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Familial hypophosphatemia

Related Terms

Achlorhydria, appetite stimulant, B12 absorption, beriberi, biotin deficiency, cachexia, copper deficiency, familial hypophosphatemia, folate deficiency, hypercalciuria, hypocalcemia, hypophosphatemia, iodine deficiency, iron absorption enhancement, iron deficiency, Korsakoff's psychosis, Kwashiorkor, malnutrition, marasmus, nutritional deficiencies, nutritional support (TPN), pantothenic acid deficiency, pellagra, pyridoxine deficiency, riboflavin deficiency, rickets, scurvy, thiamin deficiency, total parenteral nutrition, TPN, vitamin A, vitamin B12, vitamin C, vitamin D, vitamin E, vitamin K, Wernicke-Korsakoff syndrome, Wernicke's encephalopathy.

Background

Nutrition is a science that examines the relationship between diet and health. Nutrition includes the foods that provide energy and health, including proteins, carbohydrates, fats, vitamins, minerals and water. A nutritional deficiency is a state where an individual's intake of nutrients is insufficient for the body's normal functioning. The body's needs for nutrition change as it grows. So, for example, babies have different nutritional needs than a pregnant woman or an elderly person.

The body needs a regular intake of many nutrients such as protein, fat, carbohydrates, vitamins, and minerals for the health of bones, nerves, organs, and other body functions. Proteins help build body tissue (such as muscle and organs), carbohydrates provide energy, and fats are a component of all cell membranes and are an important source of stored energy in the body.

Vitamins are important for the cellular functions of the body. They are chemical substances that help the body use energy, build proteins, make cells, and repair injuries. Vitamins are divided into two general categories: fat soluble and water soluble. The fat soluble vitamins are A, D, and E. Vitamin A is necessary for eyes, bones, and skin. Vitamin D is necessary to make bones and teeth, and it allows the body to use calcium from the diet. Vitamin E is important for the immune system and for the cardiovascular system.

The water soluble vitamins are vitamin C and the B vitamins. Vitamin C is important for fighting infection and for using the stored energy in the body. Vitamin C is generally found in citrus fruits and other vegetables like tomatoes and peppers. The B vitamins are important for building blood cells, nerve cells, and are vital for many of the body's chemical reactions. These are found in many meats and vegetables.

Minerals, such as calcium, iron, zinc, and magnesium, are also essential for health.

Deficiencies, excesses, and imbalances in the diet can produce negative impacts on health, which may lead to diseases such as cardiovascular disease, birth defects, diabetes, scurvy, obesity, seizures, or osteoporosis.

Many common diseases and their symptoms can often be prevented or alleviated with better nutrition; nutritional deficiencies are very common worldwide.

Integrative therapies

Strong scientific evidence:

Biotin: Biotin is an essential water-soluble B vitamin. The name biotin is taken from the Greek word bios meaning "life." Without biotin, certain enzymes, including acetyl-CoA carboxylase and pyruvate carboxylase, do not work properly, and complications can occur involving the skin, intestinal tract, and nervous system. Metabolic problems including very low blood sugars between meals, high blood ammonia, or acidic blood (acidosis) can occur. Death is theoretically possible, although no clear cases have been reported. Recent studies suggest that biotin is also necessary for processes on the genetic level in cells (DNA replication and gene expression).

Biotin deficiency is extremely rare. This is because daily biotin requirements are relatively small, biotin is found in many foods, and the body is able to recycle much of the biotin it has already used. No significant toxicity has been reported with biotin intake.

Avoid if hypersensitive to constituents of biotin supplements.

Calcium: Calcium is the most abundant mineral in the human body and has several important functions. More than 99% of total body calcium is stored in the bones and teeth where it supports the structure. The remaining 1% is found throughout the body in blood, muscle, and the intracellular fluid. Calcium is needed for muscle contraction, blood vessel constriction and relaxation, the secretion of hormones and enzymes, and nervous system signaling. A constant level of calcium is maintained in body fluid and tissues so that these vital body processes function efficiently.

The body gets the calcium it needs in two ways. One method is dietary intake of calcium-rich foods, including dairy products, which have the highest concentration per serving of highly absorbable calcium, and dark, leafy greens or dried beans, which have varying amounts of absorbable calcium. Calcium is an essential nutrient required in substantial amounts, but many diets are deficient in calcium.

The other way the body obtains calcium is by extracting it from bones. This happens when blood levels of calcium drop too low and dietary calcium is not sufficient. Ideally, the calcium that is taken from the bones will be replaced when calcium levels are replenished. However, simply eating more calcium-rich foods does not necessarily replace lost bone calcium, which leads to weakened bone structure.

Hypocalcaemia is defined as a calcium deficiency in the blood. Symptoms of this condition include sensations of tingling, numbness, and muscle twitches. In severe cases, tetany (muscle spasms) may occur. Hypocalcaemia is more likely to be due to a hormonal imbalance, which regulates calcium levels, rather than a dietary deficiency. Excess calcium in the blood can cause nausea, vomiting, and calcium deposition in the heart and kidneys. This usually results from excessive doses of vitamin D and can be fatal in infants.

Avoid if allergic or hypersensitive to calcium or lactose. High doses taken by mouth may cause kidney stones. Avoid with high levels of calcium in the blood, high levels of calcium in urine, hyperparathyroidism (overgrowth of the parathyroid glands), bone tumors, digitalis toxicity, ventricular fibrillation (rapid, irregular twitching of heart muscle), kidney stones, kidney disease, or sarcoidosis (inflammatory disease). Calcium supplements made from dolomite, oyster shells, or bone meal may contain unacceptable levels of lead. Use cautiously with achlorhydria or irregular heartbeat. Talk to a healthcare provider to determine appropriate dosing during pregnancy and breastfeeding.

Coenzyme Q10: Coenzyme Q10 is normally produced by the human body, although deficiency may occur in patients with impaired CoQ10 biosynthesis due to severe metabolic or mitochondrial disorders, not enough dietary CoQ10 intake, or too much CoQ10 use by the body. Depending on the cause of Coenzyme Q10 deficiency, supplementation or increased dietary intake of CoQ10 and the vitamins and minerals needed to produce CoQ10 may be effective.

Allergy associated with Coenzyme Q10 supplements has not been reported in the available literature, although rash and itching have been reported rarely. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk and do not use immediately after these procedures. Use caution with history of blood clots, diabetes, high blood pressure, heart attack, or stroke, or with anticoagulants (blood thinners) or antiplatelet drugs (like aspirin, warfarin, clopidogrel (like Plavix?), blood pressure, blood sugar, cholesterol or thyroid drugs. Avoid if pregnant or breastfeeding.

Copper: Copper is a mineral that occurs naturally in many foods, including vegetables, legumes, nuts, grains, and fruits, as well as shellfish, avocado, and beef (organs such as liver). Because copper is found in the earth's crust, most of the world's surface water and ground water used for drinking purposes contains small amounts of copper. Copper is involved in numerous biochemical reactions in human cells. Copper is a component of multiple enzymes, is involved with the regulation of gene expression, mitochondrial function/cellular metabolism, connective tissue formation, as well as the absorption, storage, and metabolism of iron. Copper levels are tightly regulated in the body.

Copper deficiency can occur in infants fed only cow-milk formulas (which are relatively low in copper content), premature/low-birth weight infants, infants with prolonged diarrhea or malnutrition, individuals with malabsorption syndromes (including celiac disease, sprue, or short bowel syndrome), cystic fibrosis, in the elderly, or those receiving intravenous total parenteral nutrition (TPN) or other restrictive diets.

Avoid if allergic to copper. Avoid copper supplements during the early phase of recovery from diarrhea. Avoid with hypercupremia. Avoid with genetic disorders affecting copper metabolism (e.g. Wilson's disease, Indian childhood cirrhosis, or idiopathic copper toxicosis). Avoid with HIV/AIDS. Use cautiously with water containing copper concentrations greater than 6 milligrams/liter. Use cautiously with anemia, arthralgias, or myalgias. Use cautiously if taking birth control pills. Use cautiously if at risk for selenium deficiency. Doses that do not exceed the recommended dietary allowance appear to be safe during pregnancy and breastfeeding.

Folate: Folate and folic acid are forms of a water-soluble B vitamin. Folate occurs naturally in food and folic acid is the synthetic form of this vitamin. Folic acid is well-tolerated in amounts found in fortified foods and supplements. Sources include cereals, baked goods, leafy vegetables (spinach, broccoli, lettuce), okra, asparagus, fruits (bananas, melons, lemons), legumes, yeast, mushrooms, organ meat (beef liver, kidney), orange juice, and tomato juice. Folic acid is frequently used in combination with other B vitamins in vitamin B complex formulations.

Folate deficiency will occur if the body does not get the adequate amount of folic acid from dietary intake. Folic acid has been shown to be effective in the treatment of anemia due to folate deficiency.

Avoid if allergic or hypersensitive to folate or any folate product ingredients. Use cautiously if receiving coronary stents and with anemia and seizure disorders. It is recommended that pregnant women consume 400 micrograms daily in order to reduce the risk of fetal defects. Folate is likely safe if breastfeeding.

Iodine: Iodine is an element (atomic number 53), which is required by humans for the synthesis of thyroid hormones (triiodothyronine/T3 and thyroxine/T4).

Iodine is found in the diet, so deficiencies are caused by dietary insufficiencies. Chronic iodine deficiency can lead to numerous health problems in children and adults, including thyroid gland dysfunction (including goiter) and various neurologic, gastrointestinal, and skin abnormalities. Iodine deficiency in pregnant or nursing mothers can lead to significant neurocognitive deficits in their infants. "Cretinism" or severe mental retardation is a rare outcome of severe iodine deficiency during early development. Growth stunting, apathy, impaired movement, or speech/hearing problems may occur. Many individuals living in developing countries may be at risk of iodine deficiency and its complications, and iodine deficiency is considered to be a preventable cause of mental retardation.

Iodine deficiency is rare in industrialized countries such as the United States, due to enrichment of table salt and cattle feed with iodine. But deficiency is common in developing countries, where supplementation may be considered.

Reactions can be severe, and deaths have occurred with exposure to iodine. Avoid iodine-based products if allergic or hypersensitive to iodine. Do no use for more than 14 days. Avoid Lugol solution and saturated solution of potassium iodide (SSKI, PIMA) with hyperkalemia (high amounts of potassium in the blood), pulmonary edema (fluid in the lungs), bronchitis or tuberculosis. Avoid sodium iodide with gastrointestinal obstruction. Iodine is safe in recommended doses for pregnant or breastfeeding women.

Iron: Iron is an essential mineral and an important component of proteins involved in oxygen transport and metabolism. Iron is also an essential cofactor in the synthesis of neurotransmitters such as dopamine, norepinephrine, and serotonin. About 15 percent of the body's iron is stored for future needs and mobilized when dietary intake is inadequate. The body usually maintains normal iron status by controlling the amount of iron absorbed from food.

There are two forms of dietary iron: heme and non-heme. Sources of heme iron include meat, fish, and poultry. Sources of non-heme iron, which is not absorbed as well as heme iron, include beans, lentils, flours, cereals, and grain products. Other sources of iron include dried fruit, peas, asparagus, leafy greens, strawberries, and nuts.

Iron deficiency is the most common and widespread nutritional disorder in the world. The World Health Organization (WHO) estimates that approximately two billion people - over 30% of the world's population - are anemic. Anemia is a low level of healthy red blood cells (RBCs) in the body. RBCs carry oxygen to the tissues, and low levels of oxygen place stress on the body. Ferrous sulfate (Feratab?, Fer-Iron?, Slow-FE?) is the standard treatment for treating iron deficiency anemia. Dextran-iron (INFeD?) is given intravenously by healthcare providers to restore adequate iron levels in bone marrow when oral iron therapy has failed.

Iron is a trace mineral, and hypersensitivity is unlikely. Avoid if known allergy/hypersensitivity to products containing iron. Avoid excessive intake. Avoid iron supplements with blood disorders that require frequent blood transfusions. Use iron supplement cautiously with history of kidney disease, intestinal disease, peptic ulcer disease, enteritis, colitis, pancreatitis, hepatitis, alcoholism, those who plan to become pregnant, or are over age 55 and have a family history of heart disease. Pregnant or breastfeeding women should consult a healthcare professional before beginning iron supplementation.

L-carnitine: The main function of L-carnitine is to transfer long-chain fatty acids in the form of their acyl-carnitine esters across the inner mitochondrial membrane before beta-oxidation. In humans, it is synthesized in the liver, kidney, and brain and actively transported to other areas of the body. For example, 98% of the total body L-carnitine is confined to the skeletal and cardiac muscle at concentrations approximately 70 times higher than in the blood serum.

Supplementation may be necessary in rare cases of primary carnitine deficiency, which may be caused by a defect in carnitine biosynthesis, a defect in carnitine active transport into tissue, or a defect in renal (kidney) conservation of carnitine. Known conditions of secondary deficiency of carnitine (insufficiency), in which L-carnitine is effective, include chronic stable angina and intermittent claudication characterized by distinct tissue hypoxia (low oxygen levels). Another condition that may benefit from carnitine supplementation is decreased sperm motility.

Carnitine supplementation, both intravenous (injection) and oral (by mouth), is indicated for cases of primary and secondary carnitine deficiency. Use of L-carnitine in primary carnitine deficiency restores plasma carnitine levels to nearly normal levels. Muscle carnitine levels may rise only slightly; however, muscle function can be normalized.

Avoid if allergic or hypersensitive to carnitine. Use cautiously with peripheral vascular disease, high blood pressure, alcohol-induced liver cirrhosis and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers, or calcium channel blockers. Avoid if pregnant or breastfeeding.

Niacin: Vitamin B3 is made up of niacin (nicotinic acid) and its amide, niacinamide, and can be found in many foods, including yeast, meat, fish, milk, eggs, green vegetables, and cereal grains. Dietary tryptophan is also converted to niacin in the body. Vitamin B3 is often found in combination with other B vitamins including thiamine, riboflavin, pantothenic acid, pyridoxine, cyanocobalamin, and folic acid.

Niacin (vitamin B3) and niacinamide are approved by the U.S. Food and Drug Administration (FDA) for the treatment of niacin deficiency. Pellagra is a nutritional disease that develops due to insufficient dietary amounts of vitamin B3 or the chemical it is made from, tryptophan. Symptoms of pellagra include skin disease, diarrhea, dementia, and depression.

Avoid niacin/vitamin B3 if allergic to niacin or niacinamide. Avoid with history of liver disease or dysfunction, irregular heartbeats (arrhythmia), heart disease, high levels of homocysteine in the blood, blood clotting, bleeding disorders, asthma, anxiety, panic attacks, thyroid disorders, stomach ulcers, gout, or diabetes. Avoid if pregnant or breastfeeding.

Pantothenic acid: Pantothenic acid (vitamin B5) is essential to all life and is a component of coenzyme A (CoA), a molecule that is necessary for numerous vital chemical reactions to occur in cells. Pantothenic acid is essential to the metabolism of carbohydrates, proteins, and fats, as well as for the synthesis of hormones and cholesterol.

Pantothenic acid deficiency has been very rarely observed in humans, except in severe malnutrition. In cases of true pantothenic acid deficiency, oral pantothenic acid therapy is accepted as a treatment. It may also be merited as prevention in select patients at high risk for malnutrition. It should be included in tube feeds or parenteral (intravenous) nutrition formulas for patients unable to eat on their own.

Avoid if allergic or hypersensitive to pantothenic acid or dexpanthenol. Avoid with gastrointestinal blockage. Pantothenic acid is generally considered safe in pregnant and breastfeeding women when taken at recommended doses.

Phosphates, phosphorus: Phosphorus is a mineral found in many foods, such as milk, cheese, dried beans, peas, colas, nuts, and peanut butter. Phosphate is the most common form of phosphorus. In the body, phosphate is the most abundant intracellular anion. It is critical for energy storage and metabolism, for the utilization of many B-complex vitamins, to buffer body fluids, for kidney excretion of hydrogen ions, for proper muscle and nerve function, and for maintaining calcium balance. Phosphorus is vital to the formation of bones and teeth, and healthy bones and soft tissues require calcium and phosphorus to grow and develop throughout life. Inadequate intake of dietary phosphate can lead to hypophosphatemia (low blood phosphorus levels), which can lead to long-term potentially serious complications. Conversely, excess phosphate intake can lead to hyperphosphatemia (high blood phosphorus levels), which can occur particularly in people with impaired kidney function, and can lead to potentially serious electrolyte imbalances, adverse effects, or death.

Phosphates are used clinically to treat hypophosphatemia, hypercalcemia (high blood calcium levels), as saline laxatives, and in the management of calcium-based kidney stones. They may also be of some benefit to patients with vitamin D resistant rickets, multiple sclerosis, and diabetic ketoacidosis.

Critically ill patients receiving intravenous feedings often have low phosphate levels. Phosphate levels should be closely monitored in such patients, particularly if kidney function is impaired. Addition of phosphate to TPN solutions should be under the supervision of a licensed nutritionist.

Avoid if allergic or hypersensitive to any ingredients in phosphorus/phosphate preparations. Use phosphorus/phosphate salts cautiously with kidney or liver disease, heart failure, unstable angina (chest pain), recent heart surgery, hyperphosphatemia (high phosphate blood level), hypocalcemia (low calcium blood level), hypokalemia (low potassium blood level), hypernatremia (high sodium blood level), Addison's disease, intestinal obstruction or ileus, bowel perforation, severe chronic constipation, acute colitis, toxic megacolon, hypomotility syndrome, hypothyroidism, scleroderma, or gastric retention. Avoid sodium phosphate enemas with congenital or abnormalities of the intestine.

Riboflavin: Riboflavin (Vitamin B2) is a water-soluble vitamin that is involved in vital metabolic processes in the body and is necessary for normal cell function, growth, and energy production. Small amounts of riboflavin are present in most animal and plant tissues. Healthy individuals who eat a balanced diet rarely need riboflavin supplements. Good dietary sources of riboflavin are milk (and other dairy products), eggs, enriched cereals/grains, meats, liver, and green vegetables (such as asparagus or broccoli). Intake may be lower in vegetarians compared to non-vegetarians.

Studies suggest that riboflavin is beneficial in patients with riboflavin deficiency (ariboflavinosis). Ariboflavinosis may cause weakness, throat swelling/soreness, glossitis (tongue swelling), angular stomatitis/cheilosis (skin cracking or sores at the corners of the mouth), dermatitis (skin irritation), or anemia.

Particular groups may be particularly susceptible to riboflavin deficiency, including the elderly, those with chronic illnesses, the poor, and those with alcohol dependency. Patients with suspected riboflavin deficiency should be evaluated by a qualified healthcare professional.

Avoid if allergic or hypersensitive to riboflavin. Since the amount of riboflavin a human can absorb is limited, riboflavin is generally considered safe. Riboflavin is generally regarded as safe during pregnancy and breastfeeding.

Soy: Soy products, such as tofu, are high in protein and are considered an acceptable dietary source of protein.

Avoid if allergic to soy. Breathing problems and rash may occur in sensitive people. Soy, as a part of the regular diet, is traditionally considered to be safe during pregnancy and breastfeeding, but there is limited scientific data. The effects of high doses of soy or soy isoflavones in humans are not clear, and therefore are not recommended. People who experience intestinal irritation (colitis) from cow's milk may experience intestinal damage or diarrhea from soy. It is not known if soy or soy isoflavones share the same side effects as estrogens, like increased risk of blood clots. The use of soy is often discouraged in patients with hormone-sensitive cancers, such as breast, ovarian or uterine cancer. Other hormone-sensitive conditions such as endometriosis may also be worsened. Patients taking blood-thinning drugs like warfarin should check with a doctor and pharmacist before taking soy supplements.

Thiamin: Thiamin (also spelled "thiamine") is a water-soluble B-complex vitamin, previously known as vitamin B1 or aneurine. Thiamin was isolated and characterized in the 1920s, and thus was one of the first organic compounds to be recognized as a vitamin. Thiamin is involved in numerous body functions, including: nervous system and muscle functioning; flow of electrolytes in and out of nerve and muscle cells (through ion channels); multiple enzyme processes (via the coenzyme thiamin pyrophosphate); carbohydrate metabolism; and production of hydrochloric acid (which is necessary for proper digestion). Because there is very little thiamin stored in the body, depletion can occur as quickly as within 14 days. Severe chronic thiamin deficiency can result in potentially serious complications involving the nervous system/brain, muscles, heart, and gastrointestinal system.

Dietary sources of thiamin include beef, Brewer's yeast, legumes (beans, lentils), milk, nuts, oats, oranges, pork, rice, seeds, wheat, whole grain cereals, and yeast. In industrialized countries, foods made with white rice or white flour are often fortified with thiamin (because most of the naturally occurring thiamin is lost during the refinement process).

While typically asymptomatic, the elderly have been found to have lower thiamin concentrations than younger people. There is limited evidence that thiamin supplementation may be beneficial in individuals with persistently low thiamin blood levels.

Thiamin is generally considered safe and relatively nontoxic, even at high doses. Avoid if allergic or hypersensitive to thiamin. Thiamin appears safe if pregnant or breastfeeding when taken in the recommended dosages.

Vitamin A: Vitamin A is a fat-soluble vitamin that is derived from two sources: preformed retinoids and provitamin carotenoids. Retinoids, such as retinal and retinoic acid, are found in animal sources like liver, kidney, eggs, and dairy produce. Carotenoids like beta-carotene (which has the highest vitamin A activity) are found in plants such as dark or yellow vegetables and carrots.

Natural retinoids are present in all living organisms, either as preformed vitamin A or as carotenoids, and are required for a vast number of biological processes like vision and cellular growth. A major biologic function of vitamin A (as the metabolite retinal) is in the visual cycle. Research also suggests that vitamin A may reduce the mortality rate from measles, prevent some types of cancer, aid in growth and development, and improve immune function.

Vitamin A deficiency is rare in industrialized nations but remains a concern in developing countries, particularly in areas where malnutrition is common. Causes of vitamin A deficiency include malnutrition and liver disease. Prolonged deficiency can lead to xerophthalmia (dry eye) and ultimately to night blindness or total blindness, as well as to skin disorders, infections (such as measles), diarrhea, and respiratory disorders.

Avoid if allergic or hypersensitive to vitamin A. Recommended daily allowance (RDA) levels for vitamin A oral intake have been established by the U.S. Institute for Medicine of the National Academy of Sciences to prevent deficiencies in vitamin A. At recommended doses, vitamin A is generally considered non-toxic. Vitamin A toxicity can occur if taken at high dosages. Use cautiously with liver disease or alcoholism. Smokers who consume alcohol and beta-carotene may have an increased risk for lung cancer or heart disease. Vitamin A appears safe in pregnant women if taken at recommended doses. Use cautiously if breastfeeding because the benefits or dangers to nursing infants are not clearly established.

Vitamin B12: Vitamin B12 is an essential water soluble vitamin that is commonly found in a variety of foods such as fish, shellfish, meats, and dairy products. Vitamin B12 is frequently used in combination with other B vitamins in a vitamin B complex formulation. It helps maintain healthy nerve cells and red blood cells, and it is also needed to make DNA, the genetic material in all cells. Vitamin B12 is bound to the protein in food. Hydrochloric acid in the stomach releases B12 from protein during digestion. Once released, B12 combines with a substance called intrinsic factor (IF) before it is absorbed into the bloodstream.

The human body stores several years' worth of vitamin B12, so nutritional deficiency of this vitamin is extremely rare. The elderly are the most at risk due to a decrease in absorption of vitamin B12. Deficiency can result from being unable to use vitamin B12; this can be caused by a disease known as pernicious anemia. Additionally, strict vegetarians or vegans who are not taking in proper amounts of B12 are also prone to a deficiency state.

Vitamin B12 deficiency is a cause of megaloblastic anemia. In this type of anemia, red blood cells are larger than normal and the ratio of nucleus size to cell cytoplasm is increased. There are other potential causes of megaloblastic anemia, including folate deficiency or various inborn metabolic disorders. If the cause of megaloblastic anemia is due to vitamin B12 deficiency, then treatment with B12 is the standard approach. Patients with anemia should be evaluated by a physician in order to diagnose and address the underlying cause.

Studies have shown that a deficiency of vitamin B12 can lead to abnormal neurologic and psychiatric symptoms. These symptoms may include: ataxia (shaky movements and unsteady gait), muscle weakness, spasticity, incontinence, hypotension, vision problems, dementia, psychoses, and mood disturbances. Researchers report that these symptoms may occur when vitamin B12 levels are just slightly lower than normal and are considerably above the levels normally associated with anemia. People at risk for vitamin B12 deficiency include strict vegetarians, elderly people, and people with increased vitamin B12 requirements associated with pregnancy, thyrotoxicosis, hemolytic anemia, hemorrhage, malignancy, liver or kidney disease.

Administering vitamin B12 orally, intramuscularly, or intranasally is effective for preventing and treating dietary vitamin B12 deficiency. Avoid vitamin B12 supplements if allergic or hypersensitive to cobalamin, cobalt, or any other product ingredients. Avoid with coronary stents (mesh tube that holds clogged arteries open) and Leber's disease. Use cautiously if undergoing angioplasty and with anemia. Vitamin B12 is generally considered safe when taken in amounts that are not higher than the Recommended Dietary Allowance (RDA). There is not enough scientific data available about the safety of larger amounts of vitamin B12 during pregnancy and/or breastfeeding.

Vitamin B6: Vitamin B6 (pyridoxine) is required for the synthesis of the neurotransmitters serotonin and norepinephrine as well as for myelin formation. Pyridoxine deficiency in adults principally affects the peripheral nerves, skin, mucous membranes, and the blood cell system. In children, the central nervous system (CNS) is also affected. Deficiency can occur in people with uremia, alcoholism, cirrhosis, hyperthyroidism, malabsorption syndromes, congestive heart failure (CHF), and in those taking certain medications. Mild deficiency of vitamin B6 is common. Major sources of vitamin B6 include: cereal grains, legumes, vegetables (carrots, spinach, peas), potatoes, milk, cheese, eggs, fish, liver, meat, and flour.

Pyridoxine supplements are effective for preventing and treating pyridoxine deficiency and neuritis due to inadequate dietary intake, certain disease states, or deficiency induced by drugs such as isoniazid (INH) or penicillamine. Dietary supplements should be taken under the guidance of a qualified healthcare provider.

Pyridoxine-dependent seizures in newborns can result from use of high-dose pyridoxine in pregnant mothers or from genetic (autosomal recessive) pyridoxine dependency. Refractory seizures in newborns that are caused by pyridoxine dependence may be controlled quickly with intravenous administration of pyridoxine by a qualified healthcare provider.

The need for vitamin B6 supplementation in women taking birth control pills has not been proven although some studies show decreased pyridoxine levels in these women. Supplementation of B6 should be approached cautiously since the long-term effects of such therapy are uncertain.

Avoid vitamin B6 products if sensitive or allergic to any of their ingredients. Some individuals seem to be particularly sensitive to vitamin B6 and may have problems at lower doses. Vitamin B6 is likely safe when used orally in doses not exceeding the recommended dietary allowance (RDA). Use cautiously if pregnant or breastfeeding.

Vitamin C: Vitamin C (ascorbic acid) is a water-soluble vitamin, which is necessary in the body to form collagen in bones, cartilage, muscle, and blood vessels, and aids in the absorption of iron. Dietary sources of vitamin C include fruits and vegetables, particularly citrus fruits such as oranges.

Severe deficiency of vitamin C causes scurvy. Although rare, scurvy includes potentially severe consequences including sudden death. Scurvy is treated with vitamin C and should be monitored by a qualified healthcare professional. Based on scientific research, vitamin C appears to improve oral absorption of iron. Concurrent vitamin C may aid in the absorption of iron dietary supplements.

Avoid if allergic or sensitive to vitamin C product ingredients. Vitamin C is generally considered safe in amounts found in foods. Vitamin C supplements are also generally considered safe in most individuals if taken in recommended doses. Avoid high doses of vitamin C with glucose 6-phosphate dehydrogenase deficiency, kidney disorders or stones, cirrhosis (inflammation of the liver), gout, or paroxysmal nocturnal hemoglobinuria (bleeding disorder). Vitamin C intake from food is generally considered safe if pregnant or breastfeeding.

Vitamin D: Vitamin D is found in numerous dietary sources such as fish, eggs, fortified milk, and cod liver oil. The sun is also a significant contributor to the daily production of vitamin D, and as little as 10 minutes of exposure is thought to be enough to prevent deficiencies. The term "vitamin D" refers to several different forms of this vitamin. Two forms are important in humans: ergocalciferol (vitamin D2) and cholecalciferol (vitamin D3). Vitamin D2 is synthesized by plants. Vitamin D3 is synthesized by humans in the skin when it is exposed to ultraviolet-B (UVB) rays from sunlight or the diet.

The major biologic function of vitamin D is to maintain normal blood levels of calcium and phosphorus. Vitamin D aids in the absorption of calcium, helping to form and maintain strong bones. Recently, research also suggests vitamin D may provide protection from osteoporosis, hypertension, cancer, and several autoimmune diseases.

Rickets and osteomalacia are classic vitamin D deficiency diseases. In children, vitamin D deficiency causes rickets, which results in skeletal deformities. In adults, vitamin D deficiency can lead to osteomalacia, which results in muscular weakness in addition to weak bones. People who are at a high risk for vitamin D deficiencies are the elderly, dark skinned, obese, exclusively breastfed infants, and those who cover all exposed skin or use sunscreen whenever outside. Also, those who have fat malabsorption syndromes (e.g., cystic fibrosis) or inflammatory bowel disease (e.g., Crohn's disease) are at risk.

Familial hypophosphatemia is a rare inherited disorder characterized by impaired transport of phosphate and diminished vitamin D metabolism in the kidneys. Familial hypophosphatemia is a form of rickets. Taking calcitriol or dihydrotachysterol orally in conjunction with phosphate supplements is effective for treating bone disorders in people with familial hypophosphatemia. Management should be under medical supervision.

Avoid if allergic or hypersensitive to vitamin D or any of its components. Vitamin D is generally well-tolerated in recommended doses; doses higher than recommended may cause toxic effects. Use cautiously with hyperparathyroidism (overactive thyroid), kidney disease, sarcoidosis, tuberculosis, and histoplasmosis. Vitamin D is safe in pregnant and breastfeeding women when taken in recommended doses.

Vitamin E: Vitamin E is a fat-soluble vitamin with antioxidant properties. Vitamin E exists in eight different forms ("isomers"): alpha, beta, gamma, and delta tocopherol; and alpha, beta, gamma, and delta tocotrienol. Alpha-tocopherol is the most active form in humans. Dosing and daily allowance recommendations for vitamin E are often provided in Alpha-Tocopherol Equivalents (ATE) to account for the different biological activities of the various forms of vitamin E or in International Units (IU), which food and supplement labels may use. Vitamin E supplements are available in natural or synthetic forms. The natural forms are usually labeled with the letter "d" (for example, d-gamma-tocopherol), whereas synthetic forms are labeled "dl" (for example, dl-alpha-tocopherol).

Vitamin E deficiency is rare and may occur in people with diminished fat absorption through the gut (due to surgery, Crohn's disease, or cystic fibrosis), malnutrition, very low-fat diets, several specific genetic conditions (abetalipoproteinemia, "Ataxia and Vitamin E deficiency" [AVED]), very low birth weight premature infants, or infants taking unfortified formulas. Vitamin E supplementation is accepted as an effective therapy for vitamin E deficiency to halt progression of complications. Diagnosis of this condition and management should be under the care of a physician and nutritionist.

Avoid if allergic or hypersensitive to vitamin E. Avoid with retinitis pigmentosa (loss of peripheral vision). Use cautiously with bleeding disorders or if taking blood thinners. Avoid above the recommended daily level in pregnant women and breastfeeding women.

Vitamin K: The name "vitamin K" refers to a group of chemically similar fat-soluble compounds called naphthoquinones. Vitamin K1 (phytonadione) is the natural form of vitamin K, which is found in plants, and provides the primary source of vitamin K to humans through dietary consumption. Vitamin K2 compounds (menaquinones) are made by bacteria in the human gut and provide a smaller amount of the human vitamin K requirement. Vitamin K1 is commercially manufactured for medicinal use under several brand names (Phylloquinone?, Phytonadione?, AquaMEPHYTON?, Mephyton?, Konakion?). A water-soluble preparation is available for adults only as vitamin K3 (menadione).

Vitamin K is found in green leafy vegetables like spinach, broccoli, asparagus, watercress, cabbage, cauliflower, green peas, beans, olives, canola, soybeans, meat, cereals, and dairy products. Cooking does not remove significant amounts of vitamin K from these foods. People who eat a balanced diet including these foods are likely ingesting enough vitamin K and do not require supplementation.

Vitamin K is necessary for normal clotting of blood in humans. Specifically, vitamin K is required for the liver to make factors that are necessary for blood to properly clot (coagulate), including factor II (prothrombin), factor VII (proconvertin), factor IX (thromboplastin component), and factor X (Stuart factor). Other clotting factors that depend on vitamin K are protein C, protein S, and protein Z. Deficiency of vitamin K or disturbances of liver function (for example, severe liver failure) may lead to deficiencies of clotting factors and excess bleeding.

Vitamin K deficiency is rare, but can lead to defective blood clotting and increased bleeding. People at risk for developing vitamin K deficiency include those with chronic malnutrition (including those with alcohol dependency) or conditions that limit absorption of dietary vitamins such as biliary obstruction, celiac disease or sprue, ulcerative colitis, regional enteritis, cystic fibrosis, short bowel syndrome, or intestinal resection (particularly of the terminal ileum, where fat-soluble vitamins are absorbed). In addition, some drugs may reduce vitamin K levels by altering liver function or by killing intestinal flora (normal intestinal bacteria) that make vitamin K (for example, antibiotics, salicylates, anti-seizure medications, and some sulfa drugs). Vitamin K is routinely given to newborn infants to prevent bleeding problems related to birth trauma or when surgery is planned.

Avoid if allergic or hypersensitive to vitamin K. Injection into the muscle or vein should only be done by a healthcare professional; many serious side effects have occurred after injection. Menadiol (type of vitamin K that is not available in the United States) should be avoided with glucose-6-phosphate dehydrogenase deficiency. Avoid if pregnant. Use cautiously if breastfeeding.

Zinc: Zinc formulations have been used since ancient Egyptian times to enhance wound healing. Zinc deficiency is caused by inadequate intake or absorption, increased zinc excretion, or increased bodily need for zinc. Zinc deficiency symptoms include growth retardation, hair loss, diarrhea, delayed sexual maturation, impotence, eye and skin conditions, and loss of appetite. Additional symptoms may include weight loss, delayed wound healing, taste changes, and mental lethargy.

Zinc is generally considered safe when taken at the recommended dosages. Avoid zinc chloride since studies have not been done on its safety or effectiveness. While zinc appears safe during pregnancy in amounts lower than the established upper intake level, caution should be used because studies cannot rule out the possibility of harm to the fetus.

Good scientific evidence:

Choline: Choline is an essential nutrient related to the water-soluble B-complex vitamins, folate, pyridoxine, and B12, and to the essential amino acid, methionine. It is synthesized in the body as well as consumed in the diet. The largest dietary source of choline is egg yolk. Choline can also be found in high amounts in liver, peanuts, fish, milk, brewer's yeast, wheat germ, soy beans, bottle gourd fruit, fenugreek leaves, shepherd's purse herb, Brazil nuts, dandelion flowers, poppy seeds, mung and other beans, and a variety of meats and vegetables, including cabbage and cauliflower.

Choline is a major building block of lecithin. Choline is a precursor to acetylcholine, a chemical used to transfer nerve impulses. Therefore, choline is believed to have neurological effects.

Choline is a constituent of phosphatidylcholine (PC), which is a component of cell walls and membranes. It is involved in fat and cholesterol metabolism and transport. In this form, choline aids in fat metabolism and transport away from the liver.

Choline is likely effective when used orally as a nutritional supplement in infant formula. Also, choline is likely effective when used intravenously to treat total parenteral nutrition associated liver dysfunction.

Avoid if allergic or hypersensitive to choline, lecithin, or phosphatidylcholine. Use cautiously with kidney or liver disorders or trimethylaminuria. Use cautiously with a history of depression. If pregnant or breastfeeding, it is generally safe to consume choline within the recommended adequate intake (AI) parameters; supplementation outside of dietary intake is usually not necessary if a healthy diet is consumed.

Psychotherapy: Psychotherapy is an interactive process between a person and a qualified mental health professional. The patient explores thoughts, feelings, and behaviors to help with problem solving. Psychotherapy may improve outcome, prevent relapse, improve sexual and social adjustment, and encourage weight gain in patients with anorexia nervosa.

Psychotherapy, especially cognitive behavioral therapy, may help bulimics reduce binge eating, purging and relapse, and improve dietary restraint and attitudes towards body shape and weight. Prescription medication may be used with psychotherapy for bulimia, but may not be as successful alone.

Psychotherapy cannot always fix mental or emotional conditions. Psychiatric drugs are sometimes needed. In some cases, symptoms may worsen if the proper medication is not taken. Not all therapists are qualified to work with all problems. Use cautiously with serious mental illness or some medical conditions because some forms of psychotherapy may stir up strong emotional feelings and expressions.

Safflower oil: Two parts of safflower (Carthamus tinctoria) are primarily used: the flower itself and safflower seeds. There are two types of safflower oil with corresponding types of safflower varieties: those high in monounsaturated fatty acid (oleic) and those high in polyunsaturated fatty acid (linoleic). Currently, the seed varieties that produce oil high in oleic acid and very low in saturated fatty acids predominate in the United States market. High oleic safflower oil is lower in saturates and higher in monounsaturates than olive oil. In the U.S. diet, safflower oil has been frequently substituted for oils with higher saturated fat content, as monounsaturated fat may have a beneficial effect on the risk of coronary heart disease. Fatty acid intake is required for many physiological processes, including cellular maintenance skin repair, and production of prostaglandins. Safflower oil may improve fatty acid deficiency, especially oleic acid, linoleic acid and archadonic acid levels. Additional study is needed in this area before a strong conclusion can be made.

Avoid if allergic/hypersensitive to safflower, Carthamus tinctorius, safflower oil, daisies, ragweed, chrysanthemums, marigolds or any related constituents. Use parenteral safflower oil emulsions cautiously in newborns. Use cautiously if taking anticoagulants (blood thinners) or anti-platelet drugs, immunodepressants or pentobarbital. Use cautiously with diabetes, hypotension, inadequate liver function, hypercoagulability, and skin pigmentation conditions. Use cautiously if pregnant or breastfeeding.

Taurine: Taurine, or 2-aminoethanesulfonic acid, was originally discovered in ox (Bos taurus) bile and was named after taurus, or bull. A nonessential amino acid-like compound, taurine, is found in high abundance in the tissues of many animals, especially sea animals, and in much lower concentrations in plants, fungi, and some bacteria. As an amine, taurine is important in several metabolic processes of the body, including stabilizing cell membranes in electrically active tissues, such as the brain and heart. It also has functions in the gallbladder, eyes, and blood vessels, and it may have some antioxidant and detoxifying properties.

Early evidence suggests that taurine supplementation may aid in auditory maturation, fatty acid absorption, and increased serum taurine levels. However, additional study is needed to better understand the effects of taurine as a nutritional supplement in infant formula.

Taurine is an amino acid and it is unlikely that there are allergies related to this constituent. However, allergies may occur from multi-ingredient products that contain taurine. Use cautiously in patients with high cholesterol, low blood pressure, coagulation disorders, potential for mania, or epilepsy. Avoid consumption of energy drinks containing taurine, caffeine, glucuronolactone, B vitamins, and other ingredients, then consuming alcohol or exercising. Use cautiously if pregnant or breastfeeding.

Thiamin: Thiamin should be added to total parenteral nutrition (TPN) formulations for patients who are unable to receive thiamin through other sources (such as a multivitamin) for more than seven days.

Vitamin C: Based on scientific research, vitamin C appears to be of benefit for oral iron absorption enhancement.

Unclear or conflicting scientific evidence:

Beta-carotene: Beta-carotene is a member of the carotenoids, which are highly pigmented (red, orange, yellow), fat-soluble compounds naturally present in many fruits, grains, oils, and vegetables (green plants, carrots, sweet potatoes, squash, spinach, apricots, and green peppers). The carotenes possess antioxidant properties. Additional research is needed to better determine the effectiveness of carotenoid supplementation for carotenoid deficiency.

Avoid if sensitive to beta-carotene, vitamin A or any other ingredients in beta-carotene products.

Biotin: Intravenous feeding solutions should contain biotin, in order to avoid biotin deficiency in recipient patients. This applies for patients in whom total parenteral nutrition (TPN) is the sole source of nutrition. More study is needed in this area to make a firm recommendation.

Avoid if hypersensitive to constituents of biotin supplements.

Black currant: The black currant (Ribes nigrum) shrub is native to Europe and parts of Asia and is particularly popular in Eastern Europe and Russia.

With a vitamin C content estimated to be five times that of oranges (2,000 milligrams/kilogram), black currant has potential dietary benefits. Black currant is also rich in rutin and other flavonoids, which are known antioxidants. Because of black currant's high essential fatty acid content, researchers believe that it may be effective in the treatment of inflammatory conditions and pain management, as well as in regulating the circulatory system and increasing immunity. There is currently a lack of information in humans on the effectiveness of black currant seed oil as nutritional supplementation.

Avoid if allergic or hypersensitive to black currant, its constituents, or plants in the Saxifragaceae family. Avoid with hemophilia or those on blood thinners unless otherwise recommended by a qualified healthcare provider. Use cautiously with venous disorders or gastrointestinal disorders. Use cautiously if taking MAOIs or vitamin C supplements. Avoid if pregnant or breastfeeding.

Borage seed oil: Currently, there is insufficient available evidence evaluating the effectiveness of borage in the treatment of malnutrition.

Avoid if allergic or hypersensitive to borage, its constituents, or members of the Boraginaceae family. Use cautiously with bleeding disorders or epilepsy. Use cautiously if taking anticoagulants (e.g. warfarin or aspirin) or anticonvulsants. Avoid if immunocompromised. Avoid in pregnant patients as borage oil may be contraindicated in pregnancy given the teratogenic and labor-inducing effects of prostaglandin E agonists, such as borage oil's GLA. Avoid if breastfeeding.

Bromelain: Bromelain is an enzyme with the ability to digest proteins. However, there is little reliable scientific research on whether bromelain is helpful as a digestive aid. Better study is needed before a firm conclusion can be made on its benefits as a nutritional supplement.

There are multiple reports of allergic and asthmatic reactions to bromelain products, including throat swelling and difficulty breathing. Allergic reactions to bromelain may occur in individuals allergic to pineapples or other members of the Bromeliaceae family, and in people who are sensitive/allergic to honeybee venom, latex, birch pollen, carrot, celery, fennel, cypress pollen, grass pollen, papain, rye flour, or wheat flour. Few serious side effects have been reported with the use of bromelain. Avoid if pregnant or breastfeeding.

Carrot: Carrot (Daucus carota) is a well-known root vegetable. The thick tap root's color can range from white to orange to red or purple. This change in color represents the nutrients in the carrot because some pigments, such as beta-carotene and lycopene, are also nutrients used as antioxidants. Carrot jam may improve growth in young children with vitamin A deficiency. Although the results seem promising, more research is needed.

Avoid if allergic or hypersensitive to carrot, its constituents, or members of the Apiaceae family. Use cautiously with hypoglycemia (low blood sugar) or diabetes, or if taking hypoglycemics. Use cautiously with bowel obstruction, if taking oral drugs, herbs, or supplements, with hormone-sensitive conditions, and in children. Use cautiously with known allergy/hypersensitivity to carrot or birch pollen-related allergens, as cross-sensitivity has been documented. Use cautiously and only in food amounts in pregnant and breastfeeding women.

Chondroitin sulfate: Early research suggests that taking chondroitin with iron may help iron absorption enhancement in healthy individuals. It is unclear whether taking chondroitin would help patients with iron deficiencies absorb more iron. More research needs to be done in this area.

Use cautiously if allergic or hypersensitive to chondroitin sulfate products and with shellfish allergy. Use cautiously with bleeding disorders and with blood-thinners like warfarin (like Coumadin?). Avoid with prostate cancer or increased risk of prostate cancer. Avoid if pregnant or breastfeeding.

Copper: Copper deficiency may occur with marasmus, and supplementation with copper may play a role in the nutritional treatment of infants with this condition. Infants with marasmus should be managed by a qualified healthcare professional.

Devil's claw: Traditionally, devil's claw (Harpagophytum procumbens) was commonly used as an appetite stimulant and this remains a popular use. However, reliable scientific evidence is lacking in this area.

Avoid if allergic to devil's claw and to plants in the Harpagophytum procumbens family. Use caution with stomach ulcers or a history of bleeding disorders, diabetes, gallstones, gout, heart disease, stroke, ulcers or with prescription drugs used for these conditions. Stop use two weeks before surgery/dental/diagnostic procedures with bleeding risk, and do not use immediately after these procedures. Avoid if pregnant or breastfeeding.

Feldenkrais Method?: Early research suggests that Awareness Through Movement? sessions may improve self-confidence in patients with eating disorders, although it is not clear if eating habits are affected. Further research is needed before a conclusion can be drawn.

There is currently a lack of available scientific studies or reports of safety of the Feldenkrais Method?.

Folate: Folate deficiency in alcoholics has been observed. Alcohol interferes with the absorption of folate and increases excretion of folate by the kidney. Many alcohol abusers have poor quality diets that do not provide the recommended intake of folate. Increasing folate intake through diet, or folic acid intake through fortified foods or supplements, may be beneficial to the health of alcoholics.

Guided imagery: Therapeutic guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Evidence from early research suggests that guided imagery may be an effective treatment for bulimia nervosa, at least in the short-term. Further study is needed before firm conclusions can be drawn.

Guided imagery is usually intended to supplement medical care, not to replace it, and guided imagery should not be relied on as the sole therapy for a medical problem. Contact a qualified health care provider if mental or physical health is unstable or fragile. Never use guided imagery techniques while driving or doing any other activity that requires strict attention. Use cautiously with physical symptoms that can be brought about by stress, anxiety or emotional upset because imagery may trigger these symptoms. If feeling unusually anxious while practicing guided imagery, or with a history of trauma or abuse, speak with a qualified health care provider before practicing guided imagery.

Hydrazine: Cachexia is defined as physical wasting with loss of weight and muscle mass caused by disease. Patients with advanced cancer, AIDS, and some other major chronic progressive diseases may appear cachectic. Lack of appetite and cachexia often occur together. Cachexia can occur in people who are eating enough, but who cannot absorb the nutrients. Cachexia is not the same as starvation. A healthy person's body can adjust to starvation by slowing down its use of nutrients, but in cachectic patients, the body does not make this adjustment.

Hydrazine is an industrial chemical marketed as having the potential to repress weight loss and cancer-related cachexia and to improve general appetite status. However, in large randomized controlled trials, hydrazine has not been proven effective for improving appetite, reducing weight loss, or improving survival in adults with small cell lung cancer (when used as adjuvant therapy) or metastatic colorectal cancer (when used alone).

Hydrazine has not been well evaluated for safety or toxicity during pregnancy, lactation, or childhood. Hydrazine may cause cancer. Avoid if allergic or hypersensitive to hydrazine sulfate or any of its constituents. Use cautiously with liver or kidney problems, psychosis, diabetes or seizure disorders. Avoid if pregnant or breastfeeding.

Hypnotherapy, hypnosis: There is inconclusive evidence from preliminary research on the use of hypnotherapy for treatment of eating disorders. Additional study is needed.

Use cautiously with mental illnesses like psychosis/schizophrenia, manic depression, multiple personality disorder or dissociative disorders. Use cautiously with seizure disorders.

L-carnitine: Currently there is insufficient evidence to support the use of carnitine in the treatment of nutritional deficiencies. Additional study is needed.

Avoid if allergic or hypersensitive to carnitine. Use cautiously with peripheral vascular disease, high blood pressure, alcohol-induced liver cirrhosis and diabetes. Use cautiously in low birth weight infants and individuals on hemodialysis. Use cautiously if taking anticoagulants (blood thinners), beta-blockers or calcium channel blockers. Avoid if pregnant or breastfeeding.

Lime: There is conflicting evidence regarding the effectiveness of lime's ability to increase iron absorption. Additional study is needed before a firm conclusion can be drawn on the effectiveness of lime for treatment of iron deficiency.

Lime is considered safe when used in amounts typically found in foods. Avoid if allergic or hypersensitive to lime or any members in the Rutaceae family. Use cautiously with drugs that are broken down by the liver. Use cautiously with drugs that cause sun sensitivity. Avoid if pregnant or breastfeeding. There is no scientific evidence to support using limejuice douche to prevent HIV infection.

Pet therapy: Animal companionship has been used as an informal source of comfort and relief of suffering across cultures throughout history.

There is evidence that animal-assisted therapy in the form of a fish aquarium in an institutional care facility may improve nutritional intake, improve weight gain, and reduce the need for nutritional supplementation in patients with Alzheimer's disease.

Avoid if allergic to animal dander. Use only animals that have had veterinary screening, particularly in situations involving young children, frail elderly, immuno-compromised patients, or patients with medical conditions making them vulnerable to infection. Do not provide unsupervised use of animals with the severely mentally ill and very young children. Avoid with fear of animals or traumatic history with animals.

Phosphates, phosphorus: Long term, slow release neutral potassium phosphate has been shown to reduce calcium excretion in subjects with absorptive hypercalciuria (high urine calcium levels) and appears to be well tolerated.

Critically ill patients receiving intravenous feedings often have low phosphate levels. Phosphate levels should be closely monitored in such patients, particularly if kidney function is impaired. Addition of phosphate to total parenteral nutrition (TPN) solutions should be under the supervision of a licensed nutritionist.

The use of phosphates has not been clearly demonstrated as being beneficial for vitamin D resistant rickets in available study. Additional research is needed in this area.

Probiotics: Fermented milk containing the probiotic L. johnsonii La1 may improve nutritional status in the elderly. More research is needed to confirm early study results.

Probiotics are generally considered safe and well tolerated. Avoid if allergic or hypersensitive to probiotics. Use cautiously if lactose intolerant.

Riboflavin: Levels of important nutrients are often low in individuals with anorexia or bulimia, with up to 20-33% of patients deficient in vitamins B2 (riboflavin) and B6 (pyridoxine). Dietary changes alone, without additional supplements, can often bring vitamin B levels back to normal. However, extra B2 and B6 may be required. Nutritional and medical guidance for such patients should be under the direction of a qualified healthcare professional.

Saccharomyces boulardii: Saccharomyces boulardii is a non-pathogenic yeast strain that has been used for the treatment and prevention of diarrhea. Saccharomyces boulardii is classified as a "probiotic," or a microorganism that when ingested, may have a positive influence on the host's health. Probiotics may exert their effects on the gastrointestinal system directly or may modulate the immune system in a larger scope.

Clinical study has investigated the use of Saccharomyces boulardii for nutritional support for premature infants. No evidence was found for lipid gut absorption or increased weight gain. A benefit was noted on gut flora. Additional study is needed.

Avoid if allergic or hypersensitive to yeast, Saccharomyces boulardii, Saccharomyces cerevisiae, or other species in the Saccharomycetaceae family. Use cautiously in patients who have weakened immune systems or in critically ill patients. Use cautiously with indwelling central venous catheters, colitis, cancer, or constipation. Use cautiously in the elderly, chemotherapy patients, and infants. Use cautiously if taking medications to treat diarrhea. Avoid with a yeast infection. Avoid if pregnant or breastfeeding.

Safflower oil: Safflower oil has been used in patients with malnutrition to promote balance in their nutritional intake. Although the patients improved, the effect cannot be isolated to safflower oil intake because of the many other nutrients the patients were ingesting. Additional study is warranted in this area.

Infants require higher fat intake to support their rapid growth and brain development. Infant formula supplemented with safflower oil may increase the energy density of formula for very low-birth weight neonates. Although preliminary study is promising, more study is needed to better understand the benefits of safflower oil as a nutritional supplement in infant formula.

Parenteral nutrition requires a certain percentage of fats to provide full nutrition. Various sources of fats have been used, including safflower oil. Overall, clinical trials have shown safflower oil in total parenteral nutrition (TPN) to be safe when used at recommended doses. However, more studies should be conducted to see if safflower oil is superior to other sources of TPN lipids.

Soy: There is currently a lack of sufficient evidence to recommend for or against the use of soy-based formula in the treatment of iron deficiency anemia in children.

Spirulina: Spirulina has been studied as a food supplement for infant malnutrition but results have been mixed. More research is necessary in this area.

Avoid if allergic or hypersensitive to spirulina or blue-green algae. Use cautiously with phenylketonuria (a genetic disorder of a liver enzyme that disrupts normal body functions), autoimmune diseases, bleeding disorders, diabetes, and osteoporosis. Use cautiously with products containing the blue-green algae species Anabaena spp., Aphanizomenon spp., and Microcystis spp.; in underweight patients or in those taking antiobesity agents or appetite suppressants; and if consuming a high-protein diet. Avoid in children and if pregnant or breastfeeding.

Taurine: Preliminary study suggests that taurine aids in the ability of iron supplements to increase hemoglobin, red blood cell count, and serum ferritin. Additional study is needed before a firm recommendation can be made for the use of taurine for iron deficiency anemia.

The use of taurine has been examined in total parenteral nutrition (TPN) in various patient groups (trauma, cancer, and long term patients). Preliminary study is promising, but more study is needed.

Thiamin: Further study is necessary before a firm conclusion can be formed regarding the use of thiamin supplements for subclinical thiamin deficiency in the elderly.

Vitamin A: Vitamin A supplementation in combination with iron may have beneficial effects in patients with iron deficiency anemia, including children and pregnant women. It is not clear that there are benefits in individuals who are not vitamin A deficient. This area remains controversial, and further evidence is necessary before a clear conclusion can be drawn.

Vitamin D: Data is currently insufficient to support the use of vitamin D for hypophosphatemic vitamin D-resistant rickets. High-quality clinical trial evidence suggests that high doses of supplemental vitamin D provided to breast feeding mothers may improve the vitamin D status of both mother and child. More research is needed to better understand the role of supplementation for vitamin D deficiency in infants and nursing mothers.

Yoga: There is currently unclear evidence to support the use of yoga for treatment of eating disorders.

Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, risk for blood clots, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, or cervical spondylitis. Certain yoga breathing techniques should be avoided in people with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction (the popular Lamaze techniques are based on yogic breathing). However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

Zinc: Short-term zinc supplementation may increase weight gain and decrease infections, swelling, diarrhea, loss of appetite, and skin ulcers in children with kwashiorkor (malnutrition from inadequate protein intake).

Reports of zinc's effectiveness in treating symptoms of anorexia nervosa observed in young adults are based on small, low-quality studies, but all agree on the beneficial effects of zinc. Well-designed trials with a larger number of participants are needed to confirm these results.

Fair negative scientific evidence:

Omega-3 fatty acids: There is preliminary evidence that fish oil supplementation may not be of benefit for improvement of appetite or prevention of weight loss in cancer patients. Further study is warranted.

Avoid if allergic or hypersensitive to fish, omega-3 fatty acid products that come from fish, nuts, linolenic acid or omega-3 fatty acid products that come from nuts. Avoid during active bleeding. Use cautiously with bleeding disorders, diabetes, low blood pressure or drugs, herbs or supplements that treat any such conditions. Use cautiously before surgery. Pregnant or breastfeeding women should consult a qualified healthcare provider to determine the proper intake of omega-3 fatty acids.

Vitamin C: In a randomized controlled trial, ascorbic acid supplementation did not show benefit for nutritional support for premature infants throughout the first 28 days of life.

Prevention

Healthcare professionals recommendconsuming a variety of nutrient-dense foods (such as fresh vegetables and fruits) and beverages within the basic food groups while choosing foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol.

Consume a sufficient amount of fruits and vegetables daily. Two cups of fruit and two and one-half cups of vegetables per day are recommended for a reference 2,000-calorie intake, with higher or lower amounts depending on the calorie level.

Choose a variety of fruits and vegetables each day. In particular, select from all five vegetable subgroups (dark green, orange, legumes, starchy vegetables, and other vegetables) several times a week.

Consume three or more ounce-equivalents of whole-grain products per day, with the rest of the recommended grains coming from enriched or whole-grain products. In general, at least half the grains should come from whole grains.

Consume three cups per day of fat-free or low-fat milk or equivalent milk products.

Consume less than 10% of calories from saturated fatty acids and less than 300 milligrams daily of cholesterol, and keep trans fatty acid consumption as low as possible. Trans fatty acid consumption is linked to the development of cardiovascular diseases.

Keep total fat intake between 20 - 35% of calories, with most fats coming from sources of polyunsaturated and monounsaturated fatty acids, such as fish, nuts, and vegetable oils.

When selecting and preparing meat, poultry, dry beans, and milk or milk products, make choices that are lean, low-fat, or fat-free.

Limit intake of fats and oils high in saturated and/or trans fatty acids, and choose products low in such fats and oils.

Choose fiber-rich fruits, vegetables, and whole grains often.

Choose and prepare foods and beverages with few added sugars or caloric sweeteners. High refined sugars are linked to the development of blood sugar regulatory problems, such as type 2 diabetes and insulin resistance.

Reduce the incidence of dental caries by practicing good oral hygiene and consuming sugar- and starch-containing foods and beverages less frequently.

Consume less than 2,300 milligrams (approximately one teaspoon of salt) of sodium per day. Inreased intake of sodium may be linked to the development of high blood pressure.

Choose and prepare foods with little salt. At the same time, consume potassium-rich foods, such as fruits and vegetables.

Those who choose to drink alcoholic beverages should do so sensibly and in moderation. Moderation is defined as the consumption of up to one drink per day for women and up to two drinks per day for men.

Alcoholic beverages should not be consumed by some individuals, including those who cannot restrict their alcohol intake, women of childbearing age who may become pregnant, pregnant and lactating women, children and adolescents, individuals taking medications that can interact with alcohol, and those with specific medical conditions.

Alcoholic beverages should be avoided by individuals engaging in activities that require attention, skill, or coordination, such as driving or operating machinery.

Taking a multi-vitamin supplement daily in addition to a healthy diet is recommended. A multi-vitamin will contain the dietary reference intake (DRI) of vitamins and minerals recommended by healthcare providers.

Author information

This information has been edited and peer-reviewed by contributors to the Natural Standard Research Collaboration (www.naturalstandard.com).

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Causes and risk factors

Risk factors for developing nutritional deficiencies include unhealthy dieting to lose weight, smoking, and alcohol dependence. Also at risk are patients on special diets recovering from gastric surgery, especially those who have undergone bariatric surgery like gastric bypass. Gastric bypass surgery removes some of the stomach, leaving only a walnut-sized portion. This decrease in the size of the stomach and a decrease in the amount of food eaten may lead to nutritional deficiencies; there are not enough nutrients absorbed for the body to use (called malabsorption). Malabsorption can cause nutrient deficiencies. Other causes include achlorhydria and hypochlorhydria, states where gastric acid levels are either absent or low in the stomach, respectively, causing malabsorption of certain vitamins and minerals. Stomach acidity is necessary in order to change some vitamins and minerals, such as vitamin B12 and iron, into forms that the body can absorb.

Cachexia is the physical wasting with loss of weight and muscle mass caused by disease. Cachexia can be a sign of various underlying disorders, such as cancer, certain infectious diseases (such as tuberculosis and acquired immunodeficiency syndrome), and autoimmune disorders (such as rheumatoid arthritis). The individual does not consume and absorb enough nutrients. Loss of weight, muscle atrophy, fatigue, weakness, and significant loss of appetite occurs over time. Cachexia can occur in people who are eating enough, but who cannot absorb the nutrients.

Many prescription medications may cause various nutrients to be depleted from the body. This nutrient depletion may occur immediately (acute) or over time when taking certain prescribed medications. Medications commonly causing nutrient depletion include: antibiotic, anticonvulsant, antidiabetic, anti-inflammatory, cardiovascular, cholesterol-lowering, female hormones, antigout, psychotherapeutic, anti-ulcer, and laxative medications. Nutrient depletion caused by medications can occur due to a decrease in absorption of the nutrient caused by the medication or by biochemical changes.

Malnutrition occurs when the individual does not get enough calories or nutrients to keep themselves healthy. Nutrients are protein, fat, carbohydrates, vitamins, and minerals. Malnutrition may make the body weak, and it may cause health problems such as trouble fighting infections and healing.

Selected nutritional deficiency symptoms and complications

Note: See the Integrative Therapies section for a more detailed explanation of each nutrient and its function in the body.

Biotin: Symptoms of biotin deficiency include dermatitis, eye inflammation, hair loss, loss of muscle control, insomnia, and muscle weakness.

Calcium: Symptoms of calcium deficiency include brittle nails, cramps, delusions, depression, insomnia, irritability, osteoporosis, palpitations, periodontal disease, rickets, and tooth decay.

Copper: Symptoms of copper deficiency include anemia, arterial damage, depression, diarrhea, fatigue, fragile bones, hair loss, hyperthyroidism, and weakness.

Essential fatty acids: Symptoms of essential fatty acid deficiency include diarrhea, dry skin and hair, hair loss, immune impairment, infertility, poor wound healing, premenstrual syndrome, acne, eczema, gall stones, and liver degeneration.

Folic acid: Symptoms of folic acid deficiency include anemia, apathy, diarrhea, fatigue, headaches, insomnia, loss of appetite, neural tube defects in fetus, paranoia, shortness of breath, and weakness.

Iodine: Symptoms of iodine deficiency include cretinism, fatigue, hypothyroidism, and weight gain.

Iron: Symptoms of iron deficiency include anemia, brittle nails, confusion, constipation, depression, dizziness, fatigue, headaches, inflamed tongue, and mouth lesions.

Niacin: Symptoms of niacin deficiency include bad breath, canker sores, confusion, depression, dermatitis, diarrhea, emotional instability, fatigue, irritability, loss of appetite, memory impairment, muscle weakness, nausea, skin eruptions, and inflammation.

Pantothenic acid: Symptoms of pantothenic acid (vitamin B5) deficiency include abdominal pains, burning feet, depression, eczema, fatigue, hair loss, immune impairment, insomnia, irritability, low blood pressure, muscle spasms, nausea, and poor coordination.

Pyridoxine (vitamin B6): Symptoms of pyridoxine (vitamin B6) deficiency include acne, anemia, arthritis, eye inflammation, depression, dizziness, facial oiliness, fatigue, impaired wound healing, irritability, loss of appetite, loss of hair, mouth lesions, and nausea.

Riboflavin: Symptoms of riboflavin (vitamin B2) deficiency include blurred vision, cataracts, depression, dermatitis, dizziness, hair loss, inflamed eyes, mouth lesions, nervousness, neurological symptoms (numbness, loss of sensation, "electric shock" sensations), seizures, sensitivity to light, sleepiness, and weakness.

Thiamin: Symptoms of thiamin (vitamin B1) deficiency include confusion, constipation, digestive problems, irritability, loss of appetite, memory loss, nervousness, numbness of hands and feet, pain sensitivity, poor coordination, and weakness.

Vitamin A: Symptoms of vitamin A deficiency include acne, dry hair, fatigue, growth impairment, insomnia, hyperkeratosis (thickening and roughness of skin), immune impairment, night blindness, and weight loss.

Vitamin B12: Symptoms of vitamin B12 deficiency include anemia, constipation, depression, dizziness, fatigue, intestinal disturbances, headaches, irritability, loss of vibration sensation, low stomach acid, mental disturbances, moodiness, mouth lesions, numbness, and spinal cord degeneration.

Vitamin C: Symptoms of vitamin C deficiency include bleeding gums, depression, easy bruising, impaired wound healing, irritability, joint pains, loose teeth, malaise, and tiredness.

Vitamin D: Symptoms of vitamin D deficiency include burning sensations in the mouth, diarrhea, insomnia, blurred vision, nervousness, osteomalacia, osteoporosis, rickets, and scalp sweating.

Vitamin E: Symptoms of vitamin E deficiency include neurological problems (such as gait disturbances and poor reflexes) and shortened red blood cell life.

Vitamin K: Symptoms of vitamin K deficiency include heavy menstrual bleeding, gastrointestinal bleeding, hematuria (blood in the urine), nosebleeds, bleeding gums, and easy bruising.

Diagnosis and treatment

If a doctor believes that an individual is suffering from a lack of nutrition, the healthcare provider will weigh the individual and make a dietary assessment, which includes a diet history or food frequency analysis.

Blood tests to look for anemia, thyroid disorders, and to measure levels of specific nutrients (such as vitamins and minerals) are usually used.

Diagnosis using contrast X-rays of the gastrointestinal tract may be carried out to test for underlying digestive disorders. If the deficiency is severe, the individual will be admitted to a hospital where nutrients will be administered using a tube passed through the nose into the stomach (G-tube) or intravenously (IV) directly into the bloodstream.

Changing the diet will resolve the problem if poor eating habits are the cause. Each individual will have specific nutrient (vitamin and mineral) deficiencies, so it is important for a doctor to determine which nutrient deficiency is present. A sample of blood will generally be taken in a clinic or hospital and analyzed for vitamin and mineral status. In some cases, such as Crohn's disease (a chronic, episodic, inflammatory condition of the gastrointestinal tract characterized by affecting the entire wall of the involved bowel or intestines) or gastric bypass, long-term vitamin and mineral supplementation will be required. These conditions cause changes in the absorption of nutrients and can cause long-term vitamin and mineral deficiencies.

If medications are causing nutrient depletion, supplementation with multivitamin therapy or the depleted nutrient, such as coenzyme Q10 (with certain cholesterol-lowering medications called HMG-CoA reductase inhibitors), is recommended by healthcare providers. It is recommended to discuss any interactions with medications or dietary supplements with a healthcare provider.

Nutritionist: A nutritionist is a health professional dedicated to food and nutritional science, preventive nutrition, diseases related to nutrient deficiencies, and the use of nutrient manipulation to enhance the clinical response to human diseases. Nutritionists evaluate the diets of individuals suffering from medical disorders and suggest ways of fighting various health problems by modifying the individual's intake of certain food items.

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