and an elevated FAD stimulation of erythrocyte
glutathione activity, an additional 0.3 mg per day is
recommended. The lactating woman secretes ap-
proximately 35 mg per 100 ml of milk for an output
of about 0.26 mg per day (750 ml) during the first 6
months and 0.21 mg per day (600 ml) during the
second 6 months. Since the utilization of the
additional riboflavin for milk production is assumed
to be 70%, an additional intake of 0.5 mg is
recommended for the first 6 months and 0.4 mg for
the second. (See Lactation: Physiology.)
0018 Small amounts of riboflavin, largely as digestible
coenzymes, are present in most plant and animal
tissue. Good sources are eggs, lean meats, milk, broc-
coli, and enriched breads and cereals. Such losses as
occur during cooking are largely attributable to
leaching of the heat-stable but light-sensitive flavins
into water.
0019 When supplementation or therapy with riboflavin
is warranted, oral administration of five to 10 times
the RDA is usually satisfactory.
Deficiency Causes and Symptoms
0020 Pure, uncomplicated riboflavin deficiency is probably
never encountered in patients, but is accompanied by
multiple nutrient deficiencies. Ariboflavinosis can
result from such primary and secondary factors as
commonly affect supply or utilization of other nutri-
ents as well. Inadequate dietary intake most com-
monly related to limited availability of food, but
sometimes exacerbated by poor storage or process-
ing, remains the major cause. In addition, anorexic
persons rarely ingest adequate amounts of riboflavin
and other nutrients.
0021 Decreased assimilation results from abnormal di-
gestion, absorption, or both. Lactose intolerance as a
result of lactase insufficiency, mostly encountered
among Blacks and Asians, argues against such people
consuming nonlactase-treated milk, which is a good
source of the vitamin. Malabsorption can occur as a
result of tropical spure, celiac disease, malignancy
and resection of the small bowel, and gastrointestinal
and biliary obstruction. Poor absorption also results
from disorders that increase motility and decrease
gastrointestinal passage time, such as diarrhea, infec-
tious enteritis, and irritable bowel syndrome. (See
Food Intolerance: Lactose Intolerance.)
0022 Rather rarely encountered, but usually significantly
improved by therapeutic treatment with riboflavin,
are certain inborn errors where the genetic defect is
in formation of a normal flavoprotein. Cases in this
category include fatty acid desaturases in which spe-
cific defects have been found for the mitochondrial
FAD-dependent dehydrogenases for short-chain,
long-chain, and multi-chain acyl-CoAs (acyl coen-
zyme As). The young patients have a lipid storage
myopathy, often accompanied by carnitine insuffi-
ciency, and exhibit glutaric aciduria. A low, FMN-
dependent pyridoxine 5
0
-phosphate oxidase activity
due to an erythrocyte deficiency of FMN, confirmed
by response to oral riboflavin, was reported in the
majority of subjects with d-glucose 6-phosphate
dehydrogenase deficiency. Such cases seem to have
an accelerated conversion of FMN to FAD so that
glutathione reductase is saturated. This contrasts
with heterozygous b-thalassemia, in which there is
an inherited slow erythrocyte conversion of riboflavin
to FMN, a decrease in subsequent FAD, and a high
stimulation of the erythrocyte glutathione reductase
by extraneous FAD.
0023Defective utilization can result from disturbances
in hormonal production, certainly relating to thyroid
hormone, but less likely as a result of taking oral
contraceptives. Phenothiazine derivatives appear to
impair use of riboflavin.
0024Increased destruction of riboflavin occurs during
treatment of neonatal jaundice with phototherapy.
In this case, the side-chain of the vitamin is photo-
chemically destroyed, as it is involved in the photo-
sensitized oxidation of bilirubin to more polar,
excretable compounds.
0025The finding that phenobarbital induces microso-
mal oxidation of the 7-methyl function of the vitamin
lends credence to the belief that long-time use of
barbiturates may jeopardize flavin status.
0026Enhanced excretion of riboflavin occurs in cata-
bolic patients undergoing nitrogen loss. The relation-
ship of the vitamin to protein status has long been
recognized. Also, certain antibiotics and pheno-
thiazine drugs increase excretion of riboflavin. (See
Drug–Nutrient Interactions.)
0027Increased requirements can, of course, be the con-
sequence of one or more of the above-mentioned
factors. For example, protein–calorie malnutrition
commonly accompanies a diminution in both absorp-
tion and utilization of riboflavin. Systemic infections,
even without gastrointestinal involvement, some-
times lead to increased requirements that can result
from decreased intake, defective absorption, poor
utilization, and increased excretion. (See Protein: De-
ficiency.)
0028Clinical deficiency of riboflavin has been reduced
by feeding a riboflavin-deficient diet and/or by the
administration of an antagonist such as galactoflavin.
The deficiency syndrome is characterized by sore
throat, hyperemia and edema of the pharyngeal and
oral mucous membranes, cheilosis, angular stoma-
titis, glossitis (magenta tongue), seborrheic dermatitis,
and normochromic, normocytic anemia associated
4994 RIBOFLAVIN/Physiology