Indications for testing

• Patient with chronic illness, malabsorption or bariatric surgery
• Patients with known exposure (e.g., industrial accident)

Laboratory testing

• Order testing (chromium, copper, selenium and zinc) based on clinical scenario and/or presence of symptoms
• Fasting serum or plasma testing best reflects current nutritional status
• Urine testing may be useful for detecting exposures and for monitoring decontamination efforts

• Not recommended in the general population
• May be indicated in at-risk populations or for those on chronic parenteral feeding

The primary trace minerals of nutritional significance are chromium, copper, selenium and zinc. Signs and symptoms of toxicity correlate with routes of exposure, specific elemental form(s) to which a person is exposed, and whether exposure is acute or chronic. Deficiencies of these minerals may exist in:

•  Patients with
  • Chronic illness (eg, HIV)
  • Malabsorption syndrome
  • Unbalanced diet or parenteral nutrition
  • Pica
• Patients post-bariatric surgery
• Preterm infants

Individual Trace Minerals

Chromium

• Function – potentiates the action of insulin in patients with impaired glucose tolerance; may also improve lipid profiles (proven in animal studies but not in humans)
• Sources – yeast, meat, grain products
  • 30 µg/day considered adequate
• Deficiency – impaired glucose tolerance (poor evidence and largely historical; very flawed studies)
• Toxicity – dermatitis, renal failure, metal fume fever, pulmonary cancers (from chromium VI); unknown outside of industrial exposures
• Recommended daily intake (RDI) – no need for chromium supplementation (FDA and American Diabetes Association)

Copper

• Function – integral part of numerous enzyme systems including amine oxidase, ferroxidase, superoxide dismutase, dopamine hydroxylase
• Sources – shellfish, liver, nuts, legumes, bran, organ meats
• Deficiency –  anemia, osteopenia, degenerative changes in aortic elastin, growth retardation, hair pigment changes, cerebral and cerebellar degeneration (prototype is Menkes syndrome)
• Toxicity – nausea, emesis, diarrhea, hemolytic anemia, neurodegeneration, hepatic failure, Wilson disease
  • Toxicity more likely at intake of 10 mg/day 
• RDI – 0.9 mg/day

Selenium

• Function – component of the enzyme glutathione peroxidase which serves to protect proteins, cell membranes, lipids and nucleic acids from oxidant molecules
• Sources – seafood, muscle meat, cereals
• Deficiency – cardiomyopathy and heart failure (Keshan disease), striated muscle degeneration, deforming arthritis (Kashin-Bek disease)
  • Present in up to 20% of patients after bariatric surgery
• Toxicity – alopecia, nausea, emesis, dermatitis
• Supplementation recommended post-bariatric surgery
• RDI – 35 µg/day

Zinc

• Function – integral component of metalloenzymes; synthesizes and stabilizes proteins, DNA and RNA
• Sources – meat, shellfish, nuts, legumes
• Deficiency – growth retardation, alopecia, dermatitis, diarrhea, failure to thrive, congenital malformations
• Toxicity – reduced copper absorption, gastritis, fever, nausea, emesis, metal fume fever
  • 300-600 mg/day may induce sideroblastic anemia
• Supplementation recommended with clinical management of childhood diarrhea
• RDI – 15 mg/day

Tests generally appear in the order most useful for common clinical situations

General

• Gasteyger C, Suter M, Gaillard RC, Giusti V. Nutritional deficiencies after Roux-en-Y gastric bypass for morbid obesity often cannot be prevented by standard multivitamin supplementation. Am J Clin Nutr. 2008; 87 (5) :1128-1133.PubMed
• Hambidge KM, Krebs NF. Zinc deficiency: a special challenge. J Nutr. 2007; 137 (4) :1101-1105.PubMed
• Kirby M, Danner E. Nutritional deficiencies in children on restricted diets. Pediatr Clin North Am. 2009; 56 (5) :1085-1103.PubMed
• Kumar N. Neurologic presentations of nutritional deficiencies. Neurol Clin. 2010; 28 (1) :107-170.PubMed
• Marian M, Sacks G. Micronutrients and older adults. Nutr Clin Pract. 2009; 24 (2) :179-195.PubMed
• Schweitzer DH, Posthuma EF. Prevention of vitamin and mineral deficiencies after bariatric surgery: evidence and algorithms. Obes Surg. 2008; 18 (11) :1485-1488.PubMed
• Shah MD, Shah SR. Nutrient deficiencies in the premature infant. Pediatr Clin North Am. 2009; 56 (5) :1069-1083.PubMed
• Suskind DL. Nutritional deficiencies during normal growth. Pediatr Clin North Am. 2009; 56 (5) :1035-1053.PubMed
• Tapiero H, Tew KD. Trace elements in human physiology and pathology: zinc and metallothioneins. Biomed Pharmacother. 2003; 57 (9) :399-411.PubMed
• Thompson J. Vitamins, minerals and supplements: 6: minerals (1). Community Pract. 2007; 80 (2) :34-35.PubMed

ARUP Institute for Clinical and Experimental Pathology®

• Bornhorst JA, Hunt JW, Urry FM, McMillin GA. Comparison of sample preservation methods for clinical trace element analysis by inductively coupled plasma mass spectrometry. Am J Clin Pathol. 2005; 123 (4) :578-583.PubMed

Malabsorption
Vitamins