A Guide to Understanding and Addressing Nutritional Imbalances

January 15th, 2020

Carbs, fats, and protein tend to hog the spotlight on social media and in traditional nutrition care plans. While ensuring adequate and balanced amounts of these macronutrients is indeed important, micronutrients (i.e. vitamins and minerals) deserve equal attention.

Without adequate amounts of micronutrients, crucial processes such as metabolism, detoxification, bone creation, and immune system function are interrupted1.  Over time, micronutrient shortfalls increase the risk of both acute and chronic illnesses.

Micronutrient inadequacies are common in the United States2,3. While not eating enough whole food sources of micronutrients is a significant contributor, other factors include drug-induced nutrient depletion, genetic variants that increase nutrient needs, and impaired digestion and absorption.

An integrative and functional nutrition assessment should include an investigation of the factors that are contributing to nutrient imbalances—this is the “N” of the IFN Academy STAIN© model.

While we’ll focus on micronutrient inadequacy in this article, excessive amounts of nutrients also contribute to nutritional imbalances. For example, persistent vitamin B12 levels greater than 1,000 ng/L have been associated with solid cancers, vitamin D toxicity can lead to hypercalcemia, and excessive intakes of zinc can contribute to copper imbalances (13, 14, 15).

Before digging into the major root causes of micronutrient imbalances, let’s review micronutrient deficiency versus insufficiency.

 

Micronutrient Deficiency Versus Insufficiency

Frank micronutrient deficiencies, especially iron, vitamin A, zinc, iodine, and folate impact over 2 billion people globally1,2.  Micronutrient deficiencies are fairly straightforward to diagnose and treat.

Micronutrient insufficiencies, on the other hand, are more common than deficiencies, but tend to be less recognizable. Rather than causing symptoms of a deficiency disease (for example, scurvy), micronutrient insufficiencies can masquerade as fatigue, poor immune system function, brain fog, depression, and more 2,3.

 

Nutritional Imbalances: Contributing Factors

A micronutrient insufficiency (nutrient intake less than the Estimated Average Requirement—EAR), means a person has enough of the nutrient to prevent a frank deficiency but less than what their body needs to function optimally2.

Several factors can impact micronutrient status including:

  • Inadequate dietary intake
  • Drug-induced nutrient depletion
  • Genetic variants that increase micronutrient needs
  • Impaired digestion and absorption

 

Inadequate Dietary Intake

Research suggests most Americans aren’t meeting their micronutrient needs with food2. In fact, the standard Western diet increases the risk of numerous nutrient gaps especially calcium, potassium, iron, vitamins A, C, D, and E, choline, and magnesium2.

Other dietary patterns can increase the risk of nutritional inadequacy as well. Vegan and vegetarian diets tend to lead to vitamin B12 and D, iodine, selenium, calcium, and iron shortfalls4, 12. And therapeutic elimination diets, when not well-planned and followed long-term, can open the door for inadequate micronutrient intake4,11.

 

Drug-Induced Nutrient Depletion

As of 2020, the CDC estimated that close to 50% of Americans were using at least one prescription drug, 22% using two prescriptions drugs, and 12% using at least five prescription drugs each day5.  Prescription drugs often impact the ability to absorb one or more nutrients.

The table below lists some common drug classes and the micronutrients they impact6:

 

Drug Class Nutrients of Concern
Corticosteroids Calcium and Potassium
Vasodilators (Hydralazine) CoQ10
Pancreatic enzymes Folate
Proton Pump Inhibitors Magnesium, Vitamin B12, Calcium and Iron
Anticonvulsants Calcium, Folic Acid, and Vitamin D
Statins CoQ10
Oral Hypoglycemic (Metformin) Vitamin B12
H2 Agonists Vitamin D, Calcium, Magnesium, Vitamin B12, and Zinc
Bile acid sequestrants Vitamin K and Vitamin D
Loop and Thiazide diuretics Zinc, Calcium, Magnesium, Potassium, and Thiamine
Oral contraceptives Vitamin B6, Magnesium, Vitamin B12, Folate

 

Adapted from Table 16.

 

Genetic Variants

Standard nutrient recommendations are based on population subsets that take into account age, gender, and pregnancy status. With the emerging field of nutrigenomics (the study of how nutrition and genes interact), it’s now possible to take genetic variation into account7.

Single-nucleotide polymorphisms (SNPs-differences in the DNA blueprint) can contribute to disease risk, drug-effectiveness, and the nutrient requirements of individuals 7.

Being able to identify SNPs that impact vitamin and mineral metabolism may allow for a more tailored nutrition approach decreasing the risk of micronutrient insufficiencies and deficiencies that precede chronic disease development8.

While millions of SNPs have been identified, only a small percentage have a measurable impact7. The following table provides examples of some genes that are responsible for vitamin metabolism and the impact that SNPs in these genes may have 8,9:

Micronutrient Gene/Action Possible Impact of SNP
Vitamin A BCM01 gene encodes β-Carotene Oxygenase 1, a key enzyme in the conversion of beta-carotene to vitamin A Decreased enzyme synthesis rate can reduce vitamin A absorption
Vitamin B6 ALPL and NBPF3 genes impact enzymes necessary for alkaline phosphatase production, which is crucial for neurotransmitter synthesis in the CNS Deficiency in alkaline phosphatase, which may lead to vitamin B6 deficiency
Folate MTHFR gene encodes the methylenetetrahydrofolate reductase protein, which participates in folic acid metabolism. Folate is necessary for converting homocysteine ultimately to S-adenosylmethionine for DNA methylation The metabolic pathway from homocysteine into SAMe is altered. Homocysteine levels remain elevated increasing the risk of atherosclerosis and type 2 diabetes
Vitamin D VDR gene is involved in the making of vitamin D receptor protein, which determines how the body responds to vitamin D Reduced vitamin D receptor sensitivity can lead to an increase in calcium removal from the bones increasing the risk of osteoporosis
Vitamin D GC gene encodes the vitamin D binding protein Reduces the level of active vitamin D in the blood
Vitamin B12 FUT2 gene encodes protein fucosyltransferase 2, involved in the synthesis of antigens that contribute to how vitamin B12 is absorbed Decreases the risk of impaired vitamin B12 absorption
Iron TERF2 gene encodes for TERF2 protein, which impacts how iron gets into the cell Decreases the ability to get iron into the cell
Iron TMPRSS6 gene encodes for the protein matriptase-2, which helps with iron balance Associated with poor response to oral iron therapy

 

 

Impaired Digestion and Absorption

Eating the right amount of nutrients is just one step in the nutritional adequacy equation. A person must also be able to digest and assimilate the raw materials from food into usable information for the body.

The process of digestion is extremely complex requiring thorough mastication, appropriate amounts of digestive secretions, proper movement of food through the GI tract, adequate blood flow and hydration, an intact intestinal lining, and a balanced gut microbiome10. If any of these are impaired, people can experience malabsorption of at least one nutrient10.

Some causes of impaired digestion and absorption to consider include10, 11:

  • Exocrine pancreatic insufficiency
  • Adverse food reactions, including gluten-related allergy or sensitivity
  • Gut dysbiosis and increased intestinal permeability
  • Small intestinal bacterial overgrowth
  • Parasitic infections
  • Helicobacter pylori infection
  • Inflammatory bowel disease
  • Other autoimmune disorders such as autoimmune gastritis
  • Irritable bowel syndrome
  • Inadequate stomach acid production
  • Gallbladder and liver dysfunction
  • Chronic inflammation
  • Inadequate intrinsic factor
  • Bariatric or other gastric surgery

 

An Integrative and Functional Nutrition Approach to Micronutrient Imbalances

Nutritional imbalances are a root cause of negative symptoms and chronic disease development.  Using the IFN Academy STAIN© signature model, IFNCP Functional Nutritionists investigate and highlight the various nutrient shortfalls (and excesses) that influence a person’s health and contribute to the root causes of their condition.

While serum micronutrient testing can be helpful, it’s often unreliable as a diagnostic tool. Serum levels don’t always reflect tissue nutrient levels and they don’t provide information about how well the nutrient is functioning in the body.

Instead of relying only on serum testing, IFNCP Functional Nutritionists analyze their clients’ history (including diet history), medication use, physical symptoms, digestive function, and functional and genetic testing to create a comprehensive nutrition care plan.

To learn more about using a root-cause approach, sign up for IFN Academy training today!

by: Kellie Blake, RDN, LD, IFNCP

 

References

  1. Espinosa-Salas S, Gonzalez-Arias M. Nutrition: Micronutrient Intake, Imbalances, and Interventions. [Updated 2023 Sep 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK597352/
  2. Oregon State University Linus Pauling Institute. Micronutrient Inadequacies in the US Population: an Overview. Accessed December 3, 2024. Available from: lpi.oregonstate.edu/mic/micronutrient-inadequacies/overview
  3. Bird JK, Murphy RA, Ciappio ED, McBurney MI. Risk of Deficiency in Multiple Concurrent Micronutrients in Children and Adults in the United States. Nutrients. 2017; 9(7):655. https://doi.org/10.3390/nu9070655
  4. Chouraqui JP. Risk Assessment of Micronutrients Deficiency in Vegetarian or Vegan Children: Not So Obvious. Nutrients. 2023;15(9):2129. Published 2023 Apr 28. doi:10.3390/nu15092129
  5. Centers for Disease Control and Prevention. Prescription Drug Use. Prescription Drug Use – Health, United States. Accessed December 9, 2024.
  6. Mospan, C. Drug-Induced Nutrient Depletions: What Pharmacists Need to Know. US Pharm. 2019: 44(12): 18-24. Drug-Induced Nutrient Depletions: What Pharmacists Need to Know
  7. Stover, P. Influence of human genetic variation on nutritional requirements. The American Journal of Clinical Nutrition. Volume 83, Issue 2, 436S-442S Influence of human genetic variation on nutritional requirements23 – The American Journal of Clinical Nutrition
  8. Galyean S, Sawant D, Shin AC. Personalized Nutrition for Management of Micronutrient Deficiency-Literature Review in Non-bariatric Populations and Possible Utility in Bariatric Cohort. Obes Surg. 2020;30(9):3570-3582. doi:10.1007/s11695-020-04762-3
  9. Vesnina A, Prosekov A, Kozlova O, Atuchin V. Genes and Eating Preferences, Their Roles in Personalized Nutrition. Genes (Basel). 2020;11(4):357. Published 2020 Mar 27. doi:10.3390/genes11040357
  10. Zuvarox T, Belletieri C. Malabsorption Syndromes. [Updated 2023 Jul 24]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553106/
  11. Montoro-Huguet MA, Belloc B, Domínguez-Cajal M. Small and Large Intestine (I): Malabsorption of Nutrients. Nutrients. 2021;13(4):1254. Published 2021 Apr 11. doi:10.3390/nu13041254
  12. Gibbs J, Cappuccio FP. Common Nutritional Shortcomings in Vegetarians and Vegans. Dietetics. 2024; 3(2):114-128. https://doi.org/10.3390/dietetics3020010
  13. Lacombe V, Chabrun F, Lacout C, et al. Persistent elevation of plasma vitamin B12 is strongly associated with solid cancer. Sci Rep. 2021;11(1):13361. Published 2021 Jun 25. doi:10.1038/s41598-021-92945-y
  14. Asif A, Farooq N. Vitamin D Toxicity. In: StatPearls. Treasure Island (FL): StatPearls Publishing; May 24, 2023.
  15. Schoofs H, Schmit J, Rink L. Zinc Toxicity: Understanding the Limits. Molecules. 2024;29(13):3130. Published 2024 Jul 1. doi:10.3390/molecules29133130