Sunday, June 12, 2016

nutrient deficiencies

Subclinical Signs of Nutrient Deficiencies

There are often subtle signs indicating that our patients are deficient in a particular nutrient. Often these signs manifest in the skin, hair, nails and eyes, but can show up in other areas of the body as well. The fact is that we can tell a lot about our patients' nutritional needs simply by being aware of external signs of deficiencies.   

In this article, I will discuss the specific ways in which our patients' bodies give us clues as to what nutrients need to be supplemented for optimal health.

Bumps on the Back of the Arms

I have found that bumps on the back of the arms are caused by an essential fatty acid imbalance. I have noticed that when patients who have this problem begin taking omega-3 fatty acid supplements, the problem resolves.

Bumps on the back of the arms also can be caused by keratosis pilaris, a skin disorder caused when keratin hardens around the hair follicles. Researchers now think this disorder is caused by a coiled hair shaft, which ruptures the follicular epithelium leading to inflammation and abnormal follicular keratinization.

Perhaps the reason why omega-3 fatty acids resolve bumps on the back of the arms is because omega-3s are known to be anti-inflammatory and would therefore decrease the inflammation associated with keratosis pilaris, although there is no research to support this theory.

Nutrient Deficiencies and the Fingernails

I have noted that white spots on the nails (leukonychia) resolve after zinc supplementation. Within 12 to 16 weeks after supplementation, the white spots go away completely.

Other changes to fingernails also may indicate specific nutrient deficiencies. Beau's lines may be associated with a zinc or protein deficiency. Koilonychias - otherwise known as "spooning" of the fingernails - is associated with a deficiency in iron, copper, zinc and protein. Pale nail beds have been linked to iron deficiency and Muehrcke's lines with protein deficiency. Splinter hemorrhages are linked to a need for vitamin C, onycholysis with a need for iron and niacin and chronic paronychia may indicate a need for zinc.2-3

Weak nails may signify a biotin deficiency. Brittle nail syndrome resolves with supplementation of 2.5 mg of biotin daily.4
Silicon also plays an important role in nail health. Silicon is the third most abundant trace element in the human body.5 It is present in 1-10 parts-per-million (ppm) in nails. Silicon is naturally found in some foods - mostly plant foods such as cereals, oats, barley, white wheat flour and polished rice, although researchers have questioned its bioavailability from these foods.It's also present in drinking water, mineral water and beer, as well as supplement form.5
In an open study, women with fragile or thin hair, or brittle nails who were treated orally with 10 mL colloidal silicic acid once daily for 90 days experienced statistically significant improvement in the condition of the hair and nails.6 Brittle nail syndrome also was successfully treated with a 10 mg dose of silicon daily.4
Large Clots During Menstruation
If during menstruation a woman's clots are particularly large - the size of a dime- this could be a sign she needs more omega-3 fatty acids. Researchers have linked omega-3s to platelet aggregation in some studies. However, some research indicates omega-3's anti-clotting benefits are sex-specific, so even though it's important for women to supplement with both types of omega-3s - EPA  and DHA - it's especially important that women are getting enough DHA.
In a double-blind, randomized, placebocontrolled trial of 94 healthy men and women, researchers studied the effect of omega-3 fatty acids on platelet aggregation. The subjects receiving the omega-3s took either an EPA-rich capsule that contained 1,000 mg EPA and 200 mg DHA or a DHA-rich capsule that contained 200 mg EPA and 1,000 mg DHA. After the subjects took the supplements for four weeks, the researchers compared the effects between the males and females. 

The study authors found that, in regards to platelet aggregation and thrombotic disease risk, men were more likely to benefit from supplementation with EPA, whereas women were more responsive to DHA.7


Presuming acne in a particular patient isn’t linked to polycystic ovary syndrome, it may very well be caused by a zinc deficiency. Zinc levels are low in subjects with severe and very severe acne.8

Zinc also has antibacterial and antiinflammatory effects, but perhaps its most surprising role in clear skin is its potential ability to decrease sebum production. It does this by inhibiting corticotropin releasing hormone (CRH). In humans, keratinocytes, immune cells and human mast cells synthesize CRH after exposure to stress. CRH also may be involved in regulating keratinocytes' proliferation and differentiation, which is an important step in the early stages of acne development and could explain the connection between stress and acne.

Additionally, CRH is involved in the inflammation response and acts on sebum production by promoting lipogenesis in human sebocytes. CRH could therefore be a main player in the development of acne and zinc's anti-acne effects may stem from its CRH-inhibiting abilities.9-17

Incidentally, Propionibacterium acnes, a bacterium linked to acne, increases CRH expression by keratinocytes.18 

Muscle Cramps 

The scientific evidence has handed down an inconsistent verdict when it comes to whether magnesium and calcium supplementation can relieve muscle cramps. Many studies have shown no improvement with supplementation in subjects  with muscle cramps, although some studies in pregnant women have yielded positive results.19-21
However, most of the studies showing magnesium had no effect on muscle cramps failed to supplement the subjects with both magnesium and a B complex vitamin containing vitamin B6, or to look at B vitamin levels in the subjects studied. B vitamins, especially vitamin B6, are necessary for the absorption of magnesium by the cells.22Giving a B-vitamin-deficient person magnesium alone will not produce optimal results.
Additionally, the connection between magnesium deficiency and muscle cramps is well known. People taking proton pump inhibitors whose magnesium levels dropped because of the drugs experienced muscle cramps as one of the clinical presentations of the magnesium deficiency.23-24
Low serum magnesium levels in people not taking PPIs also manifests as muscle cramps as does low serum calcium levels.25-26
Poor Night Vision
The two nutrients most closely associated with poor night vision are vitamin A and zinc.
During a placebo-controlled trial in Nepal, weekly vitamin A or beta-carotene supplementation of women reduced but didn’t eliminate the incidence of night blindness during pregnancy. So researchers decided to try adding zinc into the mix, to see if that improved results. In the double-blind study, researchers randomly assigned 202 women who were reported to be night blind during pregnancy to one of six groups:
  1. Beta-carotene + 25 mg zinc
  2. Beta-carotene alone
  3. Vitamin A + 25 mg zinc
  4. Vitamin A + placebo
  5. Zinc + placebo or
  6. Two placebos (one for the vitamin A or beta-carotene study and one for the zinc study)
When supplemented alone, zinc failed to restore night vision or to improve dark adaptation. However, women given both vitamin A and zinc who had baseline serum zinc concentrations less than 9.9 micromol/L were four times more likely to have their night vision restored than were women in the placebo group. The vitamin A + zinc group also was more likely to have a small improvement in pupillary threshold scores.27
The researchers concluded, "These data suggest that zinc potentiated the effect of vitamin A in restoring night vision among night-blind pregnant women with low initial serum zinc concentrations."
Dry Hair
Dry hair may be a result of either biotin deficiency or a need for silica. As noted earlier, supplementation with 10 mL colloidal silicic acid once daily for 90 days results in statistically significant improvement in the condition of the hair and nails.
Another study investigated biotin in a family affected to the fourth generation by uncombable hair syndrome, characterized by unruly, dry, blond hair with a tangled appearance. Two of the young family members who were given oral biotin 5 mg/day experienced excellent improvement in hair appearance.28
Hair loss can be linked to a variety of nutrient deficiencies. Hair follicle cells have a high turnover. Therefore, nutrient deficiencies such as proteins, minerals, essential fatty acids and vitamins, caused by genetic errors or reduced uptake of nutrients, can result in structural abnormalities, pigmentation changes or hair loss.
Zinc and copper deficiencies have been linked to hair loss in patients following bariatric surgery.29 Inadequate vitamin A intake and biotin deficiency also cause hair loss.30-31
Furthermore, 80 females with hair loss had lower serum ferritin levels compared to 40 women who did not suffer from hair loss. Vitamin D levels also were lower in the women with hair loss.32
Pale Skin
Iron deficiency anemia is often to blame for skin that is excessively pale (pallor). In patients who look excessively pale, begin with a ferritin test and, if indicated, start them on an iron supplementation regimen. The best type of iron to use is iron bisglycinate chelate, a clinically researched, less-oxidizing form of iron with greater bioavailability. It is gentler on the stomach, less constipating and absorption is significantly higher than typical iron supplements (e.g., ferrous sulfate).33-34
Also, rule out Celiac disease because the malabsorption that occurs in these patients can cause iron deficiency anemia.35
Additionally, a deficiency in folic acid and vitamin B12 can also cause pale skin and supplementing with these two nutrients can be helpful.3
Excessive Ear Wax
It's widely agreed upon in alternative medicine that one cause of excessive ear wax build-up is an essential fatty acid deficiency. I have noticed in my practice that an ear wax problem goes away when patients start supplementing with either krill oil or fish oil and eating more omega-3-rich foods such as wild salmon. You can also investigate other potential causes including allergies, local irritation and dust.
Unable to Taste Food
Researchers have found that in breast cancer patients, nutrient deficiencies for vitamin B12, thiamin, folate, iron and riboflavin corresponded to the extent to which the patients lost their sense of taste.36
Having a gastrectomy has been associated with a vitamin B12 deficiency and a complete loss of the senses of taste and smell. This problem disappeared after liberal intake of vitamin B12.37
Lack of taste also is common in the elderly. The nutrients that have the biggest influence on taste - vitamins A, B6, B12 and thiamin, folate, zinc and copper - are often deficient in the elderly.38 It becomes a vicious circle: The elderly lose their taste for food due to low intake of those vitamins and therefore get less and less of the nutrients they need to enhance their sense of taste.
Vitamin E is another nutrient that influences the sense of taste and smell. In a study published in Nutrition in 2003, researchers measured vitamin E intake in 250 patients with taste and smell dysfunctions. They found that the vitamin E intake in these subjects was significantly below what is considered adequate. The patients had a low intake of vitamin E, even though they had a normal intake of total calories, protein, fat, carbohydrates and several vitamins including thiamin, niacin and pyridoxine as well as the minerals zinc, copper and iron.39
The study authors concluded, "Although specific relations between vitamin E intake and smell and taste dysfunctions are unclear, the non-antioxidant roles of vitamin E indicate that it is a factor in apoptosis, cellular signaling and growth of various cell lines, suggesting that this vitamin may play a role in growth and development of stem cells in taste buds and olfactory epithelium."
Cracks Around the Side of Mouth
Angular stomatitis - cracks around the side of the mouth - is linked to a deficiency in iron, riboflavin and possibly other B vitamins. When it is caused by riboflavin deficiency, it's usually accompanied by a purplish-red or magenta tongue and cheilosis (vertical fissuring of the lips).40
A bacterial or fungal infection could also contribute to the problem, so ruling out those two factors is prudent.
Cradle Cap
A biotin deficiency may play a role in cradle cap, which is caused by seborrheic dermatitis. Intravenous administration of biotin has proven more effective than oral supplementation. However, this may be because in many of the oral supplementation studies, infants were given biotin alone and not the rest of the B complex supplements. In one study, 25 infants with seborrheic dermatitis were divided into four groups:
  1. Vitamin B complex plus biotin given slowly intravenously over 24 hours.
  2. Only biotin intravenously over two to three hours.
  3. Only biotin over one to two minutes.
  4. Biotin plus antibiotics for confirmed or suspected superimposed bacterial infection.
All groups experienced significant improvement. Skin lesions improved within four to eight days and cleared completely within 15 to 30 days.41 Topically applied borage oil also has yielded excellent results.42
Dandruff and Other Manifestations of Seborrheic Dermatitis
As much as half of the population suffers from dandruff at some time during life.43
Dandruff can be characterized not only by the presence of flakes on the scalp and in the hair but also by itching. Yeasts of the Malassezia genus play a role in this disorder as well as genetic, environmental and general health factors.44
Common reasons for worsening of symptoms include changes in humidity, scratching, seasonal changes and emotional stress.44
Selenium is often used effectively as a topical agent in shampoos for dandruff. Although to my knowledge selenium has never been studied orally as an antidandruff agent, supplementing with selenium may be worth a try to see if it results in an improvement of the condition.
Crusty skin around the sides of the nose also can be caused by seborrheic dermatitis. B vitamins - and focusing specifically on higher dose biotin - may help resolve the condition.
Floaters occur when pieces of the gellike vitreous detach from the back portion of the eye. The vitreous humor, a clear gel that fills the gap between the retina and the lens, is made up of about 99 percent water and 1 percent other substances, mostly hyaluronic acid and collagen.
HA retains water molecules until, with age, the network of HA and collagen begins to slowly disintegrate. The water molecules are then released, which forms a watery core in the vitreous body. As time goes on, pieces of the gel-like collagen/ hyaluronic acid network continue to split off and float around in the watery center. Floaters are caused when light shines through this area, creating a shadow on the retina.
Replenishing the body's HA supply may therefore strengthen the vitreous humor and perhaps reduce its tendency to break down and result in floaters, although no studies exist on oral supplementation for this purpose as far as I'm aware. However, cross-linked biopolymers of hyaluronic acid have been used as an artificial vitreous substitute.45
Skin Elasticity
A decline in skin elasticity is due in part to the reduced hyaluronic acid levels that occur with age. HA plays an important role in collagen health and is critical in upholding the moisture content of the skin.
HA-based creams result in a significant improvement in skin hydration and overall elasticity compared to placebo. Measurements of wrinkle depth using mean roughness and maximum roughness values revealed significant improvement in women using HA creams after 60 days of treatment compared to the placebo-treated area.46
We can tell a lot about what nutrients our patients need by keeping an observant eye on external signs. Supplementing with specific nutrients can result in significant improvement in a number of conditions from skin and hair disorders to vision problems and beyond.

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