The son of a 78-year-old patient with multiple diseases, including diabetes, asked me: “What are the nutrients that my father needs?” I told him that at his age and with multiple diseases, both nutrients and micronutrients are important. Importantly, these must be given judiciously.”
There are three macronutrients, protein, carbohydrates, and fats. These are essential building blocks and need to be taken in the right proportion. These are visible and are present in our food in relatively large quantities. On the other hand, micro-nutrients are plenty and present in small amounts in various foods. They cannot often be seen with the eyes. Deficiencies of micronutrients are substantial in people living in developing countries like India and much less in Western countries.
There are several micronutrients — iron, vitamins (B12, other B vitamins, folate, vitamin D, A, C), minerals (magnesium, calcium, selenium, magnesium), iodine, sodium, potassium, chloride, sulphur and so on. The classic example of a severe micronutrient deficiency is scurvy. This used to occur in sea-bound people who did not eat fruits (a source of vitamin C) for several days and suffered from bleeding in gums and at other places. Such extreme deficiencies are rare now. But even slight deficiencies of some micronutrients can disturb organ functions and smooth functioning of the body. The amount of micronutrients needed daily to avoid deficiencies is termed as recommended daily intake (RDA).
Several diseases occur due to micronutrient deficiencies — iodine-goitre, iron-anaemia, vitamin B-nerve damage, vitamin D/calcium-rickets/bone weakness, folate-anaemia/foetal damage and so on. In India, the deficiency of iron, vitamin D, vitamin B12 and iodine is widespread. These deficiencies occur more commonly in childhood, adolescence, pregnancy and old age. Deficiencies may also occur in stressful situations like fever, long illnesses, intestinal dysfunctions, leading to malabsorption, chronic bleeding, diarrhoea/vomiting, chronic kidney, and liver diseases. Deficiencies of micronutrients in children or pregnant women may impact development of brain, bone, immunity, blood clotting and other vital organ functions.
Patients with diabetes may have micronutrient deficiencies, particularly those who have uncontrolled blood sugar and suffer from complications. Interestingly, our research shows that vitamin D deficiency may have a role in diabetes control, and that it should be corrected by giving supplements. A main drug for diabetes, Metformin, when used in high doses and for a long time, will result in vitamin B12 deficiency. In such cases vitamin B12 supplementation is required.
Interestingly, multiple deficits are seen in patients with diabetes who are lacto-vegetarians (B12, iodine, zinc) and vegans (iron, zinc, folate, B12, iodine) There is an emerging role of magnesium in regulation of blood sugar as well.
Elderly patients suffer from multiple micronutrient deficiencies due to insufficient food intake, intestinal dysfunction, dental problems, multiple illnesses and so on. One study showed that 20-60 per cent of the elderly population would have one or more such deficiencies, and this figure could be higher in India. They should be carefully evaluated for both macro (mostly protein) and micronutrient deficits. Besides balancing foods, such individuals will need multiple vitamins and minerals to correct these deficits. Sometimes injectable therapy is needed (e.g., iron. vitamin B12, vitamin D etc.). Frequent and prolonged use of antacid medication (pantoprazole, omeprazole etc) in the elderly (or for that matter anybody) could lead to B12, vitamin C, calcium, and magnesium deficiencies.
Pills which have multiple vitamins and minerals are commonly sold over the counter. Many people pop in these pills without supervision of their physicians. In some cases, these may help, but in most cases of micronutrient deficiencies, they don’t. In those with major vitamin and mineral deficiencies, high doses of specific nutrients are necessary (e.g., vitamin D, B12). Specific vitamins like folate are required in pregnancy to avoid birth defects. Finally, supplementation of these vitamins and minerals is not without toxic effects as seen in the excess dose of vitamin D, zinc, calcium etc. Patients with diabetes and kidney disease, when given excess potassium (mostly in fruits) develop life-threatening heart irregularities. Hence, these important small nutrients must be taken under expert observation.
(The author is Padma Shree Awardee and author of book “Diabetes with Delight)
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