Vitamins & Nutrition

Vitamins & Nutrition
Dr. Ahmed Gaber Bakry

MD Cardiology
Lecturer of Cardiology & Medicine , Faculty of medicine , SVU
1
Water Soluble vitamins
Thiamine (vitamin B1)

• Function:
• TPP is an important cofactor in CHO metabolism
• TPP is involved in the oxidation of acetyl coA in the
mitochondria., In the Kreb’s cycle, and in HMP
shunt.
• Sources: Thiamine is found in many foodstuffs,

including cereals, grains, beans, nuts, and duck
2
Thiamine deficiency
Thiamine def is seen as: - beriberi,
-In starved pt. as in cancer stomach, and in
severe hyperemesis esp. when treated with
fluids only
Beriberi :
This is now confined to the poorest areas in
south Asia. And can be prevented by eating
under milled or parboiled rice, and fortification
of rice by thiamine and general increase in food
consumption.
3
Types: There are three main clinical types w.
surprisingly rare to occur together.
1-Dry beriberi
Present: 1) Polyneuropathy2)encephalopathy
2- Wet beriberi:
-It causes oedema in the legs then extend to involve the
whole body with ascites, and pleural effusion ( due to
accumulation of lactic, and pyrovic acid producing
peripheral vasodilatation and oedema).
-Cardiomyopathy occurs and subsequent HF.
-Full bounding pulse, warm extremities and a high
venous pressure (high output state).
-ECG may show conduction defects.
6
3-Infantile beriberi: occurs usually acutely in breastfed babies at
3 months age.
The mothers usually show no signs of thiamine def.but
presumably their body stores are nil.
The infant become anorexic, oedematous, has some degree of
aphonia, tachycardia, tachypnea and finally death may occur if
lift untreated.
Diagnosis:
1-In endemic areas, the diagnosis of beriberi should always be
suspected
2-If in doubt, treatment with thiamine should be started
3-A rapid disappearance of oedema with thiamine is diagnostic.
4-The diagnosis is confirmed by measurement of transketolase
activity in RBCs.
5-Plasma pyruvate and lactic acids are elevated in acute forms
of thiamin deficiency. 8
Differential diagnosis:
1-Causes of generalized oedema (renal,
hepatic , and cardiac.
2-Causes of polyneuropathy.
Treatment: -Thiamine 50 mg IM for 3 days,

followed by 10 mg of thiamine TDS daily by
mouth. The response in wet type is
dramatic (in hours). But in dry type the
response is slow.
9
Riboflavin (vitamin B2)
• Source: Riboflavin is widely distributed throughout all plants and animal cells. Good
sources are dairy products, and leafy vegetables. and is destroyed by sunlight.
• Function: Riboflavin is a cofactor for many oxidative reactions in the cells.
• Deficiency:
• 1- Angular stomatitis or cheilosis (fissuring of the corners of the tongue.)
• 2- Glossitis : A red inflammed tongue.
• 3-Seborrhoeic dermatitis ( partic. In the face)
• 4-Conjunctivitis with vascularization of the cornea, and opacities of the lens.

Many of the above features are due to multiple def. rather than the riboflavin itself.
Treatment: Riboflavin 5 mg TDS daily usually given as vit B complex 10

Niacin (vitamin B3)
This is the generic name for the two chemical forms
nicotinic acid, and nicotinamide. The latter is found in
NAD, NADP w. are important in many oxidative
process in the body.
-Niacin is found in many foodstuffs including plants,
meat, and fish. Niacin is lost by removing bran from
cereals but it must be added to processed cereals, and
white bread.
-Niacin can be synthesized in human from tryptophane.
It needs the presence of vit B6
Pellagra
This is a rare dis. Occurs due to niacin def. 11
Causes:
1- Pellagra occurs in maize eating population due to:
Maize is deficient in nicotinic acid.
Maize is deficient in tryptophan (from which nicotinic acid
can be synthesized).
Maize contains nicotinic acid antagonists
2- In Hartnup’s dis. A rare inborn error of metabolism leads
to amino-acidurea.
3-In generalized malabsorption.
4- Very low protein diet given for renal, or liver dis.
5-In the carcinoid syndrome, and pheochromo-cytoma as
tryptophane metabolism is diverted away from the
formation of nicotinamide to form other amines.
6-INH therapy can lead to a def. of vit B6 w. is necessary for
synthesis of nicotinamide from tryptophane 12
Clinical features: Pellagra
The classical features are (3D) dermatitis, diarrhea, and

dementia
1-Dermatitis:
-It affects the sun-exposed areas of the skin.
-The lesions are often symmetrical and affects the
dorsum of the hands, and the neck.
-It stars with redness followed by cracks and occasional
ulceration. Dryness and pigmentations may develop.
2-Diarrhea:
It is often a feature but constip. may be seen.
14
-Other GIT manifest. as painful red raw tongue, glossitis,
and angular stomatitis, achlorhydria (40% of cases),
- Recurrent mouth infections may occur.
3-Dementia: This occurs in chronic dis.

-In mild cases: there are symptoms of depression,
apathy, and sometimes thinking disorders.
-In severe cases; Tremors, encephalopathy, and acute
psychosis.
Delirium in the acute form of disease and dementia in
the chronic form of disease.
15
Diagnosis:
In endemic areas, this is based on the clinical
features, remembering that other vit. Def. can
present with similar features as (angular
stomatitis).
It is diagnosed by assay of RBCs NAD
Treatment:
1- Nicotinamide 100 mg/6 hrs orally.(mostly vit B
complex is given as other def. are often present).
2-Increase in the protein content in diet.
3- treatment of other underlying conditions. 16
Pyridoxine (Vitamin B6)
Vitamin C
Ascorbic acid is a simple sugar and a powerful reducing

agent.
Sources: It is present in all fresh fruits and vegetables.
Unfortunately, ascorbic acid is easily leached out of
vegetables when they are placed in water and it is also
oxidized to dehydro-ascorbic acid during cooking.
Function:
1-It is a powerful reducing agent, its main role to control
the redox potentials in the cells.
2-It is involved in the hydroxylation of proline into
hydroxyproline w. is necessary in the formation of
collagen 18
Vit C def. (Scurvy):
-In adults, the early symptoms may be non-specific

as weakness, and muscle pain.
-Other features are:
1-Keratosis of the hair follicle, and brittle hair.
2-Swollen, spongy gums with bleeding and
suspected infection, and loosening of the teeth.
3-Spontaneous brusing.
4-Anaemia. 5-Failure of wound healing
21
Diagnosis:
1)Anaemia (Either iron def. due to decreased absorption,
or He. Or Folate def.. As folate beeing found in large
amounts in green vegetables).
2-Plasma ascorbic acid is low.
Treatment:
1-Ascorbic acid by mouth.
2- Increase fresh vegetables and fruits in diet.
Prevention:
1- In infants; Orange juice should be given to breast-fed
infants.
2-In elderly, eating adequate fresh fruits and vegetables
22
Vitamin B12 and folate
Fat soluble vitamins A,D,E, K
Vitamin A deficiency
Other Possible beneficial effects of vitamin A:

1-protection against cancer 2- Reduction in CV events.
3-Dermatological applications.
Diagnosis:
1- In parts of the world if the def. is common diagnosis
is made on basis of clinical features.
2-Def. should be suspected if any degree of malnutrition is
present
3- Blood levels of vitamin a is low
4-Response to replacement therapy
Prevention: 1- Diets must contain dairy products and green vegetables.
2-Vitamin A supplements are given to the child with measles vaccination.
Vitamin D deficiency
Vit D metabolism:
7-dehydrocholesterol is photoactivated in the skin into cholic-
alciferol (D3), which is converted in the liver into 25OH D3, and
further converted in the kidney into active metabolite 1,25 OH D3
Function:
1-Increase Ca absorption from GIT.
2-increase bone calcification.
3-Increase bone resorption.
Causes of vit D def. :
1-Inadequate synthesis in the skin
2-Low diet intake
3-Malabsorption: Coeliac disease
intestinal resection
chronic cholestasis
4-Chronic renal failure
Deficiency
1-Rickets in children
2-osteomalacia in adults
-Osteomalacia
It results from inadequate mineralization of the bone matrix
Aet: 1-Vit D def.
2-CRF 3-Mesenchymal tumors
Clinical features:
1- Vague symptoms: bone and muscle pain, tenderness.
2- Asymptomatic fractures.
3-Proximal myopathy.
investigation:
1-Decrease serum Ca 2-Increase serum AP
3-decreased serum 25OH D3.
4-Xray is usually normal or areas of defective mineralization
5-Iliac crest biopsy is diagnostic.
Treatment:
1-Correction of the cause with increase vit D in diet and
exposure to sunlight.
2-Vit D replacement
Vitamin K deficiency
Function: 1- production of clotting factors
2-production of proteins necessary for bone formation.
Deficiency: Vit K def. results in inadequate formation of clotting

factors which leads to increase prothrombin time and Hge.
Def. occurs in the following circumstances:

1-Hgic dis. of the newborn :
-Causes: low fat stores, .decrease vit K in breast milk,
.sterility of the infantile intestine,
.liver immaturity, .poor placental transport.
-Clinical presentation:
Intracranial bleeding as well as GIT and skin bleeding can be
seen in vitK-deficient infants 1-7 days after birth. So vit K IM is
given prophylactically at the time of birth
2-Vitamin K def. in adults can be seen in:
.Chronic small intestinal dis.
.Obstructed biliary tract
.After small bowel resection
.After broad spectrum antibiotic treatment.
-Diagnosis: is by elevated prothrombin time, or reduced

clotting factors
Treatment: by vit K replacement.

Vit E deficiency
Source:
Vit E is a collective name for a group of tocopherols
. The most active compound and the most widely
available in food is alfa tocopherol.
It is present in vegetables and seed oils including: soyabeans
sunflower, cereals and nuts.
Function:
1-Vit E acts as an antioxidant and radical scavenger which protect
LDL and polyunsaturated fats from oxidation. Also it protect cell
structures from damage by highly active O2 species as hydrogen
peroxide, superoxide and other O2 free radicles.
2-Vit E inhibit prostaglandin synthesis.
3-Vit E may affect cell proliferation and growth.
Deficiency:
1-Hemolytic anemia: has been described in premature infants.
2-Ataxia: has been described in children with abetalipoprotene-
mia and in pts. on long term parenteral nutrition.
Benefits of vit E:
1-Prevention of cardiovascular dis.
2-Prevention of cancer.
3-Prevention of Alzheimer’s dis.
.
High doses of vit K can impair the action of oral anti coagulants.
NUTRITION
General aspects
*In developing countries, lack of food and poor
usage of the available food can result in
protein-energy mal -nutrition (PEM); 50
million pre-school African children have PEM.
*In developed countries, excess food is available
and the most common nutritional problem is
OBESITY
Diet and disease
*Diet and disease are interrelated in many ways:
Excess energy intake, particularly when high in
animal (saturated) fat content, is thought to
contribute to a number of diseases, including
ischaemic heart disease and diabetes.
A relationship between food intake and cancer
has been found in many epidemiological
studies.
Basal metabolic rate (BMR):
The BMR can be calculated by measuring
oxygen consumption and CO2 production, but
it is more usually taken from standardized
tables that require knowledge of the subject's
age, weight and sex.
Energy stores
Although virtually all body
fat and glycogen are
available for oxidation, less
than half the protein is
available for oxidation.
Too much food and too little activity

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Vitamins & Nutrition

Dr. Ahmed Gaber Bakry

Thiamine (vitamin B1)

• Sources: Thiamine is found in many foodstuffs,

Treatment: -Thiamine 50 mg IM for 3 days,

• Function: Riboflavin is a cofactor for many oxidative reactions in the cells.

• 1- Angular stomatitis or cheilosis (fissuring of the corners of the tongue.)

• 2- Glossitis : A red inflammed tongue.

• 3-Seborrhoeic dermatitis ( partic. In the face)

• 4-Conjunctivitis with vascularization of the cornea, and opacities of the lens.

Treatment: Riboflavin 5 mg TDS daily usually given as vit B complex 10

The classical features are (3D) dermatitis, diarrhea, and

3-Dementia: This occurs in chronic dis.

Ascorbic acid is a simple sugar and a powerful reducing

-In adults, the early symptoms may be non-specific

Other Possible beneficial effects of vitamin A:

Deficiency: Vit K def. results in inadequate formation of clotting

Def. occurs in the following circumstances:

-Diagnosis: is by elevated prothrombin time, or reduced

Treatment: by vit K replacement.

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