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NUTRITION Angela Clem, PhD NUR 1021

Role of Nutrition • Source of nutrients and energy • Promotes, maintains and restores health • Important in maintaining wellness • Adequate nutrition leads to optimal health • Link between diet and disease

• Cultural, social and psychological implications

Energy Balance • Amount of energy input (food) in relation to amount of energy output (work) • Positive energy balance • Negative energy balance • Can be affected by health status and environmental factors

Energy Balance • Body stores energy as glycogen, fats & proteins • When food is not available body draws on stored energy in liver, muscle and adipose tissue.

Energy Balance • Energy output comes from ATP • Amount of energy expended is determined by BMR and physical activity

Energy Balance • Basal Metabolic Rate (BMR) • Amount of energy required to maintain the resting body’s internal activities after an overnight fast • Measured in kcal/hr/kg • Ten percent of total kcal used for processing ingested food

Basal Metabolic Rate • BMR = 1 kcal/kg body weight/hour • Energy needed for ADL’s Female – 1.3 kcal/kg/hr 1.3 kcal x 50 kg x 24 hours = 1560 calories Male – 1.5 kcal/kg/hr 1.5 kcal x 100 kg x 24 = 3600 calories

Factors Affecting Energy Balance • Age • Illness • Amount of lean • Metabolic rate muscle mass and fat increases 7% for each degree in • Endocrine Influences temperature • Climate/Environment • Cancer & • Activity level hyperthyroidism increases metabolic rate • Malnutrition

Digestion and Absorption of Foods • Digestion – Breakdown of foods to be absorbed in body fluids • Mechanical Digestion – chewing, peristalsis • Chemical Digestion – Enzymes, HCL, Mucus, H2O & electrolytes

• Secretions are controlled by neural and hormonal mechanisms • Think of your favorite food!!!!

Absorption • Small Intestine • • • •

Maximum absorption of nutrients Protein absorbed as amino acids Fats absorbed as fatty acids or glycerides Carbohydrates absorbed as glucose or fructose • Vitamins and minerals are also absorbed

Absorption • Large Intestine • Absorption of water, minerals and electrolytes • Takes 8 to 72 hours for food to reach rectum • Bacteria in colon synthesize Vit K and Vit B, break down bilirubin into bile, and break down undigested proteins and CHO

Age Related Changes • Oral Cavity • Periodontal disease • Altered taste buds • Preference for salty and sweet foods changes

Age Related Changes • Esophagus/Stomach/Intestines • • • • •

Dilation of esophagus Loss of cardiac sphincter Decreased gag reflex Atrophy of gastric mucosa Slowed gastric motility

Cultural Dimensions of Nutrition • Jewish Faith • Passover seder, kosher food, prohibits serving meat & dairy together

• Catholics • No meat on certain days, fasting

• Seventh Day Adventists, Hindus, Buddhists are vegetarians

Influences of Nutritional Knowledge and Life Style • Extremes in dietary habits can cause severe deficiencies • Macrobiotic, Total Vegetarianism, Cabbage, Stillman diet

• Patient education by nurse!!

• High stress, fast paced life style • Living alone • Alcohol & Tobacco • “Couch Potato” • Personal Preference • Economic situation

Nutrition of the Older Adult • Basic Four Food Groups • • • • •

Bread Fruit/Vegetables Meat/Poultry/Fish Dairy Fats & Sweets (sparingly)

Nutrition of the Older Adult • Recommended Daily Allowance Calories • Age 65-75 = 2300 kcal/day • Age 75+ = 2050 kcal/day • CHO – 60%, Fat 20 – 25%, Protein 15 – 20%

Nutrition of the Older Adult • Factors affecting nutrition • • • •

Diminished sense of smell Decreased appetite Early satiety Decreased absorption of Vit. B12, D, folate

Nutrition of the Older Adult • Factors affecting nutrition • • • • •

Ill fitting dentures Chronic illness Medications Alcoholism Socioeconomic status

Nutrition Problems in the Elderly • Dehydration occurs easily • Forget to drink fluids • Decreased sense of thirst

• • • • •

Environmental Factors Decreased SC fat and muscle tissue Acute and Chronic Diseases Kidney failure Medications and treatments

Alterations in Nutrition • Protein-Caloric Malnutrition • 3 categories • Protein Deficiency State • Due to major injury, surgery • Malnutrition develops in 10 days • S&S include fatigue, apathy, edema, decreased serum protein,WBC, transferrin, wt. loss, muscle weakness, impaired wound healing

Alterations in Nutrition • Protein-Caloric Malnutrition • Cachexia • Prolonged period of insufficient food • S&S include emaciation, tissue wasting, diarrhea

• Mixed State • Severe depletion of vitamins, impaired GI absorption • Aggressive nutritional support needed.

Eating Disorders • Anorexia Nervosa • Self imposed starvation • Causes amenorrhea, nutritional deficiency, metabolic imbalances and death

Eating Disorders • Bulimia • Uncontrolled binge eating followed by self induced vomiting, use of laxatives or diuretics

Assessment of Nutrition • History – Personal, family, social, life style habits, coping, self image • Physical Exam – general appearance, vitality, skin, hair, teeth, mucous membranes, abdomen, musculoskeletal status, height, weight, anthropometric measurements.

Diagnostics • Laboratory Tests • Blood Tests - CBC, Albumin, Transferrin, Calcium, Phosphorous, FBG, Fatty acids, Cholesterol, Lipids, Triglycerides • Urine Tests – Protein serum Urine, Creatinine Serum Urine, Urea Nitrogen serum Urine • X-ray Studies – Abdominal x-rays and scans • Endoscopic Examinations

Nursing Diagnoses • Altered nutrition less than body requirements • Etiology – Inability to ingest foods, inability to digest foods, inability to absorb nutrients, knowledge deficit, peer pressure, personal preferences, aversions, sociocultural tradition.

Nursing Diagnoses • Altered nutrition more than body requirements • Etiology – overeating, sedentary life style, hypothyroidism, compulsive eating, anxiety, depression, diet high in fats and sugars.

Implementation of Optimum Nutrition • Preventive Care • Life style analysis, counseling, values clarification, health education, daily meal planning.

• Supportive Care • Nutritional supplements, smart shopping, exercise program (HR=75% of max rate 30min)

Implementation of Optimum Nutrition • Restorative Care (starvation & disease) • Special Diets • Soft, liquid, high fiber, low residue, bland, ADA, low fat, low sodium, low protein, low potassium • Position for safe eating, assisting patient with dysphasia, special utensils, enteral feeding, TPN

• Rehabilitative Care • Maximize nutritional status, counseling, support groups

Evaluation of Data and Charting • Physical findings, anthropometric measures, lab tests, weight, choosing healthy foods, no tissue breakdown, no fluid & electrolyte imbalances, no diarrhea

Evaluation of Data and Charting • Chart • Weight loss or gain, edema, type of diet, percent of food eaten, calorie count, degree of assistance needed, assistive devices, fluid intake, knowledge and understanding of special diets, preferred foods, encourage family to bring in favorite foods

Nutritional Considerations • Energy – Power to do work. Nutrition is source of energy. (1.5 kcal/hr/kg) • Proteins • Amino acids/peptides used to build enzymes, antibodies, transport proteins • All body tissues and organs are made of protein • Proteins maintain fluid balance by increasing osmotic pressure, attract water and buffer acids

Nutritional Considerations • Energy – Power to do work. Nutrition is source of energy. (1.5 kcal/hr/kg) • Proteins • Protein in food supplies body with amino acids to make its own protein • AA are not stored in the cells • Essential AAs (9) – AAs the body cannot make • Dietary complete protein provides all essential AA to synthesize protein

Nutritional Considerations • Examples of AAs • Histadine, Leucine, Lysine, Phenylalamine, Tryptophan

• 1 gram protein = 4 kcal energy • Adequate CHO and Fat intake will prevent protein breakdown for energy.

Nutritional Considerations • Fats • Lipids, Fats, oils, sterols • Composed of triglycerides = 3 fatty acids + glycerol • 9 kcal of energy /gram • Insulates body organs, facilitates nerve conduction, transports other molecules, used in hormones

Nutritional Considerations • Saturated Fatty Acids • Every carbon bond holds a H atom • Examples include animal foods, meats, coconut oil, palm oil

• Mono saturated Fatty Acid • One point on chain is missing a H atom • Examples include canola oil, olive oil

• Polyunsaturated Fatty Acids • More that one point of unsaturation • Examples include Omega 3 fatty acids, fish

Nutritional Considerations • Cholesterol • Made in liver from CHO and Fat • HDL, LDL • High levels in meat, dairy, eggs, shell fish.

Nutritional Considerations • Carbohydrates • • • •

Needed for brain, muscle and nerve function 1 gram CHO = 4 kcal energy Monosaccharides – glucose, fructose, galactose Disaccharides - maltose, sucrose, lactose

Nutritional Considerations • Carbohydrates • Polysaccharides – glycogen, starches, fiber • Dietary fiber absorbs water, minerals, lipids, increases motility of GI tract, management of constipation, diarrhea, hemorrhoids, colon cancer, decrease glucose and lipids.

Nutritional Considerations • Vitamins • Organic nutrients required to produce energy, RBC and repair tissue • Fat Soluble – A,D,E,K – found in fats and oils, stored in body fat. • Water Soluble – 8 B vitamins + C – readily excreted in urine

Fat Soluble and Water Soluble Vitamins Vitamin A

Vitamin C

Pyridoxine B6

Vitamin D

Vitamin B1

Folic Acid

Vitamin E


Cobalamin B12

Vitamin K


Pantothenic Acid

Nutritional Considerations • Minerals • Essential chemical elements that maintain numerous body processes – Ca++, K+, Na critical in illness

Minerals Calcium





Potassium Fluoride








Selenium Manganese

Recommended Daily Allowances • Guidelines for intake of specific nutrients for health people • RDA standards guide health care providers to determine dietary intake, parenteral (TPN), enteral formulas and food supplements.

Dietary Reference Intakes • • Used to calculate daily nutrient recommendations for dietary planning based on the DRIs • Contains most current scientific knowledge on nutrient needs (National Academy of Science’s Institute of Medicine) • Individual requirements may be higher or lower than the DRIs

Nutrient Data Laboratory

• • Develops food composition databases and methods to acquire, evaluate, compile and disseminate composition data on foods and dietary supplements available in the U. S.


Sources • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Sources • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •,0,143,673,712,1064,eca4856c.jpg

Sources • • • • • • • • • • • • • • • • • • • • • • • • • • • • •,%20fennel%20salad%20and%20chervil%20dressing.jpg

Sources • • • • • • • • • • • •

Vitamin A • Important role in vision, bone growth, reproduction, cell division, cell differentiation, immune system regulation, and healthy epithelia • Fat-soluble vitamin

Vitamin A • Two categories of Vitamin A • Preformed vitamin A • From animal-based sources • Absorbed in the form of retinol (one of the most usable/active forms of vitamin A)

• Provitamin A carotenoids (beta-carotene, alphacarotene, and beta-cryptoxanthin) • From plant sources • Can be made into retinol in the body (beta-carotene most efficiently converted to retinol)

Vitamin A • Vitamin A Deficiency • Rarely seen in the U.S. • Strict dietary restrictions and excess alcohol intake • Zinc deficiency can interfere with Vitamin A metabolism • Iron deficiency can also affect Vitamin A metabolism • Vitamin A deficiency may exacerbate iron deficiency anemia

• Fat malabsorption disorders (celiac disease, Crohn’s disease, pancreatic disorders)

• 250,000 to 500,000 malnourished children in the developing world go blind each year from vitamin A deficiency

Vitamin A • Vitamin A Deficiency • Initial symptoms of Vitamin A Deficiency • Night blindness • Diminished immunity – increased risk of respiratory and diarrheal illnesses

Vitamin A • Vitamin A Deficiency • Initial symptoms of Vitamin A Deficiency • Bitot's spots -- changes in the conjunctiva (corner of the eye) with mild deficiency • Severe or prolonged vitamin A deficiency causes xeropthalmia (dry eye)  corneal ulcers, scarring, and blindness

Bitot’s spots


Vitamin A • Hypervitaminosis A • Overconsumption of preformed vitamin A is relatively rare • Four major adverse effects: birth defects, liver abnormalities, reduced bone mineral density leading to osteoporosis, and central nervous system disorders • Signs of acute toxicity: nausea and vomiting, headache, dizziness, blurred vision, muscular incoordination, fatigue, loss of appetite, dry skin, desquamation, cerebral edema, bulging fontanels in infants, liver damage, hemorrhage, coma • A high intake of provitamin A carotenoids can turn the skin yellow (not hazardous)

Vitamin A • •

Chronic toxicity  dry itchy skin, desquamation, loss of appetite, headache, cerebral edema, and bone and joint pain Chronic alcohol consumption results in depletion of liver stores of vitamin A  may contribute to alcohol-induced liver damage  liver toxicity of preformed vitamin A (retinol) is enhanced by chronic alcohol consumption Oral contraceptives that contain estrogen and progestin increase retinol binding protein (RBP) synthesis by the liver  increasing the export of RBP-retinol complex in the blood Retinoids or retinoid analogs (acitretin), all-trans-retinoic acid, bexarotene, etretinate and isotretinoin (Accutane), should not be used in combination with vitamin A supplements, because they may increase the risk of vitamin A toxicity

Vitamin A Food

Vitamin A (IU)


Liver, beef, cooked, 3 ounces



Carrot juice, canned, ½ cup



Carrots, boiled, ½ cup slices



Liver, chicken, cooked, 3 ounces



Spinach, frozen, boiled, ½ cup



Kale, frozen, boiled, ½ cup



Carrots, 1 raw (7½ inches)



Vegetable soup, canned, chunky, readyto-serve, 1 cup



Cantaloupe, 1 cup cubes



Vitamin D • •

• • • •

Fat-soluble vitamin Essential for promoting calcium absorption in the gut and maintaining adequate serum calcium and phosphate concentrations Needed for bone growth and bone remodeling by osteoblasts and osteoclasts Modulation of neuromuscular and immune function and reduction of inflammation Many genes encoding proteins that regulate cell proliferation, differentiation, and apoptosis are modulated in part by vitamin D May aid in the prevention of osteoporosis, colon, prostate, and breast cancers, type 1 and type 2 diabetes, hypertension, and multiple sclerosis

Vitamin D • Produced endogenously when ultraviolet rays from sunlight strike the skin and trigger vitamin D synthesis • Vitamin D3 (cholecalciferol) can be synthesized by humans in the skin upon exposure to ultraviolet-B (UVB) radiation from sunlight, or it can be obtained from the diet • Vitamin D must undergo two hydroxylations in the body for activation (first occurs in the liver and converts vitamin D to 25-hydroxyvitamin D [25(OH)D] aka calcidiol and the second occurs primarily in the kidney and forms the physiologically active 1,25-dihydroxyvitamin D [1,25(OH)2D] aka calcitriol • Most people meet their vitamin D needs through exposure to sunlight

Vitamin D • Vitamin D deficiency • Rickets (soft bones and skeletal deformities in children), osteomalacia (bone pain and muscle weakness in adults), secondary hyperparathyroidism • Higher risk with milk allergy, lactose intolerance, and strict vegetarianism, breastfed infants, older adults, limited sun exposure, people with dark skin, fat malabsorption disorders, obesity, gastric bypass surgery

Vitamin D • Vitamin D toxicity • Nausea, vomiting, poor appetite, constipation, weakness, and weight loss elevated blood levels of calcium (hypercalcemia) (resulting in confusion and heart rhythm abnormalities) Excessive sun exposure does not result in vitamin D toxicity because the sustained heat on the skin is thought to photodegrade previtamin D3 and vitamin D3 as it is formed • Toxicity is more likely to occur from high intakes of supplements

Vitamin D •

• •

Plants synthesize ergosterol, which is converted to vitamin D2 (ergocalciferol) by ultraviolet light  Vitamin D2 is less active than vitamin D3 Corticosteroids (like prednisone) can reduce calcium absorption and impair vitamin D metabolism Weight-loss drug orlistat (Xenical® and alli™) and the cholesterol-lowering drug cholestyramine (Questran®, LoCholest®, and Prevalite®) can reduce the absorption of vitamin D and other fat-soluble vitamins Phenobarbital and phenytoin (Dilantin®) increase the hepatic metabolism of vitamin D to inactive compounds and reduce calcium absorption

Vitamin D Vitamin D (IUs /serving)

Percent DV



Salmon (sockeye), cooked, 3 ounces



Mushrooms that have been exposed to ultraviolet light to increase vitamin D, 3 ounces (not yet commonly available)



Mackerel, cooked, 3 ounces



Tuna fish, canned in water, drained, 3 ounces





Orange juice fortified with vitamin D, 1 cup (check product labels, as amount of added vitamin D varies)



Yogurt, fortified with 20% of the DV for vitamin D, 6 ounces (more heavily fortified yogurts provide more of the DV)



Food Cod liver oil, 1 tablespoon

Milk, nonfat, reduced fat, and whole, vitamin Dfortified, 1 cup

Vitamin E • Fat-soluble compounds • Naturally occurring vitamin E exists in eight chemical forms (alpha-, beta-, gamma-, and delta-tocopherol and alpha-, beta-, gamma-, and delta-tocotrienol) with varying levels of biological activity • Alpha- (or α-) tocopherol is the only form that is recognized to meet human requirements

Vitamin E • Absorbed in the small intestine then taken up by the liver – liver preferentially resecretes only alphatocopherol via the hepatic alpha-tocopherol transfer protein – liver metabolizes and excretes the other vitamin E forms

Vitamin E • Functions as antioxidants, involved in immune function and other metabolic processes • Vitamin E deficiency is rare • Peripheral neuropathy, ataxia, skeletal myopathy, retinopathy, and impairment of the immune response • Higher risk for Crohn’s disease, cystic fibrosis, abetalipoproteinemia, ataxia and vitamin E deficiency (AVED)

• No adverse effects from vitamin E in food • High dose alpha-tocopherol supplements can cause hemorrhage

Vitamin E •

Vitamin E can inhibit platelet aggregation and antagonize vitamin K-dependent clotting factors –> increased bleeding with warfarin Vitamin E supplements with vitamin C, selenium, and betacarotene blunted the rise in high-density lipoprotein (HDL) cholesterol levels, especially levels of HDL2, (most cardioprotective HDL component), among people treated with a combination of simvastatin (Zocor®) and niacin Antioxidant supplements during cancer chemotherapy or radiotherapy because they might reduce the effectiveness of these therapies by inhibiting cellular oxidative damage in cancerous cells Phenobarbital, phenytoin, and carbamazepine, may decrease plasma levels of vitamin E

Vitamin E Food Wheat germ oil, 1 tablespoon Almonds, dry roasted, 1 ounce Sunflower seeds, dry roasted, 1 ounce Sunflower oil, 1 tablespoon Safflower oil, 1 tablespoon Hazelnuts, dry roasted, 1 ounce Peanut butter, 2 tablespoons Peanuts, dry roasted, 1 ounce

Vitamin E (mg)

Percent DV

















Vitamin K • Fat-soluble vitamin • Two naturally occurring forms of vitamin K • Plants synthesize phylloquinone (vitamin K1) • Bacteria synthesize a range of vitamin K forms using repeating 5-carbon units in the side chain of the molecule (designated menaquinone-n (MK-n) AKA Vitamin K2 • MK-4 is synthesized by animals (including humans) from phylloquinone

Vitamin K • Essential for the functioning of several proteins involved in blood clotting • Cofactor for an enzyme that catalyzes the carboxylation of glutamic acid, resulting in its conversion to gamma-carboxyglutamic acid (Gla) -critical to the calcium-binding function of those proteins  Vitamin K-dependent coagulation factors are synthesized in the liver  severe liver disease results in lower blood levels of vitamin K-dependent clotting factors and an increased risk of uncontrolled bleeding

Vitamin K • Three vitamin-K dependent proteins have been isolated in bone: osteocalcin, matrix Gla protein (MGP), and protein S  bone mineralization and metabolism • Gas6 is a vitamin K-dependent protein involved in cell growth regulation, the nervous system, platelet signaling and vascular homeostasis – found in the nervous system, heart, lungs, stomach, kidneys, and cartilage

Vitamin K • Vitamin K deficiency is usually uncommon • Impaired blood clotting, easy bruising, nosebleeds, bleeding gums, blood in the urine, blood in the stool, tarry black stools, or extremely heavy menstrual bleeding • Increased risk for those on anticoagulants, liver damage or disease, and those with disorders of fat malabsorption, newborns

Vitamin K • No known toxicity with phylloquinone • Synthetic menadione (vitamin K3) can interfere with glutathione (antioxidant) resulting in induced liver toxicity, jaundice, and hemolytic anemia

• Large doses of vitamin A and vitamin E have been found to antagonize vitamin K • Excess vitamin A appears to interfere with vitamin K absorption, whereas a form of vitamin E (tocopherol quinone) may inhibit vitamin K-dependent carboxylase enzymes

Vitamin K • Vitamin K antagonists (warfarin) may be inhibited by very high dietary or supplemental vitamin K intake • Prolonged use of broad spectrum antibiotics may decrease vitamin K synthesis by intestinal bacteria • Cephalosporins and salicylates may decrease vitamin K recycling by inhibiting vitamin K epoxide reductase • Cholestyramine, cholestipol, orlistat, mineral oil, and the fat substitute, olestra, may decrease vitamin K absorption

Vitamin K Vitamin K (mcg)



Kale, raw

1 cup (chopped)


Swiss chard, raw

1 cup


Parsley, raw

1/4 cup


Broccoli, cooked

1 cup (chopped)


Spinach, raw

1 cup


Watercress, raw Leaf lettuce (green), raw Soybean oil

1 cup (chopped) 1 cup (shredded) 1 Tablespoon

85 62.5 25.0

Vitamin C • L-ascorbic acid • Water-soluble vitamin • Humans (unlike most animals) are unable to synthesize vitamin C • Required for the biosynthesis of collagen, L-carnitine, and certain neurotransmitters (norepinephrine) • Also involved in protein metabolism, wound healing, antioxidant, immune function, and improving the absorption of nonheme iron (plant-based foods) • May also be involved in the metabolism of cholesterol to bile acids

Vitamin C • Deficiency – Scurvy (fatigue or lassitude, widespread connective tissue weakness, and capillary fragility, bleeding and bruising easily, hair and tooth loss, and joint pain and swelling ) • Signs can occur within 1 month of limited Vitamin C intake(vitamin C intake falls below approximately 10 mg/day for many weeks) • Smokers and passive smokers at higher risk, infants fed evaporated or boiled cow’s milk, limited food variety, severe intestinal malabsorption, cachexia, end-stage renal disease/chronic hemodialysis

Vitamin C • High intake of Vitamin C • Low toxicity • Possible diarrhea, nausea, abdominal cramps from high intake, may increase risk of kidney stones in individuals with hereditary hemochromatosis, chronic consumption of high doses of vitamin C could exacerbate iron overload and result in tissue damage

Vitamin C • Antioxidants (such as Vitamin C) might protect tumor cells from the action of radiation therapy and chemotherapeutic agents • Vitamin C, in combination with other antioxidants, may attenuate the increase in high-density lipoprotein levels resulting from combination niacin–simvastatin (Zocor®) therapy

Vitamin C Food

Vitamin C (mg) per serving

Percent (%) DV*

Red pepper, raw, ½ cup



Orange juice, ¾ cup



Kiwifruit, 1 medium



Orange, 1 medium



Grapefruit juice, ¾ cup



Green pepper, raw, ½ cup



Broccoli, cooked, ½ cup



Vitamin B1 (Thiamin) • Vitamin B1 or aneurine • Occurs in the human body as free thiamin and as phosphorylated forms (thiamin monophosphate (TMP), thiamin triphosphate (TTP), and thiamin pyrophosphate (TPP)) • Coenzyme production (thiamin pyrophosphate (TPP))

Vitamin B1 (Thiamin) • Deficiency -- Beriberi (dry, wet, or cerebral) • Dry (paralytic or nervous) beriberi produces peripheral neuropathy, exaggerated reflexes, diminished sensation, limb weakness and difficulty rising from a squatting position, muscle pain and tenderness, possible seizures • Wet beriberi produces neurologic symptoms plus cardiac symptoms (rapid pulse, cardiac enlargement, severe edema, SOB, CHF) • Cerebral beriberi may produce Wernicke's encephalopathy and Korsakoff's psychosis (especially at risk those with alcohol abuse, stomach cancer, and AIDS)

Vitamin B1 (Thiamin) • Anti-thiamin factors (ATF) in foods (tea, coffee, betel nuts) can contribute to the risk of thiamin deficiency • Thiaminase (found in certain raw freshwater fish, raw shellfish, and ferns) can contribute to thiamin deficiency

Vitamin B1 (Thiamin) • Toxicity is uncommon • Possible anaphylaxis with high-dose IV thiamin

• Thiamine may reduce the risk of cataracts • Phenytoin (anticonvulsant), 5-fluorocuracil (cancer therapy), and diuretics (especially Lasix) can contribute to thiamine deficiency

Vitamin B1 (Thiamin) Food


Thiamin (mg)

Wheat germ breakfast cereal

1 cup


Pork, lean (cooked)

3 ounces


Fortified breakfast cereal

1 cup


Long grain white rice, enriched (cooked)

1 cup


Peas (cooked)

1/2 cup



1 ounce


Long grain brown rice (cooked)

1 cup


Brazil nuts

1 ounce


Riboflavin • Vitamin B2 • Integral component of the coenzymes, flavin adenine dinucleotide (FAD) and flavin mononucleotide (FMN) • Involved in oxidation-reduction reactions, antioxidants (glutathione reductase, glutathione peroxidase, xanthine oxidase)

Riboflavin • Ariboflavinosis (riboflavin deficiency) • Typically occurs in combination with deficiencies of other water-soluble vitamins • Sore throat, redness and swelling of the lining of the mouth and throat, cracks or sores on the outsides of the lips (cheliosis) and at the corners of the mouth (angular stomatitis), inflammation and redness of the tongue (magenta tongue), and a moist, scaly skin inflammation (seborrheic dermatitis), vascularization of the cornea, normochromic normocytic anemia, decreased conversion of vitamin B6 to its coenzyme form (PLP) and decreased conversion of tryptophan to niacin • Riboflavin deficiency may impair iron absorption, increase intestinal loss of iron, and/or impair iron utilization for the synthesis of hemoglobin

Riboflavin • Increased riboflavin intake has been associated with decreased plasma homocysteine levels • No known toxicity with high riboflavin intake • Flavinuria (bright yellow urine from high-dose riboflavin – harmless effect) • Excess riboflavin may increase the risk of DNA strand breaks in the presence of chromium (IV)

Riboflavin •

• •

Phenothiazine derivative (chlorpromazine and tricyclic antidepressants), quinacrine(anti-malarial), and adriamycin (chemotherapy agent), inhibit the incorporation of riboflavin into FAD and FMN Anti-convulsant, phenobarbitol may increase destruction of riboflavin, by liver enzymes, increasing the risk of deficiency Chlorpromazine , tricyclic antidepressants , quinacrine, and adriamycin inhibit the incorporation of riboflavin into FAD and FMN Phenobarbitol may increase destruction of riboflavin by liver enzymes

Riboflavin Riboflavin (mg)



Fortified cereal

1 cup

Milk (nonfat)

1 cup (8 ounces)


Egg (cooked)

1 large



1 ounce


Spinach (boiled)

1/2 cup


Chicken, dark meat (roasted)

3 ounces


Beef (cooked)

3 ounces


Asparagus (boiled)

6 spears


0.59 to 2.27

Niacin • Nicotinic acid or vitamin B3 • Nicotinamide -- derivative of niacin and used by the body to form the coenzymes nicotinamide adenine dinucleotide (NAD) and nicotinamide adenine dinucleotide phosphate (NADP) • Involved in oxidation-reduction reactions, enzyme functioning

Niacin • In addition to its synthesis from dietary niacin, NAD may also be synthesized in the liver from the dietary amino acid, tryptophan • Synthesis of niacin from tryptophan also depends on enzymes that require vitamin B6 and riboflavin as well as an enzyme containing heme (iron)

• Severe niacin deficiency • Pellagra (dermatitis, diarrhea, dementia, and death) -- thick, scaly, darkly pigmented rash develops symmetrically in areas exposed to sunlight, bright red tongue, vomiting, and diarrhea, headache, apathy, fatigue, depression, disorientation, and memory loss

Niacin • •


Niacin from foods is not known to cause adverse effects Nicotinamide is generally better tolerated than nicotinic acid -does not generally cause flushing but can cause nausea, vomiting, and signs of liver toxicity (elevated liver enzymes, jaundice), decreased insulin sensitivity Flushing of the skin primarily on the face, arms, and chest is a common side effect of nicotinic acid and may occur initially at doses as low as 30 mg/day in addition to nausea and vomiting

Niacin • •

Coadministration of nicotinic acid with lovastatin (another cholesterol lowering medication) may result in rhabdomyolysis Long-term administration of the cancer chemotherapy agent, 5Fluorouracil (5-FU), has been reported to cause symptoms of pellagra Niacin supplementation is also recommended during long-term treatment of tuberculosis with isoniazid, a niacin antagonist, because such treatment has resulted in pellagra-like symptoms Estrogen and estrogen-containing oral contraceptives increase the efficiency of niacin synthesis from tryptophan, resulting in a decreased dietary requirement for niacin

Niacin Food


Cereal (fortified)

1 cup

Tuna (light, packed in water)

3 ounces

Salmon (chinook) Chicken (light meat)

Turkey (light meat) Cereal (unfortified) Peanuts Beef (lean)

3 ounces (cooked) 3 ounces* (cooked without skin) 3 ounces (cooked without skin) 1 cup 1 ounce (dry roasted) 3 ounces (cooked)

Niacin (mg) 20-27 11.3 8.5 7.3

5.8 5-7 3.8 3.1

Vitamin B6 (Pyridoxine) • Water-soluble vitamin • Three forms • Pyridoxal (PL), pyridoxine (PN), pyridoxamine (PM)) • Phosphate ester derivative pyridoxal 5'-phosphate (PLP) is the principal coenzyme form and has the most importance in human metabolism

• Proper functioning of nearly 100 enzymes (gluconeogenesis), neurotransmitter synthesis, heme synthesis, niacin formation from tryptophan, hormone function (steroid hormones), nucleic acid synthesis

Vitamin B6 (Pyridoxine) • Vitamin B6 deficiency • Uncommon • Seizures (infants), abnormal EEGs, irritability, depression, and confusion, inflammation of the tongue, sores or ulcers of the mouth, and ulcers of the skin at the corners of the mouth • Alcoholics most at risk

Vitamin B6 (Pyridoxine) • Toxicity • Associated with supplements • Sensory neuropathy (pain and numbness of the extremities and in severe cases, difficulty walking)

Vitamin B6 (Pyridoxine) • Anti-tuberculosis medications,( isoniazid and cycloserine), the metal chelator penicillamine, and antiparkinsonian drugs including L-dopa, all form complexes with vitamin B6 creating a functional deficiency • High doses of vitamin B6 have been found to decrease the efficacy of two anticonvulsants, phenobarbital and phenytoin, as well as L-dopa

Vitamin B6 (Pyridoxine) Food

Vitamin B6 (mg)

% DV

Ready-to-eat cereal, 100% fortified, ¾ c



Potato, Baked, flesh and skin, 1 medium



Banana, raw, 1 medium



Garbanzo beans, canned, ½ c



Chicken breast, meat only, cooked, ½ breast



Ready-to-eat cereal, 25% fortified, ¾ c



Oatmeal, instant, fortified, 1 packet



Pork loin, lean only, cooked, 3 oz



Roast beef, eye of round, lean only, cooked, 3 oz



Folic Acid • Folic acid, the more stable form, occurs rarely in foods or the human body but is the form most often used in vitamin supplements and fortified foods • Folate in foods is typically bound with multiple glutamic acids (polyglumate)  intestinal cells hydrolyze this to monoglutamate and attach a methyl group  delivered by special transporters to the liver and other cells  glutamates are reattached and folate is stored as polyglutamate

• Folates are found in foods as well as in metabolically active forms in the human body • Functions as coenzyme (metabolism of nucleic acids and amino acids)

Folic Acid • Folate deficiency • Megaloblastic/macrocytic anemia, hypersegmented neutrophils, diarrhea, loss of appetite, and weight loss can occur, as can weakness, sore tongue, headaches, heart palpitations, irritability, forgetfulness, and behavioral disorders • Higher risk during pregnancy and lactation, with alcohol abuse, malabsorption, kidney dialysis, liver disease, anemias • Folate deficiency can result in decreased synthesis of methionine and a buildup of homocysteine

• Important in preventing neural tube defects (anencephaly or spina bifida)

Folic Acid •

• •

Folic acid has been shown to have the greatest effect in lowering basal levels of homocysteine in the blood when there is no coexisting deficiency of vitamin B12 or vitamin B6 Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin or ibuprofen, taken in very large therapeutic dosages (i.e., to treat severe arthritis), they may interfere with folate metabolism Anticonvulsants, (for example, phenytoin), has been shown to inhibit the intestinal absorption of folate Cholesterol-lowering agents, cholestyramine and colestipol, may decrease the absorption of folic acid

Folic Acid • •

Methotrexate is a folic acid antagonist used to treat a number of diseases, including rheumatoid arthritis and psoriasis Trimethoprim (antibiotic), pyrimethamine (antimalarial), triamterene (blood pressure), and sulfasalazine (ulcerative colitis) have antifolate activity

Folic Acid Food

Folate (μg)

% DV





Cowpeas (blackeyes), immature, cooked, boiled, ½ cup



Breakfast cereals, fortified with 25% of the DV, ¾ cup



Spinach, frozen, cooked, boiled, ½ cup







Breakfast cereals fortified with 100% of the DV, ¾ cup Beef liver, cooked, braised, 3 ounces

Great Northern beans, boiled, ½ cup Asparagus, boiled, 4 spears

Vitamin B12 • Cobalamin • Water-soluble • Largest and most complex chemical structure of all the vitamins • Contains a metal ion, cobalt • Cofactor for methionine synthase (methionine synthesis from homocysteine), • Cofactor for L-methylmalonyl-CoA mutase (production of energy from fats and proteins, synthesis of hemoglobin)

Vitamin B12 • Vitamin B12 is required for proper red blood cell formation, neurological function, and DNA synthesis • Methylcobalamin and 5-deoxyadenosylcobalamin are the forms of vitamin B12 that are active in human metabolism

Vitamin B12 • Vitamin B12 deficiency is estimated to affect 10%-15% of individuals over the age of 60 • Stomach acid and enzymes free vitamin B12 from food  B12 binds to other proteins called R proteins In the alkaline environment of the small intestine, R proteins are degraded by pancreatic enzymes, freeing vitamin B12 to bind to intrinsic factor (IF) (proteins secreted by specialized cells in the stomach)  Receptors on the surface of the small intestine take up the IF-B12 complex only in the presence of calcium, which is supplied by the pancreas • Vitamin B12 can also be absorbed by passive diffusion, but this process is very inefficient—only about 1% absorption of the vitamin B12 dose is absorbed passively

Vitamin B12 • Vitamin B12 deficiency • Most commonly from pernicious anemia (autoimmune destruction of stomach parietal cells and antibody binding to intrinsic factor) and vitamin B12 malabsorption (from atrophic gastritis, a chronic inflammation of the lining of the stomach  loss of glands in the stomach (atrophy) and decreased stomach acid production  intrinsic factor still present and can bind to B12 supplements), also surgical resection of stomach, malabsorption syndromes, vegetarian diet  megaloblastic anemia, numbness and tingling of the arms and the legs, difficulty walking, memory loss, disorientation, and dementia with or without mood changes, tongue soreness, appetite loss, and constipation

Vitamin B12 • •

No toxicity from high B12 intake Proton pump inhibitors (omeprazole (Prilosec®) and lansoprazole (Prevacid®)) may interfere with vitamin B12 absorption from food by slowing the release of gastric acid into the stomach Histamine H2 receptor antagonists (cimetidine (Tagamet®), famotidine (Pepcid®), ranitidine (Zantac®)) may interfere with the absorption of vitamin B12 from food by slowing the release of hydrochloric acid into the stomach Metformin (for diabetes) may reduce the absorption of vitamin B12

Vitamin B12 • Adequate vitamin B12 intake in addition to folic acid may be beneficial in the prevention of neural tube defects • Large doses of folic acid given to an individual with an undiagnosed vitamin B12 deficiency could correct megaloblastic anemia without correcting the underlying vitamin B12 deficiency, leaving the individual at risk of developing irreversible neurologic damage

Vitamin B12 Vitamin B12



Clams (steamed)

3 ounces


Mussels (steamed)

3 ounces


Crab (steamed)

3 ounces


Salmon (baked)

3 ounces


Beef (cooked)

3 ounces


Rockfish (baked)

3 ounces


Milk (skim)

8 ounces


Egg (poached)

1 large



Pantothenic Acid • Vitamin B5 • Water-soluble • Found in cells as coenzyme A (CoA), a vital coenzyme in numerous chemical reactions (involved in the synthesis of essential fats (sphingolipids, phospholipids), cholesterol, steroid hormones, acetylcholine, melatonin, heme, and involved in the metabolism of many drugs and toxins by the liver) • May also aid in wound healing and lowering cholesterol

Pantothenic Acid • Deficiency • Very rare and only in severe malnutrition • Headache, fatigue, insomnia, intestinal disturbances, and numbness and tingling of their hands and feet, possible hepatic encephalopathy

• Not known to be toxic • Possible diarrhea from very high intakes (10 to 20 grams/day of calcium Dpantothenate)

Pantothenic Acid • Oral contraceptives (birth control pills) containing estrogen and progestin may increase the requirement for pantothenic acid • Use of pantethine in combination with HMG-CoA reductase inhibitors (statins) or nicotinic acid may produce additive effects on blood lipids

Pantothenic Acid Food


Pantothenic Acid (mg)

Avocado, California

1 whole



8 ounces


Chicken, cooked

3 ounces


Sweet potato (cooked)

1 medium (1/2 cup)



1 cup (8 ounces)


Lentils (cooked)

1/2 cup


Egg (cooked)

1 large


Split peas (cooked)

1/2 cup


Biotin • B-complex vitamin • Water soluble vitamin • Required by all organisms but can be synthesized only by bacteria, yeasts, molds, algae, and some plant species • Enzyme cofactor for carboxylases (energy metabolism) • Histone biotinylation (regulation of DNA replication and transcription) • Biotin produced by enteric bacteria may also be absorbed from the intestines

Biotin • Biotin deficiency is very rare • From unsupplemented TPN, long-term ingestion of raw egg whites (avidin in egg white binds biotin and prevents absorption), biotinidase deficiency, liver disease, pregnancy • Hair loss and a scaly red rash around the eyes, nose, mouth, and genital area, depression, lethargy, hallucination, and numbness and tingling of the extremities, biotin deficient facies (characteristic facial rash with unusual facial fat distribution), impaired glucose use

• Not generally toxic in high doses

Biotin • High doses of pantothenic acid may compete with biotin for absorption • Anticonvulsants may increase urinary biotin excretion, inhibit GI absorption, and decrease biotinidase activity

Biotin Food


Biotin (mcg)

Liver, cooked

3 ounces


Egg, cooked

1 large


Salmon, cooked

3 ounces



1 whole


Pork, cooked

3 ounces



1 packet (7 grams)

Cheese, cheddar

1 ounce


Cauliflower, raw

1 cup



Calcium • Most abundant mineral in the body • Required for muscle contraction, blood vessel expansion and contraction, secretion of hormones and enzymes (required for the activation of the seven "vitamin K-dependent" clotting factors in the coagulation cascade), and transmitting impulses throughout the nervous system • Maintained within a very narrow concentration range • Less than <1% of total body calcium is needed to support these functions • 99% of the body's calcium supply is stored in the bones and teeth

Calcium •

Calcium concentrations in the blood and fluid that surrounds cells are tightly controlled  low blood calcium stimulates secretion of parathyroid hormone  stimulates conversion of Vitamin D to its active form (calcitriol) in the kidneys  calcitriol increases calcium absorption from the small intestine and (with parathyroid hormone) increases calcium release from bone by osteoclasts and decreases calcium excretion (increased kidney reabsorption)  with normal blood calcium, parathyroid glands stop secreting parathyroid hormone and kidneys excrete excess calcium Vitamin D is required for optimal calcium absorption

Calcium • • • • •

Calcium inhibits intestinal absorption of lead, and adequate calcium intake is protective against lead toxicity Calcium decreases iron absorption from nonheme sources (i.e., most supplements and food sources other than meat) High intakes of sodium and protein increase calcium excretion Caffeine in coffee and tea can modestly increase calcium excretion and reduce absorption Alcohol intake can affect calcium status by reducing its absorption and by inhibiting enzymes in the liver that help convert vitamin D to its active form Fruits and vegetables, when metabolized, shift the acid/base balance of the body towards the alkaline by producing bicarbonate, which reduces calcium loss

Calcium • •

Efficiency of absorption decreases as the amount of calcium consumed at a meal increases Net calcium absorption is as high as 60% in infants and young children, who need substantial amounts of the mineral to build bone  Absorption decreases to 15%-20% in adulthood and continues to decrease as people age As dietary protein intake increases, the urinary excretion of calcium also increases

Calcium • • •

High sodium intake results in increased loss of calcium in the urine Phosphorus, which is typically found in protein-rich foods, tends to decrease the excretion of calcium in the urine Phosphorus-rich foods also tend to increase the calcium content of digestive secretions, resulting in increased calcium loss in the feces

Calcium • Hypocalcemia • Numbness and tingling in the fingers, muscle cramps, convulsions, lethargy, poor appetite, and abnormal heart rhythms, death • Primarily from medical problems or treatments (renal failure, surgical removal of the stomach, certain medications such as diuretics, low magnesium levels (which decrease in the responsiveness of osteoclasts to parathyroid hormone), alcohol abuse

Calcium • Hypercalcemia • Impairs kidney function, and lead to reduced absorption of other essential minerals, such as iron, zinc, magnesium, and phosphorus • Most commonly associated with hyperparathyroidism, advanced cases of cancer or excessive intakes of vitamin D from supplements at doses of 50,000 IU/day or higher

Calcium •

• • • •

Calcium can decrease absorption of these drugs when taken together: biphosphonates (osteoporosis), fluoroquinolone and tetracycline antibiotics, levothyroxine, phenytoin (anticonvulsant), and tiludronate disodium (Paget's disease) Thiazide-type diuretics can interact with calcium carbonate and vitamin D supplements—higher risk of hypercalcemia and hypercalciuria aluminum- and magnesium-containing antacids increase urinary calcium excretion Mineral oil and stimulant laxatives decrease calcium absorption Glucocorticoid (such as prednisone) can cause calcium depletion and eventually osteoporosis when they are used for months

Calcium Food

Calcium (mg)


Yogurt, plain, low fat, 8 ounces



Sardines, canned in oil, with bones, 3 ounces



Cheddar cheese, 1.5 ounces



Milk, nonfat, 8 ounces



Milk, reduced-fat (2% milk fat), 8 ounces



Milk, lactose-reduced, 8 ounces



Ready-to-eat cereal, calciumfortified, 1 cup



Soy beverage, calcium-fortified, 8 ounces



Phosphorus • Required by every cell in the body for normal function • Structural components -- phospholipids, energy production -ATP and creatine phosphate, nucleic acids, normal acidbase balance, enzyme and hormone activity

• 85% is found in bone (hydroxyapatite) • Dietary phosphorus is readily absorbed in the small intestine, and any excess phosphorus absorbed is excreted by the kidneys

Phosphorus • The phosphorus in all plant seeds (beans, peas, cereals, and nuts) is present in a storage form of phosphate called phytic acid or phytate • Only about 50% of the phosphorus from phytate is available because humans lack enzymes (phytases) to liberate phosphorus from phytate • Yeasts possess phytases  whole grains incorporated into leavened breads have more bioavailable phosphorus than whole grains incorporated into breakfast cereals or flat breads

Phosphorus • Hypophosphatemia • Loss of appetite, anemia, muscle weakness, bone pain, rickets (in children), osteomalacia (in adults), increased susceptibility to infection, numbness and tingling of the extremities, and difficulty walking, death • Usually rare

Phosphorus • Hyperphosphatemia • Usually rare due to excretion by kidneys • Can occur in end-stage renal disease • Most severe effect is the calcification of nonskeletal tissues (most commonly the kidneys)

Phosphorus • Aluminum-containing antacids reduce the absorption of dietary phosphorus by forming aluminum phosphate • Excessively high doses of calcitriol, the active form of vitamin D, or its analogs may result in hyperphosphatemia • Potassium supplements or potassium-sparing diuretics taken together with a phosphate may result in high blood levels of potassium (hyperkalemia)

Phosphorus Food


Yogurt, plain nonfat

8 ounces


Fish, salmon

3 ounces, cooked


Milk, skim

8 ounces


Fish, halibut

3 ounces, cooked



1/2 cup, cooked


Beef Turkey Chicken

3 ounces, cooked 3 ounces, cooked 3 ounces, cooked

Phosphorus (mg)

173 173 155

Magnesium • Fourth most abundant mineral in the body • Approximately 50% of total body magnesium is found in bone, 50% inside cells of body tissues and organs, and 1% is found in blood – tightly regulated • Dietary magnesium is absorbed in the small intestines • Magnesium levels are affected by the GI tract and kidneys – Crohn’s disease and other malabsorption disorders limit absorption of magnesium, health kidneys limit magnesium excretion, poorly controlled diabetes and alcohol abuse increase magnesium excretion

Magnesium • Magnesium is excreted through the kidneys • Risk of magnesium toxicity increases with kidney failure

• Needed for more than 300 biochemical reactions • Maintain normal muscle and nerve function, keeps heart rhythm steady, supports a healthy immune system, and keeps bones strong, regulate blood sugar levels, promotes normal blood pressure, involved in energy metabolism and protein synthesis

Magnesium • Sufficient magnesium stores may be protective against cardiovascular disease and immune dysfunction • High doses of zinc interfere with the absorption of magnesium • Large increases in the intake of dietary fiber have been found to decrease magnesium utilization

Magnesium • Magnesium deficiency • Loss of appetite, nausea, vomiting, fatigue, and weakness, numbness, tingling, muscle contractions and cramps, seizures, personality changes, abnormal heart rhythms, and coronary spasms – usually rare • Can lead to hypocalcemia and are associated with hypokalemia • Inadequate blood magnesium levels are known to result in low blood calcium levels  resistance to parathyroid hormone (PTH) action, and resistance to some of the effects of vitamin D

Magnesium • Magnesium toxicity • Symptoms can be similar to magnesium deficiency • Changes in mental status, nausea, diarrhea, appetite loss, muscle weakness, difficulty breathing, extremely low blood pressure, and irregular heartbeat

• Increased protein intake may increase magnesium absorption • The active form of vitamin D (calcitriol) may slightly increase intestinal absorption of magnesium

Magnesium â&#x20AC;˘ Diuretics (Lasix, Bumex, Edecrin, and hydrochlorothiazide), antibiotics (Gentamicin, Amphotericin), and anti-neoplastic medication (Cisplatin) can increase urinary excretion of magnesium â&#x20AC;˘ Magnesium binds tetracycline antibiotics in the gut leading to decreased tetracycline absorption

Magnesium â&#x20AC;˘


Magnesium interferes with the absorption of digoxin (a heart medication), nitrofurantoin (an antibiotic), certain anti-malarial drugs, bisphosphonates (e.g., alendronate and etidronate) (for osteoporosis) Magnesium also reduces the efficacy of chlorpromazine (a tranquilizer), penicillamine, oral anticoagulants, and the quinolone and tetracycline classes of antibiotics

Magnesium FOOD

Magnesium (mg)


Halibut, cooked, 3 ounces



Almonds, dry roasted, 1 ounce



Cashews, dry roasted, 1 ounce



Soybeans, mature, cooked, ½ cup



Spinach, frozen, cooked, ½ cup



Nuts, mixed, dry roasted, 1 ounce



Cereal, shredded wheat, 2 rectangular biscuits



Oatmeal, instant, fortified, prepared w/ water, 1 cup



Sulfur â&#x20AC;˘ Sixth most abundant macromineral in breast milk and the third most abundant mineral based on percentage of total body weight â&#x20AC;˘ Sulfur-containing amino acids (SAAs) are methionine, cysteine, cystine, homocysteine, homocystine, and taurine

Sodium â&#x20AC;˘ Multiple mechanisms to maintain tight control â&#x20AC;˘ Principal ions in the extracellular fluid, maintenance of membrane potential, absorption of sodium in the small intestine plays an important role in the absorption of chloride, amino acids, glucose, and water, chloride is an important component of gastric juice, maintenance of blood volume and blood pressure

Sodium • Hyponatremia -- headache, nausea, vomiting, muscle cramps, fatigue, disorientation, fainting, cerebral edema (swelling of the brain), seizures, coma, and brain damage • From dilutional hyponatremia (from inappropriate antidiuretic hormone (ADH) secretion) or increased sodium loss • Sodium (and chloride) deficiency does not generally result from inadequate dietary intake, even in those on very lowsalt diets • Diuretics, NSAIDS, opiates, phenothiazines, serotoninreuptake inhibitors, tricyclic antidepressants are associated with hyponatremia

Sodium • Hypernatremia -- nausea, vomiting, diarrhea, and abdominal cramps, dizziness or fainting, low blood pressure, and diminished urine production, edema (swelling), hypertension, rapid heart rate, difficulty breathing, convulsions, coma, and death • From excess water loss, rarely excess intake, impaired urinary sodium excretion • The Food and Nutrition Board of the Institute of Medicine in 2004 established an upper level of sodium intake of 2.3 grams/day (5.8 grams/day of salt) for adults based on the adverse effects of high sodium intakes on blood pressure

Sodium Food


Sodium (mg)

Canned, chicken noodle soup

1 cup


Macaroni and cheese, canned

1 cup


Potato chips, salted

8 ounces (1 bag)


Corned beef hash

1 cup



3 ounces


Pretzels, salted

2 ounces (10 pretzels)


Fish sandwich w/ tartar sauce & cheese

1 sandwich


Tomato juice, canned (salt added)

1 cup (8 fl. ounces)


Low Sodium Sodium (mg)



Olive oil

1 tablespoon


Orange juice (frozen)

1 cup (8 fl. ounces)


Popcorn, air-popped (unsalted)

1 cup


Almonds (unsalted)

1 cup


Pear, raw

1 medium



1 fruit



1 medium


Fruit cocktail, canned

1 cup


Potassium â&#x20AC;˘ Maintains membrane potential of cells (principal positively charged ion (cation) in the fluid inside of cells), cofactor for enzymes (pyruvate kinase -carbohydrate metabolism)

Potassium â&#x20AC;˘ Hypokalemia â&#x20AC;˘ Fatigue, muscle weakness and cramps, and intestinal paralysis, which may lead to bloating, constipation, and abdominal pain, muscular paralysis, cardiac arrhythmias, death â&#x20AC;˘ Most commonly a result of excessive loss of potassium, magnesium depletion, epinephrine, decongestants, bronchodilators, labor suppressing agents, certain diuretics, fludrocortisones, black licorice, carbenoxolone, gossypol, penicillin, nafcillin, carbenicillin, caffeine, phenolphthalein, sodium polystyrene sulfonate

Potassium • Hyperkalemia • Tingling of the hands and feet, muscular weakness, and temporary paralysis • From kidney failure, one-time doses 18 grams or higher of potassium, potassiumsparing diuretics, hypoaldosteronism, cardiac arrhythmia, ACE inhibitors, NSAIDs, trimethoprim-sulfamethoxazole, pentamidine, digitalis, heparin, beta-blockers, alphablockers, angiotensin receptor blockers

Potassium Potassium (mg)



Potato, baked with skin

1 medium


Plums, dried (prunes)

1/2 cup



1/2 cup


Prune juice

6 fluid ounces


Lima beans, cooked

1/2 cup


Acorn squash, cooked

1/2 cup (cubes)



1 medium


Spinach, cooked

1/2 cup


Chloride • Multiple mechanisms to maintain tight control • Principal ion in the extracellular fluid, maintenance of membrane potential • Absorption of sodium in the small intestine plays an important role in the absorption of chloride, amino acids, glucose, and water • Chloride is an important component of gastric juice, and helps maintain blood volume and blood pressure

Iron •

Essential component of hundreds of proteins and enzymes • Oxygen transport --hemoglobin, energy metabolism – cytochromes, antioxidants—catalase and peroxidases, oxygen sensing -- iron-dependent prolyl hydroxylase enzyme, DNA synthesis -- ribonucleotide reductase) • Tyrosine hydroxylase (an iron-dependent enzyme is a limiting factor in the synthesis of the neurotransmitter, dopamine • Sufficient iron is critical to several immune functions  differentiation and proliferation of T lymphocytes and the generation of reactive oxygen species (ROS) by irondependent enzymes, which help kill pathogens

Iron â&#x20AC;˘ Iron deficiency is the most common nutrient deficiency in the U.S. and the world -Microcytic/hypochromic anemia -- fatigue, rapid heart rate, palpitations, and rapid breathing on exertion, cold intolerance, brittle, spoon-shaped nails, sores at the corners of the mouth, taste bud atrophy, and a sore tongue, Plummer-Vinson syndrome (formation of webs of tissue in the throat and esophagus resulting in difficulty in swallowing), pica â&#x20AC;˘ Iron deficiency may increase the risk of lead poisoning in children

Iron •

Heme iron comes mainly from hemoglobin and myoglobin in meat, poultry, and fish (heme iron typically accounts for only 1015% of the iron found in the diet, but may provide up to one third of total absorbed dietary iron) Plants, dairy products, meat, and iron salts added to foods and supplements are all sources of nonheme iron (absorption of nonheme iron is strongly influenced by enhancers and inhibitors present in the same meal) – vitamin C, organic acids (Citric, malic, tartaric, and lactic acids), Meat, fish, and poultry enhance nonheme iron absorption • Phytic acid or phytate, Polyphenols, and Soy protein inhibit nonheme iron absorption

Iron • Vitamin A deficiency may exacerbate iron deficiency anemia • Adequate copper intake is necessary for normal iron metabolism and red blood cell formation • High doses of iron can inhibit the absorption of zinc  When taken with food, supplemental iron does not appear to inhibit zinc absorption • When consumed together in a single meal, calcium has been found to decrease the absorption of heme and nonheme iron

Iron • Acute iron toxicity (20-60 mg/kg of body weight) -nausea, vomiting, abdominal pain, tarry stools, lethargy, weak and rapid pulse, low blood pressure, fever, difficulty breathing, and coma  death or symptoms may subside for 24 hours  organ failure (heart, kidney, liver, blood, central nervous system) • Oral lethal dose of elemental iron -- approximately 200-250 mg/kg of body weight

Iron • Hereditary hemochromatosis – four types of genetic disorders of iron metabolism that result in tissue iron overload  cirrhosis of the liver, diabetes, heart muscle damage (cardiomyopathy), or joint problems • Hereditary anemias -- sideroblastic anemia, pyruvate kinase deficiency, thalassemia major – may also develop iron overload from increased iron absorption and transfusions

Iron • • •

• •

Therapeutic levels of iron may produce GI irritation, nausea, vomiting, diarrhea, or constipation, dark stools Antacids, histamine (H2) receptor antagonists (cimetidine, ranitidine), and proton pump inhibitors (omeprazole, lansoprazole), may decrease iron absorption Iron supplements taken at the same time can reduce the absorption and effectiveness of levodopa, levothyroxine, methyldopa, penicillamine, quinolones, tetracyclines, and bisphosphonates Cholestyramine resin interferes with iron absorption Allopurinol (gout) may increase iron storage in the liver

Iron Iron content (mg)



Raisin bran cereal

1 cup, dry



6 medium


Black-strap molasses

1 tablespoon



1/2 cup, cooked



3 ounces, cooked


Prune juice

6 fluid ounces


Tofu, firm

1/4 block (~1/3 cup)


Kidney beans

1/2 cup, cooked


Iodine • Required for the synthesis of thyroid hormones (essential component of the thyroid hormones, triiodothyronine (T3) and thyroxine (T4)) • Iodine deficiency is an important health problem throughout much of the world  goiter

Iodine • Iodine deficiency -- mental retardation and cretinism, hypothyroidism, goiter, growth and developmental abnormalities • Selenium deficiency can exacerbate the effects of iodine deficiency (selenium-dependent enzymes (iodothyronine deiodinases) are also required for the conversion of thyroxine (T4) to the biologically active thyroid hormone, triiodothyronine (T3)) • Vitamin A or iron deficiencies may exacerbate the effects of iodine deficiency

Iodine â&#x20AC;˘ Goitrogens â&#x20AC;&#x201C; substances in foods that interfere with iodine utilization or thyroid hormone production -casava, some species of millet and cruciferous vegetables (for example, cabbage, broccoli, cauliflower, and Brussels sprouts), soybean isoflavones (genistein and daidzein) have been found to inhibit thyroid hormone synthesis, tobacco smoking may be associated with an increased risk of goiter in iodine-deficient areas

Iodine • Acute iodine poisoning is rare • Burning of the mouth, throat, and stomach; fever; nausea; vomiting; diarrhea; a weak pulse; and coma • Children with cystic fibrosis may also be more sensitive to the adverse effects of excess iodine

Iodine • Amiodarone (for abnormal heart rhythms) contains high levels of iodine and may affect thyroid function • Medications used to treat hyperthyroidism (propylthiouracil (PTU) and methimazole), may increase the risk of hypothyroidism • Use of lithium in combination with high doses of potassium iodide may result in hypothyroidism • High doses of potassium iodide may decrease the anticoagulant effect of warfarin

Iodine Food


Iodine (mcg)


1/4 ounce, dried


3 ounces*

Variable; may be greater than 4,500 mcg (4.5 mg) 99

Salt (iodized)

1 gram


Potato with peel, baked

1 medium


Milk (cow's)



1 cup (8 fluid ounces) 3 ounces

Fish sticks

2 fish sticks


Turkey breast, baked

3 ounces



Fluoride • Prevention of dental caries (tooth decay) (Fluoroapatite hardens tooth enamel and stabilizes bone mineral – Fluoride displaces the hydroxyl ion in hydroxyapatite crystals to form fluoroapatite) • About 95% of the total body fluoride is found in bones and teeth

• May also help in the prevention of osteoporosis however high doses of fluoride may cause gastrointestinal irritation, joint pain in the lower extremities, and the development of calcium deficiency as well as stress fractures

Fluoride • Deficiency -- increased risk of dental caries (tooth decay) for individuals of all ages • Acute toxicity (more than 120 mg of fluoride (224 mg of sodium fluoride) dispensed at one time) -- Nausea, abdominal pain, and vomiting, diarrhea, excessive salivation and tearing, sweating, and generalized weakness, dental fluorosis (small opaque white flecks on tooth enamel  mottling and staining of teeth  marked staining and pitting of teeth)

Fluoride • Fluoride toxicity (chronic > 10-25 mg/day for at least 10 years) – skeletal fluorosis (increased bone mass, joint pain and stiffness, calcification of ligaments, immobility, muscle wasting, neurological problems • Diets low in chloride (salt) has been found to increase fluoride retention by reducing urinary excretion of fluoride

Fluoride • Both calcium and magnesium form insoluble complexes with fluoride  significantly decreasing fluoride absorption when present in the same meal • Calcium supplements and antacids can decrease fluoride absorption • Absorption of fluoride in the form of monofluorophosphate (unlike sodium fluoride) is unaffected by calcium

Fluoride Fluoride (mg)



Canned sardines (with bones)

100 g (3.5 ounces)



100 ml (3.5 fluid ounces)



100 ml (3.5 fluid ounces)


Grape juice

100 ml (3.5 fluid ounces)


Fish (without bones)

100 g (3.5 ounces)


Zinc • Required for the catalytic activity of approximately 100 enzymes • Plays a role in immune function, protein synthesis, wound healing, DNA synthesis, and cell division • Supports normal growth and development during pregnancy, childhood, and adolescence • Required for proper sense of taste and smell

• Daily intake of zinc is required – not stored in body

Zinc â&#x20AC;˘ Zinc deficiency â&#x20AC;˘ Based on individuals with acrodermatitis enteropathica, a genetic disorder resulting from the impaired uptake and transport of zinc â&#x20AC;˘ Growth retardation, loss of appetite, impaired immunity, hair loss, delayed sexual maturation, impotence, hypogonadism (males), weight loss, delayed healing of wounds, taste abnormalities, mental lethargy, characteristic skin rashes, chronic and severe diarrhea, immune system deficiencies, diminished appetite, night blindness, swelling and clouding of the corneas, and behavioral disturbances

Zinc • Zinc deficiency •

Zinc deficiency is associated with decreased release of vitamin A from the liver  may contribute to symptoms of night blindness that are seen with zinc deficiency • Gastrointestinal surgery and digestive disorders (ulcerative colitis, Crohn’s disease, and short bowel syndrome) can decrease zinc absorption and increase endogenous zinc losses primarily from the gastrointestinal tract and, to a lesser extent, from the kidney

Zinc • Zinc deficiency • Malabsorption syndrome, chronic liver disease, chronic renal disease, sickle cell disease, diabetes, malignancy, chronic diarrhea, alcoholism and other chronic illnesses are associated with zinc deficiency • Large amounts of supplemental iron (greater than 25 mg) might decrease zinc absorption • High levels of dietary calcium may impair zinc absorption  Calcium in combination with phytic acid reduces zinc absorption (for example, tortillas made with lime (calcium oxide) • Low zinc intake may decrease folate absorption

Zinc • Phytates—which are present in whole-grain breads, cereals, legumes, and other foods—bind zinc and inhibit its absorption • The enzymatic action of yeast reduces the level of phytic acid in foods. Therefore, leavened whole grain breads have more bioavailable zinc than unleavened whole grain breads

Zinc • Acute zinc toxicity -- nausea, vomiting, loss of appetite, abdominal cramps, diarrhea, and headaches • High zinc intakes can inhibit copper absorption, sometimes producing copper deficiency and associated anemia • Intakes of 150–450 mg of zinc per day have been associated with such chronic effects as low copper status, altered iron function, reduced immune function, and reduced levels of high-density lipoproteins • Zinc-associated anosmia (loss of smell) may be irreversible  intranasal zinc preparations should be avoided

Zinc • Quinolone antibiotics (for example, Cipro®) and tetracycline antibiotics (Achromycin® and Sumycin®) interact with zinc in the gastrointestinal tract  inhibit the absorption of both zinc and the antibiotic • Zinc can reduce the absorption and action of penicillamine (for rheumatoid arthritis) • Thiazide diuretics (for example, chlorthalidone (Hygroton®) and hydrochlorothiazide (Esidrix® and HydroDIURIL®) increase urinary zinc excretion by as much as 60%

Zinc Food

Zinc (mg)

Percent DV*

Oysters, 6 medium



Beef shanks, cooked, 3 ounces



Crab, Alaska king, cooked, 3 ounces



Pork shoulder, cooked, 3 ounces



Breakfast cereal fortified with 25% of the DV for zinc, 他 cup serving



Chicken leg, roasted, 1 leg



Pork tenderloin, cooked, 3 ounces



Lobster, cooked, 3 ounces



Selenium • At least 25 identified selenoproteins • Important antioxidants, thyroid function regulation, and immune system function • Selenium as gluthathione peroxidase appears to support the activity of vitamin E in limiting the oxidation of lipids • Thioredoxin reductase (a selenoprotein) maintains the antioxidant function of vitamin C by catalyzing its regeneration from its oxidized form, dehydroascorbic acid

Selenium • Selenium deficiency and toxicity are rare in the U.S. • Deficiency usually associated with severe GI problems and surgical removal of part of the stomach • Three specific diseases associated with selenium deficiency: • Keshan Disease (enlarged heart and poor heart function) in selenium deficient children and those on TPN • Kashin-Beck Disease  degeneration of articular cartilage between joints (osteoarthritis) • Myxedematous Endemic Cretinisn  mental retardation

Selenium • Selenium deficiency may exacerbate the effects of iodine deficiency (selenoenzymes called iodothyronine deiodinases are also required for the conversion of thyroxine (T4) to the biologically active thyroid hormone triiodothyronine (T3)) • Insufficient selenium intake results in decreased activity of the glutathione peroxidases as well as some other thioredoxin reductase and thyroid deiodinases  muscular weakness, muscle wasting, and cardiomyopathy (inflammation and damage to the heart muscle) • Valproic acid (anticonvulsant) has been found to decrease plasma selenium levels

Selenium • High blood levels of selenium (greater than 100 μg/dL) • Selenosis (gastrointestinal upsets, hair loss, white blotchy nails, garlic breath odor, fatigue, irritability, and mild nerve damage) • Usually due to industrial accidents and manufacturing errors

Selenium Food

Selenium (μg)

Percent DV*

Brazil nuts, dried, unblanched, 1 ounce



Tuna, light, canned in oil, drained, 3 ounces



Beef, cooked, 3½ ounces



Spaghetti w/ meat sauce, frozen entrée, 1 serving



Cod, cooked, 3 ounces



Turkey, light meat, roasted, 3½ ounces







Beef chuck roast, lean only, roasted, 3 ounces Chicken Breast, meat only, roasted, 3½ ounces

Copper • Critical functional component of cuproenzymes • Energy production, collagen and elastin cross-linking, CNS functioning, formation of melanin, myelin sheath maintenance, antioxidants • Necessary for normal iron metabolism and red blood cell formation

Copper • Copper deficiency is rare • Anemia unresponsive to iron therapy (but responsive to copper supplementation), low levels of neutrophils, increased susceptibility to infection, osteoporosis (low-birth weight infants and young children), loss of pigmentation, neurological symptoms, impaired growth

• Copper toxicity is rare • Abdominal pain, nausea, vomiting, and diarrhea, severe liver damage, kidney failure, coma, and death

Copper • Zinc intakes of 50 mg/day or more for extended periods of time may result in copper deficiency • High dietary zinc increases the synthesis of an intestinal cell protein called metallothionein, which binds certain metals (especially copper) and prevents their absorption by trapping them in intestinal cells

• Penicillamine is used to bind copper and enhance its elimination in Wilson's disease, a genetic disorder resulting in copper overload • Antacids may interfere with copper absorption when used in very high amounts

Copper Food


Copper (mcg)

Liver (beef), cooked

1 ounce


Oysters, cooked

1 medium oyster



1 ounce


Crab meat, cooked

3 ounces


Clams, cooked

3 ounces


Sunflower seeds

1 ounce


Lentils, cooked

1 cup



1 ounce


Cobalt • Component of vitamin B12 – responsible for the pink color of vitamin B12 • Aids in hemoglobin synthesis and iron absorption • Best dietary sources • meat, kidney, and liver • all green leafy vegetables contain some cobalt

Chromium • Required in trace amounts • Found primarily in two forms • trivalent (chromium 3+), which is biologically active and found in food • hexavalent (chromium 6+), a toxic form (recognized carcinogen) that results from industrial pollution  reduced to trivalent form due to reducing agents in food and stomach acidity

Chromium • Chromium is known to enhance the action of insulin • Chromium also appears to be directly involved in carbohydrate, fat, and protein metabolism • Chromium is stored in the liver, spleen, soft tissue, and bone • Deficiencies in humans are rare • Glucose intolerance and insulin resistance

• Minimal toxicity with high intake

Chromium • Diets high in simple sugars (comprising more than 35% of calories) can increase chromium excretion in the urine • Infection, acute exercise, pregnancy and lactation, and stressful states (such as physical trauma)  increased chromium loss

Chromium • Vitamin C and Niacin enhance chromium absorption • Iron overload in hereditary hemochromatosis may interfere with chromium transport by competing for transferrin binding  may contribute to the diabetes that occurs with hereditary hemochromatosis

Chromium â&#x20AC;˘ Antacids, Corticosteroids, H2 blockers (such as cimetidine, famotidine, nizatidine, and rantidine), and Proton-pump inhibitors (such as omeprazole, lansoprazole, rabeprazole, pantoprazole, and esomeprazole) can impair chromium absorption or increase excretion

Chromium â&#x20AC;˘ Beta-blockers (such as atenolol or propanolol), Corticosteroids, Insulin, Nicotinic acid, Nonsteroidal anti-inflammatory drugs (NSAIDS), and Prostaglandin inhibitors (such as ibuprofen, indomethacin, naproxen, piroxicam, and aspirin) may have their effects enhanced with chromium or may increase chromium absorption

Chromium Food

Chromium (mcg)

Broccoli, ½ cup


Grape juice, 1 cup


English muffin, whole wheat, 1


Potatoes, mashed, 1 cup


Garlic, dried, 1 teaspoon


Basil, dried, 1 tablespoon


Beef cubes, 3 ounces


Orange juice, 1 cup


Maganese • Constituent of multiple enzymes and an activator of other enzymes • • • •

Antioxidant -- manganese superoxide dismutase Metabolism of carbohydrates, amino acids, and cholesterol Formation of healthy cartilage and bone Wound healing

• Men generally absorb less manganese than women; this may be related to the fact that men usually have higher iron stores than women • Infants and children have higher intestinal absorption of manganese, as well as lower biliary excretion of manganese

Maganese • Deficiency usually not common in humans • Low levels of dietary manganese may contribute to osteoporosis, glucose intolerance, and seizures

• Focus is on toxicity from manganese overexposure • Maganese neurotoxicity can occur with TPN administration, mineral supplementation, high levels in drinking water • Manganese is eliminated from the body mainly in bile  decrease liver function may lead to manganese accumulation neurological problems and Parkinson's disease-like symptoms

Maganese â&#x20AC;˘ Foods high in phytic acid (beans, seeds, nuts, whole grains, and soy products, or foods high in oxalic acid, such as cabbage, spinach, and sweet potatoes) and tannins in teaď&#x192;  may inhibit manganese absorption

Maganese • Intestinal absorption of manganese is increased during iron deficiency, and increased iron stores (ferritin levels) are associated with decreased manganese absorption • Absorption of manganese from a meal decreases as the meal's iron content increases • Iron deficiency has been shown to increase the risk of manganese accumulation in the brain

Maganese •

Magnesium (200 mg/day) has been shown to slightly decrease manganese bioavailability in healthy adults, either by decreasing manganese absorption or by increasing its excretion •

Magnesium-containing antacids and laxatives and tetracycline may decrease the absorption of manganese

Calcium (500 mg/day) slightly decreased manganese bioavailability in healthy adults

Maganese Food


Manganese (mg)


1 ounce (19 halves)


Brown rice, cooked

1/2 cup


Instant oatmeal (prepared with water)

1 packet


Spinach, cooked

1/2 cup


Raisin bran cereal

1 cup

Pineapple, raw

1/2 cup, chunks



1 ounce (23 whole kernels)


Tea (green)

1 cup (8 ounces)