Clinical Pharmacy Lec 11 Nutritional Deficiencies PDF

Clinical Pharmacy I, PP904 Lecture 11: Nutritional deficiencies Dr. Nashwa El Tantawy Lecturer of Clinical Pharmacy Egyptian Chinese University [email protected] Office hours: Monday 12:00 - 2:00pm  Marks Distribution...

Clinical Pharmacy I, PP904 Lecture 11: Nutritional deficiencies Dr. Nashwa El Tantawy Lecturer of Clinical Pharmacy Egyptian Chinese University [email protected] Office hours: Monday 12:00 - 2:00pm  Marks Distribution Exam Marks Periodical 20 marks Clinical Pharmacy I, PP904 Practical Project 5 marks Credit Hours : 3 (2+1) Lab Evaluation 5 marks Practical (OSCE) 10 marks Practical final Exam 20 marks Final written Exam 75 marks Oral Exam 15 marks Total 150  1. Introduction to clinical Pharmacy facilities 2. Clinical Case presentation 3. Clinical laboratory data and physical examination 4. Therapeutic planning 5. Drug-related problems Course Outline 6. Medication errors & Reconciliation 7. Special care populations( geriatric, pediatric) 8. Special care populations (pregnancy ,Hepatic) 9. Supportive care of oncological diseases 10. Supportive care of blood disorders 11. Nutritional deficiencies 12. Revision Nutrition is the source of energy that is required to carry out all the processes of human body. A balanced diet is a combination Nutrients : Macro Micro Needed in Needed in large small amounts amounts (in (in grams) mg or µg) Carbohydrates Lipids Vitamins Proteins Minerals Fiber Water “Nutritional inadequacy” Intake of nutrients that is lower than the estimated average requirement, whereas : “Nutritional deficiency” consists of severely reduced levels of one or more nutrients, making the body unable to normally perform its functions and thus leading to an increased risk of several diseases like, cancer , diabetes and Heart disease. Malnutrition could be caused by environmental factors, like food scarcity, as well as disease conditions, like anorexia ner-vosa, fasting, swallowing inability, persistent vomiting, impaired digestion, intestinal malabsorption, or other chronic diseases. Malnutrition could also be caused by bad food choices or insufficient food intake Nutritional diseases can cause nutrients deficiencies or excesses, eating disorders, obesity, chronic diseases like cardiovascular diseases, hypertension, diabetes mellitus, cancer, inherited metabolic disorders, developmental abnormalities, food intolerances and allergies. Macronutrients Deficiency Protein-energy malnutrition (PEM) is a condition in which individuals have a very little dietary intake of proteins, energy or both. The two major diseases linked with this condition marasmus kwashiorkor Kwashiorkor suppresses the production of insulin, causing a reduced protein complete food synthesis deprivation with extreme which leads to exceptionally limited protein hypoproteinemia, immunosuppression, quantities of deficiency edema, and diarrhea protein and energy Children have swollen belly, Infants with caused by the fluid marasmus are retention (edema), and exceptionally affected children are underweight, as they mostly weak, wasted, have lost almost all poorly grown, and more their subcutaneous susceptible to infectious fat diseases Carbohydrates deficiency Specific cells of human body, like neurons, need high amounts of glucose. In the absence of carbohydrates, gluconeogenesis depends upon the breakdown of amino acids obtained from dietary proteins, body proteins, and glycerol obtained from fats Gluconeogenesis takes place in the liver. Long-term insufficiency of carbohydrate lead to ketosis (increased ketones production), that is characterized by the peculiar sweet odor of the patient’s breath. Ketosis other complications linked with low carbohydrate intake can be prevented by consuming daily 50 to 100 g of carbohydrate; although, for a healthy and balanced diet, at least about a minimum of 250 g of daily carbohydrate intake Essential fatty acids deficiency Omega-3 and Omega-6 are polyunsaturated and essential fatty acids (EFA). Clinical symptoms of EFAs deficiency include diminished growth in children and infants, scaly dry rash, reduced wound healing, and increased infection susceptibility. the association of lower omega-3 index with higher risk of mortality by coronary heart disease. Furthermore, the supplementation of omega-3 PUFA during pregnancy decreases the risk of premature births and increases the birth weight and gestational age at delivery. Several preparations of omega-3 fatty acid have been approved and recommended by US Food and Drug Administration for hypertriglyceridemia treatment. Similarly, replacing other dietary saturated fatty acids (SFAs) with omega-6 PUFA decreases the total blood cholesterol. Micronutrient deficiencies significant role in growth and development through the production of catalysts, hormones. Micronutrient-related malnutrition occurs due to the deficiency of essential vitamins and minerals in human food. Both over and undernutrition are associated with micronutrients deficiency. Vitamin A,D,C,B12, iron, Calcium ,Biotin , Zinc, Magnesium and iodine are the most common deficient micro-nutrients. A lack of various key minerals and vitamins may cause brain damage, anemia, night blindness, stunted growth, and child mortality Vitamin A deficiency ❑ causes ophthalmologic diseases. ❑ vitamin A is crucial for preserving the integrity of epithelial tissues in the eye and in the urinary, intestinal, and respiratory tracts.  C. Vitamin A deficiency The initial clinical symptoms of vitamin A deficiency include xerophthalmia, Bitot spots development, and night blindness. With the progression of the vitamin A deficiency, keratomalacia and permanent blindness. Furthermore, children with vitamin A deficiency may also exhibit protein energy malnutrition. In subclinical vitamin A deficiency, children have higher infection susceptibility and reduced physical growth. xerophthalmia keratomalacia Bitot Spots Vitamin B deficiency Feature Vit B 6 (Pyridoxine) Vit B 12 (Folate/Folic Acid) Vit B 9 (Cobalamin) Function - Helps in protein, fat, and Supports red blood cell - Crucial for DNA synthesis carbohydrate metabolism. formation. and repair. - Aids neurotransmitter - Helps maintain nerve - Important in cell division synthesis (serotonin, function. and growth. dopamine, GABA). - Crucial for DNA - Prevents neural tube - Supports red blood cell synthesis and energy defects during pregnancy. production. production. Food Source - Animal products: meat, fish, dairy, and Poultry, fish (salmon, - Leafy greens (spinach, eggs. tuna). kale). - Fortified plant-based - Potatoes, bananas, - Legumes (lentils, beans). foods (e.g., cereals). chickpeas. - Fortified cereals. - Supplements - Fortified cereals. - Liver and eggs. (especially for vegetarians ). Deficiency Symptoms Megaloblastic anemia. Megaloblastic anemia. - Irritability, depression. - Fatigue and weakness. - Nerve damage - Peripheral neuropathy. - Birth defects in babies if (tingling, numbness). - Seborrheic dermatitis. deficient during pregnancy. - Memory loss or confusion. Feature Vit B 6 (Pyridoxine) Vit B 12 (Folate/Folic Acid) Vit B 9 (Cobalamin) Excess/Toxicity - Can lead to nerve damage - Can lead to nerve damage - No known toxicity from (rare, only with high (rare, only with high high doses (water-soluble). supplementation). supplementation). Special Notes - Stored in small amounts -Folate is natural; folic acid -Found almost exclusively in in muscles is synthetic (better animal products. - needs regular dietary absorbed). - Deficiency common in intake. - Crucial in early pregnancy. vegans or those with - Supports metabolism - essential for red blood absorption issues (e.g., and neurotransmitter cells pernicious anemia). function. - nerve health -vital for DNA synthesis, - energy metabolism. especially during growth and pregnancy. Vitamin C deficiency ▪ (ascorbic acid) is considered an essential nutrient and is mainly derived from diet, its deficiency causes scurvy and could also lead to behavioral and mood changes. ▪ Vitamin C plays a significant role also in osteoblast , carnitine synthesis, catecholamines synthesis, reductions of urinary folic acid excretion, and higher dietary iron absorption. ▪ In the first 3 months of ascorbic acid deficiency, the symptoms are bleeding gums, hyperkeratosis, coiled hairs, impaired wound healing, and arthralgias. ▪ Humans are incapable of synthesizing vitamin C, therefore they totally depends upon dietary vegetables and fruits for its sufficient intake and storage. ▪ Good vitamin C sources can be citrus fruits, tomatoes, strawberries, potatoes and green leafy vegetables Vitamin D deficiency ▪ Calciferol, is a fat-soluble that is essential for the intestinal absorption and metabolism of calcium, magnesium and phosphorous. ▪ Vitamin D stimulates the osteoclasts to release calcium and phosphorus, and activates the synthesis of enterocyte calcium channel, which enhances the absorption of calcium. ▪ Vitamin D sources are fish and fish oils (which contain the highest proportion of available vitamin D), eggs, mushrooms, liver, and fortified foods (like orange juice and milk). ▪ Vitamin D deficiency causes hypocalcemia and hypophosphatemia, which lead to osteomalacia among adults and rickets among children.  Vitamin D deficiency ✓vitamin D deficiency is associated with immunomodulatory disorders, cardiovascular diseases, hypertension, and insulin resistance in adults. ✓Vitamin D deficiency depends upon various dietary and environmental factors, such as body mass index, sun exposure, and milk ingestion. Long-term and short-term therapy of vitamin D deficiency mainly involves vitamin D supplementation occurs due to its malabsorption, decreased and implementation of vitamin D- and calcium-rich synthesis and reduced dietary intake. diets. cow milk, infant formulas, and In order to solve vitamin D deficiency, for most different cereals are supplemented with vitamin D people over 1 year of age it is considered sufficient. to supplement 50,000 IU at least eight weeks  Calcium deficiency Hypocalcemia Hypocalcemia is characterized by low levels of serum calcium. A long-standing calcium deficiency could lead to Cataracts dental changes Brain alterations Osteoporosis rickets. Sufficient calcium intake is crucial throughout life to maintain bone health. Also certain diseases and specific diets, like vegetarian diets, might cause calcium deficiency. Calcium supplementation is required also in inflammatory bowel disease patients, particularly those administered with corticosteroids/glucocorticoids  Iron deficiency Most prevalent nutritional deficiency, with young children and premenopausal women at the highest risk of iron deficiency -Being iron a major contributor in hemoglobin synthesis Depletion of its reserves leads to microcytic hypochromic anemia,(characterized by smaller- size red blood cells containing a smaller amount of hemoglobin than normal red blood Cells). Symptoms of anemia Include fatigue, apathy, paleness, weakness, breathing difficulty upon exertion, and decreased resistance for cold temperatures. Iron deficiency could affect development, behavior, learning abilities, and growth during childhood.  Severity Anemia due to iron deficiency may also increase risks of complications during pregnancy and maternal death. Iron deficiency mostly caused by insufficient dietary iron intake blood loss during menstruation intestinal blood loss blood loss due to hookworm tumors, hemorrhoids, and regular use of drugs like aspirin  Iodine deficiency ❖ A trace element that plays a major role in thyroid hormone synthesis. Thyroid hormone is essential for regulating human development and growth. ❖ Iodine is naturally present in some foods and is also used as a dietary supplement, added to salt, or used in organic form. ❖ Physiologically, iodine reserves are estimated to be 60μg; on the other hand, during deficiency, the reserves are as low as 10-20 μg ▪ Absorption and utilization of iodine can be impaired due to goitrogens presence or exposure to disulfides and thiocyanates ▪ Reduced dietary intakes of iodine (10-20 μg daily) may result in hypothyroidism, followed by goiter. ▪ Thyroid hormone is necessary for optimum fetal and postnatal development and growth of the central nervous system.  pregnancy During the early stages of pregnancy, maternal iodine deficiency may lead to iodine deficiency disorder, which causes permanent neurological damage and mental retardation in the offspring. From the embryonic stage to adulthood, iodine deficiency disorder includes diminished mental functions, goiters, creinism, and hyper- or hypothyroidism. Infants and pregnant women are at the highest risk of developing iodine deficiency Universally, salt iodization is the most efficient and practical strategy used to reduce global iodine deficiency  Zinc deficiency Zinc is a trace mineral that is essential for health and is associated with cellular metabolism. Zinc is needed for the proper functioning of over 200 enzymes and is crucial for normal growth and development, immune system function, DNA and protein synthesis, and cell division. Since human body cannot store zinc for long, constant dietary intake of zinc is required to maintain normal functions. Primarily, zinc is found in seafood, animal products, and human breast milk. Zinc absorption greatly impaired by lignins, phytates and fiber, which reduce the bioavailability of zinc from non-animal sources  Severe zinc deficiency zinc people suffering from hereditary zinc metabolic disorders like acrodermatitis enteropathica. Zinc deficiency symptoms include skin lesions increased susceptibility to infection diarrhea poor appetite night blindness reduced taste and hair los low sperm count, impotence slow wound healing.  Magnesium deficiency In humans, magnesium deficiency is linked with 1. colorectal cancer 2. osteoporosis 3. Hypertension 4. metabolic syndrome 5. diabetes. In human primary cell cultures, magnesium deficiency results in: mitochondrial DNA damage, increased telomere shortening, activation of cell-cycle arrest proteins. Common magnesium sources include beans, green leafy vegetables, nuts and whole grains. Magnesium blood levels are strongly controlled and therefore could not be used for the assessment of the nutritional status of magnesium  Biotin deficiency Essential cofactor of four carboxylases: pyruvate carboxylase, acetyl-CoA carboxylase, 3-methylcrotonyl-CoA-carboxylase, and propionyl-CoA- carboxylase. Biotin is both synthesized by the intestinal bacteria and obtained from dietary sources Sources of dietary biotin: eggs, walnuts, liver, mushrooms, peanuts, soybeans and cow milk. Biotin is both available Most of the acquired biotin deficiencies are linked with from dietary sources and excessive intake of raw egg synthesized by the whites, gastrointestinal human microbiota, malabsorption, extended acquired biotin deficiency parenteral nutrition, and is very rare. extended use of anticonvulsants.  Biotinidase deficiency leads to metabolic acidosis, conjunctivitis, ataxia, organic aciduria, developmental delay, encephalopathy, sensorineural hearing loss, seizures, periorificial dermatitis, and alopecia  Causes of micronutrient deficiencies impaired absorption which can be due to sufficient intake infections or chronic inflammation micronutrient deficiencies are caused by In INFANTS maternal micronutrient deficiencies in utero or due to rapid postnatal growth  Lactation and pregnancy ❖increases the requirements of macro- and micronutrients. ❖An inadequate nutritional intake of pregnant mothers may lead to insufficient nutritional levels. Infants and children ❖causing stunting, infection susceptibility, and developmental delays ❖Nutrient deficiency can also be caused by selective diets ❖Any diet that completely excludes a specific food group is potentially inadequate for macro- and micronutrient intake. vegan diets exclude all animal-based foods, thus leading to an increased risk of causing B vitamins deficiency Chronic alcoholism causes depletion of the liver reserves of vitamin A and might contribute to alcohol-induced cirrhosis Conclusion Nutritional deficiencies not only cause developmental failure loss of various body functions, several other diseases such as diabetes, vision loss, immunity loss but it also has several long-term effects cancer on economic productivity. The major causes of nutritional deficiencies are insufficient intake of food, inability to absorb nutrients, and consumption of diets that lack some of the essential nutrients.  Micronutrient deficiencies are the most prevalent type of nutritional deficiencies, usually caused by the insufficient intake of one or more of the micronutrients that are essential to maintain optimal health. ▪ Some of these essential micronutrients are iron, Iodine Calcium Zinc ▪ Macro- and micronutrient deficiencies may cause Magnesium several serious diseases. Fluoride like goiter Vitamins A, B6, B12, C, mental retardation D, E and K. acute respiratory infections decreased cognitive function, cancer, vision loss, rickets, pellagra, beriberi, and diarrhea Dietary supplementation is one of the major solutions for managing micronutrient deficiencies, as it can increase the under-consumed nutrients intake within a population and fill the nutritional gaps.