Abstract
Jeffrey Gladd, MD, a family medicine physician and graduate of the University of Arizona Fellowship in Integrative Medicine, in Tucson, Arizona, realized the need to improve his own health through better nutrition and lifestyle behaviors. He now offers his knowledge and insights to patients in his integrative medicine practice. In this column, Dr. Gladd discusses the nuances of nutrient depletion and how a patient's problems can be complicated by nutritional deficiencies.
There are many case studies, 1 –4 and anecdotal examples in our office, of people on PPIs with chronic iron deficiency, osteopenia, and even osteoporosis 5 because of poor nutrient absorption. Leaky gut and increased intestinal permeability with PPI use was highlighted earlier this year in a study connecting PPI use with a weakened microbiome. 6 So, it is important to help people supplement nutrients that are impacted, such as iron, calcium, and magnesium, and also work with these patients on implementing a lifestyle that allows them to wean off PPIs. After doing this, all of a sudden, nutrient levels come back into normal ranges and bone-density levels off or even increases a bit.
Another example is metformin, which is heavily used as a treatment for diabetes and may lead to vitamin B12 depletion 7 if not monitored or supplemented. A classic example of how this can cause confusion in the office setting is when a clinician sees a patient with hyperglycemia, and he or she is then started on metformin. The clinician doesn't necessarily, at that moment, think of the potential for nutrient depletion. Fast-forward a few years. The patient's hemoglobin A1C levels have normalized, and the prescription continues to be refilled. However, now, the patient returns with neuropathy symptoms, and the immediate thought is that this person has diabetic neuropathy. Potentially more medications are prescribed, but the possibility of vitamin B12 depletion caused by the original medication is not considered, and that, in fact, may be where the problem lies.
If clinicians and patients understood the potential for vitamin B12 depletion caused by metformin, then patients might be advised to start incorporating more foods that contain vitamin B12, such as wild-caught fish or grass-fed dairy products, if tolerated. Alternatively, one could add a vitamin B12 supplement or a comprehensive B-vitamin supplement to protect against nutrient depletion. Through this example, one can see how this becomes a vicious cycle if clinicians and patients are not alert to the potential for nutrient depletion that comes along with the use of certain medications.
Another common class of medications that affect nutrient status is the oral contraceptives, which are linked to riboflavin deficiency and have been shown to increase the daily requirement for a wide range of nutrients. Some clinicians are familiar with the scenario of a young woman who is started on birth control pills, and, within a year or two, returns with complaints of depression. This is where evaluating vitamins B12 and B6 are important. There are also antibiotics that deplete nutrients, 8,9 with the B-vitamins and vitamin K topping the list of concerns. Certainly, when used long-term, such as in the treatment of acne, there is the potential for an adverse effect.
One of our major concerns in the healthcare system today is polypharmacy. There are the known side-effects of certain medications; however, when medications are combined, which may lead to altered liver metabolism and potentially negative synergistic effects, this can lead to nutrient depletions that have not been revealed in the research literature. Nutrient depletion is a pretty easy thing to protect a patient against—or, at least, monitor—and yet, it is often not recognized. However, the cycle can start with just one medication. So medication use is a big category that clinicians should consider, and the role of nutrient depletion needs to be in the forefront of thinking. This is true not only in the medical-office setting, but also at the pharmacy level and in packaging medications, which should contain warnings of such depletions.
In terms of other common causes of nutrient depletion, anyone who is practicing integrative or functional medicine is typically in tune with the importance of considering digestive tract function in their patients. There are so many factors that may impact the motility of the digestive tract and the necessary acid and enzymes needed to break down the food that people are eating in order to process nutrients. Utilizing the beneficial effects of probiotics, trying to avoid use, and obviously overuse, of antibiotics, and trying to minimize consuming antibiotics in the food supply—most of which people probably do not know they are consuming—are all very important.
As a result of high-yield farming practices, certainly, the data are there that minerals in the soil are lost, and that translates into depleted levels of nutrients in the diet. Scientific American had a great article several years ago outlining this issue. 10 Today, for the same level of vegetable intake, people are consuming fewer nutrients, compared to 10 or 20 years ago. Two major nutrients on that list are selenium and magnesium, which are so essential for optimal function of the human body.
Today, for the same level of vegetable intake, people are consuming fewer nutrients, compared to 10 or 20 years ago.
Then, there is the very real fact that people are simply not consuming as many whole foods today. Society's reliance on processed and refined foodlike products as the major source of nutrition certainly is a setup for nutrient depletion. People are not consuming near the nutrients that should and used to be when more whole foods were consumed. The overprocessing of grains that essentially strip most of the nutrition and certainly the fiber from what could potentially be beneficial for people who can tolerate these grains is a factor. Few people are consuming the levels of vegetables and fruits, as well as poultry/meat and eggs, from healthy sources that would provide the vast array of important nutrients. In addition, drinking alcohol beyond recommended guidelines can potentially deplete the same B-vitamins and vitamin K as antibiotics via alcohol's potential to act as an antiseptic. There is also concern and preliminary evidence suggesting a connection between alcohol consumption and increased intestinal permeability leading to imbalance of the microbiome. 11,12
When all these factors are put together—the standard American lifestyle wherein people are generally not consuming nutrient-heavy foods, along with overconsumption of medications, alcohol and/or antibiotics (both from medication overuse and from the food supply)—the risk of nutrient depletion is very real. One may question how a body can be healthy when it is bombarded with these problems.
It is important to point out, however, that it can be overwhelming for a patient when he or she sits down with a provider who helps connect the dots on how some of the patient's medications interact and affect his or her nutritional status. The patient may be thinking: “I did not love the idea of being on the medication, and now I am seeing the direct role it may play as detrimental to my health.” Patients are interested in their providers' help in assessing and/or reversing these nutrient depletions and helping to figure out how to promote health in order to whittle medication lists down. A provider has to be sure to take one step at a time so as to not overwhelm someone who then goes home and says: “Well, that is all too complicated. I am not going to do any of it.”
In 2011, I was at a conference and heard pharmacist Alan Simon [RPh] speak on the topic of nutrient depletion. I had this “aha” moment, thinking, “my goodness, what an obvious thing to be working on with patients.” Yet, I could not find a good resource for either patient education or for providers. So, at that time, I worked on building a nutrient depletion calculator that included a database of all this information presented in a user-friendly way. I use this tool,
It is fairly easy to evaluate the levels of vitamins in patients and decide “yes” or “no” whether they need supplementation or to stop and say, “the symptoms the patient is experiencing connect here,” with regard to the problems that the patient is presenting. Then, of course, if a person's diet is not optimal, clinicians need to consider the risk for nutrient depletion and work with the patient on improving dietary habits.
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What all of this boils down to is that we have to spend time with our patients. We have to complete full evaluations, listen to their stories, and look at their medication lists. Unfortunately, in a healthcare system that does not allow for time, it is tough for some clinicians to accomplish this.
In terms of laboratory tests, I usually choose the major ones that are easier and less expensive to do. Initially, I will order a red blood cell (RBC) folate along with serum vitamin B12, 25-hydroxy vitamin D, an iron profile, and an RBC magnesium. That is my base nutrient assessment, in addition to methylmalonic acid and homocysteine levels, to give me an idea of where the patient stands. If several of these nutrients come back as being depleted, then I might dive deeper and order a larger panel of blood tests depending on how the patient is presenting. Obviously, the larger the panel and the more nutrient tests ordered, the more expensive the evaluation. I try to keep it simple and focused on the 20% of a giant investigation that is going to get at least 80% of the improvement. That is where we start, and then, if the patient were not making progress, I would dig even deeper and bring out bigger nets of investigation.
Typically, I start with patients by letting them know if they have some nutritional deficiencies and focusing on correcting those. Then, I also focus on healing the digestive tract and improving the diet to both treat and prevent deficiencies. Usually in 3–6 months, I will reevaluate and recheck some of these blood levels. If the patient is back on track with nutrients in the optimal range, and the patient's lifestyle is improving, that is when I like to transition from multiple single nutrients to a multivitamin. Again, it may be difficult for a person to obtain all of what he or she needs in a good, balanced, whole-food diet, so I like to start with targeted individual nutrients when they are needed.
Usually, at some point in working with a patient, either in the first or second visit, there is sort of this "aha" moment of how interconnected and interwoven the body is, and how that patient's decisions and what he or she does affect so many things downstream. If a patient can understand this, that patient is going to be a much better caretaker of his or her health.