VITAMIN DEFICIENCY AND EXCESS

vitamins

Vitamins are the organic substances in food, which are required in very small amounts and are not synthesized by the body.

They occur naturally in food and are essential for good health.

Vitamins are broadly categorized into two forms

Fat soluble vitamins – Vitamin A,D,E and K Water soluble – Vitamin B complex and

vitamin C

VITAMIN A(RETINOL)

Liver is the richest source,fish,eggs Green leafy vegetables, carrots, and yellow fruits Plays an important role in vision. Retinaldehyde is the

part of the photoreceptors of rods in retina Vitamin A is also necessary for normal growth, fetal

development, fertility, haemopoiesis and immune function

DEFICIENCY Causes- Nightblindness Xerophthalmia Bitot’s spots Corneal ulceration and necrosis Keratomalacia with scarring leading to blindness

Deficiency is treated by a single large dose of retinol as palmitate or acetate 200000 IU orally or IM

Xerophthalmia – 60mg of vit A in oily soln

TOXICITY of vitamin A causes liver damage,hyperostosis and teratogenicity.

Acute overdose can cause nausea and headache, raised intracranial pressure and skin desquamation.

Excessive intake of carotene causes hypercarotenosis (pigmentation of skin)

VITAMIN D

Natural form of Vitamin D is cholecalciferaol. It is formed in the skin by the action of ultraviolet rays on 7-dehydrocholesterol.

Dietary sources are egg yolk , fish oil, butter and milk.

Cholecalciferol is not biologically active. It is converted in the liver to 25-hydroxycholecalciferol which is further hydroxylated in kidneys to 1,25 dihydroxycholecalciferol. This is the active form of vitamin D

Functions Vitamin D helps in uptake of calcium

from the gut and bone formation Maintains normal functioning of

muscles, immune function and inflammation.

DEFICIENCY leads to poor bone mineralization causing rickets in children and osteomalacia in adults.

Deficiency occurs due to malabsorption or chronic renal disease

TOXICITY leads to hypercalcaemia leading to renalcolic ,polyuria, polydipsia,lethargy,nausea, depression, drowsiness

VITAMIN E

α- tocopherol is the active form of vitamin E in human body.

FUNCTIONS• The main function of vitamin E is anti oxidant. It

intercepts free radicals & prevents destruction of cell membrane.

• It prevents the oxidation of PUFA by free radicles.

• It is involved in anti-inflammatoy and immune systems.

• It inhibits platelets aggregation.

• It enhances vasodilatation.

Vitamin E Dietary Sources Vegetable oils

Almonds & peanuts

sunflower oil

Spinach

Carrots (least)

Vitamin E deficiency

•Severe vitamin E deficiency causes: Neurological symptoms (impaired coordination) & muscle weakness causing ataxia.

Increased risk of cardiovascular diseases

Visual scotomas

Deficiency occurs in severe PEM and fat malabsorption syndrome

Deficiency is t/t by 800-1200mg of tocopherol/d

THERAPEUTIC USES

Prevention of cardiovascular diseases

Diabetes Mellitus

Cancer prevention

Boost immunity

Dementia

TOXICITY

Excess vitamin E may cause:

Impaired blood clotting leading to increased risk of bleeding in some persons.

It is recommended that vitamin E supplements to be stopped one month before elective surgery.

VITAMIN K

The K is derived from the German word Koagulation.

There are 2 naturally occurring forms of vitamin K. Plants synthesize phylloquinone (vitamin K1) & bacteria synthesize menaquinone-3 (vit K2).

FUNCTIONS•Vitamin K is needed for production of vitamin K-dependent coagulation factors in the liver.

•Other functions include:

Assist in bone mineralization. The mineral binding capacity of osteocalcin requires vit K.

SOURCES OF VITAMIN K

Bacteria in large intestine produce vit K2 and supply 40-50% of human requirement.

Vegetable oils

Almonds & peanuts

Avocado & Broccoli

Spinach, Lettuce.

Vitamin K deficiency

deficiency leads to delayed coagulation and bleeding.

Is uncommon in adults. Only those with severe liver disease (obst. Jaundice) chr. Small intn dis & those on oral anticoagulants are at risk.

Exclusively breast fed & premature babies are at risk coz human milk is low in vitamin K.

Hemorrhagic disease of the newborn is a serious threat to life & routine vit k prophylaxis is recommended.

VITAMIN C Humans, unlike other mammals, are unable to make ascorbic acid & they get it from food.

Rich dietary sources are citrus juices (orange, grapefruit & lime), strawberry, Guava, tomato, sweet red pepper & broccoli.

Recommended daily intake is between 15-120 mg/day depending on age. Smokers & lactating mother needs the higher range.

FUNCTIONS

Collagen synthesis

Antioxidant property

promotes absorption of non-heme ironConnective tissue metabolism

Vitamin C deficiency

Severe deficiency leads to Scurvy with the following manifestations:

Bleeding & bruising easily- swollen bleeding gums, petechial h’ges,ecchymosis

Joint pain & swelling

Poor wound healing

Fatigue & lack of concentration

• Cardiovascular diseases

• Cataracts

• Diabetes Mellitus

• Cancer prevention

• Common cold

Treatment -250 mg vit C 8hrly

THERAPEUTIC USES

VITAMIN B Complex

Thiamine (Vit. B1)

Known as B1 cause first identified. Function – important role in

peripheral nerve conduction. Food sources– pork, meat, yeast,

beef, legumes, whole grains, nuts. Deficiency – poor intake, chronic

illness, chronic alcoholism, hyperemesis, bariatric surgery.

Signs and symptoms – anorexia, irritability

and Beri BeriTypes of Beri Beri --- wet, dry and infantileWet type – Cardiovascular symptoms, Cardiomegaly, tachycardia, CCFDry type – symmetrical peripheral neuropathy

In alcoholics – chronic deficiency causes CNS manifestations like horizontal nystagmus, ophthalmoplegia, cerebellar ataxia, mental impairment known as Wernicke’s Encephalopathy.

Wernicke’s Encephalopathy with loss of memory and psychosis is known as Wernicke’s Korsakoff’s syndrome

TREATMENT– acute deficiency 100 mg/day IM for 7 days f/b 10

mg/day till recovery.

Riboflavin (Vit. B2)

Important for metabolism of CHO,fat,proteinsDeficiency causes-- Lesions of mucocutaneous surface of oral cavity and skin, Corneal vascularization, Anemia and Personality changes Sources are-- Milk and dairy products, Enriched breads, Cereals, Fish, Eggs, Broccoli and LegumesToxicity– not known becoz GI absorption is verylimited.

Niacin (Vit. B3)

Refers to nicotinic acid nicotinamide and derivatives. They are precursors of NAD and NADP which are important in oxidation and reduction reactions in the body.

Sources—beans, milk, meat, eggs Deficiency causes Pellagra Common in corn eating population,

alcoholics Hartnup’s disease, carcinoid syndrome

S/S of Pellagra

Loss of appetite, gen weakness, irritability abdominal pain and vomiting

Red tongue Characteristic skin rash, pigmented

and scaling skin(rash known as Casal’s necklace)

Diarrhea, dementia,depression,seizures

Severe Pellagra--3Ds leading to death dermatitis diarrhea dementia

Treatment – 100 -200 mg of nicotinamide TDS daily for 5 days

Pantothenic Acid (Vit. B5) Component of co-enzyme A Source– liver, yeast, egg yolk, whole

grains, vegetables Deficiency—GI disturbances,

depression, muscle cramps paresthesias, ataxia

No toxicity known

Pyridoxine (Vit B6)

It is a cofactor for many enzymes involved in amino acid metabolism

Synthesis of heme and neurotransmitters

Metabolism of glycogen, lipids, steroids and several vitamins.

Sources– legumes, nuts, wheat bran, meat . Bioavailability is more in animal sources.

Deficiency Epithelial changes, Depression, confusion Microcytic hypochromic anemia due to

reduced heme Hyperhomocystenemia -increased risk of

CV disease In infants diarrhea ,seizures Some drugs like

INH ,penicillamine ,alpha dopa

Toxicity Sensory neuropathy Photosensitivity Treatment RDA--- 1.5-- 2 mg/day 100mg im daily for seizures

Folic Acid (Vitamin B9)

Functions:1. Needed for RBC & DNA formation, cell multiplication

esp. GI cells2. Newly discovered functions:

a. Prevents neural tube defectsb. Prevents heart disease (reduces homocysteine

levels)c. Prevents colon cancer

Etiology: Peak incidence 4-7 months Deficient dietary intake: goat’s milk deficient &

powdered milk poor source Sources are liver, green leafy veg, and fortified cereals.

DEFICIENCYDeficient absorption as in celiac

disease, achlorhydria, anticonvulsant drugs and zinc deficiency

hypothyroidism, drugs like trimethoprim & alcoholism

Increased requirement during rapid growth & infection

Asso with vitamin B12 deficiency & chronic alcoholism

Increased destruction possible in cigarette smoking

Folic Acid Deficiency

Clinical Manifestations:1.Megaloblastic anemia w/ irritability,

failure to gain wt & chronic diarrhea2.Thrombocytopenic hemorrhages

advanced cases

RDA: 20-50mcg/24 hrs

Treatment:3.Parenteral folic acid 2-5mg/24 hrs,

response in 72 hrs, therapy for 3-4 wks4.Transfusions only when anemia severe

Cobalamine (Vitamin B12)

Vitamin B12 is absorbed from the terminal ileum in presence of intrinsic factor

Deficiency occurs in elderly patients, alcoholics, malabsorption, drugs like neomycin

Clinical Manifestations of deficiency:1. Megaloblastic anemia 2. Neurological includes ataxia, paresthesias,

hyporeflexia, Babinski responses, clonus & coma

3. Tongue smooth, red & painful

RDA: Infants 0.5 mcg/dayOlder children & adults 3mcg/day

Treatment:1. Prompt hematological response w/

parenteral vitamin B12 1-5mcg/24hrs2. If there is neurological involvement

1mg IM daily for at least 2wks3. Pernicious Anemia: Monthly vitamin

B12 1mg IM necessary throughout patient’s life

TRACE ELEMENTS

CALCIUM Dietary sources – milk ,cheese,

yoghurt, eggs, fish, almonds, peanuts, peas and beans

Calcium absorption is impaired in vit. D deficiency, malabsorption and some foods like spinach

Deficiency causes impaired bone mineralization in children and increased bone loss in adults

phosphorus

Dietary deficiency is rare Phosphates are added to processed

foods Deficiency occurs in premature

infants, renal tubular phosphate loss. Deficiency causes

hypophosphatemia and muscle weakness

IRON

Needed in formation of Hb, and involved in many enzymatic reactions.

Dietary sources are red meat, liver, fish, shellfish,oatmeal, legumes, nuts, dried fruits

Normal daily loss is 1 mg by desquamated surface cells and intestinal loss.

30 mg of iron is lost in menstruation Daily intake of 8 mg Vitamin C enhances iron absorption Overload of iron leads to haemochromatosis

and liver cirrhosis

IODINE

Sources are sea fish, seaweed and plants grown near the sea.

Deficient in mountainous regions. Deficiency cause IDD, goitre is

common, congenital hypothyroidism, deafness, poor reflexes and poor learning

ZINC

Present in meat, shellfish, nuts and legumes Zn helps in synth and stabilization of protiens Deficiency is seen in PEM, malabsorption

syndromes, alcoholics and alcoholic liver disease.

Deficiency is characterized by growth retardation, hair loss, chronic diarrhea ,muscle wasting and, mental apathy.

Zn promotes general well being, healing of skin lesions and improves appetite

SELENIUM

Prevents free radical damage to the cells.

Takes part in conversion of thyroxin to triiodothyronine in liver

Deficiency – hypothyroidism, cardiomyopathy in children and myopathy in adults

FLUORIDE

Prevents dental caries. Deficiency is seen where people

consume soft water. Excess fluoride cause increase bone

density, calcification of ligaments and tendons, also affects the dental enamel and causes mottling, pitting and pigmentation.

COPPER

DEFICIENCY can cause microcytic hypochromic anemia, neutropenia, retarded growth in children, skeletal rarefaction and dermatosis

Abnormal copper metabolism is seen in wilson’s disease

Deficiency occurs in PEM or prolonged parenteral nutrition

THANK YOU

Clinical finding of vit defiNutrient Clinical Finding

Thiamine Beriberi: neuropathy, muscle weakness and wasting, cardiomegaly, edema, ophthalmoplegia, confabulation

Riboflavin Magenta tongue, angular stomatitis, seborrhea, cheilosis

Niacin Pellagra: pigmented rash of sun-exposed areas, bright red tongue, diarrhea, apathy, memory loss, disorientation

Vitamin B6 Seborrhea, glossitis, convulsions, neuropathy, depression, confusion, microcytic anemia

Folate Megaloblastic anemia, atrophic glossitis, depression,  homocysteine

nutrientClinical finding

Vitamin B12 Megaloblastic anemia, loss of vibratory and position sense, abnormal gait, dementia, impotence, loss of bladder and bowel control, homocysteine, methylmalonic acid

Vitamin C Scurvy: petechiae, ecchymosis, coiled hairs, inflamed and bleeding gums, joint effusion, poor wound healing, fatigue

Vitamin A Xerophthalmia, night blindness, Bitot's spots, follicular hyperkeratosis, impaired embryonic development, immune dysfunction

Vitamin D Rickets: skeletal deformation, rachitic rosary, bowed legs; osteomalacia

Vitamin E Peripheral neuropathy, spinocerebellar ataxia, skeletal muscle atrophy, retinopathy

Vitamin K Elevated prothrombin time, bleeding

Element Deficiency Toxicity

Boron No biologic function determined

Developmental defects, male sterility, testicular atrophy

Calcium Reduced bone mass, osteoporosis

Renal insufficiency (milk-alkali syndrome), nephrolithiasis, impaired iron absorption

Copper Anemia, growth retardation, defective keratinization and pigmentation of hair, hypothermia, degenerative changes in aortic elastin, osteopenia, mental deterioration

Nausea, vomiting, diarrhea, hepatic failure, tremor, mental deterioration, hemolytic anemia, renal dysfunction

Chromium Impaired glucose tolerance

Occupational: renal failure, dermatitis, pulmonary cancer

Fluoride Dental caries Dental and skeletal fluorosis, osteosclerosis