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 evaluating for the development of petechiae • MRI may reveal focal areas of hemorrhage or small infarcts in the bone marrow
Treatment Goals › Normalize Deficient Levels and Reduce Risk for Complications • Review results of laboratory tests and diagnostic studies related to nutritional status and evaluate for deficiencies in nutrition; report findings to the treating clinician • Clinician may prescribe oral or parenteral vitamin C or orange juice as treatment for vitamin C deficiency –Vitamin C 250 mg 4 times daily for 1 week is usually prescribed • Clinician may prescribe iron supplements if anemia is present –For information on other dietary supplements, see Food for Thought, below • Monitor weight fluctuation and encourage weight management; request clinician referral to physical/occupational therapy for evaluation and formulation of an individualized program involving regular, gentle activity to decrease pain, if present, and improve functional status and independence in ADLs › Provide Emotional/Psychosocial Support and Educate • Review diet history information to assess dietary intake and pattern sand provide detailed patient education regarding importance of following a calorie-appropriate and nutrient-dense diet; the effect of diet, exercise, and other lifestyle factors on nutritional status, weight, and related medical conditions; and strategies for meal planning, grocery shopping, and food preparation. (For more information, see What Do I Need to Tell the Patient/Patient’s Family? and Discharge Planning, below) • Assess patient’s anxiety level and coping ability; provide emotional support, educate, and encourage discussion of concerns with the diagnosis, symptoms, potential complications, treatment risks and benefits, and individualized prognosis; if appropriate, request referral to a social worker for identification of local resources for low-cost vitamin C supplements and groceries, subsidized dental care, and smoking cessation programs • Reassure patients and family members that taking vitamin C supplements and changing dietary intake to include foods high in vitamin C will quickly improve scurvy symptoms and prevent subsequent vitamin C deficiency
Food for Thought › Humans and other primates, guinea pigs, and Indian fruit bats are the only mammals that require dietary intake of vitamin C; other species synthesize it from glucose › The Egyptians recorded the first known descriptions of scurvy in 1550 BC. Hippocrates described it as follows: “the mouth feels bad; the gums are detached from the teeth; blood runs from nostrils… ulcerations on the legs; some of these heal… skin is thin.” The link between scurvy and diet is traced to John Woodall, the surgeon general of the East India Company in 1614, and to James Lind, a British naval surgeon in 1753 › British sailors became known as “limeys” for eating limes to prevent scurvy, and German soldiers as “krauts” because they ate sauerkraut for the same reason Red Flags › Bleeding into the femur and tibia can be very painful in patients with scurvy › A scorbutic tongue is an inflamed tongue that results from vitamin C deficiency › Pasteurization destroys vitamin C › Hair follicles can be the site of pinpoint bleeding, and tiny spring-likecorkscrew curls in body hair can occur in scurvy
What Do I Need to Tell the Patient/Patient’s Family? › Recovery is rapid once vitamin C has been provided, often within 1 week › Smoking cessation will speed recovery and help increase ongoing absorption of vitamin C › Include sources of vitamin C–rich fruits and vegetables at every meal, including citrus fruits, broccoli, berries, cantaloupe, cauliflower, cabbage, spinach, potatoes, and tomatoes › Eat a calorie-appropriate diet that includes fish and other lean proteins, unsaturated fats (including omega-3 fatty acids), complex carbohydrates (e.g., whole, unrefined grains), legumes, nuts and seeds, and a variety of fruits and vegetables (For more information on eating a balanced diet, see the USDA food guidance system, MyPlate at https://www.myplate.gov) • Drink adequate water to support hydration and prevent or relieve constipation (if medically appropriate) • Refrain from consuming sugar-sweetened beverages • Educate about dietary strategies for optimal health, including the following: –Consume meals containing a variety of at least 5 fruits and vegetables a day in order to supply ample vitamins, minerals, phytonutrients (i.e., beneficial plant-derivednutrients), and fiber. Eating a variety of deeplycolored fruits and vegetables (e.g., spinach, carrots, berries) should be emphasized - Include sources of vitamin C–rich fruits and vegetables at every meal, including citrus fruits, broccoli, berries, cantaloupe, cauliflower, cabbage, spinach, potatoes, and tomatoes –Eat 25–30 g of fiber/day (food sources: oat bran, barley, nuts, seeds, beans, lentils, peas, and fruits and vegetables). At least half of all grains consumed should be whole grains –Ingest adequate calcium (at least 1,200 mg/day) to reduce risk for osteoporosis and cardiovascular disease (CVD); good calcium sources are dairy products, fish with bones, broccoli, and legumes –Consume fish, especially oily fish, at least twice a week. Fish is a great source of omega-3, an unsaturated fat that has many health benefits, including reduced risk for CVD. Omega-3 can also be obtained in lesser amounts from plant sources (e.g., soybean, walnuts, canola, and flaxseed) –Reduce risk for CVD, cancer, DM2, and stroke by choosing unsaturated fats (including omega-3 fatty acid) and by limiting total fat intake to 20–35% of daily calories, and limiting saturated fat(found in meat, whole milk, cream, butter, and cheese) to less than 10% of daily calories › Emphasize importance of portion size › Take supplemental vitamins as prescribed › Participate in regular moderate physical activity of at least 150 minutes each week, including strength training at least 2 days each week, if medically appropriate › Recruit the help of family and friends to assist in meal planning, grocery shopping, and food preparation
Discharge Planning › Follow a calorie-appropriate, nutritious diet, and follow strategies for weight management as advised in What Do I Need to Tell the Patient/Patient’s Family, above. › Participate in regular screening for scurvy and other nutrient deficiencies (e.g., iron) to reduce the risk of future malnutrition and related health complications
Related Guidelines › For guidelines on determining nutrient needs see Nutritional Assessment and Treatment Goals, above
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