population and economic change (summarize notes)
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section_e.pdf
VITAMINS Objectives 1. Classify vitamins to different groups 2. Know what "Recommended Daily Dietary Allowance" 3. Describe situations in which vitamins are required as dietary supplements 4. List risks and benefits 5. List vitamins of the B group 6. Discuss present ideas on folate supplements 7. Separate facts from supposition in the actions of vitamins C, E, A, D
VITAMINS: Substance essential for maintaining normal metabolic functions, but is not made in the body therefore must be provided from an outside source.
*CLASSIFICATION OF VITAMINS (memorize!) Water soluble: Vitamin C & 11 vitamins in the B group Fat soluble: Vitamin A, D, E, K *Are Vitamins Drugs? • Vitamins are considered to be drugs when consumed as pills/tablets (chemically pure
form), but are not considered to be drugs when consumed as food (healthy diet). DRI: Dietary recommended intakes EAR: Estimated average requirement *RDA: Recommended daily allowance • Daily intake sufficient to meet the needs of 97% to 98% of healthy people in a group
(Age, gender) • Recommended amounts of nutrients and calorie daily, necessary for good health
determined by public health organizations. AI: Adequate intake • Recommended daily intake based on scientific data for specific groups of individuals
(Age, gender…etc.) UL: Upper limit • Highest recommended daily intake that won't lead to any bad health risks. (Maximum
amount of nutrients/calorie…etc. recommended to people to prevent any adverse health effects)
*When are vitamins required as dietary supplements? 1. Inadequate intake (not enough vitamins consumed)
o Due to poverty, or geography
• Ex. Aboriginal people living in North of Canada o People who consume a diet of one major food.
• Ex. Black people in S. Africa who lives on a corn diet only. o People eating uncommon food due to psychiatric disturbance. (Eccentric
diet/Idiosyncratic diet) o Inadequate diet due to religion o Due to Alcohol dependence. This leads to inadequate food intake since large
calories are obtained from alcohol. o Some people are on restrictive diets (Doesn’t eat certain food)
2. Disturbances in absorption of vitamins o Due to prolonged diarrhea o Liver disease o Some people taking antibiotics can alter intestinal bacteria
• Vitamin K and biotin (both from vitamin B group) are derived from intestinal bacteria
3. Increased requirements o During growth, you need more vitamins o During times of hard physical work , more vitamins are required o Pregnancy, lactation (breast feeding), menstruation o Stress o Illness
• Hyperthyroidism • Fever • Tissue wasting
*Consequences of too much vitamin intake • Can lead to production of toxic effects. • Excess water-‐soluble vitamins can be excreted in the urine, so are safe. • However, overdosing vitamin B6 (pyridoxine) can cause nerve injury • High doses of fat soluble vitamins (A, D, E) can cause accumulation of body fat, and
cause serious toxic effects. WATER SOLUBLE VITAMINS VITAMIN C (ASCORBIC ACID) (Important for collagen synthesis!) *RDA for vitamin C is higher for smokers compared to non-‐smokers Vitamin C is most important for synthesis of collagen in humans. Collagen is required to hold together cells in our body. Without this, our organs won't be held in place. So with inadequate vitamin C, cells/organs would not be held together well, and can cause bleeding, spongy/swollen gums and loose teeth. This disease is called Scurvy.
HISTORY • British navy first discovered that citrus fruits, lime juice cured scurvy • *citrus fruits are vitamin C rich!
*Vitamin C is used to prevent and treat scurvy. *Vitamin C is also used the prevent and treat common cold (but is highly controversial)
*NEGATIVE EFFECTS OF VITAMIN C when Vitamin C is taken above RDA (recommended daily allowance) -‐-‐ TOO MUCH VITAMIN C • Diarrhea • Formation of kidney stones • Rebound Scurvy when stop taking vitamin C
VITAMIN B (B GROUP OF VITAMINS) There are 11 members of the B group of vitamins. They are grouped together because were derived from the same sources (liver and yeast)
Thomas Robinson Never Plays Poor Fun Basketball Consistently Thomas (B1 Thiamine) Robinson (B2 Riboflavin) Never (B3 Niacin) Plays (B5 Pantothenic Acid) Poor (B6 Pyroxidine) Fun (Folate) Basketball (Biotin) Consistently (B12 Cyanocobalamin) *Memorize these! FOLATE • Important for women because it can reduce risks of neural tube defects (spina bifida)
in their offspring (when bearing a child) • 400ug recommended daily
VITAMIN B6 (Pyroxidine) • High intake of this vitamin decreases risk of heart disease
VITAMIN B12 (Cyanocobalamin) • Older people have difficulty absorbing Vitamin B12, so they should take vitamin B12
as a supplement (Vitamin B12 tablets) or eat Vitamin B12 fortified foods. FAT SOLUBLE VITAMINS
VITAMIN A Vitamin A is important for growth and development. Therefore without it, growth and development will be retarded. Vitamin A is a component of rhodopsin (rods of the eye)which is required for night vision. Therefore without it, can lead to night blindness and dryness of the eye (xerophthalmia) Without Vitamin A, can lead to respiratory infection, and changes in cells lining the LUNG. Deficiency of Vitamin A can also lead to dry, thick skin Use of Vitamin A More Vitamin A is required for infants, pregnant women. Vitamin A is used to treat Vitamin A deficiency and for other skin diseases. What about too much Vitamin A? • Toxicity results, leading to dry and itchy skin, vomiting, headache, enlarged liver and
spleen VITAMIN D Mechanism of Vitamin D Provitamin D is present in our skin. When sunlight is exposed to our skin, the vitamin D we have consumed from food (meat/fish) converts into 25 hydroxyvitamin D in our liver. It is converted again to 1,25 Dihydroxyvitamin D in our kidney. This is how active Vitamin D is formed in our body. *So, you need sunlight for Vitamin D! Some countries have milk with Vitamin D, because older people aren't exposed in the sunlight enough.
*What does Vitamin D do? • Increases calcium and phosphate absorption from the intestines
*Calcium and phosphate helps make new bone! • Helps regulates blood calcium level
*Blood calcium level must be regulated for optimal health • Involved in removal of calcium from older bone to form new bone (bone growth)
Vitamin D Deficiency: BAD! • Decreased absorption of calcium and phosphate • Decrease blood calcium level • Defective bone growth for infants, children, even adults (bowleggedness, called
rickets) TOO MUCH VITAMIN D causes:
• Toxicity results • Elevated calcium levels • Excess removal of calcium from bone • Fatigue, nausea, vomiting, diarrhea, impaired kidney function
*It is recommended that men an women over the age of 55 take vitamin D supplements to prevent osteoporosis *It have been suggested recently that Vitamin D also have protective effects against breast cancer VITAMIN E Vitamin E is present in adequate amounts in the normal adult diet. Vitamin E is essential for normal reproduction for mammals/humans. • Research studies revealed that female rats with Vitamin E deficiency failed in
pregnancy, and male rats with Vitamin E deficiency experienced irreversible sterility. • Therefore, vitamin E is being studied for a possible treatment for abortion
Vitamin E deficiency can lead to muscular dystrophy (degeneration) in some mammals, but not for humans. Vitamin E deficiency is associated with anemia for some animals. It can be useful in treating premature babies with hemolytic anemia. Vitamin E leads to heart muscle degeneration for some animals. Some studies say Vitamin E have a beneficial effect in cardiovascular disease, but some say no. Still needs to be resolved. There are claims that Vitamin E is effective in minor skin problems and in schizophrenia, but not proven. Summary: 1. Effective in premature babies with an uncommon type of hemolytic anemia. 2. Some studies indicate a beneficial effect of high dietary intake of vitamin E in
cardiovascular disease. Other studies do not confirm beneficial effects. Questions of usefulness remains to be resolved.
3. Ineffective in muscular dystrophy, habitual abortion and sterility. 4. Claims of effectiveness in minor skin ailments and in schizophrenia have not
been substantiated. OVER-‐THE-‐COUNTER (OTC) DRUGS Objectives: 1. Select 10 OTC drugs that are appropriate for home use
2. State the mechanism of action and toxicity of the commonly used OTC drugs 3. State the type of information that is required before using an OTC drug 4. List the conditions that must be followed when using OTC drugs 5. List the criteria for selecting an OTC drug
Over-‐the-‐counter (OTC drugs): Drugs that are sold to anybody without a prescription (general cold medicine…etc.). The general public does not consider these as drugs. However, they are drugs, and can cause toxicities. The sale of OTC drugs is controlled by the Food and Drug Act. This Act controls safety, efficacy. Advertising and sale of these products.
The List of OTC drugs 1. Internal Analgesics (먹는 약) *ANALGESICS = PAIN KILLERS*
o Acetylsalicylic acid (ASA) (Aspirin) • Analgesic (reduces pain) • Antipyretic (reduces fever) • Anti-‐inflammatory (reduces inflammation (염증))
How? By inhibiting synthesis of prostaglandins (which enhances pain and fever)
Toxicities (consequences with high doses of ASA) • Gastric irritation and bleeding. • Tinnitus (ringing in the ears)
*ASA is associated with Reyes syndrome in children when given during fever. Therefore Acetaminophen is recommended to children with fever. ASA poisoning for children and adults is common Buffered ASA are not better than ASA alone. It reduces gastric irritation, but doesn't have enough antacid contained. Effervescent analgesics (Alka Seltzer)(type of pain killer) contains ASA and high concentration of sodium (sodium bicarbonate/systemic antacid) so it shouldn't be taken frequently. It is considered both an analgesic and antacid. High concentration of sodium -‐-‐> bad to people with hypertension (high blood pressure) or kidney disease! * It is better to use an analgesic and antacid separately, than taking Effervescent analgesics. 1. Acetaminophen (Tylenol) • Just like ASA, it is an analgesic (pain killer) and antipyretic (reduce fever) • Has equal efficacy as ASA • However, unlike ASA, it is not anti-‐inflammatory (reduce inflammation)
How? Similar to ASA, by inhibiting synthesis of prostaglandin
*Acetaminophen is the DRUG OF CHOICE (recommended) because ASA can cause gastric irritation, and it is not recommended for children with fever. (Acetaminophen is not associated with Reyes syndrome)
*Acetaminophen can be available in liquid (syrup) so convenient for use in children
Consequences with high dosage (at least 10g/20 tablets or more) • Can lead to fatal liver injury
1. Ibuprofen • Non-‐steroidal • Anti-‐inflammatory (reduce inflammation) • Antipyretic (reduces fever)
Higher efficacy than ASA for menstrual and dental pain • This means that less ibuprofen is more effective than consuming more ASA
Consequences • Gastric irritation (but less than ASA) • Skin rash • Dizziness • Blurred vision • Fluid retention
COMBINATION • Popular combination for better effect is ASA or Acetaminophen with Codeine and
caffeine However, single product is preferred. (Don't combine!)
1. Topical analgesics (바르는 약) • Examples: Absorbine Jr., Deep Heat Rub, Ben Gay, Capiscum • Cause vasodilation and feeling of warmth • Less effective than internal analgesics (먹는 약) • Usually effective for mild conditions.
감기약 • Can lead to death to some young children, so no longer recommended for children
under 6yrs old. • There is no cure for common cold. Treatment is to relieve the symptoms.
1. Antihistamines • Drugs that block histamine receptor, to prevent causing vasodilation (혈관확장) and
inflammation
• Have anticholinergic properties (decrease nasal and salivary secretions (콧물/가래)) • Have a very limited role in reducing/alleviating symptoms of a cold. • *can cause drowsiness, especially older medicine. Newer antihistamines cause less
sedation. 1. Decongestants • Agonists (alpha-‐ adrenergic receptor stimulants) • Cause vasoconstriction and reduction in congestion • Phenylephrine agents is not used orally but so best applied locally (nose drops)
• 0.5% Phenylephrine is an effective decongestant • Shouldn't be used for more than 7 days! • However problems with local decongestants is rebound congestion
• Pseudoephedrine is best used orally 1. Cough suppressants • Two kinds: centrally acting cough suppressants & peripheral cough suppressants • Centrally acting cough suppressants block processing information in the medulla (in
brain) and reduce frequency of the cough. • Codeine-‐ need 30mg to block cough centre, but most OTC drugs only have
8mg (not effective enough!) this is because codeine can cause dependence.
• Dextromethorphan HBr-‐ More preferred than Codeine. Also 30 mg is effective to block coughs. Most OTC drugs have 7.5mg, but doesn't cause dependence.
*Productive cough (cough that clears airways of mucus) shouldn't be suppressed, but non-‐productive cough(dry cough) should be suppressed*
• Peripheral cough suppressants block the nerve endings in the throat and bronchioles. • Camphor & menthol-‐ vaporizer form, or cream that is rubbed on to
throat/chest. However efficacy is questionable. Inhibits peripheral nerves on throat, but only small response. They do no harm.
** Therefore, the Recommended cough medicine is dextromethorphan HBr** 1. Expectorants • Stimulates secretions in bronchial tree and loosen phlegm (가래) in the airway. • Most commonly used chemical agent for this medicine is glyceryl guiacolate • They say it reduces the viscosity of sputum by increasing secretions, but the dose for
drug preparations in the market is far too low to be effective, therefore it is questionable.
• Clinical trials HAVE NOT demonstrated a good response. • Other agents: ammonium chloride, potassium iodide. • Nothing to recommend out of the agents described.
Summary: • Most common expectorants: Glyceryl guiacolate • Other expectorants: Ammonium chloride, Potassium iodide
• Dosage for the preparations that are currently being sold is too low to be effective. • Loosens phlegm by stimulating secretions
1. Analgesics (PAINKILLERS) • Effective in reducing fever and achy feeling associated with cold. • DRUGS OF CHOICE (recommended): ASA, Acetaminophen • Acetaminophen may be a better choice • Useful for fever & for pain killers • Better to take one type than both (don't take both ASA and Acetaminophen)
1. Cold Therapy
What do the medical experts for Consumers Union suggest? • Rest • Fluids (drink lots) • Analgesics and antipyretics (acetaminophen!) • Chicken soup (good for cold)
If congestion is a problem, short-‐term use of pseudophedrine would be useful Dextromethorphen would be useful if the cough is non-‐productive(dry cough) and troublesome All drugs are to be taken as a single-‐entity (don't mix!) Antitussives (drugs that relieves coughs) • Can contain many Ingredients: alcohol, sugar, codeine or dextromethorphan, and an
expectorant (glyceryl guiacolate or ammonium chloride) Over the Counter antitussives (drugs that don't need prescription) usually don't contain a lot of those ingredients to be effective.
Normally, the drug of choice is just dextromethorphan HBr, and no other ingredient. Mouth Washes & Lozenges Lozenges: small medicinal tablets taken for sore throats • Both are used to control bad breath and treat sore throats. • Mouth washes contain an antiseptic (disinfectant) • Contact time with organisms in the mouth (~1minute) in the mouth is too short to kill
germs (millions) , so their efficacy as an antibacterial agent is questionable. It is more considered to be a cosmetic to prevent bad breath. -‐-‐mouth washes
• Lozenges also contain an antiseptic (but not effective!) and a local anesthetic (locally numbs pain). They relieve sore throat. Overall, Lozenges numbs pain, and increases salivary secretions (more 침!ㅋㅋ), keeping the throat moist. However, any hard candy can be just as effective.
S le e p in g Pre p a ra t io n s ( A NTIHIS TA MINE & A NA LGES IC) • Help fall asleep or RELIEVE sleeplessness • Main ingredients: antihistamine that has sedative properties (doxylamine or
diphenhydramine) and an analgesic (usually acetaminophen) • There is a general agreement that these sleeping aids are not very effective to treat
insomnia according to placebo trials. Therefore, non-‐pharmacological methods should be tried first.
Hay Fever Preparations (ANTIHISTAMINE) • Hay Fever= Allergic rhinitis (건초열) e.g. pollen allergies • Hay fever is an antibody-‐mediated inflammatory disease of the nasal mucous
membranes • Leads to congestion and runny nose • A substance called histamine is released as a result, so antihistamines are the
drugs of choice for treating hay fever • First generation antihistamines: cause sedation/drowsiness, anticholinergic
properties-‐-‐ cause dry mouth • Second generation antihistamines: (cetirizine and loratidine) don't
produce sedation -‐-‐ PREFERRED/RECOMMENDED • Antihistamines are effective, but won't alleviate all of the symptoms. If congestion is
severe, a decongestant may be needed for short-‐term.
Medications: • Dristan: contains antihistamines, decongestants and analgesics (painkiller).
SHOULD NOT BE USED • Instead, people with hay fever should avoid exposure to the allergen (pollens) • Decongestants should be used WITH CAUTION for treatment of hay fever. Long
term use, especially sprays will lead to chronic rhinitis/rebound congestion. Therefore, only should be used for short term/occasionally.
Poison Ivy • Cause allergic dermatitis through their leaves of the plants. • Symptoms: red, itchy eruption (inflammatory) • Poison Ivy, poison oak, poison sumac should be avoided. If contact occurs, was with
tide detergent asap. • Calamine lotion can give temporary relief if exposure is mild.
• Calamine lotion: astringent (cause contraction of skin) that prevents itching, but doesn't treat inflammation (염증)
• 0.5% hydrocortisone ointment: topical anti-‐inflammatory agent that is effective for the inflammation. -‐-‐ more effective than calamine lotion.
Therefore, the best way to be treated for poison ivy is by topical medicine (연고) -‐-‐ 0.5% hydrocortisone ointment (recommended) Insect Bites (e.g. bees) • Bees, and other common harmful insects contain a venom that produces a local
inflammatory response similar to poison ivy. • Treatment for mild bites (for non-‐allergic people): identical to poison ivy;
calamine lotion and 0.5% hydrocortisone cream. Cold compresses may also be good to prevent the spread of the venom of bees
• One or two bee stings can lead to life threatening reaction. (these people should carry epinephrine; prescribed by a doctor)
Sunscreens • Solar energy emits UVA, UVB and UVC radiation • UVB is causes sunburn and tanning, and also associated with skin cancer. • UVA is responsible for drug photosensitivity, pigment darkening reaction, and
sunburn. • 75% of some forms of skin cancer are caused by UV radiation • Sunscreens are absorbed into the outer layer of the skin (stratum corneum) and
absorbs/scatter UV energy, preventing from reaching to the lower layer of skin (dermis)
• Chemicals contained in sunscreens: para-‐aminobenzoic acid derivatives, benzophenone, cinamic acids.
SPF (Sun Protection Factor)
Minimum erythema dose: time of exposure to UV radiation that will cause burn/redness of skin Choice of Sunscreen • SKIN TYPE
• Fair skin will burn quickly, so will need good protection (SPF 15). Dark skin requires less protection
• TYPE OF ACTIVITY • Swimming requires water-‐insoluble product
• Mountain climbers/skiers need higher SPF because UV is greater at higher elevations
• SITE OF APPLICATION • Lips & nose have thin layer of skin compared to arms so will require higher SPF
• CONDITION OF SKIN • If skin is dry, cream is a better choice. If you have oily skin, or have acne, gel or
alcoholic solution would be a better choice. Antacids (preventing acid in the stomach) • Two types: Systemic and non-‐systemic • Systemic antacid: e.g. Sodium bicarbonate is ABSORBED in the stomach
• Can cause systemic alkalosis • Can increase calcium, so used as a source of calcium
• Non-‐systemic antacid: NOT absorbed • DOES NOT cause systemic alkalosis • Aluminum hydroxide is very little absorbed
1. Sodium bicarbonate: Systemic antacid. Widely used by public. Rapidly neutralizes
acid in the stomach Disadvantages • Causes systemic alkalosis • Liberates CO2 (can cause gastric distention, formation of ulcer) • Can cause hypertension due to retained sodium
2. Aluminum hydroxide: Non-‐systemic antacid. Slow onset of action (insoluble) • Acts as demulcent (relieves inflammation/irritation), protecting it from the acid
(by coating the lining of the stomach) -‐-‐ MORE POPULAR Disadvantages • Can decrease phosphate absorption (can lead to osteomalacia, loss of
bone calcium) • Decrease in tetracyclines and anticholinergic agents • Can cause constipation
• Magnesium hydroxide (Milk of Magnesia): Non-‐systemic antacid. Widely used as
antacid and cathartic. Reacts very rapidly. Has good neutralizing capacity Disadvantages: • Cathartic action • Some magnesium can be absorbed (if you have poor kidneys, magnesium
can be retained, causing magnesium toxicity)-‐-‐ neurological, cardiovascular disease
• Magnesium trisilicate: Non-‐systemic antacid. Slow onset of action. • Gel-‐like (so it protects against the acid)
Disadvantages
• Large doses have to raise pH in stomach above 2.5, which can cause diarrhea
• Magnesium ion can be absorbed-‐-‐ magnesium toxicity
• Antacid mixtures: • To overcome constipating effects of aluminum hydroxide and the cathartic action of
magnesium antacids, these two are often combined to single preparation. • Antacid Therapy • Objective: to hold pH of gastric contents at about 4, so need proper dosage of
antacids. • Avoid systemic antacids containing sodium bicarbonate. • Aqueous suspensions are MORE EFFECTIVE than tablets.
CONCLUSION: antacids are useful for epigastric distress (heartburn) or excess acid. Use should be limited to few days or a week. H2 Antagonists • Histamines are involved in the release of stomach acids. Histamine receptors in the
stomach are different from the histamine receptors that cause allergies. • Famotidine and ranitidine are new drugs that blocks the H2 receptors, reducing the
amount of acid. These are more effective than antacid in reducing acid, and are more convenient to take.
• Antacids are taken every 3 hours, and famotidine is taken once a day. • Famotidine and ranitidine does not have adverse effects.
Cathartics and Laxatives • Laxative effect: Excretion of soft formed stool • Cathartic effect: More fluid evacuation
• Stimulant cathartics (contact cathartics)
• Increase motor activity of intestine and can cause cramps. • Increase mucus secretion, water and electrolytes • Examples:
• Castor oil • Phenolphtalein (major site of action: colon)
• 15% of oral dose is absorbed, and can cause toxicities. NOT RECOMMENDED
• Bisacodyl (acts on colon) • VERY EFFECTIVE • 5% oral dose is absorbed. Adverse effect is too much cathartic
action.
• Anthroquinone cathartics • Cascara sagrada and senna are available, but NOT RECOMMENDED
• Saline cathartics • Example: Magnesium sulfate (Epson salt) • Intestinal transit is increased indirectly • May enhance secretion of cholecystokinin (substance which may enhance intestinal
motility) • Undesirable effects: Dehydration, magnesium toxicity
• Bulk-‐forming laxatives • Polysaccharides (sugar) : e.g. Methylcellulose. Dietary fibre and bran are included in
this category • Contribute to osmotic effect in the gut • May indirectly stimulate peristalsis • Effect is seen in 12-‐24 hours, but full effect seen in 2-‐3days. • PREFERRED LAXATIVES
• Emollient Laxatives • Soften stool without stimulation of peristalsis • Surface active agents (e.g. Dioctyl sodium sulfosuccinate)
• Lower surface tension, and allow water to penetrate the feces • Toxicity can cause nausea and vomiting with large dosage
• Mineral oil • Soften stool by retarding absorption of water • Toxicity: can decrease absorption of fat soluble vitamins (A,D,E,K), mineral oil can
access to lungs causing lipoid pneumonia, mineral oil may inhibit complete evacuation of the bowel.
• Therefore Mineral should NOT BE USED • Use of Cathartics and laxatives • Constipation • In conjunction with anthelmintics to remove helminths • Prior to radiological examination • Prior to bowel surgery • To soften stools in patients suffering from Cardiovascular (C.V.) disease or
hemorrhoids. These are available as OTC drugs . However one must be aware that spastic colitis and other functional disturbances can result from long-‐term use, and also water/electrolyte disturbances can be observed.
Section E (vitamins) 1. All of the following vitamins are correctly associated with a deficiency disease
which is caused by their absence except: A. Vitamin A-‐-‐ night blindness and xerophthalmia B. Vitamin C-‐-‐ scurvy C. Vitamin D-‐-‐ beriberi D. Vitamin B12-‐-‐ Pernicious anemia E. Niacin (Vitamin B3)-‐-‐ pellagra
1. A supplement of which of the following vitamins is recommended for women of
childbearing age to decrease the incidence of neural tube defects such as spina bifida in their offspring?
A. Folic Acid B. Vitamin B12 C. Vitamin B6 D. Riboflavin (Vitamin B2) E. Thiamin (Vitamin B1)
1. Which of the following vitamins requires successive biotransformation (chemical
change) in the liver and kidney to become a biologically active substance? A. Vitamin A B. Vitamin C C. Vitamin E D. Vitamin D E. Vitamin B12
1. A low daily intake of vitamin C in humans will result in which of the following? A. Inadequate carbohydrate absorption B. Inadequate calcium absorption C. Inadequate phosphate absorption D. Inadequate synthesis of DNA E. Inadequate formation of collagen and intercellular ground substance
