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Nutritional Pathology

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Nutritional Pathology

  1. 1. Nutritional Pathology James L. Fishback, M.D. Associate Professor University of Kansas School of Medicine
  2. 2. Food Safety <ul><li>Numerous natural constituents, toxic substances, and food additives may threaten human health: </li></ul><ul><ul><li>Carcinogens (safrole in nutmeg, estragole in basil) </li></ul></ul><ul><ul><li>Natural pesticides (celery, parsnips, parsley) </li></ul></ul><ul><ul><li>Toxicants (aflatoxin, botulinum) </li></ul></ul><ul><ul><li>Microorganisms ( E. coli , Salmonella, etc .) </li></ul></ul><ul><ul><li>Additives (colors, sweeteners, preservatives) </li></ul></ul><ul><ul><li>Indirect additives (residual hormones, drugs, pesticides, packaging residue) </li></ul></ul><ul><ul><li>Industrial contaminants (PCBs, etc .) </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  3. 3. Nutritional Deficiencies <ul><li>Protein energy (calorie) malnutrition (PEM) </li></ul><ul><li>Anorexia nervosa and bulimia </li></ul><ul><li>Vitamin deficiencies (more common in alcoholics) </li></ul><ul><li>Mineral deficiencies </li></ul>06/07/09 © 2009, James L. Fishback, M.D.
  4. 4. Protein-Energy Malnutrition (PEM) <ul><li>Inadequate intake of protein and calories to meet the body’s needs </li></ul><ul><ul><li>Most common in underdeveloped and developing countries </li></ul></ul><ul><ul><ul><li>Up to 25% of children may be affected </li></ul></ul></ul><ul><ul><ul><li>Major cause of death in children < 5yrs </li></ul></ul></ul><ul><ul><ul><li>Associated with diarrheal diseases </li></ul></ul></ul><ul><ul><li>Less common in developed countries </li></ul></ul><ul><ul><ul><li>Associated with poverty, alcoholism, ignorance, acute or chronic illness, and voluntary diet restriction </li></ul></ul></ul><ul><ul><li>A child with weight < 80% normal is malnourished </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  5. 5. Protein Compartments <ul><li>Somatic protein compartment </li></ul><ul><ul><li>Skeletal muscles </li></ul></ul><ul><li>Visceral protein compartment </li></ul><ul><ul><li>Protein stores in organs (predominantly liver) </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  6. 6. Marasmus Kwashiorkor <ul><li>Deficiency of total food intake </li></ul><ul><li>Deficiency of protein intake </li></ul><ul><ul><li>Babies who are weaned early (many times because of arrival of another child) and then fed an exclusively carbohydrate diet </li></ul></ul><ul><ul><li>Less severe forms can occur with </li></ul></ul><ul><ul><ul><li>chronic diarrhea (where protein is not absorbed) </li></ul></ul></ul><ul><ul><ul><li>protein losing enteropathies </li></ul></ul></ul><ul><ul><ul><li>nephrotic syndrome </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  7. 7. Marasmus Kwashiorkor <ul><li>Somatic protein compartment more severely impacted </li></ul><ul><ul><li>Spindly arms and legs </li></ul></ul><ul><li>Serum albumin normal or slightly reduced </li></ul><ul><li>Visceral protein compartment more severely impacted </li></ul><ul><ul><li>Apathy, listlessness, loss of appetite </li></ul></ul><ul><ul><li>Enlarged fatty liver </li></ul></ul><ul><li>Hypoalbuminemia </li></ul><ul><ul><li>Anasarca </li></ul></ul><ul><li>Other characteristics </li></ul><ul><ul><li>Skin: alternating zones of hyperpigmentation, desquamation </li></ul></ul><ul><ul><li>Hair: loss of color or alternating bands of pale and darker hair </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  8. 8. Both Marasmus and Kwashiorkor <ul><li>Stunted growth </li></ul><ul><li>Anemia </li></ul><ul><li>Infections and defects in immunity </li></ul><ul><li>Multi-vitamin deficiencies </li></ul>06/07/09 © 2009, James L. Fishback, M.D.
  9. 9. Marasmus Kwashiorkor <ul><li>In the public domain, Centers for Disease Control, www.cdc.gov </li></ul>06/07/09 © 2009, James L. Fishback, M.D.
  10. 10. Secondary Protein-Energy Malnutrition <ul><li>Common in chronically ill and hospitalized patients </li></ul><ul><ul><li>Increased basal metabolic rate (cytokines, tumor necrosis factor, etc .) </li></ul></ul><ul><ul><li>Cachexia (Marasmus-like PEM) </li></ul></ul><ul><ul><ul><li>Usually seen in setting of AIDS, cancer, end-stage lung disease ( e.g , emphysema). </li></ul></ul></ul><ul><ul><ul><ul><li>Depletion of subcutaneous fat, muscle wasting and ankle or sacral edema </li></ul></ul></ul></ul><ul><ul><li>Kwashiorkor-like PEM </li></ul></ul><ul><ul><ul><li>Usually seen with severe trauma, burns, sepsis </li></ul></ul></ul><ul><ul><ul><ul><li>Edema, serum albumin < 2.8 gm/dL </li></ul></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  11. 11. Anorexia Nervosa Bulimia <ul><li>Self-induced starvation (PEM-like findings) </li></ul><ul><li>Amenorrhea </li></ul><ul><li>Decreased thyroid hormone release </li></ul><ul><ul><li>Cold intolerance, bradycardia, constipation, dry scaly skin, lanugo body hair </li></ul></ul><ul><li>Decreased bone density </li></ul><ul><li>Anemia, lymphopenia </li></ul><ul><li>Hypoalbuminemia </li></ul><ul><li>Binge eating followed by induced vomiting </li></ul><ul><li>Menstrual irregularities </li></ul><ul><li>Vomiting complications </li></ul><ul><ul><li>Pulmonary aspiration of gastric contents </li></ul></ul><ul><ul><li>Esophageal and cardiac rupture </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  12. 12. Anorexia and Bulimia <ul><li>Anorexia: approx 1% of adolescent females </li></ul><ul><li>Bulimia: approx 4% of college-aged females </li></ul><ul><li>Approx 10% with anorexia or bulimia are male </li></ul><ul><li>Prone to hypokalemia </li></ul><ul><ul><li>Increased risk of sudden death due to cardiac arrhythmia </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  13. 13. Vitamin Deficiencies <ul><li>13 vitamins are essential for health </li></ul><ul><ul><li>Vitamins A, D, E, and K are fat soluble </li></ul></ul><ul><ul><li>Vitamin C and the 8 B-complex vitamins are water soluble </li></ul></ul><ul><ul><li>Deficiencies in a single vitamin are uncommon </li></ul></ul><ul><ul><li>Deficiencies can be submerged in PEM </li></ul></ul><ul><li>These vitamins must be supplied in the diet </li></ul><ul><ul><li>Exception: small amounts of D, K, biotin and niacin can be synthesized endogenously </li></ul></ul><ul><ul><ul><li>Vitamin D from UV light </li></ul></ul></ul><ul><ul><ul><li>Vitamin K and biotin from intestinal microflora </li></ul></ul></ul><ul><ul><ul><li>Niacin from tryptophan (amino acid) </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  14. 14. Vitamin A <ul><li>Group of related natural and synthetic chemicals with hormone-like activity </li></ul><ul><li>Dietary sources </li></ul><ul><ul><li>Pre-formed vitamin A </li></ul></ul><ul><ul><ul><li>animal derived (liver, fish, eggs, milk, butter) </li></ul></ul></ul><ul><ul><li>Carotenoids ( e.g ., beta-carotene) for synthesis of vitamin A </li></ul></ul><ul><ul><ul><li>yellow and leafy green vegetables (carrots, squash and spinach) </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  15. 15. Vitamin A Functions Deficiency <ul><li>Maintains normal vision </li></ul><ul><ul><li>Reduced light </li></ul></ul><ul><ul><ul><li>Vitamin A (retinol) -containing pigments </li></ul></ul></ul><ul><ul><ul><ul><li>rhodopsin (rod cells) and iodopsins (cone cells) </li></ul></ul></ul></ul><ul><li>Maintains ocular epithelium (lubrication, corneal) </li></ul><ul><li>Impaired vision (early manifestation) </li></ul><ul><ul><li>Night blindness </li></ul></ul><ul><li>Xerophthalmia (dry), keratin build-up (Bitot spots), keratomalacia, and eventual blindness (erosion of the roughened cornea) </li></ul>06/07/09 © 2009, James L. Fishback, M.D.
  16. 16. Vitamin A Functions Deficiency <ul><li>Differentiation of epithelial cells </li></ul><ul><ul><li>Maintains respiratory epithelium (mucociliary) </li></ul></ul><ul><ul><li>Maintains urothelium </li></ul></ul><ul><ul><li>Healthy epidermis (skin) </li></ul></ul><ul><li>Deficiency causes squamous metaplasia </li></ul><ul><ul><li>Loss of function predisposes to pulmonary infections </li></ul></ul><ul><ul><li>Hyperplasia and hyperkeratinization </li></ul></ul><ul><ul><ul><li>Follicular or papular dermatosis </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  17. 17. Vitamin A Functions Deficiency <ul><li>Enhances immunity to infections </li></ul><ul><li>Related carotenoids are photoprotective and anti-oxidants </li></ul><ul><li>Immune deficiency </li></ul><ul><ul><li>Higher mortality rates from measles, pneumonia, and infectious diarrhea </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  18. 18. Vitamin A Deficiency 06/07/09 © 2009, James L. Fishback, M.D.
  19. 19. Vitamin A Toxicity <ul><li>Acute toxicity </li></ul><ul><ul><li>Headache, vomiting, stupor, death </li></ul></ul><ul><li>Chronic toxicity </li></ul><ul><ul><li>Weight loss, vomiting, dryness of lips </li></ul></ul><ul><ul><li>Bone and joint pain, hyperostosis, hepatomegaly with fibrosis </li></ul></ul><ul><ul><li>Predisposition to bone fractures (due to stimulation of osteoclasts) </li></ul></ul><ul><li>Congenital malformations </li></ul><ul><ul><li>Synthetic retinoids for acne (Accutane™) contraindicated during pregnancy </li></ul></ul><ul><ul><ul><li>Cause CNS, cardiac and craniofacial defects </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  20. 20. Carotenemia <ul><li>Excess vitamin A precursors </li></ul><ul><ul><li>Usually from eating too many carrots, or artificial “suntanning” pills </li></ul></ul><ul><ul><li>Yellow-orange colored skin (mainly palms and soles) </li></ul></ul><ul><ul><ul><li>Sclera remain white ( vs . real jaundice) </li></ul></ul></ul><ul><li>Not associated with toxicity, even in large amounts </li></ul>06/07/09 © 2009, James L. Fishback, M.D.
  21. 21. Vitamin D Function Deficiency <ul><li>Maintenance of normal plasma levels of calcium and phosphorus </li></ul><ul><li>Maintenance of ionized calcium in extracellular compartment </li></ul><ul><li>Poor bone mineralization </li></ul><ul><ul><li>Rickets (if epiphyses have not closed) </li></ul></ul><ul><ul><li>Osteomalacia (epiphyses have closed) </li></ul></ul><ul><li>Hypocalcemic tetany </li></ul><ul><ul><li>Insufficient ionized calcium causes continuous excitation (convulsive state) </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  22. 22. Vitamin D <ul><li>Two sources </li></ul><ul><ul><li>Endogenous synthesis </li></ul></ul><ul><ul><ul><li>Precursor 7-dehydrocholesterol in the skin and UV light </li></ul></ul></ul><ul><ul><ul><li>Requires healthy kidneys for conversion to di-hydroxy Vitamin D </li></ul></ul></ul><ul><ul><li>Diet </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  23. 23. Normal Vitamin D Metabolism 06/07/09 © 2009, James L. Fishback, M.D.
  24. 24. Vitamin D Deficiency 06/07/09 © 2009, James L. Fishback, M.D.
  25. 25. Rickets 06/07/09 © 2009, James L. Fishback, M.D.
  26. 26. Predisposing Conditions for Poorly Mineralized Bone (Rickets, Osteomalacia) <ul><li>Inadequate synthesis of dietary deficiency of vitamin D </li></ul><ul><ul><li>No exposure to sunlight or pigmented skin; limited intake of vitamin D </li></ul></ul><ul><li>Decreased vitamin D absorption </li></ul><ul><ul><li>Cholestatic liver disease, pancreatic insufficiency, biliary tract obstruction, extensive small bowel disease/severe malabsorption </li></ul></ul><ul><li>Derangements of vitamin D metabolism </li></ul><ul><ul><li>Increased degradation by induction of cytochrome P450 enzymes, impaired synthesis of 25 and 1,25(OH) 2 D, inherited deficiency of renal alpha-1 hydroxylase </li></ul></ul><ul><li>End-organ resistance </li></ul><ul><ul><li>Inherited absence of or defective receptors for 1,25(OH) 2 D </li></ul></ul><ul><li>Phosphate depletion </li></ul><ul><ul><li>Poor phosphate absorption due to aluminum OH antacids </li></ul></ul><ul><ul><li>Excess renal tubule excretion of phosphate (X-linked hypophosphatemic rickets) </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  27. 27. Vitamin E <ul><li>Functions </li></ul><ul><ul><li>Major anti-oxidant (scavenges free radicals) </li></ul></ul><ul><li>Sources </li></ul><ul><ul><li>Vegetables, grains, nuts and their oils, dairy products, fish and meat </li></ul></ul><ul><li>Deficiency </li></ul><ul><ul><li>Usually in association with fat malabsorption that accompanies cholestasis, cystic fibrosis and primary small intestinal disease </li></ul></ul><ul><ul><li>Neurologic manifestations </li></ul></ul><ul><ul><ul><li>Absent tendon reflexes, ataxia, dysarthria, loss of vibration and position sense and pain sensation </li></ul></ul></ul><ul><ul><ul><li>Spinocerebellar degeneration </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  28. 28. Vitamin K <ul><li>Functions </li></ul><ul><ul><li>Required for functional activity of clotting factors II, VII, IX, X and protein C and S </li></ul></ul><ul><ul><li>Studies suggest it may be helpful in treating osteoporosis </li></ul></ul><ul><ul><ul><li>It may favor calcification of bone proteins </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  29. 29. Vitamin K Deficiency <ul><li>Increased risk with </li></ul><ul><ul><li>Fat malabsorption syndromes </li></ul></ul><ul><ul><li>Diffuse liver disease </li></ul></ul><ul><ul><li>Absence of vitamin K-synthesizing bacterial flora </li></ul></ul><ul><ul><ul><li>Broad spectrum antibiotics can destroy it </li></ul></ul></ul><ul><ul><ul><li>Not fully developed in neonates (vitamin K given prophylactically to all newborns) </li></ul></ul></ul><ul><li>Deficiency causes bleeding diathesis (skin, gums, umbilicus, viscera, intracranial) </li></ul><ul><ul><li>Coumarin (warfarin) induces deficiency </li></ul></ul><ul><ul><ul><li>Desirable in thromboembolic disease </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  30. 30. B-Complex Vitamins <ul><li>B 1 (thiamine), B 2 (riboflavin), B 3 (niacin), B 5 (pantothenic acid), B 6 (pyridoxine), B 7 (biotin), B 12 and folate </li></ul><ul><ul><li>8 of the 9 water soluble vitamins </li></ul></ul><ul><li>All function as coenzymes, and needs are tied to energy intake </li></ul><ul><li>Not much is present in polished rice, white flour, white sugar </li></ul>06/07/09 © 2009, James L. Fishback, M.D.
  31. 31. Thiamine (B 1 ) Deficiency <ul><li>Uncommon on a dietary basis in developed countries (widely available in diet) </li></ul><ul><ul><ul><li>Still occurs in developing countries where polished (white) rice is most of the diet </li></ul></ul></ul><ul><li>Major targets of deficiency are nerves, heart and brain </li></ul><ul><ul><ul><li>Dry beriberi (polyneuropathy) </li></ul></ul></ul><ul><ul><ul><ul><li>Classically presents with toe drop, foot drop, wrist drop </li></ul></ul></ul></ul><ul><ul><ul><li>Wet beriberi (cardiovascular) </li></ul></ul></ul><ul><ul><ul><li>Wernicke-Korsakoff syndrome </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  32. 32. Beriberi (Thiamine Deficiency) <ul><li>Common in alcoholics (25% of those admitted) </li></ul><ul><ul><li>May also occur in </li></ul></ul><ul><ul><ul><li>Pernicious vomiting of pregnancy </li></ul></ul></ul><ul><ul><ul><li>Debilitating diseases that impair appetite, predispose to vomiting or cause protracted diarrhea </li></ul></ul></ul><ul><ul><ul><li>Extended iv glucose therapy without supplemental vitamins (may convert sub-clinical to overt disease in chronically malnourished individuals) </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  33. 33. Beriberi (Thiamine Deficiency) 06/07/09 © 2009, James L. Fishback, M.D.
  34. 34. Riboflavin (B 2 ) <ul><li>Sources: meat, dairy, vegetables </li></ul><ul><li>Absorbed in upper GI tract </li></ul><ul><li>Ariboflavinosis </li></ul><ul><ul><ul><li>Persons in economically deprived developing countries </li></ul></ul></ul><ul><ul><ul><li>Alcoholics, chronic infections, advanced cancer and other debilitating diseases, anorexics and individuals who avoid milk </li></ul></ul></ul><ul><ul><li>Morphology </li></ul></ul><ul><ul><ul><li>Cheliosis (cracks and fissures at angles of mouth) </li></ul></ul></ul><ul><ul><ul><li>Glossitis (atrophic tongue) </li></ul></ul></ul><ul><ul><ul><li>Corneal opacities and ulcerations </li></ul></ul></ul><ul><ul><ul><li>Dermatitis </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  35. 35. Niacin (B 3 ) <ul><li>Sources </li></ul><ul><ul><li>Grains, legumes, seed oils (small quantities in meats) </li></ul></ul><ul><ul><ul><li>Niacin in corn is in a bound form and unabsorbable </li></ul></ul></ul><ul><ul><ul><ul><li>Deficency can be seen where corn is most of the diet </li></ul></ul></ul></ul><ul><ul><li>Can be synthesized endogenously from tryptophan </li></ul></ul><ul><ul><ul><li>A deficiency of tryptophan can mimic niacin deficiency </li></ul></ul></ul><ul><li>Deficiency (pellagra) </li></ul><ul><ul><li>Alcoholics, chronic debilitating diseases ( e.g ., HIV) </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  36. 36. Niacin (B 3 ) Deficiency (Pellagra) <ul><li>Three D’s: </li></ul><ul><ul><li>Dermatitis </li></ul></ul><ul><ul><ul><li>Thickened red rough skin, bilaterally symetric on exposed areas of the body </li></ul></ul></ul><ul><ul><li>Diarrhea </li></ul></ul><ul><ul><ul><li>Atrophy of columnar epithelium of GI tract </li></ul></ul></ul><ul><ul><li>Dementia </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  37. 37. Niacin (B 3 ) Deficiency (Pellagra) 06/07/09 © 2009, James L. Fishback, M.D.
  38. 38. Pyridoxine (B 6 ) <ul><li>Clinically overt deficiency of vitamin B 6 is rare in humans </li></ul><ul><ul><li>Findings resemble riboflavin (B 2 ) and niacin (B 3 ) deficiency </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  39. 39. Vitamin C (Ascorbic Acid) <ul><li>Functions: formation of normal collagen, antioxidant </li></ul><ul><li>Deficiency disease is called scurvy </li></ul><ul><ul><li>Uncommon </li></ul></ul><ul><ul><ul><li>Those most at risk are elderly who live alone, alcoholics, infants fed exclusively processed milk </li></ul></ul></ul><ul><ul><li>Used to be seen with long sea voyages </li></ul></ul><ul><ul><li>Symptoms reversible almost immediately with vitamin C </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  40. 40. Scurvy (Vitamin C Deficiency) <ul><ul><li>Poor wound healing – poor collagen synthesis </li></ul></ul><ul><ul><li>Ecchymoses and purpura in skin and gingival mucosa (small vessels have defective collagen) </li></ul></ul><ul><ul><ul><li>Secondary gum infections </li></ul></ul></ul><ul><ul><ul><li>Papular rash </li></ul></ul></ul><ul><ul><li>Sub-periosteal hematomas and hemarthrosis after minimal trauma </li></ul></ul><ul><ul><li>Retrobulbar, subarachnoid and intracerebral hemorrhages (can be fatal) </li></ul></ul><ul><ul><li>Skeletal changes due to insufficient osteoid matrix </li></ul></ul><ul><ul><ul><li>Growing children: bowing of long bones, depression of the sternum with outward projection of the ends of the ribs </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  41. 41. Vitamin C Deficiency (Scurvy) 06/07/09 © 2009, James L. Fishback, M.D.
  42. 42. Vitamin Deficiency Comparison Vit C Vit D <ul><li>Poor osteoid production </li></ul><ul><ul><li>Bowing of long bones of lower legs </li></ul></ul><ul><ul><li>Depression of sternum with outward projection of ribs </li></ul></ul><ul><li>Poor mineralization (calcification of bone) </li></ul><ul><ul><li>Bowing of long bones of lower legs </li></ul></ul><ul><ul><li>Protrusion of sternum with overgrowth of cartilage at costochondral junction “rachitic rosary” </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  43. 43. Folate <ul><li>Sources </li></ul><ul><ul><li>Whole-wheat flour, beans, nuts, liver, green leafy vegetables </li></ul></ul><ul><ul><li>Depleted in cooked and processed foods </li></ul></ul><ul><li>In the U.S. 15-20% of adults probably have a low level </li></ul><ul><ul><li>Folate requirement is increased during pregnancy! </li></ul></ul><ul><ul><ul><li>Deficiency can predispose to fetal neural tube defects </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  44. 44. Vitamin B 12 Deficiency <ul><li>Sub-acute combined degeneration of the spinal cord </li></ul><ul><ul><li>Potentially reversible </li></ul></ul><ul><ul><li>Numbness and tingling in the lower extremities progressing to spastic weakness and then paraplegia </li></ul></ul><ul><ul><li>Degeneration of both ascending and descending tracts of the spinal cord </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  45. 45. Subacute combined degeneration or Posterolateral myelopathy of B 12 deficiency
  46. 46. Mineral Deficiencies <ul><li>Many trace minerals are found within the body </li></ul><ul><li>Deficiencies can occur due to </li></ul><ul><ul><li>Inadequate supplementation in total parenteral nutrition (TPN) </li></ul></ul><ul><ul><li>Interference with absorption by dietary constituents </li></ul></ul><ul><ul><li>Inborn errors of metabolism leading to abnormal absorption </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  47. 47. Mineral Deficiencies <ul><li>5 minerals are associated with well-characterized deficiency states </li></ul><ul><ul><li>Iron, zinc, copper, selenium and iodine </li></ul></ul><ul><ul><ul><li>Iron deficiency is most common in U.S. </li></ul></ul></ul><ul><ul><ul><ul><li>In children, usually inadequate intake </li></ul></ul></ul></ul><ul><ul><ul><ul><li>In adults, usually blood loss or pregnancy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hypochromic microcytic anemia (defective heme synthesis) </li></ul></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  48. 48. Zinc Deficiency <ul><li>Abundant in the diet: meat, shellfish, fish, whole-grain cereals, legumes </li></ul><ul><li>Deficiency usually due to </li></ul><ul><ul><li>TPN unsupplemented by zinc </li></ul></ul><ul><ul><li>Congenital zinc deficiency (auto recessive, rare) </li></ul></ul><ul><li>Findings </li></ul><ul><ul><li>Acrodermatitis enteropathica </li></ul></ul><ul><ul><ul><li>Rash around eyes, nose mouth and anus </li></ul></ul></ul><ul><ul><li>Anorexia, diarrhea, growth retardation, impaired night vision, depressed mental function </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  49. 49. Zinc Deficiency 06/07/09 © 2009, James L. Fishback, M.D.
  50. 50. Selenium Deficiency <ul><li>Anti-oxidant (like vitamin E and C) </li></ul><ul><li>Deficiency is known as Keshan disease </li></ul><ul><ul><li>Results from low level in soil, water and food </li></ul></ul><ul><ul><li>Congestive cardiomyopathy </li></ul></ul><ul><ul><ul><li>Mainly in children and young women </li></ul></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  51. 51. Obesity <ul><li>Food derived energy chronically exceeds energy expenditure </li></ul><ul><li>Global epidemic </li></ul><ul><ul><li>Sedentary lifestyles, improved socioeconomic conditions, high calorie fast foods and soft drinks </li></ul></ul><ul><li>30% of adults in U.S. are obese </li></ul><ul><ul><li>Body mass index (BMI) > 30 kg/m 2 </li></ul></ul><ul><ul><li>Hypertension, diabetes and coronary artery disease begin to increase at BMI values > 25 </li></ul></ul>06/07/09 © 2009, James L. Fishback, M.D.
  52. 52. Obesity <ul><li>Etiology is extremely complex </li></ul><ul><ul><li>Genetic, environmental and psychological factors </li></ul></ul><ul><li>Central or visceral obesity has a higher risk for disease ( vs . diffusely increased subcutaneous fat) </li></ul>06/07/09 © 2009, James L. Fishback, M.D.
  53. 53. Complications of Obesity <ul><li>Syndrome X (metabolic syndrome) </li></ul><ul><ul><li>Abdominal obesity, insulin resistance, hypertriglyceridemia, low HDL, hypertension, coronary artery disease </li></ul></ul><ul><li>Gallstones, pancreatitis, fatty liver, </li></ul><ul><li>Congestive heart failure, arrhythmias, deep vein thrombosis (and subsequent pulmonary embolus), ischemic stroke </li></ul><ul><li>Obesity hypoventilation syndrome, sleep apnea </li></ul><ul><li>Osteoarthritis, gout </li></ul><ul><li>Endometrial cancer (excess estrogen, difficulty in screening) </li></ul>06/07/09 © 2009, James L. Fishback, M.D.

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