A 32-year-old woman comes to the office for bloating, intermittent diarrhea, and abdominal cramps. Her symptoms have been ongoing for many years and are usually triggered by meals. Medical history and family history are both unremarkable. Vital signs are within normal limits. BMI is 27 kg/m². The patient is well-appearing, and the abdomen is soft and nontender. Laboratory analysis is unremarkable. The patient is diagnosed with irritable bowel syndrome, and it is recommended that she take loperamide and consume an adequate amount of dietary fiber. After reading about her disorder on the internet, the patient decides to manage her symptoms with a strict vegan diet. Which of the following should be provided as a nutritional supplement for this patient?

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11ec160b_3cc4_94fa_9249_cdfed2fcc62e_MD0001_00 Individuals who adhere to a vegan diet consume only plant-based foods and avoid all meat and other animal-derived products (eg, milk). Adherence to a vegan diet is associated with a decreased risk of type 2 diabetes, hypercholesterolemia, coronary artery disease, and stroke. However, most people obtain a significant portion of daily calcium and vitamin D requirements from dairy products; individuals on a vegan diet often consume less calcium and vitamin D than non-vegans. Supplementation is recommended to avoid long-term consequences, including osteoporosis and bone fractures. Cobalamin (vitamin B₁₂) deficiency can also be seen in vegans, leading to megaloblastic anemia and subacute combined degeneration of the dorsal columns of the spinal cord. (Choice B) Folic acid is found in many plant-based products, including leafy vegetables and legumes. Supplementation is recommended during pregnancy to prevent fetal neural tube defects but is not needed in a vegan diet. (Choice C) Magnesium is found in almost all foods. Hypomagnesemia can cause neuromuscular excitability (eg, tetany) and arrythmias but is usually related to fluid losses (eg, diarrhea, diuretic use) or heavy alcohol use rather than dietary inadequacy. (Choice D) Niacin deficiency can lead to pellagra, characterized by diarrhea, dermatitis, and possible dementia. Deficiency usually occurs in severely malnourished individuals (eg, alcohol use disorder, anorexia nervosa); however, niacin is found in a number of common vegetables and deficiency is uncommon in a vegan diet. (Choice E) Thiamine is found in legumes, brown rice, and whole-grain cereal. Thiamine deficiency is most common in those with alcohol use disorder and leads to Wernicke-Korsakoff syndrome (oculomotor dysfunction, ataxia, memory loss). Educational objective: Individuals on a vegan diet are at increased risk for deficiencies in calcium and vitamin D. Supplementation is recommended to avoid long term consequences, including osteoporosis and bone fractures. Cobalamin (vitamin B₁₂) deficiency can also occur. __________ References: Bone nutrients for vegetarians. (http://www.ncbi.nlm.nih.gov/pubmed/24898231) The long-term health of vegetarians and vegans. (http://www.ncbi.nlm.nih.gov/pubmed/26707634)

A 32-Year-Old Woman Comes to the Office for Bloating, Intermittent