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Nutritional Disorders
Vitamins and Minerals
(The Micronutrients)

Dr. Zainab A. Al-Mayyahi

Department of Medicine
College of Medicine
University of Basrah
Vitamin D
Vitamin D
• A group of sterol compounds which have a vital
role in bone metabolism.
• Vitamin D and parathyroid hormone are the main
regulators of calcium and phosphorous in the
body.
• Tow pro-forms of vitamin D:
• Cholecalciferol (D3).
• Ergocalciferol (D2) .

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Sources of vitamin D
• Cholecalciferol (D3) :
1- formed in the skin aJer exposure to sun.
2- Animal source like Lsh, Lsh oil, milk,
eggs , liver etc.
• Ergocalciferol (D2) :
1- ForOLed cereals.
2- SyntheOc supplements.

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Daily requirement of
vitamin
D
• Non-pregnant adults : 25 Sg /day.
• Pregnant women , infants and lactaOng women :
100 Sg /day.
• 1 Sg = 40 IU

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 25
Hydroxylase

HCC(Calcidiol) 25

Alfa-1 DHCC(Calcitriol) 1,25

Hydroxylase
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parathyroid hormone
Alfa hydroxylation-1
The acOvity of 1- Alfa hydroxylase depends on:
• Calcium level ( low level increase acOvity)
• Phosphorous level ( low level increase it)
• Level of Calcitriol (decrease acOvity)
• The parathyroid hormone (sOmulate acOvity)

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Mechanism of action of
vitamin D
• AcOve vitamin D will bind to speciLc receptor VDR
‘’vitamin D receptor” in target Ossues and exert
it’s metabolic acOon.

• 1,25 DHCC has 3 Omes more a`nity to these

receptor than other vitamin D metabolites.

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Functions of active
vitamin D
1. Increase calcium and phosphate absorpOon
from the small intesOne.
2. Increase calcium re-absorpOon from the
kidneys.
3. Increase bone mineralizaOon.
4. Inhibit parathyroid hormone secreOon.

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Vitamin D transport and
storage
• 25 HCC is the storage form of vitamin D in the liver
• 88% of 25 HCC circulates bound to speciLc
vitamin D–binding protein, 0.03% is free, and the
rest circulates bound to albumin

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Functions of vitamin D
• Bone metabolism: increase Ca absorpOon from gut
and kidneys and increase deposiOon of Ca in
bones (solidiLcaOon of bones).
• Retard cell proliferaOon and promote cell
dieerenOaOon “AnO-cancer eeect” ( breast and
colonic cancer).
• Pharmacological role in treatment of psoriasis.

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Other rules for vitamin
D
• Vitamin D receptors was found in most
Ossues (e.g., immune cells, brain,
breast, colon, and prostate) and is
thought to be important for:
• PrevenOon of cardiovascular diseases
• Immune funcOon.( type 1 diabetes)

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Other rules for vitamin
D
• Brain funcOon ( depression, mulOple
sclerosis)
• PrevenOon of hypertension
• Low grade ingammaOon ( tuberculosis)

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Vitamin D deHciency
 Causes of vitamin D
deHciency
• Limited sun exposure.
• MalnutriOon.
• MalabsorpOon.
• Liver diseases.
• Renal diseases (CKD and nephroOc syndrome).
• Drugs like anOepilepOcs phenytoin and phenobarbital
decrease hepaOc level of vit. D.

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Clinical features of
Vitamin D deHciency
• Vitamin D deLciency cause bone demineralizaOon
(loss of bone matrix).

*Rickets is demineralizaOon of growing bone

(before closure of the epiphyseal plates).
*Osteomalacia is bone demineralizaOon aJer
closure of the epiphyseal plates.

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Clinical features of
Vitamin D deHciency
• Symptoms of hypocalcaemia:
1. Carbopedal spasm.
2. Facial twitching
3. Hypocalcaemic tetani
4. Seizers.

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Other features of
Vitamin D deHciency
• Burning sensaOon in the mouth
• Diarrhea
• Insomnia
• Nervousness
• Myopia
• Scalp sweaOng

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Vitamin D deHciency
syndromes
Osteomalacia and Rickets
 Osteomalacia
• It is bone demineralizaOon aJer closure of the
epiphyseal plates .
• The normal bone is replaced by soJ osteoid that
contains less minerals than normal bone (loss of bone
matrix).
• Other cases of osteomalacia are : bone tumors, excess
Aluminum and Florid, and drugs like bisphosphonates.

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Clinical features of
Osteomalacia
1. Back pain , bone pain and tenderness,
spontaneous fractures (Pathological fractures).
2. Proximal muscle weakness , Waddling gate and
di`culty in climbing stairs or gelng out of a chair.
3. Symptoms of hypocalcaemia

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Diagnosis of
osteomalacia
• Clinical features.
• Biochemical tests.
• Radiological tests.
• Bone biopsy.

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Biochemical
investigations
• Decrease calcium level .
• Decrease phosphate level.
• Decrease vitamin D level (25 HCC).
• Increase parathyroid hormone level.
• Increase alkaline phosphatase level.

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Radiological
investigation
X-rays:
• Normal in early disease.
• Focal radiolucent areas “Looser's zones” may be
seen in ribs, pelvis and long bones.
• Radiographic osteopenia
• Pathological fractures.

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 Radiological
investigation
Radionuclide bone scan:
• Total body techneOum
bone scan in
osteomalacia shows
increase uptake (hot
spots) in pseudo-
fractures areas.

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Bone biopsy

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 Treatment
• CorrecOon of underlying cause
• Ergocalciferol (250-1000 Sg daily) for 3-4 months
then maintenance of 10-20 Sg daily.
• Calcium supplements.
• Higher doses required for paOents with
malabsorpOon.
• AcOve vitamin D “Calcitriol” should be used for
paOents with renal diseases.

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 Prevention
• Exposure to sunlight.
• Adequate intake of vitamin D rich foods.
• ProphylacOc vitamin D (10-20 Sg) for risk groups ,
lactaOng women ,elderlies and paOents on
anOepilepOc drugs.

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 Rickets
• Rickets is demineralizaOon of
growing bone before closure
of the epiphyseal plates
(growing bone).
• Mostly aeect infants who are
kept indoor or covered and
are exclusively feed on
natural milk.

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Clinical features of
Rickets
• Muscle hypotonia (goppy infant).
• Delayed development (teething , crawling,
walking).
• Delayed closure of anterior fontanelle.
• “Craniotabes” : a cracking feeling during pressure
on the bones of the skull due to unossiLed areas is
the earliest bone sign of rickets.

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 Clinical features of
Rickets
• Bossing of the
frontal and parietal
bones.

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 Clinical features of
Rickets
• Enlargement of
epiphyses at the
lower end of the
radius.

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 Clinical features of
Rickets
• Swelling of the
costochondral
juncOons of
the ribs.
(rickety rosary)

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 Clinical features of
Rickets
• When the infant
start walking
deformiOes of
the legs will
develop.
“bow legs”

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Clinical features of
Rickets
• Later, if untreated a
lateral collapse of
both chest walls
(Harrison's sulcus)
may appear.

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 Diagnosis of Rickets
• Clinical features.
• Biochemical tests .
• X-rays: wrist x-ray will shows widening of the
epiphysis (cupping) which is highly suggesOve of
rickets.

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X-rays in rickets

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Treatment of rickets
• Ergocalciferol (250-1000 Sg daily) for 3-4 months
then maintenance of 10-20 Sg daily.
• Encourage intake of vitamin D rich foods.

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Prevention of Rickets
• Sunlight and vitamin D rich foods.
• ProphylacOc vitamin D drops for
infants at risk of vitamin D deLciency.

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Hypervitaminosis D
• High doses of vitamin D can cause life-threatening
hypercalcemia.
• Calcium mainly deposit in the kidneys and brain.
• symptoms include weakness, vomiOng ,
consOpaOon , lassitude, impaired memory,
demenOa, delirium, and coma.
• Treatment include, guids , diuresis, and
someOmes corOcosteroids.

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