Environmental & Nutritional Diseases

1. Environmental & Nutritional Diseases Ashley Inman 11-10-2014

2. Outline • Environmental Diseases • Malnutrition • Obesity • Vitamin Deficiencies

3. Carbon Monoxide • Important cause of accidental and suicidal death • Nonirritating, colorless, tasteless, odorless gas • Automotive engines, furnaces, cigarettes • Hemoglobin has much stronger affinity for CO than oxygen  carboxyhemoglobin

5. Lead Poisoning • Binds to sulfhydryl groups in proteins and interferes with calcium metabolism • Exposure may occur through contaminated air, food, and water • Lead paint in older homes • Children more susceptible due to higher intestinal absorption and a more permeable blood-brain barrier

8. Basophilic stippling On PBS

9. Smoking • Most prevalent preventable cause of human death

11. Alcohol • Acute: • Mainly CNS effects • Depressant that can lead to respiratory arrest • Chronic: • Liver: fatty change; cirrhosis • Thiamine deficiency • Alcoholic cardiomyopathy • Pancreatitis (acute & chronic) • Bleeding from gastritis and gastric ulcers • Increased incidence of oral, esophageal, liver, and breast cancer

12. Malnutrition • Also called “protein energy malnutrition” • Results from inadequate intake of proteins and calories or problems with digestion/malabsorption of proteins • BMI <16 kg/m2 (normal 18.5-25 kg/m2) • 2 main forms: • Marasmus • Kwashiorkor

13. Two protein compartments • Somatic compartment: • Proteins in skeletal muscle • Reduced circumference of mid-arm • Affected more by marasmus • Visceral compartment: • Protein stores in visceral organs (mostly liver) • Decrease in serum proteins (albumin) • Affected more by kwashiorkor

14. MARASMUS < 60% body weight Diet lacks protein & carbohydrate Loss of muscle mass (somaticprotein)- amino acids for energy Loss of subcutaneous fat (broomstick) Serum proteins (visceral compartment) NORMAL EMACIATION- loss of muscle and fat

15. MARASMUS Head appears too large; “stick figure” Multiple vitamin deficiencies coexist Immune deficiency- especially T cell immunity

19. KWASHIORKOR Protein deprivation > caloric deprivation **2nd birth First child is weaned too soon and put on a high carbohydrate diet MORE dangerous than Marasmus Severe loss of visceral protein Hypoalbuminemia causes generalized EDEMA which can mask the loss of weight Subcutaneous fat and muscle are SPARED

20. SIGNS OF KWASHIORKOR Flaky Paint Skin- alternating zones of hypo- and hyper-pigmentation and desquamation Hair loss or color change FATTY LIVER- due to loss of apolipoproteins; also smallintestine atrophywith loss of villi and disaccharidasedeficiency PITTING EDEMA and ascites due to hypoalbuminemia

21. Signs Continued…(Seen in both marasmus & kwashiorkor) Growth failure Multivitamin deficiencies Immune defects and infections Anemia- usually hypochromic/microcytic Cerebral atrophy in infants due to loss of neurons and impaired myelinization of white matter May have hypoplastic bone marrow (mainly due to loss of RBC precursors)

24. CACHEXIA CANCER and AIDS Loss of muscle and fat Fatigue Good appetite Higher metabolic rate Cytokines- TNF, IL-6 Proteolysis-inducing factor (PIF)

27. ANOREXIA NERVOSA Self-induced starvation Like PEM plus: Amenorrhea (decreased secretion of gonadotropin-releasing hormone w/ subsequent endocrine effects) Hypothyroidism Scaly, yellow skin and lanugo Decreased bone density (mimicks postmenopausal osteoporosis) Anemia, lymphopenia, hypoalbuminemia HYPOKALEMIA AND CARDIAC ARRHYTHMIA  SUDDEN DEATH

29. BULIMIA Binge eating followed by induced vomiting < ½ have amenorrhea, but menstrual irregularities common Weight and gonadotropin levels near normal

30. BULIMIA • Major complications due to frequent vomiting and chronic use of laxatives: • Hypokalemiaand CARDIAC ARYTHMIA • Aspiration of gastric contents • Mallory-Weiss Syndrome- longitudinal laceration of the esophagus or stomach • Boerhaave’s Syndrome- rupture of esophagus or stomach

32. Obesity • Hypertension • Insulin resistance • DM type II • High serum lipids • Atherosclerosis • Gallstones • Osteoarthritis • Malignancy • Nonalcoholic fatty liver disease • Sleep apnea

34. Metabolic Syndrome • Visceral/intra-abdominal adiposity • Insulin resistance • Hyperinsulinemia • Glucose intolerance • Hypertension • Hypertriglyceridemia • Low HDL cholesterol

35. VITAMINS Fat Soluble- A, D, E, K Absorbed in the ileum Toxic- accumulate in fatty tissues Water soluble- B’s, C, Folate Toxicity rare b/c excreted in urine Fat soluble vitamins are more readily stored, BUT they are poorly absorbed in fat malabsorption disorders (cystic fibrosis, celiac disease, ileal resection)

36. VITAMINS ENDOGENOUS Synthesis- D, K and Niacin DIET- all the others Vitamin Deficiency can be PRIMARY (diet) or Secondary (malabsorption)

37. VITAMIN A (RETINOL) Functions: Night vision Growth and differentiation of mucus-secreting epithelium Immunity (children) Vitamin A stored in ITOCELLS in the liver; 6-month supply

39. VITAMIN A DEFICIENCY Night blindness (insufficient retinal rhodopsin) Xerophthalmia (dry eye)- keratinized squamous epithelium replaces mucus-secreting epithelium Bitot spots (keratin debris) and keratomalacia (destruction of the cornea) Squamous metaplasia in LUNG (infections) and BLADDER (stones) Increased mortality in measles and diarrhea

41. Corneal Destruction

42. VITAMIN A TOXICITY Increased intracranial pressure Papilledema, headache, vomiting Bone pain and hypercalcemia (increased osteoclast activity)

43. VITAMIN D Major function is to maintain adequate plasma levels of CALCIUM and PHOSPHORUS

44. VITAMIN D FUNCTIONS Stimulates intestinal absorption of calcium and phosphorus Interacts with PTH to regulate blood calcium levels Stimulates PTH-dependent re-absorption of calcium in the distal renal tubule

46. VITAMIN D DEFICIENCY HYPOCALCEMIA and loss of bone: RICKETS or OSTEOMALACIA Malnutrition Intestinal malabsorption (pancreatic insufficiency) Inadequate sunlight exposure Liver disease Renal disease

48. Vitamin D Deficient Normal