Fat Soluble Vitamins- A,D Xerophthalmia Rickets Osteomalacia

1. DR SHAHNAWAZ F SHAH
MD, FPM, FIAPM,FCPM (MUHS)
Interventional Spine & Pain Physician
Surat

2. OBJECTIVES
• Introduction
• Classification
• General Functions
• Individual Characteristics (Vit A & D)
• Individual Dietary Sources & RDA
• Individual Mechanism of Action
• Individual Function
• Deficiencies
– XEROPHTHALMIA
– RICKETS & OSTEOMALACIA

3. INTRODUCTION
 The Latin word “vita”, means "life".
 Vitamins are organic components in food that
are needed in very small amounts
 for growth
 for maintaining good health
 Eating a healthy diet remains the best way to
get sufficient amounts of the vitamins and
minerals you need

4. CLASSIFICATION

5. Fat Soluble Vitamins (A,D,E,K)
• Build bones. Bone formation would be impossible
without vitamins A, D, and K.
• Strong bones. A combination of calcium, vitamin D,
vitamin K, magnesium, and phosphorus protects your
bones against fractures.
• Protect vision. Vitamin A also helps keep cells healthy
and protects your vision.
• Interact favorably. Without vitamin E, your body would
have difficulty absorbing and storing vitamin A.
• Protect the body. Vitamin E also acts as an antioxidant
(a compound that helps protect the body against
damage from unstable molecules).

6. Water Soluble Vitamins
(C & B Complex)
• Release energy. Several B vitamins are key components of
certain coenzymes (molecules that aid enzymes) that help
release energy from food.
• Produce energy. Thiamin, riboflavin, niacin, pantothenic
acid, and biotin engage in energy production.
• Build proteins and cells. Vitamins B6, B12, and folic acid
metabolize amino acids (the building blocks of proteins)
and help cells multiply.
• Make collagen. One of many roles played by vitamin C is to
help make collagen, which knits together wounds, supports
blood vessel walls, and forms a base for teeth and bones.

7. DIFFERENCE
WATER SOLUBLE FAT SOLUBLE
Absorption Directly to blood Lymph via CM
Transport free Require carrier
Storage Circulate freely In cells with fat
Excretion In urine Stored with fat
Toxicity Rarely Possible with
supplements
Likely with supplements

8. ABSORPTION
• Absorption of fat-soluble vitamins

10. VITAMIN A
It is the name given to a group of related
compounds :
Retinol (vitamin A alcohol)
Retinal ( vitamin A aldehyde)
Retinoic acid ( vitamin A acid)
Its provitamin carotenes are found in plants.

11. SOURCES
Yellow and dark green vegetables and fruits are
sources of provitamin A carotenes
Non Veg
• Fish Oil
• Liver
• Egg
Yolk
Veg
• Carrots
• Mango
• Papaya
Dairy
• Milk
• Cheese
• Butter

12. DIETARY SOURCES OF VITAMIN A

13. RDA
Category
Vitamin A: Recommended Dietary Allowance (RDA) in
micrograms (mcg) of Retinol Activity Equivalents (RAE)
CHILDREN
1-3 years 300 mcg/day
(or 1,000 International Units/day)
4-8 years 400 mcg/day
(1,320 IU/day)
9-13 years 600 mcg/day
(2,000 IU/day)
FEMALES
14 years and up 700 mcg/day
(2,310 IU/day)
Pregnant 14-18 years: 750 mcg/day (2,500 IU/day)
19 years and over: 770 mcg/day (2,565 IU/day)
Breastfeeding Under 19 years: 1,200 mcg/day (4,000 IU/day)
19 years and over: 1,300 mcg/day (4,300 IU/day)
MALES
14 years and up 900 mcg/day
(3,000 IU/day)

14. FUNCTIONS
Vitamin A plays a role in a variety of functions throughout
the body, such as:
• Vision
• Gene transcription
• Immune function
• Embryonic development and reproduction
• Bone metabolism
• Hematopoiesis (the production of blood cells and
platelets)
• Skin and cellular health
• Antioxidant activity

15. VITAMIN- A DEFICIENCY
• May be due to:
– Inadequate dietary intake
– Impaired intestinal absorption
– Chronic alcoholism.
• Impaired vision – Night blindness.
• Extremely dry skin ,hair or nails.
• Epithelial metaplasia and keratinization.
• Xerophthalmia (dry eye)

16. DEFICIENCY
WHO IS AT RISK ?
• Young children
• Children with inadequate health care.
• Adults with diseases of :
– Pancreas
– Liver
– Intestine

22. TREATMENT
• Xerophthalmia:
– 60 mg of Vitamin A in Oily Solution in soft gel
Capsule on day 1 & day 14
• Adults with Night Blindness or Bitot’s Spots:
– 3mg/d or 7.5mg per week for 3 months
• For prevention in high risk areas-
– Infants(6 to 11 months)- 30mg of Vit A
– Children(12 to 59 months)- 60mg of Vit A

23. Too Much Can Be Toxic !!
Hypervitaminosis A leads to toxic symptoms:
Dry , itchy skin
Hair loss
Liver damage
Skin coloration
Loss of appetite
Head ache and fatigue
Blurred vision

25. VITAMIN D
• SUNSHINE VITAMIN, ANTIRACHITIC FACTOR,
CALCIFEROL
• Two important forms
– D2 (ergocalciferol) - in plants
– D3 (cholecalciferol) - in animals.
• derivatives of cholesterol and are involved in
the calcium and phosphorous metabolism.

26. SOURCES
Sunlight
Milk
Fish
Orange juice
Fortified cereals

27. also synthesized by monocyte-macrophages in the immune
system
CALCIDIOL
CALCITRIOL
CALCITRIOL

28. FUNCTIONS
• Maintenance of adequate plasma levels of
calcium and phosphorous
• Bone mineralization
• Metabolic functions
• Neuromuscular transmission
• acts locally as a cytokine, defending the body
against microbial invaders by stimulating the
innate immune system.

29. HUMAN REQUIREMENTS
• Greatly influenced by the amount of
ultraviolet light to which the individual is
exposed
• Half an hour of direct sunlight on the cheeks
of a baby each day is sufficient to generate
daily requirement of vitamin D
• For adults also, exposure to sunlight for 30
minutes a day is believed to satisfy the daily
requirement.

30. • In some areas, the sunshine is not much
beneficial
• 400 IU is recommended for infants,lactating
mother,and pregnent women.
• For adult also 400 IU is adequate.

31. VIT D LEVEL IN SERUM
• DEFICIENT < 10 ng/ml
• INSUFFICIENT 10 - 30
• OPTIMAL 30 - 60
• HIGH 60 - 90
• TOXIC >90

32. Too Much Vitamin D !!!
• High dose can cause accumulation in the liver.
• Signs of toxicity include:
– excess calcium in the blood
– nausea
– vomiting
– decreased appetite.

33. VIT D DEFICIENCY
• Rickets
– Disease of growing bones of children(in it
epiphyseal plate not closed) in which defective
mineralization occurs in both bone and cartilage
of epiphyseal growth plate.
• Osteomalacia
– Disorder of mature bones in adult (after
epiphyseal plate closure) in which mineralization
of new osteoid bone is inadequate or delayed

34. Types
RICKETS
Vit D
DEFICIENT
Vit D
DEPENDENT
Vit D
RESISTANT
Hypophosphataemic
End Organ
Resistance

35. CAUSES
• Nutritional deficiency:
– commonest cause in the developing countries
– Excess of phytate in diet which form insoluble compounds
with calcium so prevent its absorption (chapati flour)
• Malabsorption: Celiac disease,Pancreatic insufficiency
• Hepato-biliary disease: Biliary Artesia, Cirrhosis,
Neonatal hepatitis
• Drugs: Anti-convulsants (Phenobartbitone, Phenytoin)
• Renal causes : Renal osteodystrophy, Renal tubular
acidosis.

36. CLINICAL FEATURES
• General
– Failure to thrive
– Apathetic , listless, irritable
– Shorter, lower body weight and anemic
– Excessive sweating particularly at hand & face

37. CLINICAL FEATURES
• Head
– Craniotabes(soft skull)
– Frontal & Parietal bossing
– Widening of suture, persistent fontanelae
– Delayed dentition, caries

38. CLINICAL FEATURES
Chest
• Rachitic rosary
Swelling of the costo-chondral junction
• Harrison groove
Lateral indentation of the chest wall
at the site of attachment of diaphragm
• Pigeon chest
• Respiratory infection
• Atelectasis

39. CLINICAL FEATURES
• Widening of wrist, knee and ankle due to
physeal over growth

40. CLINICAL FEATURES
Abdomen – prominent
Muscle weakness (floppy baby, delayed walking)
Pelvis - narrow inlet

41. CLINICAL FEATURES
Deformity
Toddlers:
Bowed legs
(genu varum)
Older children:
Knock-knees
(genu valgum) windswept knees

42. CLINICAL FEATURES
• Thoracic kyphosis
• increased tendency for fracture, especially
green stick #
• Growth disturbance
• Bone pain or tenderness
• Tetany
• Sign of PEM

43. Extra – skeletal manifestations
• SEIZURES
• TETANY i.e periodic painful muscular spasms
and tremors, caused by faulty calcium
metabolism and associated with diminished
function of the parathyroid glands.
• HYPOTONIA AND DELAYED MOTOR
DEVELOPMENT Muscle weakness

44. DIAGNOSIS
• Clinical features of rickets:
– Skeletal manifestations
– Extraskeletal manifestations
• Investigations
– Serum Ca,
– S.Ph,
– Alkaline phosphatase,
– PTH ,
– S.Vit-D,
– S.creatinine
– X-Ray of long bones & joints

45. RADIOLOGICAL FEATURES
• Widening, fraying, cupping of the distal ends
of shaft

47. • Osteoporosis
– weakening of the bones
– degeneration of already constructed bone, making
them brittle
• Osteomalacia
– softening of the bones.
– an abnormality in the building process of bone,
making them soft.

48. CAUSES
• Vitamin D deficiency - most common cause
• Kidney or liver problems
• Celiac disease - Celiac disease is an
autoimmune disorder, which means eating
gluten can cause sensitivity in people with this
disease.
• Surgery

49. CLINICAL FEATURES
• Insidious course
• Bone pain, back ache and bone tenderness
• Proximal muscle weakness
• Fracture
• Vertebral collapse, kyphosis or knock knee
perhaps due to adolescent rickets- may
increase in later life.

50. CLINICAL FEATURES
• Long standing case sign of secondary
hyperparathyroidism
– Depression
– Polyuria
– Increased thirst
– Constipation
– Nephrolithiasis
– Peptic Ulcer Disease

51. • Looser zones:
– also known as cortical infractions, Milkman lines
or pseudofractures,
– wide, transverse lucencies with sclerotic borders
traversing partway through a bone, usually
perpendicular to the involved cortex
– associated most frequently with osteomalacia and
rickets.

52. DIAGNOSIS
• Blood and urine tests - low levels of vitamin D,
calcium and phosphorus.
• X-rays - small cracks in the bones.
• Alkaline phosphatase isoenzymes test –
– an enzyme produced by osteoblasts (the cells that
form new bones)
– high level
• Bone biopsy - A needle is inserted through skin
into the pelvic bone above the hip to collect a
small sample of the bone.

53. DEFERENTIAL DIAGNOSIS
Osteomalacia Osteoporosis
Feelings Unwell Well
PAIN Generalized
chronic ache
after fracture
Muscles weakness normal
Looser’s zone Present Absent
S. Ph3 level decrease normal
Alk. Ph3ase increase normal

54. DEFERENTIAL DIAGNOSIS
Primary Hyperparathyroidism
Hypercalcaemia
Hypophosphaetemia
Raised PTH & alkaline phosphatase
Myeloma
Anemia
Increase ESR
Blood and urine electrophoresis raised of single Ig
Bence jones protein

55. TREATMENT
Depending on etiology, severity and metabolic
abnormality
• If the caused by a lack of vitamin D:
– Adequate Sun Exposure
– Intake of Fortified Foods
– Oral administration of 1.25mg(50,000IU)/week for 6 to 8
weeks followed by 20μg/d(800IU) from food and
supplements until normal level is achieved
• If calcium and phosphate levels are low in the body,
calcium and phosphate supplements are given.
• If osteomalacia is due to an underlying condition, the
treatment procedure will start immediately.

56. RICKETS TREATMENT
• Vit D deficiency state
– Vit D 300,000-600,000 IU IM /Orally in a day (2-4 doses) OR
– Vit D 2,000 – 5,000 I.U./day 4- 6 wk
– Calcium --- 1g/ day
– General nutrition , sunlight
– Followed by 400 IU / day
• Absorption defect
– Vit- D 1,500 – 25,000 IU / day
– Calcium 1 g/ day
– Treatment of underling pathology; where appropriat, low fat or gluten free
diet
• Vit D resistant
– Vit D 20,000- 60,000 IU/day Or dihydrotachysterol (dose 1/3 of vit D)
– Neutral phosphate-1.5- 6 g/ day (4-5 dose)
– Calcium – 1 g / day

57. PREVENTION
• Eat foods rich in vitamin D like oily fish, egg
yolks, milk, yogurt, cereal, etc.
• Eat foods rich in calcium like milk, yogurt,
cheese, tofu, leafy greens, etc.
• Adequate Sun Exposure

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