Vitamin C Deficiency

Vitamin C deficiency, widely known in its severe form as scurvy, is a nutritional condition caused by an inadequate intake of ascorbic acid. Historically associated with long sea voyages, this deficiency remains a relevant health concern today for various reasons. Vitamin C is a critical nutrient involved in numerous bodily functions, including collagen production for healthy skin, bones, and blood vessels, as well as robust immune system function and iron absorption. Since the human body cannot produce or store vitamin C, a consistent dietary supply is essential. When this vital intake falls short, a range of symptoms can emerge, impacting overall health and well-being. 

Vitamin C deficiency occurs when your body does not get enough vitamin C (ascorbic acid) from your diet. Unlike most animals, humans lack the enzyme required to synthesise vitamin C, meaning it must be obtained entirely through food or supplements. It is a water-soluble vitamin, so any excess is excreted through urine, and the body does not build up large reserves. This makes a consistent daily intake crucial.

Vitamin C is involved in several critical bodily functions. Perhaps its most well-known role is in the production of collagen, a structural protein that forms the connective tissue found in skin, bones, cartilage, blood vessels, and teeth. Without sufficient vitamin C, collagen synthesis is impaired, leading to weakened tissues throughout the body. This directly impacts wound healing, the integrity of blood vessels, and the strength of teeth and gums.

Beyond collagen, vitamin C is a potent antioxidant, protecting cells from damage caused by free radicals. It also plays a key role in immune system function, enhancing the activity of various immune cells and improving the body's defence mechanisms. Furthermore, it aids in the absorption of non-haem iron (iron from plant sources) in the digestive tract, which is important for preventing iron deficiency anaemia. It's also involved in the metabolism of cholesterol and in the synthesis of certain neurotransmitters and hormones. When the body's stores fall below a critical level, the various processes relying on vitamin C begin to falter, leading to the diverse set of symptoms associated with vitamin C deficiency. The severe form of this deficiency is historically known as scurvy, a condition characterised by widespread connective tissue dysfunction.

Cases of clinical scurvy, though rare, are still reported in hospitals, often in individuals with severe malnutrition, alcoholism, or psychiatric disorders. Globally, in regions affected by food insecurity or where access to fresh fruits and vegetables is limited, vitamin C deficiency can be more widespread. The World Health Organization (WHO) continues to highlight the importance of micronutrient sufficiency, including vitamin C, as a public health priority.

Vitamin C deficiency isn't typically categorised into distinct "types" in the same way some other diseases are. Instead, it's generally understood as a spectrum, ranging from:

• Subclinical or Marginal Deficiency: This is the most common form, where individuals have insufficient vitamin C intake but do not yet exhibit overt symptoms of scurvy. They might experience vague symptoms like fatigue or mild bruising.
• Clinical Deficiency (Scurvy): This occurs when the deficiency is prolonged and severe, leading to the classic, recognisable symptoms of scurvy, such as bleeding gums, skin haemorrhages, joint pain, and impaired wound healing.

The progression from subclinical to clinical deficiency depends on the individual's dietary intake over time, their existing vitamin C stores, and any factors that increase their need for the vitamin.

Vitamin C deficiency, ultimately, stems from insufficient intake or increased demand that isn't met. Several factors can contribute to this imbalance.

Inadequate Dietary Intake: This is the primary cause. People who consume a very limited diet lacking fresh fruits and vegetables are at high risk. This can include:

• Picky eaters: Children or adults with extremely selective eating habits.
• Poverty and Food Insecurity: Limited access to affordable, nutrient-rich foods.
• Restrictive Diets: Unsupervised or poorly planned elimination diets.
• Reliance on Processed Foods: Diets high in processed, pre-packaged foods that typically lack fresh produce.

Malabsorption: Conditions that impair the absorption of nutrients in the digestive system can lead to vitamin C deficiency, even if dietary intake is theoretically adequate. These include:

• Inflammatory Bowel Diseases (IBD): Such as Crohn's disease or ulcerative colitis.
• Bariatric Surgery: Procedures that alter the digestive tract.
• Chronic Diarrhoea: Can reduce nutrient absorption time.

Increased Requirements: Certain physiological states or medical conditions increase the body's need for vitamin C, making a typical intake insufficient:

• Smoking: Smokers have significantly lower vitamin C levels due to increased oxidative stress and metabolism of the vitamin. They need a higher daily intake compared to non-smokers.
• Pregnancy and Lactation: The demand for vitamin C increases to support both the mother and the developing foetus or nursing infant.
• Chronic Diseases: Conditions like kidney disease requiring dialysis, some cancers, and chronic infections can increase oxidative stress and deplete vitamin C stores.
• Surgery and Trauma: The body's need for vitamin C increases to support wound healing and tissue repair.
• Extreme Physical Stress: Intense physical exertion can also temporarily increase demand.

Alcoholism: Chronic alcohol abuse can lead to poor dietary habits, impaired nutrient absorption, and increased excretion of vitamin C, making alcoholics highly susceptible to deficiency.

Elderly Individuals: Older adults may have reduced appetite, difficulty chewing or swallowing fresh produce, limited access to varied foods, or specific medical conditions and medications that affect their vitamin C status. They are at increased risk of low vitamin C levels.

Mental Health Conditions: Individuals with severe mental health conditions, such as anorexia nervosa or severe depression, may neglect their nutritional needs, leading to inadequate vitamin C intake.

Cooking Methods: Vitamin C is heat-sensitive and water-soluble. Overcooking or prolonged boiling of fruits and vegetables can significantly reduce their vitamin C content.

The symptoms of vitamin C deficiency can develop gradually, typically appearing after several weeks or months of insufficient intake. They are primarily related to the impaired synthesis of collagen and the vitamin's role as an antioxidant. The severe form of the deficiency is known as scurvy symptoms, and these can be quite distinctive.

• General Weakness and Fatigue: One of the earliest and most common signs. You might feel unusually tired and lacking energy.
• Irritability and Depression: Mood changes can occur due to the vitamin's role in neurotransmitter synthesis and overall brain function.
• Muscle and Joint Aches: Often described as unexplained pain, particularly in the legs, due to weakened connective tissue.
• Easy Bruising: Blood vessels become fragile due to impaired collagen synthesis, leading to easy bruising even from minor bumps.
• Follicular Hyperkeratosis (Corkscrew Hairs): Hair follicles become plugged with keratin, and hairs may coil and break easily. This is a classic, though somewhat unusual, sign.
• Bleeding Gums and Swollen Gums: The gums may become red, swollen, spongy, and bleed easily, especially when brushing teeth. In severe cases, teeth can loosen or even fall out. This is a hallmark sign of scurvy.
• Poor Wound Healing: Wounds heal slowly or incompletely due to impaired collagen formation, which is vital for tissue repair. Old scars might even reopen.
• Petechiae and Purpura: Tiny red or purple spots (petechiae) or larger bruised areas (purpura) can appear on the skin, especially on the shins, due to fragile capillaries.
• Dry Skin and Hair: Skin can become rough, dry, and scaly, and hair may appear brittle.
• Anaemia: Vitamin C aids in iron absorption. A deficiency can lead to iron deficiency anaemia, compounding fatigue and pallor.
• Nosebleeds: Frequent nosebleeds can occur due to weakened blood vessels.
• Swollen and Painful Joints: Similar to muscle aches, joints can become swollen and painful due to compromised connective tissue.
• Weight Loss: Unexplained weight loss can occur in severe cases due to general malaise and reduced appetite.

Diagnosing vitamin C deficiency primarily relies on a combination of clinical assessment, dietary history, and specific blood tests.

Clinical Evaluation: Your doctor will conduct a thorough physical examination, looking for the characteristic signs of scurvy such as bleeding gums, easy bruising, skin changes (petechiae, corkscrew hairs), and poor wound healing. They will also inquire about your general well-being, including fatigue, muscle pain, and mood changes.

Dietary History: A detailed discussion about your typical eating habits is crucial. The doctor will ask about your consumption of fruits and vegetables, your cooking methods, and any restrictive diets you follow. This helps to identify potential dietary gaps.

Medical History: Information about any existing medical conditions (e.g., inflammatory bowel disease, kidney disease), recent surgeries, smoking habits, alcohol consumption, and medications is important, as these can affect vitamin C levels.

Blood Tests:

• Plasma Ascorbic Acid Level: This is the most direct method to measure vitamin C levels in the body. A low plasma ascorbic acid concentration confirms a deficiency. Levels below 0.2 mg/dL (11.4 µmol/L) are indicative of scurvy.
• Full Blood Count (FBC): This test can identify associated anaemia, which is common in vitamin C deficiency due to impaired iron absorption and potential bleeding.
• Inflammatory Markers: In some cases, inflammatory markers might be checked, as chronic inflammation can sometimes deplete vitamin C.
• Iron Studies: Since vitamin C deficiency can lead to iron deficiency, iron levels, ferritin (iron stores), and transferrin saturation might be assessed.

Treatment for vitamin C deficiency is generally straightforward and highly effective, involving the replenishment of the body's vitamin C stores.

Vitamin C Supplementation: The primary and most effective treatment is oral vitamin C (ascorbic acid) supplements (Brands: Limcee, New Celin). The dosage will depend on the severity of the deficiency.

• For established scurvy, high doses are typically administered initially, such as 100−200 mg three times a day for a week, followed by a daily dose until symptoms resolve.
• For milder deficiencies or ongoing maintenance, lower daily doses (e.g., 100 mg to 500 mg once daily) are often sufficient.
• In very rare cases of severe malabsorption or inability to take oral supplements, intravenous vitamin C might be considered, but this is uncommon.

Dietary Changes: Alongside supplementation, incorporating a diet rich in vitamin C-containing foods is crucial for long-term prevention and overall health. Emphasise fresh fruits and vegetables. Excellent sources include:

• Citrus fruits (oranges, grapefruits, lemons)
• Berries (strawberries, raspberries, blueberries)
• Kiwi fruit
• Bell peppers (especially red and yellow)
• Broccoli
• Tomatoes
• Potatoes
• Cabbage
• Spinach and other leafy greens
• Melons
• Cook these foods gently, as vitamin C is destroyed by excessive heat and prolonged cooking. Steaming or microwaving can help retain nutrient content.

Addressing Underlying Causes: If the deficiency is due to an underlying medical condition (e.g., malabsorption disorder, alcoholism), treating that condition is essential for preventing recurrence. Smokers will be advised to quit or significantly increase their vitamin C intake to compensate.

Monitoring: Your doctor may recommend follow-up appointments to monitor your progress and ensure your symptoms are resolving. Blood tests might be repeated to confirm that your vitamin C levels have normalised.

Management of Symptoms: While supplementation addresses the root cause, symptomatic relief might also be necessary. For instance, pain relief for joint aches, or dental care for gum problems.

Improvements are often rapid, with many symptoms beginning to resolve within days to weeks of starting treatment. Full recovery typically occurs over several weeks or months. It's important to complete the full course of treatment as advised by your doctor to fully replenish your body's stores.

• Limited intake of fresh fruits and vegetables.
• Chronic alcoholism.
• Smoking (cigarette smokers have higher vitamin C requirements).
• Malabsorption disorders (e.g., Crohn's disease, coeliac disease).
• Kidney dialysis.
• Elderly individuals, especially those with poor diets or limited mobility.
• Severe mental health conditions or eating disorders.
• Poverty and food insecurity.
• Restrictive diets without proper nutritional planning.
• Infants fed only pasteurised milk without vitamin C supplementation.

• Severe anaemia due to impaired iron absorption and internal bleeding.
• Widespread internal haemorrhages (bleeding into joints, muscles, internal organs).
• Dental problems, including tooth loss and severe gum disease.
• Impaired wound healing and reopening of old scars.
• Neuropathy (nerve damage) in severe, prolonged cases.
• Oedema (swelling) due to fluid retention.
• Cardiovascular problems due to weakened blood vessels.
• Increased susceptibility to infections due to impaired immune function.
• Growth retardation and bone abnormalities in children.
• In rare, severe cases, heart failure or death if left untreated.

While recovering from vitamin C deficiency, focus on these five practical tips:

• Prioritise Vitamin C Intake: Make a conscious effort to include high-vitamin C foods in every meal and stick to your prescribed supplements without fail.
• Gentle Cooking: Opt for raw, steamed, or lightly sautéed vegetables to preserve their vitamin C content, avoiding overboiling.
• Monitor Your Body: Pay close attention to your symptoms. Note any improvements or new issues and report them to your doctor during follow-up appointments.
• Hydration and Rest: Support your body's healing process by staying well-hydrated and ensuring you get sufficient rest, especially if you're experiencing fatigue.
• Address Underlying Issues: Work with your healthcare team to manage any underlying health conditions (e.g., malabsorption, alcoholism) that contributed to the deficiency, to prevent recurrence.

"Scurvy is a historical disease that no longer exists." 

While once prevalent among sailors, scurvy still occurs today, particularly in vulnerable populations with very poor diets, highlighting that it's not just a relic of the past.

"A single orange a day is enough to prevent deficiency." 

While oranges are a good source, relying on just one food item might not be sufficient. A varied diet rich in multiple vitamin C sources is best, especially for those with higher needs.

"Vitamin C supplements can cure colds." 

While vitamin C is important for immune function, high doses of supplements generally don't prevent colds. They might slightly reduce the duration or severity of cold symptoms in some individuals, but it's not a "cure."

It is advisable to see a doctor if you suspect you might have vitamin C deficiency, or if you experience any of the following symptoms:

• Persistent Fatigue and Weakness: Especially if accompanied by muscle or joint aches.
• Unexplained Bruising or Bleeding: Particularly bleeding gums, frequent nosebleeds, or easy bruising.
• Slow Wound Healing: If cuts or sores take an unusually long time to heal, or old scars reopen.
• Skin Changes: Such as very dry skin, rough patches, or red/purple spots (petechiae).
• If You Are in a High-Risk Group: Smokers, chronic alcohol users, individuals with severe mental health issues, or those with malabsorption disorders should seek medical advice if they experience any symptoms.
• Planning Pregnancy: Women planning to conceive should discuss their nutritional status, including vitamin C, with their doctor.

• Based on my symptoms and tests, what is the severity of my vitamin C deficiency?
• What specific dosage of vitamin C supplement do you recommend for me, and for how long?
• Are there any underlying medical conditions or lifestyle factors contributing to my deficiency that need addressing?
• What specific foods should I focus on to increase my dietary vitamin C intake? Can you provide resources for a vitamin C-rich diet?
• Are there any potential interactions between vitamin C supplements and other medications I am currently taking?
• How often will I need follow-up appointments or blood tests to monitor my recovery?
• What are the long-term health implications if my vitamin C levels are not adequately managed?

Vitamin C deficiency, encompassing conditions from mild depletion to scurvy, underscores the critical role this nutrient plays in our health. Its wide-ranging effects on connective tissue, immunity, and overall well-being highlight the importance of adequate intake. Thankfully, this deficiency is largely preventable and effectively treatable with vitamin C supplements and a diet rich in fruits and vegetables. By understanding the risk factors and recognizing the signs, individuals can take proactive steps. Timely intervention and consistent healthy habits ensure replenished vitamin C levels, mitigating the potential for serious health complications and supporting sustained health.