Community pharmacy Topic: 2 part(1) Vitamins supplements

1. Community pharmacy Topic: 2part(1)Vitamins supplements 1

2. Vitamins They are complex organic compounds required by the body in very small amounts. They are concerned with vital metabolic function in the body, and hence essential for maintenance of health. Since vitamins can not be manufactured in body, they have to be supplied through the diet. 2

3. Vitamins are classified into two major groups: Fat soluble vitamins: A, D,E,K Water soluble vitamins: B complex and C (ascorbic acid)… 3

4. Ref: Food and Vitamins and Supplements! Oh My! Demystifying nutrition: the value of food, vitamins and supplements, Harvard Medical School, 2013 4

5. IU mg 5 mcg

6. Dietary supplement containing multiple vitamins for children and adults

7. Recommended doses classification 7 • Recommended Dietary Allowance (RDA): • average daily level of intake sufficient to meet the nutrient requirements of nearly all (97%–98%) healthy individuals. 2. Adequate Intake (AI): • established when evidence is insufficient to develop an RDA and is set at a level assumed to ensure nutritional adequacy.

8. 8 3. Estimated Average Requirement (EAR): • average daily level of intake estimated to meet the requirements of 50% of healthy individuals. It is usually used to assess the adequacy of nutrient intakes in population groups but not individuals. 4. Tolerable Upper Intake Level (UL): • maximum daily intake unlikely to cause adverse health effects.

9. International unit (IU) • Standard measure of the biological activity (biological effect) of manufactured medicinal drugs and vitamins. • For every substance to which this unit is assigned, there is an internationally accepted biological effect expected with a dose of 1 IU. • Ex: • 1 IU = • 0.3 microgram (0.0003 milligram) of vitamin-A • 50 micrograms (0.050 milligram) of vitamin-C • 25 nanograms (0.000025 milligram) of vitamin-D.

10. Vitamin A In pregnancy Teratogenic in excessive amounts Avoid multivitamins containing vitamin A like fish liver oils 10 • VITAMIN A: Retinol, retinal, and retinoic acid — two forms of vitamin A in the body are: • preformed vitamin A (retinol and its esterified form, retinyl ester) • Alpha,Beta carotene can easily be converted to vitamin A as needed.

11. 11 • Benefits: 1. Vision: • Essential component of rhodopsin ( protein that absorbs light in the retinal receptors) • It supports the normal differentiation and functioning of the conjunctival membranes and cornea • Foods rich in the carotenoids may protect against cataracts 2. Skin: Keeps tissues and skin healthy. 3. Bone: Plays an important role in bone growth.

12. 12 4. Cancer: Diets rich in the carotenoids alpha carotene and lycopene seem to lower lung cancer risk. 5. Antioxidants : Carotenoids. 6. Body system: • supports cell growth and differentiation, • playing a critical role in the normal formation • Maintenance of the heart, lungs, kidneys • involved in immune function, reproduction

13. Recommended amount (daily RDA or daily AI) 13 • Because the body converts all dietary sources of vitamin A into retinol, 1 mcg of physiologically available retinol is equivalent to the following amounts from dietary sources: • 12 mcg of beta-carotene • 24 mcg of alpha-carotene. • Vitamin A is listed on food and supplement labels in international units (IUs).

14. 14 Converting from RAE to IU depend on vit A type From dietary supplements, the body converts 2 mcg of beta-carotene to 1 mcg of retinol. 1 IU retinol = 0.3 mcg RAE Ex: the RDA of 900 mcg RAE for adolescent and adult men is equivalent to 3,000 IU if the food or supplement source is preformed vitamin A (retinol) Multivitamin supplements typically contain 2,500–10,000 IU vitamin A, often in the form of both retinol and beta-carotene

16. Deficiency signs :Loss of night vision (night blindness)….xerophthalmia • Risk groups: • Premature Infants • Infants and Young Children in Developing Countries • Pregnant and Lactating Women in Developing Countries • People with Cystic Fibrosis 16

17. 17 Health Risks from Excessive Vitamin A Chronic intake of excessive amount: increased intracranial pressure, dizziness, nausea, headaches, skin irritation, pain in joints bones, liver damage, and even coma Congenital birth defects: Total intakes of preformed vitamin A that exceed the UL and some synthetic retinoids used as topical therapies (such as isotretinoin) Risk of lung cancer and cardiovascular disease in smokers

18. THIAMIN (vitamin B1) 18 Benefits: Helps to convert food into energy. Needed for healthy skin, hair, muscles, and brain and helps the nervous system, heart, digestive system and nerve tissues damaged by alcoholism.

19. 19 Heating foods containing thiamin can reduce their thiamin content. For example, bread has 20%–30% less thiamin than its raw ingredients, and pasteurization reduces thiamin content in milk by up to 20% Thiamin is available in many dietary supplements. Multivitamin supplements with thiamin typically provide about 1.5 mg thiamin (100% of the DV) and sometimes more The most commonly used forms of thiamin in supplements are thiamin mononitrate and thiamin hydrochloride

20. 20 • Deficiency signs: • Early stage: can cause weight loss and anorexia, confusion, short-term memory loss, muscle weakness; and cardiovascular symptoms. • Beriberi: rare condition which is characterized mainly by peripheral neuropathy, some have impaired sensory, motor, and reflex functions. In rare cases, beriberi causes congestive heart failure that leads to edema in the lower limbs and, occasionally, death

21. 21 Wernicke-Korsakoff syndrome : 8–10 times more in alcoholic Groups at Risk of Thiamin Inadequacy: People with alcohol dependence Older adults People with HIV/AIDS People with diabetes People who have undergone bariatric surgery

22. RIBOFLAVIN(vitamin B2) 22 Helps to convert food into energy. Needed for healthy skin, hair, blood, brain, proper metabolism of fat, protein and carbohydrates, the eyes and sensitive oral areas. M: 1.3 mg, W: 1.1 mg Deficiency signs: Itching of the lips, eyes, throat, nose and mouth. Can also show up as cracking in the lip corners.

23. 23 Safety: This vitamin is water soluble and excess amounts are excreted in the urine. No known toxicity During lactation there is increased requirements for some vitamins and minerals (folate, vitamin B2, B6, B12, C) Avoid use of megadose regimens.

24. NIACIN (vitamin B3, nicotinic acid) 24 Helps convert food into energy. Essential for healthy skin, blood cells, brain, and nervous system M: 16 mg, W: 14 mg Niacin occurs naturally in food and can also be made by your body from the amino acid tryptophan, with the help of B6.

25. PANTO-THENIC-ACID (vitamin B5) 25 Helps to convert food into energy. Helps to make lipids (fats), neurotransmitters, steroid hormones, and hemoglobin M: 5 mg, W: 5 mg Deficiency: causes burning in feet and other neurologic symptoms. Wide variety of nutritious foods, including chicken, whole grains, broccoli, mushrooms, avocados, tomato products

26. VITAMINB6(pyridoxine, pyridoxamine) 26 Help in lowering homocysteine levels and may reduce the risk of heart disease. Helps to convert tryptophan to niacin and serotonin (a neurotransmitter that plays key roles in sleep, appetite, and moods). Helps to make red blood cells, enzyme reactions and protein metabolism 31–50: M: 1.3 mg, W: 1.3 mg 51+: M: 1.7 mg, W: 1.5 mg

27. 27 • Prevents issues with nerves, skin problems, increases proper absorption of carbohydrates and protein • Deficiency signs: • Isolated vitamin B6 deficiency is uncommon; inadequate vitamin B6 status is usually associated with low concentrations of other B-complex vitamins, such as B12 and folic acid….Inflammation of the skin • Vitamin B6 deficiency is associated with microcytic anemia

28. 28 Dietary supplements: Vitamin B6 is available in multivitamins, in supplements containing other B complex vitamins, and as a stand-alone supplement . The most common form in supplements is pyridoxine (in the form of pyridoxine hydrochloride

29. Groups at Risk of Vitamin B6 Inadequacy 29 Individuals with Impaired Renal Function Individuals with Autoimmune Disorders(RA inflammation) People with Alcohol Dependence Safety: chronic use may cause issues with the nervous system (administration of 1–6 g oral pyridoxine per day for 12–40 months can cause severe and progressive sensory neuropathy characterized by ataxia (loss of control of bodily movements)

30. Vitamin B12(cobalamin) 30 Vitamin B12 is required for proper red blood cell formation, neurological function, and DNA synthesis. M: 2.4 mcg, W: 2.4 mcg Meat, fish, milk, cheese, eggs, fortified cereals and liver, fortified soymilk

31. 31 • Dietary supplements: • In dietary supplements, vitamin B12 is usually present as cyanocobalamin, body readily converts to the active forms methylcobalamin and 5-deoxyadenosylcobalamin • Prescription medications: • The form of cyanocobalamin and occasionally hydroxocobalamin • can be administered parenterally, usually by intramuscular injection • vitamin B12 deficiency caused by pernicious anemia

32. 32 Vitamin B12 deficiency: malabsorption, pernicious anaemia – lack of gastric intrinsic factor. Deficiency Signs: Anemia, fatigue, memory issues, numbness and tingling.

33. Groups at Risk of Vitamin B12 Deficiency 33 Older adults Individuals with pernicious anemia  Individuals with gastrointestinal disorders Individuals who have had gastrointestinal surgery Vegetarians Pregnant and lactating women who follow strict vegetarian diets and their infants

34. 34 Dementia and cognitive function: A deficiency in vitamin B12 causes an accumulation of homocysteine in the blood and might decrease levels of substances needed to metabolize neurotransmitters A positive associations between elevated homocysteine levels and the incidence of both Alzheimer's disease and dementia. Low vitamin B12 status has also been positively associated with cognitive decline.

35. 35 Energy and enduranceDue to its role in energy metabolism, vitamin B12 is frequently promoted as an energy enhancer and an athletic performance and endurance. As The anemia caused by vitamin B12 deficiency associated with symptoms of fatigue and weakness. However, vitamin B12 supplementation appears to have no beneficial effect on performance in the absence of a nutritional deficit

36. 36 MetforminMetformin, a hypoglycemic agent used to treat diabetes, might reduce the absorption of vitamin B12, possibly through alterations in intestinal mobility, increased bacterial overgrowth, or alterations in the calcium-dependent uptake by ileal cells of the vitamin B12-intrinsic factor complex

37. 37 Some people, particularly older adults, are deficient in vitamin B12 because they have trouble absorbing this vitamin from food. Safety: This vitamin is water soluble and not known to be toxic. Damaged By: Alcohol, estrogen, sunlight and water.

38. BIOTIN (Vitamin H) 38 Helps to convert food into energy and synthesize glucose. Helps to make and break down some fatty acids. Needed for healthy bones and hair Strong's the hair and nails, keeping blood sugar levels stable and helping metabolism react to changes in the body. M: 30 mcg, W: 30 mcg

39. 39 body needs very little biotin. Some is made by bacteria in the GI tract. However, it’s not clear how much of this the body absorbs. It’s a Key role in metabolizing fats, carbohydrates, and proteins Deficiency: Not common; symptoms include baldness, a rash around the mouth and nose, dry and flaky skin, Fatigue, loss of hair, muscle weakness and pain, poor appetite, & depression and nausea.

40. 40 Biotin can used in high doses. For example, in the treatment of seborrheic dermatitis in infants, no adverse effects are reported.

41. Vitamin C (ascorbic acid) 41 Foods rich in vitamin C may lower the risk for some cancers, including those of the mouth, esophagus, stomach, and breast. Long-term use of supplemental vitamin C may protect against cataracts. Helps to make collagen (a connective tissue that knits together wounds and supports blood vessel walls) Vitamin C supplementation (citrus fruit) improves absorption of iron.

42. 42 • Helps to make the neurotransmitters serotonin and norepinephrine Acts as an antioxidant, neutralizing unstable molecules that can damage cells. • Wound healing, protection from viral and bacterial infections, immune system support, prevention of scurvy, cell lifespan and lowering cholesterol. • Total body content of vitamin C ranges from 300 mg (at near scurvy) to about 2 g

43. Safety: Over 2000 mg daily can cause nausea and diarrhea. There is a chance that 1000 to 5000 mg daily can have damaging effects on DNA 43

44. 44 For cold and influenza: Vitamin C is an antioxidant that neutralises the oxidising compounds released by neutrophils during a viral infection. Doses of 1–4 g/ day decrease duration and severity of cold symptoms by 10–30%. At high doses it interferes with diabetes urine tests and increases risk of production of urinary oxalate leading to renal stones.

45. 45 Deficiency: Acute vitamin C deficiency leads to scurvy. Poor wound healing, fatigue and gum bleeding Damage by: Heat, smoking, boiling foods, and light. Risk groups: Smokers and passive, Infants fed evaporated or boiled milk, Individuals with limited food variety or with malabsorption and certain chronic diseases

46. VITAMIN D(calciferol) 46 Vitamin D promotes calcium absorption in the gut and maintains adequate serum calcium and phosphate concentrations to enable normal mineralization of bone and to prevent hypocalcemic tetany

47. 47

48. 48 Safety: Vitamin D is stored in the body’s fat cells and can accumulate. Too much vitamin D can cause toxicity, but the overdose amounts are different for everyone. For example, children should not take more than 400 iu daily. cod liver oil, 1 tablespoon (1,360 IU) salmon, cooked, 3 ounces (447 IU) vitamin D-fortified orange juice, 1 cup (137 IU)

49. 49 Calcitriol (hydroxylated derivative of vitamin D) Stimulates active transport of calcium Acts on bone mineralisation Side-effect: occurrence of hypercalcaemia Monitor plasma calcium concentration and creatinine levels.

50. In supplements and fortified foods, vitamin D is available in two forms, D2 (ergocalciferol) and D3(cholecalciferol) 50