Department of Orthopedics Khon Kaen University, Khon Kaen, Thailand Trace elements Dr. Suppasin Soontrapa Department of Orthopedics Khon Kaen University, Khon Kaen, Thailand

Vitamin and mineral Calvin Plus 1’s RDA *Thai RDA Calcium 600 mg Vitamin D 200 iu. 200-400 iu 200 iu Magnesium 40 mg 280-400 mg 350 mg Zinc 7.5 mg 12-15 mg 15 mg Copper 1 mg 2 mg Manganese 1.8 mg 2-5 mg 3.5 mg Boron 0.25 mg none *Ref: ค่าสารอาหารที่แนะนำให้บริโภคประจำวันสำหรับคนไทยอายุตั้งแต่ 6 ปีขึ้นไป (Thai Recommended Daily Intakes– Thai RDI) จัดทำโดย คณะอนุกรรมการพิจารณาการแสดงคุณค่าทางโภชนาการบนฉลากของอาหาร 2538

Magnesium

Elemental Composition of the Human Body Magnesium Elemental Composition of the Human Body Magnesium is found in small amount in the human body Element % of total atoms H O C N Ca P Cl K S Na Mg 63 25.5 9.5 1.4 0.31 0.22 0.08 0.06 0.05 0.03 0.01 (http://ods.od.nih.gov/factsheets/magnesium.asp#h2)

Magnesium Approximately 50% of total body magnesium is found in bone. The other half is found predominantly inside cells of body tissues and organs. Only 1% of magnesium is found in blood (http://ods.od.nih.gov/factsheets/magnesium.asp#h2)

The function of Magnesium Magnesium has positive charge Magnesium has many necessary function in cells Co-factor in many basic cellular function especially in process of energy production Magnesium is needed for more than 300 biochemical reactions in the body

The function of Magnesium regulate blood sugar levels promotes normal blood pressure to be involved in energy metabolism and protein synthesis Maintain normal muscle and nerve function keeps heart rhythm steady supports a healthy immune system keeps bones strong.

Magnesium Magnesium is absorbed in the small intestines. Magnesium is excreted through the kidneys

Sources of Magnesium Green vegetables spinach are good sources of magnesium because the center of the chlorophyll molecule (which gives green vegetables their color) contains magnesium. Some legumes (beans and peas), nuts and seeds whole grains, unrefined grains are also good sources of magnesium

DRIs (Dietary Reference Intakes) Recommended Dietary Allowances (RDA) Adequate Intakes (AI) Tolerable Upper Intake Levels (UL).

DRIs (Dietary Reference Intakes) Recommended Dietary Allowances (RDA) The RDA recommends the average daily intake that is sufficient to meet the nutrient requirements of nearly all (97-98%) healthy individuals in each age and gender group

DRIs (Dietary Reference Intakes) Adequate Intakes (AI) An AI is set when there is insufficient scientific data available to establish a RDA for specific age/gender groups. AIs meet or exceed the amount needed to maintain a nutritional state of adequacy in nearly all members of a specific age and gender group

DRIs (Dietary Reference Intakes) Tolerable Upper Intake Levels (UL) UL is the maximum daily intake unlikely to result in adverse health effects.

Recommended Dietary Allowances (RDAs) for magnesium for children and adults Age (years) Male (mg/day) Female (mg/day) Pregnancy (mg/day) Lactation (mg/day) 1-3 80 N/A 4-8 130 9-13 240 14-18 410 360 400 19-30 310 350 31+ 420 320

Causes of Magnesium Deficiency Magnesium is absorbed in the intestines and then transported through the blood to cells and tissues. Approximately one-third to one-half of dietary magnesium is absorbed into the body Gastrointestinal disorders impair absorption Crohn's disease can limit the body's ability to absorb magnesium. Chronic or excessive vomiting and diarrhea may also result in magnesium depletion

signs and symptoms of magnesium deficiency loss of appetite, nausea, vomiting, fatigue, and weakness. As magnesium deficiency worsens, numbness, tingling, muscle contractions and cramps, seizures, personality changes, abnormal heart rhythms, and coronary spasms can occur Severe magnesium deficiency can result in low levels of calcium in the blood (hypocalcemia). Magnesium deficiency is also associated with low levels of potassium in the blood (hypokalemia)

Who may need extra magnesium? specific health problem poorly-controlled diabetes persons with alcoholism condition limits magnesium absorption Individuals with chronic malabsorptive problems such as Crohn's disease, gluten sensitive enteropathy, regional enteritis, and intestinal surgery may lose magnesium through diarrhea and fat malabsorption

Who may need extra magnesium? Older adults are at increased risk for magnesium deficiency. The 1999-2000 and 1988-94 National Health and Nutrition Examination Surveys suggest that older adults have lower dietary intakes of magnesium than younger adults Ford ES and Mokdad AH. Dietary magnesium intake in a national sample of U.S. adults. J Nutr. 2003;133:2879-82. Bialostosky K, et al., Dietary intake of macronutrients, micronutrients and other dietary constituents: United States 1988-94. Vital Heath Stat. 11(245) ed: National Center for Health Statistics, 2002:168.

Magnesium and osteoporosis Bone health is supported by many factors most notably calcium and vitamin D some evidence suggests that magnesium deficiency may be an additional risk factor for postmenopausal osteoporosis Several human studies have suggested that magnesium supplementation may improve bone mineral density Institute of Medicine. Food and Nutrition Board. Dietary Reference Intakes: Calcium, Phosphorus, Magnesium, Vitamin D and Fluoride. National Academy Press. Washington, DC, 1999

Magnesium and osteoporosis magnesium deficiency alters calcium metabolism and the hormones that regulate calcium1 In a study of older adults, a greater magnesium intake maintained bone mineral density to a greater degree than a lower magnesium intake2 Elisaf M, Milionis H, Siamopoulos K. Hypomagnesemic hypokalemia and hypocalcemia: Clinical and laboratory characteristics. Mineral Electrolyte Metab 1997;23:105-12. Tucker KL, Hannan MT, Chen H, Cupples LA, Wilson PW, Kiel DP. Potassium, magnesium, and fruit and vegetable intakes are associated with greater bone mineral density in elderly men and women. Am J Clin Nutr 1999;69(4):727-36.

Conclusion Magnesium is very important in older adults to maintain many functions Magnesium deficiency usually found in poor controlled DM, alcoholism, chronic malabsorptive problems, ect. magnesium supplementation may improve bone mineral density and prevent osteoporosis

Conclusion Calvin-plus contain Magnesium 40 mg (~ 10% of RDA)

Copper

What is copper? copper is a trace mineral that plays an important role in our metabolism, it allows many critical enzymes to function properly. the total amount of copper in the body is only 75-100 mg Copper stored primarily in the liver, with lesser amounts found in the brain, heart, kidney, and muscles

The function of copper? Copper is an essential component of many enzymes. Copper plays a role in a wide range of physiological processes including iron utilization, elimination of free radicals, development of bone and connective tissue, production of the skin and hair pigment called melanin.

Iron Utilization Approximately 90% of the copper in the blood is incorporated into a compound called ceruloplasmin, which is a transport protein responsible for carrying copper to tissues that need the mineral. ceruloplasmin also acts as an enzyme, catalyzing the oxidation of iron.

Iron Utilization The oxidation of iron by ceruloplasmin is necessary for iron to be bound to its transport protein (called transferrin) so that it can be carried to tissues where it is needed. Iron deficiency anemias may be a symptom of copper deficiency.

Elimination of Free Radicals Superoxide dismutase (SOD) is a copper-dependent enzyme that catalyzes the removal of superoxide radicals from the body. Superoxide radicals are generated during normal metabolism white blood cells attack invading bacteria and viruses (a process called phagocytosis). If not eliminated quickly, superoxide radicals cause damage to cell membranes

Elimination of Free Radicals When copper is not present in sufficient quantities, the activity of superoxide dismutase is diminished The damage to cell membranes caused by superoxide radicals is increased

Development of Bone & Connective Tissue Copper is also a component of lysyl oxidase, an enzyme that participates in the synthesis of collagen and elastin

Melanin Production Tyrosinase, a copper-containing enzyme, converts tyrosine to melanin, which is the pigment that gives hair and skin its color.

The symptoms of copper deficiency iron deficiency anemia ruptured blood vessels osteoporosis elevated LDL cholesterol and reduced HDL cholesterol levels increased susceptibility to infections due to poor immune function loss of pigment in the hair and skin weakness, fatigue, breathing difficulties

The risk factors of copper deficiency ? most Americans consume less than recommended amounts of copper in their diet Certain medical conditions result in decreased absorption of copper and may increase the risk of developing a copper deficiency chronic diarrhea celiac sprue Crohn's disease Celiac Disease Defined What is Celiac Disease?Celiac disease (CD) is a genetic disorder. In people with CD, eating certain types of protein, called gluten, sets off an autoimmune response that causes damage to the small intestine. This, in turn, causes the small intestine to lose its ability to absorb the nutrients found in food, leading to malnutrition and a variety of other complications. The offending protein, gluten, is found in wheat, barley, rye, and to a lesser extent, oats (WBRO). Related proteins are found in triticale, spelt, kamut. Refer to grains and flours Glossary for a more extensive list of both safe and offending grains. Celiac Disease is: a genetic, inheritable disease. linked to genetically transmitted histocompatibility cell antigens (HLA DR3-DQ2, DR5/7 DQ2, and DR4-DQ8). COMMON. Approximately 1 in 133 people have CD, however, only about 3% of these have been diagnosed. This means that there are over 2.1 million undiagnosed people with celiac disease in the United States. characterized by damage to the mucosal lining of the small intestine which is known as villous atrophy. responsible for the malabsorption of nutrients resulting in malnutrition. linked to skin blisters known as dermatitis herpetiformis (DH). not age-dependent. It may become active at any age. Celiac Disease is NOT:    simply a food allergy. an idiosyncratic reaction to food proteins (mediated by IgE). typified by a rapid histamine-type reaction (such as bronchospasm, urticaria, etc.).

The risk factors of copper deficiency ? copper requires sufficient stomach acid for absorption, so if you consume antacids regularly you may increase your risk of developing a copper deficiency. Celiac Disease Defined What is Celiac Disease?Celiac disease (CD) is a genetic disorder. In people with CD, eating certain types of protein, called gluten, sets off an autoimmune response that causes damage to the small intestine. This, in turn, causes the small intestine to lose its ability to absorb the nutrients found in food, leading to malnutrition and a variety of other complications. The offending protein, gluten, is found in wheat, barley, rye, and to a lesser extent, oats (WBRO). Related proteins are found in triticale, spelt, kamut. Refer to grains and flours Glossary for a more extensive list of both safe and offending grains. Celiac Disease is: a genetic, inheritable disease. linked to genetically transmitted histocompatibility cell antigens (HLA DR3-DQ2, DR5/7 DQ2, and DR4-DQ8). COMMON. Approximately 1 in 133 people have CD, however, only about 3% of these have been diagnosed. This means that there are over 2.1 million undiagnosed people with celiac disease in the United States. characterized by damage to the mucosal lining of the small intestine which is known as villous atrophy. responsible for the malabsorption of nutrients resulting in malnutrition. linked to skin blisters known as dermatitis herpetiformis (DH). not age-dependent. It may become active at any age. Celiac Disease is NOT:    simply a food allergy. an idiosyncratic reaction to food proteins (mediated by IgE). typified by a rapid histamine-type reaction (such as bronchospasm, urticaria, etc.).

Men & women >70 years: 900 mg Pregnant & women 14-50 years: 1000 mg RDAs of Copper Boys & girls 9-13 years: 700 mg Boys & girls 14-18 years: 890 mg Men & women 19-70 years: 900 mg Men & women >70 years: 900 mg Pregnant & women 14-50 years: 1000 mg Lactating women 14-50 years: 1300 mg A good food source of copper contains a substantial amount of copper in relation to its calorie content and contributes at least 10 percent of the U.S. Recommended Dietary Allowance (U.S. RDA) for copper in a selected serving size. The U.S. RDA for copper is 2 milligrams per day. (The U.S. RDA given is for adults, except pregnant or lactating women, and children over 4 years of age.) The U.S. RDA for copper is the amount of the mineral used as a standard in nutrition labeling of foods. This allowance is based on the 1968 estimate of need made by the Food and Nutrition Board of the National Academy of Sciences. The 1989 range of Estimated Safe and Adequate Intakes for adults is 1.5 to 3 milligrams per day.

Conclusion Copper have many functions in man Most US people consume less amounts of copper than recommended Copper in calvin plus = 1 mg can supplement adequate amount of copper per day

Zinc

Zinc: What is it? Zinc is an essential mineral that is found in almost every cell. It stimulates the activity of approximately 100 enzymes, which are substances that promote biochemical reactions in the body, including alkaline phosphatase1-2 Zinc supports a healthy immune system3-4 1. Sandstead HH. 1994;124:322-327. 2. Institute of Medicine. National Academy Press. Washington, DC, 2001. 3. Solomons NW. Nutr Rev 1998;56:27-28. 4. Prasad AS. Zinc: An overview. Nutrition 1995;11:93-99

Zinc: What is it? Zinc is needed for wound healing1 maintain your sense of taste and smell2 Zinc is needed for DNA synthesis3 Zinc also supports normal growth and development during pregnancy, childhood, and adolescence4,5 1. Heyneman CA. Ann Pharmacother 1996;30:186-187. 2. Prasad AS, et al. Proc Assoc Am Physicians 1997;109:68-77. 3. Institute of Medicine. National Academy Press. Washington, DC, 2001. 4. Simmer K and Thompson RP. Acta Paediatr Scand Suppl 1985;319:158-163. 5. Fabris N and Mocchegiani E. Aging (Milano) 1995;7:77-93.

What foods provide zinc? Zinc is found in a wide variety of foods1 Oysters contain more zinc per serving than any other food, Red meat and poultry provide the majority of zinc in the American diet. Other good food sources include beans, nuts, certain seafood, whole grains, fortified breakfast cereals, and dairy products1-2 Institute of Medicine. National Academy Press. Washington, DC, 2001. U.S. Department of Agriculture, Agricultural Research Service. 2001. Nutrient Data Laboratory Home Page, http://www.nal.usda.gov/fnic/foodcomp Search the database online.

The 2001 RDAs for zinc for infants 7 through 12 months, children and adults in mg per day Age Infants and Children Males Females  Pregnancy  Lactation 7 mo. to 3 years 3 mg   4 to 8 years 5 mg 9 to 13 years 8 mg 14 to 18 years 11 mg 9 mg 13 mg 14 mg 19+ 12 mg Institute of Medicine. National Academy Press. Washington, DC, 2001

Inadequate intake of zinc Low zinc status has been observed in 30% to 50% of alcoholics. Alcohol decreases the absorption of zinc and increases loss of zinc in urine. Many alcoholics do not eat an acceptable variety or amount of food, so their dietary intake of zinc may be inadequate1-3 Institute of Medicine. National Academy Press. Washington, DC, 2001 Menzano E and Carlen PL. Alcohol Clin Exp Res 1994;18:895-901 Navarro S, et al., Pancreas 1994;9:270-274.

Inadequate intake of zinc Individuals who have had gastrointestinal surgery Digestive disorders that result in malabsorption including sprue Crohn’s disease short bowel syndrome1-3 These patients may benefit from zinc supplementation Institute of Medicine. National Academy Press. Washington, DC, 2001 Hambidge KM, In: Mills CF, ed. Zinc in Human Biology, New York: Springer-Verlag 1989 Pp 281-296. Naber TH, et al., Scand J Gastroenterol 1998;33:514-523.

Signs of zinc deficiency growth retardation hair loss diarrhea delayed sexual maturation impotence eye and skin lesions loss of appetite Institute of Medicine. National Academy Press. Washington, DC, 2001.

Signs of zinc deficiency weight loss delayed healing of wounds taste abnormalities mental lethargy1-5 Hambidge KM, In: Zinc in Human Biology, 1989 Pp 281-296. King JC and Keen CL. In: Modern Nutrition in Health and Disease, 1999, Pp223-239. Krasovec M and Frenk E. Dermatology 1996;193:361-363. Ploysangam A, et al., J Trop Pediatr 1997;43:192-198. Nishi Y. J Am Coll Nutr 1996;15:340-344.

Who may need extra zinc? There is no single laboratory test that adequately measures zinc nutritional status1-2 risk factors of zinc deficiency1 inadequate caloric intake alcoholism digestive diseases Institute of Medicine. National Academy Press. Washington, DC, 2001. Van Wouwe JP. Clinical and laboratory assessment of zinc deficiency in Dutch children. A review. Biol Trace Elem Res 1995;49:211-225.

Who may need extra zinc? Vegetarians may need as much as 50% more zinc than non-vegetarians because of the lower absorption of zinc from plant foods it is very important for vegetarians to include good sources of zinc in their diet1-2 Institute of Medicine. National Academy Press. Washington, DC, 2001. Gibson RS. Content and bioavailability of trace elements in vegetarian diets. Am J Clin Nutr 1994;59:1223S-1232S.

Conclusion Zinc is an essential mineral for many function including bone growth Many people consume inadequate zinc especially vegetarians Zinc in calvin plus = 7.5 mg can supply about 50% of daily requirement of zinc

Boron

โบรอนในธรรมชาติ ในธรรมชาติสามารถพบโบรอนในรูปของเกลือโบเรต (borate) สามารถพบในอัตราส่วนที่สูงในน้ำทะเลและในดิน ในน้ำทะเลพบความเข้มข้นของโบรอนโดยเฉลี่ยประมาณ 4.6 mg/L

ระดับของโบรอนในเนื้อเยื่อของมนุษย์ เราสามารถพบโบรอนได้ในเนื้อเยื่อทั่วร่างกายของมนุษย์ ปริมาณของโบรอนทั้งหมดในร่างกายมีตั้งแต่ 3 ถึง 20 mg พบสูงสุดในกระดูก เล็บมือและเล็บเท้าและเส้นผม (4.3 – 17.9 ppm)

อาการของการขาดโบรอน การเจริญเติบโตลดลง มีการพัฒนาของกระดูกที่ผิดปกติ เพิ่มการขับแคลเซียมในปัสสาวะ เพิ่มอาการของการขาดวิตามินดี (เช่นการสร้างกระดูกที่ผิดปกติและการเจริญเติบโตที่ผิดปกติ)

การดูดซึมโบรอน โบรอนสามารถถูกดูดซึมได้ง่ายทาง GI tract และทาง mucous membrane เช่นปาก ตา ช่องคลอดและทวารหนัก Hunt รายงานว่ามนุษย์และสัตว์สามารถดูดซึม inorganic boronได้เกือบร้อยเปอร์เซ็นต์

การขับโบรอน โบรอนส่วนใหญ่จะถูกขับออกทางปัสสาวะ ประมาณร้อยละสองขับออกทางอุจจาระ ขับทางน้ำดี เหงื่อและลมหายใจ ในปริมาณเพียงเล็กน้อย

ปริมาณโบรอนต่อวัน การประเมินปริมาณโบรอนที่รับประทานค่อนข้างลำบาก เนื่องจากไม่มีข้อมูลของปริมาณโบรอนในอาหารและใน personal care products และปริมาณของโบรอนในน้ำดื่ม ในประเทศฟินแลนด์ รับประทานโบรอนเฉลี่ยต่อวันประมาณ 1.7 mg ขณะที่ในประเทศสหรัฐอยู่ระหว่าง 1.7 ถึง 7 mg/day

Samman และคณะได้วิเคราะห์อาหารที่รับประทานในช่วง 7 วัน พบว่า ปริมาณโบรอนต่อวัน Samman และคณะได้วิเคราะห์อาหารที่รับประทานในช่วง 7 วัน พบว่า บุรุษและสตรีของประเทศออสเตรเรียรับประทานโบรอนโดยเฉลี่ย 2.28 + 1.3 mg/day และ 2.16 + 1.1 mg/day ตามลำดับ

แหล่งอาหารของโบรอน แหล่งอาหารหลักของโบรอนคือ ผลไม้และผัก ส่วนใหญ่ได้แก่ เมล็ด ก้านและเปลือกจะมีโบรอนในปริมาณสูงยกเว้นมะนาว berries และสับปะรด ผักใบเขียวจะมีปริมาณโบรอนสูงที่สุด หัวที่อยู่ใต้ดิน (tubers) และ legumes จะมีปริมาณของโบรอนที่สูงกว่าอาหารประเภทธัญพืช (ข้าวโพด ข้าวและข้าวสาลี)

ความต้องการโบรอนในมนุษย์ คาดกันว่ามนุษย์มีความต้องการโบรอนในปริมาณ 500 mg/d จากข้อเสนอแนะของ The Food and Nutrition Board of the Institute of Medicine พบว่าโบรอนสูงสุดที่มนุษย์ที่มีอายุมากกว่า 18 ปีสามารถรับได้คือ 20 mg/day

Evidence Grading Grading A: Strong scientific evidence for this use B: Good scientific evidence for this use C: Unclear scientific evidence for this use D: Fair scientific evidence against this use F: Strong scientific evidence against this use

Uses based on scientific evidence Evidence Grading Uses based on scientific evidence Grade Hormone regulation Boron may increase hormone (estrogen) levels in women, reducing vaginal discomfort after menopause. More research is needed in humans before a strong conclusion can be reached. C Improving cognitive function Preliminary human study reports better performance on tasks of eye-hand coordination, attention, perception, short-term memory, and long-term memory with boron supplementation. However, additional research is needed before a firm conclusion can be drawn.

Uses based on scientific evidence Evidence Grading Uses based on scientific evidence Grade Osteoarthritis Based on human population research, in a boron rich environment, people appear to have fewer joint disorders. It has also been proposed that boron deficiency may contribute to the development of osteoarthritis. However, there is no clear human evidence that supplementation with boron is beneficial as prevention against or as a treatment for osteoarthritis. C

Uses based on scientific evidence Evidence Grading Uses based on scientific evidence Grade Osteoporosis Animal and preliminary human studies report that boron may play a role in mineral metabolism, with effects on calcium, phosphorus, and vitamin D. However, research of bone mineral density in women taking boron supplements does not clearly demonstrate benefits in osteoporosis. Additional study is needed before a firm conclusion can be drawn. C

Uses based on scientific evidence Evidence Grading Uses based on scientific evidence Grade Vaginitis Inorganic boron (boric acid, borax) has been used as an antiseptic based on proposed antibacterial and antifungal properties. It is proposed that boric acid may have effects against candidal and non-candidal vulvovaginitis. A limited amount of poor-quality research reports that boric acid capsules used in the vagina may be effective for vaginitis. Further evidence is needed before a recommendation can be made. C

Uses based on scientific evidence Evidence Grading Uses based on scientific evidence Grade Bodybuilding aid (increasing testosterone) There is preliminary negative evidence for the use of boron for improving performance in bodybuilding by increasing testosterone. Although boron is suggested to raise testosterone levels, in early human research, total lean body mass has not been affected by boron supplementation in bodybuilders. Additional research is necessary before a firm conclusion can be drawn. D

Uses based on scientific evidence Evidence Grading Uses based on scientific evidence Grade Menopausal symptoms It has been proposed that boron affects estrogen levels in post-menopausal women. However, preliminary studies have found no changes in menopausal symptoms. D

Uses based on scientific evidence Evidence Grading Uses based on scientific evidence Grade Prevention of blood clotting (coagulation effects) It has been proposed that boron may affect the activity of certain blood clotting factors. Study results conflict. There is not enough evidence in this area to form a clear conclusion. D Psoriasis (boric acid ointment) Preliminary human study of an ointment including boric acid does not report significant benefits in psoriasis.

Conclusion Boron มีบทบาทสำคัญมากมายต่อร่างกาย จนถึงปัจจุบันยังไม่มีข้อมูลที่ชัดเจนเกี่ยวกับภาวะโบรอนในร่างกาย การเสริมโบรอนเชื่อว่าสามารถให้ประโยชน์ต่อร่างกายในหลายๆด้านรวมทั้งโรคกระดูกพรุน Calvin plus เป็นยาแคลเซียมเพียงตัวเดียวที่มีโบรอนเป็นส่วนประสมอยู่ในปริมาณ 0.25 mg

Thank you