Environmental pathology:

disorders
of
Nutrition
Ma. Minda Luz M. Manuguid, M.D.
 Nutritional Disease
 MALNUTRITION- usually used as a
synonym of Undernutrition, but may be
caused by dietary excesses as well.
 Undernutrition is globally the most
important category of Environmental
Disease
 Overnutrition- predisposes to illnesses
& increased mortality
***Overt morphologic changes are relatively late
manifestations & may be preceded for long
periods of time by functional deficits.***

Etiology of Malnutrition

 Primary: lack of food- esp. Protein

 Secondary:
 Reduced intake- poor dentition; dysphagia;
systemic dses w/ anorexia; bizarre/restricted
diets; Anorexia nervosa
Anorexia nervosa
Etiology of Malnutrition
 Secondary Malnutrition
 Malabsorption- biliary/pancreatic dses; enteric
malabsorption syndromes; pernicious anemia
(vit B12 malabsorption)
 Increased requirements- rapid growth periods
(infancy, childhood, adolescence); pregnancy;
trauma/wound healing; burns; excessive losses
(enteropathies, nephropathies)
 Special categories- TPN (total parenteral /iV
nutrition); drug interference with absorption;
genetic metabolic disorders
 Protein- calorie malnutrition/
Protein- energy malnutrition
 worldwide incidence
 mostly affects children
 Kwashiorkor- mainly Protein deficiency
 Marasmus- mainly Carbohydrate deficiency
common features:
 growth failure;
 anemia, hypoplastic bone marrow
 impairment of the immune response &
increased susceptibility to infections;
 thymus & lymph node atrophy
Kwashiorkor & Marasmus
 Apathy; Anorexia  Alertness; Hunger
 “moonface”- round,  “old man’s face”-
edematous pinched, wizened
 Anasarca – bipedal  “skin & bones”,
pitting edema, “broomstick” limbs-
ascites - low serum muscle wasting;
Albumin loss of
 Fatty hepatomegaly subcutaneous fat
 Flag sign (hair)  Cerebral atrophy: ↓
 Flaky paint lesion no. of neurons
 Kwashiorkor & Marasmus

“flaky paint” dermatosis cerebral atrophy

“flag sign”-hair reduced number of
Ascites; intestinal parasitism neurons
Kwashiorkor & Marasmus
Kwashiorkor
 Nutritional excess: Obesity

 “too much food and/or

too little activity”
 Storage of excess
calories in fat depots
 Genetic
predisposition-
minimal role
“Men are apples, women
are pears”
 Obesity
 BMI- body mass index

Healthy Weight: BMI between 18.6 to 24.9

Overweight: BMI between 25 to 29.9
Obesity: BMI between 30 to 34.9
Severe Obesity: BMI between 35 to 39.9
Morbid Obesity: BMI over 40
 Obesity
 Insulin resistance
 Diabetes mellitus II
 Hypertension
 Coronary heart disease
 Hyperlipidemia
 Cholesterol gallstones
 Osteoarthritis, esp. knees
 Pickwickian syndrome
 assoc w/ breast, colon CA
 excess mortality over the
general population
 Pickwickian syndrome

 obesity, hypersomnolence, narcolepsy,

sleep apnea
 respiratory difficulty, ↓vital capacity
 Vitamins
 Vitamins are organic micronutrients
essential for health ; they act as critical
catalytic co-factors or prosthetic groups on
enzymes in vital metabolic reactions
 Fat-soluble vitamins : vit A, vit D, vit E & vit K

 Water-soluble Vitamins : vit C, vit B1, B2, B6,

B12, Niacin, Pantothenic acid; Biotin; Folic
acid
 Fat-soluble vitamins:
A, D, E, K
 need fat, bile salts, & pancreatic enzymes
to be absorbed in the GIT
 can be stored in the body
 can give rise to toxicity syndromes
 not easily destroyed by cooking
 vitamin A: Retinol,
Retinoic acid, Retinal
sources: eggs, butter,
meat, whole milk, fish
liver; carotenoids, esp.
β-carotene, in leafy
green & yellow
vegetables: spinach,
carrots, sweet potatoes,
squash
storage: Liver
 Vitamin A
 actions:
 maintains the integrity of mucosal membranes;
 needed in vision, esp. dark vision;
 enhances immunity to infections esp. in children
 is an anti-oxidant (anti-cancer, anti-aging)
 deficiency :
 Nyctalopia- “night blindness” –usually the first Sx
 Squamous metaplasia of mucosae
 Xerophthalmia- conjunctival keratinization
 Follicular hyperkeratosis; Acne
 Impaired immunity in chidren, ↑susceptibility to
infections, esp. measles
 Vitamin A deficiency
 Keratomalacia-
corneal softening
& ulceration→
corneal scarring
→ blindness
 Bitot’s spots-
gray-white
plaques of piled-
up squamous cells
 Hypervitaminosis A
 Headaches; nausea; vomiting; diarrhea;
irritability; drowsiness; alopecia
 Lymphadenopathy; immunologic
abnormalities
 Bony hyperostosis
 Hypercarotenemia: yellow-orange
discoloration of skin but not the sclerae
 In infants: premature closure of fontanels
 Synthetic retinoids given to pregnant women
predispose to congenital malformations of the
child.
 Vitamin D :
Ergosterol; Calcitriol
sources:
 endogenous synthesis in
skin exposed to UV light:
7-dehydrocholesterol →
vit D
 exogenous/dietary: deep sea
fish; grains; fortified milk &
dairy products
actions: maintenance of
adequate Calcium &
Phosphate levels for normal
bone mineralization
 Vitamin D
deficiency & excess
 deficiency: Inadequate bone mineralization :
 in children- Rickets – inadequate provisional
calcification of epiphyseal cartilage→ impaired bone
growth; excess of unmineralized osteoid
 in adults- Osteomalacia – osteopenia-
- ↑ susceptibility to fractures, most often of the
vertebrae, hips, wrists, ribs; kyphoscoliosis
- Looser’s zones / “milkman’s fractures”: radiolucent
narrow lines at right angles to cortical outlines of
bones- usually bilateral, symmetrical, in scapulae,
lower ribs, neck of proximal femur, posterior margins
of proximal ulnae
 excess : Hypercalcemia :
 metastatic calcification; renal calculi
 Rickets
 Bowed legs
 Rachitic rosary-
costochondral overgrowth
 “pigeon breast” deformity-
anterior sternal protrusion
 Harrison’s groove- depressed
lower margin of ribs
 Craniotabes: frontal bossing,
‘squared’ head
 Lumbar lordosis
 Vitamin E :
Tocopherols, Tocotrienols
*most potent is α-tocopherol
sources: vegetables; wheat;
grains & their oils; fish, nuts;
margarine; eggs; butter;
liver; sweet potatoes
action: ANTI-OXIDANT-
protects cellular & sub-
cellular polyunsaturated
membrane fatty acids
absorption: requires fat
storage: adipose tissue; liver,
muscle
 Vitamin E
deficiency & excess
 Vitamin E deficiency:
 spinocerebellar degeneration- dysarthria;
ophthalmoplegia; ataxia; loss of position &
vibration sense; loss of pain sensation
 Skeletal muscle changes- ↓ to absent tendon
reflexes
 Hemolytic anemia in infants
 Pigmented retinopathy
 Vitamin E excess:
 gastrointestinal disturbances
 Vitamin K: sources
 Endogenous -made in
the body by normal
intestinal bacterial flora
(acidophilus)
 Exogenous- green leafy
vegetables, liver, milk,
vegetable oils, egg yolks,
tomatoes, whole grains,
seaweed, oats and meat.
*Storage: Liver & Bones*
 Vitamin K: actions
 needed as co-factor in the manufacture of
clotting factors II (Prothrombin), VII, IX, &
X (vit K-dependent clotting factors /
Prothrombin complex)
 helps keep proper bone density; involved in
bone formation and repair; possibly slows
down bone loss & decreases the severity of
Osteoporosis esp. in postmenopausal women
 assists in converting glucose to glycogen in
the liver
 
 Vitamin K
deficiency & excess
 deficiency:
APCD: acquired Prothrombin
complex deficiency- in infants
purely breastfed & born at
home & in adults on antibiotic
therapy- bleeding diathesis-
into skin, umbilicus, viscera
 toxicity: rare- flushing,
sweating, jaundice and
anemia 
 Water-soluble vitamins:
vit B complex & vit C
 easily lost during cooking and processing.
 excess quantities of most, except vits B6 & B12, are not
stored by the body & are readily excreted in urine, so
foods bearing them must be consumed frequently
 generally nontoxic when present in excess of needs,
although symptoms may be reported in people taking
megadoses of niacin, vitamin C, or pyridoxine (vit B6).
 All the B vitamins function as coenzymes or cofactors,
assisting in the activity of important enzymes and
allowing energy-producing reactions to proceed normally.
 any deficiency mostly affects growing or rapidly
metabolizing tissues such as skin, blood, the digestive
tract, and the nervous system
 Vit B1 : Thiamine

 Sources: Pork/pork
products, beef, liver,
yeast/baked products,
enriched and whole
grain cereals, nuts &
seeds, milk, leafy green
vegetables
 Toxicity: none reported
 Thiamine: actions
 active form: thiamine
pyrophosphate (TPP)
 co-factor in the oxidative
decarboxylation of α-
ketoacids in the synthesis of
ATP (metabolism of
carbohydrates)
 co-factor for transketolase in
the PPP
 maintenance of neural
membranes & normal nerve
conduction
 Thiamine deficiency
 “dry” Beri Beri: anorexia, weight loss,
weakness, peripheral neuropathy
 “wet” Beri-beri: anasarca; high-output
cardiac failure (dilated, flabby heart)
 Wernicke-Korsakoff syndrome: in
chronic alcoholics: staggered gait,
crossed eyes, dementia, disorientation,
memory loss
 Vit B2 : Riboflavin

 Sources: Milk, eggs,

mushrooms, whole
grains, enriched
grains, green leafy
vegetables, yeast,
liver, and oily fish
 Riboflavin
 stable when heated in ordinary cooking, but not
when the food is exposed to ultraviolet
radiation /sunlight; To prevent riboflavin
breakdown, riboflavin-rich foods such as milk,
milk products, and cereals are packaged in opaque
containers.
 is a component of two coenzymes—flavin
mononucleotide (FMN) and flavin adenine
dinucleotide (FAD)—that act as hydrogen carriers
when carbohydrates and fats are used to produce
energy
 is helpful in maintaining good vision and healthy
hair, skin and nails, and it is necessary for normal
cell growth
 Riboflavin: deficiency & excess
 deficiency: Ariboflavinosis:
inflammation of tongue
(glossitis), cracks at corners
of mouth (cheilosis),
stomatitis, dermatitis,
conjunctivitis, growth
retardation, corneal
vascularization, nerve
damage
 toxicity: none reported “magenta tongue”
 Niacin: niacinamide,
nicotinamide, nicotinic acid
 readily absorbed from the stomach and the small
intestines
 stored in small amounts in the liver and transported to
tissues, where it is converted to coenzyme forms
 any excess is excreted in urine
 one of the most stable of the B vitamins, is resistant to
heat and light, and to both acid and alkali
environments
 co-enzymes in redox reactions
 The human body is capable of converting the amino
acid tryptophan to niacin when needed.
 However, when both tryptophan and niacin are
deficient, tryptophan is used for protein synthesis.
 Niacin / Nicotinic acid
 high doses taken orally as nicotinic acid at 1.5
to 2 grams per day can decrease cholesterol and
triglyceride levels, and along with diet and
exercise can slow or reverse the progression of
heart disease.

 toxicity: flushing of skin, itching, nausea &

vomiting, and liver damage occurs at intake
over 35 mg/day from supplements
 Niacin deficiency
 PELLAGRA:
diarrhea
dermatitis
dementia
 Long-term deficiency
leads to central nervous
system dysfunction
manifested as confusion,
apathy, disorientation,
and eventually coma and
death.
 vit B5: Pantothenic acid
 sources : widely distributed in
foods; watercress; broccoli;
alfalfa sprouts; mushrooms
 action: incorporated in
coenzyme A, as co-factor in
carboxylation reactions
 deficiency: rare: muscle
cramps; poor concentration;
teeth grinding; nausea &
vomiting
 toxicity: none reported
 Vit B6: Pyridoxine
 sources: meat, fish, poultry,
spinach, potatoes, bananas,
avocados, sunflower seeds,
eggs, whole grains, fortified
breads & cereals, legumes
 actions: natural anti-
depressant; needed in
balancing proteins, in
hormone production, & in
balancing the sex hormones
 Pyridoxine
deficiency & excess
 deficiency: dermatitis, cheilosis, glossitis,
peripheral neuropathy (tingling hands),
anemia, convulsion, depression,
confusion, decline in immune function,
water retention, nervous irritability
 toxicity: none from foods, but excess
intake above 100 mg/day from
supplements causes neuropathy (nerve
destruction) and skin lesions
 Vit B8 : Biotin
 sources: Whole grains,
eggs, nuts and seeds,
widely distributed in
small amounts
 action: cofactor in
carboxylation reactions
 deficiency: Infants:
dermatitis, convulsions,
hair loss (alopecia),
neurological disorders,
impaired growth
 toxicity: not known
 Folic acid / Folate
 sources: ready-to-eat breakfast
cereals, enriched grain
products, green vegetables,
liver, legumes, oranges
 actions: transfer & utilization
of C units in DNA synthesis;
maturation of RBC
**The use of fortified foods are
encouraged for all women of
child bearing age (15-45
years)**
 Folate
deficiency & toxicity
 deficiency:
megaloblastic
(macrocytic) anemia,
abdominal pain,
diarrhea, birth defects
in babies of deficient
pregnant women
 toxicity: none (up to 5
mg/day);
 Vit B12: Cyanocobalamin
 found in its free-vitamin form, called cyanocobalamin,
and in two active coenzyme forms
 absorption requires the presence of intrinsic factor of
Castle, a protein synthesized by gastric parietal cells
 absorbed in the ileum
 stored in the liver
 efficiently conserved in the body, since most of it is
secreted into bile and reabsorbed
 stable when heated and slowly loses its activity when
exposed to light, oxygen, and acid or alkaline
environments
 Vit B12: Cobalamin,
Cyanocobalamin
 sources: meat, fish (tuna,
sardines); poultry, oysters,
ready-to-eat fortified
breakfast cereals, eggs,
fermented dairy products
(cheese, yogurt, etc).

**The use of fortified foods

and supplements are
recommended for adults 51
and over**
 Cyanocobalamin
 coenzymes help recycle folate coenzymes involved in
the synthesis of DNA and RNA, and in the normal
formation of red blood cells
 prevents degeneration of the myelin sheaths esp. of
spinal cord tracts & help maintain normal electrical
conductivity through the nerves
 since vit B12 is well conserved in the body, it is difficult
to become deficient from dietary factors alone, unless a
person is a strict vegan and consumes a diet devoid of
eggs and dairy for several years.
 Vit B12 deficiency
 usually observed when B12 absorption is
hampered by disease or surgery to the stomach
or ileum,
 damage to gastric mucosa by alcoholism, or
 prolonged use of anti-ulcer medications that
affect secretion of intrinsic factor.
 age-related decrease in stomach acid
production also reduces absorption of B12 in
elderly persons
**These groups are advised to consume fortified
foods or take a supplemental form of vitamin
B12**
 Cobalamin
deficiency & toxicity
 deficiency:
Pernicious Anemia:
macrocytic anemia;
Combined degeneration of
posterolateral spinal cord
tracts: paresthesia (tingling
and numbness in limbs),
tender muscles, difficulty
walking, loss of bowel and
bladder control, dementia
 toxicity: none reported
 Choline
 for many years not considered a vitamin;
however, research now shows that production in
the body is not enough to cover requirements.
Choline is not considered a B vitamin because it
does not have a coenzyme function and the
amount in the body is much greater than other B
vitamins.
 helps maintain the structural integrity of
membranes surrounding every cell in the body
 can play a role in nerve signaling, cholesterol
transport, and energy metabolism.
 widely found in foods, so it is unlikely that a
dietary deficiency will occur.
 Vit C: Ascorbic acid

Sources:
 citrus fruits,
 strawberries,
 guavas
 peppers
 greens, broccoli
 tomatoes
 Ascorbic acid actions
 Anti-oxidant : protects membranes, anti-aging,
anti-cancer
 Collagen synthesis: proper wound healing,
integrity of blood vessel walls
 Biosynthesis of neurotransmitters
 Carnitine biosynthesis
 Immunologic function
 vit C deficiency (Scurvy) &
hypervitaminosis C
 deficiency: SCURVY : in adults-
fatigue, poor wound healing, pinpoint
hemorrhages around hair follicles on
back of arms & legs, bleeding gums &
joints; in children- hemorrhages, skin
purpura over lower legs, gingival
swelling, perifollicular hyperkeratotic
papular rash, “scorbutic rosary”
(abnormal osteoid)
 toxicity: megadoses over 2 g/day
cause nausea, abdominal cramps,
diarrhea, uricosuria
 Minerals
 inorganic elements that originate in the earth and
cannot be made in the body
 play important roles in various bodily functions
 necessary to sustain life and maintain optimal health,
and thus are essential nutrients.
 provide structure to bones and teeth and participate in
energy production, the building of protein, blood
formation, and several other metabolic processes
 Most of the minerals in the human diet come directly
from plants and water, or indirectly from animal foods
 Major & Trace
minerals
 Iron (Fe) (Na)
Sodium
 Copper
Potassium
(Cu)
(K)
 Chromium (Cr)
 Chloride
Fluoride (Fl)(Cl)
 Iodine
Calcium (I) (Ca)
 Manganese
Magnesium
(Mn)
(Mg)
 Molybdenum (Mo)
 Phosphorus
Selenium (Se) (P)
 Zinc
Sulfur(Zn)(S)
 other Trace Minerals
 Aluminum
Arsenic (As)(Al)
 Silver
Boron(Ag)
(B)
 Gold
Cobalt(Au)
(Co)
 Cadmium
Nickel (Ni)(Cd)
 Bromine
Silicon (Si)
(Br)
 Barium
Vanadium (Ba)(V)
 Major minerals : functions
 Na, K, Cl : fluid balance :regulated by charged sodium and
chloride ions in the ECF and potassium in the ICF, and by
some other electrolytes across cell membranes. Tight
control is critical for normal muscle contraction, nerve
impulse transmission, heart function, and blood pressure.
 Sodium plays an important role in the absorption of other
nutrients, such as glucose, amino acids, and water.
 Chloride is a component of hydrochloric acid, an
important part of gastric juice (an acidic liquid secreted by
glands in the stomach lining) and aids in food digestion.
 Potassium and sodium act as cofactors for certain
enzymes.
Major minerals: functions
 Calcium, magnesium, and phosphorus are essential for
the development and maintenance of bones and teeth;
& needed for maintaining cell membranes and
connective tissue.
 Several enzymes, hormones, and proteins that regulate
energy and fat metabolism require calcium,
magnesium and/or phosphorus to become active.
 Calcium also aids in blood clotting.
 Sulfur is a key component of various proteins and
vitamins and participates in drug-detoxifying pathways
in the body.
 Trace minerals: Iron
 sources: beef esp. liver,
chicken, rice, broccoli,
canned tuna, wheat germ,
tofu, boiled egg, molasses,
cooked mussels
 actions: necessary for the
production of normal
hemoglobin, & therefore,
normal RBC
 Iron :
deficiency & excess
deficiency: Microcytic
hypochromic anemia;
cold intolerance; poor
wound healing; alopecia;
koilonychia; atrophic
glossitis; reversible loss of
cognitive function;
malaise; ↓ immunity
excess: Hemochromatosis:
“bronze diabetes”
 Copper
 sources: nuts, sunflower
seeds, lobster, green
olives, wheat bran, liver,
cocoa, oysters, black
pepper, blackstrap
molasses
 actions: needed for
hemoglobin synthesis,
normal iron metabolism,
maintenance of blood
vessels, bone, nerves,
 Copper:
deficiency & toxicity
 deficiency :impaired
bone calcification,
hypochromic anemia
not responsive to
Iron therapy,
neutropenia
 excess : Wilson’s
disease: liver
cirrhosis, with
Copper deposition
 Selenium
 sources: meat, liver, oysters,
wheat germ, yeast, pumpkin
seeds, alfalfa, wild yam
 actions : anti-oxidant; part of
glutathione peroxidase;
 deficiency : Keshan disease;
muscle pain & tenderness in
TPN; Kashin-Beck disease
 toxicity: hair loss, abnormal
nails, peripheral neuropathy,
dermatitis, nausea, diarrhea,
fatigue, irritability, garlic breath
 Zinc
 sources: brazil nuts, seafood,
poultry, red meat, grains, eggs,
garlic; oats, brown rice,
vegetables (soil)
 actions: component of
hundreds of enzymes
 deficiency: Acrodermatitis
enteropathica; maternal
deficiency- ↑ fetal
malformations & low birth
weight
 toxicity: very rare: microcytosis,
neutropenia, impaired
immunity, vomiting, diarrhea
 Fluoride, Iodine, Chromium, Manganese,
Molybdenum

 Fluoride- (Fl) -prevention of deficiency

cavities
states:
 Iodine- (I) - necessary for
thyroid hormone production
 Chromium – (Cr)- needed for  Fl- dental
proper carbohydrate
metabolism Caries
 Manganese- (Mn)- component
of enzymes, e.g. superoxide
 I - Goiter /
dismutase Hypothyroidis
 Molybdenum- (Mo) -enzyme m
component  Cr, Mn, Mo
-Metabolic
Thank you !