NUTRITION, LIVER AND BILIARY TRACT DISEASES [CH 325-333, 336] (JAN 7, 2022)

. . Reporters:. MORALES, KIMBERLY C.. MEENAVALLI, AKHIL CHOWDARY.

. . TOPIC OUTLINE. 1 Nutrient Requirements and Dietary Assessment.

. . Nutrient Requirements and Dietary Assessment.

● Nutrients are substances that are not synthesized in sufficient amounts in the body and therefore must be supplied by the diet. ● The absence of essential nutrients leads to growth impairment, organ dysfunction, and failure to maintain nitrogen balance or adequate status of protein and other nutrients. ● The amounts of essential nutrients required by individuals differ by their age and physiologic state ● Requirements for organic nutrients include 9 essential amino acids, several fatty acids, glucose, 4 fat- soluble vitamins, 10 water-soluble vitamins, dietary fiber, and choline. Several inorganic substances, including 4 minerals, 7 trace minerals, 3 electrolytes, and the ultratrace elements, must also be supplied by diet. INTRODUCTION.

● Energy For weight to remain stable, energy intake must match energy output. ● The average energy intake is ~2600 kcal/d for American men and ~1800 kcal/d for American women, although these estimates vary with body size and activity level. ● Protein Dietary protein consists of both essential and nonessential amino acids that are required for protein synthesis. ● The nine essential amino acids are histidine, isoleucine, leucine, lysine, methionine/ cystine, phenylalanine/tyrosine, threonine, tryptophan, and valine. ● The need of protein increase during growth, pregnancy, lactation, and rehabilitation after injury or malnutrition. ● Tolerance to dietary protein is decreased in renal insufficiency (with consequent uremia) and in liver failure. ESSENTIAL NUTRIENTS REQUIREMENTS.

● Fat and Carbohydrate Fats are a concentrated source of energy and constitute, on average, 34% of calories in U.S. diets. ● The brain requires ~100 g of glucose per day for fuel; other tissues use about 50 g/d. ● However, for optimal health, fat intake should total no more than 30% of calories. ● Water For adults, 1–1.5 mL of water per kilocalorie of energy expenditure is sufficient under usual conditions to allow for normal variations in physical activity, sweating, and solute load of the diet. ● Water losses include 50–100 mL/d in the feces; 500–1000 mL/d by evaporation or exhalation; and, depending on the renal solute load, ≥1000 mL/d in the urine. ● Infants have high requirements for water because of their large surface. area to volume ratios, their inability to communicate their thirst, and the limited capacity of the immature kidney to handle high renal solute loads..

● However Water intake needs to be increased during pregnancy are ~30 mL/d. During lactation, milk production increases daily water requirements so that ~1000 mL of additional water is needed, or 1 mL for each milliliter of milk produced DIETARY REFERENCE INTAKES AND RDAS ● The capacity for adaptation is not too much, as well as too little, intake of a nutrient can have adverse effects or alter the health benefits conferred by another nutrient. Therefore, benchmark recommendations regarding nutrient intakes have been developed to guide clinical practice. ● These quantitative estimates of nutrient intakes are collectively referred to as the dietary reference intakes (DRIs). The DRIs have supplanted the RDAs—the single reference values ● DRIs include an estimated average requirement (EAR) for nutrients as well as other reference values used for dietary planning.

● Estimated Average Requirement When florid manifestations of the classic dietary-deficiency diseases such as rickets (deficiency of vitamin D and calcium), scurvy (deficiency of vitamin C), xerophthalmia (deficiency of vitamin A), and protein-calorie malnutrition were common, nutrient adequacy was inferred from the absence of their clinical deficiency signs. ● The EAR is the amount of a nutrient estimated to be adequate for half of the healthy individuals of a specific age and sex. ● Recommended Dietary Allowances The RDA, the nutrient intake goal for planning diets of individuals, is the average daily dietary intake level that meets the nutrient requirements of nearly all healthy persons of a specific sex, age, life stage, or physiologic condition (e.g., pregnancy or lactation). ● The risk of dietary inadequacy increases as one’s intake falls below the RDA..

● On food labels, the nutrient content in a food is stated by weight or as a percent of the daily value (DV), a variant of the RDA used on the nutrition facts panel that, for an adult, represents the highest RDA for an adult consuming 2000 kcal. ● Adequate Intake It is not possible to set an RDA for some nutrients that lack an established EAR. ● Tolerable Upper Levels of Nutrient Intake Healthy individuals gain no established benefit from consuming nutrient levels above the RDA or AI. ● excessive nutrient intake can disturb body functions and cause acute, progressive, or permanent disabilities. ● The tolerable UL is the highest level of chronic nutrient intake (usually daily) that is unlikely to pose a risk of adverse health effects for most of the population..

. . ● Data on the adverse effects of large amounts of many nutrients are unavailable or too limited to establish a UL. Therefore, the lack of a UL does not mean that the risk of adverse effects from high intake is nonexistent..

. . FACTORS ALTERING NUTRIENT NEEDS. ● The DRIs are affected by age, sex, growth rate, pregnancy, lactation, physical activity level, concomitant diseases, drugs, and dietary com- position..

. . DIETARY COMPOSITION. ● Dietary composition affects the biological availability and use of nutrients..

. . Route of Intake. ● The RDAs apply only to oral intakes. When nutrients are administered parenterally, similar values can sometimes be used for amino acids, glucose (carbohydrate), fats, sodium, chloride, potassium, and most vitamins because their intestinal absorption rate is nearly 100%..

. . TABLE 325-1 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes forVitamins LIFESTAGE GROUP Infants Birth to 6 mo 6-12 mo Children 1-3 y Males 9-13 y 14-18 y 19-30 y 31-50 y 51-70 y >70y Females 9-13 y 14-18 y 19-30 y 31-50 y 51-70 y >70y Pregnant Women 14-18 Y 19-30 y 31-50 y Lactating Women 14-18 y 19-30 y 31-50 y VITAMIN A (gg/d)' 40(Y 500' 300 700 700 700 700 700 750 770 770 1200 1300 1300 VITAMIN C (mg/d) 75 75 75 75 75 120 120 VITAMIN D (gg/d)b 10 10 20 20 VITAMINE VITAMIN K (gg/d) 55' 75' 120' 120' 120' 120' 19 19 19 THIAMIN RIBOFLAVIN (mg/d) 0.2 0.5 0.6 0.9 1.2 1.2 1.2 1.0 1.1 (mg/d) 0.5 0.6 0.9 NIACIN 16 17 17 17 VITAMIN (mg/d) 0.6 1.7 1.7 1.9 2.0 2.0 2.0 FOLATE (gg/d)' 200 300 300 VITAMIN B (vg/d) 0.9 2.4 2.4 2.4 2.4h 2.4h 2.4 2.4 2.4 2.4h 2.4h 2.6 2.6 2.6 2.8 2.8 2.8 PANTOTHENIC ACID (mg/d) BIOTIN (gg,'d) 12' 35 • 35 • CHOLINE (mg/d)' 125• 150• 200• 250' 375' 550' 550' 550' 550• 550' 373 425' 425' 425' 425' 45T 45T 450' 550' 550' 550'.

. . LIFESTAGE GROUP Infants Birth to 6 6—12 Children Males 9-13 y 14-18 y 19-30 y 31-50 y 51-70 y >70y Females 9-13 y 14—18 y 19-30 y 31-50 y 51-70 y >70y TABLE 325-2 Dietary Reference Intakes (DRIs): Recommended Dietary Allowances and Adequate Intakes for Elements 2.3' 2.3' 2.3 2.3 2.3' 2.3' CALCIUM (mg/d) 200' 260' 700 1000 1300 1000 1000 1000 1300 1300 1000 1000 CHROMIUM COPPER FLUORIDE (mg/d) 0.01' IODINE IRON MAGNESIUM MANGANESE MOLYBDENUM (pg/d) 11 • 21 • 29' 45 • (gg,/d) 200' 220• 700 890 700 890 1000 1000 1000 1300 1300 (gg,/d) (mg/d) (mg/d) (mg/d) 0.003' 23 2.3' 2.3' 18 1.8' 2.6' (gg/d) 17 45 45 PHOSPHORUS (mg,/d) 100' 273 1250 700 700 700 700 1250 700 700 700 700 700 700 700 700 SELENIUM 15' 20 30 55 55 55 60 70 70 70 ZINC (mg,/d) 110' 130' 120 150 150 150 150 150 120 150 150 150 150 150 220 220 220 290 290 0.27' 11 10 11 8 8 8 8 15 18 18 8 27 27 27 10 9 9 130 420 240 360 310 320 320 320 350 360 360 310 320 POTASSIUM 4.7 • 4.7' 5.1' SODIUM 0.12' 0.37' 1.5' 1.3' 1.5' 1.5' 13 1.5' CHLORIDE 0.18' 0.57' 2.3 2.0' 1.8' 2.3' 2.3' 2.3' Pregnant Women 14-18 y 19-30 y 31-50 y 1300 1000 1000 Lactating Women 14—18 y 19-30 y 31-50 y 1300 1000 1000.

. . 6—12 Children 1—3 y Males 9-13 y 14—18 y 19—30 y 31-50 Y 51—70 y Females 9—13 y 14—18 y 19—30 y 31-50 Y 51—70 y Pregnant 14—18 y 19-30 y 31-50 y TABLE 325-3 Dietary Reference Intakes (DRIs): Recornmended Dietary Allowances and Adequate Intakes for Total Water and Macronutrients LIFE-STAGE GROUP Infants Birth to 6 mo 0.8 0.5 3.3 3.8 TOTAL WATER- 3.7 3.7 3.o• 3.0* CARBOHYDRATE (g/d) 130 130 130 130 130 130 130 130 130 130 130 130 175 175 175 210 210 TOTAL FIBER ( g,/d) ND 31 • 30 • 21' FAT (g/d) ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND ND LINOLEIC ACID IT IT a-LINOLENIC ACID (g/d) 0.5' Women Lactating Women 14—18 19—30 y 31—50 y PROTEINO (g/d) 9.1 • 11.0 19 71 71.

. . Nutrition assessment in clinical situations is an iterative process that involves:.

. . ACUTE CARE SETTINGS. ● In acute-care settings, anorexia, various other diseases, test procedures, and medications can compromise dietary intake the goal is to identify and avoid inadequate intake and to assure appropriate alimentation..

. . ● Most therapeutic diets offered in hospitals are calculated to meet individual nutrient requirements and the RDA if they are eaten Exceptions include clear liquids, some full-liquid diets, and test diets (such as those adhered to in preparation for gastrointestinal procedures), which are inadequate for several nutrients and should not be used, if possible, for more than 24 h..

Ambulatory Settings ● The aim of dietary assessment in the outpatient setting is to determine whether or not the patient’s usual diet is a health risk in itself or if it contributes to existing chronic disease-related problems. ● The assessment should focus on the dietary constituents that are most likely to be involved or compromised by a specific diagnosis as well as on any comorbidities that are present ● More than one day’s intake should be reviewed to provide a better representation of the usual diet, upon which personalized dietary recommendations can be base ● There are many ways to assess the adequacy of a patient’s habitual diet a commonly used food guide for healthy persons is the USDA’s Choose My Plate, which is useful as a rough guide for avoiding inadequate intakes of essential nutrients as well as likely excesses in the amounts of fat (especially saturated and trans fats), sodium, sugar, and alcohol consume.

● The Choose Myplate graphic emphasizes a balance between calories and nutritional needs, encouraging increased intake of fruits and vegetables, whole grains, and low-fat milk in conjunction with reduced intake of sodium and high-calorie sugary drinks ● Patients who follow ethnic or unusual dietary patterns may need extra instruction on how foods should be categorized and on the appropriate portion sizes that constitute a serving. ● Reviewing the guide with patients helps them transition to healthier dietary patterns and identifies food groups eaten in excess of recommendations or in insufficient quantities..

. . DIETARY '-m OF MEASURE Fruits, cups (Focus fruits.) Vegetables, cups (Vary vegetables.) Grains, oz eq (Make at least half of grains whole.)a Protein foods, oz eq (Go lean with protein.)b Dairy, cups or ozc (Choose calcium-rich foods.) "Empty" calories, kcald Sodium, mg Physical activity, min 5 5 3 120 3 260 <2300 at all energy I eve I s At least 150 min vigorous physical activity per at all energy levels.

. . Vitamin and Trace. Mineral Deficiency and. Excess.

. . ● Vitamins are required constituents of the human diet since they are synthesized inadequately or not at all in the human body. Only small amounts of these substances are needed to carry out essential biochemical reactions.

. . ● Therapeutic modalities can deplete essential nutrients from the body; for example, hemodialysis or diuretics remove water-soluble vitamins, which must be replaced by supplementation..

. . VITAMINS. THIAMINE (VITAMIN B1). ● Thiamine was the first B vitamin to be identified and therefore is referred to as vitamin B1..

Deficiency Most dietary deficiency of thiamine worldwide is the result of poor dietary intake. ● In Western countries, the primary causes of thiamine deficiency are alcoholism and chronic illnesses such as cancer. ● Alcohol interferes directly with the absorption of thiamine and with the synthesis of thiamine pyrophosphate, and it increases urinary excretion thus Thiamine should always be replenished when a patient with alcoholism is being refed, as carbohydrate repletion without adequate thiamine can precipitate acute thiamine deficiency with lactic acidosis. ● Alcoholic patients with chronic thiamine deficiency also may have central nervous system (CNS) manifestations known as Wernicke’s encephalopathy ● Thiamine deficiency in its early stage induces anorexia and non- specific symptoms (e.g., irritability, decrease in short-term memory). Prolonged thiamine deficiency causes beriberi, which is classically categorized as wet or dry although there is considerable overlap between the two categories..

TREATMENT ● In acute thiamine deficiency with either cardiovascular or neurologic signs, 200 mg of thiamine three times daily should be given intravenously until there is no further improvement in acute symptoms; oral thiamine (10 mg/d) should subsequently be given until recovery is complete. Toxicity ● Although anaphylaxis has been reported after high intravenous doses of thiamine. ● Thiamine supplements may be bought over the counter in doses of up to 50 mg/d..

. . RIBOFLAVIN (VITAMIN B2 ). ● Riboflavin is important for the metabolism of fat, carbohydrate, and.

. . Deficiency and Excess. ● Riboflavin deficiency almost always is due to dietary deficiency..

NIACIN (VITAMIN B3 ) ● The term niacin refers to nicotinic acid and nicotinamide and their biologically active derivatives. Nicotinic acid and nicotinamide serve as precursors of two coenzymes, nicotinamide adenine dinucleotide (NAD) and NAD phosphate (NADP),which are important in numerous oxidation and reduction reactions in the body. Metabolism and Requirements ● Nicotinic acid and nicotinamide are absorbed well from the stomach and small intestine. The bioavailability of niacin from beans, milk, meat, and eggs is high Deficiency ● Niacin deficiency causes pellagra The early symptoms of pellagra include loss of appetite, generalized weakness and irritability, abdominal pain, and vomiting. ● Bright red glossitis then ensues and is followed by a characteristic skin rash that is pigmented and scaling, particularly in skin areas exposed to sunlight. ● This rash is known as Casal’s necklace, it is seen in advanced cases the 4Ds 1. Dermatitis 2. Diarrhea 3. Dementia 4. Death.

. . TREATMENT. Treatment of pellagra consists of oral supplementation with 100–200 mg of nicotinamide or nicotinic acid three times daily for 5 days. Toxicity.

. . PYRIDOXINE (VITAMIN B6). ● Vitamin B6 refers to a family of compounds that includes pyridoxine, pyridoxal, pyridoxamine, and their 5′-phosphate derivatives. 5′-Pyridoxal phosphate (PLP) is a cofactor for >100 enzymes involved in amino acid metabolism..

● Deficiency Symptoms of vitamin B6 deficiency include epithelial changes, as seen frequently with other B vitamin deficiencies. ● In addition, severe vitamin B6 deficiency can lead to peripheral neuropathy, abnormal electroencephalograms, and personality changes that include depression and confusion In infants, diarrhea, seizures, and anemia have been reported. ● vitamin B6 is necessary for the conversion of homocysteine to cystathionine, it is possible that chronic low-grade vitamin B6 deficiency may result in hyperhomocysteinemia and increased risk of cardiovascular disease ● The increased ratio of AST to ALT seen in alcoholic liver disease reflects the relative vitamin B6 dependence of ALT..

. . ● Vitamin B6 dependency syndromes that require pharmacologic doses of vitamin B6 are rare; they include cystathionine β-synthase deficiency, pyridoxine- responsive anemias, and gyrate atrophy with chorioretinal degeneration due to decreased activity of the mitochondrial enzyme ornithine aminotransferase. In these situations, 100–200 mg/d of oral vitamin B6 is required for treatment..

VITAMIN - C ● Actions of vitamin C include antioxidant activity, promotion of nonheme iron absorption, carnitine biosynthesis, conversion of dopamine to norepinephrine, and synthesis 2313 of many peptide hormones. ● Vitamin C is also important for connective tissue metabolism and cross-linking (proline hydroxylation), and it is a component of many drug-metabolizing enzyme systems, particularly the mixed-function oxidase systems. ABSORPTION And Dietary sources ● Vitamin C is almost completely absorbed if <100 mg is administered in a single dose however, only ≤50% is absorbed at doses >1 g. Enhanced degradation and fecal and urinary excretion of vitamin C occur at higher intake levels. ● Good dietary sources of vitamin C include citrus fruits, green vegetables, tomatoes, and potatoes. Consumption of five servings of fruits and vegetables a day provides vitamin C in excess of the RDA of 90 mg/d for men and 75 mg/d for women..

. . DEFICIENCY. ● Vitamin C deficiency also can occur in young adults who eat severely unbalanced diets and can also causes scurvy.

VITAMIN - A ● Vitamin A, in the strictest sense, refers to retinol. However, the oxidized metabolites retinaldehyde and retinoic acid are also biologically active compounds. ● Retinaldehyde is the form of vitamin A that is required for normal vision, whereas retinoic acid is necessary for normal morphogenesis, growth, and cell differentiation. ● Vitamin A is found in the human food supply in two forms: pre- formed as esters and provitamin A in car ● The liver contains ~90% of the vitamin A reserves and secretes vitamin A in the form of retinol, which is bound in the circulation to retinol-binding protein..

. . DIETARY SOURCES. ● Liver, fish, and eggs are excellent food sources for preformed vitamin A; vegetable sources of provitamin A carotenoids include dark green and deeply colored fruits and vegetables..

. . TREATMENT. ● Any stage of xerophthalmia should be treated with 60 mg (or RAE) or 200,000 IU of vitamin A in oily solution, usually contained in a soft-gel capsule..

. . VITAMIN - D. ● Vitamin D is thought to be important for maintaining normal function of many non skeletal tissues such as muscle, for immune function, and for inflammation as well as for cell proliferation and differentiation..

Deficiency ● Vitamin D status has been assessed by measuring serum levels of 25-dihydroxyvitamin D (25[OH] vitamin D); however, there is no consensus on a uniform assay or on optimal serum levels. ● The optimal level might, in fact, differ according to the targeted disease entity. ● Risk factors for vitamin D deficiency are old age, lack of sun exposure, dark skin (especially among residents of northern latitudes), fat malabsorption, and obesity. ● Rickets represents the classic disease of vitamin D deficiency. Signs of deficiency are muscle soreness, weakness, and bone pain. ● The consumption of fortified or enriched foods as well as suberythemal sun exposure should be encouraged for people at risk for vitamin D deficiency. ● If adequate intake is impossible, vitamin D supplements should be taken, especially during the winter months ● Vitamin D deficiency can be treated by the oral administration of 50,000 IU/week for 6–8 weeks followed by a maintenance dose of 800 IU/d (20 μg/d) from food and supplements once normal plasma levels have been attained..

Toxicity ● The upper limit of intake has been set at 4000 IU/d ● Contrary to earlier beliefs, acute vitamin D intoxication is rare and usually is caused by the uncontrolled and excessive ingestion of supplements or by faulty food fortification practices. High plasma levels of 1,25(OH) vitamin D and calcium are central features of toxicity and 2 mandate discontinuation of vitamin D and calcium supplements; in addition, treatment of hypercalcemia may be required..

VITAMIN - E ● Vitamin E is the collective designation for all stereoisomers of tocopherols and tocotrienols, although only the RR tocopherols meet human requirements. ● It acts as a chain-breaking antioxidant and is an efficient peroxyl radical scavenger that protects low-density lipoproteins and polyunsaturated fats in membranes from oxidation. A network of other antioxidants (e.g., vitamin C, glutathione) and enzymes maintains vitamin E in a reduced state. ● Vitamin E also inhibits prostaglandin synthesis and the activities of protein kinase C and phospholipase A2. Absorption and Metabolism ● After absorption, vitamin E is taken up from chylomicrons by the liver, and a hepatic α-tocopherol transport protein mediates intracellular vitamin E transport and incorporation into very low density lipoprotein. ● The transport protein has a particular affinity for the RRR isomeric form of α-tocopherol; thus, this natural isomer has the most biologic activity..

. . Requirement Vitamin E. ● Vitamin E is widely distributed in the food supply, with particularly high levels in sunflower oil, safflower oil, and wheat germ oil..

. . TREATMENT. ● Symptomatic vitamin E deficiency should be treated with 800– 1200 mg of α-tocopherol per day..

. . VITAMIN -K. ● There are two natural forms of vitamin K vitamin K1, also known as phylloquinone, from vegetable sources, and vitamin K2, or menaquinones, which are synthesized by bacterial flora and found in hepatic tissue..

Deficiency ● The symptoms of vitamin K deficiency are due to hemorrhage; newborns are particularly susceptible because of low fat stores, low breast milk levels of vitamin K, relative sterility of the infantile intestinal tract, liver immaturity, and poor placental transport. ● Intracranial bleeding as well as gastrointestinal and skin bleeding can occur in vitamin K–deficient infants 1–7 days after birth. Thus, vitamin K (0.5–1 mg IM) is given prophylactically at delivery. ● Vitamin K deficiency in adults may be seen in patients with chronic small-intestinal disease (e.g., celiac disease, Crohn’s disease), in those with obstructed biliary tracts, or after small-bowel resection ● Vitamin K deficiency is treated with a parenteral dose of 10 mg. For patients with chronic malabsorption, 1–2 mg/d should be given orally or 1–2 mg per week can be taken parenterally. Toxicity ● Toxicity from dietary phylloquinone and menaquinones has not been described. High doses of vitamin K can impair the actions of oral vitamin K antagonist anticoagulants..

. TABLE 326-1 Principal Clinical Findings ofVitamin Malnutrition NUTRIENT Thiamine Riboflavin Niacin Vitamin BG Folate Vitamin B Vitamin C Vitamin A Vitamin D Vitamin E Vitamin K CLINICAL FINDING Beriberi: neuropathy, muscle weakness and wasting, cardiomegaly, edema, ophthalmoplegia, confabulation Magenta tongue, angular stomatitis, seborrhea, cheilosis, ocular symptoms, corneal vascularization Pellagra: pigmented rash of suræxposed areas, bright red tongue, diarrhea, apathy, memory loss, disorientation Seborrhea, glossitis, convulsions, neuropathy, depression, confusion, microcytic anemia Megaloblastic anemia, atrophic glossitis, depression, t homocysteine Megaloblastic anemia, loss of vibratory and position sense, abnormal gait, dementia, impotence, loss of bladder and bowel control, t homocysteine, t methylmalonic acid Scurvy: petechiae, ecchymosis, coiled hairs, inflamed and bleeding gums, joint effusion, poor wound healing, fatigue Xerophthalmia, night blindness, Bitot's spots, follicular hyperkeratosis, impaired embryonic development, immune dysfunction Rickets: skeletal deformation, rachitic rosary, bowed legs; osteomalacia Peripheral neuropathy, spinocerebellar ataxia, skeletal muscle atrophy, retinopathy Elevated prothrombin time, bleeding DIETARY LEVEL PER DAY ASSOCIATED WITH OVERT DEFICIENCY IN ADULTS <0.3 mg/1000 kcal <0.4 mg <9.0 niacin equivalents <0.2 mg <100 vg/d <1.0 pg/d <10 mg/d <300 Wd <2.0 pg/d Not described unless underlying contributing factor is present <10 ug./d CONTRIBUTING FACTORS TO DEFICIENCY Alcoholism, chronic diuretic use, hyperemesis, thiaminases in food Alcoholism, individuals with poor diets and low intake of milk products Alcoholism, vitamin BE deficiency, riboflavin deficiency, tryptophan deficiency Alcoholism, isoniazid Alcoholism, sulfasalazine, pyrimethamine, triamterene Gastric atrophy (pernicious anemia), terminal ileal disease, strict vegetarianism, acid-reducing drugs (e.g., H blockers), metformin Smoking, alcoholism Fat malabsorption, infection, measles, alcoholism, protein-energy malnutrition Aging, lack of sunlight exposure, fat malabsorption, deeply pigmented skin Occurs only with fat malabsorption or genetic abnormalities of vitamin E metabolism/transport Fat malabsorption, liver disease, antibiotic use.

. . Malnutrition and Nutritional Assessment. 03. Reporter: MORALES, KIMBERLY C..