/food guideailment/index-eng.php Health Canada. (2007). Eating Well with Canadas Food Guide: First Nations, Inuit and Metis. Retrieved. May 21, 2009, from http://www.hc-sc. gc.ca/hl-vs/alt_formats/pacrb-dgapar/pdf/iyh-vsv/life-vie/obes-eng.pdf Health Canada. Dietary reference intakes (2006). Retrieved June 27, 2009, from http://www.hc-sc.gc.ca/fn-an/nutrition/reference/reportsrapports/index-eng.php Heyland, D. K., Dhaliwal, R., Drover, J. W., et al., and the Canadian Critical Care Clinical Practice Guidelines Committee. (2003). Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. Journal of Parenteral and Enteral Nutrition, 27(5), 355373. Johnson-Down, L., Ritter, H., Starkey, L. J., et al. (2006). Primary food sources of nutrients in the diet of Canadian adults. Canadian Journal of Dietary Practices and Research, 67(1), 713. Mahan, L. K., & Escott-Stump, S. (Eds.). (2004). Krauses food, nutrition, and diet therapy (11th ed.). Philadelphia, PA: W. B. Saunders. Mason, J. B. (2004). Consequences of altered micronutrient status. In L. Goldman, & D. Ausiello (Eds.), Cecil textbook of medicine (22nd ed., pp. 13261336). Philadelphia, PA: W. B. Saunders. McMahon, M. M. (2004). Parenteral nutrition. In L. Goldman, & D. Ausiello (Eds.), Cecil textbook of medicine (22nd ed., pp. 13221326). Philadelphia, PA: W. B. Saunders. Miller, E., Pastor-Barriuso, P., Dalal, D., et al. (2005). Meta-analysis: High-dosage vitamin E supplementation may increase all-cause mortality. Annals of Internal Medicine, 142(1). Retrieved June 26, 2009, from http://www.annals.org/cgi/reprint/000060520050104000110v1.pdf Pronsky, Z. M., & Crowe, J. P. (2005). In L. K. Mahan & S. Escott-Stump (Eds.), Krauses food, nutrition, and diet therapy (11th ed., pp. 455474). Philadelphia, PA: W. B. Saunders. Reiter, P. D., & Sacks, G. S. (2005). Prevalence and signicance of malnutrition. In J. T. DiPiro, R. L. Talbert, G. C. Yee, et al. (Eds.), Pharmacotherapy: A pathophysiologic approach (6th ed., pp. 25792590). New York: McGraw-Hill. Rock, C. L. (2004). Nutrition in the prevention and treatment of disease. In L. Goldman & D. Ausiello (Eds.), Cecil textbook of medicine (22nd ed., pp. 13081311). Philadelphia, PA: W. B. Saunders. Rombeau, J. L. (2004). Enteral nutrition. In L. Goldman, & D. Ausiello (Eds.), Cecil textbook of medicine (22nd ed., pp. 13191322). Philadelphia, PA: W. B. Saunders. Smeltzer, S. C., & Bare, B. G. (2008). Brunner & Suddarths textbook of medical-surgical nursing (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Torrance, G. M., Hooper, M. D., & Reeder, B. A. (2002). Trends in overweight and obesity among adults in Canada (19701992): Evidence from national surveys using measured height and weight. International Journal of Obesity and Related Metabolism Disorders, 26(6), 797804.
CHAPTER
58
KEY TERMS

Drugs to Aid Weight Management

OBJECTIVES
After studying this chapter, you will be able to:
Anorexiants Body mass index Obesity Overweight
1. Promote healthful lifestyle measures to maintain body weight within a

desirable range and avoid obesity.
2. Assess patients for risk factors and manifestations of obesity. 3. Calculate body mass index (BMI). 4. Counsel patients about the health consequences of obesity. 5. Assist overweight patients to develop and maintain a safe and realistic
weight-loss program.
6. Identify reliable sources for information about nutrition, weight loss, and
weight maintenance. 7. Discuss nursing process implications of approved weight-loss drugs.
Applying Your Knowledge

Pauline McKay, aged 51, has had a weight problem all her life. She has been on countless diets, but always with the same result: she loses weight, and then regains it plus additional weight. She is 191 cm tall and weighs 120.5 kg. Her physician starts her on orlistat (Xenical).
Introduction
Carbohydrates, proteins, and fats are required for human nutrition. Either deciencies or excesses impair health, cause illness, and impair recovery from illness or injury. Proteins are basic anatomic and physiologic components of all body cells and tissues; carbohydrates and fats serve primarily as sources of energy for cellular metabolism. Energy is measured in kilocalories (kcal, commonly called calories) per gram of food oxidized in the body. Carbohydrates and proteins supply 4 kcal per g; fats supply 9 kcal per g. Excessive amounts of any of these nutrients are converted to fat and stored in the body, resulting in overweight and obesity. This chapter discusses obesity and pharmacological and non-pharmacological treatment strategies, to aid weight loss and weight maintenance.
Overweight and Obese Adults

Overweight and obesity are worldwide problems and are increasing in Canada, in both children and adults. Statistics Canada reports that two out of every three adults in Canada are overweight or obese. The proportion of obese children has tripled in the last 25 years. Obesity is a risk factor in a number of chronic diseases; a healthy weight is important in reducing the risk of those diseases and to improve overall health. In the First Report of the Institute of Wellbeing, 67% of Canadian teenagers report excellent or very good health down from 80% in 1998. Health Canada classies overweight as a body mass index (BMI) of 25 to 29.9 kg per m2; obese is classied as a BMI of 30 or more kg per m2. The BMI reects weight in relation to height and is a better indicator than weight alone. The desirable range for BMI is 18.5 to 24.9 kg per m2 of body surface, with values below
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Box 58-1
BMI
Calculation of BMI
Physiologic Factors
In general, increased weight is related to an energy imbalance in which energy intake (food/calorie consumption) exceeds energy expenditure. Total energy expenditure represents the energy expended at rest (ie, the basal or resting metabolic rate), during physical activity, and during food consumption. When a person ingests food, about 10% of the energy content of that food is expended in the digestion, absorption, and metabolism of nutrients. Foods that contain carbohydrates and proteins stimulate energy expenditure; high-fat foods have little stimulatory effect. The energy required to metabolize and to use food reaches a maximum level about 1 hour after the food is ingested. In addition, men tend to expend more energy than women because men have proportionally more muscle mass. Energy expenditure usually decreases in older men and women of all ages because these groups have less muscle tissue and more adipose tissue. Muscle is more metabolically active (ie, has higher energy needs and burns more calories) than adipose tissue. Excessive weight can result from eating more calories, exercising less, or a combination of the two factors. Consuming an extra 500 calories each day for a week results in 3,500 excess calories or 1 lb of fat. Excess calories are converted to triglycerides and stored in fat cells (adipocytes). With continued intake of excessive calories, fat cells increase in both size and number.
BMI can be calculated as weight in kilograms divided by height in metres squared, as follows: BMI = weight (kg) height (m)2
Example: A person who weighs 68.18 kg and is 162.5 cm tall 68.2 (1.63)2 68.2 = 25.64 (2.66)
18.5 indicating underweight and values of 25 or above indicating excessive weight (Box 58-1). A large waist circumference (>88 cm [35 in.] for women, >102 cm [40 in.] for men) is another risk factor for health problems such as type 2 diabetes, coronary heart disease (CHD), and hypertension. Waist to hip ratio (WHR) is also used by health professionals to estimate the distribution of fat and it indicates increased risk when measurements approximate these levels. Obesity may occur in anyone but is more likely to occur in women, minority groups, and poor people. It results from consistent ingestion of more calories than are used for energy and it substantially increases risks for development of numerous health problems (Box 58-2). Most obesity-related disorders are attributed mainly to the multiple metabolic abnormalities associated with obesity. Abdominal fat out of proportion to total body fat (also called central or visceral obesity), which often occurs in men and postmenopausal women, is considered a greater risk factor for disease and death than lower body obesity. In addition to the many health problems associated with obesity, obesity is increasingly being considered a chronic disease in its own right. Although it has been the focus of much research in recent years, no current theory adequately explains the disorder and its resistance to treatment.
Genetic Factors
Various studies indicate that a signicant portion of weight variation within a given environment is genetic in origin. For example, identical twins raised in separate environments often have similar body types. Most cases of human obesity are attributed mainly to the combination of genetic susceptibility and environmental conditions.
Environmental Factors
Environmental factors contributing to the greater number of overweight and obese individuals include increased food consumption and decreased physical activity. The ready availability and relatively low cost of a wide variety of foods, in addition to large portion sizes and high-calorie foods, promote overeating. In addition, many social gatherings are associated with eating or overeating. In relation to physical activity, the usual activities of daily household maintenance living for many people, including work-related activities, require relatively little energy expenditure. In addition, few Canadians are thought to exercise in the optimal frequency, intensity, or duration to maintain health and prevent excessive weight gain. For both adults and children, using a car for transportation, increased time watching television, playing video or computer games, and working on computers contributes to less physical activity and is thought to promote weight gain and obesity. Statistics Canada found a direct correlation between the amount of time young people spent watching TV and playing videogames and their likelihood of being overweight or obese.
Prevalence
The prevalence of overweight people and obesity has dramatically increased over the past 20 years. Some authorities estimate that approximately 30% of Canadian adults are overweight or obese. There are differences in prevalence by gender, ethnicity, and socioeconomic status. In general, more women than men are obese, whereas more men than women are overweight; and women in lower socioeconomic classes are more likely to be obese than those women in higher socioeconomic classes.
Etiology
The etiology of excessive weight is thought to involve complex and often overlapping interactions among physiologic, genetic, environmental, psychosocial, and other factors.
Chapter 58 Drugs to Aid Weight Management
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Box 58-2
Health Risks of Obesity

that lead to heart failure more rapidly. Weight loss of as little as 4.5 kg (10 lb) can decrease blood pressure and cardiovascular risk in many people with obesity and hypertension. Diabetes Mellitus Obesity is strongly associated with impaired glucose tolerance, insulin resistance, and diabetes mellitus. In addition, obesity during adolescence is associated with higher rates of diabetes as adults as well as more severe complications of diabetes at younger ages. The cellular effects by which obesity causes insulin resistance are unknown. Proposed mechanisms include down regulation of insulin receptors, abnormal postreceptor signals, and others. Whatever the mechanism, the impaired insulin response stimulates the pancreatic beta cells to increase insulin secretion, resulting in a relative excess of insulin called hyperinsulinemia, and causes impaired lipid metabolism (increased LDL cholesterol and triglycerides and decreased HDL). These metabolic changes increase hypertension and other risk factors for cardiovascular disease. As with cardiovascular disease and diabetes in general, central obesity seems to increase the likelihood of serious disease. The abdominal fat of central obesity seems to be more insulin resistant than peripheral fat deposited over the buttocks and legs. Intentional weight loss signicantly reduces mortality in obese individuals with diabetes. Dyslipidemias Obesity strongly contributes to abnormal and undesirable changes in lipid metabolism (eg, increased triglycerides and LDL cholesterol; decreased HDL cholesterol) that increase risks of cardiovascular disease and other health problems. Gallstones Obesity apparently increases the risk for developing gallstones by altering production and metabolism of cholesterol and bile. The risk is higher in women, especially those who have had multiple pregnancies or who are taking oral contraceptives. However, rapid weight loss with very low calorie diets is also associated with gallstones. Metabolic Syndrome Metabolic syndrome is a group of risk factors and chronic conditions that occur together and greatly increase the risks of diabetes mellitus, serious cardiovascular disease, and death. The syndrome is thought to be highly prevalent in North America. Major characteristics include many of the health problems associated with obesity (eg, dyslipidemias, hypertension, impaired glucose tolerance, insulin resistance, central obesity). More specically, metabolic syndrome includes three or more of the following abnormalities:

Obesity is associated with serious health risks. Several disease states and chronic health problems, as well as increased mortality, are more prevalent in obese patients. Studies indicate that a high BMI is associated with an increased risk of death from all causes, among both men and women, and in all age groups. In addition, a higher death rate occurs in people who gain weight of 10 kg or more after 18 years of age. Some of the major health risks include the disorders listed below. In general, these conditions tend to worsen as the degree of obesity increases and improve with weight loss. Cancer Obesity is associated with a higher prevalence of breast, colon, and endometrial cancers. With breast cancer, risks increase in postmenopausal women with increasing body weight. Women who gain >10 kg from age 18 to midlife have double the risk of breast cancer compared with women who maintain a stable weight during this period of their life. In addition, central obesity apparently increases the risk of breast cancer independent of overall obesity. In women with central obesity, this additional risk factor may be related to an excess of estrogen (from conversion of androstenedione to estradiol in peripheral fatty tissue) and a deciency of sex hormonebinding globulin to combine with the estrogen. Colon cancer seems to be more common in obese men and women. In addition, a high BMI may be a risk factor for a higher mortality rate with colon cancer. Endometrial cancer is clearly more common in obese women, with adult weight gain again increasing risk. Cardiovascular Disorders Obesity is a major risk factor for cardiovascular disorders and increased mortality from cardiovascular disease. Studies have conrmed the relationship between obesity and increased risk of CHD and stroke in both men and women. In addition, obesity during adolescence is associated with higher rates and greater severity of cardiovascular disease as adults. Obesity increases risks by aggravating other risk factors such as hypertension, insulin resistance, low HDL cholesterol, and hypertriglyceridemia. In addition, obesity seems to be an independent risk factor for cardiovascular disorders, and central obesity may be more important than BMI as a risk factor for death from cardiovascular disease. The increased mortality rate is seen even with modest excess body weight. Hypertension, dyslipidemia, insulin resistance, and glucose intolerance are known cardiac risk factors that tend to cluster in obese individuals. Hypertension often occurs in obese persons and is thought to play a major role in the increased incidence of cardiovascular disease and stroke observed in patients with obesity. Metabolic abnormalities that occur with obesity and type 2 diabetes mellitus (eg, insulin resistance and the resultant hyperinsulinemia) aggravate hypertension and increase cardiovascular risks. The combination of obesity and hypertension is associated with cardiac changes (eg, thickening of the ventricular wall, ischemia, and increased heart volume)
Central obesity (waist circumference > 102 cm [40 in.] for men and >88 cm [35 in.] for women) Serum triglycerides of 1.7 mmol/L or more
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Box 58-2

Health Risks of Obesity (continued)

that leads to collapse of the upper airways with inspiration during sleep. The obstructed breathing leads to apnea with hypoxemia, hypercarbia, and a stress response. Sleep apnea is associated with increased risks of hypertension, possible right heart failure, and sudden death. Weight loss leads to improvement in sleep apnea. Miscellaneous Effects Obesity is associated with numerous difculties in addition to those described above. These may include:

HDL cholesterol < 1.0 mmol/L in men and <1.3 mmol/L in women Blood pressure of 130/85 mm Hg or higher Fasting serum glucose of 6.27.0 mmol/L or higher
Osteoarthritis Obesity is associated with OA of both weight-bearing joints, such as the hip and knee, and nonweight-bearing joints. Extra weight can stress affected bones and joints, contract muscles that normally stabilize joints, and may alter the metabolism of cartilage, collagen, and bone. In general, obese people develop OA of the knees at an earlier age and are more likely than nonobese people to require knee replacement surgery. The important role of obesity in OA is supported by the observation that weight loss delays onset and reduces symptoms and disability. Weight reduction may also decrease infection, wound complications, and blood loss if surgery is required. Despite the benets of weight loss, however, persons with OA have difculty losing weight because painful joints limit exercise and activity. Sleep Apnea Sleep apnea commonly occurs in obese persons. A possible explanation is enlargement of soft tissue in the upper airways
Nonalcoholic fatty liver disease, which is being increasingly recognized and which may lead to liver failure Poor wound healing Poor antibody response to hepatitis B vaccine A negative perception of people who are obese that affects their education, socioeconomic, and employment status High costs associated with treatment of the medical conditions caused or aggravated by obesity as well as the costs associated with weight-loss efforts In women, obesity is associated with menstrual irregularities and increased complications of pregnancy (eg, gestational diabetes, higher rates of labour induction and caesarean section, and increased risk of neural tube and other congenital defects in offspring of obese women).
Psychosocial Factors
Psychosocial disorders may be either a cause or an effect of obesity. Although much is still unknown about the psychological aspects of obesity development, depression and/or abuse may play a role. Obese people often report symptoms of depression and some people overeat and gain weight during depressive episodes. It may be that obesity and depression commonly occur together and reinforce each other. A depressed person is less likely to take the active measures in diet and exercise that are required to lose weight, even if obesity is a prominent factor in the development of depression. In women, sexual, physical, and emotional abuse can result in obesity. Abuse during childhood and adolescence tends to produce more severe effects.
Other Factors
Diseases are rarely a major cause of obesity development. However, numerous disease processes may limit a persons ability to engage in calorie-burning physical activity. In addition, numerous prescription medications reportedly cause weight gain in some or most of the patients who take them (Box 58-3).
Childhood obesity is a major public health concern because these children have or are at risk of developing hypertension, dyslipidemias, type 2 diabetes, and other disorders that may lead to major disability and death at younger adult ages than nonobese children. Obesity, type 2 diabetes, and other health problems are mainly attributed to poor eating habits and too little exercise. In addition, the child who is obese after 6 years of age is highly likely to be obese as an adult, especially if a parent is obese. Obesity in adults that began in childhood tends to be more severe. In addition to major health problems, reduced energy, and less physical agility, obese children are often ridiculed or bullied by other children and may be discriminated against by adults in schools and workplaces.
General Characteristics of Drugs for Obesity

Most organizations generally recommend reserving drug therapy for those with a BMI of 30 kg per m2 or greater and health problems (eg, hypertension, dyslipidemia, CHD, type 2 diabetes, sleep apnea) that are likely to improve with weight loss. Drug therapy for obesity should be used as part of a weight-management program that also includes a sensible diet, physical activity, and behavioural modication. Guidelines also emphasize that drug
Overweight and Obese Children

Being overweight and obesity are common and increasing among children and adolescents, in a similar dramatic fashion as Canadian adults. Overweight is dened as a BMI above the 85th percentile for the age group, and obesity as a BMI above the 95th percentile.
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Box 58-3
Anti-Depressants
Effects of Selected Medications on Weight

of which may contribute to weight gain. Other mechanisms may also be involved. As a result, some clinicians question the use of beta-blockers in overweight or obese patients with uncomplicated hypertension. Alpha-blockers may also cause weight gain, but apparently at a low incidence of 0.5%1%. Angiotensin-converting enzyme (ACE) inhibitors and calcium channel blockers are not reported to promote weight gain. Anti-Psychotics Weight gain is often reported and extensively documented with the use of atypical drugs, the most commonly used anti-psychotic drugs. Although the exact mechanism is unknown, weight gain has been associated with anti-histaminic effects, anti-cholinergic effects, and blockade of serotonin receptors. In addition, dietary factors and activity levels may also play signicant roles. Clozapine (Clozaril) and olanzapine (Zyprexa) can cause signicant weight gain in 40% or more of patients. Compared with clozapine and olanzapine, risperidone causes less weight gain, and quetiapine (Seroquel) causes the least weight gain. Weight gain may lead to noncompliance with drug therapy. In addition to weight gain, clozapine and olanzapine adversely affect glucose regulation and can aggravate pre-existing diabetes or cause new-onset diabetes. The extent to which these effects are related to weight gain is unknown. Typical antipsychotics (such as chlorpromazine) also cause weight gain. Cholesterol-Lowering Agents Weight gain has been reported with the statin group of drugs; mechanisms and extent are unknown. Corticosteroids Systemic corticosteroids may cause increased appetite, weight gain, central obesity, and retention of sodium and uid. Inhaled and intranasal corticosteroids have little effect on weight. Gastrointestinal Drugs Increased appetite and weight gain have been reported with the proton pump inhibitors (PPIs) such as omeprazole (Losec) and others. The mechanisms and extent are unknown. Hormonal Contraceptives The weight gain associated with using hormonal contraceptives may be related more to retention of uid and sodium than to increased body fat. Mood Stabilizing Agent Weight gain has been reported with long-term use of lithium, with approximately 20% of patients gaining 10 kg or more. This increased weight is attributed to uid retention, consumption of high-calorie beverages as a result of increased thirst; or a decreased metabolic rate. Weight gain is a common reason for noncompliance with lithium therapy and weight gain may be more common in women with lithium-induced hypothyroidism and in those who are already overweight.
SSRIs, such as uoxetine (Prozac) and related drugs, apparently promote weight loss with short-term use. However, with long-term use, they reportedly may cause as much weight gain as TCAs such as amitriptyline (Elavil). TCAs have long been associated with excessive appetite and weight gain. Mirtazapine (Remeron) and phenelzine (Nardil) are also associated with weight gain. The effects of bupropion (Wellbutrin, Zyban) on weight are unclear from clinical trials; however, anorexia and weight loss occurred at a higher percentage rate than increased appetite and weight gain. Anti-Diabetic Drugs Although little attention is paid to the topic in most literature about diabetic drugs, weight gain occurs with insulin, sulphonylureas, and the glitazones (but not with metformin [Glucophage] or acarbose [Prandase]). Almost all patients with type 2 diabetes eventually require insulin; those who are failing on oral agents generally gain a large amount of body fat when switched to insulin therapy. Although the mechanism of weight gain is unknown, it may be related to the chronic hyperinsulinism induced by long-acting insulins and the sulphonylureas (which increase insulin secretion). Less weight is gained when oral drugs are given during the day and intermediate- or long-acting insulin is injected at bedtime. This strategy is thought to cause less daytime hyperinsulinemia than the more traditional insulin strategies. For nearnormal-weight diabetic patients who require drug therapy, a sulphonylurea may be given. However, for obese patients, metformin is usually the initial drug of choice because it does not promote weight gain. Anti-Epileptic Drugs Weight gain commonly occurs with the use of anti-epileptic drugs (AEDs). This has been observed for many years with older drugs (eg, phenytoin, valproic acid [Epival, Depakene], carbamazepine [Tegretol]) and more recently with newer AEDs (eg, gabapentin [Neurontin], lamotrigine [Lamictal]). Mechanisms by which the drugs promote weight gain are unclear, but may involve stimulation of appetite and/or a slowed metabolic rate. Consequences of weight gain may include increased risks of diabetes mellitus, hypertension, and other physical health problems as well as psychological distress over appearance, especially in children and adolescents. Anti-histamines Histamine1 (H1) antagonists (eg, diphenhydramine [Benadryl], loratadine [Claritin]) reportedly increase appetite and cause weight gain. Anti-Hypertensives The main anti-hypertensive drugs reported to cause weight gain are the widely used beta-blockers. The drugs can cause fatigue and decrease exercise tolerance and metabolic rate, all
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Table 58-1
GENERIC/TRADE NAME
Drugs at a Glance: Drugs for Obesity

ROUTE AND DOSAGE RANGES
PO 1530 mg daily in the morning PO 1015 mg once daily, in the morning, with or without food PO 120 mg with each main meal, up to three capsules daily
APPETITE SUPPRESSANTS Phentermine hydrochloride (Ionamin) Sibutramine (Meridia) FAT BLOCKER Orlistat (Xenical)
PO, oral.
therapy should be used to decrease medical risk and improve health rather than promote cosmetic weight loss. Drug therapy for obesity has a problematic history, mainly because of serious adverse effects and rapid weight regain when the drugs were stopped. The drug, phenylpropanolamine, and the components of many over-the-counter and herbal weightloss products, ephedra and ma huang, have been taken off the market because of their adverse effects. Older drugs include amphetamines and similar drugs. Amphetamines (see Chap. 15) are not recommended because they are controlled substances with a high potential for abuse and dependence. Diethylpropion (Tenuate) and phentermine (Ionamin) are adrenergic drugs (see Chap. 17) that stimulate the release of norepinephrine and dopamine in the brain. This action in nerve terminals of the hypothalamic feeding centre suppresses appetite. These drugs are central nervous system (CNS) and cardiovascular stimulants and are contraindicated in cardiovascular disease, hyperthyroidism, glaucoma, and agitated states. Of the adrenergic anorexiant drugs, only phentermine is commonly used. Two newer drugs, sibutramine (Meridia) and orlistat (Xenical), are more commonly used and are the only weight-loss drugs approved for long-term use. According to some clinicians, sibutramine and orlistat may be continued as long as they are effective and adverse effects are tolerable. The drugs are described below; dosage ranges are listed in Table 58-1.
or agitation because of CNS stimulant effects. The most commonly reported adverse effects are nervousness, dry mouth, constipation, and hypertension. As with all weight loss medications, it should be used in conjunction with dietary restrictions for weight reduction and maintenance.
Sibutramine
Sibutramine (Meridia) inhibits the reuptake of serotonin and norepinephrine in the brain, thereby increasing the amounts of these neurotransmitters. Clinical effects include increased satiety, decreased food intake, and a faster metabolism rate. Sibutramine is approved by Health Canada for long-term use, but effects are mostly unknown beyond 1 year. The drug increases blood pressure and heart rate and is contraindicated in patients with cardiovascular disorders (eg, CHD, dysrhythmias, heart failure, hypertension) or psychiatric illness. It should be used cautiously in patients who take other medications that increase blood pressure and pulse rate. It should also be used cautiously in patients with impaired hepatic function, narrow-angle glaucoma (may cause mydriasis), or a history of substance abuse or dependency. Sibutramine has not been studied in children under 18 years of age or in patients over age 65. It is not recommended for women who are pregnant or lactating. The drug is contraindicated in people with severe renal or hepatic dysfunction. Oral sibutramine is rapidly absorbed from the intestine and undergoes rst-pass metabolism, during which time active metabolites are formed. Peak plasma levels of the active metabolites occur within 3 to 4 hours and drug half-life is 14 to 16 hours. The long half-lives of the active metabolites allow for once-daily dosing. The drug is highly bound to plasma proteins and rapidly distributed to most body tissues, with the highest concentrations in the liver and kidneys. It is metabolized in the liver, mainly by the cytochrome P450 3A4 enzymes. The active metabolites produced by rst-pass metabolism are further metabolized to inactive metabolites, which are then excreted in urine and feces. Common adverse effects of sibutramine include dry mouth, headache, insomnia, nervousness, and constipation; cardiovascular effects include hypertension, tachycardia, and
Individual Drugs
Phentermine
Phentermine hydrochloride (Ionamin) is the most frequently prescribed adrenergic anorexiant. It is a controlled drug and recommended only for short-term use (3 months or less). Its use is contraindicated in patients with hypertension or other cardiovascular disease and in those with a history of drug abuse. Because it increases blood pressure, phentermine should be used with caution even in patients with mild hypertension. The drug should also be used cautiously in patients with anxiety
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palpitations. Potentially serious drug interactions may occur if sibutramine is taken with other cardiovascular stimulants (increased risk of hypertension and dysrhythmias), CNS stimulants (increased anxiety and insomnia), anti-psychotics, and serotonergic drugs (serotonin syndrome). Other drugs that increase serotonin include the selective serotonin reuptake inhibitors (SSRIs) (eg, uoxetine [Prozac] and related drugs); St. Johns wort; the triptan anti-migraine drugs (eg, sumatriptan [Imitrex]); dextromethorphan (a common ingredient in cough syrups); and lithium. The combination of sibutramine with any of these drugs may cause serotonin syndrome, a condition characterized by agitation, confusion, hypomania, impaired coordination, loss of consciousness, nausea, tachycardia, and other symptoms. In clinical trials, people lost the most weight during the rst 6 months of sibutramine therapy. However, continued drug therapy helped to maintain weight loss for 12 to 24 months. Most of the clinical trials included diet and behavioural modication techniques in addition to sibutramine therapy. As with other weight-loss drugs, studies indicate that sibutramine therapy is more effective when it is combined with lifestyle modication and diet than when used alone.
fatty, malodourous stools) worsen with high fat consumption. Long-term effects of orlistat are unknown, although one study reported safe and effective use for 2 years. In addition to weight loss and reduced cholesterol levels, clinical trials found reduced severity and improved management of other health problems associated with obesity, such as diabetes and hypertension. In general, the addition of orlistat therapy to diet and other lifestyle changes produced greater weight loss than the addition of a placebo. In some patients with impaired glucose tolerance, weight loss with orlistat and lifestyle changes prevented or delayed the occurrence of diabetes mellitus. After the medication was stopped, most patients regained weight. In a new direction, a recent European study found that modulating the activity of the endocannabinoid system by blocking its receptors could reduce weight, waist circumference, lipid concentrations, and insulin resistance. Further research will need to be done to ensure the validity and reliability of these ndings.

Pauline asks how orlistat (Xenical) will help her when nothing else in the past has been successful. How would you respond?
Orlistat
Orlistat (Xenical) differs from phentermine and sibutramine because it decreases absorption of dietary fat from the intestine (by binding to gastric and pancreatic lipases in the gastrointestinal [GI] tract lumen and making them unavailable to break down dietary fats into absorbable free fatty acids and monoglycerides). The drug blocks the absorption of approximately 30% of the fat ingested in a meal; increasing dosage does not increase this percentage. Decreased fat absorption leads to decreased caloric intake, resulting in weight loss and improved serum cholesterol values (eg, decreased total and low-density lipoprotein [LDL] cholesterol levels). The improvement in cholesterol levels is thought to be independent of weight-loss effects. The use of orlistat has not been studied in pregnant or lactating women. Orlistat is not absorbed systemically and its action occurs in the GI tract. Consequently, it does not cause systemic adverse effects or drug interactions as phentermine and sibutramine do. Its main disadvantages are frequent administration (three times daily) and GI symptoms (abdominal pain, oily spotting, fecal urgency, atulence with discharge, fatty stools, fecal incontinence, and increased defecation). Adverse GI effects occur in almost all orlistat users but usually subside after a few weeks of continued drug usage. The drug also prevents the absorption of the fat-soluble vitamins, A, D, E, and K. As a result, people taking orlistat should also take a multivitamin containing these vitamins daily. The multivitamin should be taken 2 hours before or after the orlistat dose. If taken at the same time, the orlistat prevents the absorption of the fat-soluble vitamins. Orlistat is intended for people who are clinically obese, not those wanting to lose a few kilograms. In addition, high-fat foods still need to be decreased because total caloric intake is a major determinant of weight, and adverse effects (eg, diarrhea;
Natural Health Products

Many people use herbal or dietary supplements for weight loss, even though reliable evidence of safety and effectiveness is lacking. Some herbal products claim to decrease appetite and increase the rate at which the body burns calories. However, in most cases, there is no scientic evidence that they work at all. Some supplements for weight loss contain cardiovascular and CNS stimulants that may cause serious, even life-threatening, adverse effects. In general, many consumers do not seem to appreciate the benets of proven weight-management techniques (eg, appropriate diet and exercise) or the potential risks of taking unproven weight-loss products. Selected products are described below. Acai (Euterpe oleracea), a berry from the acai palm tree native to Central and South America, has recently been proposed to foster weight loss. Juice from the berry is used for osteoarthritis (OA), hypercholesterolemia, weight loss, and obesity and for improving general health. Research has centred on the anti-oxidant properties rather than weight loss. There is no scientic evidence to support its role in weight loss. Ephedra (ma huang) is an herb that has long been a component of many weight-loss products (eg, Herbalife). It is not recommended for use by anyone because it is a strong cardiovascular and CNS stimulant that increases risks of heart attack, seizure, stroke, and sudden death. Many ephedracontaining products also contained caffeine, which can further increase cardiovascular and CNS stimulation. In 2002, Health
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Canada announced a recall of products containing ephedra; it is authorized for use only as an over-the-counter nasal decongestant. Glucomannan expands on contact with body uids. It is included in weight-loss regimens because of its supposed ability to produce feelings of stomach fullness, thereby causing a person to eat less. It also has a laxative effect. There is little evidence to support its use as a weight-loss aid. Products containing glucomannan should not be used by people with diabetes; glucomannan may cause hypoglycemia alone and increases hypoglycemic effects of anti-diabetic medications. Guarana, a major source of commercial caffeine, is found in weight-loss products as well as caffeine-containing soft drinks, bodybuilding supplements, smoking-cessation products, vitamin supplements, candies, and chewing gums. Caffeine is the active ingredient; the amount varies among products, and caffeine content of any particular product cannot be accurately predicted. Guarana is promoted to decrease appetite and increase energy and mental alertness. It is contraindicated in patients with dysrhythmias and may aggravate gastroesophageal reux disease (GERD) and peptic ulcer disease. Adverse effects include diuresis, cardiovascular symptoms (premature ventricular contractions, tachycardia), CNS symptoms (agitation, anxiety, insomnia, seizures, tremors), and GI symptoms (nausea, vomiting, diarrhea). Such effects are more likely to occur with higher doses or concomitant use of guarana and other sources of caffeine. Adverse drugdrug interactions include additive CNS and cardiovascular stimulation with beta-adrenergic agonists (eg, epinephrine, salbutamol and related drugs, pseudoephedrine) and theophylline. In addition, concurrent use of cimetidine, uoroquinolones, or oral contraceptives may increase or prolong serum caffeine levels and subsequent adverse effects. Guar gum is a dietary bre included in weight-loss products because it is bulk-forming and produces feelings of fullness. Several small studies indicated that it is no more effective than a placebo for weight loss. It may cause esophageal or intestinal obstruction if not taken with an adequate amount of water and may interfere with the absorption of other drugs if taken at the same time. Adverse effects include nausea, diarrhea, atulence, and abdominal discomfort. Hydroxycitric acid (in Citrimax and other supplements) apparently suppresses appetite in animals, but there are no reliable studies that indicate its effectiveness in humans. One 12-week study did not show weight loss. Laxative and diuretic herbs (eg, aloe, rhubarb root, buckthorn, cascara, senna, parsley, juniper, dandelion leaves) are found in several products. Laxative and diuretic herbs can cause a signicant loss of body uids and electrolytes, not fat. Adverse effects may include low serum potassium levels, with subsequent cardiac dysrhythmias and other heart problems. In addition, long-term use of laxatives may lead to loss of normal bowel function and the necessity for continued use (ie, laxative dependency). Health Canada is warning Canadians not to use the unauthorized product, Slim Magic Herbal Weight Loss, as it is found
to contain an undeclared pharmaceutical ingredient similar to sibutramine. YGD, a combination of Yerba Mat, Guarana, and Damiana in capsule form, was tested in a research study investigating weight loss and delayed gastric emptying. The study published in 2001, demonstrated signicant weight loss using YGD capsules compared to placebo after 45 days with patients maintaining weight loss while on maintenance treatment of YGD in an uncontrolled context. Delaying of gastric emptying was thought to be a signicant contributor to the weight loss.
Nursing Process
Assessment
Assess each overweight or obese patient for factors contributing to overweight and health risks related to excess weight, regardless of the reason for the contact. Some specic assessment factors include the following:
Assess usual drinking and eating patterns, including healthful (eg, whole-grain breads and cereals, fruits, vegetables, low-fat dairy products) and unhealthy (eg, sugarcontaining beverages and desserts, fried foods, saturated fat, fast foods, high-calorie snack foods) intake. The best way is to ask the patient to keep a food diary for 2 or 3 d. If food intake is not written down, people tend to underestimate the amount and caloric content. (If available, consult a nutritionist to assess a patients diet and work with the patient to improve health and weight status.) Assess any obviously overweight person for health problems caused or aggravated by excessive weight (eg, elevated blood pressure, other cardiovascular problems, diabetes mellitus, sleep apnea). Calculate or estimate the BMI (see Box 58-1) and measure waist circumference. Check available reports of laboratory tests. Overweight patients may have abnormally high values for total and LDL cholesterol, triglycerides, and blood sugar, and low values for high-density lipoprotein (HDL) cholesterol. If no laboratory reports are available, ask patients if a health care provider has ever told them that they have high cholesterol or blood sugar. List all prescription and non-prescription medications being taken and ask about vitamins, herbals, and other dietary supplements. Review the list for drugs used to treat health problems associated with obesity, drugs that may promote weight gain, and any products that may be used to promote weight loss. Assess usual patterns of physical activity and exercise, including work and recreational activities. Assess motivation to develop and adhere to a weightmanagement plan. Ask if there are concerns about weight;
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if there is interest in a weight-management program to improve health; and what methods, over-the-counter products, or herbal or dietary supplements have been previously used to reduce weight, if any. The nurse must be very tactful in eliciting information and assessing whether a patient would like assistance with weight management. If the nursepatient contact stems from a health problem caused or aggravated by excessive weight, the nurse may use this information to help motivate the patient to lose weight and improve health.
snack foods readily available, frequently eating at fast-food restaurants).
Promote exercise and activity. For overweight and obese patients, exercise may decrease appetite and distract from eating behaviours as well as increase calorie expenditure. For very sedentary, physically unt patients, emphasize that any exercise can be benecial and to start slowly, increasing the amount and intensity as physical condition improves. Encourage any efforts toward improving diet and increasing exercise to improve health. Weigh patients at regular intervals and measure waist circumference periodically. Refer patients to a dietitian when indicated. Be alert for the psychological consequences of obesity and refer patients for counselling if indicated. Refer overweight and obese children to pediatric obesity specialists when possible.
Nursing Diagnoses
Imbalanced nutrition: More than body requirements related to excessive caloric intake Disturbed body image related to excessive weight gain Decient knowledge: Weight management, participation in physical activity
Planning/Goals
The patient will
Evaluation
Reduce the impact of excessive weight on chronic health problems Modify lifestyle behaviours toward weight loss and weight maintenance at a more healthful level Increase participation in physical activities Take anorexiant drugs only as prescribed Describe problems associated with unproven weight-loss dietary supplements
Assess overweight or obese patients for food intake, weight loss, decreased waist circumference, and appropriate use of exercise and anorexiant drugs.

In addition to proper administration of her medication, what strategies should you review with Ms. McKay to assist her in being successful with weight loss?
Interventions
Support programs/efforts to help promote a healthful lifestyle and prevent obesity (eg, in families and schools). Serve as a role model by maintaining a healthful lifestyle and weight. Serve as a reliable source of information about weight loss, weight-loss products and programs, and physical activity (see accompanying Patient Teaching Guidelines). For an obese patient who reports interest and motivation in losing weight, assist to formulate realistic goals. Patients often expect to rapidly lose large amounts of weight with little or no effort. Most treatment programs result in a weight loss of 10% of body weight or less. Discuss health risks of obesity and anticipated benets of achieving and maintaining a healthier weight. Emphasize that losing 5%10% of body weight is a reasonable goal and can signicantly reduce the medical problems associated with being overweight. Assist patients to identify factors that support weight-loss efforts (eg, family and friend encouragement) and factors that sabotage weight-loss efforts (eg, having high-calorie
Principles of Therapy
Strategies to Prevent Becoming Overweight and Obese
Preventing excessive weight gain is a major struggle for many Canadians as they ght the battle of the bulge daily. Many people want to lose weight, often more for appearance than for health. However, many are also unwilling or unable to adapt their lifestyles toward more healthful eating, exercising, and weight-controlling habits. As a result, millions of dollars are spent annually on weight-loss diets, products, and programs in an effort to nd an easy way to lose weight. Health care providers need to promote efforts to prevent overweight and obesity when possible. When prevention is not possible, efforts should be aimed toward early recognition and treatment, before obesity and major health problems develop. Some strategies include the following:
Personally practice a healthful lifestyle, primarily for ones own health and well-being, but also to serve as a role model and proponent for healthful practices in daily life.
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Weight Management and Drugs That Aid Weight Loss

General Considerations

Because of the extensive health problems associated with overweight and obesity, individuals whose weight is within a normal range should try to prevent excessive weight gain by practicing a healthful lifestyle in terms of diet and exercise. Following are useful recommendations: 1. Eat a variety of foods daily (eg, 68 servings of grain products; 710 servings/d of vegetables and fruit; milk products, servings/d: children 49 y: 2, youth 918 y: 34, adults: 2; meat and alternatives, 23 servings/d). Also limit the intake of saturated fat (eg, in meats), trans fats (eg, hydrogenated oils in many commercial baked goods and other products), cholesterol, added sugars, salt, and alcohol. The amount of trans fat in commercial products must be added to the Nutrition Facts label and many manufacturers are reformulating their products without trans fats. Canola oil and olive oil are healthy fats, but they have a high calorie content (120 cal/tablespoon [15 mL]), which must be considered in weight control efforts. 2. To maintain body weight in a healthy range, balance diet (ie, calories gained) with exercise (ie, calories used). To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase physical activity. Engage in regular physical activity and reduce sedentary activities to promote health, psychological well-being, and a healthy body weight. To reduce the risk of chronic disease, engage in at least 3060 min of moderate-intensity physical activity, above usual activity, at work or home on most days of the week. For most people, greater health benets can be obtained by engaging in physical activity of more vigorous intensity or longer duration. 3. Physical tness can be developed or improved by including cardiovascular conditioning, stretching exercises for exibility, and resistance exercises or calisthenics for muscle strength and endurance. Individuals who are already overweight or obese should try to lose weight and maintain a lower weight because the likelihood of serious health problems and early death increases as weight increases. However, try to emphasize goals for improvement in health status rather than losing a large amount of weight. Remember that even a modest weight loss of 4.513 kg (1030 lb) can benet your health. Most people are unlikely to achieve their ideal weight, and having unrealistic expectations sets one up for failure in any weight-loss program. Obesity is considered a chronic disease that requires longterm treatment, much like the treatment of diabetes and hypertension. Weight loss can be induced by severe calorie restriction, but without lifestyle changes (eg, in eating and activity behaviour), body fat is invariably regained. The safest and most effective way to lose weight and keep it off is permanent lifestyle changes that involve eating less and exercising more. Reducing caloric intake by 5001,000 cal/d allows the loss of 0.51 kg (12 lb) of fat/week, respectively. Higher levels of physical activity can help with weight loss and prevent weight regain. Additional health benets include lower rates of cardiovascular disease and death.
Use available resources. For example, if unable to implement needed changes alone, consult a dietitian, qualied obesity expert, or behavioural therapist. Such clinicians can help modify the eating, activity, and thinking habits that predispose to obesity. In addition to feeling better, health benets of weight loss may include reduced blood pressure, reduced blood fats, less likelihood of having a heart attack or stroke, and less risk for development of diabetes mellitus. Any weight loss program should include a nutritionally adequate diet with decreased calories and increased exercise. Regular physical examinations and follow-up care are needed during weight loss programs. Although many weight-loss supplements are available and heavily advertised in newspapers, magazines, and television, none are considered safe and effective and none are recommended for use. If you do choose to use any of these products, notify your primary health care provider. Depending on your condition (ie, whether you have chronic health problems such as diabetes mellitus, hypertension, or others), the medications you take, and so forth, some weightloss supplements can be harmful to your health. Diet and exercise are recommended for people who want to lose weight. Medications to aid weight loss are usually recommended only for people whose health is endangered (ie, those who are overweight and have other risk factors for heart disease and those who are obese). Read package inserts and other available information about the drug being taken, who should not take the drug, instructions and precautions for safe usage, and so forth. Keep the material for later reference if questions arise. If unclear about any aspect of the information, consult a health care provider before taking the drug. Appetite-suppressant drugs must be used correctly to avoid potentially serious adverse effects. Because most of these drugs stimulate the heart and the brain, adverse effects may include increased blood pressure, fast heartbeat, irregular heartbeat, heart attack, stroke, dizziness, nervousness, insomnia (if taken late in the day), and mental confusion. In addition, prolonged use of prescription drugs may lead to psychological dependence. Avoid over-the-counter decongestants, allergy, asthma, and cold remedies, and weight-loss herbal or dietary supplements when taking a prescription appetite suppressant. The combination can cause serious adverse effects from excessive heart and brain stimulation. Inform health care providers when taking an appetite suppressant, mainly to avoid other drugs with similar effects. Orlistat (Xenical) is not an appetite suppressant and does not cause heart or brain stimulation. It works in the intestines to keep fats in foods from being absorbed. It should be taken with a low-fat diet. Adverse effects include fatty stools and bloating.
Self-Administration
Take appetite suppressants in the morning to decrease appetite during the day and avoid interference with sleep at night.
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Do not crush or chew sustained-release products. With sibutramine (Meridia) Take once daily, with or without food. Have blood pressure and heart rate checked at regular intervals, eg, monthly (the drug increases them). Notify a health care provider if a skin rash, hives, or other allergic reaction occurs. With orlistat (Xenical)
Take one capsule with each main meal or up to 1 h after a meal, up to three capsules daily. If you miss a meal or eat a meal with no fat, you should omit a dose of orlistat. Take a multivitamin containing fat-soluble vitamins (A, D, E, and K) daily, at least 2 h before or after taking orlistat. Orlistat prevents absorption of fat-soluble vitamins from food or multivitamin preparations if taken at the same time.
Provide or assist others to obtain reliable information about healthful lifestyle habits. For example, Health Canada publishes Eating Well with Canadas Food Guide and Canadian Guidelines for Healthy Weights as well as numerous other guides related to healthy living and physical activity, which are available online at http://www.hc-sc.gc.ca. The WHO Weight Classication System uses similar categories to assess weight. Selected recommendations include the following:
Box 58-4
Web Sites for Information on Nutrition and Weight Loss
Eat a variety of foods from each food group daily (eg, 6 to 8 servings per day of whole-grain bread and cereals; 7 to 10 servings per day of vegetables and fruit; 2 servings per day of milk products for adults; 2 to 3 servings per day of meat and alternatives). Also limit intake of saturated fat (eg, in meats, cheeses), trans fats (eg, hydrogenated oils in many baked goods), cholesterol, added sugars, salt, and alcohol. Nutrition labelling became mandatory for most prepackaged foods in December, 2005, and the list of ingredients and any health claims must be listed. For example, the amount of trans fat in commercial products must be listed on the label, moving many manufacturers to reformulate their products without trans fats. Canola oil and olive oil are healthy fats, but they have 120 cal per tablespoon, which must be considered in weight-control efforts). To maintain body weight in a healthy range, balance diet (ie, calories gained) with exercise (ie, calories used). To prevent gradual weight gain over time, make small decreases in food and beverage calories and increase physical activity. Engage in regular physical activity and reduce sedentary activities to promote health, psychological well-being, and a healthy body weight. To reduce the risk of chronic disease, engage in at least 30 to 60 minutes of moderate-intensity physical activity, above usual activity, at work or home on most days of the week. For most people, greater health benets can be obtained by engaging in physical activity of more vigorous intensity or longer duration. For further information on physical activity see http://www.phac-aspc.gc.ca.
Alberta Agriculture, Food, and Rural Development (www.agric.gov.ab.ca) Canadian Institutes of Health Research (CIHR) Obesity Research in Canada (www.cihr.irsc.gc.ca/e/20406.html) Canadian Inventory of Nutrition and Dietetic Associated Research (www.dietitians.ca) Canadian Medical Association (www.cmaj.ca/misc/obesity/ index.shtml) Centre for Chronic Disease Prevention and Control (www.phac-aspc.gc.ca/ccdpc-cpcmc/) Health Canada (www.hc-sc.gc.ca/index-eng.php) Food Safety Network (www.foodsafetynetwork.ca) International Obesity Task Force (www.iotf.org) National Centre for Complementary and Alternative Medicine (NCCAM) (www.nccam.nih.gov) National Heart, Lung, and Blood Institute and the North American Association for the Study of Obesity. The Practical Guide: Identication, Evaluation, and Treatment of Overweight and Obesity in Adults (www.nhlbi.nih.gov/guidelines/obesity/practgdc.htm) National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Disease: Weight Control Network (www.niddk.nih.gov/HealthEducation/ HealthNutrition.htm) Natural Medicines Comprehensive Database (www.naturaldatabase.com) RNAO Nursing Best Practice Guidelines Program (www.rnao.org) Weight Watchers (www.weightwatchers.ca/Index.asp)
Management of Overweight and Obese Patients

Treatment options for obesity include diet, exercise, behavioural modication, drug therapy, and, if these options fail, possibly referring a patient for bariatric (weight-loss) surgery. The safest and most effective treatment for most people usually includes a combination of diet, exercise, and behavioural modication. Drug therapy and bariatric surgery are recommended only for
In addition to these recommendations, many books, magazine and newspaper articles, and Internet sites (Box 58-4) contain useful information. However, all of these resources are not equally reliable; they must be carefully evaluated.
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seriously overweight people with major medical problems that can be improved by weight loss. In addition, neither of these treatments is a substitute for the necessary changes in eating and physical activity patterns. The Centre for Chronic Disease Prevention and Control (CCDPC) provides recommendations for prevention and control of a range of chronic diseases. Recommendations include the following:
After weight loss, weight-loss maintenance with dietary therapy, physical activity, and behaviour therapy should be continued indenitely. Drug therapy can also be used, but the Public Health Agency of Canada, CCDPC, does not suggest using this therapy.
Weight loss to reduce health problems of individuals: decrease blood pressure if hypertensive; lower elevated levels of total cholesterol, LDL cholesterol, and triglycerides, and raise low levels of HDL cholesterol if dyslipidemic; lower elevated blood glucose levels in persons with type 2 diabetes. Use the BMI to assess overweight and obesity and estimate disease risks. Measure waist circumference initially and periodically to assess abdominal fat content. Weigh regularly to monitor body weight for gain, loss, or maintenancewhether or not the person is involved in a weightloss program. The initial goal of weight-loss therapy should be to reduce body weight by about 10 percent from baseline, at a rate of 0.05 to 1 kg (1 to 2 lb) per week for a period of 6 months. It is important to determine if the goal is realistic and if the goal can be maintained. A 4.5 kg weight loss has important effects on blood pressure and lipid values. Steady weight loss over a longer period reduces fat stored in the body, limits the loss of vital protein tissues, and avoids the sharp decline in metabolic rate that accompanies rapid weight loss. After weight loss, weight maintenance should be the priority goal because weight regain is a problem with all weight-loss programs. In some cases, after a period of weight maintenance, additional losses may be desirable. Dietary recommendations include creating an energy decit based on restricted energy intake or energy expenditure or both. Low-calorie diets for weight loss reduce caloric intake by 500 to 1,000 cal daily. A moderate decit diet of 1,200 to 1,500 kcal per day for females and 1,400 to 2,000 kcal per day for males is suggested. Reducing dietary fat can reduce calories. However, reducing dietary fat without reducing total caloric intake does not produce weight loss. Vitamin and mineral supplements that meet age-related requirements are usually recommended with weight-loss programs that provide less than 1,200 kcal for women or 1,800 kcal for men. Physical activity recommendations should be part of any weight-management program because physical activity contributes to weight loss, may decrease abdominal fat, increases cardiorespiratory tness, and helps with weight maintenance. Initially, physical activity for 30 to 45 minutes, 3 to 5 days a week, is encouraged. Long-term, adults should try to accumulate at least 30 minutes or more of moderate-intensity physical activity on most days of the week. In general, lifestyle change strategies support decreased food intake, increased physical activity, and behaviour programs.
Behavioural modication is an integral part of a weightloss program. The goals of behavioural programs are to help patients modify their eating, activity, and thinking habits that predispose to obesity. Techniques include identifying triggers that promote overeating and barriers that keep one from adopting a more healthful lifestyle. One strategy is keeping an accurate record of food/calorie intake and physical activity (most people tend to underestimate food intake and overestimate activity). In addition, stress management with techniques such as relaxation and meditation, stimulus control, and social support for reinforcement of positive changes are helpful. Patients who eat more when stressed can learn to manage stress more healthfully. Counselling by a behavioural therapist may be needed. Stimulus control has to do with avoiding or minimizing circumstances that promote overeating (eg, cooking calorie-dense foods; having high-calorie snacks and junk food readily available; eating high-fat, high-calorie foods at fast-food restaurants). Social support involves family, friends, coworkers, and fellow dieters who encourage weight-loss efforts rather than sabotage them by urging one to eat high-calorie foods. In general, weight-loss regimens that use several of these strategies seem to be most effective.
In addition to the CCDPC guidelines, additional recommendations and comments include the following:
Emphasize health benets of weight reduction. There is strong evidence that weight loss reduces risk factors for cardiovascular disease, including blood pressure, serum triglycerides, and total and LDL cholesterol. It also increases HDL cholesterol. In addition, in overweight and obese people without diabetes, weight loss reduces blood glucose levels and the risk for development of type 2 diabetes. For people who already have type 2 diabetes, weight loss reduces blood levels of glucose and glycosylated (A1c) hemoglobin. These effects make the diabetes easier to manage, reduce complications of diabetes, and may allow smaller doses of anti-diabetic medications. For people who already have hypertension, losing excess weight reduces blood pressure and may reduce the number or amount of anti-hypertensive drugs. For people who already have dyslipidemias, blood lipid proles improve with weight loss. Weight-loss diets wax and wane in popularity with the North American public (Box 58-5). Although all of them can lead to weight loss if adhered to long enough, some are healthier than others, and most are discarded before signicant weight loss is achieved. Actually, any diet that reduces caloric intake in relation to caloric expenditure can lead to weight loss, and adherence is probably more important than the particular diet unless specic restrictions result in nutritional deciencies. Regardless of what some diet gurus and others say, total
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Box 58-5
Characteristics of Selected Diets

The Atkins diet is a high-fat, low-carbohydrate diet consisting of unlimited amounts of meat, sh, eggs, and some cheeses. Sweets, starchy snacks, many fruits, some starchy vegetables, and some grains are prohibited. The high-protein foods cause a feeling of satiety with less food, so fewer calories are consumed. Also, during the rst 10 d of this diet, ketosis is induced (by burning fat for energy when carbohydrates are not available). Ketosis increases water loss, which can cause rapid weight loss initially. Then, weight loss occurs more slowly. The main premise of this diet is that carbohydrates increase insulin levels and induce metabolic changes that cause weight gain. Although the Atkins diet seems to cause more short-term weight loss than traditional low-fat diets, weight loss is similar with the two diets after a year. The South Beach diet is an adaptation of the Atkins diet. This diet emphasizes good versus bad carbohydrates and the glycemic index. The glycemic index indicates the effect of foods on blood glucose levels. Some carbohydrates with a high glycemic index (eg, potatoes, pasta, white rice, white bread) can increase blood glucose as much as or more than similar amounts of sucrose. The elevated blood sugar level stimulates increased insulin secretion and leads to excessive insulin in the blood. In general, high glycemic index foods are thought to promote fat accumulation and obesity. Low glycemic index foods are digested and absorbed more slowly, do not produce surges in blood glucose and blood insulin levels, and therefore are thought to promote weight control. Adverse effects of low-carbohydrate diets may include constipation, dehydration, electrolyte imbalance, headache, aggravation of renal impairment (increased breakdown of body protein and fat increases the workload of the kidneys), and hyperuricemia leading to gout. In addition, some people experience a worsening of blood lipid levels and one study of adolescents on a very low calorie, low-carbohydrate diet showed increased calcium excretion and decreased bone mineral content. This could lead to later development of osteoporosis.
Various diets all work if total caloric intake is less than energy expenditure. Many diets are quite restrictive, however, and most people soon drop out and rapidly regain the weight they lost. As a result, the best diet is nutritionally adequate except for calories and can be followed long term. Low calorie. These diets provide about 1,2001,600 kcal/d. The usual recommendation is to reduce caloric intake by 5001,000 cal daily, to allow weight loss of 0.51 kg weekly. This rate of loss is likely to be more successful in terms of weight loss, and continuing a reduced-calorie diet promotes weight maintenance rather than weight regain. Note that losing weight through diet alone, without increased physical activity, is unlikely to improve cardiovascular health. Very low calorie. These diets usually consist of 800 cal or fewer per day. Numerous commercial products that promise magical results have been marketed. These diets result in rapid initial weight losses due mainly to diuresis and loss of sodium and water. Multiple health risks accompany such diets, including abnormalities in electrolytes, trace elements, and vitamins; gout; gallstones; cold intolerance; fatigue; light-headedness; anemia; menstrual irregularities; and other problems. It is not recommended to use diets that provide fewer than 800 cal daily. If used at all, very low calorie diets should be used intermittently, for short periods, with a diet that maintains weight and is more nutritionally adequate. Low fat. These diets do not cause signicant weight loss unless caloric intake is reduced. Because fats are energy dense (9 cal/g), reducing fat is a practical way to reduce caloric intake. For both, health and weight loss, current recommendations emphasize reducing intake of bad fats (eg, saturated and trans fat) but including healthy monounsaturated and polyunsaturated fats (eg, olive and canola oil) within the caloric allotment. The weight loss that occurs with these diets is attributed to caloric reduction or water loss, rather than the carbohydrate restriction. There have been no studies evaluating the longterm safety of low-carbohydrate diets.
caloric intake must be considered because it is a major determinant of weight loss, gain, or maintenance.
Various formula diets or meal-replacement programs are available. The good ones contain high-quality protein, sugar as fructose, and a moderate amount of monounsaturated fat. The usual recommendation is to replace two meals daily for weight loss and one meal for weight maintenance. They can also be used as single meal replacements. Although both calorie-reduced diets and sufcient exercise can lead to weight loss and maintenance, the CCDPC guidelines are based on studies indicating that a combination of the two strategies is more effective than either alone. However, many overweight and obese people may be physically unt and unable or unwilling to increase activity. Thus, activity should be started slowly and gradually increased, with the goal of exercise becoming part of the daily routine.
Activities can include chair dancing, oor exercises, water aerobics, and swimming. Aerobic exercise increases the metabolic rate during and for approximately 1 hour after activity. Consistent adherence to a reduced-calorie diet and exercise routine is a major factor in achieving weight control and health benets.
For any patients following a weight-loss regimen, provide psychological support and positive reinforcement for efforts toward weight management. Programs or support groups involving supervision or regular participation within a social group appear to be more successful over time. Weight Watchers seems more successful than most other commercial programs; Overeaters Anonymous and Take Off Pounds Sensibly (TOPS) are large self-help support groups. For more information on commercial programs, see the accompanying Research Brief.
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Weight-loss medications are used in the treatment of obesity. When drug therapy is indicated, a single drug in the lowest effective dose is recommended. As with most other drugs, low doses decrease risks of adverse drug effects.
Commercial Weight-Loss Programs Source: Tsai, A. G., & Wadden, T. A. (2005). Systematic review: An evaluation of major commercial weight loss programs in the United States. Annals of Internal Medicine, 142(1), 5666. Summary: The authors evaluated published studies of medically based weight-loss programs (Health Management Resources and OPTIFAST), non-medical programs (Weight Watchers, Jenny Craig, and L. A. Weight Loss), very low calorie diets, commercial Internet-based programs (eDiets. com), and two non-prot self-help programs (Overeaters Anonymous and Take Off Pounds Sensibly). The studies included adults in the United States, had >10 participants, and lasted >12 weeks. Few high-quality studies were found; many presented the best-case scenario because they did not account for people who dropped out of the program. Of the programs evaluated, Weight Watchers had the strongest studies to support it. No high-quality studies of Jenny Craig or L. A. Weight Loss were found. The studies of the medically based very low calorie diets were of limited quality. Patients who stayed on the program lost substantial weight over 6 mo, but regained about half of the lost weight in 12 y; many dropped out. The few studies of Internet-based and self-help programs were of limited quality and found that these approaches produced minimal weight loss. Nursing implications: This information can be used to counsel patients who are considering a commercial weight-loss program. Except for Weight Watchers, the programs demonstrate little evidence of effectiveness. Costs vary but may be extensive. The Cochrane Central Register of Controlled Trials published a British study (2006) comparing Dr. Atkins diet, Slim-Fast plan, and Weight Watchers and Rosemary Conleys diets and all participants lost weight while on the diets. Clinically useful weight loss can be achieved in all who are motivated to adhere to a diet for a period of time.

Ms. McKay says she needs to lose 140 lb and would like to accomplish this by her next birthday. How should you respond?
Management of Obesity in Special Populations

Managing Obesity in Ethnic Populations
The WHO notes that while BMI and waist circumference are useful measures to provide meaningful comparisons within and between populations, caution must be exercised in applying this standard to all ethnic groups. The standards for waist circumference, in particular, were derived from a Caucasian population and, therefore, their application in other populations, especially in determining the level of risk of incurring disease, is problematic. Asian populations have been shown to differ in the level of risk associated with a specic waist circumference. For Chinese and Japanese populations, the WHO report notes that health risks occur at lower body fat levels and smaller waist circumferences than for Caucasians. South Asians (Indians) tend to have a more centralized distribution of body fat but may not be considered obese using BMI standards. It is also suggested that Asians who were born at a low birth weight and are obese as adults tend to develop metabolic syndrome, possibly related to genetics. The normal-weight BMI classication is considered between 18.5 and 22.9, with the waist circumference cutoff point of less than 90 cm for men and less than 80 cm for women, with an increased risk of comorbidities if waist circumference was beyond this point. This report also notes that the ethnic differences prevail in immigrant populations in industrialized countries. This report uses the WHO classication system, but different cutoff points. It is also questionable as to whether appropriate levels of risk can be assigned if First Nations populations are assessed using the standard BMI and waist circumference measures. Health Canada has produced a Canadas Food Guide tailored for First Nations, Inuit and Metis, providing them with necessary information on healthy living.
Managing Obesity in Children

Children in general need increased amounts of protein, carbohydrate, and fat in proportion to their size to support growth and increased physical activity. However, reports of childhood obesity have greatly increased over recent years, and childhood obesity has become a major public health concern. Therefore, the goal of nutrition is to meet needs without promoting obesity. When possible, specialists in childhood obesity should design and supervise treatment programs.
Efforts are needed toward both prevention and treatment of childhood obesity. Prevention should focus on identifying at-risk and overweight children and adolescents at an early stage, educating families about the health consequences of being overweight, and encouraging weight-control measures (eg, a more active lifestyle, a low-fat diet, regular meals, avoidance of snacking, drinking water instead of calorie-containing beverages, decreasing the time spent watching television and playing computer games, and walking instead of using a car for transportation). These measures are implemented successfully mainly within a family unit and family support is needed to assist the child in weight control and a more healthful lifestyle. In addition, schools should teach children the basic principles of good nutrition and why eating a balanced diet is important to health. Currently, an amended version of BMI is used for assessing pediatric overweight and obesity. This set of reference BMI
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values for children can be used cautiously with an awareness of its limitations. Pediatric clinicians recommend treatment for children and adolescents who are overweight and have complications of obesity, and for all children who are obese. Treatment of childhood obesity should focus on healthy eating and increasing physical activity. In general, children should not be put on diets. For a child who is overweight, the recommended goal is to maintain weight or slow the rate of weight gain so that weight and BMI gradually decline as the child grows in height. If the child has already reached his or her anticipated adult weight, maintenance of that weight and prevention of additional gain should be the long-term treatment goal. If the child already exceeds the optimal adult weight, the goal of treatment should be a slow weight loss of 10 to 12 lb per year until the optimal adult weight is reached. As with adults, increased activity is required for successful weight loss or management in children. Family involvement and support are vital to childrens weight management. Actually, the goal beyond weight control for a child is to develop healthier eating and exercise habits for long-term health benets for the entire family. Studies indicate that children who eat adequate amounts of fruits, vegetables, and dairy products tend to continue these healthy eating habits. In general, young children who learn to eat a healthy diet are likely to reap the benets throughout their lives. Improved diets and increased activity are unlikely to occur without active participation of parents and other caregivers.
Managing Obesity in Patients With Renal Impairment

In relation to drugs for obesity, little information is available about their use in patients with renal impairment. With sibutramine, dosage reductions are not recommended with mild to moderate impairment because the drug and its active metabolites are eliminated by the liver. However, some inactive metabolites are also formed and these are excreted renally. The drug is contraindicated in patients with severe renal impairment.
Managing Obesity in Patients With Hepatic Impairment

In relation to drugs for obesity, little information is available about their use in patients with hepatic impairment. Because sibutramine is metabolized in the liver, it is contraindicated in patients with severe hepatic impairment.
Managing Obesity in Home Care

The home care nurse may be involved with weight-management issues in almost any home care setting. Because nutrition, exercise, and weight control are so important to health, the home care nurse should take advantage of any opportunity for health promotion in this area. Health promotion may involve assessing the nutritional and tness status of all members of the household and providing counselling or other assistance to improve health status. Those who are obviously overweight or who have obesity-related health problems must be approached with diplomacy and tact; they have probably tried repeatedly to lose weight and been told by previous health care providers that they need to lose weight. The home care nurse should be able to provide accurate information about realistic and successful techniques for losing weight and keeping it off; health benets of even modest weight loss; and reasons to avoid fad diets, weight-loss herbal and dietary supplements, and programs that promise rapid and easy weight loss with little effort.
Managing Obesity in Older Adults

Overweight and obesity are common among older adults. Although caloric needs are usually decreased, primarily because of slowed metabolism and decreased physical activity, most people continue usual eating patterns. With the high incidence of atherosclerosis and cardiovascular disease in older adults, it is especially important that fat intake be reduced. The Public Health Agency of Canada promotes healthy active living in an aging society and has information at http://www.phac-aspc. gc.ca/pau-ap/paguide/older/phys_guide.html regarding endurance, exibility, and strength and balance to maintain health and independence. Anorexiant drugs should be used very cautiously, if at all, because older adults often have cardiovascular, renal, or hepatic impairments that increase risks of adverse drug effects.

How Can You Avoid This Medication Error? Ms. McKays prescription is for orlistat (Xenical) three times a day. She takes the dose with breakfast, lunch, and dinner. She has a meeting today that runs through lunch and so she skips lunch but takes her pill on time.
D r u gs for We i ght L oss an d M ai nte nanc e

NURSING ACTIONS 1. Administer accurately
a. With phentermine (1) Give single-dose drugs in the early morning. (2) Give multiple-dose preparations 30 min before meals and the last dose of the day about 6 h before bedtime. b. With sibutramine, give once daily in the morning.
For maximum appetite-suppressant effects during the day, For maximum appetite-suppressant effects at mealtime and to avoid interference with sleep from the drugs stimulating effects on the CNS.
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Dr ugs for We i ght L oss an d M ai nte nance

NURSING ACTIONS
c. With orlistat, give one capsule with each main meal or up to 1 h after a meal, up to three capsules daily. If a meal is missed or contains no fat, the dose should be omitted.
( c o ntinu ed )
The drug needs to be in the gastrointestinal tract when fat-containing foods are eaten, to prevent fat absorption.
2. Assess for therapeutic effects

a. With phentermine and sibutramine, assess for decreased caloric intake and weight loss. b. With orlistat, assess for weight loss and improvements in health status (eg, reduced LDL cholesterol, elevated HDL cholesterol, improved glycemic control, reduced blood pressure). The recommended rate of weight loss is 0.51 kg (12 lb) weekly. Most weight loss occurs in the rst 6 mo of therapy, but the reduced weight can be maintained as long as orlistat is continued. The metabolic improvements are very benecial for people with obesity-related health problems such as diabetes, dyslipidemia, hypertension, and metabolic syndrome.
3. Assess for adverse effects

a. With phentermine and sibutramine, assess for (1) Nervousness, insomnia, and hyperactivity These effects result from excessive stimulation of the CNS. They are more likely to occur with large doses or too-frequent administration. Anorexiant drugs stimulate the sympathetic nervous system and may cause or aggravate hypertension. This usually occurs within 46 weeks and is an indication for discontinuing drug administration. Continued administration and/or large doses do not maintain appetite-suppressant effects. Instead, they increase the incidence of adverse effects. These effects commonly occur. They usually improve within a few weeks of continued drug use, but worsen with a high intake of dietary fat, which should be avoided.
(2) Hypertension (3) Development of tolerance to appetite-suppressant effects
b. With orlistat, assess for abdominal cramping, gas pains, diarrhea, and fatty stools.
4. Assess for drug interactions

a. Drugs that increase effects of phentermine and sibutramine: (1) Anti-depressants (tricyclic) (2) Other CNS stimulants (3) Other sympathomimetic drugs (eg, epinephrine) b. Drugs that decrease effects of phentermine and sibutramine: (1) Anti-hypertensive drugs (2) CNS depressants (eg, alcohol) c. Drugs that increase effects of sibutramine: (1) Adrenergics (eg, epinephrine, pseudoephedrine) (2) Anti-depressants (tricyclic anti-depressants [TCAs; eg, amitriptyline], SSRIs [eg, uoxetine]) May increase hypertensive effects Additive stimulant effects Additive hypertensive and other cardiovascular effects
Decrease blood pressureraising effects of anorexiants Antagonize or decrease effects Additive increases in blood pressure TCAs and sibutramine increase levels of norepinephrine and serotonin in the brain; SSRIs increase serotonin levels. Concurrent use of these drugs may cause excessive CNS stimulation, hypertension, and serotonin syndrome and should be avoided. Decrease metabolism and may increase adverse effects and toxicity of sibutramine Additive serotonin effects Additive serotonin effect
(3) Anti-fungals (eg, itraconazole and related azoles) (4) Anti-migraine triptans (eg, sumatriptan) (5) Lithium
Applying Your Knowledge Answers

58-1
Orlistat works by blocking the fat absorbed from the intestine. This drug will block approximately 30% of the fat ingested in a meal. It is important to teach that increasing the dose will not increase the percentage of fat blocked. This drug also blocks the absorption of fat-soluble vitamins, so you should advise Ms. McKay to take a multivitamin at a different time than the orlistat.
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58-2
Strategies should include the practice of a healthy lifestyle by eating a variety of foods daily and by eating a diet rich in whole grains, vegetables, and lowfat dairy products. Limit the intake of saturated fat, trans fat, cholesterol, added sugars, salt, and alcohol. Ms. McKay must also include some regular physical activity. The initial goal of weight-loss therapy should be to reduce body weight by about 10% from baseline and to
lose weight at a rate of 0.51 kg/week for the rst 6 mo. Assist Ms. McKay to set a realistic and healthy goal.
58-4
The dose of orlistat should not be taken if the patient misses a meal. Teach Ms. McKay to omit the dose if a meal is omitted.
58-3
Key Concepts
Overweight and obesity are major concerns because of their association with numerous health problems, including diabetes, hypertension, other cardiovascular disorders, and muscles and joint disorders. Ingesting 500 cal more per day than those used in exercise and physical activity leads to a weight gain of 1 lb in 1 week; decreasing caloric intake or increasing caloric output of 500 cal/d for 1 week leads to a weight loss of 1 lb.
Reducing caloric intake and increasing caloric expenditure are part of any successful weight-loss program. Weight-loss drugs are generally recommended only for people who are seriously overweight or have health problems associated with or aggravated by obesity. Many people lose weight but regain it within a few months if they do not change their lifestyle habits toward eating more healthfully and exercising more.
Review and Application Exercises

Short Answer Exercises
1. Calculate the BMI for yourself, one or more members of your family, or a patient. 2. Assess eating and physical activity habits of yourself, one or more members of your family, or a patient. In general, do these habits promote health or obesity? 3. If you, the family member, or the patient has health problems related to overweight and obesity, list at least three things that can be done to improve health. 4. Debate whether or not it is important that health care providers demonstrate healthful practices in diet, exercise, and weight control to the general public. 5. With an overweight or obese patient who wants to lose weight, what are some nursing interventions to assist and support the patient? 6. List the advantages and disadvantages of drug therapy for weight loss or maintenance. 8. Which of the following statements would indicate a need for drug therapy for weight management? a. A BMI of 22 and a desire to lose 10 lb b. A BMI of 24.5 and physically t c. A BMI of 27 or more with weight-related health problems d. A BMI of 2529 and healthy 9. For which of the following disorders would sibutramine (Meridia) be contraindicated? a. Cardiovascular disease b. Diabetes mellitus c. Chronic fatigue syndrome d. GERD 10. Which of the following statements describes how orlistat (Xenical) aids weight loss? a. Decreasing appetite b. Increasing satiety and feelings of fullness c. Increasing metabolism d. Decreasing absorption of dietary fat 11. Which of the following strategies should be taught to a patient to decrease diarrhea when taking orlistat (Xenical)? a. Avoid large amounts of fatty foods. b. Drink eight glasses of water daily. c. Avoid caffeine-containing beverages. d. Increase physical activity.
CRNE-Style Questions
7. Which of the following is a characteristic of low-calorie or reduced-calorie diets? a. They provide about 5001,000 kcal/d. b. They reduce daily intake by about 1,600 kcal/d. c. They are required for weight loss. d. They focus on high-fat, high-carbohydrate foods.
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Selected References
Anderson, T., & Fogh, J. (2001). Weight loss and delayed gastric emptying following a South American herbal preparation in overweight patients. Journal of Human Nutrition and Dietetics, (14)3, 243250. Belanger-Ducharme, F., & Tremblay, A. (2005). Prevalence of obesity in Canada. The International Association for the Study of Obesity, 6, 183186. Canadian Pharmacists Association. (2009). Compendium of pharmaceuticals and specialties. Ottawa, ON: Author. Dennis, K. E. (2004). Weight management in women. Nursing Clinics of North America, 39, 231241. Endocrine and metabolic disorders: Obesity. Accessed at NurseONE, Dr. H. K. Mussallem eLibrary, eTherapeutics, May 27, 2009. Facts & Comparisons. (Updated monthly). Drug facts and comparisons. St. Louis, MO: Author. Health Canada. (2006). Its your health: Obesity. Retrieved May 21, 2009 from http://www.hc-sc.gc.ca/hl-vsfn-an/food guide-ailment/ index-eng.php Health Canada. (2007). Eating well with Canadas food guide. Retrieved May 21, 2009 from http://www.hc-sc.gc.ca/fn-an/food guideailment/index-eng.php Health Canada. (2007). Eating well with Canadas food guide: First Nations, Inuit and Metis. Retrieved May 21, 2009 from http: //www.hc-sc.gc.ca/hl-vs/alt_formats/pacrb-dgapar/pdf/iyh-vsv/life-vie/ obes-eng.pdf Institute of Wellbeing. (2009). How are Canadians really doing? Accessed June 28, 2009, www.ciw.ca Kkuhnlein, H. V., Receveur, O., Soueida, R., et al. (2004). Arctic indigenous peoples experience the nutrition transition with changing dietary patterns and obesity. The American Society for Nutritional Sciences Journal of Nutrition, 134, 14471453. LaQuatra, I. M. (2004). Nutrition for weight management. In L. K. Mahan, & S. Escott-Stump (Eds.), Krauses food, nutrition and diet therapy (11th ed., pp. 558593). Philadelphia, PA: W. B. Saunders. Luo, W., Morrison, H., deGroh, M., et al. (2007). The burden of adult obesity in Canada. Chronic Diseases in Canada, 27(4), 135143. Pereira, M., Kartashov, A. I., Ebbeling, C. B., et al. (2005). Fast-food habits, weight gain, and insulin resistance (the CARDIA study): 15-year prospective analysis. Lancet, 365(9453), 3642. Pleuss, J. (2005). Alterations in nutritional status. In C. M. Porth (Ed.), Pathophysiology: Concepts of altered health states (7th ed., pp. 217 238). Philadelphia, PA: Lippincott Williams & Wilkins. Pronsky, Z. M., & Crowe, J. P. (2004). Food-drug interactions. In L. K. Mahan, & S. Escott-Stump (Eds.), Krauses food, nutrition and diet therapy (11th ed., pp. 455474). Philadelphia, PA: W. B. Saunders. Public Health Agency of Canada (PHAC). (2003). Physical activity unit. Retrieved May 22, 2009, from http://www.phac-aspc.gc.ca/pau-uap/ paguide/index.html Public Health Agency of Canada (PHAC). (2003). The healthy heart kit. Retrieved May 21, 2009, from http://www.phac-aspc.gc.ca/ ccdpc-cpcmc/hhk-tcs/english/index_eng.php Saper, R. B., Eisenberg, D. M., & Phillips, R. S. (2004). Common dietary supplements for weight loss. American Family Physician, 70(9), 17311738. Smeltzer, S. C., & Bare, B. G. (2004). Brunner & Suddarths textbook of medical-surgical nursing (10th ed.). Philadelphia, PA: Lippincott Williams & Wilkins. Van Gall, L. F., Rissanen, A. M., Scheen, A. J., et al. for the RIOEurope Study Group. (2005). Effects of the cannabinoid-1 receptor blocker rimonabant on weight reduction and cardiovascular risk factors in overweight patients: 1-year experience from the RIO-Europe study. The Lancet, 365, 13891397. Waitman, J. A., & Aronne, L. J. (2004). Pharmacological treatment. In G. D. Foster, & C. A. Nonas (Eds.), Managing obesity: A clinical guide (pp. 151157). Chicago, IL: American Dietetic Association. World Health Organization. (1998). Obesity: Preventing and managing the global epidemic: Report of a WHO consultation on obesity. Geneva: WHO. Retrieved May 21, 2009, from http://www.whqlibdoc.who.int/trs/ who_trs_894.pdf Yancy, W. S. Jr., Olsen, M. K., Guyton, J. R., et al. (2004). A low-carbohydrate, ketogenic diet versus a low-fat diet to treat obesity and hyperlipidemia: A randomized, controlled trial. Annals of Internal Medicine, 140(10), 769777.

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CHAPTER

Nutritional Support Products, Vitamins, and MineralsElectrolytes

1. Assess patients for risk factors and manifestations of protein-calorie

2. Identify patients at risk for development of vitamin and/or mineral

Applying Your Knowledge

Chapter 57 Nutritional Support Products, Vitamins, and MineralsElectrolytes

Nutritional Deciency States

Liquid Enteral Products

Dietary Reference Intakes

Section 9 Drugs Affecting the Digestive System

Dietary Reference Intakes (continued)

Chapter 57 Nutritional Support Products, Vitamins, and MineralsElectrolytes

SIGNS AND SYMPTOMS OF EXCESS

Fatigue, nausea, headache, blurred vision, and diarrhea

Vitamin D (see Chap. 25)

Section 9 Drugs Affecting the Digestive System

SIGNS AND SYMPTOMS OF EXCESS

Chapter 57 Nutritional Support Products, Vitamins, and MineralsElectrolytes

SIGNS AND SYMPTOMS OF DEFICIENCY

SIGNS AND SYMPTOMS OF EXCESS

Flushing; pruritus; hyperglycemia; hyperuricemia; and increased liver enzymes

No deciency state established

(continued on page 908)

Section 9 Drugs Affecting the Digestive System

SIGNS AND SYMPTOMS OF EXCESS

Thiamine (B1) A coenzyme in carbohydrate metabolism; essential for energy production

Chapter 57 Nutritional Support Products, Vitamins, and MineralsElectrolytes

Drugs at a Glance: Vitamin Drug Preparations

Vitamin E Vitamin K (Phytonadione, Mephyton)

(continued on page 910)

Section 9 Drugs Affecting the Digestive System

Drugs at a Glance: Vitamin Drug Preparations (continued)

Pyridoxine (Vitamin B6)

525 mg daily for 3 weeks then 1.52.5 mg daily

Riboavin (Vitamin B2)

Deciency, PO 530 mg daily in divided doses

Thiamine hydrochloride (Vitamin B1) Vitathion-ATP

VITAMIN C Vitamin C (ascorbic acid)

100300 mg in divided doses

Chapter 57 Nutritional Support Products, Vitamins, and MineralsElectrolytes

Minerals and Electrolytes

(continued on page 912)

Section 9 Drugs Affecting the Digestive System

Minerals and Electrolytes (continued)

SIGNS AND SYMPTOMS OF DEFICIENCY

SIGNS AND SYMPTOMS OF EXCESS

Brewers yeast and

Chapter 57 Nutritional Support Products, Vitamins, and MineralsElectrolytes

RECOMMENDED LEVELS OF INTAKE

SIGNS AND SYMPTOMS OF DEFICIENCY

SIGNS AND SYMPTOMS OF EXCESS

Mottling of teeth and osteosclerosis

Iodine Essential component of thyroid hormones

Thyroid gland enlargement; possible hypothyroidism

(continued on page 914)

Section 9 Drugs Affecting the Digestive System

Minerals and Electrolytes (continued)

SIGNS AND SYMPTOMS OF DEFICIENCY

SIGNS AND SYMPTOMS OF EXCESS

Selenium Important for function of myocardium and probably other muscles

Fish, meat, breads, and cereals

Chapter 57 Nutritional Support Products, Vitamins, and MineralsElectrolytes

Chelating Agents (Metal Antagonists)

Agents Used in Mineral Electrolyte Imbalances