Vitamin 13 deficiency

As mentioned, some patients have documented deficiencies of several vitamins. Indeed, isolated clinically significant deficiency of a single vitamin is probably rare. Yet the import of multiple deficiencies is not always clear. Even for the best recognized avitaminoses, such as pellagra or the Wernicke-Korsakoff syndrome, defects in cognition are attributable to lack of more than just the one classically implicated vitamin. Deficiency of multiple water soluble vitamins pertains especially to alcoholics, to the elderly, and to severely ill hospitalized patients. For example, low folate stores, combined with inadequate niacin and thiamine, probably contribute to the chronic memory disorder of alcoholism. 

This sort of problem also plagues the institutionalized elderly. High dose multivitamin supplementation of hospitalized geriatric patients was 

To ascertain whether dietary food records were inaccurate because of associated mild cognitive deficits, blood levels of these nutrients were measured. Scores on the Halstead-Reitan Category Test were worse in subjects with lower blood levels of ascorbate, riboflavin, Bj2, and folate, while those on the Wexler Memory Test were correlated with ascorbate and Bj2 levels. These findings do not appear to be explained by age variation within the group, since there was no overall correlation between any nutritional variable and age per se. To correct for any effects of educational status and income level, analysis of covariance was performed it did not alter the degree or the statistical significance of the associations between performance on the cognitive tests and blood levels of the vitamins. 

It is possible that poor cognitive status predisposes to poor nutrition. However, obviously demented subjects were excluded from this study. The subjects were apparently healthy, active individuals whose cognitive impairment was detectable only by sophisticated testing. Evidently, there was a relation between nutrition and cognition even in these independent and financially secure elderly. No prospective trial has yet been performed to determine whether changes in memory and abstract thinldng ability can be corrected with dietary supplementation (Goodwin et al, 1983). 

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The vitamin deficiency is often due to failure to absorb B12 from the stomach and can be alleviated by giving mg doses with extracts of hog s stomach which contains the intrinsic anti-pernicious anaemia factor (a muco-protein), which promotes the absorption. 

In this period, the empirical healing of certain diseases by foods was estabUshed. Examples (3) were the treatment of night blindness (vitamin A deficiency) with hver ia many cultures over centuries, of beriberi (vitamin deficiency) by use of unpoHshed rice by the Japanese navy, of scurvy (vitamin C deficiency) by citms fmits ia the British navy or piae needle extracts by North American natives, and pellagra (niacia deficiency) by a dietary shift away from corn-based foods ia many countries. Other, nondietary empirical treatments iavolved, eg, exposure of children ia northern latitudes to sunlight to cute tickets (vitamin D deficiency) (4). 

Fohc acid is safe, even at levels of daily oral supplementation up to 5—10 mg (97). Gastrointestinal upset and an altered sleep pattern have been reported at 15 mg/day (98). A high intake of foHc acid can mask the clinical signs of pernicious anemia which results from vitamin deficiency and recurrence of epilepsy in epileptics treated with dmgs with antifolate activity (99). The acute toxicity (LD q) is approximately 500 and 600 mg per kg body weight for rats and mice, respectively (100). 

Vitamin Deficiency. Vitamin deficiency is uncommon in normal adults. However, when it does occur, it can be serious, particularly in pregnant women. Some vitamin deficiency can occur because of a large reduction of fat intake, which decreases absorption. Strict vegetarians also risk reduced vitamin intake. Premature infants and elderly people who are exposed to minimal sunlight and consume Htde vitamin also have a reduced capacity to metabolize and can develop vitamin deficiency. 

People who experience the exclusion of sunlight (living in northern climates cultures where apparel limits sunlight), as weU as infants and children that are confined to bed or limited outdoor activity because of weather or illness, also can show a tendency towards vitamin deficiency. 

Disease States. Rickets is the most common disease associated with vitamin D deficiency. Many other disease states have been shown to be related to vitamin D. These can iavolve a lack of the vitamin, deficient synthesis of the metaboUtes from the vitamin, deficient control mechanisms, or defective organ receptors. The control of calcium and phosphoms is essential ia the maintenance of normal cellular biochemistry, eg, muscle contraction, nerve conduction, and enzyme function. The vitamin D metaboUtes also have a function ia cell proliferation. They iateract with other factors and receptors to regulate gene transcription. 

Alcohol dextrose solutions are used cautiously in patients with hepatic and renal impairment, vitamin deficiency (may cause or potentate vitamin deficiency),... 

Fat-soluble vitamin supplementation is usually required in pancreatic insufficiency. Specially-formulated products for CF patients (ADEKs and Vitamax ) are usually sufficient to attain normal serum vitamin levels at a dose of 1 tablet daily for younger children and 2 tablets daily for teenagers and adults. Additional supplementation may be needed in uncontrolled malabsorption or for replacement of severe vitamin deficiency.5,15 Appetite stimulants such as cyproheptadine may be an option for promoting nutrition and weight gain, but efficacy has not been established. 

As patients lose exocrine function of the pancreas, they have decreased ability to absorb lipids and protein ingested with normal dietary intake. Weight loss from nutritional malabsorption is a common symptom of chronic pancreatitis not often seen in acute pancreatitis. Fatty- or protein-containing stools are also common carbohydrate absorption is usually unaffected. Even though patients with chronic pancreatitis have decreased ability to absorb lipid from the gastrointestinal tract, there does not appear to be an increased incidence of fat-soluble vitamin deficiency in these patients.34... 

Water-soluble vitamins removed by hemodialysis (HD) contribute to malnutrition and vitamin deficiency syndromes. Patients receiving HD often require replacement of water-soluble vitamins to prevent adverse effects. The vitamins that may require replacement are ascorbic acid, thiamine, biotin, folic acid, riboflavin, and pyridoxine. Patients receiving HD should receive a multivitamin B complex with vitamin C supplement, but should not take supplements that include fat-soluble vitamins, such as vitamins A, E, or K, which can accumulate in patients with renal failure. 

Weight loss, steatorrhea, and vitamin B12 and fat-soluble vitamin deficiencies... 

The liver serves as an important storage site for vitamins and iron. Sufficient quantities of several vitamins may be stored so as to prevent vitamin deficiency for some period of time ... 

Single vitamin deficiencies are uncommon multiple vitamin deficiencies more commonly occur with undernutrition. For information on iron-deficiency and other anemias, see Chap. 33. 

Co deficit Everywhere Low content of Co in Podsoluvisols, Podzols, Arenosols and Histosols. The average Co content in plant species is < 5 ppb The decrease of Co content in tissues decrease of vitamin BJ2 in liver (tr.—130 ppm), in tissue (tr.—0.05 ppm), in milk (tr.—3 ppm). Synthesis of vitamin Bi2 and protein is weakened. Cobalt-deficiency and Bj2 vitamin-deficiency. The number of animal diseases is decreasing in raw sheep —cattle — pigs and horses. Low meat and wool productivity and reproduction... 

Cu + Co deficit Especially in Swamp ecosystems Low content of Cu and Co in Podsoluvisols, Podzols, Arenosols and Histosols. Declining contents of Cu and Co in forage species (Cu from 3 to 0.7 ppm, Co < 5 ppb) Depressed synthesis of BJ2 vitamin and oxidation ferments. Cobalt-deficiency and B12 vitamin-deficiency complicated by Cu deficiency. The prevalent diseases of sheep and cattle... 

I, Co, Cu deficit Various mountain regions Carpathian, Caucasian, Crimea, Tien-Shan, etc Mountain soils Endemic increase of thyroid gland and endemic goiter, Cobalt-deficiency and B12 vitamin-deficiency... 

Colesevelam [22,23] 14-28 2-3 Caution in patients with fat-soluble vitamin deficiency... 

Radiographic study of the small intestine may provide useful information (A6, F12, F14, K4, L2, M2, P3). If a simple suspension of barium sulfate is used, the upper small intestine of a normal person usually displays a fine feathery appearance a similar pattern is seen in most patients with pancreatogenous malabsorption. In the patient with enteropathy, however, the opaque medium appears in massive clumps. This was at one time thought to be due to vitamin deficiencies, but it was demonstrated experimentally that the cause was flocculation of the barium sulfate with excessive secretion of mucus. This clumped appearance may be seen in normal children, possibly due to the... 

Nutritional deficiency diseases are relatively rare in the temperate zone. The etiology of numerous other clinical conditions involve vitamin deficiencies, due to faults in absorption, transfer, or utilization. Because of the central position of the vitamins as sources of coenzymes, such functional deficiencies are important in malabsorption, where the picture is often complicated by multiple deficiencies, in anemias where the defect is in general highly specific, and in many other diseases where the deficiency is secondary to other pathologic events, but nevertheless of grave consequences. 

The chemistry, metabolism, and clinical importance of folic acid have been the subject of many excellent reviews (A7, Gil, H14, H20, Rl). Folic acid deficiency leads to a macrocytic anemia and leucopenia. These symptoms are due to inadequate synthesis of nucleic acid. The synthesis of purine bases and of thymine, required for nucleic acid synthesis, is impaired in folic acid deficiency. Detection of folic acid activity in biologic fluids and tissues is of the utmost importance it distinguishes between the various anemias, e.g., those due to vitamin Bi2 or folic acid deficiency. Because morphology of the abnormal red cell does not help in diagnosing vitamin deficiency, one must rely on assay methods for differential diagnosis. Treatment of pernicious anemia with folic acid has led to subacute combined degeneration of the spinal cord despite... 

The establishment of quantitative methods for the determination of vitamins in body fluids and tissues by microbiological assay techniques should stimulate the search for the significance of vitamins in disease, not only in nutritional deficiency, but in the much wider field of all metabolic disturbances. Functional vitamin deficiencies are produced by malabsorption, by inhibitors of the vitamin function through products of the body, and particularly through drugs and other toxic substances. Vitamin deficiencies may be relative deficiencies whenever an individual s metabolism is deranged so as to require enhanced quantities of a given vitamin to cure or to counteract certain symptoms as, e.g., in Darier s disease (keratosis follicularis) (P2a). 

Vitamin deficiency can cause a megaloblastic anemia of the same type seen in folate deficiency (discussed in Chapter 17). In a patient with megaloblastic anemia, it is important to determine the underlying cause because Bjj defidency, if not corrected, produces a peripheral neuropathy owing to aberrant fatty acid incorporation into the myelin sheets associated with inadequate methylmalonyl CoA mutase activity. Excretion of methylmalonic acid indicates a vitamin Bjj deficiency rather than folate. 

Vitamin deficiencies may produce a more mild form of homocystinemia. Mild homocystinemia is associated with increased risk for atherosclerosis, deep vein thrombosis, and stroke. The vitamin deficiencies causing homocystinemia include ... 

Answer D. Sideroblastic anemia in a person being treated for tuberculosis (with isoni-azid) is most likely due to vitamin deficiency. 6-Aminolevulinate synthase, the first enzyme in heme synthesis requires vitamin Bj (pyridoxine). 

Despite these clues, a definitive diagnosis often cannot be made. In that case, a prudent course is to treat what would be treatable. The initial evaluation should carefully look for treatable medical causes of dementia or depression. These include vitamin deficiency and hypothyroidism among others. If no medical causes are found, then treatment for depression should be started. If the patient is depressed and suffering from a pseudodementia, the patient can expect full recovery of memory as the depression resolves. But if the patient has a progressive dementia such as Alzheimer s disease, then treatment for depression has done no harm and may still provide some benefit. 

Nutritional Deficiency-Related Dementias. We have already mentioned that chronic alcoholics are subject to thiamine deficiency that can cause dementia. It usually occurs only after heavy, prolonged abuse of alcohol. In developed countries, the other key nutritional concern is vitamin deficiency. Vitamin deficiency can surprisingly strike even those with a healthy diet. Such people are missing a vital protein, intrinsic factor, which would enable them to absorb it from their digestive tract. 

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