ADVANCED DIPLOMA IN PRINCIPLES OF NUTRITION

@ShawPhotoTomCourse Educators: Thomas Woods, William Eames

BY AMANDA BRODERICK BSc ANutR

BSC HONS Sports Biomedicine and Nutrition

BY AMANDA BRODERICK LESSON: 7

Course Educator:

Amanda Broderick Course Educator

B.A. (Hons.)

Special Diets Semester :

Lesson 7Treating Nutritional Deficiencies

@ShawNutritionA amandabroderick@shawacademy.com

Lesson 7 Learning Outcomes

Vitamins and their deficiency diseases A D C B1 B12 Folate

Minerals and their deficiency diseases Phosphorous Magnesium Potassium Iron Zinc Iodine

Fat soluble A, D, E, K Water-soluble vitamins (B group and C)

Risk of deficiency Very low fat dietsConditions where fat absorption is impaired

Diets lacking variety

Stability in foods Robust to heat and light Various: often labile to heat and light

Storage in body Can be large and long term Often small, so frequent regular intakes required

Risk of toxicity High Low: high intakes can usually be excreted in urine. However, excessive intakes of some can have short- or long-term side-effects

Vitamins

Peter suffers from blindness associated with a

vitamin deficiency

An estimated 250million preschool children are

deficient in this vitamin

An estimated 250,000 to 500,000 children become

blind every year due to a deficiency in this vitamin

The deficiency of this vitamin is the leading cause of

preventable blindness in children and increases the

risk of disease and death from severe infections

In pregnant women, a deficiency in this vitamin may

increase the risk of maternal mortality

What is it??

Quiz question!

Normal development and differentiation of tissue Reproduction, embryonic development and

growth Preventing blindness

Requirements: 700ug/day men 600ug/day women Children aged 1-10years is 400-500ug/day 11-14year olds 600ug/day During pregnancy daily requirement is increased

by 100ug Lactation: increase intake by 350ug

Vitamin A

Sources:• Liver and liver products• Fortified margarine and fat spreads• Dairy products (milk, butter, cheese, cream)• Oily fish• Egg yolk• Fish liver oils• B-carotene is also added as a colourant (E160a) to

margarine and fat spreads and some soft drinks

The most concentrated food sources of carotenoids are :• Carrots• Red peppers• Dark green leafy vegetables (e.g. spinach, broccoli)• Tomatoes• Yellow fruits such as peaches, apricots, mangoes

Vitamin A

Deficiency Night blindness Growth retardation Foetal abnormalities Increased susceptibility to infection

Toxicity Surplus amounts accumulate in the body Can cause liver damage and be fatal >1.5mg/day can be harmful to bones (NHS)

Vitamin A: Deficiency and Toxicity

Acute Toxicity (symptoms) Abdominal pain, vomiting and headaches Usually with intakes >100,000ug RE (adults)

Chronic toxicity (symptoms) Skin and eye problems Hair loss, bone loss, joint pain Chronic headache

• Women who are/wish to become pregnant should not take dietary supplements containing vitamin A without medical advice. They should avoid concentrated sources such as liver and liver products

Vitamin A: Deficiency and Toxicity

Baby Jane presented with:

Delayed growth

Pain in the spine, pelvis and legs

Muscle weakness

She was found to have rickets

Because rickets softens the growth

plates at the ends of a child's bones, it

can cause skeletal deformities such as:

Bowed legs

Thickened wrists and ankles

Breastbone projection

Doctors confirmed that it developed

due to nutritional deficiency…but due

to what?

Quiz question

Vitamin D needed for calcium and phosphorus absorption from food

Rickets can occur in children and Osteomalacia in adults

Sources: Sunlight Fish oils, fatty fish Egg yolk Fortified foods- milk, cereal and some fruit juices

What can affect absorption? Coeliac disease Inflammatory bowel disease Cystic fibrosis Kidney problems

Vitamin D

HOW?

Active form is a steroid hormone

Controls amount of calcium absorbed and

excreted

Involved in maintaining plasma calcium via

bone resorption

Regulated by parathyroid hormone which is

secreted in response to low calcium levels

Prevention of bone disease?

Eat a diet rich in vitamin D and

calcium and spend some time in the

sunlight

Requirements are high in young

children and during pregnancy

Vitamin D

Controls calcium concentration by stimulating active intestinal absorption of calcium and bone resorption

Vitamin D deficiency is likely to contribute to acceleration of fractures

Low vitamin D levels can cause muscle weakness which can affect balance and mobility, increased risk of falls.

Vitamin D

Requirements: (UK guidelines) Most people meet their needs by exposure to the

sun Pregnant women - take 10μg/day Babies and children <5 years should take

supplement drops. RNI 7-8.5μg/day (this should be given under medical guidance)

Be aware formula is usually fortified with vitamin D People >65 years, supplement 10μg/day (400IU) In people with Vitamin D deficiency 20 μg/day

(800IU)

Vitamin D

Jack is an alcoholic

Recently he has been suffering from

confusion, loss of full body movements,

paralysis of eye muscles and a

characteristic psychosis

Doctors have diagnosed him with

Wericke-Korsakoff syndrome related to

vitamin deficiency

Which vitamin?

Quiz question

Function- the release and utilisation of energy from food

Required for normal functioning of the nervous system

Requirements (UK) 1mg a day for men 0.8mg a day for women

Sources Fortified breads and cereals Meat Vegetables Yeast and yeast extracts Pork Nuts Pulses

Thiamine (vitamin B1)

Deficiency: Severe deficiency is Beri-beri- characterised by

severe weakness, muscle wasting and polyneuropathy

Wernicke-Korsakoff syndrome- usually responds well to thiamine administration

• Deficiency may also be partly responsible for the growth retardation and congenital malformations seen in foetal alcohol syndrome caused by maternal alcohol abuse

Thiamine (vitamin B1)

Over the course of two months, a 62-year-old Mary

developed numbness and a “pins and needles” sensation

in her hands, had trouble walking, experienced severe

joint pain, began turning yellow, and became

progressively short of breath. She was also experiencing

fatigue and lethargy, dyspnoea, faintness, palpitations and

headache

She then developed deep depression, paranoia and

delusions, memory loss, incontinence, loss of taste and

smell

Doctors diagnosed her with pernicious anaemia and a

severe vitamin deficiency.

Which one?

Quiz question

Function: Important vitamin for maintaining healthy nerve

cells, and it helps in the production of DNA and RNA, the body's genetic material

Vitamin B12 also works closely with vitamin B9, also called folate or folic acid, to help make red blood cells and to help iron work better in the body

Folate and B12 work together to produce S-adenosylmethionine (SAMe), a compound involved in immune function and mood

The maintenance of normal blood homocysteine levels, together with folate and vitamin B6 (raised levels are a risk factor in cardiovascular disease)

Vitamin B12 (cobalamin)

Requirement (UK) Adults need approximately 0.0015mg a day of vitamin B12

Sources Meat (especially liver) Milk and dairy products Fish (especially oily) Fortified breakfast cereals

• Yeast extract and other fortified/supplemented foods such as breakfast cereals, soya milks, soya/veggie burgers, and vegetable margarines are all good sources

Vitamin B12 (cobalamin)

Autoimmune condition that affects your stomach

Vitamin B12 is absorbed into your body through your stomach

A protein called "intrinsic factor" attaches itself to vitamin B12

Pernicious anaemia causes your immune system to attack the cells in your stomach that produce the intrinsic factor, which means your body in unable to absorb vitamin B12

More common in women around 60 years of age

B12 Deficiency -

pernicious anaemia

Causes:

Can occur due to a lack of B12 in the diet - rare

Absorptive difficulty e.g. Crohn’s

Resection of the small intestine

Who is at risk?

Vegetarians/vegans

Older adults

Treatment: parenteral administration of vitamin

B12

B12 Deficiency -

pernicious anaemia

Function: Important role in the synthesis of DNA and RNA Crucial role in cell division

Requirement RNI for children is 70-150ug/day Adults need 200ug/day (DH, 1991) of folic acid 400ug of folic acid per day pre-and during

pregnancy

Sources: Cereal products Vegetables Potatoes Milk and dairy products Green leafy vegetables

Folate

Megaloblastic anaemia

Cause:Malabsorption - medications, disease states,

coeliac disease

Important to distinguish it from B12 deficiency -neurological damage may continue unnoticed

Prevent Neural tube defects

Poor folate status may increase the risk of CVD

Inversely related to blood homocysteine level - risk marker for CVD

Toxicity - safe

Folate Deficiency

Tom is a smoker

Recently he has notices his gums are

bleeding, he has joint and bone pain

and re-opening of previously healed

wounds

He has not been eating well recently

and Doctors have diagnosed him with

a case of scurvy due to dietary

deficiency of which vitamin?

Quiz question

Function Affects many oxidation/reduction reactions Converts ferric (Fe3+) ion to more soluble

ferrous (Fe2 + form)…aids absorption of non-haem iron

Antioxidant Synthesis of collagen Essential for the structure and maintenance of

blood vessels, connective tissue and cartilage

Vitamin C (ascorbic acid)

Requirements The RNI for children is 30mg/day and for

adults 40mg/day (DH 1991) During pregnancy there is an increase to the

RNI by 10mg/day and during lactation by 30mg/day

Smokers need 80mg/day

Sources: Fruit and vegetables

Vitamin C (ascorbic acid)

Minerals (required in milligram

quantities)

Trace elements (required in

microgram quantities)

Calcium Copper

Phosphorous Chromium

Magnesium Manganese

Sodium Molybdenum

Potassium Selenium

Iron Iodine

Zinc

*Fluoride (semi-essential)

Minerals and trace elements

Present in all cells in the body Function: Essential for many metabolic processes and bone

health 85% of body phosphorous is in bones- as

hydroxyapatite Remaining 15%- found in phospholipids,

nucleotides and nucleic acids

Essential to the release of oxygen and energy to cells

Involved in acid-base balance Parathyroid hormone (PTH) regulates balance

between phosphorus and calcium

Phosphorous

Requirement: Adults need 550mg of phosphorus a day

additional 440mg/day being required during lactation

Absorption: 60% dietary phosphorus is absorbed

Deficiency; unlikely in a healthy person Hypophosphataemia include muscle weakness,

respiratory and cardiac failure, neuropathy and tissue hypoxia

Phosphorous

Source:

Milk, meat, fish, eggs, nuts,

cereals, vegetables

Hyperphospataemia:

Has a pathological cause

Phosphate restriction is

usually necessary when

managing kidney

disease

Phosphorous

2nd most abundant mineral in the body 50% is present in the skeleton and remainder is in

cells

Function Skeletal development Protein synthesis Muscle contraction Neurotransmission

Metabolically - closely linked with calcium

Requirement: RNI for adults over the age of 19 years has been set at 300mg/day for men and 270mg/day for women, with an additional increment of 50mg/day during lactation.

Magnesium

Absorption: 20-50% of dietary magnesium is absorbed

Fibre rich foods decrease magnesium bioavailability

Protein may enhance absorption Deficiency: not common in healthy individuals

Sources:Green leafy veg, whole grainsNutsHard drinking waterBread and cereal productsBeveragesMeat and meat productsMilk and milk productsPotatoes and savoury snacksVegetables

Magnesium

Function Plays a fundamental role in Acid-base regulation Fluid balance Muscle contraction Nerve conduction

Requirement: Loss of potassium in urine and stool daily (approx. 15mmol/day)

RNI for adults approx. 3500mg/day

Absorption: 90% of ingested potassium is absorbed

Deficiency: skeletal muscle weakness, cardiac arrhythmias, problems with GI tract, mental impairment

Potassium

Fruit: especially bananas, apricots, rhubarb, blackcurrants, citrus fruits, dried and crystallised fruit, fruit juices.

Vegetables especially potatoes and potato snacks, mushrooms, beetroot, pulses including baked beans, tomato juice

Chocolate, cocoa and chocolate-containing products Coffee and coffee containing productsMalted milk drinks Yeast extracts and spreads, stock cubes, bottled

sauces and ketchups Chutneys and pickles Tinned and packet soupsWine, sherry, beer and cider Cream of tartar, curry powder, chilli, ginger, salt

substitutes (usually based on potassium chloride)

Potassium

Tracy is 25 years old

She suffers from heavy periods on a

monthly basis which leave her feeling

drained

She recently wanted to lose some weight

and went on a strict juicing diet for 1 month

She presented at her GP surgery with

breathlessness, fatigue, pale complexion

The Doctor ruled out B12 and folate

deficiency anaemia

What nutrient is she deficient in?

Haemoglobin

levels <13g/dl

in men and

<12g/dl in

women can

indicate iron

deficiency

anaemia

Quiz question

Infants >6 months, where weaning is delayed or

not providing iron

Menstruating women

Pregnant women - a risk in those with low iron

stores

Vegetarians/vegans: strict or unbalanced diets

may be lacking in iron

Insufficient Vitamin C

People with malabsorption or blood loss

Iron Deficiency Anaemia

At Risk Groups

Major role: Oxygen carrier in haemoglobin in blood and

myoglobin in muscle Central role in energy metabolism

Human body contains 2-4g iron, 2/3 haemoglobin

No mechanism for iron excretion - regulated by absorption

Absorption: Usually 15% of iron is absorbed This increases during times of high

requirement e.g. pregnancy Decreases during iron sufficiency

Iron

Haem iron - contained in haemoglobin and myoglobin of animal foods, well absorbed, relatively unaffected by other food components

Non-haem iron - 90% of dietary iron intake - more variable and greatly influenced by iron status and dietary composition

• Non- haem ironTannins, phytates etc inhibit absorption

Vitamin C aids absorption - ferric ions converted to ferrous form (more readily absorbed

Iron

About 1mg/iron/day is lost via urine, faeces, sweatMenstruation - additional loss of 20mgiron/month

Requirements greater during growth - adolescence and pregnancy

Males: 11-18 years 11.3mg/day>19 years 8.7mg/day

Females: 11-50 years 14.8mg/day>50 years 8.7mg/day

0-3 months-1.7mg/day 4-6months-4.3mg/day 7-12 months-7.8mg/day 1-3 years- 6.9mg/day 4-6 years- 6.1mg/day 7-10 years- 8.7mg/day

Iron Requirements

The body has the capacity to increase its iron absorption in the face of increased physiological demand such as during pregnancy, lactation or growth spurts, and in conditions of iron insufficiency or following acute blood loss

Iron Requirements

Good sources of iron include:

•liver•meat•beans•nuts•dried fruit, such as dried apricots•wholegrains, such as brown rice•fortified breakfast cereals•soybean flour•most dark-green leafy vegetables, such as watercress and curly kale

Iron Sources

Paul has gone to his GP with

symptoms:

Nausea

Abdominal pain

Constipation

Joint pain

He has been found to have high iron

stores

This condition is know as??

Quiz question

One of the most common genetic disorders As many as 1 in 100 likely to be at risk Iron overload disorder Causes person to absorb excess amounts of iron

from food Over time - absorb and accumulate excessive

amounts of iron Iron can deposit in other parts of the body - organs

such as heart and liver

Iron Toxicity

Haemochromatosis

Long term health consequences: liver damage, heart failure, diabetes (if left untreated)

Primary haemochromatosis - inherited (most common)

Secondary haemochromatosis - results from another condition e.g. chronic liver disease

Treatment: phlebotomy-regular removal of blood

• Men usually show symptoms before women

Iron Toxicity

Haemochromatosis

Reduce your consumption of red meat (such as beef and lamb) and avoid organ meat (such as liver, kidney and heart) -iron is much more readily absorbed from meat than from vegetables, cereals and beans

Avoid taking iron supplements and eating foods fortified with iron, such as breakfast cereals

Reducing Iron in the Diet

Dietary Advice To Aid Haemochromatosis

Reduce the amount of vitamin C you consume, as this increases the absorption of iron and helps it to be deposited in some organs

Avoid drinking too much alcohol, especially with meals, as this can increase iron absorption and cause liver disease

Consume tea and dairy products with a meal to reduce the amount of iron absorbed

Reducing Iron in the Diet

Dietary Advice To Aid Haemochromatosis

Function It is an essential component/cofactor for more

than 300 enzymes involved in the synthesis and metabolism of carbohydrates, lipids, proteins, nucleic acids and other micro-nutrients.

It stabilises cellular components and membranes and so is important for cell and organ structure and integrity.

It is essential for cell division and is needed for normal growth and development during pregnancy, childhood and adolescence.

It is involved in DNA synthesis and the process of genetic expression.

It is important for immune function (both cellular and humoral immunity).

It is involved in wound healing and tissue repair. It is needed for the senses of taste and smell.

Zinc

Requirements: Daily intake needed to maintain adequate body levels RNI 5.5-9.5mg a day for men 4-7mg a day for women Lactation: 6mg/day extra needed for first 4 months and

2.5mg/day thereafter

Red meat and poultry (these are the main sources of zinc for many)

Oysters, crab, lobster and other shellfish (oysters contain more zinc per serving than any other food)

Pulses, nuts and legumes. Wholegrain cereals. Fortified breakfast cereals. Dairy products such as cheese. Note that phytates in wholegrain bread, cereals,

legumes and some other foods inhibit zinc absorption and so affect the bioavailability of zinc from plant foods.

Zinc

Risk factors

Inadequate diet Gastrointestinal diseases including ulcerative

colitis, Crohn's disease, short bowel syndrome and chronic diarrhoea

Chronic liver disease Chronic kidney disease Alcoholism (decreases zinc absorption and

increases urinary zinc excretion) Sickle cell disease Diabetes Pregnancy and breast-feeding Vegetarian diet People taking large amounts of iron

supplementation (iron can interfere with zinc absorption)

Zinc Deficiency

Consequences: Anorexia, lethargy, diarrhoea Growth restriction (delayed bone maturation) Impaired immune function and susceptibility to

infection

Severe cases can lead to: Delayed sexual maturation, impotence,

hypogonadism and hypospermia Alopecia, dermatitis, paronychia Intellectual disability, impaired nerve conduction

and nerve damageWeight lossMacular degeneration Impaired taste and smell Impaired wound healing

Zinc Deficiency

Many diseases are associated with a deficiency in a vitamin or mineral

Vitamin A deficiency can cause blindness Vitamin D deficiency can cause rickets in

children and osteomalacia in adults A lack of Vitamin D and Calcium in the diet can

lead to the development of osteoporosis Bone formation is regulated by parathyroid

hormone

In Conclusion

A vitamin B1 deficiency is strongly linked to alcoholism and can result in Wericke-Korsakoffsyndrome

B12 deficiency can be detrimental to health and causes pernicious anaemia

Folate deficiency can lead to megaloblastic anaemia and neural tube defects

Vitamin C deficiency can lead to scurvy Iron deficiency anaemia is very common

particularly in teenage girls and is highly preventable

A varied, balanced diet can help to avoid nutrition-related deficiency diseases

In Conclusion

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Further Reading1) SIGN- osteoporosis guidelineshttp://www.sign.ac.uk/guidelines/fulltext/71/section4.html

2) NHS- iodine:http://www.nhs.uk/Conditions/vitamins-minerals/Pages/Iodine.aspx

3) NHS- Vitamin Ahttp://www.nhs.uk/Conditions/vitamins-minerals/Pages/Vitamin-A.aspx

4) NHS- B vitaminshttp://www.nhs.uk/Conditions/vitamins-minerals/Pages/Vitamin-B.aspx

5) NHS- Vitamin Chttp://www.nhs.uk/Conditions/vitamins-minerals/Pages/Vitamin-C.aspx

6) NHS- Vitamin Dhttp://www.nhs.uk/Conditions/vitamins-minerals/Pages/Vitamin-D.aspx

7) NHS- Ironhttp://www.nhs.uk/Conditions/vitamins-minerals/Pages/Iron.aspx