FNES 264 WILLIAM MCGINTY

VITAMIN CASE STUDIES

Be sure to answer all questions. Answers must be complete and referenced us-
ing APA or AMA reference style. (5 points)

A 32-year-old male reports to the emergency room with active bleeding from his nose. History
reveals that he has been taking Orlistat for weight loss for the past year. He has no history of
any bleeding disorder or medical illness and has not had any such bleeding episodes in the
past.

What vitamin deficiency or toxicity do you suspect? (4 points)

I suspect a Vitamin K deficiency.

What role does Orlistat have in your diagnosis? (5 points)

Oriistat is a weight loss medication that prevents dietary fat absorption.1 It is likely due to
the medication’s anti absorption factor Vitamin K is not being absorbed by the male.1

He states he has lost 30 pounds only taking Orlistat but is still overweight and wants to lose
more. What would be your recommendation(s)? (4 points)

I would recommend that if he were to pursue further weight-loss, it would be wise to do

so without taking Oriistat any further. Proper nutritional education and counseling from a
Dietitian would be advised. The nutritional education would help fix any knowledge
deficits on the requirements for weight loss (such as caloric deficit, TEE, physical activi-
ty) and counseling would set realistic food and activity goals for the patient to reach.2
This way weight loss can occur via a balanced diet/exercise and prevent any nutrient de-
ficiencies from developing or getting worse.

A young woman lives in an extremely impoverished area of the world where the primary food
source is corn. Upon examination, you notice a severe rash that is particularly prominent on the
areas of her body most often exposed to the sun (her face, neckline, hands and legs below her
skirt). She also complains of feeling depressed, tired, suffering from memory loss and having
frequent diarrhea.

What vitamin deficiency or toxicity do you suspect? (Include the vitamin and the name of the
condition) (4 points)

I suspect a Niacin (vitamin b3) deficiency. The young woman has signs and symptoms of
pellagra.3

What factor(s) in this case led to your conclusion? (5 points)

The young woman is exhibiting pellagrous dermatitis on areas of her body exposed to
the sun. She is also displaying two D’s of pellagra which are diarrhea and dementia via
memory loss.3 Being that niacin is involved in energy production a deficiency would lead
to feelings of tiredness as well.3

As her diet is reliant on corn, what can she do to improve her condition? (3 points)

The young woman can improve her condition by eating foods rich in niacin, This in-
cludes dairy, meat, whole grains, and other foods fortified with niacin.3

During the Industrial Revolution in Britain, most children were put to work in mills, factories, and
coal mines. Often, they were up before dawn and could work anywhere from 12-16 hours a
day, 6 days a week. Food quality was poor and there was not much of it available.

If you examined a skeleton of a young child in these conditions, what would you expect to see?
(Include physical signs and the name of the condition) (5 points)

I would expect to see the bones of the child bowing under pressure; This is known as
rickets.4

What factor(s) in this case led to your conclusion? (5 points)

The children are not exposed to sunlight throughout the day which is a significant
source of Vitamin D.4 They are up before the sun is shining and inside of the mills, facto-
ries, and coal mines, where sunlight is not present. Their diets are poor quality and most
likely not eating much so it is unlikely they are consuming a sufficient amount of Vitamin
D.

A 20-year-old female, is 3 months post bariatric surgery (Roux-en-Y). She presents to the hos-
pital with nausea and vomiting for the past 6 weeks and an 83-pound weight loss. She also
shows confusion, difficulty with balance and rapid eye movements.

What would likely be her medical diagnosis? (5 points)

Based on her symptoms this patient most likely would be diagnosed with Wernicke Syn-
drome as well as Bariatric Beriberi.3

What vitamin deficiency or toxicity likely contributed to this diagnosis? (4 points)

This patient likely has a thiamin deficiency.

How might her history of bariatric surgery have contributed to the diagnosis? (4 points)

Her history of bariatric surgery may have led to decreased absorption. In a Roux-en-Y
gastric bypass a gastric pouch is formed and food bypasses a portion of the stomach
and the duodenum.3 The food consumed will bypass the duodenum (where most water
soluble vitamins are absorbed) leading to poor absorption of thiamin consumed.3
The patient was noted to have a high blood lactic acid level. Provide an explanation regarding
this vitamin’s function as to why the level was high. (5 points)

Without adequate thiamin, lactic acidosis may occur.3 There is no conversion of pyruvate
to AcetylCoA and thiamin is one of the vitamins involved in this process.3 Lactic acid
then accumulates in the blood.3

A 34-year-old female presents with yellow-orange tinted skin. Medical exams have ruled out
liver dysfunction. Upon taking a diet history, you discover she is a vegetarian and her diet con-
sists of mostly fruits and vegetables such as carrots, peppers, sweet potatoes, and mangos.

What may be causing her skin problem? (4 points)

The female is exhibiting hypercarotenemia, which causes yellowing of the skin.4 This is
associated with Vitamin A toxicity.4
Is this condition dangerous to her health? (3 points)
The condition potentially can be dangerous to her health. Hypercarotenemia isn’t dan-
gerous by itself, however a toxicity of Vitamin A potentially can be.4 Signs and symptoms
such as decreased bone mineralization, hemorrhaging, and liver damager could occur.4
Additionally, excess Vitamin A is associated with a decrease in Vitamin K absorption as
well as Vitamin E plasma concentrations, which could lead to a deficiency elsewhere.4

What recommendations would you make to help resolve the problem? (4 points)
I would recommend eating more fruits and vegetables lower in Vitamin A, trading them in
for some of her current selections. For example, cauliflower and potatoes. Increasing in-
take of other vegetarian friendly options such as whole grains, legumes, and lentils
would also suffice.

A 15-year-old vegetarian boy presents with easy fatigue, breathlessness, numb hands and feet,
and pain in the legs on walking, noted during the past few weeks. Paleness had also been not-
ed by the parents for about 2 years, although these findings became more obvious within the
last few weeks. The vegetarian patient has not consumed any food of animal origin for many
years and the family only rarely eats fresh fruits or vegetables. The patient was diagnosed with
macrocytic anemia.

What two vitamin deficiencies may be present? (4)

Based on the symptoms a vitamin B12 and folate deficiencies may be present.5

Based on the symptoms, which one appears more likely? Why? (6)
Vitamin b12 deficiency seems more likely as the boy is displaying nerve degeneration as
he is feeling numbness in the hands and feet.5 Folate deficiency does not involve neu-
ropathy.5

What lab values would you look at to confirm both the diagnosis of macrocytic anemia and the
confirmation of the vitamin deficiency? (6)

We would look at Methylmalonic Acid to determine which vitamin (B12 or folate) is defi-
cient.5 We would look at the Mean Corpuscular Volume lab value to determine if the diag-
nosis of macrocytic anemia is present.5

A college student is extremely stressed, tired and run down. He sees a commercial for “Miracle
Vitamin” promising to boost energy and decrease stress. Being promised a quick fix, he de-
cides to go to the vitamin store to purchase the product. In the store, a salesman introduces
himself as a nutritionist and shows him the “Miracle Vitamin” on the shelf. The product costs
$40 for a bottle of 50 pills though he sees other vitamin supplements being offered for much
less. When he questions the salesman, he states that “Miracle Vitamin” is worth the price be-
cause it is all natural. He also points out the % Daily Values on the supplement label and shows
it contains over 500 % for vitamin A, D, folic acid and niacin as well as some others. When the
college student asks if this is too much, the salesman reassures him that any excess vitamin will
be excreted in his urine and it is better to take more vitamins than not enough. The student is
convinced and despite his limited budget, he purchases the supplement.

Discuss three things that concern you with this scenario. Be sure to provide your rationale as to
why you are concerned. (15 points)

The first thing that concerns me with this scenario is the fact that the salesman is offer-
ing nutritional advice that is potentially dangerous to the college student. The “Miracle
Vitamin” contains large doses of fat soluble vitamins. Excess intake of these vitamins is
dangerous as they are not readily excreted through the urine as the salesman is advertis-
ing.4 Fat soluble vitamins are stored throughout the body.3 Toxicity could occur which
would be harmful to the college student. The second thing is that the “Miracle Vitamin” is
not the most budget friendly supplement option. Cheaper multivitamins that do not con-
tain the same potentially dangerous large doses of fat soluble vitamins are out there and
would provide the same benefit to the college student. Additionally, there are a plethora
of cheaper food alternatives that would most likely fit into the college students budget.
$40 could buy you a variety of fruits, vegetables, and other minimally processed whole
foods that would increase the student’s micronutrient consumption and potentially in-
crease his energy levels. The final thing that concerns me is the fact that the salesman is
not a Registered Dietitian but he is giving out nutritional education to this college stu-
dent and potentially others who enter the store. Evidence based research is imperative
when providing nutritional advice and this service is within the scope of practice of a Di-
etitian.2 Your local salesman at a supplement store does not have the same education as
a Dietitian and most likely doesn’t understand the importance of individualized nutrition-
al education/counseling to someones health. Inappropriate consumption of vitamins,
minerals, and macronutrients can be detrimental to ones wellbeing and in some cases
fatal. Scope of practice is incredibly important and nutritional education should be left to
the appropriately educated and trained Registered Dietitian rather than the supplement
salesman.
 Citations
1. Baxter, K. and Sharp, J. (2019). Orlistat and possible drug interactions that can

affect over-the-counter sales. [online] Pharmaceutical Journal. Available at:

https://www.pharmaceutical-journal.com/careers/career-feature/orlistat-and-

possible-drug-interactions-that-can-affect-over-the-counter-sales/11009379.ar-

ticle?firstPass=false [Accessed 30 Oct. 2019].

2. Westfal S. The Nutrition Care Process. Lecture presented. Nutrition Assess-

ment at Queens College; September 5, 2019; Flushing, NY.

3. Westfal S. Thiamin, Riboflavin, Niacin. Lecture presented. Nutrition II at

Queens College; October 3, 2019; Flushing, NY.

4. Westfal S. Vitamin A and D. Lecture presented. Nutrition II at Queens College;

September 12, 2019; Flushing, NY.

5. Westfal S. Folate, B12, B6. Lecture presented. Nutrition II at Queens College;

October 10, 2019; Flushing, NY.