Overview of Zinc

TABLE OF CONTENTS
Acknowledgements .............................................................................................................. 3
Document guide.................................................................................................................... 4
Take home points: zinc summary chart ................................................................................ 5
A trace mineral...................................................................................................................... 9!
Historical perspective............................................................................................................ 9
Functions and deficiencies .................................................................................................. 9
Functions ................................................................................................................. 10
Consequences of deficiency .................................................................................... 10
Zinc-dependent cellular functions ............................................................................ 10
Immune function and wound healing ....................................................................... 11
Normal growth and development / growth and development of nervous system and
neurological functions .............................................................................................. 13
Sexual maturity and reproduction ............................................................................ 14
Normal blood sugar balance and metabolic rate ..................................................... 14
Proper appetite, sense of taste and smell................................................................ 14
Age-related macular degeneration........................................................................... 15
Symptoms of deficiency ...................................................................................................... 15
Individuals most at risk ....................................................................................................... 16
Absorption, transport, and storage in the body ................................................................... 18
Food (and supplement) sources ......................................................................................... 19
Requirements across populations / recommended dosage................................................ 21
Toxicities ............................................................................................................................. 22
Micronutrient interconnectedness and nutrient-nutrient interactions .................................. 23!
Absorption inhibitors and enhancers .................................................................................. 24
Stability ............................................................................................................................... 24!
Zinc and fortification............................................................................................................ 24
Measurement indicators / biomarkers of vitamin A deficeincy (clinical, functional,
histological, and biochemical) ............................................................................................. 26!
2

Acknowledgements
The creation of this zinc training module would not have been possible without the
contribution of numerous sites and organizations. Specifically, the Linus Pauling Institute;
the National Institutes of Healths Office of Dietary Supplements (NIH / ODS); Wardlaw,
Hampl, and DiSilvestros 2004 sixth edition of Perspectives in Nutrition; and Tufts
Universitys Friedman School of Nutrition Science and Policy Introduction to Human
Nutrition course (McKay, Fall 2004). Special thanks to the Flour Fortification Initiative (FFI)
for their willingness to share the material on their website.
This zinc module is the third in a series of micronutrient modules adapted from an internal
organizational training program developed by Project Healthy Children (PHC). The
material is intended to provide the reader with an in-depth look at the major micronutrients
generally targeted in nutrition interventions to ensure a detailed understanding of how the
nutrients work and why they are important. Previous modules include vitamin A and iron;
subsequent modules cover zinc and iodine.
For any questions regarding the material, please contact Project Healthy Childrens
Director of Nutrition Programming, Laura Rowe, at lrowe@projecthealthychildren.org.

Document guide: suggestions on how to tackle this module

This document has been structured so that it delivers information in the same way as the
previous modules. Therefore, a similar warning pertains: reading through this entire
document in one day may be dangerous!
Divide up the document and the time you have to read it so that you are only going through
a few sections at a time. This will help you to get through it in a more manageable way.
The tackling technique is the same as that outlined for the other modules:
Each section is followed by a quick recap to summarize main points and provide a
convenient way of returning to each section for review. However, reading the entire
document is advised as diagrams attempt to make potentially confusing points clearer and
explain the why behind much of what we already know about zinc.
If you understand the content included in the take home points: zinc summary chart and
the quick recaps you will have retained the nuts and bolts of this module. If you would like
further explanation any of the modules cited sources are good to review.
Please note this information is not intended to be used as individual nutritional guidance. It
is meant only to be used as education material.

Functions and
functional
explanations

Take home points: zinc summary chart

Numerous zinc-dependent enzymes exist that affect protein
structure and synthesis, replication of DNA and RNA,
regulations of gene activity, cell division and activation
o Required by more enzymes in the body than all trace
minerals combined. Needed to catalyze chemical
reactions; ensure proteins and cell membranes work
properly; read DNA instructions; ensure cell signaling,
hormone release, and nerve impulse transmission.
Immune function and wound healing
o Low zinc status = poor thymic development. A poorly
developed thymus = weak T-cells that are unable to
recognize and fight off infection, impacting rates of
diarrhea and respiratory tract infections.
o Due to zincs role in maintaining skin and mucus
membranes, zinc is important for wound healing.
o Zinc and the common cold: zinc prevents the
replication of rhinovirus (a common cause of colds).
Normal growth and development during pregnancy,
childhood, and adolescence / growth and development of
the nervous system and neurological functions
o Affects the growth-regulating hormone IGF-1. Without
zinc, this growth hormone cannot do its job leading to
stunted growth in young children.
o Bone growth is affected due to zinc-dependent
enzymes and hormones required for bone
development.
o If a pregnant woman is zinc deficient, the fetus can
experience growth retardation in utero adversely
affecting the childs long-term immune functioning
and neurological and behavioral development.
Sexual maturity and reproduction
o Required for the functioning of the prostate gland, to
manufacture testosterone, and to ensure healthy
sperm since the pituitary gland needs zinc to release
hormones to create testosterone. Zinc deficiency in
adolescents can lead to delayed puberty.
Normal blood sugar balance and metabolic rate
o Decrease in zinc = decrease in insulin response =
destabilized blood sugar.
o Decrease in zinc = decrease in our metabolic rate.
o Decrease in zinc = decreased hormonal output by the
thyroid gland causing a zinc deficiency to have similar
detrimental effects on iodized salt as iron deficiency.
That is, iodine cant assist the thyroid to create the

Consequences of
deficiency

Symptoms of
deficiency
Individuals most at
risk

Absorption,
transport, and
storage

thyroid hormone without adequate zinc or iron.

Proper appetite, sense of taste and smell
o We need the protein gustin, found in the saliva, in
order to taste. Gustin needs zinc to function. Since
smell and taste are connected, deficiency causes
impaired sense of taste and smell.
Proper functioning of the retina
o Zinc prevents cellular damage to the retina. A lack of
zinc = poor retina and macula functioning
(responsible for central vision).
o Zinc in the retina decreases with age impacting
vision.
o Zinc is needed to convert retinol to retinal allowing for
proper night vision.
Contributes to 800,000 child deaths / year due to zincs
impact on immune functions. Global estimates indicate that
~1/3 of the worlds population live in countries where the risk
of zinc deficiency is high
Diarrhea rates are linked to insufficient levels of zinc with
diarrhea causing 18% or 3 million child deaths a year
Causes dwarfism due to zincs impact on growth and
development
Impairs vitamin A metabolism contributing to vit A deficiency
Impaired taste and smell, hair loss, loss of appetite,
diarrhea, delayed sexual maturity, growth retardation /
stunting in children, mental lethargy, night blindness.
Aside from diets low in zinc, deficiency is common when
diets are high in phytates. Soaking beans, grains, and seeds
will activate natural phytases, which deactivate phytates.
Those most at risk include:
Preterm infants b/c zinc is stored up during the last trimester
Pregnant and lactating women b/c the fetus requires high
levels of zinc
Infants older than 6 mo still breastfeeding since breast milk
provides sufficient zinc for the first 4-6 months of life only
Individuals with sickle cell anemia, HIV/AIDS, malabsorption
problems, older adults, and alcoholics (alcohol decreases
the bodys ability to absorb zinc and increases excretion).
Zinc is absorbed in the small intestine and binds to the
storage protein metallothionein.
If the body does not need zinc, it is sloughed off along with
dead cells and excreted by the pancreas into the intestinal
tract and then leaves the body via the feces and to a lesser
extent in urine and sweat.
If the body does need zinc, metallothionein hands zinc off to
albumin and transferrin for transport to tissues that need it
mostly muscle and bone tissues.
6

Sources

Recommended
Daily Allowance
(RDA)

Toxicity symptoms

Nutrient-nutrient
interactions and
interconnectedness

Absorption
inhibitors and
enhancers
Stability
Zinc and
fortification

Bioavailability is higher in animal products due to the

absence of compounds that inhibit absorption (i.e. phytates
and oxalates) and the presence of certain amino acids (i.e.
cysteine and methionine) that improve absorption.
Good animal sources: goat, beef, shellfish, liver, eggs.
Good plant sources: whole grains, peanuts, legumes. Breast
milk is a good source of zinc for the infant but is not affected
by maternal status.
Supplements are recommended by WHO and UNICEF to
treat acute childhood diarrhea.
RDA for adolescents and adults: 8-11 mg/day; 11-13
mg/day for pregnant and lactating women (higher for
lactating). Infants 0-6 months: 2mg/day; infants 7-12
months: 3 mg/day.
UL is based on when zinc begins to interfere with copper. A
copper deficiency can reduce HDL (good cholesterol) levels.
UL for adult: 40 mg/day
Too much zinc can also interfere with iron causing anemia.
Symptoms of overload: abdominal pain, diarrhea, vomiting.
Zinc and vitamin A: zinc is needed by retinal binding protein
(RBP). Therefore, a lack of zinc = a lack of vitamin A to
tissues in need. Zinc is needed to convert retinol into retinal
retinal is needed to create rhodopsin, the protein in the
eye that absorbs light. Therefore, a lack of zinc = potential
for night blindness.
Zinc and copper: high zinc = copper is trapped and not able
to be absorbed = lowers levels of HDL.
Zinc and iron: too much zinc can decrease iron absorption
causing anemia. Too much iron can decrease zinc
absorption.
Zinc and calcium: calcium, in combination with phytic acid,
reduces zinc absorption.
Zinc and folic acid: folate bioavailability may go up when
zinc is present.
Zinc and protein: protein deficiency can cause zinc
deficiency because zinc needs proteins to shuttle and store
it through the body.
Inhibitors: phytates, oxalates, fiber, calcium, iron, copper.
Enhancers: phytases, protein, human milk, low zinc stores.
High sensitivity to heat and food processing.
Zinc oxide is the most common form used in fortification due
to low cost and high stability.
Low extraction (i.e. highly processed foods) may allow for
low phytate but also causes low zinc content. A good
strategy to increase the zinc in low extraction flours: activate
7

Measurement
indicators /
biomarkers

phytases by soaking or allowing to ferment / germinate.

The addition of animal sources also improves absorption.
Few reliable biomarkers for zinc deficiency exit to date.
Serum and plasma zinc are the most common indicators
used. A big down side is that plasma zinc decreases during
pregnancy, protein-energy malnutrition (PEM), and infection.
Proxy indicators are used in lieu of a lack of reliable
biomarkers and include:
o Prevalence of inadequate intakes of zinc (through
dietary surveys) > 25%
o HAZ for children under the age of five > 20%.
o A high prevalence of diarrhea is also often used as a
proxy indictor, although there is no designated cut-off
at this point in time.

A Trace Mineral1
Zinc is a trace mineral, which, as you may recall, means it holds the following properties of
all trace minerals:
Trace Mineral General Properties
1. Named because your body only requires very small amounts of them (less
than 100mg/day) to function properly.
2. Although trace minerals constitute less than 1% of all minerals in the body,
they are dietary essentials that have specified biological functions.
3. Includes: iron, zinc, manganese, copper, fluoride, molybdenum, iodine,
chromium and selenium.
4. Plant sources are dependent on the soil content. If the soil is poor or low in a
mineral, the plant will be too.
5. Animal sources are, in general, better absorbed.
6. Dietary deficiency produces physiological or structural abnormalities.
7. All minerals assist in energy metabolism.
Historical perspective2,3
Zinc was recognized as an essential nutrient for animals in the 1900s. However, the
significance of zinc in human nutrition was not recognized until 1961, when in Egypt and
Iran it was determined that a zinc deficiency was the cause of growth retardation and
inadequate sexual development in humans. However, the diet of these populations was
not actually that low in zinc. The factor at play was a diet high in phytates that caused low
zinc bioavailability. Consuming mostly unleavened bread meant little zinc was absorbed
since yeast fermentation (used to leaven bread) significantly reduces the effect of phytic
acid. Parasitic infections among these populations also contributed to the severe zinc
deficiency.
In the US, zinc deficiency was first recognized in the 1970s in hospitalized patients
receiving parenteral nutrition (i.e. feeding a person intravenously). Originally the protein
source for the solution was based on milk, which contains zinc. Later, the solution was
changed to contain isolated amino acids as the protein source (very low in zinc), causing
deficiency symptoms to develop. Zinc deficiency is now recognized as an important health
issue, particularly in developing countries, making it the fifth and newest member to the
top-micronutrients-to-consider-in-interventions list joining iron, vitamin A, folic acid, and
iodine. Its impact on diarrhea rates is enormous and will be outlined below.
Functions and deficiencies4,5,6,7

Wardlaw, Hampl, DiSilvestro. 2004. Perspective in Nutrition. Sixth edition.

Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/
3
Wardlaw, Hampl, DiSilvestro. 2004. Perspective in Nutrition. Sixth edition.
4
Ibid.
5
National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/
6
Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/
7
Whole Food. http://whfoods.org/genpage.php?tname=nutrient&dbid=115
2

1. Numerous zinc-dependent enzymes exist that affect protein structure and synthesis,
replication of DNA and RNA, regulations of gene activity, cell division and activation
2. Immune function and wound healing through the production of antibodies
3. Growth and development of the nervous system and neurological functions
4. Normal growth and development during pregnancy, childhood, and adolescence
5. Sexual maturity and reproduction
6. Normal blood sugar balance and metabolic rate
7. Proper appetite, sense of taste and smell
8. Proper functioning of the retina
Consequences of deficiency
If the body does not receive adequate zinc, the consequences can be severe:

Consequences of zinc deficiency8,9,10,11

Contributes to 800,000 child deaths / year due to zincs impact on immune
functions. Global estimates indicate that ~1/3 of the worlds population lives in
countries where the risk of zinc deficiency is high. (CDC)
Diarrhea rates are linked to insufficient levels of zinc with diarrhea causing 18% or
3 million child deaths year. (CDC, MI, Investing in the future)
Causes dwarfism due to zincs impact on growth and development (NIH/ODS)
Impairs vitamin A metabolism, thereby contributing to vitamin A deficiency

Zinc supplementation in combination with ORT (oral rehydration therapy) has shown to
reduce the incidence of diarrhea in children by 27%, acute lower respiratory infection by
15%, and mortality by 6%, in addition to significantly reducing the incidence of stunting12.
What is the connection?
Zinc-dependent cellular functions13,14
Almost every bodily structure and process is either directly or indirectly affected by zinc. In
fact, zinc is required by more enzymes in the body than all trace minerals combined.
(Enzymes are proteins that catalyze, or increase the rate, of chemical reactions). It is
known to form part of more than 300 metalloenzymes, which cannot function in its
absence. At the cellular level, zinc is required to play critical catalytic, structural, and
regulatory roles. Catalytic role: zinc is required by over a 100 different enzymes to catalyze
vital chemical reactions. Structural role: zinc plays a role in the proper structure and
function of proteins and cell membranes. Regulatory role: zinc helps to regulate gene
expression by binding to DNA, plays a role in cell signaling, and has been found to
8

Center for Disease Control. IMMPACT Project. http://www.cdc.gov/immpact/micronutrients/index.html#Zinc

Micronutrient Initiative. http://www.micronutrient.org/english/view.asp?x=580
10
Investing in the future: A united call to action on vitamin and mineral deficiencies. Micronutrient Initiative, 2009;
UNICEF and MIs Vitamin and Mineral Deficiency: A damage report
11
National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/
12
Investing in the future: A united call to action on vitamin and mineral deficiencies. Micronutrient Initiative, 2009;
UNICEF and MIs Vitamin and Mineral Deficiency: A damage report
13
National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/
14
Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/
9

10

influence hormone release and nerve impulse transmission. In terms of DNA, zinc is
needed to read genetic instructions. A lack of zinc = DNA instructions get misread.
Quick-recap: Zinc is required by more enzymes in the body than all trace minerals
combined. Zinc is needed to catalyze chemical reactions, to ensure proteins and cell
membranes work properly, to read DNA instructions, to ensure cell signaling, and to
ensure hormone release and nerve impulse transmission.
Immune function and wound healing15,16,17,18
Zinc has shown the most specific and in many ways the strongest effect on the function of
the immune system of any micronutrient, Cunningham-Rundles, Cornell University
Medical School.
In order to develop and activate T-lymphocyte cells the bodys defense against infection
and bacteria zinc must be present in sufficient quantities; hence the connection between
a lack of zinc and increased susceptibility to infection. How does it work? Although the
exact mechanisms behind the relationship between zinc and immunity are still up for
debate, several hypotheses have been made.
First, lets take a quick look at how the immune system is built: After birth, all immune
system-specific cells appear first in the bone marrow. Some of these cells will have the
potential ability to recognize self from non-self (i.e. the difference between healthy cells
and infectious agents). However to gain the ability to recognize healthy cells from nonhealthy cells, the cells must first become educated on how to do so. This education
occurs in the thymus a gland critical to the development of the immune system since it
educates future fighter cells. After circulating through the thymus, cells emerge as active
(educated) Thymus lymphocyte cells or T-cells, for short.

15

National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/

Shankar AH, Prasad AS. Zinc and immune function: the biological basis of altered resistance to infection. Am J Clin
Nutr. Aug;68(2 Suppl):447S-463S.1998.
16

17

Cunningham-Rundles, S. Zinc and immune function: the importance of zinc for health. Cornell University Medical
School.
18
Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/

11

So where does zinc come into play? Since zinc is a structural component of the thymic
hormone, low zinc status means poor thymic development. A poorly developed thymus
leads to reduced and weak T-cells (since T-cells mature in the thymus) that are unable to
recognize and fight off infection. In other words, the body requires zinc to develop and
activate T-lymphocytes since thymic weakness is induced by zinc deficiency leading to
increased susceptibility to infections, particularly in children. So T-cells cant be educated
without sufficient zinc.
Two other plausible connections between zinc and immune function are 1) zincs role in
controlling lymphocyte cell death (otherwise known as apoptosis), irregular death of
lymphocyte cells negatively impacts immune functioning, and 2) the fact that zinc is a
lymphocyte mitogen (i.e. it causes the expansion of immune cells).
Even a mild reduction of circulating zinc levels is associated with reduced T-cell production
of cytokines, which regulate immune response and act as growth factors for the immune
system.
Due to zincs role in maintaining the integrity of skin and mucosal membranes, adequate
zinc levels are critical to wound healing.
Zincs impact on the immune system is what makes it so interconnected to rates of
diarrhea and respiratory tract infections such as pneumonia. Since zinc is required for a
proper immune response (due to its role in the creation and activation of T-cells and
therefore its means of controlling how well our body fights infections), a deficiency means
greater susceptibility to infections. At the same time, persistent diarrhea contributes to zinc
deficiency and malnutrition a vicious cycle. Recent research indicates that zinc
deficiency may also strengthen the effects of toxins produced by diarrhea-causing bacteria
like E. coli, thereby increasing the impact this bacteria has on the individual. A number of
meta-analyses have shown significantly decreased rates of both diarrhea and lower
12

respiratory tract infections after zinc supplementation.

Finally, zinc has the ability to reduce the severity and duration of the common cold by
inhibiting the binding and preventing the replication of a virus called rhinovirus (a common
cause of colds) in the mucus of the nose and by suppressing inflammation. A recent
Cochrane review indicates that zinc is best at reducing colds when taken within 24 hours
of the onset of symptoms. Further research is needed, however, on optimal dosage, zinc
formulations, and duration of treatment.19
Quick-recap: Low zinc status = poor thymic development. A poorly developed thymus =
weak T-cells that are unable to recognize and fight off infection. Due to zincs role in
maintaining skin and mucus membranes, zinc is important for wound healing. Zincs
impact on the immune system is what makes it so interconnected to rates of diarrhea and
respiratory tract infections. Zinc prevents the replication of the rhinovirus (a common cause
of colds).
Normal growth and development during pregnancy, childhood, and adolescence / Growth
and development of the nervous system and neurological functions 20,21,22
Although the exact mechanism behind zincs role in limiting and / or stunting growth is not
fully understood, recent research indicates that zinc affects cell-signaling systems that
coordinate the response to the growth-regulating hormone (IGF-1). In other words, the
growth hormone cannot do its job without zinc. This leads to stunted growth in young
children. Severe zinc deficiency can also affect bone growth due to the large number of
enzymes and hormones required for bone development that are dependent on zinc.
If a pregnant woman is zinc deficient, the fetus can experience growth retardation in utero.
Zinc deficiency in utero can adversely affect the childs long-term immune functioning.
Impacts of maternal zinc deficiency can also be seen on the childs neurological and
behavioral development. Low maternal zinc status has been associated with diminished
attention in newborns and poor motor function at 6 months of age.
Limited maternal zinc status has been associated with a number of adverse pregnancy
outcomes. These include low birth weight, premature delivery, labor and delivery
complications, and congenital anomalies.
Quick-recap: Zinc and normal growth: zinc affects the growth regulating hormone IGF-1.
Without zinc, this growth hormone cannot do its job leading to stunted growth in young
children. Bone growth is also affected due to zinc-dependent enzymes and hormones
required for bone development. Zinc and pregnancy: If a pregnant woman is zinc deficient,
the fetus can experience growth retardation in utero adversely affecting the childs longterm immune functioning and neurological and behavioral development. Limited maternal
zinc deficiency has been associated with adverse pregnancy outcomes.

19

National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/

Dardeene M. Zinc and immune function. European Journal of Clinical Nutrition. 56, Suppl 3 S20-S23, 2002.
21
Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/
22
Wardlaw, Hampl, DiSilvestro. 2004. Perspective in Nutrition. Sixth edition.
20

13

Sexual maturity and reproduction23,24

Zinc plays a significant role in ensuring normal sexual maturity due to its role in cell
division and protein synthesis both connected to growth. The health of the prostate
gland, in particular, is dependent on adequate zinc levels. This is because the prostate
contains a high percentage of zinc and requires adequate zinc for normal functioning. At
the same time, a zinc deficiency predisposes the prostate to infection. Zinc is also needed
to manufacture testosterone, may have a role in hormonal functions of various endocrine
organs, and may ensure healthy sperm. How? Low zinc levels prevent the pituitary gland
from releasing hormones required to stimulate testosterone production. Moderate zinc
deficiency leads to delayed puberty in adolescents and hypogonadism (when the sex
gland produces little to no hormones) in males.
Quick-recap: Zinc is required for the normal functioning of the prostate gland, to
manufacture testosterone, and to ensure healthy sperm. This is because zinc is needed for
the pituitary gland to release hormones needed for testosterone production. Zinc
deficiency in adolescents can lead to delayed puberty.
Normal blood sugar balance and metabolic rate25
In order for our bodies to maintain a sufficient insulin response, zinc is required. Insulin is a
hormone made in the pancreas that moves sugar from our bloodstream into our cells. A
decrease in zinc = a decrease in insulin response = destabilized blood sugar levels.
Similarly, zinc is required to maintain a normal metabolic rate. A decrease in adequate zinc
levels = a decrease in our metabolic rate (in other words the rate at which our body
creates and uses energy decreases). Finally, low levels of zinc = decreased hormonal
output by the thyroid gland. Recall that thyroid hormones are needed to direct brain
development. Therefore zincs role in limiting thyroid hormone release may also be linked
to the neurological effects of zinc deficiency.
Based on zincs effect on the thyroid hormone, zinc deficiency, like iron deficiency, can
have a similar detrimental effect on the consumption of iodized salt. If someone is iron and
/ or zinc deficient and they are consuming iodized salt, the iodized salt might not effectively
impact the functioning of the thyroid since iodine can't do its job synthesize thyroid
hormone without zinc or iron.
Quick-recap: A decrease in zinc = a decrease in insulin response = destabilized blood
sugar levels. A decrease in adequate zinc levels = a decrease in our metabolic rate (the
rate at which our body creates and uses energy decreases). Finally, low levels of zinc =
decreased hormonal output by the thyroid gland causing a zinc deficiency to have similar
detrimental effects on iodized salt as iron deficiency: iodine cant assist the thyroid to
create the thyroid hormone without adequate zinc or iron.
Proper appetite, sense of taste and smell26
A small protein called gustin, found in saliva, is responsible for our sense of taste. Gustin
23

Prasad AS. Clinical, endocrinological and biochemical effects of zinc deficiency. Clin. Endocrinol. Metab. Aug;
14(3):567-89. 1985.
24
Advanced Health. http://www.advancehealth.com/zinc.html#Zinc,%20Testosterone%20and%20Men's%20Health
25
Whole Food. http://whfoods.org/genpage.php?tname=nutrient&dbid=115
26
Ibid.

14

can only work properly, however, if zinc is present since gustin is a zinc-binding protein.
Without sufficient quantities of zinc, gustin cant do its job of allowing us to taste. Since
smell is connected to taste, zinc deficiency causes impaired taste and smell.
Quick-recap: We need gustin in order to taste. Gustin needs zinc to function. Since smell
and taste are connected, zinc deficiency causes impaired taste and smell.
Age-related macular degeneration27
Although the interconnectedness of zinc and vitamin A will be outlined later, it is worth
noting here due to the impact it has on the
prevention of night blindness and age-related
macular degeneration a leading cause of
blindness in people over the age of 65 in the US.
(The macula is the portion of the retina in the back
of the eye involved in central vision). It has been
suggested that zinc (along with other antioxidants)
delays the progression of age-related macular
degeneration (AMD) and vision loss by preventing
cellular damage to the retina and, therefore, the
macula. Additionally, zinc is required for the enzyme
that converts retinol to retinal (recall, retinal is
needed to create rhodopsin, the protein in the eye that allows light to be absorbed).
Therefore, zinc deficiency can contribute to night blindness.
Lets look at this a bit closer. There are three specific links that zinc has to AMD: 1) zinc is
found in high concentrations in the part of the retina affected by AMD or the macula,
therefore, a lack of sufficient zinc would impact functioning, 2) retinal zinc content has
been shown to decrease with age, and 3) the activities of some zinc-dependent retinal
enzymes have been shown to decrease with age. So, a lack of zinc impacts the
functioning of the retina and the macula responsible for central vision AND zinc content in
the retina and some retinal enzymes that require zinc decrease with age. Results from
randomized controlled trials on the impact of zinc supplementation on individuals with early
signs of AMD, however, have been mixed and further study is warranted.
Quick-recap: Zinc prevents cellular damage to the retina. A lack of zinc = poor retina and
macula functioning (responsible for central vision). Zinc in the retina decreases with age
also impacting vision. Zinc is needed to convert retinol to retinal allowing for proper night
vision.
Symptoms of deficiency28,29,30
A common symptom of zinc deficiency is an impaired sense of taste and / or smell. This is
due to the link between zinc and the taste-related protein, gustin, found in our saliva.
Other, more serious, symptoms of zinc deficiency include: growth retardation in children,
27

Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/

Whole Food. http://whfoods.org/genpage.php?tname=nutrient&dbid=115
29
National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/
30
Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/
28

15

loss of appetite, impaired immune function (frequent colds and infections), hair loss,
diarrhea, delayed sexual maturity, impotence, hypogonadism in males (when the sex gland
produces little to no hormones), eye and skin lesions, weight loss, mental lethargy, night
blindness, swelling and clouding of the corneas, and behavioral disturbances. Oral zinc
therapy can address many of these symptoms.
It is now understood that mild zinc deficiency contributes to several health problems in
children, particularly in developing country settings, including stunting, impaired physical
and neuropsychological development, and increased susceptibility to infections. The lack
of a sensitive indicator to measure mild zinc deficiency, however, hinders further study.
Quick-recap: Impaired taste and smell, hair loss, loss of appetite, diarrhea, delayed sexual
maturity, growth retardation / stunting in children, mental lethargy, night blindness.
Individuals most at risk of deficiency31,32,33
Primary risk factors for zinc deficiency include diets low in zinc or high in phytates,
malabsorption disorders (including intestinal parasites and diarrhea), impaired utilization of
zinc, and genetic disorders. Those most at risk include:
Pre-term infants
Pre-term infants are at risk of zinc deficiency for the same reason outlined for iron (recall
that iron is stored up by the infant during the last trimester; the same is true for infants and
zinc), however, the extent of this kind of zinc deficiency has not been well studied.
Pregnant and lactating women
Due to high zinc requirements by the fetus, pregnant women are at an increased risk of
becoming zinc deficient. This is particularly the case when starting pregnancy with
marginal zinc status. Similarly, lactation can deplete maternal zinc stores.
Older infants (7-12 months of age)
Breast milk provides sufficient zinc (2 mg/day) for the first 46 months of life but does not
provide recommended amounts of zinc for infants aged 712 months, who need 3 mg/day.
Infants of this age should receive zinc from appropriate complementary foods. Zinc
supplementation has improved growth rates in some children who demonstrate mild-tomoderate growth failure and who have a zinc deficiency.
Individuals with sickle cell disease
Both children and adults with sickle cell disease have been found to be deficient in zinc.
This is likely due to increased nutrient requirements and / or poor nutritional intake.
Strict vegetarians

31

Ibid.
Wardlaw, Hampl, DiSilvestro. 2004. Perspective in Nutrition. Sixth edition.
33
National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/
32

16

For vegetarians, the dietary zinc requirement may be as much as 50% higher due to high
levels of phytic acid found in grains and legumes. It
has been suggested, however, that vegetarians
adapt to low zinc intake by reducing zinc excretion
while increasing zinc absorption. A few techniques
used to increase zinc bioavailability in the diet of
vegetarians include soaking beans, grains, and
seeds in water for several hours before cooking
them and allowing them to sit after soaking until
sprouts form (soaking activates phytases in these
food, which deactivates phytates). Vegetarians can
also increase their zinc intake by consuming more
leavened grain products (such as bread) than unleavened products (such as crackers)
since leavening breaks down phytates.
Alcoholics
Alcoholics are at an increased risk of zinc deficiency for two reasons: 1) alcohol decreases
the bodys ability to absorb zinc, and 2) alcohol increases urinary zinc excretion.
Individuals with HIV/AIDS
Sufficient zinc levels are particularly critical for individuals with HIV for two reasons: 1) in
order to maintain adequate immune functioning, and 2) because individuals with HIV have
an increased susceptibility to zinc deficiency. Low serum levels of zinc have been
associated with a more advanced stage of the disease and increased mortality. However,
there have been mixed outcomes to studies looking at zinc supplementation among those
with HIV. In one study, the incidence of opportunistic infections decreased after one month
of 45mg/day among AIDS patients. Yet in another study, increased zinc intake was
associated with more rapid disease progression and poorer survival. This is due to the fact
that the HIV virus actually requires zinc and any excess zinc intake may stimulate the
progression of the infection. Further research is obviously needed to ensure the right
balance of intake via supplements for this population.
Adults over the age of 65
Generally speaking, older adults tend to have lower zinc intakes than the recommended
RDA. Couple this with a reduced absorption capacity for zinc (due to decreased levels of
gastric acids in the intestine), an increased likelihood for diseases that alter zinc use, an
increased drug use that may cause increased zinc excretion, and the need for a strong
immune system for the health of older adults, and the increased risk among this population
becomes clear.
Genetic disorders
The genetic disorder, acrodermatitis enteropathica, which impairs zinc absorption and
transport, can also be a cause of zinc deficiency.
Additional groups at risk include:
- Patients receiving total parenteral nutrition (intravenous feeding): due to the use of
zinc-poor amino acids as the source of protein
17

Individuals with protein-energy malnutrition and anorexia nervosa

Individuals with severe or persistent diarrhea: leads to excessive loss of zinc
Individuals with malabsorption syndromes, including celiac disease
Individuals with diabetes: due to frequent urination experienced by those with
diabetes whereby zinc is lost, moderate zinc deficiency is relatively common. Zinc
supplementation among this population, however, needs further study as the impact
on glucose levels is not yet known
Individuals with inflammatory bowel disease, including Crohns disease, ulcerative
colitis, and short bowel disease: these conditions can decrease zinc absorption and
increase zinc losses primarily from the GI tract and, to a lesser extent, from the
kidney

Quick-recap: Aside from diets low in zinc, deficiency is common when diets are high in
phytates. Soaking beans, grains, and seeds will activate natural phytases, which
deactivate phytates. Those most at risk include: preterm infants since zinc is stored up
during the last trimester; pregnant and lactating women since the fetus requires high levels
of zinc; infants older than 6 months who are still breastfeeding since breast milk provides
sufficient zinc for the first 4-6 months of life only; individuals with sickle cell anemia,
HIV/AIDS, malabsorption problems, older adults, and alcoholics (alcohol decreases the
bodys ability to absorb zinc and increases excretion).
Absorption, transport, and storage in the body34
Zincs pathway of absorption, transport, and storage in the body is very similar to that of
iron. After zinc is consumed from food, absorption occurs in the small intestine. When zinc
is absorbed into intestinal cells, it induces the synthesis of metallothionein a protein that
binds zinc. (Metallothionein and zinc are analogous to ferritin and iron both serve as
binding and storage mechanisms). And zinc must be bound for the same protective
reasons that iron must be bound. That is, free roaming zinc can promote free radicals that
damage cells and can lead to cancer. Zinc is stored (temporarily) in metallothionein.
However, there are no permanent stores of zinc in the body.
Zinc can then take one of two pathways. If the body does not need zinc, it is sloughed off
along with the cell and excreted (think back to the mucosal block and iron its the same
process, however, the mucosal block works to a much greater extent with iron). If large
doses of zinc are consumed, the mucosal block is actually overridden. Zinc is readily
excreted by the pancreas into the intestinal tract and then leaves the body via the feces
and to a lesser extent in urine and sweat. So there are two ways zinc leaves the body: 1)
via the mucosal block and 2) intestines to body and back to intestines (via the pancreas
where it is used to make digestive enzymes) and finally leaves via the feces.
If the body does in fact need zinc, a second pathway is used. Metallothionein releases zinc
(or hands it off) to albumin and transferrin for transport to tissues in need (again, this is
because zinc must be bound to something or else risk the promotion of free radicals). Most
zinc in humans is found in the muscle (60%) and bone (30%).

34

Wardlaw, Hampl, DiSilvestro. 2004. Perspective in Nutrition. Sixth edition.

18

Like iron, absorption occurs most efficiently from animal products, when body needs are
high, and when small amounts are consumed.

Quick-recap: Zinc is absorbed in the small intestine and binds to the storage protein
metallothionein. (Zinc must be bound or else it can cause free radicals that can damage
cells). If the body does not need zinc, it is sloughed off along with dead cells and excreted
by the pancreas into the intestinal tract and then leaves the body via the feces and to a
lesser extent in urine and sweat. If the body does need zinc, metallothionein hands zinc to
albumin and transferrin for transport to tissues that need it mostly muscle and bone
tissues.
Food (and supplement) sources35,36,37
Good animals sources of zinc include shellfish, beef, liver, and eggs. Good plant sources
include leavened whole grains (whole grains are a better source of zinc than refined grains
since they have the ability to produce enzymes that destroy phytates), nuts and legumes.
The bioavailability of zinc is higher, however, in animal products due to the relative
absence of compounds that inhibit absorption (i.e. phytates and oxalates) and the
presence of certain amino acids (i.e. cysteine and methionine) that improve zinc
absorption.

35

Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/

Allen, Lindsay. Maternal Micronutrient Malnutrition: Effects on breast milk and infant nutrition, and priorities for
intervention. http://www.unsystem.org/SCN/archives/scnnews11/ch09.htm
37
Whole Food. http://whfoods.org/genpage.php?tname=nutrient&dbid=115
36

19

Food
Oysters
Beef
Crab, Dungeness
Turkey (dark meat)
Whole grain wheat flour
Sesame seeds
Pumpkin seeds, raw
Pork
Chicken (dark meat)
Yogurt
Milk
Cashews
Almonds
Beans, baked
Chickpeas (garbanzo beans)
Spinach, boiled
Green peas, boiled
Eggs, hardboiled

Serving
6 medium (cooked)
3 ounces (cooked)
3 ounces (cooked)
3 ounces (cooked)
1 cup
cup
cup
3 ounces (cooked)
3 ounces (cooked)
1 cup (8 ounces)
1 cup (8 ounces)
1 ounce
1 ounce
1/2 cup
1/2 cup
1 cup
1 cup
1

Zinc (mg)
76.3
6.0
4.7
3.8
3.5
2.8
2.6
2.2
1.8
1.8
1.8
1.6
1.0
1.8
1.3
1.4
1.9
1.4

Source: Linus Pauling Institute

OK, thats good to know but how many of the foods listed above does one really find in a
low consumption (i.e. developing country) setting? Not many. So lets look at some more
relevant foods and their zinc content.38
Food
Goat meat, cooked, roasted
Peanuts, oil-roasted
Whole grain wheat flour
Cabbage, cooked
Kidney beans, cooked
Spinach, cooked

Serving
1 piece / 340 g
1 cup
1 cup
1 cup
1 cup
1 cup

Zinc (mg)
17.9 (119% DV)
4.7 (31% DV)
3.5 (23% DV)
2.5 (17% DV)
1.9 (13% DV)
1.4 (9% DV)

Is breast milk a good source of zinc? The answer is yes. Zinc is highly bioavailable in
breast milk. Is zinc in breast milk affected by the mothers status? The answer is no. The
concentration of zinc in breast milk is relatively unaffected by maternal deficiency or
maternal supplementation. The mother is, however, especially vulnerable to further
depletion during lactation.
Supplements39,40
38
39
40

Nutrition Data. http://nutritiondata.self.com/facts/vegetables-and-vegetable-products/2389/2

Food and Nutrition Bulletin. Vol. 30 No. 1. March 2009.
National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/

20

Recent studies have demonstrated the importance of zinc in reducing stunting, diarrhea,
and child mortality in addition to having a positive impact on the duration of pregnancy and
a reduction in premature delivery.
WHO guidelines for therapeutic supplementation of zinc
Age group
Dose and Duration
Children less than six months with diarrhea
10 mg/day for 10-14 days
Children older than six months with diarrhea
20 mg/day for 10-14 days
Pregnant women
20-90 mg/day
A number of zinc supplements are available, including zinc acetate, zinc gluconate, zinc
picolinate, and zinc sulfate. WHO and UNICEF now recommend short-term zinc
supplementation (20 mg of zinc per day for children older than six months, or 10 mg for
infants under 6 months, for 1014 days) to treat acute childhood diarrhea.
Quick-recap: The bioavailability of zinc is higher in animal products due to the absence of
compounds that inhibit absorption (i.e. phytates and oxalates) and the presence of certain
amino acids (i.e. cysteine and methionine) that improve absorption. Good animal sources:
goat, beef, shellfish, liver, eggs. Good plant sources: whole grains, peanuts, legumes.
Breast milk is a good source of zinc for the infant but is not affected by maternal status.
Supplements are recommended by WHO and UNICEF to treat acute childhood diarrhea.
Variability of requirements across populations and recommended dosage41
Since a sensitive indicator of zinc status is not currently available, the RDA for zinc is
based on a wide range of zinc-status indicators.
The Recommended Dietary Allowance (RDA) for Zinc
Life Stage
Age
Males (mg/day) Females (mg/day)
Infants
0-6 months
2 (AI)
2 (AI)
Infants
7-12 months
3
3
Children
1-3 years
3
3
Children
4-8 years
5
5
Children
9-13 years
8
8
Adolescents
14-18 years
11
9
Adults
19 years and older
11
8
Pregnancy
18 years and younger
12
Pregnancy
19 years and older
11
Breast-feeding
18 years and younger
13
Breast-feeding
19 years and older
12
Source: Linus Pauling Institute

Quick-recap: RDA for adolescents and adults: 8-11 mg/day; 11-13 mg/day for pregnant
and lactating women (higher for lactating). Infants 0-6 months: 2mg/day; infants 7-12
41

Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/

21

months: 3 mg/day.
Toxicity42,43
The primary consequence of long-term consumption of excessive zinc (total zinc intakes of
60 mg/day [50 mg supplemental and 10 mg dietary zinc] for several weeks) is copper
deficiency. Since zinc and copper compete for similar pathways, over-supplementation of
zinc can cause low copper levels, which can have detrimental effects on the
cardiovascular system by reducing levels of HDL (good cholesterol).
Similarly, since zinc and iron (elemental iron from supplements, not dietary iron) compete
with one another for absorption, excessive intake of zinc could lead to impaired iron status
and, therefore, anemia.
Symptoms of acute toxicity, such as when food or beverages contaminated with zinc from
galvanized containers are consumed, include abdominal pain, diarrhea, nausea, and
vomiting. Single doses of 225 to 450 mg of zinc usually induce vomiting. Milder GI distress
has been reported at doses of 50 to 150 mg/day of supplemental zinc.
The UL, set by the Food and Nutrition Board, is based on the amount that would begin to
interfere with copper.
Tolerable Upper Intake Level (UL) for Zinc
Age Group
UL (mg/day)
Infants 0-6 months
4
Infants 7-12 months
5
Children 1-3 years
7
Children 4-8 years
12
Children 9-13 years
23
Adolescents 14-18 years
34
Adults 19 years and older
40
Source: Linus Pauling Institute

Quick-recap: The UL for zinc is based on when it begins to interfere with copper. Too
much zinc can cause a copper deficiency, which can reduce HDL levels. Too much zinc
can also interfere with iron causing anemia. Symptoms of overload include abdominal
pain, diarrhea, vomiting.
Drug Interactions44
Zinc supplements can interact with a number of medications. Examples include:
Antibiotics: Both quinolone antibiotics (such as Cipro) and tetracycline antibiotics (such as
Achromycin and Sumycin) interact with zinc in the GI tract, inhibiting the absorption of both
42

Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/

Cunningham-Rundles, S. Zinc and immune function: the importance of zinc for health. Cornell University Medical
School.
44
Linus Pauling Institute. http://lpi.oregonstate.edu/infocenter/minerals/zinc/
43

22

zinc and the antibiotic. Taking the antibiotic at least 2 hours before or 46 hours after
taking a zinc supplement minimizes this interaction.
Penicillamine: Zinc can reduce the absorption and action of penicillamine, a drug used to
treat rheumatoid arthritis.
Diuretics: Diuretics increase urinary zinc excretion by as much as 60% and, therefore,
increases zinc excretion.
Zincs interconnectedness with other nutrients / nutrient-nutrient interactions45,46
Vitamin A
Zinc and vitamin A are connected in two rather significant ways:
1. Zinc is a component of retinol-binding protein (RBP). Recall this is necessary to
transport vitamin A from the liver to target tissues in need. Therefore, during zinc
deficiency, tissues in need of vitamin A do not receive it.
2. Zinc is required for the enzyme that converts retinol to retinal. Retinal is needed to
create rhodopsin the protein in the eye that absorbs light. Therefore, zinc
deficiency can contribute to night blindness.
Copper
A high intake of zinc (50 mg/day or more over a period of weeks) can cause the creation of
metallothionein within the intestine. Metallothionein interferes with copper bioavailability by
trapping copper in the intestinal cells and preventing if from being absorbed. The use of
zinc lozenges for up to 6-8 weeks can induce copper deficiency.
Iron
Iron supplements (38-65 mg/day) can decrease zinc absorption, prompting some health
experts to recommend zinc supplements for pregnant and lactating women taking more
than 60 mg/day of iron. However, this interaction has not been found to be the case with
dietary sources of iron. At the same time, excessive zinc can lead to impaired iron status
since they compete for similar pathways.
Calcium
Calcium in combination with phytic acid reduces zinc absorption.
Folic acid
The bioavailability of dietary folate may be increased when zinc is present in the diet.
Protein
Protein deficiency, particularly a deficiency of the amino acid cysteine, can cause zinc
deficiency by preventing synthesis of the transport and storage molecules used to shuttle
and store zinc in the body.

45
46

Ibid.
Whole Food. http://whfoods.org/genpage.php?tname=nutrient&dbid=115

23

Quick-recap:
Zinc and vitamin A: zinc is needed by RBP. Therefore, a lack of zinc = a lack of
vitamin A to tissues in need. Zinc is needed to convert retinol into retinal retinal is
needed to create rhodopsin, the protein in the eye that absorbs light. Therefore, a
lack of zinc = potential for night blindness.
Zinc and copper: high zinc = copper is trapped and not able to be absorbed =
lowers levels of HDL.
Zinc and iron: too much zinc can decrease iron absorption causing anemia. Too
much iron can decrease zinc absorption.
Zinc and calcium: calcium in combination with phytic acid reduces zinc absorption.
Zinc and folic acid: folate bioavailability may go up when zinc is present.
Zinc and protein: protein deficiency can cause zinc deficiency since zinc needs
proteins to shuttle and store zinc in the body.
Absorption inhibitors / promoters47,48
Factors that affect the absorption of zinc include the bodys need for zinc and the
composition of the meal in which zinc is consumed. Inhibitors of absorption include: fiber,
phytates, oxalates, calcium, iron, and copper. Zinc competes with iron and copper for
absorption. Studies have found that up to a 50% decrease in zinc absorption occurs when
calcium supplements are taken with a meal. It should be noted, however, that although
foods high in phytates inhibit zinc absorption, a greater amount of zinc is absorbed when
these food are fortified.
Enhancers of zinc absorption include: protein (amino acids cysteine and methionine),
picolinic acids (from human milk), and low zinc stores.
Quick-recap: Absorption inhibitors: phytates, oxalates, fiber, calcium, iron, and copper.
Absorption enhancers: phytases, protein, human milk, low zinc stores.
Stability49
Generally speaking, zinc in foods is quite sensitive to heat. Cooked navy beans, for
example, lose 50% of their original zinc. Wheat flour processing also causes zinc losses.
In 60% extraction wheat flour, ~75% of the original zinc is lost.
Quick-recap: High sensitivity to heat and food processing.
Zinc and fortification50,51,52
A number of different zinc compounds can be used to fortify foods, however further study
is still needed in order to identify the most effective compound and to improve upon
technical issues such as the inhibitory effects of phytates and inhibitory effects of zinc on
iron absorption. Fortificant forms include sulfate, chloride, gluconate, oxide and stearate.
47

Wardlaw, Hampl, DiSilvestro. 2004. Perspective in Nutrition. Sixth edition.

Cunningham-Rundles, S. Zinc and immune function: the importance of zinc for health. Cornell University Medical
School.
49
Whole Food. http://whfoods.org/genpage.php?tname=nutrient&dbid=115
50
Allen L, de Benoist B, Dary O, Hurrell R. Guidelines on food fortification with micronutrients. WHO and FAO. 2006
51
Bill and Melinda Gates Foundation. Appendix 4: Fortification. September 2006.
52
National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/
48

24

Zinc oxide tends to be the preferred choice due to its low cost and high stability over other
forms, which often tend to impact the taste of food and so are not frequently used.
Although a low extraction rate will result in reduced phytate content of cereals, it also
reduces the zinc content. Therefore, the net effect on the zinc supply tends to be minimal.
One strategy that works to increase the zinc content of low extraction flours is to activate
phytases that are naturally present in most phytate-containing foods. How do you activate
phytases? Germination, fermentation, and /or soaking. Therefore, a technique to increase
zinc bioavailability includes soaking beans, grains, and seeds in water for several hours
before cooking and allowing them to sit after soaking until sprouts form. This allows for the
activation of phytates and the deactivation of phytates. The addition of animal sources can
also improve zinc absorption in high-phytate diets.
Quick-recap: Zinc oxide is the most common form of zinc used in fortification due to low
cost and high stability. Low extraction (i.e. highly processed foods) flours may allow for low
phytate but also cause a low zinc content. A good strategy to increase the zinc content of
low extraction flours: activate phytases by soaking or allowing to ferment / germinate. The
addition of animal sources can also improve zinc absorption.

25

Indicators / biomarkers of zinc deficiency53,54,55,56

Few reliable biomarkers for zinc deficiency exist to date. This is largely due to the fact that most tests used are not sensitive
enough to detect small changes in zinc status, require specialized equipment or expertise, or have readings that can be
affected by factors other than zinc status. For this reason, global prevalence of zinc deficiency is largely unknown. However,
there is reason to believe zinc deficiency is common for the following reasons: 1) low plasma zinc, an indicator of severe
depletion, has been demonstrated to be quite high in several population groups, and 2) several randomized control trials
among stunted children and / or those with low plasma levels have demonstrated positive responses to zinc supplementation.
Indicator
Serum or plasma
(most common
indicator)

Cut-off to define deficiency

<70 microgram/dl

Erythrocytes (RBC)
Hair

No universally agreed cut-off

No universally agreed cut-off

Cons
Lack of agreement on cut-off
Homeostatically regulated, therefore may not detect marginal
deficiency
Values change daily in individuals
Plasma zinc is decreased by pregnancy, protein-energy
malnutrition (PEM), and infection
May be used as a secondary supportive indicator
Needs more research before this can be a supportive indicator
Not widely used as an indicator at the population level

Why is zinc so hard to measure? Since zinc is distributed so widely throughout the body as a component of various proteins
and nucleic acids, it becomes difficult to identify a unique biomarker that gauges its presence. However, there are proxy
measures, such as stunting rates, diarrhea and mortality rates, and dietary intake surveys, which can be used.
WHO, UNCEF, and IZiNCG recommend three indicators to assess a populations risk of zinc deficiency: 1) concentration of
zinc in blood plasma serum, 2) quantitative dietary intake surveys, and 3) HAZ for children under the age of five.
Zinc deficiency is considered to be a public health concern when: 1) prevalence of inadequate zinc intake is > 25%, 2) HAZ for
children under the age of five is > 20%, and 3) a high prevalence of diarrhea exists, although there is no designated cut-off at
53

Wardlaw, Hampl, DiSilvestro. 2004. Perspective in Nutrition. Sixth edition.

National Institutes of Health. Office of Dietary Supplements. http://ods.od.nih.gov/factsheets/Zinc-HealthProfessional/
55
Allen L, de Benoist B, Dary O, Hurrell R. Guidelines on food fortification with micronutrients. WHO and FAO. 2006.
56
Food and Nutrition Bulletin. Volume 30. Number 1. March 2009.
54

this point in time.

Quick-recap: Few reliable biomarkers for zinc deficiency exit to date. Serum or plasma zinc are the most common indicators
used. A big downside is that plasma zinc is decreased by pregnancy, protein-energy malnutrition (PEM), and infection. Proxy
indicators are used in lieu of a lack of reliable biomarkers: 1) prevalence of low serum zinc concentrations is > 20%, 2)
prevalence of inadequate intakes of zinc is > 25%, and 3) HAZ for children under the age of five is > 20%. A high prevalence of
diarrhea is also often used as a proxy indictor, although there is no designated cut-off at this point in time.

27