Advancing the Integration of Food as Medicine in Modern Healthcare Using Proof from the Past
What is Scurvy?
“A disease caused by prolonged severe dietary deficiency of ascorbic acid, in which the breakdown of intercellular cement substances leads to capillary hemorrhages and defective growth of fibroblasts, osteoblasts, and odontoblasts results in impaired synthesis of collagen, osteoid, and dentine; it is characterized by haemorrhagic gingivitis affecting especially the interdental papillae (in the absence of teeth, the gums are normal), subperiosteal hemorrhages, bone lesions (including the corner fraction sign, a ground-glass appearance, and trabecular atrophy) seen on radiography, perifollicular hemorrhages, and frequently petechial hemorrhages (especially on the feet).” – World Health Organization
“An illness of the body tissues that is caused by not having enough vitamin C” – Cambridge Dictionary
“Scurvy is a disease that results from a vitamin C deficiency. It can lead to anemia, exhaustion, spontaneous bleeding, limb pain, swelling, and sometimes ulceration of the gums and loss of teeth.” – MedicalNewsToday
“Vitamin C deficiency, also known as scurvy, is a disease primarily associated with socioeconomic status and access to food.” – Maxfield
Role of Vitamin C
This is because vitamin C is”‘necessary to make collagen, an important component in connective tissues.” 1 Connective tissues are “essential for structure and support in the body, including the structure of blood vessels.” 2 A “lack of vitamin C will also affect the immune system, iron absorption, cholesterol metabolism, and other functions.” 3
Causes & Risk Factors
Scurvy is caused by not having enough vitamin C in your diet “for at least 3 months”. 2 Several risk factors that can contribute to the development of scurvy:
- An “inadequate diet lacking in fresh fruits and vegetables, possibly due to low income or famine.” 2
- Smoking “reduces the amount of vitamin C your body absorbs from food.” 4
- “Excessive consumption of alcohol or use of certain substances.” 2
- “Illnesses such as anorexia and other mental health issues.” 2
- “Restrictive diets due to allergies, difficulty orally ingesting foods, or other reasons.” 2
- Conditions or “treatments that reduce the body’s ability to absorb nutrients”, such as Crohn’s disease, ulcerative colitis, and chemotherapy. 2
Symptoms
Scurvy is a “progressive disease; the longer it’s left untreated, the more symptoms you’ll experience.” 5 Some of the most common symptoms include:
- Lethargy – It’s “usually the first symptom to appear. It includes feeling very tired, weak, irritable, and depressed”. 5
- Body Aches – “Primarily felt in the joints, but can be similar to body aches from the flu.” 5
- Swelling – “Noticeable swelling in the arms and legs.” 5
- Oral Problems – “Gums turn spongy and porous. Your breath will smell rotten, and your teeth may start to loosen in their sockets.” 5
- Wounds Reopening – “Poor wound healing and re-opening of old healed scars due to low levels of collagen in the body.” 5
- Easily Bruised Skin or Bleeding Under the Skin (purpura) 5
- Shortness of Breath 5
- Death – “Likely due to a hemorrhage near [the] heart or brain.” 5
History
It has been estimated the disease killed more than “2 million sailors between the 16th and 18th centuries.” 6 Vasco da Gama lost “116 of 170 men on his first voyage to India in 1499, almost all to scurvy while Commodore George Anson returned from a four-year circumnavigation in 1744 with only 188 of the 1,854 men he had departed with, most losses because of scurvy.” 6 According to historian Stephen Bown, “scurvy was responsible for more deaths at sea than storms, shipwrecks, combat, and all other diseases combined.” 7
Early Observations
Scurvy has been known since ancient Greek and Egyptian times, with the “first observations on scurvy first appearing in Egyptian medical scrolls 3500 years ago”. 8 The disease continued to be “alluded to in many historical texts from Hippocrates in the 5th century all the way to the Crusades, where the first comprehensive description of the disease was recorded”. 9 Despite its recognition, its causes were largely unknown. The lethargy caused by scurvy was “so intense that people once believed that laziness was the cause of the disease.” 5 Moreover, the fact that other mammals can synthesize vitamin C, and therefore cats and dogs on ships remained healthy despite eating no fruit or vegetables, “seemed to point away from diet as scurvy’s cause”. 6
When was Scurvy discovered?
1847
Who is attributed with connecting the disease or deficiency to food as medicine?
James Lind
Discovery of its connection to nutrition
Throughout the early 20th century, the understanding that consuming foods rich in vitamin C could effectively treat scurvy underwent a cycle of frequent neglect and rediscovery.
- “In the 1497 expedition of Vasco da Gama, the curative effects of citrus fruit were already known and confirmed by Pedro Álvares Cabral and his crew in 1507.” 10
- “In 1500, one of the pilots of Cabral’s fleet bound for India noted that in Malindi, its king offered the expedition fresh supplies such as lambs, chickens, and ducks, along with lemons and oranges, due to which “some of our ill were cured of scurvy.” 11
- In 1579, the Spanish friar and physician Agustin Farfán published a book in which he “recommended oranges and lemons” for scurvy. 12
- “In 1593, Admiral Sir Richard Hawkins advocated drinking orange and lemon juice as a means of preventing scurvy.” 13
- A 1609 book by Bartolomé Leonardo de Argensola recorded a number of different remedies for scurvy known at this time in the Moluccas, including a kind of wine mixed with cloves and ginger, and ‘certain herbs.’14
- The “restorative effects of fresh fruit and vegetables were first published in 1636” by John Woodall 15
In 1747, an “important milestone in the history of clinical research was set, as the Scottish surgeon James Lind conducted the first randomized controlled trial of 12 sailors.” 16 He formally demonstrated that a “dietary intervention with oranges and lemons, rich in vitamin C, was effective in recovering from scurvy.” 16 However, Lind was “still wedded to the established humor-based view of health and tried to shoehorn his findings into it.” 6 The result of his studies was published in 1753 —A Treatise on the Scurvy—in which “only a few paragraphs were devoted to his shipboard experiment”, and “poor diet was identified as just one of several causes”. 6
Food as Medicine – Historical approaches to treating the disease
Throughout history, various foods have been employed to treat scurvy, a debilitating disease caused by vitamin C deficiency. As early as the 11th century, “seafarers were advised to carry a range of fruits and vegetables such as apples, pears, pomegranates, cucumbers, citrons, lemons, muscats, and pickled vegetables as preventive measures against scurvy.” 17 Early explorers in North America also noticed that Native Americans, “confined to a diet of dried meat during the winter, supplemented their diets with tea made from pine needles and scurvy grass”. 6 Following these observations, several European countries experimented with “preparations of various conifers, such as spruce beer, as cures” for scurvy. 18
By the end of the 18th century, sprouted beans and beer were recommended as antiscorbutics, though both proved to be of minimal value after processing (e.g., dried, powdered, boiled). 17 In “the 19th century, Native Americans helped save some newcomers from scurvy by directing them to eat wild onions.” 18 Then, Following Lind’s discovery that citrus juice cured the disease, “three-quarters of an ounce of lemon juice per day was mandated to be given to every sailor serving throughout the Royal Navy,” essentially eradicating scurvy. 5
Food as Medicine – Antiscorbutic foods
Source: Vitamin C – Health Professional Fact Sheet
The U.S. Department of Agriculture’s (USDA’s) FoodData Central lists the nutrient content of many foods and provides a comprehensive list of foods containing vitamin C arranged by nutrient content and by food name.
Vitamin C Content Database: USDA National Nutrient Database for Standard Reference Release 28
Contemporary Understanding
The contemporary understanding of scurvy started to emerge in the 20th century. In 1907, Holst and Frølich found they could “cure scurvy in guinea pigs with the addition of fresh foods and extracts.” 20 Then, in 1927, Hungarian biochemist Albert Szent-Györgyi isolated a compound he called “hexuronic acid,” which he suspected to be the “antiscorbutic agent”, but he could not prove it. 21 In 1932,” the connection between hexuronic acid and scurvy was finally proven by American researcher Charles Glen King”. 22 Finally, everything became clear in 1933 when Norman Haworth showed that “vitamin C is fundamental for our body, and since the human body is not able to produce it, vitamin C has to be obtained through the diet.” 23
Modern Medical Intervention
Treatment involves administering vitamin C supplements.
The recommended dosages are :
Adults: “1 to 2 grams of vitamin C be administered daily for the first 2 to 3 days, followed by 500 mg per day for the next week. Afterward, a daily intake of 100 mg of vitamin C should be given for 1 to 3 months.” 24
Children: “100 mg 3 times daily for at least one week, followed by 100 mg daily until symptoms have resolved.” 25
Within “24-72 hours, people can expect to see an improvement in fatigue, lethargy, pain, anorexia, and confusion”. 26 Meanwhile, “full recovery can be expected in 1-3 months.” 26
Scurvy Today
Modern cases of scurvy are “rare in the United States or Europe due to the wider availability of fresh fruits and vegetables.” 3 However, it can still occur in “economically exploited regions and some low or middle-income countries.” 27 For example, “in developing countries such as northern India, the incidence can be as high as 73.9% due to limited access to Vitamin C-rich fruit and vegetables.” 26
Public Health Interventions
As understanding of the relationship between vitamin C deficiency and scurvy deepened, public health efforts expanded to address the broader population, including:
- The development of methods to preserve citrus fruits, such as canning and drying, ensured a longer shelf life and broader access to vitamin C-rich foods, even in regions where fresh produce was scarce. 28
- Nutritional education and awareness campaigns.
- Food Fortification Programs – In regions where access to fresh fruits and vegetables is limited, food fortification programs have been implemented to address micronutrient deficiencies, including vitamin C. 29
- Community-based Nutrition Interventions – Local health authorities and NGOs often collaborate to establish community-based nutrition interventions that focus on promoting healthy eating habits and providing vitamin C-rich foods to at-risk populations. These initiatives include the distribution of fresh produce or support for community gardens. 30
Anecdote- Inuit Diets
Inuit’s Puzzling Diets
“One puzzle for 19th century students of scurvy, who believed in the special properties of fresh fruits and vegetables, was that despite lack of access to these foods Inuits normally remained scurvy free. Inuits eat large quantities of meat and fish in a raw, or only slightly cooked, state. A considerable amount of vitamin C is thereby contributed to the diet even if the average con-centration is relatively low (see annex for the vitamin C content of some traditional Inuit diets). Inuits have been reported to eat the raw liver of both seals and caribou, and even a small amount of such organ meat would satisfy a day’s requirement for the vitamin.” 17
Why do Americans Call the British Limeys? Scurvy!
“Limey is a US slang for British person since the late 18th century and is an abbreviation of lime-juicer, which dates from the 1850’s. Originally, the term referred specifically to British sailors because of their enforced habit (since 1795) of drinking lime juice to prevent scurvy… By that time, the Americans, and indeed sailors everywhere, followed suit and adopted well-established rules. Thus, for Americans, Brits have retained limeys ever since.” 31
Research Studies
- When the limp has a dietary cause: A retrospective study on scurvy in a tertiary Italian pediatric hospital (Frontiers, 2022)
- Relationship between Vitamin C Deficiency and Cognitive Impairment in Older Hospitalized Patients: A Cross-Sectional Study (National Library of Medicine, 2022)
- Vitamin C and scar strength: analysis of a historical trial and implications for collagen-related pathologies (National Library of Medicine, 2022)
- Scurvy in the Intensive Care Unit (Sage Journals, 2021)
- Vitamin C in Human Health and Disease (National Library of Medicine, 2021)
- Scurvy, Starvation, and Flea Infestation – A Case Report From 21st Century Europe – PMC (National Library of Medicine, 2021)
- The Neuropsychiatry of Scurvy (Science Direct, 2021)
- Pediatric Scurvy: How an Old Disease Is Becoming a New Problem – PMC (National Library of Medicine, 2021)
- Scurvy: A New Old Cause of Skeletal Pain in Young Children (Frontiers, 2020)
- Clinical Profile of Scurvy in Hamilton Since 2009: a Cohort Study (National Library of Medicine, 2020)
- The risk for scurvy in children with neurodevelopmental disorders (Wiley Online Library, 2020)
- Global Vitamin C Status and Prevalence of Deficiency: A Cause for Concern? (National Library of Medicine, 2020)
- Scurvy may occur even in children with no underlying risk factors: a case report (BMC, 2020)
- Adult scurvy associated with psychiatric disorders and breastfeeding (BMJ Journals, 2018)
- Scurvy in 2017 in the USA (National Library of Medicine, 2018)
- Modern American scurvy — experience with vitamin C deficiency at a large children’s hospital (Springer Link, 2016)
- Brief Report: Scurvy as a Manifestation of Food Selectivity in Children with Autism (Springer Link, 2015)
- MRI findings in pediatric patients with scurvy (Springer Link, 2014)
News and Media
- It took centuries (and vitamins) for doctors to finally stop scurvy (Popular Science, 2023)
- 15 Signs and Symptoms of Vitamin C Deficiency (Healthline, 2023)
- Malnutrition, scurvy and rickets – the shameful truth about child health in 2023 (The Independent, 2023)
- The History of Nutrition in Healing as Related to Scurvy (WoundSource, 2022)
- The 11 Best Vitamin C Supplements – Nutrition (Healthline, 2022)
- The British ‘Limeys’ Were Right: A Short History of Scurvy (Health.mil, 2022)
- Cases of scurvy have ‘more than doubled’ in the UK – warning signs (Express, 2022)
- Ask the Dentist: Vitamin C essential for health of teeth and gums (The Irish News, 2022)
- New analysis of landmark scurvy study leads to update on vitamin C needs (UW News, 2021)
- Scurvy is still found in Canada (News Medical Life Sciences, 2020)
- Hamiltonians are developing scurvy, study shows — particularly the most vulnerable | (CBC News, 2020)
- Am I Getting Enough Vitamin C? Signs of Scurvy, Screening for Deficiency, and More (Everyday Health, 2020)
- Scurvy: is it really making a comeback in the UK? (The Conversation, 2019)
- Explainer: what is scurvy and is it making a comeback? (The Conversation, 2019)
- How to prevent Vitamin C deficiency (The Times of India, 2019)
- Ahoy, Scurvy Awareness! – UF Health (University of Florida Health, 2019)
- Scurvy: Forgotten diagnosis helps ‘paralyzed’ child become mobile | Mumbai News (The Times of India, 2018)
- James Lind: The man who helped to cure scurvy with lemons (BBC, 2016)
- Scurvy: The Disease of the Enlightenment – WSJ (Wall Street Journal, 2016)
- Poor diet sees scurvy reappear in Australia (Medical Xpress, 2016)
- The Return of Scurvy? Houston Neurologist Diagnoses Hundreds of Patients with Vitamin Deficiencies (Houston Public Media, 2016)
- Rare Case of Scurvy in Infant Highlights Potential Dangers of Plant-Based Diet (ABC News, 2016)
- Is scurvy making a comeback? (BBC, 2016)
- NASA HRP: An Orange a Day Keeps Scurvy Away (NASA, 2015)
- Not just pirates anymore: Scurvy afflicts the poor and homeless (STAT, 2015)
Key Words
Searched on Google, Google News, Google Scholar, and PubMed, with search terms:
Scurvy (Google Scholar)
Scurvy (Google News)
Scurvy (PubMed, Filter for 2013-2023)
Historical Treatment of Scurvy
References
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