Nutritional deficiencies in the United States – Well fed and under nourished
Open a medical text book or an internet search on nutritional deficiencies in the United States, and you are led to believe nutritional deficiencies occur only in developing nations, where protein and calories are hard to come by. However, speaking both as a patient who suffered many nutritional deficiencies and as a physician who has tested dozens of patients over the last year, nutritional deficiencies in the United States are extremely common. If you or your loved ones suffer from fatigue, hair loss, dry skin, gastrointestinal symptoms, chronic disease such as diabetes, depression or anxiety, Alzheimer’s, or cognitive decline, I estimate your chances of nutritional deficiency are around 95%. In reviewing this post today on 12/20/2019, I reflect on the patients I saw this week who were coming in for follow up to review their test results. Every one of them had a nutritional deficiency of one form or another. I saw several people with a vitamin D deficiency, a couple with hormonal problems we found zinc deficiency, in my own mother, found CoQ10 deficiency which may be contributing to difficult to control hypertension, multiple B vitamin deficiencies: B12, riboflavin, thiamine, to name a few. Now with more advanced testing such as with SpectraCell micronutrient cellular analysis (https://spectracell.sitewrench.com/search-tests), and U.S. Biotek organic acids profile (https://www.usbiotek.com/tests/urinary-metabolic-profile), analytes that were difficult to obtain before from standardized labs can easily be measured.
Over the last 2 years, treating patients with chronic conditions, most who had a primary pulmonary condition, but also autoimmunity and other chronic disease, many complained of non-specific complaints such as fatigue, hair loss, itching, etc. I very commonly found elevated homocysteine levels reflecting poor B vitamin status and utilization, B12 deficiency, iron deficiency (both with and without anemia, - anemia is only one of several manifestations of iron deficiency), severe zinc deficiency, zinc:copper imbalance which should be 1:1, vitamin A deficiency, just to name a few. One woman I treated for pulmonary vasculitis had years of hair loss restored by a simple zinc supplement after diagnosing zinc deficiency. Vitamin C deficiency is commonly found in smokers due to increased vitamin C utilization in respiratory tobacco metabolism, and in COPD where vitamin C intake seems often be insufficient to meet increased utilization in oxidant stress. And even in Texas, where sunshine is plentiful, the majority of patients I test are vitamin D deficient. This was much worse in Baltimore, where upward of 80-90% of patients were vitamin D deficient. And as many now understand, having a low vitamin D level deleteriously affects multiple systems in the body and is pro-inflammatory.
Why are we undernourished? There are many reasons but the common ones I’ve encountered include: poor GI absorption of dietary nutrients due to increased intestinal permeability/leaky gut (which in vitamin A and zinc deficiency it’s a brutal cycle of the deficiencies causing leaky gut and the leaky gut causing poor absorption of these nutrients), underlying gastrointestinal disease such as celiac (where iron deficiency is common), inflammatory bowel disease, a diet high in overly processed foods with few nutrients and what little nutrients are there are not well-absorbed due to competing additives and what I like to call “chemical food”. Pregnancy and breastfeeding are commonly associated with nutritional deficiencies due to significantly increased demand for many nutrients. Other causes include food allergies and sensitivities which inflame the intestinal mucosa causing malabsorption soil depletion of many nutrients due to over farming, poor diet (Standard American Diet – SAD), dysbiosis (few good and many bad bacteria in the intestine) and chronic disease.
If you have any of the above conditions mentioned, symptoms such as chronic fatigue, hair loss, poor skin condition, have had multiple pregnancies or prolonged breast feeding, cognitive or memory issues, or you’re just concerned about your overall health or worried you may have a nutritional deficiency, I would recommend starting with the following nutritional assessments:
· Ferritin and iron studies. Iron deficiency is common in menstruating women, small children, and did you know you can have significant symptoms of Iron deficiency and not be anemic?!? I did not know this until I experienced it myself and developed profound ice pica during pregnancy with normal blood counts but an undetectable ferritin level (iron stores). If you are suffering from Dysautonomia or POTS, getting your ferritin above 50 can be very helpful. However, iron supplementation has significant risks, as Iron drives the Fenton reaction - creating free radicals and oxidative stress. Talk with your doctor about how to mitigate this risk with anti-oxidant support and glutathione. (you may need an integrative specialist who is knowledgable).
· Homocysteine level (ideal is <8, or less than 6 if you have alzheimer’s or cognitive decline per Bredesen/ReCODE protocol). Homocysteine is a marker for how well you are methylating at a cellular basis. I check this in almost everyone. Great marker for B vitamin deficiencies and other pathways of methylation.
· B12 level. The standard reference values go far too low for this vitamin. Best is >600. Levels less than 600 often cause elevated homocysteine levels and poor methylation at the cellular level.
· Zinc level (most accurate if RBC zinc but a serum Zinc:copper levels can give you a good idea). Ideal for both is around 100. Zinc is a critical. Deficiency causes leaky gut/increased intestinal permeability, thyroid problems (zinc is a cofactor in thyroid hormone production), skin, hair and nail problems including hair loss, increased risk of infections and oral ulcers.
· Vitamin A level. I see vitamin A deficiency quite often. Low vitamin A levels cause dry eyes, poor skin condition/dry skin, decreased vision and increased risk of infections. Genetic polymorphisms cause some people not to convert beta carotene from foods into active form of vitamin A, so for some, vitamin A is needed as opposed to beta carotene.
· Vitamin D level: 25-OH vitamin D for most. Ideal 50-60, but good is 40-80. If kidney disease, sarcoidosis or other granulomatous disease, check 25-OH vit D and 1,25-vit D as well as monitor calcium levels. Certainly the most common of deficiencies. Think about it, we used to live primarily outdoors. Now we live indoors, even the most adventurous of us spends more time indoors than out. Vitamin D affects everything, and I mean everything. One of my patients had a history of hypothyroidism. It completely normalized with vitamin D repletion. It has also been found to be effective in fighting some cancers.
· Vitamin C: ref range 0.6-2 mg/dL, but ideal >1.2. Less than 0.6, symptoms of scurvy arise (Yes, I have seen scurvy 3 times in my practice.)
· Special considerations: if you’ve had your gall bladder removed or risk of fat malabsorption, consider also testing vitamin E and K levels (fat soluble vitamins are A,D,E, K)
· Biotin (B7) if you’re having hair loss. Biotin supplementation has been shown to help with hair loss only in biotin deficiency
· Folate level particularly if homocysteine is elevated or planning pregnancy. The MTHFR genetic polymorphism C677T and A1298C are quite common (carriers up to 30% and homozygous close to 10% in certain ethnic groups) and contribute to multiple problems and make folic acid found in many vitamins and fortified foods not bioavailable. People with MTHFR often need supplements with methylated folate (not folic acid) and Methylcobalamin (not cyanocobalamin) form of B12, and often overlooked, even by experts, is the need for extra Riboflavin/B2. This is particularly important if you are considering conceiving or are pregnant. In my opinion this should be examined in all women considering conceiving or pregnant as its implications in fetal and maternal health are large.
How do you improve nutrient status?
· Consider ruling out food allergy/sensitivity and dysbiosis as this not an uncommon cause of nutrient malabsorption. This should particularly be considered if there are gastrointestinal symptoms, though some patients are asymptomatic.
· Eat a nutrient-dense whole food diet. What does this look like? Shopping on the perimeter of the grocery store, and minimally in the middle where packaged and processed foods are. Shoot for vegetable consumption of 5-9 servings per day, fruit consumption of 2-4 servings/day, and protein consumption of 1-3 servings per day. Add nuts and seeds for 1-2 servings per day. A great way to start the day off right is a green smoothie, very tasty and full of nutrients. Need ideas, there’s lots on-line or I have a list of ingredients in separate blog that I think taste ideal together.
· Add some sunshine to your life (and up your vitamin D!). Early morning sunshine will also help regulate circadian rhythm and cortisol production. Full body exposure to mid-day sun for up to 30 minutes provides 10,000-20,000 Units of vitamin D in light-skinned individuals. Dark-skinned individuals need more exposure for the same benefit due to melanin absorption of rays. Worried about skin cancer? Of course, we’ve been slathering on sunblock for decades. However, a diet rich in beta carotene (think carrots and sweet potatoes) and lycopene have been shown to lower skin cancer risk.
· Buy or grow organic when possible. Dairy, vegetables, fruit and proteins produced organically may have better nutritional value, and certainly fewer hormones. Non-GMO in some cases also may have better nutrients.
· Consider supplementation carefully. Many studies have shown that diet positively affects health significantly. However, numerous studies have negated the health benefits of nutritional supplements. Supplements certainly have their place, but discuss in detail with your doctor and try to get as many nutrients as possible from food. For example, in zinc deficiency, oysters, pumpkin seeds, legumes, and meat, are great ways to increase dietary zinc. However, in significant deficiency, early supplementation to normal levels can be very helpful and supplements can be tapered as diet and lifestyle modifications normalize levels naturally. Some supplements may need to be continued long term such as magnesium, vitamin D and sometimes B vitamins.
Written by : Leann Silhan, MD
References:
Bird JK. Nutrients. 2017 Jul; 9(7): 655
Cicarma E. Anticancer Res. 2009 Sep;29(9):3495-500
Bredesen D. The End of Alzheimer's: The First Program to Prevent and Reverse Cognitive Decline. Penguin Random House, 2017