Nutrient DeficienciesNutrient Deficiencies

N323N323

VitaminsVitamins

FAT-SOLUBLE:FAT-SOLUBLE: A, D, E & KA, D, E & K Are absorbed with fat.Are absorbed with fat. Transported by protein lipids (LDL)Transported by protein lipids (LDL) Excessive amounts are stored.Excessive amounts are stored. Not necessary to eat every day but Not necessary to eat every day but

toxic amounts can accumulate.toxic amounts can accumulate. Found in fat or oil portion of foods. Found in fat or oil portion of foods.

VitaminsVitamins

WATER-SOLUBLE:WATER-SOLUBLE: C & B (thiamine, riboflavin, niacin, C & B (thiamine, riboflavin, niacin,

folate, Bfolate, B66, B, B1212, biotin & pantothenic , biotin & pantothenic acid)acid)

Are absorbed with water.Are absorbed with water. Transported free floating in blood.Transported free floating in blood. Excessive amounts are excreted.Excessive amounts are excreted. Necessary to eat every day; toxic Necessary to eat every day; toxic

amounts unlikely to accumulate.amounts unlikely to accumulate. Found in water portion of foods.Found in water portion of foods.

Requirements Requirements

Recommended Daily Allowance: (RDA):Recommended Daily Allowance: (RDA): Average daily intake sufficient to meet Average daily intake sufficient to meet nutrient requirements for a healthy nutrient requirements for a healthy individual.individual.

Dietary Reference Intake (DRI):Dietary Reference Intake (DRI): New set of New set of 4 values to set dietary goals: 4 values to set dietary goals: RDARDA plus: plus:

Estimated Average Requirement (EAR):Estimated Average Requirement (EAR): Amt. of nutrient sufficient to meet the Amt. of nutrient sufficient to meet the needs of 50% of individuals.needs of 50% of individuals.

RequirementsRequirements

Adequate Intake (AI):Adequate Intake (AI): Recommended Recommended daily intake when actual amt. is daily intake when actual amt. is unproven.unproven.

Tolerable Upper Intake Level (UL):Tolerable Upper Intake Level (UL): Highest level of daily nutrient intake that Highest level of daily nutrient intake that is not apt to cause harm. is not apt to cause harm.

SourcesSources

BREAD, CEREAL, RICE FOOD GROUPBREAD, CEREAL, RICE FOOD GROUP B vitamins (thiamine, riboflavin, B vitamins (thiamine, riboflavin,

niacin, folate, B6), Vitamin Eniacin, folate, B6), Vitamin E Fortified cereals contain almost all Fortified cereals contain almost all

vitamins.vitamins.

VEGETABLE GROUP:VEGETABLE GROUP: Beta-carotene, C, K, & folateBeta-carotene, C, K, & folate

FRUIT GROUP:FRUIT GROUP: Beta-carotene & vitamin CBeta-carotene & vitamin C

SourcesSources

MILK, YOGURT & CHEESE GROUPMILK, YOGURT & CHEESE GROUP Vitamin A, D, B6, B12, riboflavinVitamin A, D, B6, B12, riboflavin

MEAT, POULTY, FISH, BEANS, EGGS & MEAT, POULTY, FISH, BEANS, EGGS & NUTSNUTS

B vitamins (B6, B12, niacin, riboflavin)B vitamins (B6, B12, niacin, riboflavin) Vitamin A (fish)Vitamin A (fish)

FATS & OILS GROUPFATS & OILS GROUP Vitamin EVitamin E

Vitamin AVitamin A

ACTION:ACTION: Promotes night visionPromotes night vision Integrity of mucus membrane & skinIntegrity of mucus membrane & skin Bone growthBone growth

SOURCES:SOURCES: Preformed A: animal fats; No-fat milk and Preformed A: animal fats; No-fat milk and

cereals are fortified. cereals are fortified. Beta-carotene (precursor to vitamin A): Beta-carotene (precursor to vitamin A):

yellow & orange vegetables and fruits, yellow & orange vegetables and fruits, dark green leafy vegetablesdark green leafy vegetables

Vitamin AVitamin A

TOXICITY:TOXICITY: Unlikely except by supplements.Unlikely except by supplements. Teratogenic during pregnancy so Teratogenic during pregnancy so

excess supplements are not excess supplements are not recommended (Accutane is vitamin A).recommended (Accutane is vitamin A).

Beta-carotene, if excessive is not Beta-carotene, if excessive is not converted to vitamin A, but stored in converted to vitamin A, but stored in body fat. Can turn skin yellow-orange body fat. Can turn skin yellow-orange (hypercarotenemia)(hypercarotenemia)

Vitamin AVitamin A

DEFICIENCY:DEFICIENCY: Tender gums, sores at corners of Tender gums, sores at corners of

mouth.mouth. A major cause of blindness worldwide A major cause of blindness worldwide

Xerophthalmia Xerophthalmia = dry, lusterless = dry, lusterless conjunctiva. conjunctiva. KeratomalaciaKeratomalacia = necrosis = necrosis of cornea with perforation and loss of of cornea with perforation and loss of ocular fluid ocular fluid

““Smart” rice is A-fortified to prevent Smart” rice is A-fortified to prevent this.this.

Vitamin AVitamin A

PEOPLE AT RISK:PEOPLE AT RISK: Eat no vegetablesEat no vegetables Constant dietersConstant dieters ““Statin” drug usersStatin” drug users poor absorption of fatpoor absorption of fat

Vitamin DVitamin D

ACTION:ACTION: Necessary for calcium absorption from GI Necessary for calcium absorption from GI

tract; incorporation of calcium into bone.tract; incorporation of calcium into bone.

SOURCE:SOURCE: Ultraviolet sunlight & a precursor to Ultraviolet sunlight & a precursor to

cholesterol is synthesized by liver; cholesterol is synthesized by liver; activated by kidney.activated by kidney.

Liver, fatty fish & egg yolks only natural Liver, fatty fish & egg yolks only natural food sources.food sources.

Milk is fortified to supply vitamin D.Milk is fortified to supply vitamin D.

Vitamin DVitamin D

TOXICITY:TOXICITY: Vitamin most apt to cause toxicity.Vitamin most apt to cause toxicity. Increases GI calcium absorption = Increases GI calcium absorption =

kidney stones, hypercalcemia.kidney stones, hypercalcemia.

DEFICIENCY:DEFICIENCY: Osteomalacia in adults (weakened Osteomalacia in adults (weakened

bones)bones) Rickets in children (curved bones)Rickets in children (curved bones) Tetany (from hypocalcemia)Tetany (from hypocalcemia)

Vitamin DVitamin D

PEOPLE AT RISK:PEOPLE AT RISK: Elderly (receive less sunlight; kidneys Elderly (receive less sunlight; kidneys

don’t function as well)don’t function as well) People living in heavy smog, pollution People living in heavy smog, pollution

areas.areas. Children who don’t drink milk.Children who don’t drink milk.

RicketsRickets

Weakened bone formation from lack of Weakened bone formation from lack of calciumcalcium

ASSESSMENT:ASSESSMENT: CraniotabesCraniotabes Delayed tooth developmentDelayed tooth development Rachitic rosary & epiphysis swellingRachitic rosary & epiphysis swelling Late closure of fontanellesLate closure of fontanelles Bow legs; KyphosisBow legs; Kyphosis Pelvic contractionPelvic contraction Confirmed by x-ray examinationConfirmed by x-ray examination

RicketsRickets

NURSING DIAGNOSIS:NURSING DIAGNOSIS: Immobility related to poor bone Immobility related to poor bone

formation.formation.

THERAPY/INTERVENTIONS:THERAPY/INTERVENTIONS: Vitamin D, calcium & sun exposureVitamin D, calcium & sun exposure

EXPECTED OUTCOME:EXPECTED OUTCOME: Child ingests adequate intake.Child ingests adequate intake. Bone changes stop with treatment but Bone changes stop with treatment but

are not irreversible.are not irreversible.

Vitamin EVitamin E

ACTION:ACTION: Potent antioxidant (keeps Potent antioxidant (keeps

polyunsaturated fats from being polyunsaturated fats from being destroyed; protects against destroyed; protects against atherosclerosis, cell wall damage)atherosclerosis, cell wall damage)

Important for immune function.Important for immune function.

SOURCES:SOURCES: Found in almost all plants.Found in almost all plants.

Vitamin EVitamin E

TOXICITY:TOXICITY: Large amts. interfere with vitamin K so Large amts. interfere with vitamin K so

can lead to hemorrhage.can lead to hemorrhage.

DEFICIENCY:DEFICIENCY: Rare because sources are so abundant.Rare because sources are so abundant. Premature infants develop anemia from Premature infants develop anemia from

oxidization of red blood cells.oxidization of red blood cells.

RISKS:RISKS:

Low-birth weight infants; poor fat Low-birth weight infants; poor fat absorption.absorption.

Vitamin KVitamin K

ACTION:ACTION: Important for blood clotting (synthesis of Important for blood clotting (synthesis of

prothrombin).prothrombin).

SOURCES:SOURCES: Green, leafy vegetables, liver, milkGreen, leafy vegetables, liver, milk Manufactured in intestines by bacteria.Manufactured in intestines by bacteria.

Vitamin KVitamin K

TOXICITY:TOXICITY: RareRare

DEFICIENCY:DEFICIENCY: Not a lot is stored so deficiency can occur.Not a lot is stored so deficiency can occur. Hemorrhagic Disease of the newbornHemorrhagic Disease of the newborn

RISKS:RISKS: Newborns for 1st 24 hours (why vitamin K Newborns for 1st 24 hours (why vitamin K

is routinely administered).is routinely administered). Coumadin users (blocks vitamin K action)Coumadin users (blocks vitamin K action) Intestinal surgery with antibioticsIntestinal surgery with antibiotics

Thiamine (B1)Thiamine (B1)

ACTION:ACTION: Necessary for glucose metabolism & Necessary for glucose metabolism &

nervous system health.nervous system health.

SOURCES:SOURCES: Meat & grainsMeat & grains Alcohol impairs absorptionAlcohol impairs absorption

Thiamine (B1)Thiamine (B1)

TOXICITY:TOXICITY: RareRare

DEFICIENCY:DEFICIENCY: BeriberiBeriberi

RISK:RISK: Alcoholics Alcoholics Poor protein intake in developing Poor protein intake in developing

countriescountries

BeriberiBeriberi

Thiamine (B1) deficiency (found in people who Thiamine (B1) deficiency (found in people who eat polished rice as dietary staple (Beat polished rice as dietary staple (B11 is found is found in hull of rice)in hull of rice)

ASSESSMENT:ASSESSMENT: Tingling/numbness of extremities; edema, Tingling/numbness of extremities; edema,

heart palpitation; exhaustion & dyspneaheart palpitation; exhaustion & dyspnea Diarrhea/vomitingDiarrhea/vomiting Infants dry without sound (aphonia) Edema & Infants dry without sound (aphonia) Edema &

convulsions convulsions

THERAPY/INTERVENTIONS:THERAPY/INTERVENTIONS: ThiamineThiamine

Riboflavin (B2)Riboflavin (B2)

Necessary for glucose metabolism Necessary for glucose metabolism Either toxicity or deficiency rareEither toxicity or deficiency rare

Niacin (B3)Niacin (B3)

ACTION:ACTION: Necessary for glucose & fat metabolism.Necessary for glucose & fat metabolism. Lowers cholesterol.Lowers cholesterol.

SOURCE:SOURCE: Whole grains and protein rich foods.Whole grains and protein rich foods.

TOXICITY:TOXICITY: Causes severe flushing from Causes severe flushing from

vasodilatationvasodilatation Hypotension from vasodilatation.Hypotension from vasodilatation.

Niacin (B3)Niacin (B3)

DEFICIENCY:DEFICIENCY: Rare as body can convert an amino acid Rare as body can convert an amino acid

to niacin.to niacin. PellagraPellagra

RISKS:RISKS: People who use corn as dietary staple.People who use corn as dietary staple. Reduces cholesterolReduces cholesterol

PellagraPellagra

Niacin deficiency (found in people who eat Niacin deficiency (found in people who eat corn as main dietary staple)corn as main dietary staple)

ASSESSMENT:ASSESSMENT: 4 Ds:4 Ds: DermatitisDermatitis: looks like sunburn at first, then : looks like sunburn at first, then

dry and cracked; tone is sore and raw-dry and cracked; tone is sore and raw-looking. looking.

Dementia:Dementia: loss of memory; general loss of memory; general irritabilityirritability

Diarrhea:Diarrhea: Death:Death:

PellegraPellegra

THERAPY/INTERVENTIONS:THERAPY/INTERVENTIONS: Niacin administration.Niacin administration. Caution that severe flushing will occur.Caution that severe flushing will occur.

Pyridoxine (B6)Pyridoxine (B6)

ACTION:ACTION: Necessary for amino acid & fat Necessary for amino acid & fat

metabolism.metabolism. Produciton of heme; myelin sheaths. Produciton of heme; myelin sheaths.

Converts tryptophan to niacin.Converts tryptophan to niacin.

SOURCES:SOURCES: Meat, fish, grainsMeat, fish, grains

TOXICITY:TOXICITY: RareRare

Pyridoxine (B6)Pyridoxine (B6)

DEFICIENCY:DEFICIENCY: May be associated with convulsion in May be associated with convulsion in

infants.infants. May be associated with premenstrual May be associated with premenstrual

syndrome.syndrome. Pain, numbness of extremities; muscle Pain, numbness of extremities; muscle

weaknessweakness

RISKS:RISKS: AlcoholicsAlcoholics

People on INHPeople on INH

Folate (Folic Acid)Folate (Folic Acid)

ACTION:ACTION: Necessary for synthesis of DNA (new cell Necessary for synthesis of DNA (new cell

growth)growth) Necessary to activate B12.Necessary to activate B12. SOURCES:SOURCES: Green leafy vegetablesGreen leafy vegetables

Folate (Folic Acid)Folate (Folic Acid)

TOXICITY:TOXICITY: RareRare

DEFICIENCY:DEFICIENCY: Neural tube defects during pregnancy.Neural tube defects during pregnancy. Megaloblastic anemiaMegaloblastic anemia

RISKS:RISKS: Rapid growth periodsRapid growth periods Hemolytic anemiasHemolytic anemias

Cobalamin (B12)Cobalamin (B12)

ACTION:ACTION: Necessary to activate folate.Necessary to activate folate. Fat metabolism; myelin sheaths.Fat metabolism; myelin sheaths.

SOURCES:SOURCES: Animal sourcesAnimal sources Intrinsic factor necessary for absorptionIntrinsic factor necessary for absorption

Cobalamin (B12)Cobalamin (B12)

TOXICITY:TOXICITY: RareRare

DEFICIENCY:DEFICIENCY: Pernicious anemiaPernicious anemia

RISKS:RISKS: Elderly; gastric surgery; Elderly; gastric surgery; gastric gastric

secretionssecretions

Vitamin CVitamin C

ACTION:ACTION: Necessary for collagen formation.Necessary for collagen formation. Poor muscle, bone, blood vessel Poor muscle, bone, blood vessel

formation.formation. Inc. iron absorption.Inc. iron absorption. Strengthens immune system.Strengthens immune system.

SOURCES:SOURCES: Citrus fruits; vegetablesCitrus fruits; vegetables

Vitamin CVitamin C

TOXICITY:TOXICITY: No specific effectsNo specific effects

DEFICIENCY:DEFICIENCY: ScurvyScurvy

RISKS:RISKS: Elderly (fruit spoils easily)Elderly (fruit spoils easily)

ScurvyScurvy

Vitamin C deficiency interferes with Vitamin C deficiency interferes with collagen formationcollagen formation

ASSESSMENT:ASSESSMENT: Infants 2 to 12 months of age. Infants 2 to 12 months of age. Walls of capillaries become fragile; Walls of capillaries become fragile;

petecchial hemorrhage from vessels occurs.petecchial hemorrhage from vessels occurs. Gums are swollen & bleed easilyGums are swollen & bleed easily Extreme muscle tenderness (cry when Extreme muscle tenderness (cry when

handled)handled) Can be suspect for child abuse.Can be suspect for child abuse.

ScurvyScurvy

THERAPY/INTERVENTIONS:THERAPY/INTERVENTIONS: Vitamin C (why English sailors are called Vitamin C (why English sailors are called

limeys)limeys)

ProteinProtein Major nutrient necessary for building cells.Major nutrient necessary for building cells. Necessary for immune system function.Necessary for immune system function. If not enough carbohydrate present, is used If not enough carbohydrate present, is used

for energy (carbohydrates are protein for energy (carbohydrates are protein sparing)sparing)

Composed of carbon, hydrogen, oxygen plus Composed of carbon, hydrogen, oxygen plus nitrogen. Excess nitrogen is excreted as nitrogen. Excess nitrogen is excreted as urea = excessive load for kidneys.urea = excessive load for kidneys.

Protein is broken down into amino acids and Protein is broken down into amino acids and then used to construct 22 amino acids (8 are then used to construct 22 amino acids (8 are essential in adults; 9 in children)essential in adults; 9 in children)

ProteinProtein

Use of protein is all or none concept: if all Use of protein is all or none concept: if all ingredients for essential amino acids are ingredients for essential amino acids are not present, they are not made. Excess is not present, they are not made. Excess is excreted.excreted.

Complete protein:Complete protein: animal sources. animal sources. Incomplete:Incomplete: plant sources. plant sources. Complementary proteins:Complementary proteins: two incomplete two incomplete

that make a complete proteinthat make a complete protein

Essential Amino AcidsEssential Amino Acids

Tryptophan (TRIP-toe-fane)Tryptophan (TRIP-toe-fane) Valine (VAY-leen)Valine (VAY-leen) Threonine (THREE-o-neen)Threonine (THREE-o-neen) Isoleucone (I-so-LOO-seen)Isoleucone (I-so-LOO-seen) Lysine (LYE-seen)Lysine (LYE-seen) Leucine (LOO-seen)Leucine (LOO-seen) Phenylalanine (fee-nul-AL-uh-neen)Phenylalanine (fee-nul-AL-uh-neen) Methionine (meh-THIGH-o-neen)Methionine (meh-THIGH-o-neen) In infants: Histidine (HISS-tuh-deen)In infants: Histidine (HISS-tuh-deen) TV TILL PMTV TILL PM

KwashiorkorKwashiorkor

Protein deficiencyProtein deficiency

ASSESSMENT:ASSESSMENT: 1-3 years of age1-3 years of age Developing countriesDeveloping countries Growth failure; extensive edema and Growth failure; extensive edema and

ascites; muscle wasting.ascites; muscle wasting. ““Zebra” hair , anorexiaZebra” hair , anorexia Concurrent iron-deficient anemiaConcurrent iron-deficient anemia

KwashiorkorKwashiorkor

THERAPY/INTERVENTIONS:THERAPY/INTERVENTIONS: ProteinProtein May have long-term cognitive effects.May have long-term cognitive effects.

MarasmusMarasmus

Deficient food intakeDeficient food intake

ASSESSMENT:ASSESSMENT: Seen in developing countries or poor Seen in developing countries or poor

parentingparenting Under 1 year of ageUnder 1 year of age Wasted muscles, diarrhea, growth failure.Wasted muscles, diarrhea, growth failure. HungryHungry

THERAPY/INTERVENTIONS:THERAPY/INTERVENTIONS: FeedFeed

Maple Syrup Urine DiseaseMaple Syrup Urine Disease

Unable to convert leucine and valine into Unable to convert leucine and valine into breakdown products.breakdown products.

Raw amino acids built up in blood stream.Raw amino acids built up in blood stream. Toxic to brain cells.Toxic to brain cells. Severe cognitive impairmentSevere cognitive impairment Can be recognized in utero by amniocentesisCan be recognized in utero by amniocentesis Urine smells like maple syrupUrine smells like maple syrup Placed on low Leucine & Valine dietPlaced on low Leucine & Valine diet Almost impossible to maintain so outcome is Almost impossible to maintain so outcome is

limitedlimited

Phenylketonuria (PKU)Phenylketonuria (PKU)

H p

H HH Hp

p PH pp

Inborn error or Inborn error or metabolismmetabolism

Unable to use an Unable to use an essential amino essential amino acidacid

Autosomal Autosomal RecessiveRecessive• H = Healthy H = Healthy

genegene• pp = PKU gene = PKU gene

PhenylketonuriaPhenylketonuria

Lack liver enzyme (phenylalanine Lack liver enzyme (phenylalanine hydroxylase) that converts phenylalanine hydroxylase) that converts phenylalanine into tyrosine. into tyrosine.

Tyrosine is responsible for formation of Tyrosine is responsible for formation of • epinephrine epinephrine • thyroxinethyroxine• melaninmelanin

PhenylketonuriaPhenylketonuria

Without ability to convert phenylalanine Without ability to convert phenylalanine to tyrosine, to tyrosine, •high levels of phenylalanine build up in high levels of phenylalanine build up in

blood streamblood stream•Cross blood-brain barrierCross blood-brain barrier•Toxic to brain cells leading to cognitive Toxic to brain cells leading to cognitive

impairmentimpairment•Excess is excreted in urine as Excess is excreted in urine as

phenylpyruvic acid.phenylpyruvic acid.

PhenylketonuriaPhenylketonuria

ASSESSMENT:ASSESSMENT: Urine has a musty odor compared to Urine has a musty odor compared to

mouse urinemouse urine Without ability to produce tyrosineWithout ability to produce tyrosine

• Short statureShort stature• Light skinned, blonde hairedLight skinned, blonde haired• Eczema or atopic dermatitisEczema or atopic dermatitis

PhenylketonuriaPhenylketonuria

Diagnosed by:Diagnosed by: All newborns in U.S. are tested by a All newborns in U.S. are tested by a

Guthrie Test at birthGuthrie Test at birth Must have 24 to 48 hours of milk intake Must have 24 to 48 hours of milk intake

b/4 testb/4 test Parents must return newborn for test if Parents must return newborn for test if

discharged b/4 24 hours.discharged b/4 24 hours. Can not be diagnosed by amniocentesis Can not be diagnosed by amniocentesis

as mother clears excess phenylalanineas mother clears excess phenylalanine

PKUPKU

THERAPY:THERAPY:Low phenylalanine dietLow phenylalanine diet• Protein foods contain highest levels of Protein foods contain highest levels of

amino acids so diet is very low in protein amino acids so diet is very low in protein • LofenalacLofenalac is a synthetic milk almost is a synthetic milk almost

devoid of phenylalanine.devoid of phenylalanine.• A little regular milk or breast milk is A little regular milk or breast milk is

added to supply some phenylalanineadded to supply some phenylalanine

PKUPKU

NURSING INTERVENTIONS:NURSING INTERVENTIONS: Teach parents to perform regular Guthrie Teach parents to perform regular Guthrie

Tests.Tests. Educate parents about diet.Educate parents about diet. BreakfastBreakfast: : Lofenalac 6 oz. 1 serving Lofenalac 6 oz. 1 serving

puffed rice cereal; 1 serving applesaucepuffed rice cereal; 1 serving applesauce LunchLunch:: Lofenalac, 6 oz. Orange and pear Lofenalac, 6 oz. Orange and pear

slicesslices Dinner:Dinner: Lofenalac, 6 oz. 1 serving Lofenalac, 6 oz. 1 serving

mashed potatoes; 1 serving carrotsmashed potatoes; 1 serving carrots

PKUPKU

EXPECTED OUTCOMES: EXPECTED OUTCOMES: Child demonstrates normal G&DChild demonstrates normal G&D Diet looks so deficient, unlicensed Diet looks so deficient, unlicensed

hospital personnel may assume hospital personnel may assume something is missing and add: meat or something is missing and add: meat or milkmilk

Educate children not to trade lunches in Educate children not to trade lunches in schoolschool

How to select lunches from school lunch How to select lunches from school lunch menu or take lunch.menu or take lunch.

PKUPKU

Caution that Holidays are often most Caution that Holidays are often most difficult times:difficult times:• Birthday cakeBirthday cake• TurkeyTurkey• Hotdogs on 4th of JulyHotdogs on 4th of July• Must remain on diet until past 5 years Must remain on diet until past 5 years

(brain growth is 90%)(brain growth is 90%)• Many advocate for always following Many advocate for always following

diet.diet.

PKUPKU

Women who intend to be pregnant must Women who intend to be pregnant must return to diet 3 months b/4 conceiving return to diet 3 months b/4 conceiving

Otherwise fetus grows in a high Otherwise fetus grows in a high phenylalanine environment. Cognitive phenylalanine environment. Cognitive impairment will occur.impairment will occur.