Chapter 20 Clinical nutrition
An adequate intake of nutrients is essential for normal growth and development and for the maintenance of health. These nutrients include proteins, to supply amino acids, energy substrates (carbohydrates and fat), inorganic salts, vitamins and other essential nutrients such as essential fatty acids. The daily requirements for these nutrients are determined by many factors, including age, sex, physical activity and the presence of disease; if an individual’s requirements are not met, a clinical deficiency syndrome may develop.
This chapter discusses the pathology of some specific deficiency syndromes, with particular reference to the role of the laboratory in their diagnosis and management. This role is also discussed in relation to patients suffering from, or at the risk of, generalized malnutrition. Nutritional support for these patients can be provided enterally (i.e. into the alimentary tract, either by mouth or through a feeding tube) or parenterally (intravenously, bypassing the gut). Such treatment requires close cooperation between the clinician and the laboratory, particularly when the patients are also acutely ill, and when such support is required in the long term.
Excessive intake of nutrients can also be harmful. Obesity is a common condition in the developed world, and its prevalence is increasing. Its ultimate cause is an intake of energy substrates in excess of requirements, although the factors that contribute to this are complex and not fully understood. There is much evidence linking several common diseases, including coronary heart disease, hypertension and some cancers, with a relative excess or insufficiency of one or more components of the diet.
The biochemical functions of most vitamins are well understood, but while the deficiency syndrome may obviously relate to a known function (e.g. osteomalacia in vitamin D deficiency), this is not always the case (e.g. beriberi and Wernicke’s encephalopathy in thiamin deficiency). Although the clinical presentation of individual vitamin deficiency states is usually characteristic, in generalized malnutrition multiple deficiencies can occur and cause a complex clinical presentation.
The classic deficiency syndromes are the end result of a process in which deficiency of a vitamin leads first to mobilization of body stores, then to tissue depletion, biochemical impairment (subclinical deficiency) and, eventually, frank deficiency. The actions of vitamins are almost entirely intracellular, and their plasma concentrations do not necessarily reflect intracellular concentrations and thus functional availability.
It follows that plasma concentrations of vitamins may be unreliable as indicators of the body’s vitamin status. In deficiency states, plasma concentrations tend to fall before tissue concentrations. On the other hand, if a vitamin is administered to a deficient patient, a rise in plasma concentration to normal is not necessarily indicative of adequate replacement.
In practice, the best means of assessing a patient’s vitamin status depends on the vitamin in question. The range of techniques that can be used is illustrated by the examples given in the following sections.
Thiamin pyrophosphate is a cofactor in the metabolism of pyruvate to acetyl coenzyme A (CoA), 2-oxoglutarate to succinyl CoA, and in a reaction of the pentose shunt pathway catalysed by the enzyme transketolase. The body contains only about 30 times the daily requirement of this vitamin. Diets high in carbohydrate require more thiamin for their assimilation than diets high in fat, and so, for example, subclinical thiamin deficiency may be unmasked in malnourished patients given glucose intravenously.
Case history 20.1
An elderly woman, a resident in a private nursing home, complained of difficulty in walking, with paraesthesiae and numbness in her legs. The physical signs were consistent with a peripheral neuropathy.
|Red cell transketolase activity:|
|without added thiamin pyrophosphate||2.0 mmol/h/109 red cells|
|with added thiamin pyrophosphate||2.4 mmol/h/109 red cells|
The patient’s symptoms showed some improvement with the vitamin supplements. Red cell transketolase activity (measured by the decrease in substrate concentration as it is metabolized) was at the lower limit of normal and increased by 20% in the presence of thiamin pyrophosphate. This is consistent with mild thiamin deficiency: an increase of up to 14% is considered normal, while an increase of >25% is clear evidence of deficiency. Peripheral neuropathy is a common clinical problem: thiamin deficiency is but one of many causes (see p. 273).
Deficiency of vitamin B1 causes a primarily sensory polyneuropathy (dry beriberi), cardiac failure (wet beriberi), Wernicke’s encephalopathy, characterized by ophthalmoplegia and ataxia and which may progress rapidly to stupor and death, and Korsakoff’s psychosis, of which memory loss is usually the most obvious feature. These can occur alone or in combination. In the UK, the most frequent manifestation is encephalopathy, seen chiefly in chronic alcoholics whose diet is poor.
Wernicke’s encephalopathy responds rapidly to thiamin and, because the vitamin is cheap and non-toxic, this therapeutic response can be used to make the diagnosis. Laboratory tests for deficiency are seldom necessary.
It may, however, be necessary formally to document deficiency in nutritional research. Thiamin concentration can be measured directly in whole blood. Alternatively, a functional assay may be used in which red cell transketolase activity is measured both with and without the addition of thiamin pyrophosphate to the reaction mixture. Enzyme activity may be normal in subclinical deficiency but is increased by the addition of the coenzyme. If the deficiency is clinically obvious, the basal enzyme activity will be low.
An analogous technique can be used to assess riboflavin (vitamin B2) status by measurement of the red cell enzyme glutathione reductase with and without the vitamin, and pyridoxine (vitamin B6) using red cell alanine or aspartate aminotransferases. Direct whole blood assays of the vitamins are now also available and are generally easier and cheaper to perform. Deficiency of each of these vitamins (manifest in both cases principally by angular stomatitis, cheilosis and dermatitis) is uncommon in developed countries but may sometimes be seen in alcoholics and grossly malnourished individuals.
Nicotinic acid is the precursor of nicotinamide. This is a constituent of the coenzymes nicotinamide adenine dinucleotide (NAD) and its phosphate (NADP), which are essential to glycolysis and oxidative phosphorylation.
Part of the body’s nicotinic acid requirement is met by endogenous synthesis from tryptophan. The deficiency syndrome, pellagra (comprising an erythematous skin rash that leads to desquamation, gastrointestinal disturbance, particularly diarrhoea, and dementia) can result from either an inadequate dietary intake of nicotinic acid or decreased synthesis. The latter may be a feature of the carcinoid syndrome (see p. 303), in which there is increased metabolism of tryptophan to hydroxyindoles, with consequently less available for nicotinic acid synthesis, and of Hartnup disease, a rare inherited disorder of the epithelial transport of neutral amino acids, due to decreased intestinal absorption of tryptophan from the gut.
A derivative of folic acid is vital to purine and pyrimidine (and hence nucleic acid) synthesis. Folic acid deficiency is relatively common: its most usual manifestation is as a macrocytic anaemia with megaloblastic marrow changes. Folic acid is usually measured by immunoassay, although microbiological assays were widely used in the past. The concentration in red cells reflects the body’s folate reserves, while plasma concentrations reflect recent dietary intake.
It is essential to diagnose the cause of megaloblastic anaemia before it is treated. Giving folate alone to patients with vitamin B12 deficiency risks precipitating or exacerbating the neurological manifestations of vitamin B12 deficiency.
Vitamin B12 comprises a number of closely related substances called cobalamins, which are essential to nucleic acid synthesis. Deficiency can cause megaloblastic anaemia and neurological manifestations, either alone or together. The neurological features, which may be caused by demyelination, include peripheral neuropathy, subacute combined degeneration of the spinal cord, dementia and optic atrophy.
Dietary deficiency of this vitamin is rare except in strict vegetarians (vegans): considerable amounts are stored in the liver, with the result that deficiency is not common even with severe malabsorption (unless of very longstanding). Vitamin B12 deficiency is most frequently seen in pernicious anaemia. This is an autoimmune disease, in most cases of which there is lack of production in the stomach of intrinsic factor, essential for the absorption of the vitamin from the terminal ileum. Autoantibodies to intrinsic factor are present in 50% of patients with pernicious anaemia and are specific for the condition, whereas parietal cell antibodies, although present in 90% of patients, also occur in many older people with gastric atrophy.
Vitamin B12 is measured in plasma by immunoassay. Subclinical deficiencies of both folate and vitamin B12 increase plasma concentrations of homocysteine which is a risk factor for cardiovascular disease. Decreased availability of vitamin B12 also increases the plasma concentration of methylmalonic acid, measurement of which may be helpful in borderline deficiency of the vitamin.
Ascorbic acid is essential for the hydroxylation of proline residues in collagen and thus for the normal structure and function of this protein. It is a powerful antioxidant and acts by maintaining iron in the hydroxylating enzyme in the reduced (Fe2+) state. Vitamin C also facilitates the intestinal absorption of dietary non-haem iron by keeping it in the Fe2+ state. Subclinical deficiency of ascorbic acid is quite often present in elderly housebound people. The concentration of ascorbate in plasma reflects recent dietary intake and is a poor index of tissue stores of the vitamin. These are better assessed by determination of ascorbate concentration in leukocytes. In practice, this is seldom necessary, because ascorbic acid is cheap and non-toxic, so a therapeutic trial of vitamin supplementation is the simplest procedure to confirm suspected vitamin C deficiency. (See also Case history 20.2.)
This vitamin is a constituent of the retinal pigment rhodopsin. It is also essential for the normal synthesis of mucopolysaccharides and growth of epithelial tissue. Mild deficiency causes night blindness, while in more severe cases degenerative changes in the eye may lead to complete loss of vision. The normal liver contains considerable stores of the vitamin, and deficiency is rarely seen in affluent societies. It is, however, an important cause of blindness in many areas of the world.
Vitamin A is present in the diet and can also be synthesized from dietary carotenes. It can be measured in plasma, in which it is transported bound to prealbumin and a specific retinol-binding globulin. A low binding protein concentration can cause the plasma concentration of vitamin A to be low and impair its delivery to tissues even when hepatic stores of the vitamin are adequate. Measurements of vitamin A status are rarely required in practice, because deficiency is rare in the western world, but may be useful (together with vitamin E) for monitoring adequacy of pancreatic enzyme replacement in children with cystic fibrosis (see Chapter 16). In areas where deficiency is endemic the facilities required to provide laboratory confirmation of the diagnosis are often not available, although the diagnosis is usually obvious clinically.
Case history 20.2
An 80-year-old widow was admitted to hospital with bronchopneumonia and obvious self-neglect. She lived alone but had several cats, and a neighbour who had called the doctor said that most of the woman’s pension was spent on her pets. On examination, she was seen to have widespread perifollicular haemorrhages, and a clinical diagnosis of scurvy was made. She was given ascorbic acid (11 mg/kg body weight/day) and her urinary ascorbate excretion was measured. Only after eight days of treatment was there any increase from the initial very low level.
In a person with normal tissue ascorbate stores, ascorbate ingested in excess of requirements is rapidly excreted in the urine. In a patient with ascorbate deficiency, the vitamin is retained until tissue stores are replenished; in severe deficiency, this can take more than a week, but it should be noted that this test provides only retrospective confirmation of the diagnosis.
Vitamin D is obtained from endogenous synthesis, by the action of ultraviolet light on 7-dehydrocholesterol in the skin to form cholecalciferol (vitamin D3), and from the diet. Dietary vitamin D is largely ergocalciferol (vitamin D2), the predominant form in plants. The only important dietary sources are fish and some margarines, which are artificially fortified with vitamin D. Vitamins D2 and D3 undergo the same metabolic changes in the body and have identical physiological actions. For this reason, the terms ‘cholecalciferol’ and ‘vitamin D’ are frequently used to refer to both forms of the vitamin.
In most individuals, endogenous synthesis is the major source of vitamin D. Privational (dietary) vitamin D deficiency is seen most frequently in people who also have decreased endogenous synthesis, such as the elderly housebound. It is also seen in the UK in people of south Asian origin, particularly women, in whom the effects of low intake may be exacerbated by decreased production by sunlight due to their traditional clothing and darker skin colour. Binding of calcium in the gut by dietary phytates may also contribute to the osteomalacia to which they are prone. Breast milk contains relatively little vitamin D and infants are at risk of vitamin D deficiency particularly if premature (the vitamin is transported across the placenta mainly in the last trimester of pregnancy) or if the mother is vitamin D deficient. Vitamin D insufficiency (Figure 20.1) is increasingly recognized as a public health concern in Europe and North America. At the end of winter, up to one-third of white adults and two-thirds of dark skinned adults may have suboptimal vitamin D concentrations, especially at more northern latitudes.
Cholecalciferol itself has little physiological activity. It is hydroxylated first in the liver to 25-hydroxycholecalciferol (25-HCC, calcidiol) and then in the kidney to 1,25-dihydroxycholecalciferol (1,25-DHCC, calcitriol). These metabolites are transported in the circulation by a specific binding protein. Calcitriol is a hormone of vital importance in calcium homoeostasis; its actions and the control of its production are discussed in Chapter 12.
Vitamin D status can be assessed in the laboratory by measurement of the plasma concentration of calcidiol, the major circulating metabolite. This undergoes seasonal variation, being higher in the summer than in the winter. The definition of vitamin D sufficiency has been much debated, but concentrations at which there is no secondary rise in circulating parathyroid hormone are often taken to be optimal. Figure 20.1 shows typical reporting ranges from a UK laboratory.
Decreased synthesis or dietary deficiency of vitamin D causes rickets in children and osteomalacia in adults. Other causes include disordered metabolism of cholecalciferol and malabsorption. The clinical biochemistry of rickets and osteomalacia is considered in more detail in Chapter 15. Vitamin D insufficiency is strongly associated with decreased bone density and an increased risk of fractures, especially in women.
The role of vitamin D is not confined to calcium and bone metabolism: it is also involved in cellular differentiation, particularly of immunocompetent cells. Vitamin D insufficiency has been linked with an increased risk of developing cardiovascular disease, diabetes mellitus, breast and gastrointestinal cancers, infections such as tuberculosis and influenza, autoimmune disorders such as rheumatoid arthritis, and possibly multiple sclerosis. Whether vitamin D insufficiency is a direct cause of these disorders is debatable, but there is a definite inverse association of vitamin D concentration and all-cause mortality in the general population.