Barbara has come to you, her D

Barbara has come to you, her Dietitian, for a nutritionevaluation. Barbara is an 85 year old female recently diagnosedwith osteoporosis. She weighs 115 pounds and is 64 inches tall.Unfortunately, last week she had a fall that broke her hip. Barbarasuffers from chronically poor appetite and therefore eats a limiteddiet. Barbara tells you that her usual intake is fruit juice andtoast with butter for breakfast, cottage cheese and fruit or tunaand toast for lunch, and a frozen meal for dinner consistingusually of chicken, rice, and vegetables. Before bed she oftendrinks a glass of warm milk. Barbara’s serum vitamin D level on hermost recent bloodwork is below normal. Barbara lives in SouthernCalifornia, but she spends most of her time indoors. During thishospital visit for her broken hip, Barbara was prescribed a bloodthinning medication by the doctor.

Please answer the following questions related to Barbara’sstory:

1. Which factors might put elderly people at risk of vitamin Ddeficiency? (2 points)

2. What food(s) in Barbara’s diet are the best sources ofvitamin D? (2 points)

3. Since Barbara’s serum vitamin D is low and her usual dietdoes not contain much vitamin D, you consider recommending avitamin D supplement for Barbara. What factors will you tellBarbara to consider when selecting a supplement? (List threefactors.) (4 points)

5. Since the doctor prescribed a blood thinner to Barbara, youtell her that vitamin K rich foods might interfere with hermedication. What will you tell her about vitamin K rich foods?(that is, should she eat more, less, or consistent amounts ofvitamin K?) Which foods are rich in vitamin K? (2 points)


Question number:1

Elderly people are at more risk of vitamin D deficiencybecause

1. With age there is thinning of theskin which reduces vitamin D synthesis in the skin. Obese peoplealso have less vitamin D synthesis in the skin.

2. Complexion of skin- fair or lightskin produces more vitamin D than darker tones of skin.

3. In skin 7 dehydrocholesterol(precursor) is converted to provitamin D3 which is laterhydroxylated in the liver(25-hydrocholecalciferol). Thishydroxylated form is further metabolized and converted to abiologically active form in the kidney(1-25 dihydrocholecalciferol). Both of these processes also decline withage.

4. Elderly stay mostly indoors or havelimited sun exposure. Keeping the body covered while in sun and useof sunscreens also decreases vitamin D synthesis by the skin.

5. Decreased dietary intake of foodrich in vitamin D (more common in strict vegetarians, those withmilk allergy, lactose intolerance) as well as an overall reductionin dietary intake due to loss of appetite secondary to inactivityor effects of drugs taken for chronic conditions.

Question number:2

Foods in Barbara’s dietwhich are the best sources of vitamin D are Tuna andcheese.

Some pre-packaged juice is alsofortified with vitamin D, but there is no information on thisregard whether Barbara’s juice is homemade or fortifiedone.

The same is for milk, it may ormay not be fortified depending on the source. Without fortificationmilk is low in vitamin D.

Question number :3

Factors Barbara should keep in mind while selecting vitamin Dsupplement are:

1. The form of vitamin d that iswhether D2 or D3. Both are good for preventing or treating vitaminD deficiency but vitamin D3 has longer half-life therefore lessfrequent dosing is required.

2. Supplements areregulated by US Pharmacopeia not by FDA. So look for the USP markof approval on the product’s label.

3. Taking too muchvitamin D dose can also be harmful. So take them after measurementof vitamin D and also get it checked periodically thereafter.Higher levels of vitamin D can be toxic sometimes, it can lead toan increased level of calcium in the body. Too much calcium mayresult in deposition and hardening of blood vessels and alsoincreases the risk of kidney stones.

4. Regarding formone can go for power, liquid, or soft gel capsules.

Question number :5

Some foods can interfere with theeffectiveness of blood thinners. Warfarin is a commonly used bloodthinner. Eating an increased amount of foods rich in vitamin K canlower prothrombin time reducing the effectiveness of blood thinnersand potentially increasing the risk of blood clots.

Therefore people who take bloodthinner should aim to eat a relatively similar amount of vitamin Keach week.

The high amount of vitamin Kis found in green and leafy vegetables such as broccoli, lettuce,amaranth, collard, kale, spinach, and kiwi fruit.

It is not necessary to avoidor increase the intake of these foods. But it is important to tryto keep the amount of vitamin K in food consistent.

Foods low in vitamin K are avocado,celery, carrot, banana, corn, cucumber, tomato, cauliflower,pumpkin, potato, radish, turnip. She need not opt for low vitamin Kfood. Consistency is the key.

Alcohol intake can affect how thebody metabolizes certain blood thinners. So one should avoiddrinking alcohol daily. Alcohol should be limited to no more than 1to 2 servings of alcohol occasionally. The antiplatelet effect ofalcohol increases the risk of major bleeding, even if the INRremains within the target range.

The most important point toremember is one should eat what he/she normally eats and not tomake any major changes in the diet without contacting yourhealthcare provider.

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