Calories, vitamins and supplements

“Could you please stop washing my suit?” I asked my wife. “It’s shrinking, and I can’t get into it.” She looked at me from across the room, glowering (a great Scottish word meaning ‘with contemptuous anger’), and said: “I don’t wash suits. You are fat and ugly, go do something about it.” I protested, and described my well-balanced diet (bread, biscuits, pasta, pizza, potatoes, rice, beer, wine and candy). “Balanced on the edge of the abyss,” she replied. “So, what do other people eat?” I asked, and I learned about salads, and fish-meat-chicken, bacon-and-egg, cheese and nuts. “You have a sedentary job, it’s diet or surgery, take it or leave it,” she said. “You will never make it to the gym.” For two months, I gave up my favourite foods, my alcohol (replaced by diet ginger-ale) and my stress-eating. I lost 20 pounds. Colleagues asked if I had cancer. Read: The heart's rhythm and blues What I thought were 12-pack abs disappeared, as did my need for a belt. I learned that sugar is added to mostly everything these days, so steer clear of the centre aisles at the food market. I realized I knew very little about nutrition, yet most of my patients’ malaise was obesity-driven (diabetes, hypertension, sleep apnoea, large joint arthritis, etc.). I never got taught about nutrition in med school, except in the canteen. I saw malnutrition in Africa, in my last year of training. Diseases with tropical names, like pellagra, beri-beri and kwashiorkor. And just plain total calorie deficit. Kids came to our little hospital, behind on diet, further compromised by infection (malaria, hookworm, etc.). We gave them nasogastric feeding tubes, and supplemented them with SSO (salt, sugar, oil). The response was dramatic. When I ran an intensive care unit, supplementing caloric intake was routine in post-op patients (some who hadn’t eaten well for weeks). I wasn’t afraid to prescribe TPN to those with recovering guts. One case comes to mind. It was a long time ago. I was running an ICU in a small community hospital in B.C. My patient, Jack Johnson, was sick, recovering from a bowel resection (adhesions). He was malnourished and weak, he was on ventilator support post-op. I was a firm believer in feeding people. This guy was written up for TPN, which I ordered in a standard fashion, and it was taxied over from the larger hospital’s pharmacy, 30 minutes away. But there was something odd about Jack. His serum albumin didn’t budge from 22. His other tests were satisfactory, and he was weaning from the ventilator, but he didn’t look like someone getting FED. He remained cachexic, weak, ill—despite pretty aggressive management with ventilation, antibiotics, fluid management and great nursing care. I began thinking about hypothyroidism, hepatic dysfunction, hidden sepsis, toxidromes, etc. At one point, I said, “Is this TPN doing what it should?” I found out that it didn’t contain Selenium, a trace element. I had to request it specifically, I found out. 1 Selenium. What the heck is selenium? A trace element that supports endocrine, immune and cardiovascular health. It can be low in malnourished patients, or those with gut disease. That should be supplemented, I thought. I ordered TPN+Selenium, and watched to see what would happen. Miraculously, albumin levels rose, renal function stabilized and the patient quickly weaned. Now I am a sceptic when it comes to additives, but there is no doubt something good happened to this chap when we put Selenium in his TPN. It made me think, “What else do we not consider in such patients?” It pays to ‘Se….’ beyond the routine. There are canaries out there. I was interested in what Bill Bryson had to say about vitamins. It is a $40 billion industry in the U.S., no doubt driven by ‘alternative-ism,’ ‘pills-are-good/Pharma-is-bad-ism.’ But most supplements are superfluous in the famine-free developed world (unless you are alcoholic or vegan). What should I be taking, then, if anything? We have some great doctors to acknowledge, like Ancyl Keyes (the Stanford nutritionist and Nobel prize winner whose name became forever linked to soldier’s food boxes—K rations). And to the double Nobel laureate, Linus Pauling, who gave people the (erroneous) impression high doses of vitamin C could retard the common cold and cancer. The evidence today supporting the use of VITAMINS in vitamin deficiency states: B12 in pernicious anemia patients, or those post-gastrectomy. vitamin D for patients with osteoporosis living north of the 49th parallel, or keen on avoiding cancer multivitamins for those with chronic malabsorption states. Yet my pharmacy has shelves and shelves of stuff that boggles the mind. When it comes to heavy metals and the like, it gets weird. Chromium, arsenic, nickel, zinc and iron. How much is good for you, how much is poison? The answer comes from the NIH paper2 Recommended Dietary Allowances (1989). Iron, a constituent of hemoglobin/myoglobin/enzymes, 10-11mg/d (women), a little less for men. Zinc, found in metabolic pathway enzymes, 12.5mg/day Iodine, for thyroid function, 50-75micg/day Selenium, for glutathione perioxidase functionality, 55-70micg/day (women, men) Copper, in enzymes and for CNS wellbeing, 1.5-3mg/day Manganese, in enzymes, deficiency rare. 2-5mg/day recommended. Fluoride, good for dentition, supplemented in water supply to >0.7mg/litre. Chromium, to maintain normal glucose metabolism, 50-200mcg/day Molybdenum, an enzyme constituent, 75-250mcg/day Strangely, as a victim of restless-leg-syndrome, I can vouch for the efficacy of Magnesium (I kick my wife in bed at night whenever I forget, and that makes her glower even more). I also recommend it to alcoholics, people on diuretics and patients with frequent PVCs (as an additive to anti-arrhythmic drugs). Fortunately, I have never had diarrhoea with standard doses. No article on nutrition these days can fail to mention the epidemic of our time: obesity. I started with my own story. I would say 40% of my time I am explaining how 4,500 calories a day might be OK for a labourer, but not for the 55-year-old salesman who is more adept at surfing TV channels, and keeping good company with potato-chips and beer. “But I love bread,” they say. “Yeah, you might like the almond-taste of cyanide, but not for long,” I reply. At five foot 2 inches and 300 pounds, these spherical Teletubbies are preparing for the next mega-famine. Funnily enough, that ain’t going to happen in their lifetime. Like all self-control solutions, dieting is hard, and I emphasize the need for less carbohydrates. Our cavemen ancestors were light on the cinnamon buns and heavy on the fish, leafy greens and occasionally wild meat. Rarely did they consume beer, the concentrated form of sugar that has become our most popular sedative. When times are good, and waistlines generous, let’s learn how to counsel on sensible eating. We should have prescription pads for this purpose alone. References: 1. The effect of selenium therapy in critically ill patients: an umbrella review of systematic reviews and meta-analysis of randomized controlled trials. Jaff, S et al. European Journal of Medical Research, volume 28, Article number: 104 (2023) 2. Diet and Health: Implications for Reducing Chronic Disease Risk. National Research Council (US) Committee on Diet and Health.Washington (DC): National Academies Press (US); 1989.

Casebook of a Community Internist

Calories, vitamins and supplements

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Hector Baillie

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