minerals dr reed berger nutrition course director visiting clinical professor gi/nutrition
TRANSCRIPT
General Lecture Format -test questions will come from clinical
correlations--these will be relevant in clinical training and practice
-RDA’s and food sources—see Institute of Medicine website (food and nutrition, DRI—elements)—also on nutrition website
-will not be tested on this! Contact me if you have problems with the website
-items with *** and those with photos are important!!
Minerals A naturally occurring , homogeneous,
inorganic substance required by humans in amts of 100 mg/day or more -functions -high and low serum levels -absorption -excretion -deficiency -toxicity
Calcium
-most abundant mineral in the body
-1.5 to 2% of body wt
-99% of calcium is in the bones and teeth
-the remaining 1% is in the blood and ECF in cells and soft tissues
Skeletal Calcium -available in non-exchangeable and
exchangeable pools -non-exchangeable is for short term
homeostasis -exchangeable is used for increased needs
(growth, pregnancy, lactation) and is accumulated when diet has adequate calcium
-if there is no reserve, calcium is drawn from bone—leading to deficiency
Serum Calcium -levels: 8.8 to 10.8 mg/dl 3 fractions
1) free/ionized—50% 2) complexed with phos, bicarb, citrate—5% 3) protein bound with albumin or globulin—45%
-***when albumin is low (malnutrition, liver dz), calcium is decreased in ratio of 0.8 mg of calcium to every 1 g of albumin (for each gram of albumin below 4, add 0.8 to calcium level)
-factors such as pH and changes in plasma protein affect distribution
-ionized calcium is increased in acidosis and decreased in alkalosis
-total calcium changes with plasma protein but ionized remains the same ***-example: in resp alkalosis, total serum calcium
is normal, but ionized is low—always check ionized level with acid/base disorders
Functions -building and maintaining bones and teeth -transport fxn of cell membranes and
membrane stabilizer ***-nerve transmission and regulation of
heartbeat—use calcium gluconate IV to treat hyperkalemia (EKG—peaked T waves)
-ionized form initiates formation of the blood clot
-cofactor in conversion of prothrombin to thrombin
Absorption -***absorbed mainly in the acidic part of the
duodenum -absorption is decreased in the lower GI tract
which is more alkaline 20-30% of digested calcium is absorbed Absorption is thru 1,25 (OH)2D3 (vit D
derivative)--stimulates production of calcium binding protein and alk phos
-unabsorbed form is excreted in feces
Factors that increase calcium absorption -***more efficiently absorbed when the body
is deficient -best absorbed in acidic environment (upper
duodenum) -HCL in stomach allows better absorption in
the proximal duodenum -taking calcium with food increases abs -fat increases intestinal transit time and
increases absorption
Factors that decrease absorption -***lack of vitamin D -oxalic acid forms insoluble complex which
decreases absorption (rhubarb, spinach, chard, beet greens)
-phytic acid found in outer husks of cereal grains also form insoluble complex
-alkaline medium decreases abs.(lower GI tract) -physical/mental stress increases absorption -aging decreases absorption efficiency (to be
discussed with vit D)
Maintenance of serum level -parathormone (PTH) by the parathyroid gland and
thyrocalcitonin secreted by the thyroid gland maintain serum levels
-***with decreased serum calcium levels, PTH increases and causes transfer of calcium from bone to blood to increase serum levels
-decreased levels also cause kidney to reabsorb calcium more efficiently (might normally be excreted in the urine) and to increase intestinal absorption
-when blood levels are increased, calcitonin acts by the opposite mechanisms as PTH to decrease serum levels
Maintenance of serum level cont’d ***-always need to correct low Mg level
before treating a low calcium level -calcium may correct by itself -hypomagnesemia decreases tissue
responsiveness to PTH
Causes of hypocalcemia
Decreased Intake or absorption
-***malabsorption
-small bowel bypass, short bowel
-vit D deficiency
Increased Loss
-alcoholism
-***chronic renal insufficiency
-***diuretic therapy
Causes of hypocalcemia cont’d
Endocrine Disease
-hypoparathyroidism
-***hypomagnesemia
-sepsis
-pseudohypoparathyroidism
-calcitonin secretion with medullary carcinoma of the thyroid
Causes of hypocalcemia cont’d
Physiologic Causes
-***associated with low serum albumin (ionized calcium will be wnl)
-decreased end organ response to vit D
-hyperphosphatemia
-***aminoglycosides, plicamycin, loop diuretics, foscarnet
Causes of hypercalcemiaIncreased intake or absorption
-milk-alkali syndrome-vit D or vit A excess
Endocrine Disorders-primary hyperparathyroidism-secondary hyperparathyroidism (renal insuff, malabsorption)-acromegaly-adrenal insufficiency
Causes of hypercalcemia cont’d
***Neoplastic Disease-tumors producing PTH-related proteins (ovary, kidney, lung)-***mets to bone-lymphoproliferative disease including multiple myeloma-secretion of prostaglandins and osteolytic factors
Causes of hypercalcemia cont’d
Miscellaneous causes
-***thiazide diuretic
-sarcoidosis
-paget’s disease of bone
-***immobilization
-familial hypocalciuric hypercalcemia
-complications of renal transplant
-iatrogenic
Excretion -normal is 65-70% of ingested calcium
to be excreted in the feces and urine -strenuous exercise increases loss (in
sweat) -***immobility with bed rest and space
travel increase calcium loss because of lack of bone tension
Deficiency 1)***bone—to be discussed in osteoporosis
lecture 2) tetany—decreased serum levels increase the
irritability of nerve fibers resulting in muscle spasms, fatal laryngospasm ***-Chvostek’s sign: contraction of the facial m. after
tapping the facial n. ***-Trousseau’s sign: carpal spasm after occlusion of
the brachial a. with blood pressure cuff for 3 min 3) HTN—controversial 4) prolonged QT--arrythmias
Toxicity -***polyuria, constipation, bone pain,
azotemia, coma -”stones, bones(bone pain), groans,
psychiatric overtones”
Vitamin D -to be discussed in the fat-soluble
vitamin lectures in more detail -but, some key points that may be
clinically relevant…..
-the two main sources of Vit D production are the vit D made in our skin from UV light and that taken up in the diet
-as little as 20 minutes of UV exposure 3x/wk is good even without dietary intake
-liver and the kidney are both needed for synthesis of the active form
-***disease of either organ can lead to low Vit D levels and problems with calcium regulation
-***elderly are especially at risk because of lack of sunlight and renal insufficiency with age
-northern climates that have less sun exposure, get the vitamin from diet (fatty fish such as salmon)
-osteoporosis and osteomalacia -***think of Vit D deficiency in pts with abnormal
calcium levels, osteopenia or osteoporosis, malabsorption, and/or kidney/liver disease
Phosphorus -2nd to calcium in abundance -80% is calcium phos crystals in bones
and teeth -remainder is in every cell and ECF -levels maintained by the parathyroid
gland
Functions -structure of teeth and bones -essential component in cell
membranes, nucleic acids, phospholipids
-phosphorylation of glucose -buffer system in ICF and kidney
absorption
-best occurs when calcium and phos are ingested in equal amts (milk)
-vit D also increases absorption
Sources **see handout for sources and RDA ***dietary sources should be restricted
in renal disease (usually see increased phos, decreased Ca)
-protein sources -meat, poultry, fish, eggs, legumes,
nuts, milk, cereals, grains
Renal Disease -need to monitor phos levels to prevent renal
osteodystrophy (osteitis fibrosa and osteomalacia seen in renal dz)
-***used to use phos binders in renal dz, but caused aluminum toxicity—irreversible CNS and bone dz
-***now use Ca Carbonate supplements tid as phos binders
-don’t supplement vit D until phos is controlled because vit D increased calcium and phos absorption
Causes of hypophosphatemia
Diminished supply or absorption-starvation-TPN with inadequate phos content-malabsorption, small bowel bypass-absorption blocked by oral aluminum hydroxide or bicarb (to be discussed)-vit D deficient and vit D resistant osteomalacia
Causes of hypophosphatemia cont’dIncreased loss
-phosphaturic drugs: theophylline, diuretics, bronchodilators, corticosteroids-hyperparathyoidism (primary or secondary)-hyperthyroidism-renal tubular defects-hypokalemic nephropathy-inadequately controlled DM-***alcoholism
Causes of hypophosphatemia cont’dIntracellular shift of phosphorus
-administration of glucose-anabolic steroids, estrogen, OCP-respiratory alkalosis-salicylate poisoning
Electrolyte abnormalities-hypercalcemia-hypomagnesemia-metabolic alkalosis
Causes of hypophosphatemia cont’d
Abnormal losses followed by inadequate repletion-***DM with acidosis—with aggressive therapy
-***recovery from starvation or prolonged catabolic state—refeeding syndrome
-***chronic alcoholism, especially with nutritional repletion, assoc with hypomagnesemia—”
-recovery from severe burns
Causes of hyperphosphatemiaEndocrine disease
-excessive growth hormone (acromegaly)
-hypoparathyroidism assoc with low Ca
-pseudohypoparathyroidism assoc with low Ca
Decreased excretion
-***chronic renal insufficiency
-acute renal failure
Causes of hyperphosphatemia cont’d
Catabolic states, tissue destruction
-stress or injury, rhabdomyolysis (esp with renal insufficiency)
-chemotherapy of malignant disease, particularly lymphoproliferative disease
Excessive intake or absorption
-laxatives or enemas containing phosphate
-hypervitaminosis D
Deficiency -fatal -usually rare with food intake -***respiratory muscle collapse -hemolytic anemia -increased infection -platelet dysfxn w/ petechiae -encephalopathy -heart failure -muscle aches, bone pain, and fracture
Magnesium -ranks second to calcium as intracellular
cation -60% in bone, 26% in muscle,
remainder in soft tissues, body fluids -1/2 is free, 1/3 is bound to albumin,
remainer is in bone and not exchangeable
Function
-bone, muscle contractility, nerve excitability
-antagonistic to calcium
-excess Mg inhibits bone calcification
-in a muscle contraction, Mg relaxes, and calcium contracts
-excessive calcium induces signs of typical Mg deficiency
-low Mg can cause pregnancy induced HTN
Absorption / Excretion -absorption varies -similar to calcium (low pH, upper GI),
however, no Vit D required -as dietary calcium decreases, Mg absorption
is increased-kidney conserves Mg when intake of Mg is low
-large losses with vomiting because of high levels of gastic juice
Sources -seeds, nuts, legumes, unmilled cereal
grains, dark greens -fish, meat, milk, fruits -lost during refining of flour, rice, vinegar
Causes of hypomagnesemiaDiminished absorption or intake
-malabsorption, chronic diarrhea, laxative abuse-prolonged GI suction-small bowel bypass-malnutrition-***alcoholism-refeeding
-TPN with inadequate Mg
Causes of hypomagnesemia cont’d
Increased loss-DKA-diuretics-hyperaldosteronism, Barrter’s syndrome-hypercalcuriarenal Mg wasting
Unexplained-hyperparathyroidism-postparathyroidectomy-vit D therapy-aminoglycosides, ***cisplatin, ampho B
Causes of hypermagnesemia
Decreased renal fxn
***Increased intake—abuse of Mg containing antacids (MOM) and laxatives in renal insufficiency
Deficiency -anorexia, growth failure, cardiac and
neuromuscular changes—weakness, irritability, mental derangement
-tetany, muscle cramps
Toxicity -respiratory—depression, apnea -CV—hypotension, cardiac arrest, EKG
(prolonged QRS and QT, heart block, peaked T waves)
-GI—N/V -neuromuscular—paresthesias,
somnolence, confusion, coma, hyporeflexia, paralysis, apnea
Function -respiratory transport of O2 and CO2 -immune system -cognitive performance -found in Hgb (in RBC’s) and myoglobin (in
muscles) -ATP production in mitochondria involves both
heme and non-heme enzymes -cytochrome p450 system
-***plays a role in immunity because neutrophils work better when not iron deficient
Absorption and Transport -transferrin—transports Fe in blood to
erythroblasts for use in heme synthesis -dietary Fe deficiency is reflected first
by decreased Tf levels
-dietary iron exists in heme (Hgb and myoglobin) and non-heme
-***heme Fe is absorbed better -non-heme Fe has to be present in the
duodenum or upper jejunum in soluble form if it is to be absorbed
-in Fe deficiency, 50% can be absorbed -***2-10% of Fe from veggies is absorbed and
10-30% is absorbed from animal protein
Factors affecting absorption -***ascorbic acid is the most potent enhancer -animal proteins (beef, pork, veal, lamb, liver,
fish, chicken) enhance -but, proteins from cow’s milk, cheese, eggs,
don’t -gastric acidity enhances absorption (antacids
interfere) -pregnancy, increased growth, Fe defic all
increase deficiency
-phytate and tannins decrease abs -Fe used for enrichment are less
absorbed than elemental Fe -increased intestinal motility decreases
absorption because it decreases contact time for absorption
Storage -stored as ferritin and hemosiderin -30% is in the liver, 30% in the bone marrow, rest
in spleen and muscles -long term high Fe ingestion or frequent blood
transfusions can lead to accumulation of Fe in the liver
-***hemosiderosis develops in individuals who consume a lot of Fe or have a genetic defect resulting in increased Fe absorption
-in associated with tissue damage, it is called hemochromatosis
Excretion -lost thru bleeding, feces, sweat,
exfoliation of hair and skin -none in urine -amts to about 1mg in the adult male
and less in nonmenstruating females -loss of Fe with menstruation is
0.5mg/day
Sources and Intakes -best source is liver -oysters, shellfish, kidney, lean meat, poultry,
fish -dried beans, veggies, dark molasses -egg yolks, dried fruit, enriched breads, -requirements are highest in infancy and
adolescence -females stay high because of menstruation -decrease with menopause and increased with
pregnancy
Deficiency -most common deficiency -most at risk: <2 yrs old, teens, pregnancy,
elderly -***anemia (hypochromic, microcytic) -tx: diets high in absorbable Fe and/or Fe
supplements (ferrous sulfate, ferrous gluconate)
-can be caused by injury, hemorrhage, illness, poor diet
Zinc -involved in synthesis or degradation of CHO,
proteins, lipids, nucleic acids -metallothionein is the most abundant zinc
containing protein -abundant in the nucleus where it stabilizes
RNA and DNA and in chromatin proteins involved in transcription and replication
-present in bone and is needed for bone enzymes and osteoblastic activity
Absorption -balance maintained by absorption and
excretion from intestine -zinc levels are dose-responsive post-
prandially -protein-rich meal promotes zinc
absorption by forming more absorbable zinc—AA complexes
Impaired absorption in Crohn’s or pancreatic insufficiency
-plasma zinc levels act as acute phase reactants and fall by 50% with injury (like platelets)
Excretion -feces—almost entirely -***in urine with starvation, nephrosis,
DM, alcoholism, hepatic cirrhosis (zinc supplementation in encephalopathy), porphyria
Sources and Intakes -meat, fish, poultry, milk -oysters, shellfish, meat, liver, cheese,
whole grains, dry beans, nuts
Deficiency -short stature, hypogonadism, anemia -with diets high in unrefined cereal and
unleavened bread -delayed wound healing, alopecia ***-acrodermatitis enteropathica=AR dz with
zinc malabsorption -eczematoid skin lesions, alopecia, diarrhea,
bacterial and yeast infections, death
***Causes of deficiency
Decreased intake Anorexia Nervosa TPN without zinc (diarrhea, small bowel fistulas)
Decreased absorption High intake of phytate, tannins, binding drugs (EDTA), oxalate High iron intake Malabsorption syndromes Acrodermatitis enteropathica
Increased loss Diarrhea Pancreatico-cutaneous fistula Proximal entero-cutaneous fistulas Hemolytic anemias (sickle cell anemia) Renal failure patients on dialysis
***Zinc Deficiency
42 yo female with chronic uremia on dialysis. Recently started on iron supplement for anemia. Presents with rash, hypogeusia, hyposmia and poor dark adaptation.
Acrodermatitis Enteropathica Autosomal recessive disease
associated with a defect causing a reduction in zinc absorption
Can be treated by pharmacologic doses of oral zinc
Toxicity ->100-300 mg/d -rare -interferes with copper absorption -decrease in HDL -GI irritation, vomiting
Fluoride -tooth enamel -resistance to dental caries -fluoridation of h20 has decreased
caries by half -found in drinking h20, teflon pots and
pans (cooked in these) -toxicity at doses >0.1 mg/kg/d
Abundant in nature with varying amounts naturally found in water supplies
Epidemiologic studies have demonstrated inverse relationship between fluoride intake during tooth development and dental carries prevalence
Fluoride
Prevention of dental caries Numerous interventions have demonstrated
that an intake of ~1.0 ppm of fluoride reduces dental caries by as much as 70%
Possible beneficial effect on prevention of osteoporosis
***Incidence of dental fluorosis (mottled teeth) occurs with increased intake above 1-2 ppm.
Maganese -10 to 20 mg in body -mainly in mitochondria -found in many enzymes -connective and bony tissue formation -growth and reproduction -CHO and lipid metabolism
Absorption and Excretion -carried by transmagnin -after absorption, it appears rapidly in
the bile and is excreted in the feces -concentrated in liver and increases with
liver disease
Deficiency -wt loss, ataxia, dermatitis, N/V,
decreased hair growth, impaired reproductive activity, decreased pancreatic function and CHO metabolism