Iodine deficiency disorders are the most common cause of preventable brain damage, which affects an estimated 50 million people worldwide. During pregnancy, severe iodine deficiency may impair fetal development, resulting in cretinism (irreversible mental retardation with short stature and developmental abnormalities) as well as in miscarriage and stillbirth. Other more pervasive consequences of chronic iodine deficiency include lesser cognitive and neuromuscular deficits. The ocean is a dependable source of iodine, but away from coastal areas iodine in food is variable and largely reflects the amount in the soil. In chronic iodine deficiency the thyroid gland enlarges as it attempts to trap more iodide (the form in which iodine functions in the body) from the blood for synthesis of thyroid hormones, and it eventually becomes a visible lump at the front of the neck known as a goitre. Some foods, such as cassava, millet, sweet potato, certain beans, and members of the cabbage family, contain substances known as goitrogens that interfere with thyroid hormone synthesis; these substances, which are destroyed by cooking, can be a significant factor in persons with coexisting iodine deficiency who rely on goitrogenic foods as staples. Since a strategy of universal iodization of salt was adopted in 1993, there has been remarkable progress in improving iodine status worldwide. Nonetheless, millions of people living in iodine-deficient areas, primarily in Central Africa, Southeast and Central Asia, and even in central and eastern Europe, remain at risk.

Zinc

A constituent of numerous enzymes, zinc plays a structural role in proteins and regulates gene expression. Zinc deficiency in humans was first reported in the 1960s in Egypt and Iran, where children and adolescent boys with stunted growth and undeveloped genitalia responded to treatment with zinc. Deficiency of the mineral was attributed to the regional diet, which was low in meat and high in legumes, unleavened breads, and whole-grain foods that contain fibre, phytic acid, and other factors that inhibit zinc absorption. Also contributing to zinc deficiency was the practice of clay eating, which interferes with the absorption of zinc, iron, and other minerals. Severe zinc deficiency has also been described in patients fed intravenous solutions inadequate in zinc and in the inherited zinc-responsive syndrome known as acrodermatitis enteropathica. Symptoms of zinc deficiency may include skin lesions, diarrhea, increased susceptibility to infections, night blindness, reduced taste and smell acuity, poor appetite, hair loss, slow wound healing, low sperm count, and impotence. Zinc is highest in protein-rich foods, especially red meat and shellfish, and zinc status may be low in protein-energy malnutrition. Even in developed countries, young children, pregnant women, the elderly, strict vegetarians, people with alcoholism, and those with malabsorption syndromes are vulnerable to zinc deficiency.

Calcium

Almost all the calcium in the body is in the bones and teeth, the skeleton serving as a reservoir for calcium needed in the blood and elsewhere. During childhood and adolescence, adequate calcium intake is critical for bone growth and calcification. A low calcium intake during childhood, and especially during the adolescent growth spurt, may predispose one to osteoporosis, a disease characterized by reduced bone mass, later in life. As bones lose density, they become fragile and unable to withstand ordinary strains; the resulting fractures, particularly of the hip, may cause incapacitation and even death. Osteoporosis is particularly common in postmenopausal women in industrial societies. Not a calcium-deficiency disease per se, osteoporosis is strongly influenced by heredity; risk of the disease can be lessened by ensuring adequate calcium intake throughout life and engaging in regular weight-bearing exercise. Sufficient calcium intake in the immediate postmenopausal years does appear to slow bone loss, although not to the same extent as do bone-conserving drugs.

Fluoride

Fluoride also contributes to the mineralization of bones and teeth and protects against tooth decay. Epidemiological studies in the United States in the 1930s and 1940s revealed an inverse relationship between the natural fluoride content of waters and the rate of dental caries. In areas where fluoride levels in the drinking water are low, prescription fluoride supplements are recommended for children older than six months of age; dentists also may apply fluoride rinses or gels periodically to their patients’ teeth. Fluoridated toothpastes are an important source of fluoride for children and also for adults, who continue to benefit from fluoride intake.

Sodium

Sodium is usually provided in ample amounts by food, even without added table salt (sodium chloride). Furthermore, the body’s sodium-conservation mechanisms are highly developed, and thus sodium deficiency is rare, even for those on low-sodium diets. Sodium depletion may occur during prolonged heavy sweating, vomiting, or diarrhea or in the case of kidney disease. Symptoms of hyponatremia, or low blood sodium, include muscle cramps, nausea, dizziness, weakness, and eventually shock and coma. After prolonged high-intensity exertion in the heat, sodium balance can be restored by drinking beverages containing sodium and glucose (so-called sports drinks) and by eating salted food. Drinking a litre of water containing two millilitres (one-third teaspoon) of table salt also should suffice.

Chloride is lost from the body under conditions that parallel those of sodium loss. Severe chloride depletion results in a condition known as metabolic alkalosis (excess alkalinity in body fluids).

Potassium

Potassium is widely distributed in foods and is rarely deficient in the diet. However, some diuretics used in the treatment of hypertension deplete potassium. The mineral is also lost during sustained vomiting or diarrhea or with chronic use of laxatives. Symptoms of potassium deficiency include weakness, loss of appetite, muscle cramps, and confusion. Severe hypokalemia (low blood potassium) may result in cardiac arrhythmias. Potassium-rich foods, such as bananas or oranges, can help replace losses of the mineral, as can potassium chloride supplements, which should be taken only under medical supervision.