Vitamin

Function Anti-oxidant Vision (retinol) Embryonic development Tissue differentiation Growth Coenzyme in (1) Pyruvate dehydrogenase (2) -ketoglutarate dehydrogenase (TCA) (3) Transketolase (HMP shunt) (4) Branch-chain AA dehydrogenase

Storage, longevity

High risk for Deficiency Fat malabsorption Poor diet Smoking ( -carotene) Cystic fibrosis Alcoholics Poor diet IV glucose loading Genetic transketolase def. Gastric bypass surgery

Deficiency Symptoms

Notes Used to treat measles, deficiency increases risk for measles Cant overdose, but you turn orange Toxicity: arthralgia, fatigue, headaches, Distinguish hypercarotinemia from hyperbilirubinemia (jaundice) based on color of sclera icterus (seen in hyperbilirubinemia) Wernicke-Korsakoff: confusion, ophthalmoplegia, ataxia, confabulation, permanent memory loss Dry beri-beri peripheral neuropathy Wet beri-beri cardiomegaly, tachycardia, high-output CHF

Liver, +1year

Follicular hyperkeratosis Scaling skin Night-blindness

B1 (Thiamine) B2 riboflavin B3 Niacin B5

Non appreciable Weeks

Beri-beri Wernicke-Korsakoff syndrome

Oculo-orogenital syndrome Vitamin B2 and B6 Deficiency Component of coenzymes NAD, NADP glycolysis, tissue respiration None, weeks Inadequate dietary niacin and tryptophan, alcohol Pellagra -3Ds diarrhea, dermatitis, dementia Pellagra Casals necklace, diarrhea, dermatitis, dementia Toxicity: flushing, nausea, vomiting, liver injury, diarrhea

B6 Pyridoxine

Cofactor in transamination (ALT,AST), decarboxylation reactions, heme synthesis

None

Drug interaction: isoniazid, oral contraceptives

Polyneuropathy Oxalate stone formation Seborrheic dermatitis Angular stomatitis, cheilitis Glossitis, Cheilosis Sideroblastic anemia Macrocytic anemia (pernicious) Leukopenia Thrombocytopenia Stomatitis, glossitis Macrocytic anemia Leukopenia Thrombocytopenia Glossitis, Stomatitis Neural tube defects Scurvy Corkscrew hairs Perifollicular petechiae Ecchymoses Impaired wound healing Rickets (children) Osteomalacia (adults) Premature: hemolytic anemia, retinopathy, bronchopulonary dysplasia Malabsorption: neuropathy, myopathy with creatinuria Bleeding, increased PT, ecchymoses

Glossitis and cheilosis are nonspecific and can be caused by other Vit. B deficiences Longevity inversely related to protein intake *Pernicious anemia is an exception to the rule where vitamin deficiencies run in clusters. This is an autoimmune disease that can occur without other deficiencies *Check with Schillings test Give pregnant mothers folate supplements to reduce risk of neural tube defects Metabolism is linked to Vit. B12 metabolism so coexisting problems may occur Scurvy swollen gums, bruising, hemarthrosis, anemia, Poor wound healing collagen deficiency affects cartilage, bone, skin integrity Toxicity: Hypercalcemia, hypercalciuria, loss of appetite, stupor, fatigue, headache, vomiting, growth arrest in children Lab test: serum tocopherol Toxicity: higher risk of hemorrhagic stroke

B12 Cobalamin

Methylmalonyl CoA succinyl CoA Cofactor for homocysteine methyltransferase

Liver, several years

Pernicious anemia* Gastrectomy patients

Folate (Folic Acid)

1-carbon (formyl) group transfer Biosynthesis of purines, Histidine, choline, serine

Liver, months

Intestinal malabsorption Pregnancy Smoking Drugs:Methotrexate Phenytoin, sulfonamide

Hydroxylation of proline/lysine in collagen synthesis, Antioxidant Enhances GI Iron absorption Inhibits copper absorption Facilitates calcium and phosphorus absorption and utilization,

None, 6 weeks

Smoking Physiologic stress from illness Chronic fat malabsorption Gastric bypass surgery Renal insufficiency, inadequate sun exposure Severe long term fat malabsorption, prematurity

Liver, skin, months to years lipid-rich tissues, years Liver, weeks

Antioxidant, free radical scavenger (primarily in membranes Carboxylation of Glutamic acid residues in formation of clotting factors II, VII, IX,X

Inadequate diet + antibiotic use, liver disease

INR (PT time), no toxicties documented

Iron

Oxygen transport (hemoglobin) Electron transport (cytochromes)

Months

Blood loss, poor diet Gastrectomy, Gastric bypass surgery Pregnancy

Zinc

Essential for activity of 100+ enzymes Formation of zinc fingers (transcription factor motif)

Bone, muscle, months

Malabsorption, critical illness (trauma, burns) Hypermetabolic patients (Kwashiorkor)

Selenium

Antioxidant (glutathione peroxidase) Free radical scavenger, works with vitamin E to reduce lipid peroxidation

None, years

Low soil selenium

Anemia, Pallor, Fatigue Glossitis Microcytic, hypochromic anemia Tachycardia* Growth retardation Hypogonadism Impaired taste Delayed wound healing Scaling skin Acrodermatitis enteropathica (hereditary) Cardiomyopathy (Keshan Disease) Increased cancer rates

*Compensatory mechanism of CO in response to less blood/O2 Hemochromatosis Hemosiderosis

Zinc interferes with iron and copper metabolism Possible immune function impairment

Toxicity: major hair loss, brittle fingernails, fatigue, irritability

When you have someone who is B12 deficient, often there is a coexiting folate deficiency. The thing I want to leave you with is, I want you to think of B12 and Folate together. If you give folic acid to someone who is vitamin B12 deficient, you will treat the macrocytic anemia, but you wont treat the posterior column signs (pneurologic symptoms: paresthesia, subacute combined degenration) due to abnormal myelin you find with B12 deficiency Iron deficiency is most common nutritional deficiency worldwide iron is absorbed in the duodenum ***high yield (enterocyte transport via ferroportin) requires pH