Vitamin Deficiencies Educational Format Faculty Expertise Required Expertise in the Field of Study

2019 AAFP FMX Needs Assessment

Body System: Endocrine Session Topic: Vitamin Deficiencies Educational Format Faculty Expertise Required Expertise in the field of study. Experience teaching in the field of study is desired. Preferred experience with audience Interactive REQUIRED response systems (ARS). Utilizing polling questions and Lecture engaging the learners in Q&A during the final 15 minutes of the session are required. Expertise teaching highly interactive, small group learning environments. Case-based, with experience developing and Problem- teaching case scenarios for simulation labs preferred. Other Based workshop-oriented designs may be accommodated. A typical OPTIONAL Learning PBL room is set for 50-100 participants, with 7-8 each per (PBL) round table. Please describe your interest and plan for teaching a PBL on your proposal form.

Learning Objective(s) that will close Outcome Being Professional Practice Gap the gap and meet the need Measured  Vitamin insufficiencies 1. Identify patients at risk of vitamin Learners will and deficiencies are often deficiency (e.g. D, B12), or at risk for submit written overlooked and potential vitamin-drug interactions. commitment to undertreated for at risk 2. Counsel patients regarding the change statements populations. efficacy and appropriate use of on the session  There is often poor vitamin supplementation. evaluation, communication between 3. Establish protocols to evaluate and indicating how patients and physicians monitor vitamin and nutritional needs they plan to regarding vitamin of hospitalized and long-term care implement supplementation, which patients. presented practice can lead to potential recommendations. interactions, especially for those receiving cancer therapy or those with proven or suspected cardiovascular disease.  Hospitalized patients and patients in long-term care are often at increased risk of vitamin deficiency. Faculty Instructional Goals Faculty play a vital role in assisting the AAFP to achieve its mission by providing high- quality, innovative education for physicians, residents and medical students that will encompass the art, science, evidence and socio-economics of family medicine and to support the pursuit of lifelong learning. By achieving the instructional goals provided, faculty will facilitate the application of new knowledge and skills gained by learners to practice, so that they may optimize care provided to their patients.

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 Provide up to 3 evidence-based recommended practice changes that can be immediately implemented, at the conclusion of the session; including SORT taxonomy & reference citations  Facilitate learner engagement during the session  Address related practice barriers to foster optimal patient management  Provide recommended journal resources and tools, during the session, from the American Family Physician (AFP), Family Practice Management (FPM), and Familydoctor.org patient resources; those listed in the References section below are a good place to start o Visit http://www.aafp.org/journals for additional resources o Visit http://familydoctor.org for patient education and resources  Provide updates on new treatment therapies, changes to therapies, or warnings associated with existing therapies. Provide recommendations regarding new FDA approved medications; including safety, efficacy, tolerance, and cost considerations relative to currently available options. Include relevant FDA REMS education for any applicable medications.  Provided strategies to assist physicians in establishing protocols to identify patients at risk of vitamin deficiency (e.g. D, B12), or at risk for potential vitamin-drug interactions.  Provide strategies and resources to help physicians to counsel patients regarding the efficacy and appropriate use of vitamin supplementation.  Provide recommendations for establishing protocols to evaluate and monitor vitamin and nutritional needs of hospitalized and long-term care patients.

Needs Assessment: According to the Second National Report on Biochemical Indicators of Diet and Nutrition from the Centers for Disease Control and Prevention (CDC), the U.S. population has good levels of vitamins A and D and folates overall; however, some groups still need to increase their levels of vitamin D and iron.1 In fact, calcium and vitamin D deficiencies are often related to gender, age, race, household income levels, and weight classification in the U.S.2,3 In particular, patients at highest risk for vitamin D deficiency and insufficiency include those older than 65 years of age, breastfeed exclusively without vitamin D supplantation, have dark skin, insufficient sunlight exposure, medication use that alter vitamin D metabolism (e.g. anticonvulsants, glucocorticoids), obesity, and sedentary lifestyle.4 Another at risk group for Vitamin D deficiency are hospitalized patients, who are often overlooked and undertreated.5 In 2015, family physicians diagnosed patients with vitamin D deficiency during more than 1.7 million office visits.6 Additionally, those patients with malabsorptive disorders, or prolonged use of metformin and proton pump inhibitors are at risk for vitamin B12 deficiency; however, to date no medical organization has published guidelines on screening asymptomatic or low-risk adults.7 Patients frequently do not divulge their use of vitamin supplements to their doctor, which can lead to potential interactions, especially for those receiving cancer therapy or those with proven or suspected cardiovascular disease.8-11 Family physicians are well positioned to address vitamin deficiencies, as they perform more than 17 million routine general medical examinations annually.6

Data from a recent American Academy of Family Physicians (AAFP) CME Needs Assessment Survey indicates that family physicians have knowledge gaps related to managing vitamin deficiencies.12 CME outcomes data from the 2013 and 2015 AAFP Assembly (currently FMX) Vitamin Deficiencies sessions, suggest that physicians have practice gaps regarding evidence-

based recommendations for screening at risk populations for vitamin deficiency; proactively asking patients about their vitamin supplementation; appropriate use of laboratory evaluation; recognizing which patients may be at risk for a vitamin deficiency; and having an awareness of widespread vitamin D deficiency in the population.13,14 In a more recent 2016 CME Training Needs Survey, members indicated practice gaps regarding the initial diagnosis of vitamin deficiencies, as well as disease management of those deficiencies.15

Family physicians providing care for a broad spectrum of patients, from birth to geriatric care, can be challenged to remain up to date on evidence-based guidelines and recommendations, especially when those guidelines are vague or contradictory. Physicians need continuing medical education that will help them to apply the most current and clinically relevant evidence-based recommendations to practice, including but not limited to the following:  AAFP Clinical Preventive Service Recommendation: Vitamin Supplementation16  American Society of Clinical Pathology: Choosing Wisely® Vitamin D testing recommendation17  Endocrine Society and American Association of Clinical Endocrinologists Choosing Wisely® 1,25-dihydroxyvitamin D measure18  Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline19  American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults20  Vegetarian nutrition (VN) evidence based nutrition practice guideline21  Nausea and vomiting of pregnancy22  Anemia in the long-term care setting23  Nutrition and physical activity guidelines for cancer survivors24  Health maintenance in the long term care setting25

Physicians may improve their care of patients with vitamin deficiencies by engaging in continuing medical education that provides practical integration of current evidence-based guidelines and recommendations into their standards of care, including, but not limited to the following:26-28  utritional assessment should be based on the patient history and physical data, including weight loss and dietary intake before admission; disease severity; comorbid conditions; and function of the gastrointestinal tract (e.g., Subjective Global Assessment). Serum markers (e.g., albumin, prealbumin, retinol binding protein, transferrin) alone are not adequate.  The decision to administer specialized nutrition support should consider the patient's preexisting nutritional status, the impact of the disease process on nutritional intake, and the likelihood that specialized nutrition support will improve patient outcome or quality of life.  Enteral nutrition is preferred over parenteral nutrition because it has been shown to be more cost-effective and may decrease the rate of infections.  Specialized nutrition support is not obligatory at the end of life. Enteral nutrition is unlikely to be helpful in patients with advanced dementia, and may be harmful.  Patients with risk factors for vitamin B12 deficiency should be screened with a complete blood count and serum vitamin B12 level.

 A serum methylmalonic acid level may be used to confirm vitamin B12 deficiency when it is suspected but the serum vitamin B12 level is normal or low-normal.  Oral and injectable vitamin B12 are effective means of replacement, but injectable therapy leads to more rapid improvement and should be considered in patients with severe deficiency or severe neurologic symptoms.  Patients who have had bariatric surgery should receive 1 mg of oral vitamin B12 per day indefinitely.  Serum 25-OH-D levels of 12 to 20 ng per mL (30 to 50 nmol per L) correlate to the vitamin D exposure necessary to maintain bone health. Individuals with levels less than 12 ng per mL are usually deficient in vitamin D, and 97.5% of individuals with levels higher than 20 ng per mL have adequate vitamin D intake.  Use of 25-OH-D levels to assess adequate vitamin D exposure is limited by variability in measurement technique and precision.  Routine vitamin D supplementation in community-dwelling adults is not recommended.  Routine vitamin D supplementation does not prolong life, decrease the incidence of cancer or cardiovascular disease, or decrease fracture rates.  There is insufficient evidence to recommend screening the general population for vitamin D deficiency. Treating asymptomatic individuals with identified deficiency has not been shown to improve health.  The USPSTF found adequate evidence that treating vitamin D deficiency does not reduce risk of cancer, type 2 diabetes mellitus, or death in community-dwelling adults, or fractures in persons not at high risk of fractures. Evidence is insufficient for other outcomes, including psychosocial and physical functioning.  Physicians should not measure 25-OH-D levels or prescribe vitamin D supplementation in the treatment of depression, fatigue, osteoarthritis, or chronic pain.

Best Practice Recommendations from Choosing Wisely:26,29  Do not perform population-based screening for 25-OH-D deficiency.  Do not routinely measure 25-OH-D unless the patient has hypercalcemia or decreased kidney function.  Don’t routinely use B vitamin supplements for the treatment of polyneuropathy or neuropathic pain unless a deficiency exists.  Avoid ordering Vitamin D concentrations routinely in otherwise healthy children, including children who are overweight or obese.  Don’t take a multi-vitamin, vitamin E, or beta-carotene to prevent cardiovascular disease or cancer.  Don’t test vitamin K levels unless the patient has an abnormal international normalized ratio and does not respond to vitamin K therapy.  Don’t use homeopathic medications, non-vitamin dietary supplements or herbal supplements as treatments for disease or preventive health measures.

These recommendations are provided only as assistance for physicians making clinical decisions regarding the care of their patients. As such, they cannot substitute for the individual judgment brought to each clinical situation by the patient's family physician. As with all clinical reference resources, they reflect the best understanding of the science of medicine at the time of

publication, but they should be used with the clear understanding that continued research may result in new knowledge and recommendations. These recommendations are only one element in the complex process of improving the health of America. To be effective, the recommendations must be implemented. As such, physicians require continuing medical education to assist them with making decisions about specific clinical considerations.

Resources: Evidence-Based Practice Recommendations/Guidelines/Performance Measures  AAFP Clinical Preventive Service Recommendation: Vitamin Supplementation16  AAFP American Family Physician: Nutrition topics (including vitamins)30  American Society of Clinical Pathology: Choosing Wisely® Vitamin D testing recommendation17  Endocrine Society and American Association of Clinical Endocrinologists Choosing Wisely® 1,25-dihydroxyvitamin D measure18  Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline19  American Geriatrics Society Workgroup on Vitamin D Supplementation for Older Adults20  Specialized Nutrition Support28  Vegetarian nutrition (VN) evidence based nutrition practice guideline21  Nausea and vomiting of pregnancy22  Anemia in the long-term care setting23  Nutrition and physical activity guidelines for cancer survivors24  Vitamins and Minerals: How to Get What You Need (patient education)31  Vitamin D: What You Need to Know (patient education)32  Vitamin B-12 (patient education)33  FDA Fortify Your Knowledge About Vitamins (patient education)34

References

1. Centers for Disease Control and Prevention. CDC report finds U.S. population has good levels of some essential vitamins and nutrients. 2012; http://www.cdc.gov/media/releases/2012/p0402_vitamins_nutrients.html. Accessed June, 2014. 2. Looker AC, Johnson CL, Lacher DA, Pfeiffer CM, Schleicher RL, Sempos CT. Vitamin D status: United States, 2001-2006. NCHS data brief. 2011(59):1-8. 3. Wallace TC, Reider C, Fulgoni VL, 3rd. Calcium and vitamin D disparities are related to gender, age, race, household income level, and weight classification but not vegetarian status in the United States: Analysis of the NHANES 2001-2008 data set. Journal of the American College of Nutrition. 2013;32(5):321-330. 4. Bordelon P, Ghetu MV, Langan RC. Recognition and management of vitamin D deficiency. American family physician. 2009;80(8):841-846. 5. Lyman D. Undiagnosed vitamin D deficiency in the hospitalized patient. American family physician. 2005;71(2):299-304.

6. National Center for Health Statistics. National Ambulatory Medical Care Survey. 2015; https://www.cdc.gov/nchs/ahcd/ahcd_products.htm. Accessed Apr, 2018. 7. Langan RC, Zawistoski KJ. Update on vitamin B12 deficiency. American family physician. 2011;83(12):1425-1430. 8. Ben-Arye E, Polliack A, Schiff E, Tadmor T, Samuels N. Advising patients on the use of non-herbal nutritional supplements during cancer therapy: a need for doctor-patient communication. Journal of pain and symptom management. 2013;46(6):887-896. 9. Hamrick I, Counts SH. Vitamin and mineral supplements. Primary care. 2008;35(4):729- 747. 10. Bin YS, Kiat H. Prevalence of dietary supplement use in patients with proven or suspected cardiovascular disease. Evidence-based complementary and alternative medicine : eCAM. 2011;2011:632829. 11. Simon N. Most Patients Don't Tell Their Doctors They Take Supplements. Health Discovery. 2010. http://www.aarp.org/health/drugs-supplements/info-11- 2010/most_patients_dont_tell_their_doctors_they_take_supplements.html. Accessed July 2014. 12. AAFP. 2012 CME Needs Assessment: Clinical Topics. In: American Academy of Family Physicians; 2012. 13. American Academy of Family Physicians (AAFP). AAFP FMX CME Outcomes Report. In. Leawood KS: AAFP; 2015. 14. American Academy of Family Physicians (AAFP). 2013 AAFP Scientific Assembly: CME Outcomes Report. In. Leawood KS: AAFP; 2013. 15. CME Training Session Needs Survey. In. Leawood KS: AAFP; 2016. 16. American Academy of Family Physicians (AAFP). Clinical Preventive Service Recommendation: Vitamin Supplementation. 2014; http://www.aafp.org/patient- care/clinical-recommendations/all/vitamin.html. Accessed July, 2014. 17. American Society for Clinical Pathology (ASCP). Vitamin D tests. 2014; http://www.choosingwisely.org/doctor-patient-lists/vitamin-d-tests/. Accessed July, 2014. 18. Endocrine Society, American Association of Clinical Endocrinologists. Five Things Physicians and Patients Should Question. 2014; http://www.choosingwisely.org/doctor- patient-lists/the-endocrine-society-and-american-association-of-clinical- endocrinologists/. Accessed July, 2014. 19. Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. The Journal of clinical endocrinology and metabolism. 2011;96(7):1911-1930. 20. American Geriatrics Society Workgroup on Vitamin DSfOA. Recommendations abstracted from the american geriatrics society consensus statement on vitamin d for prevention of falls and their consequences. J Am Geriatr Soc. 2014;62(1):147-152. 21. National Guideline Clearinghouse. Vegetarian nutrition (VN) evidence based nutrition practice guideline. 2011; http://www.guideline.gov/content.aspx?id=35174&search=vitamin+deficiency. Accessed 7/1/2014. 22. National Guideline Clearinghouse. Nausea and vomiting of pregnancy. 2004; http://www.guideline.gov/content.aspx?id=10939&search=vitamin+deficiency. Accessed 7/1/2014.

23. National Guideline Clearinghouse. Anemia in the long-term care setting. 2007; http://www.guideline.gov/content.aspx?id=10830&search=vitamin+deficiency. Accessed 7/1/2014. 24. Rock CL, Doyle C, Demark-Wahnefried W, et al. Nutrition and physical activity guidelines for cancer survivors. CA: a cancer journal for clinicians. 2012;62(4):243-274. 25. National Guideline Clearinghouse. Health maintenance in the long term care setting. 2012; http://www.guideline.gov/content.aspx?id=45523&search=vitamin+deficiency+and+long +term+care. Accessed 7/1/2014. 26. LeFevre ML, LeFevre NM. Vitamin D Screening and Supplementation in Community- Dwelling Adults: Common Questions and Answers. American family physician. 2018;97(4):254-260. 27. Langan RC, Goodbred AJ. Vitamin B12 Deficiency: Recognition and Management. American family physician. 2017;96(6):384-389. 28. Kulick D, Deen D. Specialized nutrition support. American family physician. 2011;83(2):173-183. 29. American Academy of Family Physicians (AAFP). Choosing Wisely. 2018; https://www.aafp.org/afp/recommendations/search.htm. Accessed June, 2018. 30. American Academy of Family Physicians (AAFP). American Family Physician: Nutrition topics. 2014; http://www.aafp.org/afp/topicModules/viewTopicModule.htm?topicModuleId=86. Accessed July, 2014. 31. FamilyDoctor.org. Vitamins and Minerals: How to Get What You Need. 2007; http://familydoctor.org/familydoctor/en/prevention-wellness/food- nutrition/nutrients/vitamins-and-minerals-how-to-get-what-you-need.html. Accessed June, 2014. 32. FamilyDoctor.org. Vitamin D: What You Need to Know. 2010; https://familydoctor.org/vitamin-d/. Accessed June, 2018. 33. FamilyDoctor.org. Vitamin B-12. 2003; https://familydoctor.org/vitamin-b-12/. Accessed June, 2018. 34. U.S. Food and Drug Adminstration. Fortify Your Knowledge About Vitamins. 2014; http://www.fda.gov/forconsumers/consumerupdates/ucm118079.htm. Accessed July, 2014.