REVIEWS Psychiatric Implications of Nutritional Deficiencies in Alcoholism Byung Joo Ham, M.D., Ph.D.1, Ihn-Geun Choi, M.D., Ph.D.1 1Department of Neuropsychiatry, Han-Gang Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea impairment and tissue damage, mainly neuronal and Abstract vascular, in the brain. Nutritional deficiency in alco- Malnutrition is common in chronic alcoholics. holics also causes neurotransmitter dysfunction, ion Hypocalcemia, hyponatremia, hypokalemia and, channel dysfunction, oxidative stress and metabolic hypophosphatemia have all been associated with dysfunction in the brain. Nutritional deficiency in chronic alcoholism. Alcohol intake is also associated chronic alcoholics frequently leads to a mild to moder- with low serum magnesium, selenium and zinc levels. ate cognitive impairment, including impairment in per- ceptual-motor skills, visual-spatial functions, learn- Water-soluble vitamins, such as vitamin B1, B2, B3, B6, ing/memory, and abstraction and problem solving. B9 and C, and fat-soluble vitamins, such as vitamin A, There are a number of nutritional deficiencies which D, E and K have also been reported to be deficient in need to be cared for but magnesium, thiamine, and alcoholics. General causes of malnutrition in alcoholics other B vitamins need to be administered immediately. are inadequate nutrient, particularly lack of water-sol- Nutritional therapy can aid in the recovery from alco- uble vitamins in their diet, reduced uptake, impaired holism. Patients who have received nutritional therapy utilization, increased requirements of nutrients and reported significantly less alcohol craving as well as genetic predisposition to nutrient deficiency. Nutrient significantly greater nutrient intakes, and a greater deficiencies are, therefore, a virtually inevitable conse- number abstained from alcohol. Although abstinence quence of alcohol abuse, not only because alcohol dis- and proper nutrition remain the cornerstones of treat- places food, but also because alcohol directly interferes ment, pharmacological modification of neurotransmit- with the body's use of nutrients, making them ineffec- ter function and/or enhancement of cerebral metabo- tive even if they are present. Chronic alcoholics exhibit lism combined with behavioral methods may also be a number of neurological disorders which are related to beneficial. nutritional deficiencies, in particular vitamin defi- ciencies that are essential for normal cerebral function- Key words: Alcoholism, Nutrition, Deficiency, ing. Specific vitamin and nutrient deficiencies arising Neuropathology, Neurophysiology, Neuropsychology in chronic alcoholics may result in severe functional [ Psychiatr Invest 2005; 2 (2): 44 -59] Correspondence: Ihn-Geun Choi, M.D., Ph.D., Department of Neuropsychiatry, Hallym University, Han-Gang Sacred Heart Hospital, 94-200 Youngdungpo-dong, Youngdungpo-gu, Seoul, Introduction Korea (150-719) Tel: +82-2-2639-5461, Fax: +82-2677-9095, E-mail: [email protected] Malnutrition is common in chronic alcoholics, 44 REVIEWS although its severity may depend on the social charac- TABLE 1. Nutritional deficiencies in alcoholism. teristics of the patient group under study and their Nutrients Prevalence in alcoholism References severity of alcohol dependence1. Alcoholics represent 3 the largest group of patients with treatable nutritional calcium 20-50% Pitts & van Thiel (1986) sodium up to 40% Pitts & van Thiel (1986)4 disorders in Western countries2. potassium 50% Pitts & van Thiel (1986)4 Approximately 20-50% of individuals admitted to the phosphorus 30% De Marchi et al. (1993)8 hospital for alcohol withdrawal or Laennec's cirrhosis magnesium 25-50% Pitts & van Thiel (1986)3 have been found to be hypocalcemic, and severe, selenium frequent Dworkin et al. (1984)11 symptomatic hypocalcemia is often seen in seriously ill zinc Valle et al. (1957)13 alcoholics3. As many as 40% of decompensated cir- vitamins 14 rhotics may also manifest significant hyponatremia at B1 (thiamine) 30-80% Morgan (1982) 15 B2 (riboflavin) common Rosenthal et al. (1973) the time of hospitalization4. Hypokalemia is also com- 16 B3 (niacin) 35% Leevy et al. (1965) mon in patients with alcoholic liver disease5. 17 B6 (pyridoxine) 50% Lumeng & Li (1974) Hypokalemia is seen in approximately 50% of chronic 14 B9 (folate) 6-80% Morgan (1982) alcoholics who are hospitalized for acute alcohol with- vitamin C 14% Roe (1979)18 drawal and usually develops after their hospitalization. vitamin D 58% Bjorneboe et al. (1987)19 However, hypokalemia common in alcoholics does not vitamin E 46% Bjorneboe et al. (1988)20 always represent true potassium depletion. Although vitamin K 58% Iber et al. (1986)21 most cirrhotics have a diminished total body potassium content, intracellular potassium concentration is usual- centration had a significant negative correlation with ly normal4. A number of studies have recorded low average daily alcohol intake, but not with alcohol inorganic phosphorus concentrations in chronic alco- intake per drinking day9. holics6, 7. On admission, 30% of patients with chronic Chronic alcoholism is also associated with low serum alcoholism had hypophosphatemia8. zinc level13. Low plasma, erythrocyte and hepatic zinc Alcoholism is the most commonly recognized cause concentrations also follow chronic ingestion of of disturbed magnesium balance. Alcohol intake per alcohol22. Zinc values were also low in patients suffer- drinking day correlated negatively with serum magne- ing from alcoholic cirrhosis23. The depression of zinc sium9. levels was related to the severity of the hepatic lesions, Approximately 25-50% of the patients hospitalized the lowest levels being observed among cirrhotics. for alcohol related problems are hypomagnesemic3. Female alcoholics were more severely affected than Low serum magnesium concentrations are frequently males with respect to their zinc levels, although they encountered especially during acute alcohol withdraw- consumed lesser amounts of alcohol and had a shorter al10. Alcohol intake is also associated with low serum duration of alcohol intake24. However, there is no indi- selenium levels. Among alcoholics admitted for detoxi- cation for zinc supplementation in well-nourished alco- fication, selenium was diminished despite the absence holics25, because the nutritional state of the alcoholics of severe malnutrition, as depressed blood selenium alone may not be an adequate explanation for their low levels occur frequently in patients with chronic heavy serum zinc level26. A reduction in zinc concentration ethanol ingestion even in the absence of severe liver occurs in the central nervous system of chronic alco- disease or overt malnutrition11, 12. Among males, alco- holics27. It was shown that involuntary intoxication of hol intake per drinking day correlated negatively with rats with 10% ethanol solution for 8 months caused a serum selenium. Among females, serum selenium con- reduction in zinc content in the brain28. 45 REVIEWS Thiamin deficiency, either overt or subclinical, has yvitamin D5. Fifty-eight percent of the heavy alcohol been reported in 30-80% of alcoholics14. Erythrocyte consumers had a concentration of 25-hydroxyvitamin 19 transketolase determination can be used to indicate a D3 below lower limit of reference (20 ng/ml) . functional deficiency of thiamin18. Thirty-eight percent Alcoholics were found to be deficient in vitamin E rel- of alcoholics showed significant erythrocyte transketo- ative to controls34. Before abstinence, vitamin E levels lase activation deficits indicative of severe thiamine were significantly depressed in alcoholics compared deficiency29. Riboflavin deficiency is recognized as a with the controls, in both plasma and erythrocytes35. common complication of chronic alcoholism15. Vitamin K deficiency is rare in alcoholics5. However, Furthermore, pyridoxine deficiency, as measured by the production of abnormal prothrombin is frequently low plasma pyridoxal-5'-phosphate (PLP), was present in alcoholics and this may represent a subclini- observed in more than 50% of alcoholics without cal vitamin K deficiency21. abnormal hematologic indices of abnormal liver func- Hypoglycemia occurs in patients drinking heavily 17 36 tion . Vitamin B12 deficiency was rarely seen in chron- and not eating , but it seems that there is no significant ic alcoholics30. Folic acid deficiency, either overt or caloric and protein undernutrition in alcoholic sub- subclinical, has been reported in 6-80% of alcoholics14. jects37. Folate deficiency is common in "derelict" chronic alco- Circulating levels of vitamins can be a valuable guide holics with inadequate diet16, 30. Evidence of niacin to nutritional status, although care is needed when deficiency is difficult to detect in alcoholics5. However, interpreting the results of such tests in alcoholics. low circulating levels of nicotinic acid have been Sensitive microbiological and biochemical tests for reported in 35% of chronic alcoholics16. Vitamin C is assessing vitamin status have been available for some deficient in alcoholics with and without liver disease31. years, and in addition, new biochemical methods are It was found that acute ethanol intoxication was constantly being developed38. accompanied by a decrease in the ascorbic acid content in the brain, liver and kidneys32. Pathophysiology of nutritional deficiencies in Deficiencies of the fat-soluble vitamins A, D and E alcoholism are not frequently reported in alcoholics without signif-