1. Ann M. Manzardo, Ph.D. Department of Psychiatry & Behavioral Sciences Kansas University Medical Center Kansas City, Kansas © AMSP 1

2. Nutritional Deficiencies Once common, now rare in west Availability of food ↑ Nationalized fortification of foods Began in US, early 1900’s Iodine added to salt (goiters) Expanded to other nutrients, 1940’s © AMSP 2

3. Nationalized Fortification Dairy products Calcium/vitamin D to milk (rickets) Vitamin A to margarine (night blindness) Grain products Replaced B vitamins lost in milling Niacin, thiamine, riboflavin Folate added 1998 © AMSP 3

4. Who is at Risk Today? High risk groups in western countries Elderly Medical conditions (v omiting/GI) Certain psychiatric conditions → Alcohol Use Disorders (AUDs) © AMSP 4

5. Lecture Focus: Nutrition & AUDs Definitions AUDs & nutrition Thiamine Other B vitamins How to help © AMSP 5

6. 6 Abuse ( ≥1) Role failure Risk of harm Run-ins with law Relationship trouble Abuse vs.Dependence Dependence ( ≥3) Tolerance Withdrawal Not sticking to limits Unable to cut down ↑ time with ETOH ↓ time elsewhere Use in spite of problems Repeats 12 months

7. What is a Micronutrient? Needed in small amounts (<100 mcg/day) “Essential” for bodily functions Diet may be only source 2 kinds Vitamins – organic compounds Minerals – “trace” elements, ions or salts © AMSP 7

8. Thiamine (B1) Riboflavin (B2) Niacin (B3) Pantothenic acid (B5) © AMSP 8 Pyridoxine (B6) Biotin (B7) Folate (B9) Cobalamin (B12) B-Complex Vitamins Meats: poultry, eggs, fish & liver Beans & grains; Brewer’s yeast

9. Lecture Focus: Nutrition & AUDs Definitions AUDs & nutrition Thiamine Other B vitamins How to help © AMSP 9

10. AUDs → Nutritional Deficiency Lifestyle factors Poor dietary habits ↓ Access to food (poverty, homelessness) Alcohol preferred to food © AMSP 10

11. AUDs → Nutritional Deficiency Gastric Problems Alcohol damage Gastric mucosa inflamed Barrier to absorption ↓ absorption of nutrients © AMSP 11

12. AUDs → Nutritional Deficiency cont’d Selective loss of B vitamins B vitamins water (not fat) soluble Low cellular stores Levels ↓ quickly ↑ daily intake needed © AMSP 12 → Thiamine Deficiency (B1)

13. Lecture Focus: Nutrition & AUDs Definitions AUDs & nutrition Thiamine (B1) Other B vitamins How to help © AMSP 13

14. Thiamine Function © AMSP 14 Thiamine (B1) Glycolysis Generates ATP for energy Oxidative Metabolism Kreb Cycle ↑ lactic acid ↑ cell damage/death Anaerobic Metabolism

15. Thiamine Function cont’d © AMSP 15 Glucose-6-PRibose-5-P Pentose Phosphate Shunt DNA RNA Transketolase Transaldolase Thiamine (B1) ↓ Cell Growth

16. Consequences of Thiamine Deficiency © AMSP 16 Tissue-selective damage Heart muscles/neurons ↑ energy demand ↓ energy stores 2 clinical syndromes (wet/dry beriberi)

17. Wet Beriberi © AMSP 17 Cardiovascular Irregular heartbeat Heart failure Edema (fluid retention)

18. Dry Beriberi © AMSP 18 Neurological Pain/numbness in limbs (neuropathy) Balance/coordination problems Emotional disturbances

19. Neurological Syndromes © AMSP 19 Rare but serious 2 main syndromes Wernicke’s encephalopathy Korsakoff’s syndrome

20. Wernicke’s Encephalopathy © AMSP 20 Sudden onset of symptoms Impaired eye movement Can’t look to side Jerky movement Staggering gait (ataxia) Reversible with treatment Opthalmoplegia of left eye Nystagmus

21. Korsakoff ‘s Syndrome © AMSP 21 Memory loss (amnesia) ↓ Formation (anterograde) ↓ Recall (retrograde) Confabulation False memories/beliefs “Storytelling” Lack of insight

22. Genetic Vulnerability Sub-population identified ~10% of Non AUD ~ 30% of Wernicke-Korsakoff Syndrome Abnormal transketolase enzyme ↓ affinity for thiamine (B1) ↑ levels needed to activate ↑ alcohol-related problems © AMSP 22

23. Lecture Focus: Nutrition & AUDs Definitions AUDs & nutrition Thiamine (B1) Other B vitamins How to help © AMSP 23

24. Other B vitamin deficiencies © AMSP 24 Folate (B9), >40% Pyridoxine (B6), up to 50% Riboflavin (B2), ~17% Overlapping effects on: DNA, RNA, red blood cell (RBC) synthesis Sugar metabolism Cell growth/energy production

25. Folate (B9) Deficiency © AMSP 25 Anemia, 2 types Abnormally large RBCs, megaloblastic Ruptured RBCs, hemolytic ↓ appetite Weakness, fatigue Hair loss

26. Pyridoxine (B6) Deficiency © AMSP 26 Similar to niacin (B3) deficiency Failure to process iron to heme Anemia, sideroblastic ↓ healthy RBCs ↑ abnormal RBC (sideroblasts)

27. Pyridoxine (B6) Deficiency © AMSP 27 Skin inflammation Dermatitis Lips/mouth, cheilosis Neuropathy in hands/feet Neurological problems Seizures

28. Riboflavin (B2) Deficiency © AMSP 28 Inflamed skin/mucous membranes Mouth ulcers Cheilosis Eyes Bloodshot, itchy/watery ↑ sensitivity to light

29. Riboflavin (B2) Deficiency cont’d © AMSP 29 Seborrheic Dermatitis Scaly, oily rash Near glands Face/upper lip Genitals (scrotum, vulva) Permanent scarring possible

30. Lecture Focus: Nutrition & AUDs Definitions AUDs & nutrition Thiamine (B1) Other B vitamins How to help © AMSP 30

31. Treatment of Nutritional Deficiency Supplement guidelines Full B-complex, 7-14 days Oral, daily treatment Add minerals, help vitamins work Prenatal vitamins often used Inexpensive/easy © AMSP 31

32. B-Complex Vitamins 100 mg thiamine (B1) 1.3 mg riboflavin (B2) 10-50 mg niacin (B3) 300mg biotin (B7) © AMSP 32 1 mg folate (B9) 1-3 mg pyridoxine (B6) 6-12 mg cobalamin (B12) 10 mg pantothenic acid (B5) Treatment of Nutritional Deficiency cont’d

33. Wernicke-Korsakoff Syndrome Hospitalization IV thiamine, 100 mg 1-2 x daily 3-5 days Include full B-complex © AMSP 33 Treatment of Nutritional Deficiency cont’d

34. Alternative Supplements Fat soluble B1 analogues Allithiamine, natural product Benfotiamine, synthetic Sustained ↑ in blood levels Inexpensive/safe © AMSP 34 Treatment of Nutritional Deficiency cont’d

35. Brief Intervention 15-min initial contact, 5 A’s Assess/screen Advise to quit/reduce Agree on goals Assist with motivation Arrange follow-up © AMSP 35 Treatment of Alcohol Abuse

36. Refer to 12-step program Alcoholics Anonymous Refer to higher-level care Day treatment Residential Clean & sober living environment © AMSP 36 Treatment of Alcohol Abuse or Dependence

37. Medications for AUDs Naltrexone (Revia), 50-150 mg/day Acamprosate (Campral), 2 g/day Disulfiram (Antabuse), 250 mg/day © AMSP 37 Treatment of Alcohol Abuse or Dependence cont’d

38. AUDs → nutritional deficiencies What kinds of deficiencies Consequences How to help © AMSP 38 Summary Topics Reviewed