Chapter 326: Vitamin and Trace Mineral Deficiency and Excess

INTRODUCTION

Vitamins are required constituents of the human diet since they are synthesized inadequately or not at all in the human body. Only small amounts of these substances are needed to carry out essential biochemical reactions (e.g., by acting as coenzymes or prosthetic groups). Overt vitamin or trace mineral deficiencies are rare in Western countries because of a plentiful, varied, and inexpensive food supply; food fortification; and use of supplements. However, multiple nutrient deficiencies may appear together in persons who are chronically ill or alcoholic. After gastric bypass surgery, patients are at high risk for multiple nutrient deficiencies. Moreover, subclinical vitamin and trace mineral deficiencies, as diagnosed by laboratory testing, are quite common in the normal population, especially in the geriatric age group. Conversely, because of the widespread use of nutrient supplements, nutrient toxicities are gaining pathophysiologic and clinical importance.

Victims of famine, emergency-affected and displaced populations, and refugees are at increased risk for protein-energy malnutrition and classic micronutrient deficiencies (vitamin A, iron, iodine) as well as for overt deficiencies in thiamine (beriberi), riboflavin, vitamin C (scurvy), and niacin (pellagra).

Body stores of vitamins and minerals vary tremendously. For example, stores of vitamins B₁₂ and A are large, and an adult may not become deficient until ≥1 year after beginning to eat a deficient diet. However, folate and thiamine may become depleted within weeks among those eating a deficient diet. Therapeutic modalities can deplete essential nutrients from the body; for example, hemodialysis or diuretics remove water-soluble vitamins, which must be replaced by supplementation.

Vitamins and trace minerals play several roles in diseases: (1) Deficiencies of vitamins and minerals may be caused by disease states such as malabsorption; (2) either deficiency or excess of vitamins and minerals can cause disease in and of itself (e.g., vitamin A intoxication and liver disease); and (3) vitamins and minerals in high doses may be used as drugs (e.g., niacin for hypercholesterolemia). Since they are covered elsewhere, the hematologic-related vitamins and minerals (Chaps. 93 and 95) either are not considered or are considered only briefly in this chapter, as are the bone-related vitamins and minerals (vitamin D, calcium, phosphorus, magnesium; Chap. 402).

VITAMINS

See also Table 326-1 and Fig. 326-1.