What are the Indian guidelines for appetite stimulation and zinc supplementation?

Indian Guidelines for Appetite Stimulation and Zinc Supplementation

Appetite Stimulation Guidelines

For appetite stimulation in patients with advanced disease, corticosteroids are recommended for short-term use (1-3 weeks), but caution must be exercised due to side effects including muscle wasting, insulin resistance, and infections. 1

Pharmacological Options for Appetite Stimulation:

1. Corticosteroids

   • Recommended for short duration (1-3 weeks) in advanced disease
   • Effective for transient appetite improvement
   • Side effects: myopathy, immunosuppression, insulin resistance, osteopenia 1
   • Best suited for patients with short life expectancy

2. Progestins

   • Can be considered for anorectic cancer patients with advanced disease
   • Side effects include thromboembolism, impotence, vaginal spotting 1
   • Use with caution due to potentially serious adverse effects

3. Long-chain N-3 Fatty Acids/Fish Oil

   • Recommended for patients with advanced cancer undergoing chemotherapy
   • Benefits: stabilizes or improves appetite, food intake, lean body mass, and body weight
   • Should be selected free of mercury, dioxin, and polychlorinated biphenyls 1

4. Non-Pharmacological Approaches

   • Physical activity: Individualized moderate-intensity training (50-75% of baseline maximum heart rate)
   • Resistance exercise: Recommended to maintain muscle strength and mass 1

Zinc Supplementation Guidelines

Indications for Zinc Supplementation:

1. Diarrheal Disease in Children

   • Zinc supplementation significantly reduces duration of diarrhea and stool output during cholera 1
   • Oral zinc supplementation is recommended for children 6 months to 5 years of age who reside in countries with high prevalence of zinc deficiency or who have signs of malnutrition 1

2. Malabsorptive Conditions

   • After bariatric surgery:
     • RYGB and SG: 15 mg zinc daily 1
     • Malabsorptive procedures (BPD/DS): At least 30 mg oral zinc daily 1
   • Maintain ratio of 8-15 mg zinc to 1 mg copper when supplementing both minerals 2

3. Gastrointestinal Losses

   • For patients on parenteral nutrition with GI losses (fistulae, stomas, diarrhea): IV doses up to 12 mg per day 1
   • For major burns >20% BSA: 30-35 mg/day IV for 2-3 weeks 1

4. Acquired Zinc Deficiency

   • Treatment: 0.5-1 mg/kg per day of elemental zinc (Zn²⁺) orally for 3-4 months 1
   • Organic compounds (zinc histidinate, zinc gluconate, zinc orotate) show better tolerability than inorganic forms 1, 3

Dosage and Administration:

• Therapeutic Dosing for Deficiency: 0.5-1 mg/kg/day elemental zinc for 3-4 months 1
• Preventive Dosing: 15 mg daily for standard risk; 30 mg daily for high-risk conditions 1
• Formulations: Zinc citrate and zinc gluconate have comparable absorption (approximately 60%) and are better absorbed than zinc oxide (approximately 50%) 3

Monitoring:

• Monitor plasma zinc levels after 3 months of supplementation
• Simultaneously check copper levels to ensure zinc supplementation isn't causing copper deficiency 2
• Be aware of potential side effects: headaches, nausea, vomiting, decreased appetite, diarrhea, and abdominal cramps 1
• High doses with prolonged use can cause low copper, anemia, leukopenia, neutropenia, and gastrointestinal ulcers 1

Clinical Considerations and Cautions

1. Populations at Higher Risk for Zinc Deficiency:

   • Infants, children, adolescents, pregnant and lactating women 1
   • Patients with eating disorders, vegetarians, vegans 1
   • Those with malabsorptive conditions (short bowel syndrome, bariatric surgery, cystic fibrosis, chronic pancreatitis, IBD) 1
   • Patients consuming diets rich in phytate 1

2. Zinc Deficiency Signs and Symptoms:

   • Severe deficiency: alopecia, skin rash, growth retardation, delayed sexual development, impaired wound healing, immune dysfunction, diarrhea, blunting of taste and smell 1
   • Mild deficiency: reduced growth rate and impaired immune defense 1

3. Zinc Toxicity:

   • Symptoms appear when ingestion exceeds 1-2 g of zinc 1
   • Treatment: anti-emetics, fluids, proton pump inhibitors or H2-blockers 1
   • Chronic toxicity is primarily treated with copper sulfate 1

Remember that zinc is essential for over 300 enzymes and more than 1000 transcription factors. It plays crucial roles in immune function, growth, DNA synthesis, cell division, and protein synthesis 4, 5. Proper supplementation can significantly improve clinical outcomes in deficient individuals.