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It’s no secret that a well-balanced diet is good for you, while a diet lacking in proper nutrients can leave you feeling less than your best. Family medicine specialist Kelly Raj, DO, talks about common vitamin deficiencies, the warning signs to be aware of and who’s most at risk. She also offers practical advice on taking a vitamin supplement and what to look for in a multivitamin.

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All About Vitamin Deficiencies with Dr. Kelly Raj

Podcast Transcript

Cassandra:  Hi, thanks for joining us for this episode of the Health Essentials podcast brought to you by Cleveland Clinic. I'm your host, Cassandra Holloway. We're broadcasting from Cleveland Clinic, Lakewood Family Health Center in Lakewood, Ohio. And we're here today with Dr. Kelly Raj, thanks for being here.

Dr. Kelly Raj:  Thank you.

Cassandra:  Before we begin, we want to remind our audience that this is for informational purposes only and should not replace your own doctor's advice. Dr. Raj is a family medicine specialists and today we're going to be talking about vitamin and mineral deficiencies and how to address them. So it's no secret that a well balanced diet is good for you, right? So we know that a poor diet can really wreak havoc on your body, and if you're not getting the proper nutrients, you kind of not feel very well most of the time. So Dr. Raj, can you start off by explaining to us what is a vitamin deficiency and why is this something that we should be concerned about?

Dr. Kelly Raj:  Sure. I think in this time of life, there's a lot of different diets that people are on, so I think the most common thing that we see in the United States is that people come to me on a different type of diet. And they oftentimes are concerned are they lacking any vitamins or nutrients either before they begin the diet or once they've started the diet. So when someone is lacking a certain vitamin or nutrient, they may develop symptoms of that vitamin deficiency or nutrient deficiency. And in our country it's often attributable to a certain fad type or a particular diet that the patient may be on versus in other developing countries it may actually be due to the lack of vitamin in that diet that they have every day.

Cassandra:  Interesting. Makes sense. What are some of the most common vitamin deficiencies in the US?

Dr. Kelly Raj:  I think some of the most common ones we see, at least in Northeast Ohio, is vitamin D deficiency. Just due to our lack of sunlight most of the year, iron deficiency is one. Vitamin B12 is very common across all age groups, calcium deficiencies, vitamin A, and magnesium. So there's a variety of them but I think vitamin D is the one I most commonly see in practice.

Cassandra:  And you mentioned vitamin D and being in Northeast Ohio, here in Cleveland. Why is that a concern for this type of environment, why are we lacking in vitamin D in Cleveland especially?

Dr. Kelly Raj:  Sure. So most people obtain it from sunlight. That's where we get our vitamin D exposure. There are also certain foods that are now fortified with vitamin D, so basically people need to try to supplement if they're not getting enough sunlight. And even when people are traveling to places when they place sunscreen on etcetera, they're prohibiting their absorption of vitamin D in that way. So living here where we see a lot of sunlight most of the year, if we cannot absorb vitamin D, that actually affects calcium absorption, which then can lead to effects on bone health.

So the long-term effects of that are great and there's a lot more research on other complications and side effects of vitamin D deficiency. I think the one issue patients may see when they do come to the doctor, we can draw blood levels for vitamin D but there's not a standard as to what the norm is. There's some guidelines as to recommendations and patients can obtain this over the counter or even prescription supplements, but it's definitely something you would want to check with your physician or provider about in regards to how much you should supplement with.

Cassandra:  Absolutely. You mentioned B12 and I feel like that's a really popular vitamin that I hear a lot of people taking. Can you talk to us a little bit about what that is and why is that important I guess in our system?

Dr. Kelly Raj:  Sure. So the number one reason I think patients will actually come to me already on B12 is because they hear a lot that it provides them with extra energy. So they will go ahead and start over the counter supplements because they want that extra energy boost. And so it is available over the counter in tablet formulation that they can come and take it in. What we see is as people age, they actually have trouble absorbing vitamin B12. So even if they have trouble absorbing it, if they tried to take pills by mouth, they're not going to be able to retain that bond in their system that they need to get the energy level. So you will often hear some people taking vitamin B12 via an injection form when they get it from their physician's office as well, so that's another formulation that can get it. But deficiencies in B12 mainly lead to fatigue, that's probably the biggest thing. But there are other nervous system type side effects that people can experience and those are things that people can speak with their physician in regards to.

Cassandra:  So let's talk about vitamin K. I feel like that's a forgotten vitamin that we hear about randomly. What is vitamin K and is that a common deficiency? What does that do for our system?

Dr. Kelly Raj:  So vitamin K deficiency is rare, when people are deficient in it they may have sensitivity to bruising, people may notice bleeding gums, excessive menstrual bleeding in females. The issue with vitamin K, it's one of those that you want to be cautious about supplementing because of the effects on bleeding. So when you have patients that are uncertain, blood thinners such as Coumadin, you want to be cautious in supplementing with that. And that's something you'd want to check with your doctor about as well. So it's not common but again, you don't want to go ahead and supplement it without talking to your doctor, especially if on some prescription medications.

Cassandra:  Absolutely. So you mentioned a couple of symptoms that one would have if they were deficient in vitamins. And I know there's many vitamins you could be deficient in, but are there any specific signs or symptoms to watch out for, that might alert someone that something might not be right in their vitamin levels?

Dr. Kelly Raj:  I think fatigue and feeling very tired isn't a very common complaint, especially in the winter here, but it's a very common complaint of patients that are deficient in many vitamins and just not feeling like themselves and feeling very tired. People may also have brittle hair, brittle nails, skin conditions, they might lose hair. So I think if someone is just feeling off in any way, I always tell patients to trust how they feel and if they feel different than they're typically feeling, we probably should investigate. There are not blood tests for every type of vitamin, and we don't test for every type. There's so many that are out there, but we do not have blood tests to test regularly for everything. So there are common ones, but I always tell patients, if you're not feeling yourself, it's definitely time to bring that to the attention of your physician.

Cassandra:  Keep a pulse on how you normally feel and just be aware. Be mindful of your body.

Dr. Kelly Raj:  Exactly, especially if someone changes their diet, that's another very common time. If all of a sudden they've started this, after the New Year they started a new diet and they notice one to two months in, they're not feeling themselves. That's just another trigger for me that there may be something they're deficient in.

Cassandra:  Absolutely. Are there any complications that can develop long-term from being deficient in vitamins or can ever be life threatening?

Dr. Kelly Raj:  There are certain diseases, one patient their deficient in vitamin C, they can develop something called scurvy, vitamin D, it's something called rickets. These things can affect, like rickets can affect the bone, so we don't see a lot of these because we catch things very early, but there can be long-term complications to the nervous system, to the bones. So it is important that patients really try to just overall have a balanced diet to prevent these. And we're very fortunate that a lot of our food is fortified in certain vitamins and nutrients. So patients may not realize they're actually obtaining B12 and folic acid and magnesium through certain foods and iodine through certain foods and products that have been fortified with this. This is not something that happens in developing countries, but it is something that happens here. So that's another reason why we don't see a lot of these diseases, we read about them, but we don't see them because our diets are fortified.

Cassandra:  Sure. You mentioned if people started a new diet, vitamin deficiencies might come up when we're starting a new diet. What are some other common causes of vitamin deficiencies?

Dr. Kelly Raj:  Certain illnesses that patients may have, certain chronic medical conditions that could affect the body's ability to absorb things. So if there's certain gastrointestinal system problems, just for example, if patients have crones disease or a patient has celiac disease. If for some reason within their GI tract they're not able to absorb vitamins and nutrients, then that will present that way.

And sometimes patients may not know that they have a chronic disease and that's when the investigation process begins. But if a patient does know, all the more reason and all the more importance to follow up with your physician. Another thing is if patients have surgeries like certain patients that have gastric bypass surgery, the importance of following up with the bariatric Institute, the importance of continued follow-up with your surgeons because vitamin and mineral nutrient deficiencies can occur several months to several years post procedures. Just again, once you've affected or changed the gastrointestinal track, you can affect the body's ability to absorb nutrients.

Cassandra:  Let's talk about risk factors. Are there certain groups or demographics that are more prone to vitamin deficiencies? You kind of touched on this if you've had a prior surgery or a prior condition, but I'm just curious, are children more prone to it or that sort of thing?

Dr. Kelly Raj:  Sure, and in the pediatric age group, the most at risk child group would be newborns that are breastfed. They need to be supplemented with vitamin D, there's drop formulations, vitamin D they can be supplemented with and that's, they just are not getting vitamin D through breast milk. That's not true of children receiving formula, but that's just an age group that is important to make sure they're receiving that supplement. Children in general do not necessarily need a multivitamin, but it's just the importance of following and making sure they have a balanced diet, which is difficult in some children because toddlers are picky eaters, so it's hard to manage that. So if I do see children that have picky eating habits, I will encourage parents to supplement with vitamins. And now the secondary risk of that is there so many vitamins that are gummy formulations, so teeth brushing becomes important, but if you can get the child to take it because it's a gummy then go for it.

Dr. Kelly Raj:  Pregnant women are another group that we recommend prenatal vitamins, prenatal vitamins contain extra folic acid, which is important to prevent neural tube defects. We recommend pregnant women try to take this several months prior to conception if possible, just to help build up their vitamin store levels. And then we have them take prenatal vitamins throughout the pregnancy and if they're going to breastfeed after as well, we recommend they continue to take it. So that's another at-risk group that really needs that extra boost and extra supplement.

Cassandra:  Sure. If someone is experiencing these symptoms, if they're just feeling rundown like you were saying or just keeping a pulse on themselves and they're just not feeling like themselves, what should their next steps be? Should they see their primary care doctor? Should they see someone else? What would you recommend their next steps be?

Dr. Kelly Raj:  Sure. I would recommend they see their primary care doctor to start and just write down a list of symptoms. I think sometimes patients forget all the symptoms they're feeling and they're all important in trying to piece the puzzle together and figure out what lab test we should or should not order. But I think scheduling an appointment with your primary care doctor is a really good place to start.

Cassandra:  And so say someone came into your office and you suspected a vitamin deficiency, walk me through how you would diagnosis this, are there certain tests? And what questions you would ask.

Dr. Kelly Raj:  Sure. Obtaining the history from them, just seeing how long they felt the certain symptoms that they felt, a physical exam, listening to their heart and lungs. Certain vitamin deficiencies as I mentioned can affect the nervous system. So sometimes that might us involve checking reflexes or muscle strength and then obtaining certain lab tests. So for example, we can check a specific vitamin D level, we can check a B-12 level, so checking those levels. And oftentimes if a patient has started a new diet or has had a change, I will recommend them to start taking a daily multivitamin if I get the sense that their regular diet is missing some nutrients at the time for certain reasons.

Cassandra:  So you mentioned multivitamin, so I want to talk a little bit about that. I feel like there's so much information out there. What should I be taking and what should I be looking for? Walk us through, what are some questions you should be asking yourself when you're looking to take a multivitamin?

Dr. Kelly Raj:  Sure. And a lot of them on the market, I mean we have to keep in mind the FDA doesn't regulate these products, so it's not like when you go to the pharmacy and obtain a prescription medication for blood pressure. So vitamins, when you look at B-12, there's different milligrams and tablets for different companies. So it's really hard for, it's overwhelming when you look down the vitamin and supplement aisle. So for peds, for kids, there's pediatric vitamins, and again, like I mentioned, there's the gummies, the one a day gummies.

A lot of vitamin supplements for kids and adults now at Omega−3 fatty acids, which we're learning, those have an additional health benefit. So when you look at the label, a general multivitamin does have your vitamin D supplements, your vitamin C contained within them. So you don't necessarily have to purchase multiple. But the labels go by ages, so there's pediatric ones, some of them will say for under four, some of them will say greater than four above. For women of childbearing age, there's multivitamin for women, for people over the age of 50, there's multivitamins for 50 plus.

 Dr. Kelly Raj:  So I often tell patients to find those labels that are based upon age. And then you can go ahead and look for the generic, you don't necessarily always have to buy the brand name vitamin that's out there.

Cassandra:  Great. And so you would recommend that vitamins do work because I feel like there's so much information on the internet that's like, you should be getting all your vitamins from food, but you recommend you do take a multivitamin.

Dr. Kelly Raj:  I would recommend if you do not have a balanced diet or if you're trying a new diet where you might be missing some things, then I would recommend taking a multivitamin. So it's not necessary for everyone to be on one but if you're not having a well-balanced diet, which means fruits, vegetables, whole grains, then you really should consider starting a multivitamin.

Cassandra:  Absolutely. And so I want to talk about treatment now. So if someone came into your office and you, let's say they were deficient in vitamin D, what would treatment look like?

Dr. Kelly Raj:  So for vitamin D, we order a lab test and if it's at a certain level that's low enough, there's a prescription strength that we will do for about two months and then we'll switch them to an over the counter, strictly vitamin D supplement. When we talked about a multivitamin, there is a certain amount of vitamin D in a multivitamin, but it's not enough oftentimes for people that are deficient in it, so we will have to add a second vitamin D supplement. So I think it's important just to note if we have to order that separate one, sometimes even the multivitamin doesn't have enough if people are deficient in something.

Cassandra:  So they'll have to double up obviously.

Dr. Kelly Raj:  Exactly. And it's not always long-term, it's just until they build up to the stores and we can check those levels. Oftentimes I've reduced the amount of times I'm checking vitamin D because I assume most people here just are not getting enough. And it's an expensive lab test to order and it's not necessarily one you want to keep ordering every three to six months because there is a cost to the patient.

Cassandra:  What about some negative consequences of, say I diagnose myself with vitamin D, I'm just feeling tired, maybe I didn't go to the doctor and so I started taking extra vitamin D. Is there anything negative that could happen? Are there complications? Can I overdose on a certain vitamin?

Dr. Kelly Raj:  There are some studies that show there's a cutoff or a threshold for vitamin D and I think what I've seen in practice is so many people, at least here are deficient in and I have not seen people harmed from it, but it still is a potential risk. So that's why I would not recommend you just go and start the maximum dose of over the counter separate vitamin D on your own without talking to your primary care doctor first, because too much is not a good thing.

Also, you're not necessarily, if you're feeling very tired, it's not, the more is better philosophy, it really won't work and you could harm yourself. And that's especially important if you're on other prescription medications that could affect the absorption. There are certain medications, for example, patients that may take thyroid medications that need to be spaced out time wise from vitamins and supplements, so that's something that you would want to check with your doctor. You could affect the body's ability to absorb those over the counter vitamins and you can also affect your ability to absorb the prescription medicine that you're taking.

Cassandra:  Does it take a while for say, I started taking B-12 because I wanted more energy? Would I see the effects right away or would it take a little bit for that to build up in my system?

Dr. Kelly Raj:  It usually takes several weeks for it to build up in your system. Even, I always keep going back to vitamin D, but once I start someone on it, I won't recheck it for several months later because it does take a while for the body to build up its depleted stores.

Cassandra:  Makes sense. So the last thing I want to talk about here is prevention. If you've identified as being maybe at risk or maybe you're getting a little bit older or maybe you live in Cleveland and it's gloomy for most of the year, what advice to prevent vitamin deficiencies do you have? What would you tell a patient that prevention matters? Talk us through that.

Dr. Kelly Raj:  Sure. So I always start with diet. We're trained in the philosophy that food is medicine now and we have to look at what we're taking in. And so I think I always start with really trying to make sure people are eating breakfast, lunch and dinner and that you're balancing that throughout the day to get fruits, vegetables, meat, and fish.

And if people do have certain dietary restrictions, whether in their own beliefs or dietary restrictions based upon health conditions, you can work with your physician to figure out healthier alternatives. Or you can work with a nutritionist or a dietitian as well just to help you try to obtain it from your diet. The body really does best to absorb vitamins and nutrients from natural sources from our diets, so that is always what I counsel patients first and foremost. We really want to try to work to obtain it that way. If we can't, then we start a daily multivitamin and then we can start to dive deeper if we need to go to specific vitamin deficiencies and then add those supplements in addition to the multivitamin.

Cassandra:  Great. That's great advice. Thank you.

Dr. Kelly Raj:  Welcome.

Cassandra:  So that's all the time we have today. Thank you, Dr. Raj for joining us.

Dr. Kelly Raj:  Thank you for your time.

Cassandra:  To make an appointment with Dr. Raj or another family medicine physician. Call (866) 320-4573 or visit clevelandclinic.org/community care. If you want to listen to more Health Essentials podcast from Cleveland Clinic experts, subscribe wherever you get your podcasts from or visit clevelandclinic.org/hepodcast. And don't forget to follow us on Facebook, Twitter, and Instagram @clevelandclinic, all one word, to stay up to date on the latest health tips, news, and information. Thanks for listening.

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