Ann M. Manzardo, Ph.D.Department of Psychiatry & Behavioral

SciencesKansas University Medical Center

Kansas City, Kansas

© AMSP 1

Nutritional DeficienciesOnce common, now rare in west

Availability of food ↑

Nationalized fortification of foods

Began in US, early 1900’s

Iodine added to salt (goiters)

Expanded to other nutrients,

1940’s© AMSP 2

Nationalized FortificationDairy products

Calcium/vitamin D to milk (rickets)

Vitamin A to margarine (night

blindness)

Grain products

Replaced B vitamins lost in milling

Niacin, thiamine, riboflavin

Folate added 1998© AMSP 3

Who is at Risk Today?High risk groups in western

countries

Elderly

Medical conditions (vomiting/GI)

Certain psychiatric conditions

→ Alcohol Use Disorders (AUDs)© AMSP 4

Lecture Focus: Nutrition & AUDs

Definitions

AUDs & nutrition

Thiamine

Other B vitamins

How to help© AMSP 5

© AMSP 6

Abuse ( ≥1)

Role failure

Risk of harm

Run-ins with law

Relationship

trouble

Abuse vs.Dependence Dependence ( ≥3)

Tolerance

Withdrawal

Not sticking to

limits

Unable to cut down

↑ time with ETOH

↓ time elsewhere

Use in spite of

problems

Repeats 12 months

What is a Micronutrient?Needed in small amounts (<100 mcg/day)

“Essential” for bodily functions

Diet may be only source

2 kinds

Vitamins – organic compounds

Minerals – “trace” elements, ions or

salts© AMSP 7

Thiamine (B1)

Riboflavin (B2)

Niacin (B3)

Pantothenic acid

(B5)© AMSP 8

Pyridoxine (B6)

Biotin (B7)

Folate (B9)

Cobalamin (B12)

B-Complex VitaminsMeats: poultry, eggs, fish & liverBeans & grains; Brewer’s yeast

Lecture Focus: Nutrition & AUDs

Definitions

AUDs & nutrition

Thiamine

Other B vitamins

How to help© AMSP 9

AUDs → Nutritional Deficiency

Lifestyle factors

Poor dietary habits

↓ Access to food (poverty,

homelessness)

Alcohol preferred to food© AMSP 10

AUDs → Nutritional DeficiencyGastric Problems

Alcohol damage

Gastric mucosa inflamed

Barrier to absorption

↓ absorption of nutrients

© AMSP 11

AUDs → Nutritional Deficiency cont’dSelective loss of B vitamins

B vitamins water (not fat)

soluble

Low cellular stores

Levels ↓ quickly

↑ daily intake needed

© AMSP 12→ Thiamine Deficiency

(B1)

Lecture Focus: Nutrition & AUDs

Definitions

AUDs & nutrition

Thiamine (B1)

Other B vitamins

How to help© AMSP 13

Thiamine Function

© AMSP 14

Thiamine (B1)

Glycolysis

Generates ATP for energy

Oxidative Metabolism

Kreb Cycle

↑ lactic acid↑ cell damage/death

Anaerobic Metabolism

Thiamine Function cont’d

© AMSP 15

Glucose-6-P Ribose-5-P

Pentose Phosphate Shunt

DNARNA

Transketolase

Transaldolase

Thiamine (B1)

↓ Cell Growth

Consequences of Thiamine Deficiency

© AMSP 16

Tissue-selective damage

Heart muscles/neurons

↑ energy demand

↓ energy stores

2 clinical syndromes (wet/dry

beriberi)

Wet Beriberi

© AMSP 17

Cardiovascular

Irregular heartbeat

Heart failure

Edema (fluid retention)

Dry Beriberi

© AMSP 18

Neurological

Pain/numbness in limbs

(neuropathy)

Balance/coordination

problems

Emotional disturbances

Neurological Syndromes

© AMSP 19

Rare but serious

2 main syndromes

Wernicke’s

encephalopathy

Korsakoff’s syndrome

Wernicke’s Encephalopathy

© AMSP 20

Sudden onset of symptoms

Impaired eye movement

Can’t look to side

Jerky movement

Staggering gait (ataxia)

Reversible with treatment

Opthalmoplegia of left eye

Nystagmus

Korsakoff ‘s Syndrome

© AMSP 21

Memory loss (amnesia)

↓ Formation

(anterograde)

↓ Recall (retrograde)

Confabulation

False memories/beliefs

“Storytelling”

Lack of insight

Genetic VulnerabilitySub-population identified

~10% of Non AUD

~ 30% of Wernicke-Korsakoff Syndrome

Abnormal transketolase enzyme↓ affinity for thiamine (B1)↑ levels needed to activate

↑ alcohol-related problems

© AMSP 22

Lecture Focus: Nutrition & AUDs

Definitions

AUDs & nutrition

Thiamine (B1)

Other B vitamins

How to help© AMSP 23

Other B vitamin deficiencies

© AMSP 24

Folate (B9), >40%

Pyridoxine (B6), up to 50%

Riboflavin (B2), ~17%

Overlapping effects on:

DNA, RNA, red blood cell (RBC)

synthesis

Sugar metabolism

Cell growth/energy production

Folate (B9) Deficiency

© AMSP 25

Anemia, 2 types

Abnormally large RBCs,

megaloblastic

Ruptured RBCs, hemolytic

↓ appetite

Weakness, fatigue

Hair loss

Pyridoxine (B6) Deficiency

© AMSP 26

Similar to niacin (B3)

deficiency

Failure to process iron to

heme

Anemia, sideroblastic

↓ healthy RBCs

↑ abnormal RBC

(sideroblasts)

Pyridoxine (B6) Deficiency

© AMSP 27

Skin inflammation

Dermatitis

Lips/mouth, cheilosis

Neuropathy in

hands/feet

Neurological problems

Seizures

Riboflavin (B2) Deficiency

© AMSP 28

Inflamed skin/mucous

membranes

Mouth ulcers

Cheilosis

Eyes

Bloodshot, itchy/watery

↑ sensitivity to light

Riboflavin (B2) Deficiency cont’d

© AMSP 29

Seborrheic Dermatitis

Scaly, oily rash

Near glands

Face/upper lip

Genitals (scrotum, vulva)

Permanent scarring possible

Lecture Focus: Nutrition & AUDs

Definitions

AUDs & nutrition

Thiamine (B1)

Other B vitamins

How to help© AMSP 30

Treatment of Nutritional Deficiency

Supplement guidelines

Full B-complex, 7-14 days

Oral, daily treatment

Add minerals, help vitamins work

Prenatal vitamins often used

Inexpensive/easy

© AMSP 31

B-Complex Vitamins

100 mg thiamine (B1)

1.3 mg riboflavin (B2)

10-50 mg niacin (B3)

300mg biotin (B7)

© AMSP 32

1 mg folate (B9)

1-3 mg pyridoxine (B6)

6-12 mg cobalamin

(B12)

10 mg pantothenic acid

(B5)

Treatment of Nutritional Deficiency cont’d

Wernicke-Korsakoff Syndrome

Hospitalization

IV thiamine, 100 mg

1-2 x daily

3-5 days

Include full B-complex© AMSP 33

Treatment of Nutritional Deficiency cont’d

Alternative Supplements Fat soluble B1 analogues

Allithiamine, natural product

Benfotiamine, synthetic

Sustained ↑ in blood levels

Inexpensive/safe © AMSP 34

Treatment of Nutritional Deficiency cont’d

Brief Intervention 15-min initial contact, 5 A’s

Assess/screen

Advise to quit/reduce

Agree on goals

Assist with motivation

Arrange follow-up

© AMSP 35

Treatment of Alcohol Abuse

Refer to 12-step program

Alcoholics Anonymous

Refer to higher-level care

Day treatment

Residential

Clean & sober living environment© AMSP 36

Treatment of Alcohol Abuse or Dependence

Medications for AUDs

Naltrexone (Revia), 50-150 mg/day

Acamprosate (Campral), 2 g/day

Disulfiram (Antabuse), 250 mg/day

© AMSP 37

Treatment of Alcohol Abuse or Dependence cont’d

AUDs → nutritional

deficiencies

What kinds of deficiencies

Consequences

How to help© AMSP 38

Summary Topics Reviewed