This document provides information about vitamins, minerals, and supplements. It begins by stating the learning objectives are to describe different supplement types and explain their functions. It then discusses vitamins in depth, including their roles, sources, and deficiency diseases. It also covers minerals, dietary reference intakes, antioxidants, herbal supplements and some guidelines for their safe use. The key information provided is on the various micronutrients, their health roles and food sources.

1. PHAR 2533 : RESPONDING TO
SYMPTOMS IN PHARMACY.
SHAHARUDDIN ABDUL RASHID
10 OCTOBER 2017
CUCMS

2. By the end of this lecture students should be
able to:
 Describe different types of vitamin, mineral and
herbal supplement
 Explain the function of each of the supplement
PHAR2533 COMMUNITY PHARMACY PRACTICE 2

3.  Vitamins are essential organic nutrients,
required in small amounts.
 They cannot be synthesized by the body.
Must be obtained by outside sources like
diet, rumen bacteria & sun.
 Required for growth, maintenance,
reproduction and lactation.
 Complex substances that regulate body
processes
 Coenzymes (partners) with enzymes in
reactions

4. 4
Nutritional Value lost by:
Light
Heat
Oxidation
Bacteria
Enzymes
Insects

5. The Institute of Medicine has established some
guidelines.
 The RDA (Recommended Dietary Allowance)
and the AI (Adequate Intake):
 are the amounts of a vitamin or mineral you need to
stay healthy and avoid nutritional deficiencies.
 They are tailored to women, men, and specific age
groups.
 The UL (Tolerable Upper Intake Level) is the
maximum amount of daily vitamins and minerals
that you can safely take without risking an
overdose or serious side effects.
 For certain nutrients, the higher you go above the UL,
the greater the chance of having problems.

6.  The DV (Daily Value) is the only
measurement you’ll find on food and
supplement labels. That’s because space is
limited, and there’s a need for one single
reference number. That number is the
amount of a vitamin or nutrient that a
person should get for optimum health from a
2,000 calories-a-day diet. The DV is
sometimes the same as the RDA and
sometimes not.
The FDA uses a different measurement
of nutritional intake.

7.  Daily Values (DV): standard nutrient intake values
developed by FDA
 Includes DRIs (Daily Recommended Intakes for
Individuals) and (DRVs) Daily Recommended Values
(Proteins, etc.)
 Disease prevention
 Best met through a consumption of a wide variety
of foods
 That number is the amount of a vitamin or nutrient
that a person should get for optimum health from a
2,000 calories-a-day diet. The DV is sometimes the
same as the RDA and sometimes not.

9. 9
Dietary Reference Intakes (DRI):
recommendation for individuals (more
accurate, but would be impossible to label)
 Age
 Gender
 Pregnancy
 Lactation

10. 10
Daily Reference Values (DRV):
standards established for protein and
other dietary components lacking a
RDA or nutrient standard
Constitute part of the Daily Values (DV)
used on food labels

11. Fat-soluble
Dissolve in fat
Can be stored
Water-soluble
Dissolve in water
Carried in
bloodstream, not
stored
A, D, E, K C and B-complex
vitamins
A and D excess can be
harmful
E and K usually not
Excess amounts may
cause extra work on
kidneys

13.  Functions:
 Normal vision
 Protects from
infections
 Regulates immune
system
 Antioxidant
(carotenoids)
 Food sources:
 Liver
 Fish oil
 Eggs
 Fortified milk or
other foods
 Red, yellow, orange,
and dark green
veggies
(carotenoids)

14. 14
 Also known as calciferol due to its role in
calcium absorption
 Main role is to maintain calcium and potassium
levels
 It is the only fat soluble vitamin that we can
make- in the presence of sunlight
 Can be made from cholesterol

15. 15
 Can be stored in fat tissues (as can all fat
soluble vitamins)
 Elderly and shut ins are at risk- not enough
sunlight
 We get vitamin D form fortified milk and cereal
 Toxicity is very dangerous
 Occurs only from excess supplementation
 Can lead to calcium deposits in kidneys,
heart and blood vessels

16.  Functions:
 Promotes absorption
of calcium and
phosphorus
 Helps deposit those
in bones/teeth
 Regulates cell
growth
 Plays role in
immunity
 Sources:
 Sunlight (10 – 15
mins 2x a week)
 Salmon with bones
 Milk
 Orange juice
(fortified)
 Fortified cereals

17. 17
Rickets can be caused by lack of
sunlight, but also from insufficient
calcium. Vitamin D linked to calcium
absorption.
(Rickets reported in NYC.)

18.  Functions:
 Antioxidant, may
lower risk for heart
disease and stroke,
some types of
cancers
 Protects fatty acids
and vitamin A
 Sources:
 Vegetable oils
 Foods made from oil
(salad dressing,
margarine)
 Nuts
 Seeds
 Wheat germ
 Green, leafy veggies

19.  Functions:
 Helps blood clot
 Helps body make
some other proteins
 Sources:
 Body can produce
on its own (from
bacteria in
intestines)
 Green, leafy veggies
 Some fruits, other
veggies, and nuts

20. 20
 Contributes to synthesis of seven blood
clotting factors
 Can be reactivated to continue biological
action
 Works as a cofactor for an enzyme that makes
two bone proteins

21. 21
 B1, thiamine
 B2, riboflavin
 B6, pyridoxamine
 B12
 Biotin
 Panothenic acid
 Niacin
 Folacin
 Vitamin C

22.  Functions:
 Helps produce energy
from carbsInvolved
in carbohydrate
metabolism
 Helps body metabolize
glucose, affects
central nervous system
 Sources:
 Whole-grain and
enriched grain
products
 Liver
Deficiency signs: loss of
appetite, muscular weakness,
severe nervous disorders,
general weakness and wasting
(BeriBeri).

23.  Functions:
 Produce energy
 Changes tryptophan
(amino acid) into
niacin
 Sources:
 Liver
 Yogurt and milk
 Enriched grains
 Eggs
 Green, leafy veggies

24. Vitamin B2 (Riboflavin)
Function: necessary for normal embryo development,
important in the metabolism of amino acids and
carbohydrates.
Deficiency signs: poor reproduction characterized by
small litters and deformed young (cleft palate and club-
footedness) curly toe paralysis in chicks, digestive
disturbances, general weakness and eye abnormalities.
Sources: milk and dairy by-products, yeast, green
forages, well cured hay (especially alfalfa), whole grains,
wheat bran and synthetic riboflavin rumen synthesis.

25.  Functions:
 Helps body use
sugars/fatty acids
 Helps enzymes
function normally
 Produces energy
 Sources:
 Foods high in
protein typically
(poultry, fish, beef,
peanut butter,
legumes)
 Enriched and
fortified grains

26.  Functions:
 Helps body make
non-essential amino
acids
 Helps turn
tryptophan into
niacin and serotonin
 Help produce body
chemicals (insulin,
hemoglobin, etc)
 Sources:
 Chicken
 Fish
 Liver
 Whole grains
 Nuts
 Legumes

27.  Functions:
 Produces DNA and
RNA, making new
body cells
 Works with vitamin
B12 to form
hemoglobin
 May protect against
heart disease
 Lowers risk of
neural tube defects
in babies
 Controls plasma
homocystine levels
(related to heart
disease)
 Sources:
 Fortified and enriched
grains and breakfast
cereals
 Orange juice
 Legumes
 Green, leafy veggies
 Peanuts
 Avocados

28.  Functions:
 Works with folate to
make RBC’s
 In many body
chemicals and cells
 Helps body use fatty
acids/amino acids
 Sources:
 Animal products
 Meat
 Fish
 Poultry
 Eggs
 Milk, other dairy

29.  Functions:
 Produces energy
 Helps body use
proteins, carbs, and
fats from foods
 Sources:
 Eggs
 Liver
 Wheat germ
 Peanuts
 Cottage cheese
 Whole grain bread

30.  Helps produce
energy
 Helps the body use
proteins, fat, and
carbs from food
 Sources:
 Found in almost all
foods
 Meat, poultry, fish
 Whole grain cereals
 Legumes
 Milk
 Fruits, veggies

31.  Functions:
 Helps produce
collagen
(connective tissue
in bones, muscles,
etc)
 Keeps capillary
walls, blood vessels
firm
 Helps body absorb
iron and folate
 Healthy gums
 Heals cuts and
wounds
 Protects from
infection, boosts
immunity
 Antioxidant
 Sources
 Citrus fruits
 Other fruits, veggies

32. Rickets (children and vitamin D)
Osteoporosis/osteomalacia
(vitamin D)
Scurvy (vitamin C)
Night blindness (vitamin A)
Beriberi (thiamin)

33. Regulate body processes
Give structure to things in
the body
No calories (energy)
Cannot be destroyed by heat

34.  Major minerals
 Calcium
 Phosphorus
 Magnesium
 Electrolytes
(sodium, chloride,
potassium)
 Trace minerals
 Chromium
 Copper
 Flouride
 Iodine
 Iron
 Manganese
 Selenium
 Zinc

36. Bone formation
Muscle contraction
Heart rate
Nerve function
Helps blood clot

37. 37
 Osteoporosis – a pediatric disease
with geriatric consequences
 1.5 million fractures each
year- major cause of
subsequent mortality (25%
within one year)
 14 billion in direct health
cost
 25 million women at risk
 DRI women 600 – 800
mg/day
National Osteoporosis
Foundation www.nof.org

38. 38

39. Risk Factors :
Your gender.
Age.
Race.
Frame size.
Eating disorders.
Low calcium intake.
Excess soda consumption (Ca:P ratio).
The link between osteoporosis and caffeinated sodas isn't clear, but caffeine
may interfere with calcium absorption and its diuretic effect may increase
mineral loss. In addition, the phosphoric acid in soda may contribute to bone
loss.
Bone density can be improved at any time.

41. Generates energy
Regulate energy metabolism
Component of bones, teeth
Part of DNA, RNA (cell growth,
repair)
Almost all foods, especially
protein-rich foods, contain
phosphorus

42. Part of 300 enzymes (regulates
body functions)
Maintains cells in nerves,
muscles
Component of bones
Best sources are legumes, nuts,
and whole grains

43.  Chloride:
 Fluid balance
 Digestion of food, transmits nerve
impulses
 Potassium
 Maintains blood pressure
 Nerve impulses and muscle contraction
 Sodium
 Fluid balance
 Muscles relax, transmit nerve impulses
 Regulates blood pressure

44.  Sources:
Salt (sodium chloride)
Fruits, veggies, milk,
beans, fish, chicken,
nuts (potassium)

45. Part of hemoglobin, carries oxygen
Brain development
Healthy immune system
Sources:
 Animals (heme) vs. plants (non-
heme)
 Better absorbed from heme
 Consume vitamin C with non-heme
 Fortified cereals, beans, eggs, etc.

47. Compounds that protect cells
from the damage caused by
oxidation
Nutrients with antioxidant
properties:
Vitamin E
Vitamin C
Vitamin A (precursor beta-
carotene)

48.  Oxidation is a chemical reaction in which
atoms lose electrons
 Reduction occurs when atoms gain a
electron

49. Stable atoms have an even number
of electrons (pairs) orbiting
Electron loss during oxidation leaves
an odd number or unpaired electron
Unstable atoms are called free
radicals
Reactive oxygen species (ROS):
oxygen molecule that becomes a
free radical
Free Radical Formation

50. Metabolic processes
 Immune system fighting infections
Environmental factors
 Pollution
 Excess sunlight
 Toxic substances
 Radiation
 Tobacco smoke
 Asbestos

51. Free radicals form within the
phospholipid bilayers of cell
membranes and steal electrons
 Damaged lipid molecules cause cell
membrane to lose its integrity

53. Free radicals damage low-density
lipoproteins (LDLs), cell proteins,
and DNA
May increase risk for chronic
diseases
 Heart disease
 Various cancers
 Diabetes
 Cataracts
 Alzheimer’s disease
 Parkinson’s disease

54. Stabilize free radicals or oppose
oxidation
Antioxidant vitamins donate their
electrons or hydrogen molecules to
free radicals to stabilize them and
reduce oxidation damage
Antioxidant minerals act as
cofactors within enzyme systems
that convert free radicals to less
damaging substances that can be
excreted

55. Antioxidant enzyme systems
(mineral)
 Break down oxidized fatty acids
 Make more vitamin antioxidants
available to fight other free
radicals

56. Antioxidant enzymes:
 Superoxide dismutase converts
free radicals to less damaging
substances, such as hydrogen
peroxide
 Catalase removes hydrogen
peroxide from the body
 Glutathione peroxidase removes
hydrogen peroxide

57.  Other compounds stabilize free radicals
and prevent damage to cells and tissues
 Nutrients with antioxidant properties:
 Vitamin E
 Vitamin C
 Vitamin A
 Beta-carotene (precursor to vitamin A)
 Selenium

58. Coenzyme Q10 (CoQ10 or
ubiquinone) is a
fat-soluble antioxidant.
Coenzyme Q10 (CoQ10) is found
in many animal
products and synthesized by the
body

60. Getting enough CoQ10
is especially important to
power these high energy
cells.
•CoQ10 produces 95 per cent of
your cell’s energy.
Found in highest concentrations in
the inner membrane of the
mitochondria.
Energy producer
•Human studies show CoQ10’s can
help to maintain heart health.

62.  Physical
 For the treatment of sickness and disease.
 Athletic and Weight-loss purposes.
 Mental
 For the treatment of memory loss, depression, sleep,
and stress.

63. Herbal medicine useful in 2 situations:
1. A well-established herbal comp.is used for a short,
self-limiting conditions such as cold or flu eg
echinacea.
2.In the case of a more serious or ongoing illness,
where no effective orthodox treatment exists &
where there is some evidence from literature that a
particular herbal comp.may help e.g milk thistle for
liver cirrhosis

64. • Try to choose a remedy that is specific for the
condition being treated; if doubt ask advice from
pharmacy  discourage the use of herbal products
when the source, active ing.& composition are
uncertain.
• If the patient taking any medication, check for any
likelihood of interactions
• Advice pt not to take several medicines
concurrently unless specifically directed to do so by
a qualified medical herbalist

65.  Use the lowest dose appropriate for the
symptoms
 Must understand the dosage instructions
 If symptoms do not improve significantly
within 7 days, seek advice
 Do not self treat for lengthy periods without
seeking professional help.

66.  Should be careful about medicinal herbs
 Some compounds in herbs can cross placenta birth
defects or other problems
 Some herbs may be passed to babies via breast milk.
 The use : black & blue cohosh, feverfew, garlic,
ginseng and St John’s wort during pregnancy not
recommended
 Cranberry juice  useful alternative for the
treatment & prophylaxis of UTI caused by E.coli in
pregnant women

68.  Claims: Antibiotic, antiviral,
general cure all, lowering of
blood pressure, cholesterol,
and regulation of circulatory
system.

69.  Well studied herb.
 Shown to lower
cholestreol by 9-12% in 8-
16 weeks of use.
 May also possess
antibiotic activities.
 Large doses may cause
heartburn.

70.  Used in Europe as an
approved remedy for
cardiovascular conditions
and for the use of the flu
and colds.

71. Source: The fresh bulb of Allium sativum, cultivated
worldwide
Constituents: Sulphur-containing compound (including
aalicin, ajoenes & aliiin), enzymes (including
alliinase), flavonoids.
Uses: Antihypertensive, antithrombotic,lipid-
lowering agent, antimicrobial. Protective
effect against cancer
ADR: Garlic should be avoided before undergoing
surgical procedures due to possible
postsurgical bleeding.
Heartburn, flatulence, GI upset have been
reported.
Possible interaction with warfarin.

72.  Claims: Treatment of
Arthritis, heart tissue,
motion sickness and
nausea.
 Proven to be effective
in nausea, motion
sickness, and arthritis.
 It is possible that it
treats heart tissue but
not likely.

73.  However, there are many precautions for the
use of ginger.
 The use of ginger may inhibit the chemicals
involved in platelet aggression.
 This leads to increased and prolonged bleeding.

74. Source: Usually powdered dried root of Zingiberis
officinalis.
Constituents: Oleoresins (gingerols and ahogaols), essential oil
(zigiberene)
Uses: Antiemetic, antanauseant, antiinflammatory,
antimicrobial. Possible gastroprotective &
hematological properties. “hot’
remediesstimulate metabolim
Common
application:
Loss of apppetite, motion sickness, inflannatory
conditions.
ADR: Occ.dyspepsia. Larger overdose may cause
depression and cardiacarrhythmias. Possible risk
of increased bleeding following surgery.
C/I in pregnancy

75. Source: The rhizome and root of Echinacea pallida
Active
ingredients:
Polysaccharides, glycoproteins, alkylamides & caffeic
acid derivatives
Uses: Thought to be immunostimulant, increasing the body’s
healing powers. Act indirectly by facilitating increased
phagocyte activity rather than by acting on bacterial
invaders directly. Stimulates cell-mediated immune
system. Anti-inflammatory
Common
application:
Common cold, fevers, URTI, oral inflammation
ADR: Nausea. Max duration of use = 8 weeks.

76. Source: Aerial parts esp.leaves of Tanacetum
parthenium
Constituents: Sesquiterpene lactones, flavonoids, melatonin
Uses: Treatment & prevention of migraine. Anti-
inflammatory, possible antiarthritic. Suggested
that it may inhibit prostaglandin production &
serotonin
Common
application:
Migraine, arthritis
ADR: Mouth ulceration or gastric disturbance .
May be contraindicated in pregnancy

77. Source: Concentrated extract of the leaves of the tree
Ginkgo biloba; prepared by extraction of dried
green leaves with acetone/water solvent.
Constituents: Flavonoids (flavone glycosides), diterpenes
(ginkgolides), sesquiterpenes (bilobalides)
Uses: Claimed to be effective in treating ailments
associated with ageing & cerebral insufficiency.
Increase blood flow. Claimed to enhance cognitive
function & memory. Antioxidant. Tinnitus. Effect of
poor circulation.
Common
application:
Tinnitus,vertigo,symp.of early stages of Alzheimer’s,
Raynaud’s syndrome, intermittent claudication
ADR: Occ. GI disturbance, headache & allergic. Reported
to cause spontaneous bleeding & may interact with
anticoagulant & antiplatelet.

78. Source: Main & lateral root parts of several sp.of
Panax, including Panax ginseng (Chinese or
Asian) Panax japonicus(Korean), Panax
quinquefolium
(American/Canadian) & Eleutherococcus
senticosus (Siberian)-not Panax genus;not
true ginseng
Uses
&Common
application:
Immudomodulatory activity. Promoted as a
tonic & stimulant. Improving stamina &
sexual performance. Stress, fatigue,
strengthens immune function. General tonic
ADR: Mild irratability, excitation, insomnia(should
NOT take at night), diarrhoea

79. Source: Extract from berries, flowers and leaves of several
sp.of Crataegus, including Crataegus oxycanthoides
Constituents: Flavonoids (including quercetin glycosides & flavones-
C-glycosides) & oligomeric procyanidins.
Uses: Beneficial effects on coronary blood flow, blood
pressure and heart rate; decrease cardiac output.
Slow acting therefore has long-term use.
Common
application:
Hypertension; treatment of angina. To facilitate
maximun effort in sport
ADR: None known. Possible interaction with orthodox
antihypertensive drugs.

80. Source: Extract from fruit (seeds) of Silybum
marianus
Constituents: Flavanolignans (esp.silymarin and its
derivative silybin), fixed oil, flavonoids and
sterols
Uses: Free radical scavenager, hepatoprotective
activity
Common
application:
Liver and gallbladder complaints
ADR: Occasional diarrhoea

81. Source: Powdered partially dried and fresh ripe fruit
of the North American tree Sabal serrulata.
Constituents: Rich in fatty acids and phytosterols. Also contains
flavonoids and polysaccharides.
Uses: Has a phyto-oestrogenic effect
Common
application:
Claimed treatment for benign prostatic hyperthropy.
Also promoted as a urinary tonic, as a diuretic, for cyctitis
and irritable bladder and as a male reproductive tonic
ADR: Occasional gastric problem. Because of its antiandrogen
and oestrogenic activity, saw palmetto may interact with
orthodox hormonal therapy, including HRT and OCP.

82. St. John’s wort has been used to
 Prevent depression
 Decrease Stress Levels
 Help nervous conditions
 Decrease severity of bacterial infection

83. How it works:
Hyperforin is a
serotonin reuptake
inhibitor. It is the
compound in the
plant and suspected
as having
antidepressant
effects.

84.  Has been proven to be mildly helpful in very
mild to moderate cases of depression. The
more serious the case, the less that St.
John’s Wort helps. In the worst cases of
depression, it can actually hurt the situation.

85. Side effects
 In cases of major
depression, it may
worsen the case.
 Blurred vision,
constipation, urinary
retention, and
excessive
drowsiness.

86. Source: Extract from the fresh or dried leaves and
the golden yellow flowering tops of
Hypericum perforatum
Uses: Affinity for nervous tissue; antidepressant
Also use as anxiolytic, sedative and antiviral
Common
application:
Mild antidepressant:
Meta analysis showed hypericum was found
significantly superior to placebo in pt with
mild to moderate depressive diorder
ADR: Minor, headache, nausea, dizziness, dry mouth
& photosensitivity

87.  Also known as Red Mold Rice
 Monascus purpureus
 RYR is a fermented rice product on which red
yeast has grown

88.  RYR forms naturally
occurring HMG-CoA
reductase inhibitors
 HMG-CoA reductase
comes from naturally
occurring substances
called monacolins.
 These naturally
occurring ingredients are
what have started many
disputes regarding RYR
Hydroxymethylglutaryl-CoA Reductase
Monacolin K

89.  HMG-CoA Reductase Inhibitors are found in
numerous cholesterol medications
 Slows down the body’s ability to make cholesterol

90.  A tentative link has been shown between RYR
consumption and heart disease
 A study of 5,000 Chinese adults who suffered from
previous heart attacked showed lower risk of having
another heart attack when taking RYR supplements.
 A similar study of 5,000 Chinese adults showed that
RYR consumption reduced cancer deaths by 2/3rds

91.  Supplements have not
been tested as
thoroughly as
pharmaceutical
medication
 Individuals taking RYR
should consult physicians
and/or do research on
supplements before they
consume.

92. Orthodox drug Effect of interaction
Anticonvulsant Reduced blood level; possible risk of seizure
Ciclosporin Reduced blood level with risk of transplant rejection
Digoxin Reduced blood level and loss of control of heart
rhythm or heart failure
Oral Contraceptive Reduced blood level with risk of conception and
breakthrough bleeding
SSRIs Increased serotonergic affects with increased
incidence of adverse reactions
Theophylline Reduced blood level and loss of cntrl of asthma or
chronic airflow limitation
Warfarins Reduced anticoagulant effect and resultant need for
increased dose
HIV proteose
inhibitor
Reduced blood levels with possible loss of HIV
suppression

94. Orthodox drug Type Herbal remedy Potential Outcome
GASTROINTESTINAL:
• Antidiarrhoeals
• Laxatives
Senna
Senna
Antagonist effect
Potentiation
CARDIOVASCULAR:
• Antihypertensives
•Beta-blockers
•Diuretics
Garlic,
hawthorn,
Ginger
Alfalfa
Garlic, ginger,
St.John’s wart
Potentiation
Antagonist effect
Hypertension
Difficulty in
controlling diuresis,
hypertension
RESPIRATORY
•Antihistamines
St.John’s wart,
Valerian
Potentiation of
drowsiness

95. Orthodox drug Type Herbal remedy Potential Outcome
CENTRAL NERVOUS SYSTEMS
•Analgesics---------
•Antidepressants ------
•Antiepileptics ------
•Anxiolytics, hypnotics -
Dandelion -----
Liquorice ----
Ginseng
St.John’s wort
Borage, EPO
Valerian, St.John’s
wort
•risk toxicity NSAIDs
•↓ plasma conc.of drug
•Hypotension with MOAI
•Antagonistic effect
•May enhance risk of seizure
•Potentiation
ENDOCRINE
•Antidiabetics -------
•Oral Contraceptives ---
Alfalfa, damiana
Devils’ claw,
ginseng
Alfalfa, ginseng,
St.John’s wort
•Potentiation
•Antagonist effect
•Reduction in effectiveness