Instructor Answer Key

Scenario #1

You are a Nutritionist seeing a family today that has been referred to you for a consult.   Address the questions after reading the patient’s brief history below:  

Caleb is a 2-year-old male.  He has been crawling all over the place, but has only started being able to support his own weight and trying to walk within the last month.  In fact, his mother notes that he has a lot of difficulty supporting himself and his legs appear bowed.  His parents are vegan and are also strict with his intake as well.  The majority of his nutrients come from fruits and vegetables.   His mother notes that Caleb was exclusively breastfed as a baby and drinks soy milk, though doesn’t really seem to like it so he doesn’t take much in.  Lately, he’s been less active, seeming tired, and at his most recent pediatrician visit the physician’s assistant noted that Caleb is not reaching his growth milestones.  

What symptoms does Caleb present that are worrisome, and why?

Caleb has difficulty supporting his weight; only beginning to try to walk at the age of 2; weakness; bowed legs; decreased activity levels; fatigued.

Why is it important to know that Caleb was exclusively breastfed as a baby?

Breastfed babies receive nutrients from the mother's milk.  If the mother is deficient in a nutrient, the baby will likely be deficient as well.  This gives context to nutrient intake and the importance of the mother's nutrition as well.

Based on the information provided, for what vitamin deficiency is Caleb most at risk? 

Vitamin D

Based on your answer to the previous question, what is the potential result(s) of this vitamin deficiency in children? 

Many students will note the symptoms Caleb is already experiencing.  Also important to note Rickets occurring in children due to a vitamin D deficiency due to the important role of vitamin D in calcium absorption. 

What would you recommend to Caleb’s parents in support of their little boy’s optimal health given his current physical evaluation? Why are those your recommendations?

Answers will vary.  Answers may include, but are not limited to: increase vitamin D intake through vitamin-rich foods; consider working with a Nutritionist regarding the best way to implement a vegan diet for a child; switch from soy milk if he does not like it to find something that is still a rich source of vitamin D that he will drink.  

Discussion may ensue about the importance of children's dietary needs within a family that follows a specific diet lifestyle, and how to be sure a child is consuming enough macronutrients and micronutrients.

Scenario #2

Lucia is a 73-year-old woman who prefers her vegetables very well cooked – she has esophageal dysphagia and needs her vegetables to be on the softer side in order to swallow them effectively. Because of her dysphagia, she doesn’t eat much meat but when she does, she makes sure it is very lean and that it has as little fat as possible.  Additionally, she’s allergic to nuts so can’t consume them. Lucia has recently been experiencing some other GI tract issues (abdominal cramping and bloating, diarrhea) for the past year, and was diagnosed with Crohn’s disease a few months ago.  To add to her ailments, Lucia has also been struggling with her vision and was diagnosed with cataracts.  Overall, she has been feeling very weak and more fatigued than usual, so she visited the doctor to get a blood test and make sure everything is okay.

What symptoms does Lucia present with that are potentially worrisome?

Fatigue; weakness; decline in vision; cataracts.  History of esophageal dysphagia; abdominal cramping and bloating; diarrhea.  Recent diagnosis of Crohn's disease.

What is Crohn’s disease, what symptoms does it cause, and how would it relate to a nutrient deficiency?

Type of inflammatory bowel disease that causes chronic inflammation of the gastrointestinal tract.  Symptoms can range from mild to severe, usually developing gradually, though sometimes with sudden incidence. Symptoms may include diarrhea, fever, fatigue, abdominal pain, abdominal cramping, blood in the stool, reduced appetite, weight loss.

Anything that causes inflammation of the gastrointestinal lining will impact the intestinal cells.  While Crohn's can impact any area of the GI tract, the small intestine is often involved.  One of the small intestine's primary functions is absorption of nutrients from food.  The villi and microvilli of the small intestine mucosa and enterocytes function to increase surface area for maximal and efficient absorption.  Inflammation can impact those structural features of the small intestine, and therefore, lead to inhibition of nutrient absorption (malabsorption), leading to nutrient deficiencies.

Based on the information provided, for what vitamin deficiency is Lucia likely deficient?  Explain how you determined this.

Vitamin E.  Clues from the case that would help to specifically implicate vitamin E would include: Lucia makes sure to consume little fat (vitamin E is fat-soluble and requires fat for absorption); allergic to nuts (rich source of vitamin E); diagnosed with cataracts (vitamin E is an antioxidant and may inhibit cataract formation by stabilizing the cell membranes of the lens in the eye).

Lucia’s doctor wants to do a blood smear to nail down her deficiency. How/why would a blood smear be specifically helpful in this case?

Vitamin E deficiency often leads to hemolytic anemia.  If so, a blood smear would show lysed blood cells.  This occurs because vitamin E normally acts as an antioxidant and stabilizing cell membranes from oxidative damage, including red blood cells.  In the case of a vitamin E deficiency, the red blood cell membranes may become unstable and lyse.

Scenario #3

Baby Anika was born via an uncomplicated vaginal delivery home birth vaginal. Mother and baby were reported to have an uneventful first few weeks at home. Breastfeeding was going well, and Anika was growing as expected. However, Anika began to develop severe bleeding from her umbilical stump and her parents were unable to stop the bleeding, so had to take her to the emergency department. Anika’s parents reported no family history of hemophilia and reported no issues with feeding intolerance, bruising, or changes in urination, stools, or activity. After a blood panel, Anika’s results returned normal with no concerns. However, the bleeding remained an issue. After multiple rounds of various treatments, Anika’s healthcare team suggested she may have a vitamin deficiency that’s leading to her bleeding.

Based on the information, for what vitamin is Anika likely deficient?

Vitamin K

Explain how this vitamin deficiency could result in uncontrollable bleeding? Describe important mechanisms this vitamin is involved in.

Vitamin K is needed for blood clotting.  In the mechanism of blood clotting, vitamin K is needed as a cofactor to activate clotting factors: II (prothrombin), VII (proconvertin), IX (thromboplastin), and X (Stuart factor).  Prothrombin (clotting factor II) is particularly important, as it is converted to thrombin, which then converts fibrinogen into fibrin, the insoluble protein that forms the fibrous mesh of a blood clot.  Without vitamin K, the blood clotting cascade is not executed effectively, and uncontrollable bleeding can occur.

At birth, Anika’s parents declined any vaccinations or injections. Why might it be particularly important for a baby to receive this vitamin injection at birth? Explain at least two reasons why babies are “at a disadvantage” when it comes to this vitamin.

Vitamin K is a nutrient humans consume through diet (phylloquinone (vitamin K1)), but is also produced by bacteria in the large intestine (menaquinone (vitamin K2)).  Babies are at a disadvantage because they are born with low stores of vitamin K.  At birth, a newborn's intestine lacks the vitamin K-producing bacteria from which adults benefit.  Furthermore, human milk typically contains low levels of vitamin K, so babies who are breastfed often have very minimal levels of vitamin K in the first few weeks of life.  

Scenario #1

Today your patient is Cai, a 52-year-old factory worker. He has been admitted to the hospital and presents with muscle weakness that has been affecting his ability to perform his job requirements. During his examination, you also note some inflammation of his mouth. As you ask Cai questions, he is a bit confused.  You inquire about drug and alcohol use, and he states that he isn’t drinking now, but he does have a history of alcohol abuse. He reports that he has lost quite a bit of weight in the last six months, and his dietary intake has been poor. He eats a lot of fast food, though his appetite has been poor.  He was laid off a year ago but he is back to work part-time. You order further testing to help determine the cause for his symptoms.

Based on the information provided, what possible vitamin deficiency(ies) do Cai’s signs and symptoms suggest? Explain how you came to this conclusion.

Cai's signs/symptoms suggest a deficiency in Vitamin B2 (Riboflavin) or Vitamin B6 (Pyridoxine).  He presents with muscle weakness, mouth inflammation, confusion, history of alcohol abuse, weight loss, poor diet.  Inflammation of the mouth (stomatitis) is seen in vitamin B2 and B6 deficiencies.  History of alcohol abuse would indicate overall malnutrition and potential for nutrient deficiencies of any kind. 

If you had multiple vitamins in mind, which one is the likely diagnosis?

Vitamin B2 (Riboflavin).  Since the case does not mention a blood test result for Cai, one could assume the deficiency is in riboflavin and not pyridoxine (a blood test for vitamin B6 deficiency would show microcytic hypochromic anemia).

What could be the cause of this probable vitamin deficiency (specific to Cai)?

Poor dietary intake; alcohol abuse.

What might be another sign(s) that you could expect to report upon examination of Cai, or a symptoms that you would expect Cai to complain of?

Answers will vary.

Vitamin B2 deficiencies are often accompanied by glossitis, or an enlarged and inflamed tongue, and/or cheilosis, or sores, swelling, and fissuring around the mouth and lips.

What specific diagnosis best fits Cai’s sign/symptoms?

Ariboflavinosis, as Cai has most classic symptoms (muscle weakness, confusion, oral inflammation).  

Always important to note that this is typically associated with broader nutrient deficiencies and malnutrition.

Based on the information provided, what vitamin(s), if any, would you recommend supplementing?

Vitamin B2, but likely all other vitamins.  A multivitamin supplement is best due to this patient's poor dietary intake and history of alcohol abuse.

What food(s) would provide the most significant source of the vitamin missing in his diet?

Sources rich in riboflavin might include: milk and other dairy products, eggs, green vegetables, meat, mushrooms, and almonds.

Scenario #2

Jules lives in a low-income household so she and her family typically eat a vegetarian diet since they can’t afford many meat products. Her typical meals include whole grains and leafy foods, but no dairy products or seafood. Jules has been struggling lately and has turned to alcohol as a coping mechanism, making her diet even worse. She enjoys drinking outside in the sunshine but has been noticing her skin is inflamed and itchy and it gets worse in the sun. But that’s not all – she met a man at the supermarket and wanted to give him her phone number, but she couldn’t remember it. Strange, right?

Based on the information, for what nutrient is Jules likely deficient? What made you choose this nutrient?

Vitamin B3 (Niacin).  Jules does not eat much meat and no dairy or seafood (animal products are rich in niacin with high bioavailability, and seafood products are rich in niacin).  Jules is drinking alcohol, experiencing forgetfulness, and dermatitis.   

What disorder does Jules likely have given her vitamin deficiency?

Jules likely has pellagra, which includes dermatitis of the skin that is made worse by sunlight.  Pellagra also includes symptoms of dementia, which may explain her memory relapse.

When Jules went to the doctor, they screened her for Hartnup disorder? Why would that be the case?  What is Hartnup disorder?

Hartnup disorder is a condition in which a genetic abnormality impairs absorption of tryptophan.  Tryptophan is an essential amino acid that is converted to niacin.  Therefore, tryptophan is an important source of niacin.

Scenario #3

Franny is a 38-year-old nurse.  She is in her first 3 weeks of pregnancy and lately has been experiencing fatigue, weakness, and recurring headaches.  She visits her primary care doctor, and he orders a blood test.  A complete blood count (CBC) test showed that the blood cells were large and immature.

What do the large and immature blood cells likely indicate?

Megaloblasts are large immature cells; they have organelles not normally found in red blood cells.

Is there a vitamin(s) for which Franny could be deficient?  Explain your rationale.

Franny is likely deficient in folate.  A folate deficiency can cause megaloblastic macrocytic anemia, indicated in her CBC.  She is also experiencing symptoms associated with that, including fatigue, weakness, and headaches.

Could this deficiency potentially impact her pregnancy? Explain in specific detail.

Franny is early in her pregnancy, and this is crucial when it comes to folate.  Folate is required for normal growth and development of neural tissue in the fetus, likely due to folate-containing enzymes needed for DNA synthesis.  Moreover, folate is important in the proper closure of the neural tube (embryonic tissue that becomes the brain and spinal cord).  The key here is that the closure of the neural tube is typically complete approximately four weeks (28 days) from conception.  After this time point, folate is not effective in helping the closure of the neural tube.

Neural tube defects can occur, resulting from improper closure of the tube. The most common type of defect is spina bifida, which can result in symptoms such as mental impairment, partial paralysis, poor bowel and bladder control, to name a few.