genpathNutriDse

8/9/2019 genpathNutriDse

1/66

Environmental pathologyEnvironmental pathology::disordersdisorders

ofofNutritionNutrition

Ma.Ma. MindaMinda Luz M.Luz M. ManuguidManuguid, M.D, M.D..


2/66

Nutritional Disease

MALNUTRITION- usually used as asynonym of Undernutrition, but may be

caused by dietary excesses as well. Undernutrition is globally the most

important category of EnvironmentalDisease

Overnutrition- predisposes to illnesses& increased mortality


3/66

EtiologyEtiology ofof MMalnutritionalnutrition

Primary: lack of foodPrimary: lack of food-- esp. Proteinesp. Protein

Secondary:Secondary:

Reduced intakeReduced intake-- poor dentition; dysphagia;poor dentition; dysphagia;systemic dses w/ anorexia; bizarre/restrictedsystemic dses w/ anorexia; bizarre/restricteddiets;diets;Anorexia nervosaAnorexia nervosa

***Overt morphologic changes are relatively latemanifestations & may be preceded for long

periods of time by functional deficits.***


4/66

Anorexia nervosa


5/66

Etiology ofEtiology of MalnutritionMalnutrition

Secondary MalnutritionSecondary Malnutrition MalabsorptionMalabsorption-- biliary/pancreatic dses; entericbiliary/pancreatic dses; enteric

malabsorption syndromes; pernicious anemiamalabsorption syndromes; pernicious anemia(vit B12 malabsorption)(vit B12 malabsorption)

Increased requirementsIncreased requirements-- rapid growth periodsrapid growth periods(infancy, childhood, adolescence); pregnancy;(infancy, childhood, adolescence); pregnancy;trauma/wound healing; burns; excessive lossestrauma/wound healing; burns; excessive losses(enteropathies, nephropathies)(enteropathies, nephropathies)

Special categoriesSpecial categories-- TPN (total parenteral /iVTPN (total parenteral /iVnutrition); drug interference with absorption;nutrition); drug interference with absorption;genetic metabolic disordersgenetic metabolic disorders


6/66

ProteinProtein-- calorie malnutrition/calorie malnutrition/

ProteinProtein-- energy malnutritionenergy malnutritionworldwide incidenceworldwide incidence

mostly affects childrenmostly affects children

KwashiorkorKwashiorkor-- mainlyProtein deficiencymainlyProtein deficiency

MarasmusMarasmus-- mainly Carbohydrate deficiencymainly Carbohydrate deficiency

common features:common features: growth failure;growth failure;

anemia, hypoplastic bone marrowanemia, hypoplastic bone marrow impairment of the immune response &impairment of the immune response &

increased susceptibility to infections;increased susceptibility to infections;

thymus & lymph node atrophythymus & lymph node atrophy


7/66

Kwashiorkor & MarasmusApathyApathy;;AnorexiaAnorexia

moonfacemoonface-- round,round,edematousedematous

AnasarcaAnasarcabipedalbipedalpitting edema, ascitespitting edema, ascites --low serum Albuminlow serum Albumin

Fatty hepatomegalyFatty hepatomegaly

Flag sign (hair)Flag sign (hair)

Flaky paint lesionFlaky paint lesion

GI mucosal atrophyGI mucosal atrophy

AlertnessAlertness;;HungerHunger

old mans faceold mans face--pinched, wizenedpinched, wizened

skin & bones,skin & bones,broomstick limbsbroomstick limbs--muscle wasting; loss ofmuscle wasting; loss ofsubcutaneous fatsubcutaneous fat

Cerebral atrophy:Cerebral atrophy: no. no.of neuronsof neurons

Organ atrophyOrgan atrophy


8/66

Kwashiorkor& Marasmus

flaky paint dermatosis cerebral atrophy

flag sign-hair reduced number of

Ascites; intestinal parasitism neurons


9/66

Kwashiorkor & Marasmus


10/66

KKwashiorkorwashiorkor


11/66

Nutritional excess: Obesity

too much food and/ortoo much food and/ortoo little activitytoo little activity

Storage of excessStorage of excesscalories in fat depotscalories in fat depots

GeneticGeneticpredispositionpredisposition--

minimal roleminimal role

Men are apples, womenMen are apples, womenare pearsare pears


12/66

Obesity

BMIBMI-- body mass indexbody mass index

Healthy Weight: BMI between 18.6 to 24.9Overweight: BMI between 25 to 29.9Obesity: BMI between 30 to 34.9Severe Obesity: BMI between 35 to 39.9

MorbidO

besity: BMI over 40


13/66

Obesity

Insulin resistanceInsulin resistance Diabetes mellitus IIDiabetes mellitus II

HypertensionHypertension

Coronary heart diseaseCoronary heart disease

HyperlipidemiaHyperlipidemia

Cholesterol gallstonesCholesterol gallstones

OsteoarthritisOsteoarthritis,, esp. kneesesp. knees

Pickwickian syndromeP

ickwickian syndrome assoc w/ breast, colon CAassoc w/ breast, colon CA

excess mortality over theexcess mortality over thegeneral populationgeneral population


14/66

Pickwickian syndrome

obesity, hypersomnolence, narcolepsy,obesity, hypersomnolence, narcolepsy,sleep apneasleep apnea

respiratory difficulty,respiratory difficulty, vital capacityvital capacity


15/66

Vitamins

Vitamins are organic micronutrientsVitamins are organic micronutrientsessential for health ; they act as criticalessential for health ; they act as critical

catalytic cocatalytic co--factors or prosthetic groups onfactors or prosthetic groups onenzymes in vital metabolic reactionsenzymes in vital metabolic reactions

FatFat--soluble vitamins : vit A, vit D, vit E & vit Ksoluble vitamins : vit A, vit D, vit E & vit K

WaterWater--soluble Vitamins : vit C, vit B1, B2, B6,soluble Vitamins : vit C, vit B1, B2, B6,B12, Niacin, Pantothenic acid; Biotin; FolicB12, Niacin, Pantothenic acid; Biotin; Folicacidacid


16/66

Fat-soluble vitamins::

A, D, E,K need fat, bile salts, & pancreatic enzymesneed fat, bile salts, & pancreatic enzymes

to be absorbed in the GITto be absorbed in the GIT

can be stored in the bodycan be stored in the body

can give rise to toxicity syndromescan give rise to toxicity syndromes

not easily destroyed by cookingnot easily destroyed by cooking


17/66

vitamin A: Retinol,

Retinoic acid, Retinalsourcessources: eggs, butter,: eggs, butter,meat, whole milk, fishmeat, whole milk, fish

liver; carotenoids, esp.liver; carotenoids, esp.--carotene, in leafycarotene, in leafygreen & yellowgreen & yellow

vegetables: spinach,vegetables: spinach,

carrots, sweet potatoes,carrots, sweet potatoes,squashsquash

storagestorage: Liver: Liver


18/66

Vitamin A

actionsactions:: maintains the integrity of mucosal membranes;maintains the integrity of mucosal membranes;

needed in vision, esp. dark vision;needed in vision, esp. dark vision;

enhances immunity to infections esp. in childrenenhances immunity to infections esp. in children

is an antiis an anti--oxidant (antioxidant (anti--cancer, anticancer, anti--aging)aging) deficiencydeficiency :

NyctalopiaNyctalopia-- night blindnessnight blindnessusually the firstusually the first SxSx

SquamousSquamous metaplasiametaplasia ofof mucosaemucosae

XerophthalmiaXerophthalmia-- conjunctivalconjunctival keratinizationkeratinization Follicular hyperkeratosisFollicular hyperkeratosis;;AcneAcne

Impaired immunityImpaired immunityinin chidrenchidren,, susceptibility tosusceptibility toinfections, esp. measlesinfections, esp. measles


19/66

Vitamin A deficiency

KeratomalaciaKeratomalacia--corneal softeningcorneal softening

& ulceration& ulcerationcorneal scarringcorneal scarringblindnessblindness

Bitots spotsBitots spots--

graygray--whitewhiteplaques of piledplaques of piled--up squamous cellsup squamous cells


20/66

Hypervitaminosis A Headaches; nausea; vomiting; diarrhea;Headaches; nausea; vomiting; diarrhea;

irritability; drowsiness; alopeciairritability; drowsiness; alopecia Lymphadenopathy; immunologicLymphadenopathy; immunologic

abnormalitiesabnormalities

Bony hyperostosisBony hyperostosis Hypercarotenemia: yellowHypercarotenemia: yellow--orangeorange

discoloration of skin but not the scleraediscoloration of skin but not the sclerae In infants: premature closure of fontanelsIn infants: premature closure of fontanels

Synthetic retinoids given to pregnant womenSynthetic retinoids given to pregnant womenpredispose to congenital malformations of thepredispose to congenital malformations of thechild.child.


21/66

Vitamin DVitamin D ::

ErgosterolErgosterol;; CalcitriolCalcitriolsourcessources:: endogenousendogenous synthesis insynthesis in

skin exposed to UV light:skin exposed to UV light:77--dehydrocholesteroldehydrocholesterol

vit Dvit D exogenous/dietaryexogenous/dietary: deep sea: deep sea

fish; grains; fortified milk &fish; grains; fortified milk &

dairy productsdairy productsactionsactions: maintenance of: maintenance of

adequate Calcium &adequate Calcium &Phosphate levels for normalPhosphate levels for normal

bone mineralizationbone mineralization


22/66

VitaminVitamin DD

deficiency & excessdeficiency & excess deficiencydeficiency: Inadequate bone mineralization :: Inadequate bone mineralization : in childrenin children--RicketsRickets inadequate provisionalinadequate provisional

calcification of epiphyseal cartilagecalcification of epiphyseal cartilage impaired boneimpaired bonegrowth; excess of unmineralized osteoidgrowth; excess of unmineralized osteoid

in adultsin adults-- OsteomalaciaOsteomalacia osteopeniaosteopenia---- susceptibility to fractures, most often of thesusceptibility to fractures, most often of thevertebrae, hips, wrists, ribs; kyphoscoliosisvertebrae, hips, wrists, ribs; kyphoscoliosis

--Loosers zones /milkmans fractures:Loosers zones /milkmans fractures: radiolucentradiolucentnarrow lines at right angles to cortical outlines ofnarrow lines at right angles to cortical outlines of

bonesbones-- usually bilateral, symmetrical, in scapulae,usually bilateral, symmetrical, in scapulae,lower ribs, neck of proximal femur, posterior marginslower ribs, neck of proximal femur, posterior marginsof proximal ulnaeof proximal ulnae

excessexcess : Hypercalcemia :: Hypercalcemia : metastatic calcification; renal calculimetastatic calcification; renal calculi


23/66

RRicketsickets

Bowed legsBowed legs

Rachitic rosaryRachitic rosary--

costochondral overgrowthcostochondral overgrowth pigeon breast deformitypigeon breast deformity--

anterior sternal protrusionanterior sternal protrusion

Harrisons grooveHarrisons groove-- depresseddepressedlower margin of ribslower margin of ribs

Craniotabes: frontal bossing,Craniotabes: frontal bossing,squared headsquared head

Lumbar lordosisLumbar lordosis


24/66

VitaminV itamin EE ::

TocopherolsTocopherols,

,

TocotrienolsTocotrienols**most potent ismost potent is --tocopheroltocopherolsourcessources: vegetables; wheat;: vegetables; wheat;grains & their oils; fish, nuts;grains & their oils; fish, nuts;margarine; eggs; butter;margarine; eggs; butter;liver; sweet potatoesliver; sweet potatoes

actionaction: ANTI: ANTI--OXIDANTOXIDANT--protects cellular & subprotects cellular & sub--cellular polyunsaturatedcellular polyunsaturated

membrane fatty acidsmembrane fatty acidsabsorptionabsorption: requires fat: requires fat

storagestorage: adipose tissue; liver,: adipose tissue; liver,musclemuscle


25/66

VitaminV itamin EE

deficiency & excessdeficiency & excess Vitamin E deficiency:Vitamin E deficiency: spinocerebellar degenerationspinocerebellar degeneration-- dysarthria;dysarthria;

ophthalmoplegia; ataxia; loss of position &ophthalmoplegia; ataxia; loss of position &

vibration sense; loss of pain sensationvibration sense; loss of pain sensation Skeletal muscle changesSkeletal muscle changes-- to absent tendonto absent tendonreflexesreflexes

Hemolytic anemiaHemolytic anemia in infantsin infants

Pigmented retinopathyP

igmented retinopathy Vitamin E excess:Vitamin E excess:

gastrointestinal disturbancesgastrointestinal disturbances


26/66

Vitamin K: sources

EndogenousEndogenous --made inmade inthe body by normalthe body by normalintestinal bacterial floraintestinal bacterial flora(acidophilus)(acidophilus)

ExogenousExogenous-- green leafygreen leafyvegetables, liver, milk,vegetables, liver, milk,vegetable oils, egg yolks,vegetable oils, egg yolks,

tomatoes, whole grains,tomatoes, whole grains,seaweed, oats and meat.seaweed, oats and meat.

*Storage: Liver & Bones**Storage: Liver & Bones*


27/66

Vitamin K: actions

needed as coneeded as co--factor in the manufacture offactor in the manufacture ofclotting factors II (clotting factors II (ProthrombinProthrombin), VII, IX, &), VII, IX, &X (X (vitvit KK--dependent clotting factors /dependent clotting factors /

ProthrombinProthrombin complex)complex) helps keep proper bone density; involved inhelps keep proper bone density; involved in

bone formation and repair; possibly slowsbone formation and repair; possibly slowsdown bone loss & decreases the severity ofdown bone loss & decreases the severity ofOsteoporosis esp. in postmenopausal womenOsteoporosis esp. in postmenopausal women

assists in converting glucose to glycogen inassists in converting glucose to glycogen inthe liverthe liver


28/66

Vitamin K

deficiency & excess deficiencydeficiency::

APCD: acquired ProthrombinAPCD: acquired Prothrombincomplex deficiencycomplex deficiency-- in infantsin infantspurely breastfed & born atpurely breastfed & born athome & in adults on antibiotichome & in adults on antibiotictherapytherapy-- bleeding diathesisbleeding diathesis--into skin, umbilicus, viscerainto skin, umbilicus, viscera

toxicitytoxicity: rare: rare-- flushing,flushing,sweating, jaundice andsweating, jaundice and

anemiaanemia


29/66

WaterWater--soluble vitamins:soluble vitamins:

vitvit B complex &B complex & vitvit CC easily lost during cooking and processing.easily lost during cooking and processing. excess quantities of most, except vits B6 & B12, are notexcess quantities of most, except vits B6 & B12, are not

stored by the body & are readily excreted in urine, sostored by the body & are readily excreted in urine, so

foods bearing them must be consumed frequentlyfoods bearing them must be consumed frequently generally nontoxic when present in excess of needs,generally nontoxic when present in excess of needs,although symptoms may be reported in people takingalthough symptoms may be reported in people takingmegadoses of niacin, vitamin C, or pyridoxine (vit B6).megadoses of niacin, vitamin C, or pyridoxine (vit B6).

All the B vitamins function as coenzymes or cofactors,All the B vitamins function as coenzymes or cofactors,assisting in the activity of important enzymes andassisting in the activity of important enzymes andallowing energyallowing energy--producing reactions to proceed normally.producing reactions to proceed normally.

any deficiency mostly affects growing or rapidlyany deficiency mostly affects growing or rapidlymetabolizing tissues such as skin, blood, the digestivemetabolizing tissues such as skin, blood, the digestivetract, and the nervous systemtract, and the nervous system


30/66

VitVit B1 : ThiamineB1 : Thiamine

SourcesSources: Pork/pork: Pork/porkproducts, beef, liver,products, beef, liver,

yeast/baked products,yeast/baked products,enriched and wholeenriched and wholegrain cereals, nuts &grain cereals, nuts &seeds, milk, leafy greenseeds, milk, leafy green

vegetablesvegetables ToxicityToxicity: none reported: none reported


31/66

TThiaminehiamine:: actionsactions

active form:active form: thiaminethiaminepyrophosphate (TPP)pyrophosphate (TPP)

coco--factor in the oxidativefactor in the oxidative

decarboxylation ofdecarboxylation of --ketoacids in the synthesis ofketoacids in the synthesis ofATP (metabolism ofATP (metabolism ofcarbohydrates)carbohydrates)

coco--factor for transketolase infactor for transketolase inthe PPPthe PPP

maintenance of neuralmaintenance of neuralmembranes & normal nervemembranes & normal nerveconductionconduction


32/66

Thiamine deficiency

dryBeriBeri:dryBeriBeri: anorexia, weight loss,anorexia, weight loss,weakness, peripheral neuropathyweakness, peripheral neuropathy

wetBeriwetBeri--beriberi: anasarca; high: anasarca; high--outputoutputcardiac failure (dilated, flabby heart)cardiac failure (dilated, flabby heart)

WernickeWernicke--Korsakoff syndromeKorsakoff syndrome: in: inchronic alcoholics: staggered gait,chronic alcoholics: staggered gait,crossed eyes, dementia, disorientation,crossed eyes, dementia, disorientation,memory lossmemory loss


33/66

VitVit B2 : RiboflavinB2 : Riboflavin

SourcesSources: Milk, eggs,: Milk, eggs,

mushrooms, wholemushrooms, wholegrains, enrichedgrains, enrichedgrains, green leafygrains, green leafy

vegetables, yeast,vegetables, yeast,

liver, and oily fishliver, and oily fish


34/66

Riboflavin stable when heated in ordinary cooking, but notstable when heated in ordinary cooking, but not

when the food is exposed to ultraviolet radiationwhen the food is exposed to ultraviolet radiation/sunlight; To prevent riboflavin breakdown,/sunlight; To prevent riboflavin breakdown,riboflavinriboflavin--rich foods such as milk, milk products,rich foods such as milk, milk products,

and cereals are packaged in opaque containers.and cereals are packaged in opaque containers. is a component of two coenzymesis a component of two coenzymesflavinflavin

mononucleotide (FMN) and flavin adeninemononucleotide (FMN) and flavin adeninedinucleotide (FAD)dinucleotide (FAD)that act as hydrogen carriersthat act as hydrogen carriers

when carbohydrates and fats are used to producewhen carbohydrates and fats are used to produce

energyenergy is helpful in maintaining good vision and healthyis helpful in maintaining good vision and healthy

hair, skin and nails, and it is necessary for normalhair, skin and nails, and it is necessary for normalcell growthcell growth


35/66

Riboflavin: deficiency & excess

deficiencydeficiency:: AriboflavinosisAriboflavinosis::inflammation of tongueinflammation of tongue((glossitisglossitis), cracks at corners), cracks at corners

of mouth (of mouth (cheilosischeilosis),),stomatitis, dermatitis,stomatitis, dermatitis,conjunctivitis, growthconjunctivitis, growthretardation, cornealretardation, corneal

vascularization, nervevascularization, nervedamagedamage

toxicitytoxicity: none reported: none reportedmagenta tongue


36/66

Niacin: niacinamide,

nicotinamide,

nicotinic acid readily absorbed from the stomach and the smallreadily absorbed from the stomach and the small

intestinesintestines stored in small amounts in the liver and transported tostored in small amounts in the liver and transported to

tissues, where it is converted to coenzyme formstissues, where it is converted to coenzyme forms any excess is excreted in urineany excess is excreted in urine one of the most stable of the B vitamins, is resistant toone of the most stable of the B vitamins, is resistant to

heat and light, and to both acid and alkaliheat and light, and to both acid and alkalienvironmentsenvironments

coco--enzymes in redox reactionsenzymes in redox reactions The human body is capable of converting the aminoThe human body is capable of converting the aminoacid tryptophan to niacin when needed.acid tryptophan to niacin when needed.

However, when both tryptophan and niacin areHowever, when both tryptophan and niacin aredeficient, tryptophan is used for protein synthesis.deficient, tryptophan is used for protein synthesis.


37/66

Niacin / Nicotinic acid

high doseshigh doses taken orally as nicotinic acid at 1.5taken orally as nicotinic acid at 1.5to 2 grams per day can decrease cholesterol andto 2 grams per day can decrease cholesterol and

triglyceride levels, and along with diet andtriglyceride levels, and along with diet andexercise can slow or reverse the progression ofexercise can slow or reverse the progression ofheart disease.heart disease.

toxicitytoxicity: flushing of skin, itching, nausea &: flushing of skin, itching, nausea &vomiting, and liver damage occurs at intakevomiting, and liver damage occurs at intakeover 35 mg/day from supplementsover 35 mg/day from supplements


38/66

Niacin deficiency

PELLAGRA:PELLAGRA:diarrheadiarrheadermatitisdermatitis

dementiadementia LongLong--term deficiencyterm deficiency

leads to central nervousleads to central nervoussystem dysfunctionsystem dysfunction

manifested as confusion,manifested as confusion,apathy, disorientation,apathy, disorientation,and eventually coma andand eventually coma anddeath.death.


39/66

vit B5: Pantothenic acid

sourcessources : widely distributed in: widely distributed infoods; watercress; broccoli;foods; watercress; broccoli;alfalfa sprouts; mushroomsalfalfa sprouts; mushrooms

actionaction: incorporated in: incorporated incoenzyme A, as cocoenzyme A, as co--factor infactor incarboxylation reactionscarboxylation reactions

deficiencydeficiency: rare: muscle: rare: musclecramps; poor concentration;cramps; poor concentration;

teeth grinding; nausea &teeth grinding; nausea &vomitingvomiting

toxicitytoxicity: none reported: none reported


40/66

Vit B6: Pyridoxine

sourcessources: meat, fish, poultry,: meat, fish, poultry,spinach, potatoes, bananas,spinach, potatoes, bananas,avocados, sunflower seeds,avocados, sunflower seeds,eggs, whole grains, fortifiedeggs, whole grains, fortified

breads & cereals, legumesbreads & cereals, legumes

actionsactions:: natural antinatural anti--

depressant; needed indepressant; needed inbalancing proteins, inbalancing proteins, inhormone production, & inhormone production, & in

balancing the sex hormonesbalancing the sex hormones


41/66

Pyridoxine

deficiency & excess deficiency: dermatitis, cheilosis, glossitis,

peripheral neuropathy (tingling hands),

anemia, convulsion, depression,confusion, decline in immune function,water retention, nervous irritability

toxicity: none from foods, but excess

intake above 100 mg/day fromsupplements causes neuropathy (nervedestruction) and skin lesions


42/66

Vit B8 : Biotin

sourcessources: Whole grains,: Whole grains,eggs, nuts and seeds,eggs, nuts and seeds,

widely distributed inwidely distributed insmall amountssmall amounts

actionaction: cofactor in: cofactor incarboxylation reactionscarboxylation reactions

deficiencydeficiency: Infants:: Infants:dermatitis, convulsions,dermatitis, convulsions,hair loss (alopecia),hair loss (alopecia),

neurological disorders,neurological disorders,impaired growthimpaired growth

toxicitytoxicity: not known: not known


43/66

Folic acid / Folate

sourcessources: ready: ready--toto--eat breakfasteat breakfastcereals, enriched graincereals, enriched grainproducts, green vegetables,products, green vegetables,

liver, legumes, orangesliver, legumes, oranges

actionsactions: transfer & utilization: transfer & utilizationof C units in DNA synthesis;of C units in DNA synthesis;maturation of RBCmaturation of RBC

**The use of fortified foods are**The use of fortified foods areencouraged for all women ofencouraged for all women ofchild bearing age (15child bearing age (15--4545yearsyears))****


44/66

Folate

deficiency & toxicity deficiencydeficiency::

megaloblasticmegaloblastic

(macrocytic) anemia,(macrocytic) anemia,abdominal pain,abdominal pain,diarrhea, birth defectsdiarrhea, birth defectsin babies of deficientin babies of deficient

pregnant womenpregnant women toxicitytoxicity: none (up to 5: none (up to 5

mg/day);mg/day);


45/66

Vit B12: Cyanocobalamin

found in its freefound in its free--vitamin form, called cyanocobalamin,vitamin form, called cyanocobalamin,and in two active coenzyme formsand in two active coenzyme forms

absorption requires the presence ofabsorption requires the presence ofintrinsic factor ofintrinsic factor ofCastle,Castle, a protein synthesized by gastric parietal cellsa protein synthesized by gastric parietal cells

absorbed in the ileumabsorbed in the ileum

stored in the liverstored in the liver

efficiently conserved in the body, since most of it isefficiently conserved in the body, since most of it issecreted into bile and reabsorbedsecreted into bile and reabsorbed

stable when heated and slowly loses its activity whenstable when heated and slowly loses its activity whenexposed to light, oxygen, and acid or alkalineexposed to light, oxygen, and acid or alkalineenvironmentsenvironments


46/66

Vit B12: Cobalamin,

Cyanocobalamin sourcessources: meat, fish (tuna,: meat, fish (tuna,

sardines); poultry, oysters,sardines); poultry, oysters,readyready--toto--eat fortifiedeat fortified

breakfast cereals, eggs,breakfast cereals, eggs,fermented dairy productsfermented dairy products(cheese, yogurt, etc).(cheese, yogurt, etc).

**The use of fortified foods**The use of fortified foodsand supplements areand supplements arerecommended for adults 51recommended for adults 51and over**and over**


47/66

Cyanocobalamin

coenzymes help recycle folate coenzymes involved incoenzymes help recycle folate coenzymes involved inthe synthesis of DNA and RNA, and in the normalthe synthesis of DNA and RNA, and in the normalformation of red blood cellsformation of red blood cells

prevents degeneration of the myelin sheaths esp. ofprevents degeneration of the myelin sheaths esp. ofspinal cord tracts & help maintain normal electricalspinal cord tracts & help maintain normal electricalconductivity through the nervesconductivity through the nerves

since vit B12 is well conserved in the body, it is difficultsince vit B12 is well conserved in the body, it is difficult

to become deficient from dietary factors alone, unless ato become deficient from dietary factors alone, unless aperson is a strictperson is a strict veganvegan and consumes a diet devoid ofand consumes a diet devoid ofeggs and dairy for several years.eggs and dairy for several years.


48/66

Vit B12 deficiency

usually observed when B12 absorption isusually observed when B12 absorption ishampered by disease or surgery to the stomachhampered by disease or surgery to the stomachor ileum,or ileum,

damage to gastric mucosa by alcoholism, ordamage to gastric mucosa by alcoholism, or prolonged use of antiprolonged use of anti--ulcer medications thatulcer medications that

affect secretion of intrinsic factor.affect secretion of intrinsic factor. ageage--related decrease in stomach acidrelated decrease in stomach acid

production also reduces absorption of B12 inproduction also reduces absorption of B12 inelderly personselderly persons****These groups are advised to consume fortifiedThese groups are advised to consume fortified

foods or take a supplemental form of vitaminfoods or take a supplemental form of vitaminB12**B12**


49/66

Cobalamin

deficiency & toxicity deficiencydeficiency::Pernicious AnemiaPernicious Anemia::macrocytic anemia;macrocytic anemia;

Combined degeneration ofCombined degeneration ofposterolateral spinal cordposterolateral spinal cordtracts:tracts: paresthesia (tinglingparesthesia (tinglingand numbness in limbs),and numbness in limbs),tender muscles, difficultytender muscles, difficulty

walking, loss of bowel andwalking, loss of bowel andbladder control, dementiabladder control, dementia

toxicitytoxicity: none reported: none reported


50/66

Choline for many years not considered a vitamin;for many years not considered a vitamin;

however, research now shows that production inhowever, research now shows that production inthe body is not enough to cover requirements.the body is not enough to cover requirements.CholineCholine is not considered a B vitamin because itis not considered a B vitamin because it

does not have a coenzyme function and thedoes not have a coenzyme function and theamount in the body is much greater than other Bamount in the body is much greater than other Bvitamins.vitamins. helps maintain the structural integrity ofhelps maintain the structural integrity of

membranes surrounding every cell in the bodymembranes surrounding every cell in the body

can play a role in nerve signaling, cholesterolcan play a role in nerve signaling, cholesteroltransport, and energy metabolism.transport, and energy metabolism. widely found in foods, so it is unlikely that awidely found in foods, so it is unlikely that a

dietary deficiency will occur.dietary deficiency will occur.


51/66

VitC: Ascorbic acid

SourcesSources::

citrus fruits,citrus fruits,

strawberries,strawberries,

guavasguavas

pepperspeppers

greens, broccoligreens, broccoli

tomatoestomatoes


52/66

Ascorbic acid actions

AntiAnti--oxidant : protects membranes, antioxidant : protects membranes, anti--aging,aging,antianti--cancercancer

Collagen synthesis: proper wound healing,Collagen synthesis: proper wound healing,integrity of blood vessel wallsintegrity of blood vessel walls

Biosynthesis of neurotransmittersBiosynthesis of neurotransmitters

Carnitine biosynthesisCarnitine biosynthesis

Immunologic functionImmunologic function


53/66

vitvit C deficiencyC deficiency (Scurvy(Scurvy) &) &

hyperv

itaminosishyperv

itaminosis CC deficiencydeficiency:: SCURVYSCURVY: in adults: in adults--

fatigue, poor wound healing, pinpointfatigue, poor wound healing, pinpointhemorrhages around hair follicles onhemorrhages around hair follicles on

back of arms & legs, bleeding gums &back of arms & legs, bleeding gums &joints; in childrenjoints; in children-- hemorrhages,hemorrhages, skinskinpurpura over lower legspurpura over lower legs, gingival, gingivalswelling, perifollicular hyperkeratoticswelling, perifollicular hyperkeratoticpapular rash, scorbutic rosary papular rash, scorbutic rosary (abnormal osteoid)(abnormal osteoid)

toxicitytoxicity: megadoses over 2 g/day: megadoses over 2 g/daycause nausea, abdominal cramps,cause nausea, abdominal cramps,diarrhea, uricosuriadiarrhea, uricosuria


54/66

Minerals

inorganic elements that originate in the earth andinorganic elements that originate in the earth andcannot be made in the bodycannot be made in the body

play important roles in various bodily functionsplay important roles in various bodily functions

necessary to sustain life and maintain optimal health,necessary to sustain life and maintain optimal health,and thus are essential nutrients.and thus are essential nutrients.

provide structure to bones and teeth and participate inprovide structure to bones and teeth and participate inenergy production, the building of protein, bloodenergy production, the building of protein, blood

formation, and several other metabolic processesformation, and several other metabolic processes Most of the minerals in the human diet come directlyMost of the minerals in the human diet come directly

from plants and water, or indirectly from animal foodsfrom plants and water, or indirectly from animal foods


55/66

Major& Trace

minerals Sodium (Na)Sodium (Na)

Potassium (K)Potassium (K)

Chloride (Cl)Chloride (Cl)

Calcium (Ca)Calcium (Ca)

Magnesium (Mg)Magnesium (Mg)

Phosphorus (P)Phosphorus (P)

Sulfur (S)Sulfur (S)

Iron (Fe)Iron (Fe)

Copper (Cu)Copper (Cu) Chromium (Cr)Chromium (Cr)

Fluoride (Fl)Fluoride (Fl)

Iodine (I)Iodine (I)

Manganese (Mn)Manganese (Mn)

Molybdenum (Mo)Molybdenum (Mo)

Selenium (Se)Selenium (Se)

Zinc (Zn)Zinc (Zn)


56/66

other Trace Minerals

Arsenic (As)Arsenic (As)

Boron (B)Boron (B)

Cobalt (Co)Cobalt (Co)

Nickel (Ni)Nickel (Ni)

Silicon (Si)Silicon (Si) Vanadium (V)Vanadium (V)

Aluminum (Al)Aluminum (Al)

Silver (Ag)Silver (Ag)

Gold (Au)Gold (Au)

Cadmium (Cd)Cadmium (Cd)

Bromine (Br)Bromine (Br)Barium (Ba)Barium (Ba)


57/66

Major minerals : functions NaNa,, KK,, ClCl ::fluid balancefluid balance :regulated by charged sodium and:regulated by charged sodium and

chloride ions in the ECF and potassium in the ICF, and bychloride ions in the ECF and potassium in the ICF, and bysome other electrolytes across cell membranes. Tightsome other electrolytes across cell membranes. Tightcontrol is critical for normal muscle contraction, nervecontrol is critical for normal muscle contraction, nerve

impulse transmission, heart function, and blood pressure.impulse transmission, heart function, and blood pressure. SodiumSodium plays an important role in the absorption of otherplays an important role in the absorption of other

nutrients, such as glucose, amino acids, and water.nutrients, such as glucose, amino acids, and water.

ChlorideChloride is a component of hydrochloric acid, anis a component of hydrochloric acid, an

important part of gastric juice (an acidic liquid secreted byimportant part of gastric juice (an acidic liquid secreted byglands in the stomach lining) and aids in food digestion.glands in the stomach lining) and aids in food digestion.

Potassium and sodiumPotassium and sodium act as cofactors for certainact as cofactors for certainenzymes.enzymes.


58/66

Major minerals: functions

CalciumCalcium,, magnesiummagnesium, and, and phosphorusphosphorus are essential forare essential forthe development and maintenance of bones and teeth;the development and maintenance of bones and teeth;& needed for maintaining cell membranes and& needed for maintaining cell membranes and

connective tissue.connective tissue. Several enzymes, hormones, and proteins that regulateSeveral enzymes, hormones, and proteins that regulate

energy and fat metabolism requireenergy and fat metabolism require calciumcalcium,, magnesiummagnesiumand/orand/or phosphorusphosphorus to become active.to become active.

CalciumCalcium also aids in blood clotting.also aids in blood clotting.

SulfurSulfur is a key component of various proteins andis a key component of various proteins andvitamins and participates in drugvitamins and participates in drug--detoxifying pathwaysdetoxifying pathwaysin the body.in the body.


59/66

Trace minerals: Iron

sourcessources::beef esp. liver,beef esp. liver,chicken, rice, broccoli,chicken, rice, broccoli,

canned tuna, wheat germ,canned tuna, wheat germ,tofu, boiled egg, molasses,tofu, boiled egg, molasses,cooked musselscooked mussels

actionsactions:: necessary for thenecessary for the

production of normalproduction of normalhemoglobin, & therefore,hemoglobin, & therefore,normal RBCnormal RBC


60/66

Iron :

deficiency & excessdeficiencydeficiency::MicrocyticMicrocytic

hypochromic anemiahypochromic anemia;;

cold intolerance; poorcold intolerance; poorwound healing; alopecia;wound healing; alopecia;

koilonychia; atrophickoilonychia; atrophicglossitis; reversible loss ofglossitis; reversible loss of

cognitive function;cognitive function;malaise;malaise; immunity immunity

excessexcess:: Hemochromatosis:Hemochromatosis:bronze diabetesbronze diabetes


61/66

Copper

sourcessources:: nuts, sunflowernuts, sunflowerseeds, lobster, greenseeds, lobster, greenolives, wheat bran, liver,olives, wheat bran, liver,

cocoa, oysters, blackcocoa, oysters, blackpepper, blackstrappepper, blackstrapmolassesmolasses

actionsactions:: needed forneeded for

hemoglobin synthesis,hemoglobin synthesis,normal iron metabolism,normal iron metabolism,maintenance of bloodmaintenance of blood

vessels, bone, nerves,vessels, bone, nerves,


62/66

Copper:

deficiency & toxicity deficiencydeficiency:impaired:impaired

bone calcification,bone calcification,hypochromichypochromic anemiaanemia

not responsive tonot responsive toIron therapy,Iron therapy,neutropenianeutropenia

excessexcess : Wilsons: Wilsonsdisease: liverdisease: livercirrhosis, withcirrhosis, withCopper depositionCopper deposition


63/66

Selenium

sourcessources:: meat, liver, oysters,meat, liver, oysters,wheat germ, yeast, pumpkinwheat germ, yeast, pumpkinseeds, alfalfa, wild yamseeds, alfalfa, wild yam

actionsactions :: antianti--oxidant; part ofoxidant; part ofglutathione peroxidaseglutathione peroxidase;;

deficiencydeficiency :: Keshan diseaseKeshan disease;;muscle pain & tenderness inmuscle pain & tenderness inTPNTPN;; KashinKashin--Beck diseaseBeck disease

toxicitytoxicity:: hair loss, abnormalhair loss, abnormalnails, peripheral neuropathy,nails, peripheral neuropathy,dermatitis, nausea, diarrhea,dermatitis, nausea, diarrhea,fatigue, irritability, garlic breathfatigue, irritability, garlic breath


64/66

Zinc

sourcessources::brazil nuts, seafood,brazil nuts, seafood,poultry, red meat, grains, eggs,poultry, red meat, grains, eggs,garlic; oats, brown rice,garlic; oats, brown rice,

vegetables (soil)vegetables (soil)

actionsactions:: component of hundredscomponent of hundredsof enzymesof enzymes

deficiencydeficiency::AAcrodermatitiscrodermatitisenteropathica;enteropathica; maternalmaternaldeficiencydeficiency-- fetalfetal

malformations & low birthmalformations & low birthweightweight toxicitytoxicity::very rare: microcytosis,very rare: microcytosis,

neutropenia, impairedneutropenia, impairedimmunity, vomiting, diarrheaimmunity, vomiting, diarrhea


65/66

Fluoride, Iodine, Chromium,Manganese,Molybdenum

FluorideFluoride-- (Fl)(Fl) --prevention ofprevention ofcavitiescavities

IodineIodine-- (I)(I) -- necessary fornecessary forthyroid hormone productionthyroid hormone production

ChromiumChromium (Cr)(Cr)-- needed forneeded forproper carbohydrateproper carbohydratemetabolismmetabolism

ManganeseManganese-- (Mn)(Mn)-- componentcomponentof enzymes, e.g. superoxideof enzymes, e.g. superoxidedismutasedismutase

MolybdenumMolybdenum-- (Mo(Mo)) --enzymeenzymecomponentcomponent

deficiency states:deficiency states:

FlFl-- dental Cariesdental Caries II -- Goiter /Goiter /

HypothyroidismHypothyroidism Cr, Mn, MoCr, Mn, Mo --

MetabolicMetabolicderangementsderangements


66/66

Thank you !

Documents

genpathNutriDse