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Quick Lesson: Scurvy

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Quick Lesson: Scurvy QUICK Scurvy LESSON Description/Etiology Scurvy is a manifestation of prolonged deficiency of vitamin C (also called ascorbic acid), which is required for synthesis of collagen, dopamine, norepinephrine, and carnitine. The deficit of collagen formation in scurvy results in capillary fragility, poor wound healing, and bone abnormalities. If not diagnosed and treated, scurvy leads to serious complications and death. Diagnosis of scurvy is based on clinical presentation and laboratory tests confirming low vitamin C levels. Treatment for scurvy involves vitamin C supplements and eating a diet high in vitamin C–rich food to normalize deficient levels. With vitamin C supplementation, recovery occurs rapidly, sometimes within 1 week. Facts and Figures Daily vitamin C requirements are 45 mg for children, 90 mg for men, 75 mg for women, and up to 120 mg for breastfeeding women. Smokers require an additional 35 mg/day. Scurvy is extremely rare in developed nations. Rates of vitamin D deficiency range from 7.1% in the United States to 74% in north India. An estimated 40% of persons with low income have vitamin D deficiency. Most patients with vitamin C deficiency are clinically asymptomatic. Vitamin C deficiency must be present for 1–3 months for symptoms of scurvy to appear. The age groups most prone to scurvy in the U.S. are infants aged 6–12 months and older adults, both due to poor diet. Risk Factors Groups at elevated risk for scurvy are defined by life circumstances and health status. Circumstantial risk factors that limit access to vitamin C include engaging in combat or living through wartime, exploration of wilderness, refugee status, and poverty. Other life circumstances that elevate the risk of scurvy include older age, low income, homelessness, Authors and living alone. Health conditions that elevate risk for scurvy include alcoholism, drug Ricki A. Lewis, PhD dependency, psychiatric disorders, Crohn’s disease, Whipple disease (i.e., a malabsorption Cinahl Information Systems, Glendale, CA syndrome), celiac disease, iron overload disorders, AIDS-related anorexia, anorexia Tanja Schub, BS Cinahl Information Systems, Glendale, CA nervosa, chemotherapy-induced anorexia, diabetes mellitus, type 1 (DM1), and undergoing dialysis. Smokers are at elevated risk because smoking lowers absorption of vitamin C Reviewers and accelerates the vitamin’s metabolism, raising the requirement. Pregnant and lactating Darlene Strayer, RN, MBA women have higher vitamin C requirements. Infants who drink solely noncommercial Cinahl Information Systems, Glendale, CA formula or other preparations that have not been supplemented with vitamin C are at Gilberto Cabrera, MD elevated risk (commercial formula is supplemented, and breast milk contains vitamin C). Cinahl Information Systems, Glendale, CA Nursing Practice Council Older adults may be at increased risk for scurvy, likely due to low food intake. A diet Glendale Adventist Medical Center, of all junk food that is sustained for more than a month can cause scurvy. Children with Glendale, CA autism spectrum disorder often consume very limited diets, which may put them at risk of developing scurvy. Susceptibility to vitamin C deficiency is partially genetically determined; Editor individuals homozygous for the Hp2-2 allele of the haptoglobin gene, which encodes the Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems, Glendale, CA plasma protein haptoglobin, have lower vitamin C levels despite adequate dietary intake. July 9, 2021 Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2021, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206 Signs and Symptoms/Clinical Presentation Symptoms of scurvy appear after 1–3 months of inadequate vitamin C intake. Initial symptoms are weakness and lethargy. Shortness of breath and bone pain follows. Then other symptoms and conditions begin, including anemia, gingivitis, skin hemorrhage, pallor, partial immobility, tooth loss, bruising, poor wound healing, hair thinning or loss, joint pain, anorexia, diarrhea, fever, and depression. Late symptoms include jaundice, edema, oliguria, neuropathy, and convulsions. If affected individuals are not treated with vitamin C, death occurs, usually from heart failure. In infants, the skeletal system is affected, with development of many microfractures and deficient bone matrix. Nutritional Assessment › Patient Medical History • Obtain patient history including assessing for/asking about –patient and family history of certain conditions known to affect or be affected by scurvy (e.g., DM1, Crohn’s disease, Whipple disease, celiac disease, poverty, older age, alcoholism) –signs and symptoms (e.g., anorexia, diarrhea, fever, depression), if any, that can indicate inadequate nutrient consumption, and can negatively affect dietary intake –level and type of regular physical activity › Physical Findings of Particular Interest • Bruises, wounds, bleeding gums, and recent tooth loss may be present (for more information on physical findings, see Signs and Symptoms/Clinical Presentation, above) › Patient Dietary History • A 24-hour dietary recall can be used to assess individual usual intake. Evaluate usual nutrition intake by asking the patient to complete a 24-hour dietary recall identifying foods generally consumed and food preferences and cultural/religious believes and medically prescribed dietary interventions –In the outpatient setting a 24-hour dietary recall when combined with a three-day diet history may be useful tools for evaluating the patient’s dietary strengths and weaknesses (i.e., patient recall of all foods and beverages consumed in a 3-day periodthat includes 1 weekend day) • Ask aboutpersonal habits, including alcohol, caffeine, and soda consumption; tobacco use; eating at night; and frequenting vending machines or fast food and use of any herbal or over the counter supplements (e.g., fish oil caps, cranberry caps, ginger, etc.) as well as prescription medications › Anthropometric Data and Calculations • Calculate the patient’s body mass index (BMI) by dividing body weight (kilograms) by height (meters squared); or 703 multiplied by weight (pounds) and divided by height (inches squared) –Underweight: less than 18.5 kg/m2; normal: 18.5–24.9 kg/m2 ; overweight: 25–29.9 kg/m2; obese: 30 kg/m2 or higher –In patients over 65 years of age, a slightly higher BMI (25–27 kg/m2) may help prevent bone deterioration and is associated with a lower risk of mortality –In some cases, body composition testing (e.g., dual-energyx-ray absorptiometry scan, skin calipers) may be necessary –The Centers for Disease Control and Prevention (CDC) has established references for weight and growth patterns, which can be trackedon weight-for-age/height-for-age/weight-for-height age-basedgrowth charts, as well as BMI for age charts which assist in the calculation of BMI for ages 2–20 years • Significant undesirable weight changes are as follows: +/- 5% during a 30-day period or +/- 10% during a 180-day period –Weight loss of 10–20% in a 180-day period indicates moderate protein-calorie malnutrition –Weight loss of greater than 20% in 180-day period indicates severe protein-calorie malnutrition –Fluid retention can impact weight variables and should be taken into account when considering the significance of weight changes • Estimate daily energy requirements in calories (kcal)by calculating the resting metabolic rate (RMR), also called basal energy expenditure (BEE), by use of theHarris-Benedict equation (for individuals with a BMI < 30 kg/m2) or the Mifflin-St.Jeor equation (for obese individuals), multiplied by the appropriate activity factors (AFs) and injury factors (IFs) as shown below –Lb/kg and in/cm conversion: 1 lb = 2.2 kg; 1 in = 2.54 cm –Harris-Benedict equation (for individuals with a BMI less than or equal to30 kg/m2): - Men: RMR = 66 + 13.8(weight in kg) + 5.0(height in cm) – (6.8 x age) - Women:RMR = 655 + 9.6(weight in kg) + 1.8(height in cm) – (4.7 x age) –Mifflin-St. Jeor Equation (for individuals with a BMI above 30 kg/m2): - Men: RMR = 10 x (weight in kg) + 6.25 x (height in cm) x age + 5 - Women: RMR = 10 X (weight in kg) + 6.25 x (height in cm) – 5 x age – 161 –Daily kcal requirement = RMR x AF x IF - AF: Confined to bed: 1.2; moderately active: 1.3; active: 1.4 - IF: Minor surgery: 1.2; skeletal trauma: 1.3; major sepsis: 1.6; severe burn: 2.1 • To encourage weight gain or loss (of 1–2 lbs/week), add or subtract 500 kcal/day respectively and monitor for weight changes › Laboratory Tests and Diagnostic Tests of Particular Interest to the Nutritionist • CBC may show anemia • Fasting serum ascorbic acid less than 0.1 mg/dL confirms the scurvy diagnosis • Leukocyte ascorbic acid concentration less than 7 mg/dL indicates vitamin C deficiency › Other Diagnostic Tests/Studies • X-rays of knee joints, wrist, and sternal ends of bones may indicate changes consistent with scurvy • Capillary fragility may be assessed by inflating a blood pressure cuff on the arm and
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