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Micronutrients

Prof.Tefera Belachew [MD, MSc, DLSHTM, PhD]

Jimma University, May 2013

What are micronutrients?


Micronutrients are nutrients that do not have

to be broken down to smaller units for use


by the body
Are Vitamins and minerals which our body only

needs in small amounts.


Vitamins are organic and can be affected by

extremes of physical and chemical environment


Minerals inorganic and make the ash after

combustion of food.

Vitamins

The name comes from Vita, meaning life, and amin,

because it was believed that all types of vitamins


contained the chemical structure of an amine.
The discovery of vitamin came late, i.e. at the turn of 20th

century.

This was because of the fact the vitamins appeared in foods

and the human body in tiny amounts and it took sophisticated


knowledge of chemistry and biology to isolate,
distinguish and learn them.

Vitamins: - Are needed in small amounts in the diet of

higher animals for growth, maintenance of health and


reproduction.

Presently, there are 13 known vitamins


They are indispensable, non-caloric organic nutrients

needed in tiny amounts in the diet.

Some vitamins like vitamin A and D are highly stored

in the liver and get released to their functional sites


when needed, and hence are called hormones

Liver is thus considered as endocrine organ

Without vitamins thousands of chemical reactions do not

occur. Most vitamins cannot be synthesized in the body.


Vitamins K (Menaquinone) and B12 are synthesized

by intestinal microorganisms though not in adequate


amounts.

Other vitamins like pyridoxine (B6), vitamin D are


synthesized in the body from their precursors.

Some of the vitamins occur in the food in a form known

as precursors of provitamins.

Group characteristics of
vitamins

Characteristics

Water soluble

Lipid soluble

Names

Vitamin C and Bcomplexes


(B1,B2,B3,B5,B6,B9,B12)

Vitamins A, D, E and K

Solubility

In Water

In organic compounds like chloroform,


benzene and ether

Storage

Not stored very much

Stored in different organs

Absorption

Directly

With lipids through the lymphatic


system

Transport in the blood

Freely

Need to be bound to carrier protein

Deficiency

Apt to develop following


acute shortages

Deficiency does not develop following


acute shortage of the vitamins

Fat mal-absorption
syndrome
(Steatorhea)

Does not result in their


deficiency

Results in their deficiency

Toxicity upon intake of


mega dose in the
form of treatment

Unlikely to occur

Likely to occur

Water Soluble Vitamins

Thiamine (Vitamin B1)

Functions
Forms thiamine pyrophosphate (TPP), a combination of two

molecules of phosphoric acid and B1, is the coenzyme form of


this vitamin.

TPP is critical in several metabolic functions, including the

removal of carbon dioxide reactions, which in turn are


important in the conversion of amino acids,
carbohydrates and fats to energy.

It is also necessary for the conversion of carbohydrates to

fat.

TPP is needed for the synthesis of acetylcholine, a lack of

which causes inflammation of the nerves and memory loss.


Deficiency
causes Beriberi, which literally means I cant I

cant, indicating the impairment of the Nervous


System and the Cardiovascular System.

Such a deficiency in alcoholics results in brain

problems known as Wernicke-Korsakoff


syndrome.

This can result in permanent memory impairment,

motor problems, and psychosis.

Vigorous exercise, excessive carbohydrates,

alcohol, and diets high in fat may also lead to


thiamine deficiency symptoms

Types of Beribri
Wet beriberi- acute form, leads to heart failure

Dry beriberi- Chronic form, affect the nervous system


(paralysis)

Infantile beriberi- Could manifest as both dry and wet beriberi

Outbreak of beriberi in African Union troops in

Somali

Prevention
Any one of the following meets thiamine requirements
of a country: Avoid over milling (over processing) of the

staple cereal
Fortify staple cereal with Vitamin B1
Avail adequate amounts of alternative foods rich in

thiamine


RDA: The requirement is therefore
0.5mg/1000Kcal. The therapeutic dose is
0-6 months 0.3mg
between 3-8 g daily.
6-12 months 0.4mg
1-3 years 0.7mg
4-6 years 0.9mg
Females
11-50 years 1.1mg
51+ years 1.0mg
Pregnant 1.5mg
Lactating 1.6mg
7-10 years 1.0mg

Males
11-14 years 1.3mg
15-50 years 1.5mg
51+ years 1.2mg


Food Sources
The best dietary sources of thiamine are whole-grain cereals
and meat however; it is found in all of the following foods.
Plant Source: Whole-grain products, Rice bran, Brewer's yeast , Chickpeas,
Beans, Soybeans, Sunflower seeds, Wheat germ, Flour, rye and whole-wheat

Animal Source
Salmon steak
Pork
Beef kidney
Beef liver

Riboflavin (Vitamin B2)

Function
Acts as component in two co-enzymes (FAD and FAMN) needed for

normal tissue respiration.


Maintains healthy mucous membranes lining respiratory, digestive,

circulatory and excretory tracts when used in conjunction with Vitamin A


Preserves integrity of nervous system, skin, eyes.
Necessary for the regeneration of glutathione
Activates pyridoxine

Deficiency
Cracks and sores in corners of mouth (angular Stomatistis/ Cheilitis)
Inflammation of tongue and lips
Eyes too sensitive to light and easily tired
Itching, burning and reddening ( Drunkards eye)
Itching and scaling of skin around nose,
mouth, scrotum, forehead, ears, scalp
Trembling
Dizziness
Insomnia
Slow learning

Food sources

seafood, lean meats and poultry, eggs,


legumes (beans and peas), nuts, seeds,
and soy products. Pork, fish, and
seafood are good or high sources of
thiamin. Beef, beans, and seeds contain
thiamin
*It is found in the bran of seeds

RDA
Intake of 0.6 mg/1000
Kilocalorie is sufficient.

0-6 months 0.4mg


6-12 months 0.5mg
1-3 years 0.8mg
4-6 years 1.1mg
7-10 years 1.2mg

Males
11-14 years 1.5mg
15-18 years 1.8mg
19-50 years 1.7mg
51+ years 1.4mg

Females
11-50 years 1.3mg
51+ years 1.2mg
Pregnant 1.6mg
Lactating 1st 6 months 1.8mg
2nd 6 months 1.7 mg

Niacin (Vitamin B3)


Niacin (Vitamin B3) is the common name for two compounds: nicotinic

acid, which is easily converted to the biologically active form, and


nicotinamide (or niacin amide)
Functions
participates in more than 50 metabolic functions, all of which are

important in the release of energy from carbohydrates


component of two co-enzymes (NAD and NADP),
Niacin also assists in antioxidant and detoxification functions
Maintains normal function of skin, nerves, and digestive system


Deficiency (a disease of 4 Ds: Diarrhea, Dematitis, Dementia & Death)
Early Symptoms:
Muscle weakness
General fatigue
Loss of appetite
Skin lesions, including rashes, dry scaly skin, wrinkles,
coarse skin texture
Nausea and vomiting
Dermatitis (affecting the sun exposed areas)
Casals Necklace
Diarrhea
Late consequences of severe deficiency called pellagra:
Dementia
Death


A pellagra epidemic in Kuito,
Angola

Age - RDA
0-6 months 5mg
6-12 months 6mg
1-3 years 9mg
4-6 years 12mg
7-10 years 13mg
Males
11-14 years 17mg
15-18 years 20mg
19-50 years 19mg
51+ years 15mg

Females
11-50 years 15mg
51+ years 13mg
Pregnant 17mg
Lactating 20mg

6.6mg/1000kcal is enough for adults.


Food Sources
Plant
Brewer's yeast
Peanuts
Sunflower seeds

Animal
Salmon
Pork
Chicken, white meat
Beef liver
Tuna
Turkey
Veal


Pyridoxine (Vitamin B6)
Vitamin B-6 is a family of water-soluble compounds that includes pyridoxine,
pyridoxal, and pyridoxamine.

Functions
It is particularly indispensable to the action of amino acid neurotransmitters, like

serotonin, dopamine, melatonin, and norepinephrine, Gama amino butyric


acid (GABA) which effect brain function.
Participates actively in many chemical reactions of proteins and amino acids

deamination and transamination reaction


Promotes conversion of tryptophan to serotonin
Helps the body to convert tryptophan, an amino acid, into niacin

Pyrodoxine deficiency
Peripheral neuropathy (pins and needles in the palms and feels)
Weakness, Mental confusion , Irritability, Nervousness, Insomnia
Poor coordination walking, Hyperactivity, Abnormal

electroencephalogram
Muscle twitching
Patients with carpal tunnel syndrome are often deficient in Vitamin B-

Pyridoxine dependency: In some people there may be a pyridoxine


dependency syndrome where these subjects need to take the vitamin all the time to
prevent the occurrence of convulsion.


Drug interaction
Isoniazid (INH) increases excresion of B-6
Tobacco decreases absorption. Smokers may require

supplemental Vitamin B-6.


Hormonal contraceptive users require more.
Hydrazine dyes inhibit Vitamin B-6 action.
Alcohol inhibits B-6.
Excess protein inhibits B-6.

Food sources
Tuna, beaf, chicken,

cauliflower, garlic, pepper,


Salmon, Cabbage


Folic Acid (Vitamin B9)
Folic Acid (Vitamin B9)
Vitamin B-9, more commonly known as folic acid, functions
together with a group of related water-soluble compounds,
collectively called folacin, in many body processes
FUNCTIONS
It is critical to cellular division because it is necessary in DNA synthesis.
Maintains the cells genetic code and transfer inherited traits from one cell to

another
Promotes normal red blood cell formation.
Regulates embryonic and foetal development of nerve cells.


Deficiency
Megalobastic anemia
Folic acid deficiency during pregnancy has been linked to several birth
defects (Neural tube defect)
Due to the overwhelming evidence of folacins impact on preventing neural
tube defects, WHO recommends supplementation of high risk women with
folate 1 month before and the first 3 months after the onset of pregnancy
Low Risk woman400 (0.4 mg) g
High-risk women should consume 4000 (4 mg) g of folic acid per day

At greatest risk for a folate deficiency are the elderly, women taking birth
control pills, long-term antibiotic patients, and alcoholics.

Folic acid is a common vitamin deficiency.


Vitamin B-12 should always be included in a folacin

supplement program because the folacin supplementation


can mask an underlying Vitamin B-12 deficiency.
Also, Vitamin B-12 reactivates folic acid in the body and a

Vitamin B-12 deficiency can cause a folic acid deficiency due


to the folate trap that will be created when vitamin B-12 is
deficient

Methylated Product

The Methylation Cycle

DNA Cycle
(Cell Replication)

The
folate
Trap

Age RDA
0-6 months 25mcg
6-12 months 35mcg
1-3 years 50mcg
4-6 years 75mcg
7-10 years 100mcg
Males
11-14 years 150mcg
15+ years 200mcg

Females
11-14 years 150mcg
15+ years 180mcg
Pregnant 400mcg
Lactating 1st 6 months 280mcg
2nd 6 months 260mcg

Food Sources
Barley
Beans
Brewer's yeast
Calves' liver
Fruits
Garbanzo beans (chickpeas)
Green, leafy vegetables
Lentils

Peas
Rice
Soybeans
Split peas
Sprouts
Wheat
Wheat germ
Orange juice
Oranges


Cyanocobalamin (Vitamin B12)
Parietal cells secrete a special digestive hormone

that increases the absorption of vitamin B-12 in the


terminal ileum called intrinsic factor.
For this reason vitamin B-12 is called extrinsic

factor.
Unlike other water-soluble vitamins, this vitamin is

stored in the body tissues, so a deficiency can take


years to appear.


FUNCTION
Acts as co-enzyme for normal DNA synthesis.
Prevents folate deficiency
Prevents Vitamin B-12 deficiency in vegan vegetarians and persons with

absorption diseases.
Plays an important role in homocysteine and energy metabolism, and

immune function.
Promotes red blood-cell development, and DNA synthesis of covering to

nerve cells, maintenance of normal function of nervous system.


Deficiency
Deficiency is not common
Pernicious anemia (megaloblastic anaemia)
Impaired brain and nervous system function; demylination of

nerve fibers in Central Nervous System (Brain and Spinal cord)


Numbness and tingling in hands and feet, difficulty

maintaining balance, pale lips, pale tongue, pale gums, yellow


eyes and skin, shortness of breath, depression, confusion and
dementia, headache, poor memory.


Risk factors for B12 deficiency
A Vitamin B-12 deficiency can result from:
An inadequate diet as in the case of vegans (absolute vegetarians)
Disease like infection with fish tapeworm called Diphyllobothyrium latum
Lack of intrinsic factor in the small intestine as in the case of surgical

removal of the parietal cells of the stomach


Surgical removal of the terminal ileum

Age RDA

Food Sources

Vitamin B-12 is found from foods of


animal origin which include:
0-6 months 0.3mcg
Milk, milk products
6-12 months 0.5mcg
Sardines
1-3 years 0.7mcg
Liver
4-6 years 1.0mcg
Beef
7-10 years 1.4mcg
Beef liver
11+ years 2.0mcg
Eggs
Pregnant +2.2mcg
Kidney
Lactating +2.6mcg
Milk, milk products
Sardines
Liver
NOTE: Vitamin B-12 is not found in plants.

VITAMIN C (ASCORBIC ACID)

In 1753, Brish Naval Physician, James Lind recognized scurvys direct link to diet

when he noted lemons, limes and fresh green produce contained a mysterious
scurvy-preventing substance.
Unbeknownst to Lind, humans are one of a very few species that cannot

manufacture vitamin C and must depend on food for this vital nutrient.

Functions
Helps to form collagen in connective tissue (Converts proline and lysine in
to their hydroxilated forms in the collagen synthesis pathway) and tissue repair.
Increases iron absorption from intestines (converts non hem iron in to

hem iron).
It is antioxidant


Deficiency
Scurvy: muscle weakness, swollen gums, loss of teeth, tiredness,

depression, bleeding under skin, Spongy bleeding gums


Easy bruising, bleeding tendency
Nose bleeding (epistaxis)
Swollen or painful joints
Anaemia: weakness, tiredness, paleness
Slow healing of wound and reopening of surgical wounds


Age RDA
11-14 years 50mg
15+ years 60mg
Pregnant 70mg
Lactating 1st 6 months 95mg
2nd 6 months 90mg
0-6 months 30mg
6-12 months 35mg
1-3 years 40 mg
4-6 years 45mg
7-10 years 45mg
1-10 years 45mg

11-14 years 50mg


15+ years 60mg
Pregnant 70mg
Lactating 1st 6 months
95mg
2nd 6 months 90mg

Food Sources:
Oranges
Papayas
Potatoes
Spinach
Strawberries
Sweet and hot peppers
Cabbage
Grapefruit
Collards

Common Sources Vitamin C are Citrus Fruits and


Green Leafy vegetables
Watercress
Mangos
Lemons
Tangerines
Tomatoes
Broccoli
Guava
Green peppers
Kale

Lipid Soluble Vitamins

Vitamin A and Vitamin D lipid soluble

vitamins that have public health


importance

Vitamin A (retinol)
Beta-carotene is a pro-vitamin A, fat-soluble
compound found in plants,
Beta-carotene has the greatest pro-vitamin A activity
The body converts beta-carotene to Vitamin A.

Retinol is the precursor to active forms of Vitamin A, found

from animals.
One RE = 1 mcg retinol = 6 mcg beta-carotene.


Function
Combines with purple
pigment of retina (opsin) form rhodopsin, which is
necessary for sight in partial darkness.
Necessary for growth of bone, testicular function,
ovarian function, embryonic development, regulation
of growth, differentiation of tissues
Forms Visual pigment :

Helps form and maintain healthy skin, hair, and

mucous membranes

Functions
These forms include retinal, which is used in

vision and retinoic acid, needed in growth,


reproduction and genetic differentiation.
Synthetic forms of retinoic acid, such as

Accutane, are used for severe acne.


Alpha-carotene and lycopene are powerful anti
oxidants , which have well-noted anti-cancer effects
Immunity- Cell mediated, VS barrier

hypothesis (epithelial barriers)====Child survival

Deficiency

Xeropthamlmia (dryness of the eyes)- due to

Lack of mucus secretion (due to destruction of goblet


cell)
N
Night blindness (Nyctalopia)
Changes in eyes with eventual blindness
if deficiency is severe and untreated
Susceptibility to infection and mortality
Night blindness
Dry, rough skin
Bitots spots
Changes in mucous membranes
Poor bone growth & Weak tooth enamel
Diarrhea
Slow growth
Infertility
Bitots Spots

WHO Classification of
Xerophthalmia
1N Night
blindness
2B Bitots spots
X3 Corneal
xerosis
X4 Corneal
ulcerations
-Keratomalaci
a
X5 Corneal
scars permanent

2B

X4

X3

X5

Bitots Spot

Keratomalacia

Xerphthalmia is the tip of the iceberg

Age RDA
Age Retinol Equivalents International Units
0-6 months 375RE =2,100IU
6-12 months 375RE = 2,100IU
1-3 years 400RE = 2,000IU
4-6 years 500RE = 2,500IU
7-10 years 700RE = 3,300IU
Males
11+ years 1,000RE = 5,000IU
Females
11+ years 800RE = 4,000IU
Pregnant 800RE = 4,000IU
Lactating 1st 6 months +500RE = +2,500IU
2nd 6 months +500RE = + 2,500IU


Over dosage toxicity
Toxicity occurs if a person takes more than the mega

dose==10XRDA
Signs and symptoms
Bulging soft spot on head in babies (infants), sometimes

hydrocephaly ("water on brain"),


confusion or unusual excitement, diarrhea, dizziness,
double vision, headache, irritability, dry skin, hair loss,

peeling skin on lips, palms and in other areas, seizures,


vomiting


Food Sources
Plant sources: Vitamin A is generally found in deep
green leafy vegetables(GLV), yellow orange fruits in the form of Bcarotene[ Papaya, Mango, Asparagus , broccoli , Cantaloupe, Carrots, Kale,
fresh Apricots, Red palm oil, Mustard greens, Pumpkin, Spinach, Squash,
Orange fleshy Sweet potatoes, Watermelon)

Animal sources: found in the form of retinole


Liver
Fish liver oil
Milk and milk products
Egg


Prevention of and control of Vitamin A deficiency

1. High Dose vitamin A Supplementation


Targets : Children 6-59 months and Lactating women:

a) Universal Supplementation Schedule


Children 6-11 moths = 100,000 IU every 6 months
Children 12-59 months= 200,000 IU every 6 months
Lactating women within 6 week after delivery = 200,000IU A
single dose

b) Diseases Targeted Supplementation


Schedule

Preventive dose: a single dose of vitamin A at the contact


of a child with acute respiratory infection (ARI), Diarrheal
disease(DD) and Severe acute malnutrition (SAM)

Therapeutic dose: For Measles and Xerophthalmia - Give


therapeutic doses of vitamin A (i.e. 3 doses) on day 1, day 2
and day 14, with the strength of the dose as stated above
Note: this dose should not be given to children who have already received a high
dose vitamin A supplement within the preceding month

2.

Breast feeding = Colustrum has high concentration of

vitamin A, it is called the first immunization of the baby

3. Dietary Modification: Fortification of oil, floor , sugar


4. Dietary Diversification Behavior change
communication on the consumption of vitamin A friendly foods
eg. Growing and consuming Orange fleshy sweet

potatoes


Vitamin D (1,25, Dihydroxychole
Calciferol)
The two most important are D-2 and D-3.
Vitamin D-2 (Ergocalciferol or its three forms) exists in fungi

and yeast and is the form generally added to milk, food, and
vitamin supplements.
Vitamin D-3 (Cholecalciferol) is found in fish oils, egg yolks, and milk.
The body produces Vitamin D-3 in the presence of ultraviolet

sunlight.
Many factors, including smoke, fog, clothes, and glass, can block

ultraviolet light and interfere with the production of this vitamin


Skin is (7-dehyderocholestrol) + UV light=== >cholecalciferol, which is

carried to liver for hydroxylation on the 25th carbon leading to the


formation of 25-hydroxy cholecalciferol.

This will be carried to the kediney where it is hydroxylated on the first

carbon resulting in the formation of 1,25,dihydroxycholecalciferol


(active form of vitamin D

Health problem of liver and kidney affects bodys content of the

vitamin


Functions
Regulates growth, hardening and repair of bone by controlling

absorption of calcium and phosphorus from small intestine.


Promotes normal growth and development of infants and children,

particularly bones and teeth.


Calcifidiol, calcitrol, and dihydrotachysterol are forms of Vitamin D

primarily used as additional medicines to treat hypocalcemia (not enough


calcium in blood).


Deficiency
Short term problems
Rickets (a childhood deficiency disease): malformations of joints or bones,

late tooth development, weak muscles, listlessness, double maleolus, Rachitic


Rossary, Bowed legs and knocked knees, delayed Fontanel closure,
craniotabes
Osteomalacia (adult rickets): pain in ribs, lower spine, pelvis and legs,
muscle weakness and spasm, brittle, easily broken bones.
Muscle diseases (myopathies)

Long-term Problems

Cephalopelvic disproportion(CPD) and birth difficulty


Shortness
Pelvic deformity
Bowed leg- cosmetic /health problem

Chest deformity

Scoliosis

Rib beading (rachitic Rosary)

Genu valgum

Genu varum

Rachitic Deformities

Bowing of long bones in legs


Age RDA
0-6 months 7.5mcg
6-12 months 10mcg
1-10 years 10mcg
Males
11-18 years 10mcg
19-24 years 10mcg
25+ years 5mcg
Females
11-18 years 10mcg
19-24 years 10mcg
25+ years 5mcg
Pregnant 10mcg
Lactating 10mcg

Sources
Food
Butter
Cod-liver oil
Egg yolks
Salmon
Sardines
Vitamin D-fortified milk
UV light plus subcutaneous fat


Vitamin E (also called alpha-

tocopherol)
The term Vitamin E applies to a family of eight related

compounds, the tocopherols and the tocotrienols.

The four major forms of Vitamin E are designated alpha (),

beta (), delta (), and gamma (), on the basis of the
chemical structure.
Alpha-tocopherol, commonly known as Vitamin E, is the

form found most in nature and the most biologically active.


Function
As an antioxidant, it stabilizes membranes and

protects them against free radical damage


-Vitamin E is an antioxidant that also profits from its interaction with other
antioxidants, like Vitamin C and selenium.

Involved in reproduction


Deficiency
Premature infants and children:
Hemolytic anemia

Adults
Apathy
Disinterest in physical activity
Decreased sexual performance/ Causes infertility


Age RDA
0-12 months 3-4mg
1-10 years 6-7mg
Males
11+ years 10mg
Females
11+ years 8mg
Pregnant 10mg
Lactating 1st 6 mos 12mg
2nd 6 mos 11mg
Note: Labels may be listed as mg or IU. 1 mg synthetic
= 1 IU. 1 mg natural = 1.3 IU.


Food Sources
All vegetable oils (Apricot oil, corn oil, cottonseed oil, peanut oil)
Wheat germ
Whole-wheat flour
Margarine
Almonds
Safflower nuts
Sunflower seeds
Walnuts

Vitamin K

Vitamin K is somewhat unique because it has both fat- or water-soluble

forms.
One form, K1 or phylloquinone, is found in many plants and animals,

and K2, or menaquinone, is manufactured by microorganisms, such as


bacteria, in the intestinal tract of many animals.
K3 (menadione) is a synthetic version with the basic structure of the

naturally occurring vitamins and is twice as active biologically. This version


is soluble in boiling water
Fifty percent of the requirement of the vitamin by most individuals is met

by intestinal bacterial synthesis

Functions
Promotes production of active prothrombin (factor II),

proconvertin (factor VII), factor IX and factor X. These are all


necessary for normal blood clotting.
Prevents hemorrhagic disease of the newborn


Deficiency
Infants:
Hemorrhagic disease of the newborn characterized by vomiting blood
and bleeding from intestine, umbilical cord, circumcision site. Symptoms
begin 2 or 3 days after birth.
Adults:
Abnormal blood clotting that can lead to nosebleeds, blood in urine,
stomach bleeding, bleeding from capillaries or skin causing spontaneous
black-and-blue marks.
Prolonged clotting time


Recommended Daily Allowance (RDA):
Adequate and safe range is 2-mcg/kg
body weights per day.
Age Estimated Safe Intake
0-6 months 5mcg
6-12 months 10mcg
1-3 years 15mcg
4-6 years 20mcg
7-10 years 30mcg
Females
11-14 years 45mcg
15-18 years 55mcg
19-24 years 60mcg
25+ years 65mcg
Pregnant 65mcg
Lactating 65mcg

Males
11-14 years
45mcg
15-18 years
65mcg
19-24 years
70mcg
25+ years 80mcg