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Managing Zinc Deciency in an Office Setting

Charles Norwood, MD, and Robert W. Moore, PhD Louisiana State University Medical Center Alexandria, Louisiana Bill Chaney, PD Pineville, Louisiana

Table 1. Formula for Zinc Sulfate Heptahydrate 0.1% Solution.

Rx Zinc sulfate heptahydrate Purified water qs 100 mg 100 mL

Abstract
Zinc, an important nutrient in the human diet, is involved in a host of metabolic processes necessary to maintain good health. Zinc deciency is widespread, even among otherwise well-nourished populations. The zinc taste test is a convenient method of assessing zinc deficiency in a clinical setting. In this article, the procedures followed in administering the zinc taste test are described. Results of performing the test on a sample of convenience (20 family practice residents and faculty members) indicated that only 20% had no zinc deficiency and 15% were severely deficient. The high prevalence of zinc deficiency and the importance of zinc in maintaining good health establish the need for regular zinc level screenings. Because the zinc taste test is so easy to perform, those screenings can be performed in a primary care office setting. related with zinc deficiency.6 Sexual function is affected, and sterility is common, especially in zinc-deficient men. Vision and hearing can be diminished by severe zinc deficiency. Smell and taste dysfunction result from a lack of zinc, and some studies7 have associated zinc deciency with depression. Zinc supplementation in developing countries has been shown to cause a 41% decrease in pneumonia and a 25% decrease in diarrhea.8

Clinical Assessment of Zinc Deciency

The methods of testing for zinc status include serum spectroscopy and analyses of white blood cell content, hair, and urinary excretion. The zinc taste test, which was first described in l984,9 can be performed in the office or at the patients bedside. This test is based on the detection of gustin, a polypeptide in the mouth that distinguishes metals. The test is performed as follows: The patient is asked not to eat, drink, or smoke for 30 minutes before the test. A 0.1% zinc sulfate heptahydrate solution (about 10 mL) (Table 1) is swished in the mouth for 10 seconds. It is then swallowed or expectorated. After 30 seconds, the patient is asked to describe the taste. Responses are classified as follows: 1. No taste or the taste of water is noted. (Severe deficiency) 2. No taste noted initially, but a taste often described as dry, minerally, like a bicarbonate, or sweet develops in 10 or 15 seconds. (Moderate deficiency) 3. A definite but not strongly unpleasant taste is noted immediately and tends to intensify in time. (Mild deficiency) 4. An immediately unpleasant, obviously aversive taste that often causes the patient to grimace is noted. (No deficiency) When compared with other methods, this simple test is inexpensive, easy to perform, and reasonably accurate;10 it can be repeated to follow progress; and its range indicates mild to severe states of zinc deficiency.

Introduction
Zinc is a very important trace element that is found in every tissue, organ, and fluid in the human body.1 Its importance in maintaining good health has been recognized: It is a cofactor in more than 200 enzymatic reactions. Zinc is especially essential for immune function, protein synthesis, and cell growth. Wound healing increases the need for zinc.2 It is required for the manufacture of many hormones produced by the body, and the important antioxidant superoxide dismutase requires zinc to function. Zinc deficiency is a worldwide problem.3 Dietary sources include meats, whole grains, nuts, fruits, vegetables, and oysters. Many soils are deficient in zinc, and much of that element is lost in processing (especially that of grains). Some substances such as phytates can interfere with zinc absorption. Metals such as copper and cadmium compete with zinc for transport in the body. The recommended daily allowance for zinc is 15 mg, but most Americans ingest approximately 10 mg daily from dietary intake.4 To be absorbed, zinc must be broken down to its ionic state by hydrochloric acid in the stomach. Many things interfere with this process, including tablet formulations that do not dissolve well in the stomach. Medications to decrease acid production may also keep zinc from being absorbed. Stress and infections can deplete zinc stores. The body can catabolize zinc from the prostate, muscle, or bone. Fitness enthusiasts are prone to zinc deficiency that results from sweating, and older patients with poor dietary habits are especially vulnerable to zinc deficiency.5 The symptoms of zinc deficiency (the most common of which is fatigue) are many and varied. The heart muscle can be affected; this leads to the development of cardiomyopathy in patients with a severe zinc deficiency. Other common symptoms include poor appetite and digestive problems. Weak immune systems can be cor-

Zinc Deciency in Health Professionals

Residents and faculty of a family practice residency program served as a sample of convenience for demonstrating the administration of the zinc taste test according to the procedures described above. In Figure 1, the levels of zinc deficiency in the 20 participants in the sample are presented. Fifteen percent were severely deficient, 60% were moderately deficient, 5% were mildly deficient, and 20% were not deficient.

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Figure 1. Zinc Deciency Levels Among Family Practice Residents and Faculty.*
70 60 50 40 30

60

20 10 0

15 Severe Moderate 5 Mild

20 None
*(n = 20)

rologist, an endocrinologist and a psychiatrist, none of whom had been able to provide help. She was taking many prescribed drugs, including antidepressants, a proton pump inhibitor, and antihypertensive and antireux medications. Physical examination revealed a very thin, lethargic, weak female. There were no other remarkable findings. Laboratory evaluations indicated a slight anemia. The results of blood chemistry analyses were normal. The patient exhibited a level 1 response to the zinc taste test, which indicated a severe zinc deficiency. Therapy was initiated with the administration of zinc sulfate heptahydrate (15 mg 3 times daily for 2 weeks). The protocol was then changed to the administration of an amino acid chelated zinc tablet. After several months of that treatment, the patient exhibited a remarkable improvement and has discontinued most of her medications.

Percent

Zinc deciency level

Conclusion
Zinc deficiency is highly prevalent, even among otherwise wellnourished health professionals. This seems to be a result of poor zinc availability in the typical American diet. The recommended daily allowance is not appropriate for many patients. The zinc taste test is a good tool for the diagnosis of zinc deficiency in the office setting because of its low cost, low risk, and ease of administration. Additional studies are needed to help understand the role of zinc in maintaining health.

Treatment Options
Treatment options must be tailored to the needs of the individual patient. If the zinc deficiency is severe, treatment should be initiated with the administration of a liquid preparation of zinc sulfate heptahydrate to replenish the metallothionein-1 transport system. In the elderly, 30 to 60 mg daily may be needed. When requirements are great (for example, as a result of trauma, burns, etc.) then up to 150 mg daily11 may be given for a short time, but the effect on the patients level of copper can lead to anemia.12 The zinccopper ratio is 10:1. If 150 mg of zinc is given, then 15 mg of copper must be given also. Selenium may be depleted by large doses of zinc. Coffee, phytates, calcium, and phosphorus may interfere with zinc absorption.13 Alcohol, even in moderate amounts, can increase the excretion of zinc in the urine.

Acknowledgement
The authors thank Ann Howard, MLS, for her help in searching the literature for pertinent material. Charles Norwood, MD, and Robert W. Moore, PhD, are associate professors in and members of the faculty of the Louisiana State University Medical Center family practice residency program. Bill Chaney, PD, a specialist in natural hormone replacement therapy and nutritional supplementation, maintains a private practice in Pineville, Louisiana. Address correspondence to: Charles Norwood, MD, 807 Jackson St., Alexandria, LA 71301.

Case Study
A 78-year-old woman presented with complaint of severe fatigue of 10-month duration. She also complained of abdominal pain, nausea, and weight loss. She was significantly depressed. She had consulted many specialists, including a gastroenterologist, a neu-

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International Journal of Pharmaceutical Compounding 441 Vol.4 No.6 November/December 2000