Тopic № 24
METHODS OF MEDICAL CONTROL OF VITAMIN SUFFICIENCY
IN THE ORGANISM
1. Learning objective
Master the methods of detection and assessment of the vitamin sufficiency in the
organism and the methods and measures of hypo- and avitaminosis prevention.
2. Basics
2.1. Y o u s h o u l d k n o w :
2.1.1. Classification and physiological significance of the vitamins in the
organism.
2.1.2. The most frequently occuring hypovitaminosis states in cases of both
individual and collective nutrition. Their causes.
2.1.3. Avitaminosis and their clinical characteristics.
2.1.4. Causes of the hypovitaminosis development.
2.2. Y o u s h o u l d h a v e t h e f o l l o w i n g s k i l l s :
2.2.1. To detect the hypo- and avitaminosis in cases of both individual and
collective nutrition.
2.2.2. To organize the hypovitaminosis prevention measures and assess their
effectiveness.
3. Self-training questions
3.1. Vitamins as a human dietary intake component, their classification,
physiological significance in organism.
3.2. The most frequent hypovitaminosis states in cases of both individual and
collective nutrition and their causes.
3.3. Symptomatic, clinical and biochemical signs of the hypovitaminosis C, its
diagnostic functional tests.
3.4. Hypovitaminosis А, methods of its detection.
3.5. Hypovitaminosis В, methods of their diagnosis.
3.6. Main sources of water-soluble vitamins.
3.7. Main sources of liposoluble vitamins.
3.8. Prevention methods and measures of hypovitaminosis. The influence of the
storage conditions, foodstuff culinary handling, and sale conditions on preservation of
the vitamins in them.
3.9. Comparative hygienic characteristics of the natural and artificial vitamin
medical preparations as hypovitaminosis prevention measures.
4. Self-training assignments
4.1. The substantial part of the students of mining industrial complex college
complain on the work capacity decrease, muscular weakness, rapid fatigability,
photophobia, eye colic during the routine physical examination. They explain such
symptoms as being caused by the decreased illumination at the working places in the
mine. The students do not complain on the canteen nutrition even if asked about it. The
pale, dry skin, hair follicle keratinization, especially on elbows and knees, hardened
skin on the heel even sometimes with fissures, acne formation, nails striation are
observed on a lot of students objectively.
The signs of what disease may be suspected after medical examination of the
students? What methods of deep examination must be used for diagnosing?
4.2. The student of the medical university also works as a nurse (night duties at
the clinic) at the non-study time. She is suffering from the tiredness, constant
fatigability, irritability, excessive sleepiness, poor progress in studies. The student says
that she has good nutrition, eats sausages, canned goods and other increased cost
products. She has no time for cooking hot meals and does not like visiting canteens. The
doctor pays attention to bruises on the hands and knees, nose, lips, gums, nails cyanosis,
skin paleness and dryness.
What disease is this girl suffering from? What examinations must be performed to
verify or change the diagnose?
5. Structure and content of the lesson
This is a laboratory lesson, consisting of 2 academic periods. The students have to
have their knowledge of basics checked, answer the self-training questions and perform
the exercises. After that the theoretical questions of this topic are discussed using
students’ quiz and tutor’s explanations (45 min.).
At the second period the students determine clinical and physiological signs of
the vitamin sufficiency in organism on each other in accordance to the appendixes 1, 2,
3. Then they make corresponding conclusions, give recommendations on the preventive
measures against hypovitaminosis. This work has to be written down in the protocol.
6. Literature
6.1. P r i n c i p a l :
6.1.1. Загальна гігієна. Пропедевтика гігієни. /Є.Г.Гончарук, Ю.І.Кундієв,
В.Г.Бардов та ін. / За ред. Є.Г.Гончарука. – К.: Вища школа, 1995. – С.434-458.
6.1.2. Общая гигиена. Пропедевтика гигиены. / Е.И.Гончарук, Ю.И.Кундиев,
В.Г.Бардов и др. – К.: Вища школа, 2000. – С.512-538.
6.1.3. Даценко І.І., Габович Р.Д. Профілактична медицина. Загальна гігієна з
основами екології. – К.: Здоровя, 1999. – С.313-353.
6.1.4. Габович Р.Д., Познанський С.С., Шахбазян Г.Х. Гигиена. – К.: Вища
школа, 1983. – С.134-155; 252-254.
6.1.5. Загальна гігієна. Посібник для практичних занять. /І.І,Даценко,
О.Б.Денисюк, С.Л.Долошицький / За заг. ред І.І.Даценко. – Львів,: Світ, 1992. –
С.90-93.
6.1.6. Lecture materials.
6.2. A d d i t i o n a l :
6.2.1. . Даценко І.І., Габович Р.Д. Основи загальної і тропічної гігієни. - К.:
Здоровя, 1995. – С.59-65.
6.2.2. Гігієна харчування з основами нутриціології. Підручник /В.І.Ципріян,
Т.І.Аністратенко, Т.М.Білко та ін./ За ред. В.І.Ципріяна – К.: Здоровя, 1999. - С.51-57.
6.2.3. Норми фізіологічних потреб населення України в основних харчових
речовинах та енергії /Наказ МОЗ України №272. – К.1999. – 10 с.
6.2.4. Ципріян В.І., Велика Н.В., Яковенко В.Г. Методика оцінки харчового
статусу людини та адекватності індивідуального харчування. /Учбовометодичний посібник. – К., 1999. – 60 с.
7. Equipment required for the lesson
7.1. Matussis or Nesterov manometer for capillary resistance determination.
7.2. Adaptometer ADM (АДМ), or Kravkov-Vishnevskiy’s adaptometer for
dark adaptation determination.
7.3. Tilmans reagent (2,6-dichlorphenol-indophenol), 0,06% solution, 8-10 ml.
7.4. Micropipette on 0,1 ml.
7.5. Stop watch.
7.6. Self-training exercises for students to determinate the hypovitaminosis
symptoms and indices. (on each other)
Appendix 1
Methods of early diagnosis and detection of the hypovitaminosis states
The indices of the organism nutritional state include also the signs of vitamin
sufficiency in organism.
Biocatalytic activity determines the vitamin physiological role – participation in
metabolic control of the organism. Hypovitaminosis C, A and in less occasions - B are
widely spread among the population especially in early spring period when the
vegetable supply and the carotene and ascorbic acid content in them is decreased.
Psychoemotional stresses characterizing the modern living conditions promote
the increase in the organism vitamin requirement and may cause the development of
hypovitaminosis states throughout the year.
Hypovitaminosis states may be detected in accordance to the clinical-andphysiological, biochemical indices and functional tests which are listed below.
Clinical and physiological indices of vitamin sufficiency in organism
In case of the partial vitamin insufficiency, no exact complains, which may be
related to any particular vitamin, exist. The most of such complaints have the general
character: weakness, sleepiness during the day, sleeplessness at night, irritability,
gurgling (borborygmus) and indeterminate pain at the abdomen and others.
The questioning of the people about their nutrition, their nutrition changes during
recent time, and also the body medical examination which must be performed at the
daytime have the considerable meaning at the medical practice. At the beginning, the
inspection of the head hair has to be performed. The dimness and fragility of the hair
may be the evidence of the protein and vitamin insufficiency in the diet. The
hypertrophy of the sebaceous glands is the cause of the increased seborrhea, especially
behind auricles, on the forehead, nasolabial folds, which is the symptom of the В2
(riboflavin) or В6 (pyridoxine) hypovitaminosis. The further development of this
hypovitaminosis state causes the atrophy of the sebaceous glands which shows in the
epithelium desquamation and the appearance of the shiny skin areas after epithelium
peeling. The pericorneal (perikeratic) injection of eye sclera vessels is the specific В2
hypovitaminosis symptom and is observed using the binocular loupe (magnifier) or slit
lamp. The purple-blue color crown is formed on the transition point between the cornea
and sclera as a result of the vessel overgrowth. The conjunctivitis with increased vessel
injection from center to circumference (periphery) often accompanies this symptom in
contrast to the catarrhal conjunctivitis (the vessel injection to the center).
Cheilitis is observed in cases of В2, В6, and sometimes РР (nicotinic acid, niacin)
hypovitaminosis. The lip mucous membrane becomes at first pale and than red due to
the epithelium maceration and it’s desquamation in the lip contact (closure) point in
case of cheilitis. The vertical labial fissures, angular stomatitis as grey-yellowish
papules in the angles of mouth and fissures covered with yellowish pellicle after papules
maceration appear. The hypertrophic glossitis as a tongue swelling and its volume
increasing, reddening with teeth impression along the edges is observed under this
vitamin insufficiency. Lingual papillaes are hypertrophied at first on the tip and than on
the lateral surfaces and upper surface (back) of the tongue. Deep furrows may also
appear (“geographic tongue”). The tongue becomes “bald”, polished, smooth, scarlet,
fiery (especially in case of PP hypovitaminosis) or with crimson hue (В2
hypovitaminosis) along the whole surface due to epithelium desquamation, which
follows the papillae hypertrophy.
The hyperkeratosis as an increased epidermis cornification on the elbows and
knee joints is observed in case of the A (retinol) hypovitaminosis. The skin is covered
with the net of small longitudinal and transversal fissures of mosaic type; hyperkeratosis
follicularis as an increased epidermis cornification on the buttocks, hips, cruses,
extensor arm surface on the hair follicles region skin, the skin becomes rigid, “gooseflesh”, “sharp”. The yellowish stains appear after epidermis peeling (desquamation),
unlike the C hypovitaminosis (the blue hemorrhage stain appears due to the epithelium
desquamation in this case).
The rapid fatigability, skin paleness, visible mucous membranes, hands, feet
cyanosis, gingival edema and swelling are the common C (ascorbic acid), P
(thioflavonoids) hypovitaminosis symptoms. Small isolated red islets on the gingival
mucous membrane and near the incisor (cutting teeth) edge interfere, producing the
border near the dental edge of the gums.
At first this border is scarlet, than becomes cyanotic, interdental papillae swell,
the mucous membrane becomes red, swollen, easy vulnerable from the tooth brush,
stale bread. The spontaneous gingival hemorrhage is observed in most evident cases and
this hemorrhage has to be differentiated from the parodontosis.
The clinical image of scorbutus (scurvy) develops when there is the strong
vitamin C insufficiency in the diet. The severe body weight loss, rheumatoid pain in
muscles and joints especially during the movement, anemia symptoms (dyspnea or
breathlessness, tachycardia), cyanotic border on the gums, spontaneous gingival
hemorrhage add to the C hypovitaminosis symptoms, described earlier. Later the gums
decay, putrificient (purulent) fetor ex ore appears, teeth get loose and begin to fall out.
Spontaneous hemorrhages in skin, muscles, joints and all internals and tissues appear.
The secondary infection is easily acquired.
The intense fatiguability especially during the walking, shank muscles tenderness,
paresthesia, lack of appetite, constipations, breathlessness, tachycardia and other are the
symptoms of vitamin В1 (thiamine) deficiency.
The deficiency of vitamin D (calciferol) in the diet and the insufficient exposure
to the solar ultraviolet radiation (work in mines, underground, indoors especially during
the winter) have such symptoms as the irritability (irritation), weakness, sweating,
muscles pain, teeth and bones (frequent fractures) brittleness. The specific children
symptoms of vitamin D deficiency are teeth development delay, susceptibility to the
respiratory tract diseases. The avitaminosis D may cause the rachitis (rickets).
The vitamin В12 (cyanocobalamin) deficiency provokes the megaloblastic
hyperchromic anemia development. The following symptoms as mucous membranes,
conjunctives paleness, dry mouth, tongue brightness, appetite loss, diarrhea,
polyneuritis are diagnosed during the objective medical examination at the beginning.
Appendix 2
Functional tests for detection of the C hypovitaminosis
1. Determination of the capillary resistance.
The Nesterov device or vacuum mercury Matussis manometer (see fig. 24.1) with
millimeter scale may be used for this purpose. The bailer rubber tube with internal
diameter 15.8 mm connects the Matussis manometer to the bulb with reflux valve or
Janet’s syringe to remove the air. The bailer border is vaselined and located on the
investigated internal surface of the forearm 1.5-2 cm lower than the antecubital fossa.
The negative pressure of 200 Hg mm is generated and maintained during 2 minutes. The
petechia number is calculated using the loupe. The loupe slide is pressed to the
investigated area, the skin becomes pale and petechia are more visible. The sample
results are evaluated according to the table:
Petechia
number
Up to 15
15-30
> 30
Degree of capillary strength
reduction
І
ІІ
ІІІ
C hypovitaminosis intensity
Absent
Pre-hypovitaminosis
Hypo- and avitaminosis
2. Tongue test with Tilmans reagent.
0.06% Tilmans reagent solution (2.6-dichlorphenol-indophenol of blue color) is
prepared. 0.007 ml of the reagent solution (the drop as a millet seed) is applied on the
middle of the tongue using the 0.1 ml micropipette with the 0.2 mm diameter injection
needle tip. The reagent decoloration time is determined with the stop-watch. The person
does not suffer from the C hypovitaminosis if the Tilmans reagent decoloration time is
22 – 23 seconds. The best time for the lingual test is one hour before eating on an empty
stomach.
3. Intradermal (skin) test with Tilmans reagent.
The reagent solution of the same concentration is sterilized with boiling water.
The small reagent quantity is injected with the single-use syringe and thin injection
needle intracutaneously to papulation of millet seed size. The reagent decoloration time
does not exceed 5 minutes if the C hypovitaminosis is absent.
4. Detection of the ascorbic acid in the morning urine excreted during one
hour by Zheleznyakova: it is recommended in the morning on an empty stomach to
get oneself free from the night urine. The time until the next urinary excretion is noted.
The urine volume per hour is calculated and the ascorbic acid content in this volume is
detected with chemical method.
The assessment of results: if 0.8 mg of ascorbic acid is excreted during 1 hour
then the organism is sufficiently supplied with vitamin C; 0.4-0.79 mg – satisfactory;
0.39 mg and less – deficiently.
Appendix 3
The adaptation to the darkness as the А, В2 hypovitaminosis sign
Hemeralopy or deviation in the adaptation to the darkness and in color perception
(yellow first of all) is the earliest symptom of the A and partly В2 hypovitaminosis. This
symptom is caused by the rhodopsin (visual purple) exhaustion in rods (cells) of retina.
The vitamin A takes part in formation of the visual purple.
Special devices – adaptometers are used to determine the adaptation to the
darkness. The Kravkov-Vishnevskiy adaptometer and medical adaptometer are widely
used for this purpose (ADM see fig. 24.2). The adaptometer is the rectangular or
globular camera with blind apertures for vision of the investigated person, the white
coloration of the internal surface and multicolored figures (squares, crosses, circles and
etc.).
The adaptometry is based on calculation of the time which is required for the
visual analyzer to perform its function during the change from high illuminance
(switching on the special lamp during 2 minutes and closing the colored figures with
special white screen) to low (twilight). For such purpose the illuminating lamp is
switched off, the white screen of adaptometer is turned off opening the colored figures.
The stop-watch is switched on at the same time.
The red spot is shown in the upper sector of the adaptometer. The examined
person fixes his vision on this red spot and informs when he sees one of the colored
figures. People with normal twilight vision need 50-55 seconds to see the colored figure
(84% of people see the figure even after 35-36 sec.). The increase of this time
demonstrates the hemeralopy presence and vitamin A deficiency.
The instruction to the adaptometer has additional information about measuring
using this device.
The individual task to student for assessment of the vitamin sufficiency in
organism
1. Answers to the questions about the patient’s feelings and nutrition.
2. Symptoms of vitamin deficiency:
Results of research: “+”, “-”.
1) swollen, edematous gums (С, Р);
2) bleeding gums (С, Р);
3) folliculosis (С);
4) petechia (С, Р);
5) skin dryness (А);
6) hyperkeratosis (А);
7) hyperkeratosis follicularis (А, С);
8) seborrhea oleosa (В2, В6);
9) cheilosis (В2, В6, РР);
10) angulitis (В2, В6 );
11) labial fissures (В2, В6, РР);
12) ciliary injection (В2 );
13) red tip of the tongue (В2, В6, РР);
14) hypertrophied lingual papillas (В2, В6, РР);
15) red polished tongue due to the papilla atrophy (В2, РР);
16) pale tongue because of the papilla atrophy (В2, В6);
17) teeth impression on the tongue (lingua) (В2, В6, РР);
18) desquamative glossitis (В2, В6, РР, Н).
3. Functional tests:
1) capillary resistance (petechia number);
2) lingual (tongue) test with Tilmans reagent (decoloration, sec.);
3) vitamin C excretion with morning urine, mg/hour;
4) dark adaptation, sec.
Conclusion about vitamin sufficiency in organism ………………………………..
Recommendations for hypovitaminosis prevention ……………………………….
The hypovitaminosis prevention is achieved by the enrichment of the diet with
necessary vitamin containing products or usage of the natural or artificial vitamin
preparations. Spending time outdoors or using the artificial ultraviolet sources prevents
the vitamin D deficiency in organism.
Fig. 24.1 Matussis manometer
(1 – mercury manometer on the support; 2 – rubber tube; 3 – glass T-joint; 4 – Birr glass bailer;
5 – Janet’s syringe)
Fig. 24.2 The adaptometer ADM (АДМ)
(1 – globe with lamp for vision blinding; 2 – apertures for vision with rubber blinds; 3 – colored
figures (cross, circle, square) inside the globe; 4 – the white screen which close the figures inside the
globe; 5 – red lamp for vision fixation inside the globe; 6 – device control system)