BANAAG, JANN KAIRA D.

Micronutrient Deficiency Stages of Subclinical MND

- MND in restrictive diet plans such as South Beach, - STAGE 1
Atkins, DASH o Depletion of vitamin stores
- Elderly at risk for MND d/t poor intake o Measured via blood/tissue
- Zinc, Iron, Vit C, Riboflavin (poor intake/absorption, - STAGE 2
anorexia, inability to cut up food, presentation) o Non specific biochemical adaptation
- Increased requirements o Decreased metabolite excretion in the urine
o iron (infants 6 to 12 mos) - STAGE 3
o Folate (pregnant) o Reduced hormones/enzymes
o Vit C (smokers) o First physical sign, lack of energy, loss of
o Recovery, immunosupp appetite, malaise
- Subclinical Deficiency issues - STAGE 4
o Late clinical manifestation o Reversible metab pathway impaired
o Imperfect measurements for assessing body o Physio changes, pronounced disturbance
stores (ADEK in fats) - STAGE 5
o MND biomarkers flawed o Irreversible tissue damage
o Subclinical isn’t always a precursor o Clinical

1. CHIEF COMPLAINT
Body Part Signs Deficiencies
Fatigue Tired, weak, exhausted - Anemia (iron/B12/folic acid/vitC)
- Hypothy (lack iodine)
- Protein energy malnut
- Osteomalacia (Ca, Vit D)
Hair - Color change, sparseness - PEM
- Alopecia, Brittle, Dryness - Biotin, Zn, Vit A E
- Corkscrew, coiled hairs - Vit C
Skin - Pallor, cyanosis - Iron, folate, b12, biotin, copper
- Yellowing - Carotene
- Acneiform, follicular keratosis (scales), - Vit A, essential fatty acids
xerosis
- Bruise,petechiae, poor healing - Vit K, Vit C, Zn
- Thickening, hyperpigmentation - Niacin
- Acne - Vit C
Eyes - Pale - Iron, folate, b12
- Bitot’s spots (foamy spot), conjunctival - Vit A
xerosis
- Angular palpebritis - Vit B2, B6, B1, B3, phosphorus
- Itching, burning, corneal inflame - B2, b3
BANAAG, JANN KAIRA D.
2. ROS
3. Nutrition evaluation

4. Anthropometrics, nutrition focused Hx PE

Thiamine B1 Loss of appetite, constipation, nausea Pyridoxine B6 Tongue inflame, side fissures
Seeds, nuts, Depression Yeast, liver, Irritability,nervousness, depression
wheatgerms, Peripheral neuropathy, unsteadiness, wheatgerm, Sideroblastic anemia (nucleated RBC
legumes , lean mental confusion, ataxia, loss of eye beans and w iron granules)
meat coord bananas
Fortified grains, Seen in alcoholics (Wernicke- Chicken, fish, INDICATORS:
cereals, and Korsakoff psychosis) kidney, liver, pork, ERYTHROCYTE ASPARTATE
bakery products; Wet Beri Beri (+cardiac failure and eggs, rice, soy AMINOTRANSFERASE
organ meats edema) beans, oats, - plasma/erythrocyte PLP
(liver, whole wheat, levels
kidney, and heart) INDICATORS: peanuts, and - urinary excretion of
walnuts xanthrenic acid after oral
ERYTHROCYTE TRANSKETOLASE tryptophan load
ACTIVITY COEFFICIENT (ETKAC) - activity index of RBC
- Most effectice measure of B1 ALT/AST
(enzyme activity before and Biotin B7 Scaly dermatitis, alopecia
after addition of TPP) Corn, soy, egg Lethargy, hypotonia, muscle pain
- Not easily available in hosps yolk, liver, kidney, Depression, hallucination
BLOOD CONC OF THIAMINE tomatoes
- < 20ng/dl INDICATORS:
MRI PLASMA AND URINE BIOTIN
- Symmetric lesions of midbrain - low
(periaqueductal area), pons, METHYL CITRATE, 3
hypo/thalamus, cerebellum Methylcrotonylglycine, and 3
Riboflavin B2 Angular stomatitis, glossitis, scaly hydroxyisovalerate
Enriched and dermatitis - elevated urine concentration
fortified grains, Photophobia with b7 deficiency
cereals, and Folate B9 Weakness, fatigue, depression
bakery products; INDICATORS: Yeast, liver, green Pallor
Meats; poultry; ERYTHROCYTE GLUTATHIONE leafy vegetables INDICATORS:
fish; and dairy REDUCTASE ACTIVITY Legumes, some CBC and MCV
products - Most common (in RBC) fruits - low hgb and hematocrit with
- Not for g6pd patients  Common MCV >100fL
Niacin B3 Superficial glossitis, sore tongue  Supplement SERUM and RBC FOLATE
Meat and Cracks and scales on exposed skin with B12 while - serum: short term folate
tryptophan- Pellagra (dermatitis, dementia, giving folate to balance
containing foods diarrhea, death) avoid masking - RBC folate is better
such as milk and - r/o B6 deficiency of neurologic HOMOCYSTEINE
eggs- Tremors symptoms - Rises early in deficiency but
dietary tryptophan INDICATORS: nonspefic (also present in b12
like seeds, nuts, ---- not reliable ----- and b6, renal insufficiency
cheese, meat) and old age)
Pantothenic B5 --- Cobalamin B12 Lemon yellow tint to skin and eyes
Yeast, grains, egg INDICATORS: Liver, kidney, egg, Smooth red thick tongue
yolk, liver, meat, BLOOD & URINE PANTOTHENATE cheese, milk Anemia, constipation, weightloss,
and legumes - not accurate diarrhea
BANAAG, JANN KAIRA D.
Neurological symptoms - Modified RDR requires 1
Mood disturbance, dementia sample only but complex if
fieldwork; ongoing
INDICATORS: surveillance not as possible
CBC, MCV Vitamin D Osteomalacia, rickets
- Low hgb and hematocrit with - Also check - r/o calcium def, renal or liver
MCV > 100mg/fl Ca and disease
SERUM B12 Phosphorus INDICATORS:
- STANDARD Eggs, butter, and 25-hydroxyvitamin D
- Easily accessible, cheap, ? fortified milk and - major circulating metabolite
sensitivity/specificity margarine) - best indicator for systemic
METHYLMALONIC ACID Synthesized in status except with stage 4/5
- Increases in b12 deficiency skin during Kidney disease
- High sensitivity but not exposure to solar o 1,25dihydroxyvitamin
accessible, expensive or artificial D if impaired renal 1-
TOTAL HOMOCYSTEINE ultraviolet light hydroxylation
- Increases in b12 def, Vitamin E Spinocerebellar degeneration,
total>12.5 Vegetable oils neuropathy, ophthalmoplegia
- High sensitivity (olive, soy, and INDICATORS:
- Low specificity because corn CBC
difficult handling oils,margarine), - Hemolytic anemia
Vitamin C Poor wound healing wheat germ, nuts, VIT E LEVELS
Fruits (especially Edema, swollen/bleeding gums/tooth green leafy - Plasma or serum conc of
citrus fruits) and loss, mottled teeth vegetables, alpha-tocopherol
vegetables with Lethargy, fatigue sunflower (<2.5MG/L)
smaller Skin lesions, purple discolorations on and cotton seeds A-B-Lipoprotein
amounts in meat, skin, petechiae - High ABL, antigliadin ab
fish, poultry, eggs, Darkskin around follicles Vitamin K Bleeding
and dairy Corkscrew hair Green leafy - r/o inherited coagulopathy,
products vegetables with anticoag therapy, antibiotic
INDICATORS: smaller amounts INDICATORS:
SERUM CONCENTRATION in milk, dairy BLEEDING TIME
- Easier bc low sample needed products, meats, - Prothrombin time (PTT) as
- Plasma: reflects recent diet eggs, cereal, measure of functional K
- WBC: tissue stores fruits, and other status
URINE EXCRETION vegetables
- Only recent intake
Vitamin A Night blindedness Calcium Spontaneous fractures
Carrots and dark- - r/o infection, syphilis, Bone pain
green leafy gonorrhea Weakness, proximal myopathy,
vegetables Xerophthalmia: xerosis, bitot spots, waddling
hyperkeratosis INDICATORS:
- not practical to quantify SERUM CALCIUM
- Protein bound
INDICATORS: (Physiologically inactive)
Conjunctival Impression Cytology - Ionized (active, intracellular
- filter paper on conjunctiva regulator)
epith cells (+/-) - Complexed (with ions)
- minimally invasive, but no URINARY
specific scale of deficiency - More responsive, but affected
- not reliable bec tedious and by lots
needs standardization - High calcium output with high
Serum Retinol protein and low phosphate
- low retinol = vit A def diet
- BUT low retinol =/= liver Magnesium Tremors, muscle spasm, tetany
stores of Vit A Personality changes
- Also affected by PEM and Iron Pallor, anemia
infection Meat, eggs, - r/o blood loss, intestinal
- Impractical (storage, venous vegetables, malabsorption, vit c def, high
sample, transpo, lab analysis) fortified cereals demands
spasms, shortness of breath
Relative Dose Response Thin concave nails with raised ridges
- More accurate measure of (koilonychias)
retinol response INDICATORS:
- Reflects liver stores HEMOGLOBIN & HEMATOCRIT &
- But needs 2 blood samples MCV
- low hgb and hct, MCV <80
BANAAG, JANN KAIRA D.
- not specific bc affected also Iodine Goiter
by infection, PEM, genetics Seafood, iodized - hypothyroidism
SERUM FERRITIN table salt, and - r/o Hashimoto’s, after surgery
- ferritin levels = iron stores certain baked hyperthy
- detect early stage breads and dairy INDICATORS:
- can use dried blood spot products CRETINISM
microsample - mental impairment, reduced
- low spec bc infection effect work capacity
TRANSFERRIN RECEPTORS GOITER
- elevated with iron def URINARY IODINE
Zinc Delayed wound healing - direct measure
Meat, liver, eggs, Hair loss, skin and eye lesions THYROID STIMULATING HORMONE
and seafood Nasolabial seborrhea IODIZED SALT CONSUMPTION
(especially Decubitus ulcers - practical index
oysters) INDICATORS: Chromium Corneal lesion (yeast, calf’s liver,
- misleading samples (hair, American cheese, and wheat germ)
plasma, rbc) Selenium cardiomyopathy
Copper Hair and skin pigments, pallor
Liver, seafood Seafood, kidney,
(especially liver, and some
shellfish), nuts, meats
legumes, and
seeds

** 1 month of treatment should show adequate response and confirm diagnosis (esp iron & vit B def)
** Vitamin supplementation is needed for infants, children up to adolescence(iron),
women in the age of fertility (iron, folic acid), middle-aged women (vitamin D), the elderly
(vitamin D), patients in chronic care facilities (vitamin D), and patients with chronic diseases
(e.g., HIV/AIDS) among others.
** iodine & iron most common
** trial of supplements for 4-6 weeks

PLAN:
- food fortification > supplementation
BANAAG, JANN KAIRA D.