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Vomiting

Vomiting is the forceful discharge of stomach contents through the mouth.

Vomiting, also called emesis, is a symptomatic response to any number of harmful triggers. Vomiting is a forceful expulsion, and is different from regurgitation — the effortless return of stomach contents to the mouth. Although unpleasant, vomiting is an important function because it rids the body of harmful substances.

Vomiting is a complex process resulting from the coordinated interaction of nerve pathways, the brain, and muscles of the gastrointestinal system. The primary vomiting trigger point in the brain is called the area postrema.


This structure is exposed to chemicals in the bloodstream and the cerebrospinal fluid (the fluid found in the brain and spinal cord). Scientific studies have shown that stimulation of the area postrema by a wide variety of drugs as well as bacterial toxins, radiation, and physiologic conditions, induces vomiting.

Certain nerve pathways (called afferent neural pathways) induce vomiting when triggered by motion, ear infections or tumors, Ménière’s disease (a disease characterized by recurrent vertigo), odors, visual stimulation, pain, and bad tastes.

Still other nerve pathways (peripheral afferent neural pathways) induce vomiting in response to stomach irritants, distension of the intestines and bile ducts, abdominal inflammation, and myocardial infarction (heart attack).

The physical act of vomiting is controlled by multiple sites of the brain stem. When activated, these structures send signals to the throat, diaphragm, and abdominal muscles.

These signals result in the simultaneous contraction of these muscles, which brings the stomach contents up through the esophagus (the tube between the stomach and the throat) and out the mouth.

During vomiting, breathing is inhibited, except for short breaths between discharges. Bradycardia (decrease in the heart rate) and changes in blood pressure may occur during retching and vomiting.

Causes and symptoms

Vomiting can be caused by many different things. Vomiting that lasts only one or two days is usually caused by infection, a reaction to medication, a toxin, uremia (accumulation of protein breakdown products in the bloodstream), and diabetic ketoacidosis (accumulation of toxins resulting from uncontrolled diabetes).

Vomiting that lasts longer than one week can be caused by a long-term medical or psychiatric condition. Causes of vomiting include:

• Medications. Drugs are the most common cause of vomiting, especially during the first days of use. Drugs can induce vomiting by stimulation of the area postrema or by direct stimulation of peripheral nerve pathways. Medications that commonly cause vomiting include cancer drugs, pain relievers (especially opioids), heart medications, diuretics, hormones, antibiotics, antiasthmatics, gastrointestinal drugs, and medications that act on the brain.
• Infections. Infections of the gastrointestinal system or whole body can cause vomiting. Gastrointestinal infections are more common in infants, toddlers, and young adults (20–29 years old) who usually get 1.2 infections each year. Infections that can cause vomiting include bacterial, viral, and parasitic gastrointestinal infections, severe acute respiratory syndrome (SARS), otitis media (ear infection), meningitis (infection of the membrane that surrounds the brain and spinal cord), and hepatitis (infection of the liver).
• Gastrointestinal and abdominal disorders. Disorders of the gastrointestinal system that can produce vomiting include blockage of the stomach or small intestine, motility disorders (muscles in the esophagus become discoordinated or weak, causing difficulty swallowing, regurgitation, and sometimes pain), indigestion, radiation therapy-induced changes, Crohn’s disease (chronic recurrent inflammation of the intestines), peptic ulcer, worm infestations, or inflammation of the appendix, gall bladder, or pancreas.
• Nervous system disorders. Cancers, infarction (an area of dead tissue caused by an obstruction in the artery supplying the area), bleeding (hemorrhage), birth defects, ear disorders, motion sickness, weightlessness, ear tumors, Ménière’s disease, unpleasant memories, psychogenic (caused by mental factors) issues, and bad tastes or smells can all cause vomiting.
• Hormones and physiological conditions. Hormonal and metabolic (physical and chemical processes of the body) conditions that can cause vomiting include: parathyroidism, diabetic ketoacidosis, hyperthyroidism (condition caused by excessive ingestion or production of thyroid hormone), Addison’s disease, uremia, and pregnancy. Pregnancy is the most common cause of vomiting associated with the hormonal system. Vomiting associated with pregnancy is often called morning sickness.
• Postoperation. Anesthesia and pain medications can cause nausea and vomiting, which are complications associated with 17–39% of surgeries.
• Cyclic vomiting syndrome (CVS). This rare disorder occurs in children usually beginning at age five years, although it also occurs in adults. It is characterized by, on average, eight attacks of vomiting lasting for 20 hours each year. Although the exact cause is unknown, there seems to be a relationship between cyclic vomiting and migraine headaches.
• Poisons. Arsenic and other heavy metals, weed killers and household cleaning agents, and many other substances may cause vomiting if inhaled or swallowed.
• Miscellaneous causes. Excessive alcohol consumption causes vomiting by acting both on the gastrointestinal tract and the brain.

Nausea is often associated with vomiting. Vomiting may be preceded by retching, in which the muscles contract as for vomiting but without the discharge of stomach contents.

The patient may hyperventilate (breathe rapidly and deeply) and salivate before vomiting begins. Patients should consult a physician immediately if there is blood in the vomitus (expelled stomach contents).

Other symptoms associated with vomiting depend upon the cause. Gastrointestinal infection would also cause fever, muscle pain, and diarrhea.

Patients with peptic ulcer, intestinal blockage, cholecystitis or pancreatitis (inflammation of the gall bladder or pancreas) would experience abdominal pain. Meningitis symptoms include neck stiffness, headache, vision changes, and changes in mental processes.

Diagnosis

Vomiting may be diagnosed by an internal medicine specialist or a gastroenterologist. A detailed medical history will be taken and will include specifics about the vomiting including frequency, a description of the vomitus, duration, how soon after meals vomiting occurs, and any other symptoms.

The history alone can help the physician to narrow down the cause to a few choices. The patient’s abdomen will be palpated (felt with the hands) to detect any abnormalities. Vital signs will be taken to identify any abnormalities in heart rate, blood pressure, or temperature.

Although the medical history and physical exam is usually sufficient to determine the cause of vomiting, certain laboratory tests may also be performed.

Blood tests may be performed to check for dehydration (decreased water), anemia (decreased number of red blood cells or iron-poor blood), and electrolyte (blood chemicals) imbalances, as well as specific tests to confirm the suspected diagnosis.

In some cases, more advanced testing may be required. These include x rays, endoscopy (a thin, wandlike camera used to visualize internal organs), magnetic resonance imaging (MRI), ultrasound (using sound waves to visualize internal organs), and computed tomography (CT) scanning. In addition, there are tests that measure stomach emptying and the pressure and motility of the stomach and intestine.

Treatment

Alternative treatments can be effective in treating vomiting, but not the underlying cause. A physician should be consulted if vomiting is recurrent and/or lasts for more than a few days.

Dietary changes

The best dietary approach is to eat foods that can be quickly cleared from the stomach. Foods that are high in fat are slow to digest and place the patient at risk for additional vomiting.

Ingestion of a low-fat, predominately liquid diet taken in frequent small meals can help relieve vomiting. Dry soda crackers are a good choice when nausea sets in. After vomiting, the patient should not eat for one hour, after which small servings of broth, bread, or flat soda may be taken.

It is important to replenish the fluids lost by vomiting. Juice therapists recommend drinking a juice made from fresh ginger, apples, and carrots. Supplementation with vitamin B6 was found to reduce the symptoms of morning sickness in pregnant women.

Herbals

The herbs that are effective in relieving nausea and vomiting include:

• apple tree (Pyrus malus) bark tea
• bergamot (Monarda citriodora) tea
• black horehound (Ballota nigra) infusion
• codonopsis (Codonopsis pilosula) decoction
• galangal (Alpinia officinarum) infusion
• ginger (Zingiber officinale) infusion or crystallized
• lemongrass (Cymbogen citratus) oil or tea
• nutmeg (Myristica fragrans) capsules
• turmeric (Curcuma longa) infusion

Chinese medicine

Practitioners of traditional Chinese medicine use acupuncture, ear acupuncture, herbals, and patent medicines in the treatment of vomiting.

The following herbals may be made into soups, which are sipped frequently: Lu Gen (Rhizoma phragmitis); Zhu Ru (Caulis bambusae in taeniis), Bai Mao Gen (Rhizoma imperatae), and Pi Pa Ye (Folium eriobotryae); and Huo Xiang (Herba agastachis) and Pei Lan (Herba eupatorii).

Placing a drop of Sheng Jiang (Rhizoma zingiberis recens) on the tongue can check vomiting. Patent medicines used to treat vomiting include: Huo Xiang Zheng Qi Wan (Agastache Pill to Rectify Qi),Yu Shu Dan (Jade Pivot Pill), Zuo Jin Wan (Left Metal Pill), and Bao He Wan (Preserve Harmony Pill).

Homeopathy

Homeopathic remedies are chosen based upon the specific set of symptoms displayed by the patient. Ipecac is chosen for strong nausea and vomiting. Bismuth or Phosphorous is indicated when vomiting is caused primarily by liquids.

Nux vomica is recommended when vomiting is caused by emotional stress and for patients with heartburn, nausea, and retching. Tabacum is indicated for vomiting caused by motion. Veratrum album is indicated for the patient with nausea, vomiting, and diarrhea.

Arsenicum is recommended for the patient with violent vomiting, diarrhea, abdominal pain, exhaustion, restlessness, and thirst. Bryonia is recommended for gastroenteritis (inflammation of the lining of the gastrointestinal system).

Ayurveda

Ayurvedic practitioners believe that vomiting is caused by high pitta in the stomach. Remedies for vomiting are:

• yogurt containing cardamon and honey
• warm milk containing cardamon and nutmeg
• tea prepared from cumin seeds and nutmeg
• fresh pineapple juice (1 cup with a pinch of ginger and black pepper and 0.5 tsp sugar) three times during a day of fasting
• water containing 10 drops lime juice, 0.5 tsp sugar, and 0.25 tsp baking soda
• cardamon seeds (chewed)
• ginger juice and onion juice (1 tsp each)
• water containing rose petal powder (0.5 tsp), sandalwood powder (0.25 tsp), rock candy powder (0.5 tsp), and lime juice (10 drops)

Other treatments

Various other treatments for vomiting include:

• Aromatherapy. The essential oil of peppermint is a traditional cure for vomiting.
• Acupressure. The acupressure points P5 and P6 located on the inner forearms are effective in treating vomiting. A wristband (Sea-Band) has been proven to be effective in reducing nausea and vomiting.
• Acupuncture. A National Institutes of Health consensus panel found that acupuncture is an effective treatment for chemotherapy and postoperative vomiting. A few people, however, experience nausea as a side effect of acupuncture.
• Behavioral interventions. Behavioral therapies such as desensitization, distraction, imagery, relaxation, and self-hypnosis have been shown to be effective in treating chemotherapy-induced vomiting.
• Hydrotherapy. Stomach upsets may be treated by drinking a glass of water containing activated charcoal powder.
• Reflexology. The reflex points solar plexus, chest, lung, diaphragm, esophagus, liver, stomach, gallbladder and thyroid, and pituitary and adrenal gland on the feet may help treat vomiting.
• Transcutaneous electrical nerve stimulation (TENS, which is a treatment where a mild electrical current is passed through electrodes on the skin to stimulate nerves and block pain signals). TENS can be effective in reducing postoperative vomiting.

Allopathic treatment

Treatment of vomiting depends upon the cause and severity but may include dietary changes, medications, and surgery. Replacement of lost fluids is an important component of treatment.

Hospitalization may be required in some cases. Surgery may be needed to treat inflammatory conditions (such as cholecystitis) and physical abnormalities (such as blockage).

Medications used to treat vomiting are called antiemetics. Scopolamine, dimenhydrinate (Dramamine), and hyoscine are used to treat motion sickness; promethazine (Mepergan, Phenergan) is used to treat postoperative nausea; meclizine (Antivert, Bonine) is used to treat inner ear inflammation; and prochlorperazine (Compazine) is used for gastroenteritis, postoperative toxins, radiation, medications, and other causes of vomiting. Other medications that target the underlying cause of the vomiting may be used.

Newer drugs that have been developed to treat postoperative or postchemotherapy nausea and vomiting include ondansetron (Zofran) and granisetron (Kytril). Another treatment that has been found to lower the risk of nausea after surgery is intravenous administration of supplemental fluid before the operation.

Expected results

Most cases of vomiting resolve spontaneously. Complications of vomiting include dehydration, malnutrition, weight loss, and abnormalities of blood chemicals (including electrolytes, pH, and potassium). Vomiting by unconscious patients can lead to aspiration (inhalation of stomach contents), which can affect the lungs.

Prevention

Antiemetic drugs are effective at preventing vomiting. Some alternative treatments are effective at reducing nausea, which may prevent vomiting.

Vitamin K

Vitamin K originates from the German term koajulation. It is also known as antihemorrhagic factor, and is one of the four fat-soluble vitamins necessary for good health.

The others are vitamins A, D, and E. The primary and best-known purpose of vitamin K is support of the process of blood clotting. Prothrombin and other clotting factors are dependent on vitamin K for production.

It also plays a role in bone health, and may help to prevent osteoporosis. Appropriate growth and development are supported by adequate vitamin K.


There are several forms of the vitamin:

• K₁ or phylloquinone; also known as phytonadione
• K₂, a family of substances called menaquinones
• K₃ or menadione, a synthetic form of this vitamin

General use

The Required Daily Amount (RDA) of vitamin K is 5 micrograms (mcg) for infants less than six months old, 10 mcg for babies six months to one year old, 15 mcg for children aged one to three years, 20 mcg for those aged four to six years, and 30 mcg for those seven to ten years old.

Males require 45 mcg from 11–14 years, 65 mcg from 15–18 years, 70 mcg from 19–24 years, and 80 mcg after the age of 24 years. Females need 45 mcg from 11–14 years, 55 mcg from 15–18 years, 60 mcg from 19–24 years, and 65 mcg after the age of 24, and for pregnant or lactating women. These values are based on an estimate of 1 mcg of vitamin K per kilogram of body weight.

The most common use of vitamin K is to supplement babies at birth, thus preventing hemorrhagic disease of the newborn. Routine administration of vitamin K to newborns is, however, being questioned by practitioners of evidence-based nursing.

In 2003 the American Academy of Pediatrics (AAP) restated that prevention of bleeding from early vitamin K deficiency by administration of the vitamin is accepted practice. The AAP also noted that a possible link between supplemental vitamin K and early childhood cancer has not been proven as of 2003.

Others who may benefit from supplemental vitamin K include those taking medications that interact with it or deplete the supply. It also appears to have some effectiveness in preventing osteoporosis, but some studies done involved patients using a high dietary intake of the vitamin rather than supplements.

Source of vitamin K

In 2003, however, a group of Japanese researchers reported that supplemental doses of vitamin K2 given together with vitamin D3 appeared to reduce bone turnover and sustain bone density in postmenopausal women with mild osteoporosis.

People taking warfarin, a vitamin K antagonist, are able to use the vitamin as an antidote if the serum level of warfarin is too high, increasing the risk of hemorrhage. Vitamin K taken by mouth appears to be more effective than intramuscular injections of the vitamin when it is used to counteract the effects of warfarin.

Vitamin K is also used to treat bleeding from the esophagus and other complications of cirrhosis, a disease of the liver.

Some women find that supplemental vitamin K relieves the symptoms of morning sickness during pregnancy. This treatment is even more effective if vitamin K is taken together with vitamin C.

Topical formulations of vitamin K are sometimes touted as being able to reduce spider veins on the face and legs.

The creams are quite expensive and the efficacy is questionable at best. However, recent clinical studies have shown that topical applications of vitamin K given to patients following laser treatments on the face are effective in minimizing bruising from the procedure.

More recently, researchers have been studying vitamin K intensively for its potential anticancer effects. Vitamin K₃ in particular may be useful as an adjuvant treatment for ovarian cancer.

Preparations

Natural sources

Dark green leafy vegetables are among the best food sources of vitamin K in the form of K₁. Seaweed is packed with it, and beef liver, cauliflower, eggs, and strawberries are rich sources as well.

Vitamin K is fairly heat-stable, but gentle cooking preserves the content of other nutrients that are prone to breaking down when heated. Some of the supply for the body is synthesized as vitamin K₂ by the good bacteria in the intestines.

Supplemental sources

Vitamin K is not normally included in daily multivitamins, as deficiency is rare. Oral, topical, and injectable forms are available, but should not be used except under the supervision of a health care provider.

Injectable forms are by prescription only. Supplements are generally given in the form of phytonadione since it is the most effective form and has a lower risk of toxicity than other types. Synthetic forms of vitamin K are also available for supplemental use.

Deficiency

Deficiency of vitamin K is uncommon in the general population but is of particular concern in neonates, who are born with low levels of vitamin K.

Hemorrhagic disease of the newborn can affect infants who do not receive some form of vitamin K at birth. Affected babies tend to have prolonged and excessive bleeding following circumcision or blood draws. In the most serious cases, bleeding into the brain may occur.

Most commonly an injection of vitamin K is given in the nursery following birth, but a series of oral doses is also occasionally used. The primary sign of a deficiency at any age is bleeding, and poor growth may also be observed in children.

Chronically low levels of vitamin K are correlated with higher risk of hip fracture in older men and women. A study done in 2003 reported that the current recommended dietary intake for vitamin K in adults may not be adequate for older women.

Vitamin K Deficiencies

Risk factors for deficiency

Vitamin K deficiency is unusual, but may occur in certain populations, including those on the medications mentioned in interactions, alcoholics, and people with diseases of the gastrointestinal tract that impair absorption. Conditions that may be problematic include Crohn’s disease, chronic diarrhea, sprue, and ulcerative colitis.

Anything that impairs fat absorption also risks decreasing the absorption of the fat-soluble vitamins. Long term use of broad spectrum antibiotics destroys the bacteria in the intestinal tract that are necessary for the body’s production of vitamin K.

Precautions

Allergic reactions to vitamin K supplements can occur, although they are rare. Symptoms may include flushed skin, nausea, rash, and itching. Medical attention should be sought if any of these symptoms occur.

Infants receiving vitamin K injections occasionally suffer hemolytic anemia or high bilirubin levels, noticeable from the yellow cast of the skin. Emergency medical treatment is needed for these babies. Liver and brain impairment are possible in severe cases.

Certain types of liver problems necessitate very cautious use of some forms of vitamin K. Menadiol sodium diphosphate, a synthetic form also known as vitamin K₄, may cause problems in people with biliary fistula or obstructive jaundice. A particular metabolic disease called G6-PD deficiency also calls for careful use of vitamin K₄.

The expertise of a health care professional is called for under these circumstances. Sheldon Saul Hendler, MD, PhD, advises there is no reason to supplement with more than 100 mcg daily except in cases of frank vitamin K deficiency.

Side effects

Oral forms of vitamin K₄ may occasionally irritate the gastrointestinal tract. High doses greater than 500 mcg daily have been reported to cause some allergic-type reactions, such as skin rashes, itching, and flushing.

Interactions

There are numerous medications that can interfere with the proper absorption or function of vitamin K. The long-term use of antacids may decrease the efficacy of the vitamin, as can certain anticoagulants. Warfarin is an anticoagulant that antagonizes vitamin K. Efficacy of the vitamin is also decreased by dactinomycin and sucralfate.

Absorption is decreased by cholestyramine and colestipol, which are drugs used to lower blood cholesterol levels. Other drugs that may cause a deficiency include long-term use of mineral oil, quinidine, and sulfa drugs. Primaquine increases the risk of side effects from taking supplements.

Other types of prescription medications that may cause vitamin K depletion include anticonvulsants (drugs to prevent seizures), including valproic acid; macrolide, aminoglycoside, cephalosporin, and fluoroquinolone antibiotics; phenobarbital; and dapsone (used to treat leprosy and skin infections).

Vitamin E

Vitamin E is an antioxidant responsible for proper functioning of the immune system and for maintaining healthy eyes and skin.

It is actually a group of fat soluble compounds known as tocopherols (i.e., alpha tocopherol and gamma tocopherol). Gamma tocopherol accounts for approximately 75% of dietary vitamin E. Vitamin E rich foods include nuts, cereals, beans, eggs, cold-pressed oils, and assorted fruits and vegetables.

Because vitamin E is a fat soluble vitamin, it requires the presence of fat for proper absorption. Daily dietary intake of the recommended daily allowance (RDA) of vitamin E is recommended for optimum health.


Vitamin E is absorbed by the gastrointestinal system and stored in tissues and organs throughout the body. Certain health conditions may cause vitamin E depletion, including liver disease, celiac disease, and cystic fibrosis.

Patients with end-stage renal disease (kidney failure) who are undergoing chronic dialysis treatment may be at risk for vitamin E deficiency. These patients frequently receive intravenous infusions of iron supplements, which can act against vitamin E.

Vitamin E deficiency can cause fatigue, concentration problems, weakened immune system, anemia, and low thyroid levels. It may also cause vision problems and irritability. Low serum (or blood) levels of vitamin E have also been linked to major depression.

General use

Vitamin E is necessary for optimal immune system functioning, healthy eyes, and cell protection throughout the body. It has also been linked to the prevention of a number of diseases.

The therapeutic benefits of vitamin E include:

• Cancer prevention and treatment. Vitamin E is a known antioxidant, and has been associated with a reduced risk of gastrointestinal, cervical, prostate, lung, and possibly breast cancer. In addition to its role as a cancer preventive, vitamin E is being studied as a cancer treatment. It has been shown to inhibit the growth of prostate tumors and to induce apoptosis (cell self-destruction) in cancer cells. Vitamin E is also being investigated as an adjunctive treatment for cancer patients undergoing radiation therapy; it is thought that high doses of dietary antioxidants may increase the efficacy of the radiation treatment while protecting healthy cells against damage.
• Immune system protection. Various studies have shown that vitamin E supplementation, particularly in elderly patients, boosts immune system function. Older patients have demonstrated improved immune response, increased resistance to infections, and higher antibody production. Vitamin E has also been used with some success to slow disease progression in HIV-positive patients.
• Eye disease prevention. Clinical studies on vitamin E have shown that supplementation significantly reduces the risk for cataracts and for macular degeneration, particularly among women.
• Memory loss prevention. Vitamin E deficiency has been linked to poor performance on memory tests in some elderly individuals.
• Alzheimer’s disease (AD) treatment. In a study performed at Columbia University, researchers found that Alzheimer’s patients who took daily supplements of vitamin E maintained normal functioning longer than patients who took a placebo. In 2002, a group of Dutch epidemiologists reported on a much larger population based study conducted in the Netherlands between 1990 and 1993, with follow-up examinations in 1994 and 1999. The study confirmed the findings of the Columbia researchers, that high dietary intake of vitamin E lowers the risk of developing AD.
• Liver disease treatment. Vitamin E may protect the liver against disease.
• Diabetes treatment. Vitamin E may help diabetic patients process insulin more effectively. It has also been found to be effective in the treatment of diabetic neuropathy, a family of nerve disorders caused by diabetes. Vitamin E appears to reduce the symptoms of diabetic neuropathy and to improve the speed of transmission of nerve impulses.
• Pain relief. Vitamin E acts as both an anti-inflammatory and analgesic (or pain reliever). Studies have indicated it may be useful for treatment of arthritis pain in some individuals.
• Parkinson’s disease prevention. High doses of vitamin E intake was associated with a lowered risk of developing Parkinson’s disease in one 1997 Dutch study.
• Tardive dyskinesia treatment. Individuals who take neuroleptic drugs for schizophrenia or other disorders may suffer from a side effect known as tardive dyskinesia, in which they experience involuntary muscle contractions or twitches. Vitamin E supplementation may lessen or eliminate this side effect in some individuals.
• Porphyria treatment. Vitamin E has been found to be beneficial in treating patients with porphyria, a group of disorders characterized by abnormalities in the metabolism of blood pigments, by lowering the level of excretion of these blood pigments in the urine.

Other benefits of vitamin E are less clear cut, and have been called into question with conflicting study results or because of a lack of controlled studies to support them. These include:

fruit as source of vitamin E

• Heart disease prevention. A number of epidemiological studies have indicated that vitamin E may prevent heart disease by lowering total blood cholesterol levels and preventing oxidation of LDL cholesterol. However, a large, controlled study known as the Heart Outcomes Prevention Evaluation (HOPE) published in early 2000 indicates that vitamin E does not have any preventative effects against heart disease. The study followed 9,500 individuals who were considered to be at a high risk for heart disease. Half the individuals were randomly chosen to receive vitamin E supplementation, and the other half of the study population received a placebo. After five years, there was no measurable difference in heart attacks and heart disease between the two patient populations. Still, vitamin E may still hold some hope for heart disease prevention. It is possible that a longerterm study beyond the five years of the HOPE study may demonstrate some heart protective benefits of vitamin E consumption. It is also possible that while the high-risk patient population that was used for the HOPE study did not benefit from vitamin E, an average-risk patient population might still benefit from supplementation. It is also possible that vitamin E needs the presence of another vitamin or nutrient substance to protect against heart disease. Further large, controlled, and long-term clinical studies are necessary to answer these questions.
• Skin care. Vitamin E is thought to increase an individual’s tolerance to UV rays when taken as a supplement in conjunction with vitamin C. Vitamin E has also been touted as a treatment to promote faster healing of flesh wounds. While its anti-inflammatory and analgesic properties may have some benefits in reducing swelling and relieving discomfort in a wound, some dermatologists dispute the claims of faster healing, and there are no large controlled studies to support this claim.
• Hot flashes. In a small study conducted at the Mayo Clinic, researchers found that breast cancer survivors who suffered from hot flashes experienced a decrease in hot flashes after taking vitamin E supplementation.
• Muscle maintenance and repair. Recent research has demonstrated that the antioxidative properties of vitamin E may prevent damage to tissues caused by heavy endurance exercises. In addition, vitamin E supplementation given prior to surgical procedures on muscle and joint tissues has been shown to limit reperfusion injury (muscle damage that occurs when blood flow is stopped, and then started again to tissues or organs).
• Fertility. Vitamin E has been shown to improve sperm function in animal studies, and may have a similar effect in human males. Further studies are needed to establish the efficacy of vitamin E as a treatment for male infertility; as of 2002, its role in such treatment is still controversial.

Preparations

The U.S. recommended dietary allowance (RDA) of the alpha-tocopherol formulation of vitamin E is as follows:

• men: 10 mg or 15 IU
• women: 8 mg or 12 IU
• pregnant women: 10 mg or 15 IU
• lactating women: 12 mg or 18 IU

In April 2000, the National Academy of Sciences recommended changing the RDA for vitamin E to 22 international units (IUs), with an upper limit (UL), or maximum daily dose, of 1500 IUs. Daily values for the vitamin as recommended by the U.S. Food and Drug Administration, the values listed on food and beverage labeling, remain at 30 IUs for both men and women age four and older.

Many nuts, vegetable-based oils, fruits, and vegetables contain vitamin E. Foods rich in vitamin E include wheat germ oil (26.2 mg/tbsp), wheat germ cereal (19.5 mg/cup), peanuts (6.32 mg/half cup), soybeans (3.19 mg/cup), corn oil (2.87/tbsp), avocado (2.69 mg), and olive oil (1.68 mg/tbsp.). Grapes, peaches, broccoli, Brussels sprouts, eggs, tomatoes, and blackberries are also good sources of vitamin E. Fresh, raw foods contain the highest levels of the vitamin.

Both heat and light can reduce vitamin and mineral potency in fresh foods, so overcooking and improper storage should be avoided. Sliced and chopped foods have more of their surface exposed to light, therefore keeping vegetables and fruits whole may also help to maintain full vitamin potency.

For individuals considered at risk for vitamin E deficiency, or those with an inadequate dietary intake, vitamin E supplements are available in a variety of different forms, including pills, capsules, powders, and liquids for oral ingestion.

For topical use, vitamin E is available in ointments, creams, lotions, and oils. Vitamin E is also available commercially as one ingredient of a multivitamin formula.

The recommended daily dosage of vitamin E varies by individual need and by the amount of polyunsaturated fats an individual consumes.

The more polyunsaturated fats in the diet, the higher the recommended dose of vitamin E, because vitamin E helps to prevent the oxidizing effects of these fats. Because vitamin E is fat soluble, supplements should always be taken with food.

Supplements are also available in either natural or synthetic formulations. Natural forms are extracted from wheat germ oil and other vitamin E food sources, and synthetic forms are extracted from petroleum oils. Natural formulas can be identified by a d prefix on the name of the vitamin (i.e., d-alpha-tocopherol).

Precautions

Overdoses of vitamin E (over 536 mg) can cause nausea, diarrhea, headache, abdominal pain, bleeding, high blood pressure, fatigue, and weakened immune system function.

Patients with rheumatic heart disease, iron deficiency anemia, hypertension, or thyroid dysfunction should consult their healthcare provider before starting vitamin E supplementation, as vitamin E may have a negative impact on these conditions.

Side effects

Vitamin E is well-tolerated, and side effects are rare. However, in some individuals who are vitamin K deficient, vitamin E may increase the risk for hemorrhage or bleeding. In some cases, side effects may be decreased or eliminated by adjusting the dosage of vitamin E and vitamin K.

Although the reasons are not yet clear, high intake of vitamin E has been associated with a statistically significant increased risk of breast cancer in men.

Vitamin E ointments, oils, or creams may trigger an allergic reaction known as contact dermatitis. Individuals who are considering using topical vitamin E preparations for the first time, or who are switching the type of vitamin E product they use, should perform a skin patch test to check for skin sensitivity to the substance.

A small, dime sized drop of the product should be applied to a small patch of skin inside the elbow or wrist. The skin patch should be monitored for 24 hours to ensure no excessive redness, irritation, or rash occurs.

If a reaction does occur, it may be in response to other ingredients in the topical preparation, and the test can be repeated with a different vitamin E formulation. Individuals who experience a severe reaction to a skin patch test of vitamin E are advised not to use the product topically. A dermatologist or other healthcare professional may be able to recommend a suitable alternative.

Interactions

Individuals who take anticoagulant (blood thinning) or anticonvulsant medications should consult their healthcare provider before starting vitamin E supplementation. Vitamin E can alter the efficacy of these drugs.

It is important for persons taking supplemental vitamin E to tell their surgeon if they are scheduled for an operation. Vitamin E may interact with some of the medications given prior to or during surgery; it has also been shown to increase bleeding time if the patient is taking such other herbal preparations as feverfew or gingko biloba.

Non-heme, inorganic iron supplements destroy vitamin E, so individuals taking iron supplements should space out their doses (e.g., iron in the morning and vitamin E in the evening).

Large doses of vitamin A can decrease the absorption of vitamin E, so dosage adjustments may be necessary in individuals supplementing with both vitamins.

Alcohol and mineral oil can also reduce vitamin E absorption, and these substances should be avoided if possible in vitamin E deficient individuals.

Vitamin E source

Vitamin D

Vitamin D, also known as calciferol, is essential for strong teeth and bones. There are two major forms of vitamin D: D₂ or ergocalciferol and D₃ or cholecarciferol.

Vitamin D can be synthesized by the body in the presence of sunlight, as opposed to being required in the diet. It is the only vitamin whose biologically active formula is a hormone.

It is fat-soluble, and regulates the body’s absorption and use of the minerals calcium and phosphorus. Vitamin D is important not only to the maintenance of proper bone density, but to the many calcium-driven neurologic and cellular functions, as well as normal growth and development.


It also assists the immune system by playing a part in the production of a type of white blood cell called the monocyte. White blood cells are infection fighters. There are many chemical forms of vitamin D, which have varying amounts of biological activity.

General use

The needed amount of vitamin D is expressed as an Adequate Intake (AI) rather than an Required Daily Amount (RDA). This is due to a difficulty in quantifying the amount of the vitamin that is produced by the body with exposure to sunlight. Instead, the AI estimates the amount needed to be eaten in order to maintain normal function.

It is measured in International Units (IU) and there are 40 IU in a microgram (mcg). The AI for vitamin D in the form of cholecarciferol or ergocalciferol for everyone under 50 years of age, including pregnant and lactating women, is 200 IU.

It goes up to 400 IU for people 51-70 years old, and to 600 IU for those over age 70. A slightly higher dose of vitamin D, even as little as a total of 700 IU for those over age 65, can significantly reduce age-related fractures when taken with 500 mg of calcium per day.

One of the major uses of vitamin D is to prevent and treat osteoporosis. This disease is essentially the result of depleted calcium, but calcium supplements alone will not prevent it since vitamin D is required to properly absorb and utilize calcium.

Taking vitamin D without the calcium is also ineffective. Taking both together may actually increase bone density in postmenopausal women, who are most susceptible to bone loss and complications such as fractures.

Osteomalacia and rickets are also effectively prevented and treated through adequate vitamin D supplementation. Osteomalacia refers to the softening of the bones that occurs in adults that are vitamin D deficient. Rickets is the syndrome that affect deficient children, causing bowed legs, joint deformities, and poor growth and development.

Vitamin D also has a part in cancer prevention, at least for colon cancer. A deficiency increases the risk of this type of cancer, but there is no advantage to taking more than the AI level. There may also be a protective effect against breast and prostate cancer, but this is not as well established.

Studies are in progress to see if it can help to treat leukemia and lymphoma. The action of at least one chemotherapeutic drug, tamoxifen, appears to be improved with small added doses of vitamin D. Tamoxifen is commonly used to treat ovarian, uterine, and breast cancers.

Many older adults are deficient in vitamin D. This can affect hearing by causing poor function of the small bones in the ear that transmit sound. If this is the cause of the hearing loss, it is possible that supplementation of vitamin D can act to reverse the situation.

Some metabolic diseases are responsive to treatment with specific doses and forms of vitamin D. These include Fanconi syndrome and familial hypophosphatemia, both of which result in low levels of phosphate. For these conditions, the vitamin is given in conjunction with a phosphate supplement to aid in absorption.

A topical form of vitamin D is available, and can be helpful in the treatment of plaque-type psoriasis. It may also be beneficial for those with vitiligo or scleroderma.

This cream, in the form of calcitriol, is not thought to affect internal calcium and phosphorus levels. Oral supplements of vitamin D are not effective for psoriasis. The cream is obtainable by prescription only.

Evidence does not support the use of vitamin D to treat alcoholism, acne, arthritis, cystic fibrosis, or herpes.

Preparations

Natural sources

Exposure to sunlight is the primary method of obtaining vitamin D

Exposure to sunlight is the primary method of obtaining vitamin D. In clear summer weather, approximately ten minutes per day in the sun will produce adequate amounts, even when only the face is exposed. In the winter, it may require as much as two hours.

Many people don’t get that amount of winter exposure, but are able to utilize the vitamin that was stored during extra time in the sun over the summer. Sunscreen blocks the ability of the sun to produce vitamin D, but should be applied as soon as the minimum exposure requirement has passed, in order to reduce the risk of skin cancer.

The chemical 7-dehydrocholesterol in the skin is converted to vitamin D3 by sunlight. Further processing by first the liver, and then the kidneys, makes D₃ more biologically active.

Since it is fat-soluble, extra can be stored in the liver and fatty tissues for future use. Vitamin D is naturally found in fish liver oils, butter, eggs, and fortified milk and cereals in the form of vitamin D₂.

Milk products are the main dietary source for most people. Other dairy products are not a good supply of vitamin D, as they are made from unfortified milk. Plant foods are also poor sources of vitamin D.

Supplemental sources

Most oral supplements of vitamin D are in the form of ergocalciferol. It is also available in topical (calcitriol or calcipotriene), intravenous (calcitriol), or intramuscular (ergocalciferol) formulations.

Products designed to be given by other than oral routes are by prescription only. As with all supplements, vitamin D should be stored in a cool, dry place, away from direct light, and out of the reach of children.

Deficiency

In adults, a mild deficiency of vitamin D may be manifested as loss of appetite and weight, difficulty sleeping, and diarrhea. A more major deficiency causes osteomalacia and muscle spasm.

The bones become soft, fragile, and painful as a result of the calcium depletion. This is due to an inability to properly absorb and utilize calcium in the absence of vitamin D. In children, a severe lack of vitamin D causes rickets.

Risk factors for deficiency

The most likely cause of vitamin D deficiency is inadequate exposure to sunlight. This can occur with people who don’t go outside much, those in areas of the world where pollution blocks ultraviolet (UV) light or where the weather prohibits spending much time outdoors.

Glass filters out the rays necessary for vitamin formation, as does sunscreen. Those with dark skin may also absorb smaller amounts of the UV light necessary to effect conversion of the vitamin.

Vitamin D and your body

In climates far to the north, the angle of the sun in winter may not allow adequate UV penetration of the atmosphere to create D3 Getting enough sun in the summer, and a good dietary source, should supply enough vitamin D to last through the winter.

Vegans, or anyone who doesn’t consume dairy products in combination with not getting much sun is also at higher risk, as are the elderly, who have a decreased ability to synthesize vitamin D.

Babies are usually born with about a nine-month supply of the vitamin, but breast milk is a poor source. Those born prematurely are at an increased risk for deficiency of vitamin D and calcium, and may be prone to tetany. Infants past around nine months old who are not getting vitamin D fortified milk or adequate sun exposure are at risk of deficiency.

People with certain intestinal, liver and kidney diseases may not be able to convert vitamin D3 to active forms, and may need at activated type of supplemental vitamin D.

Those taking certain medications may require supplements, including anticonvulsants, corticosteroids, or the cholesterol-lowering medications cholestyramine or colestipol.

This means that people who are on medication for arthritis, asthma, allergies, autoimmune conditions, high cholesterol, epilepsy, or other seizure problems should consult with a healthcare practitioner about the advisability of taking supplemental vitamin D.

As with some other vitamins, the abuse of alcohol also has a negative effect. In the case of vitamin D, the ability to absorb and store it is diminished by chronic overuse of alcohol products.

Populations with poor nutritional status may tend to be low on vitamin D, as well as other vitamins. This can be an effect of poor sun exposure, poor intake, or poor absorption.

A decreased ability to absorb oral forms of vitamin D may result from cystic fibrosis or removal of portions of the digestive tract.

Other groups who may need higher than average amounts of vitamin D include those who have recently had surgery, major injuries, or burns. High levels of stress and chronic wasting illnesses also tend to increase vitamin requirements.

Precautions

The body will not make too much vitamin D from overexposure to sun, but since vitamin D is stored in fat, toxicity from supplemental overdose is a possibility.

Symptoms are largely those of hypercalcemia, and may include high blood pressure, headache, weakness, fatigue, heart arrhythmia, loss of appetite, nausea, vomiting, diarrhea, constipation, dizziness, irritability, seizures, kidney damage, poor growth, premature hardening of the arteries, and pain in the abdomen, muscles, and bones.

If the toxicity progresses, itching and symptoms referable to renal disease may develop, such as thirst, frequent urination, proteinuria, and inability to concentrate urine. Overdoses during pregnancy may cause fetal abnormalities. Problems in the infant can include tetany, seizures, heart valve malformation, retinal damage, growth suppression, and mental retardation.

Pregnant women should not exceed the AI, and all others over one year of age should not exceed a daily dose of 2000 IU. Infants should not exceed 1000 IU. These upper level doses should not be used except under the advice and supervision of a healthcare provider due to the potential for toxicity.

Individuals with hypercalcemia, sarcoidosis, or hypoparathyroidism should not use supplemental calciferol. Those with kidney disease, arteriosclerosis, or heart disease should use ergocalciferol only with extreme caution and medical guidance.

infographic about Vitamin D

Side effects

Minor side effects may include poor appetite, constipation, dry mouth, increased thirst, metallic taste, or fatigue. Other reactions, which should prompt a call to a healthcare provider, can include headache, nausea, vomiting, diarrhea, or confusion.

Interactions

The absorption of vitamin D is improved by calcium, choline, fats, phosphorus, and vitamins A and C. Supplements should be taken with a meal to optimize absorption.

There are a number of medications that can interfere with vitamin D levels, absorption, and metabolism. Rifampin, H₂ blockers, barbiturates, heparin, isoniazid, colestipol, cholestyramine, carbamazepine, phenytoin, fosphenytoin, and phenobarbital reduce serum levels of vitamin D and increase metabolism of it.

Anyone who is on medication for epilepsy or another seizure disorder should check with a healthcare provider to see whether it is advisable to take supplements of vitamin D.

Overuse of mineral oil, Olestra, and stimulant laxatives may also deplete vitamin D. Osteoporosis and hypocalcemia can result from long-term use of corticosteroids. It may be necessary to take supplements of calcium and vitamin D together with this medication.

The use of thiazide diuretics in conjunction with vitamin D can cause hypercalcemia in individuals with hypoparathyroidism. Concomitant use of digoxin or other cardiac glycosides with vitamin D supplements may lead to hypercalcemia and heart irregularities.

The same caution should be used with herbs containing cardiac glycosides, including black hellebore, Canadian hemp, digitalis, hedge mustard, figwort, lily of the valley, motherwort, oleander, pheasant’s eye, pleurisy, squill, and strophanthus.