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.”

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.”
  • “Excessive consumption of alcohol or use of certain substances.” 2 
  • “Illnesses such as anorexia and other mental health issues.”
  • “Restrictive diets due to allergies, difficulty orally ingesting foods, or other reasons.”
  • Conditions or “treatments that reduce the body’s ability to absorb nutrients”, such as Crohn’s disease, ulcerative colitis, and chemotherapy.

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”.
  • Body Aches – “Primarily felt in the joints, but can be similar to body aches from the flu.”
  • 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.”
  • 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.

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 

News and Media 

Key Words

Searched on Google, Google NewsGoogle Scholar, and PubMed, with search terms:

Scurvy (Google Scholar) 

Scurvy (Google News) 

Scurvy (PubMed, Filter for 2013-2023) 

Antiscorbutic foods 

Scurvy + News 

Scurvy + History 

Scurvy + Treatment

Scurvy + Symptoms 

Scurvy + Trial

James Lind 

Historical Treatment of Scurvy 

Scurvy + Vitamin C 

Scurvy + Today 

Scurvy + Developing countries 

Scurvy + Developed countries 

History of Limeys

Foods Rich in Vitamin C

Vitamin C +  Deficiency 

References 

  1. McIntosh, J. (n.d.). Collagen: What is it and what are its uses?. Medical News Today. https://www.medicalnewstoday.com/ articles/262881 
  2. Crosta , P. (2023, February 6). Scurvy: Symptoms, causes, treatment, and prevention. Medical News Today. https://www.medicalnewstoday.com/articles/155758 
  3. Rowe S, Carr AC. Global Vitamin C Status and Prevalence of Deficiency: A Cause for Concern? Nutrients. 2020; 12(7):2008. https://doi.org/10.3390/nu12072008 
  4. Schectman G, Byrd JC, Gruchow HW. The influence of smoking on vitamin C status in adults. Am J Public Health. 1989;79(2):158-162. doi:10.2105/ajph.79.2.158 
  5. Beard T. What to Know About Scurvy. WebMD. April 26, 2022. https://www.webmd.com/skin-problems-and-treatments/what-to-know-scurvy#:~:text=Scurvy%20is%20a%20progressive%20disease,to%20get%20out%20of%20bed.  
  6. Philip K. Finding the cure for scurvy. Naval History Magazine. U.S. Naval Institute. August 29, 2022. Accessed July 31, 2023. https://www.usni.org /magazines/naval-history-magazine/2021/february/finding-cure-scurvy. 
  7. Price C. The age of scurvy. Science History Institute. Distillations Magazine. May 31, 2023. https://sciencehistory.org/stories/magazine /the-age-of-scurvy/#:~:text=According%20to%20historian%20Stephen%20Bown,determining%20the%20destiny%20of%20nations.%E2%80%9D. 
  8. Emmanuil Magiorkinis, Apostolos Beloukas, Aristidis Diamantis, Scurvy: Past, present and future. European Journal of Internal Medicine. Volume 22, Issue 2, 2011. https://doi.org/10.1016/j.ejim.2010.10.006. 
  9. Barton D. The history of Vitamin C and scurvy. Nutrivitality. April 1, 2021. https://www.nutrivitality.com/health-blog/history-vitamin-c-scurvy/ 
  10. Kumaravel Rajakumar; Infantile Scurvy: A Historical Perspective. Pediatrics October 2001; 108 (4): e76. 10.1542/peds.108.4.e76
  11.  Sousa G de, Tapada JP. História Da Medicina Portuguesa Durante A Expansão. Temas e Debates; 2013. 
  12. González AR. Expediciones Científicas Españolas Del Siglo XVIII. Edaf; 2023. 
  13.  Kerr G. Timeline of Britain. Canary; 2008. 
  14.  Argensola, Bartolomé Leonardo de. Conquista de las Islas Malucas. 1609. Cervantes en la BNE. Biblioteca National de Espana. http://cervantes.bne.es/es/su-biblioteca/conquista-islas-malucas2. 
  15.  D. McDonald, Lt.-Colonel, Dr. John Woodall and his treatment of the scurvy, Transactions of The Royal Society of Tropical Medicine and Hygiene, Volume 48, Issue 4, July 1954, Pages 360–365, https://doi.org/10.1016/0035-9203(54)90111-X 
  16.  Dresen E, Lee ZY, Hill A, Notz Q, Patel JJ, Stoppe C. History of scurvy and use of vitamin C in critical illness: A narrative review. Nutr Clin Pract. 2023;38(1):46-54. doi:10.1002/ncp.10914 
  17. Zita Weise Prinzo. SCURVY and its prevention and control in major emergencies. https://apps.who.int/iris/bitstream/handle/10665/66962/ ;jsessionid=5E4B8BED8C9C5364819035B388DCF028?sequence=1. Nov, 1999. 
  18.  Durzan DJ. Arginine, scurvy and Cartier’s “tree of life”. J Ethnobiol Ethnomed. 2009;5:5. Published 2009 Feb 2. doi:10.1186/1746-4269-5-5
  19.  Whitney S. Western Forests. Knopf; 2010. 
  20.  Norum KR, Grav HJ. Axel Holst og Theodor Frølich–pionerer i bekjempelsen av skjørbuk [Axel Holst and Theodor Frolich–pioneers in the combat of scurvy]. Tidsskr Nor Laegeforen. 2002;122(17):1686-1687. 
  21.  The Nobel Prize and the discovery of vitamins. NobelPrize.org. Nobel Prize Outreach AB 2023. 22 June 2004 https://www.nobelprize.org/prizes/themes/the-nobel-prize -and-the-discovery-of-vitamins
  22. Carpenter KJ. The discovery of vitamin C. Ann Nutr Metab. 2012;61(3):259-264. doi:10.1159/000343121
  23.  Sir Norman Haworth and his work on Vitamin C. Scientifixs. November 3, 2022. Accessed July 31, 2023. https://www.scientifixs.com/sir-norman-haworth -and-his-work-on-vitamin-c/. 
  24.  Léger D. Scurvy: reemergence of nutritional deficiencies. Can Fam Physician. 2008;54(10):1403-1406.
  25.  Fortenberry M, Rucker H, Gaines K. Pediatric Scurvy: How an Old Disease Is Becoming a New Problem. J Pediatr Pharmacol Ther. 2020;25(8):735-741. doi:10.5863/1551-6776-25.8.735
  26. Ngan V. Scurvy. DermNet. August 2021. https://dermnetnz.org/topics/scurvy.  
  27. Callus CA, Vella S, Ferry P. Scurvy is Back. Nutr Metab Insights. 2018;11:1178638818809097. Published 2018 Nov 21. doi:10.1177/1178638818809097 
  28. Giannakourou MC, Taoukis PS. Effect of Alternative Preservation Steps and Storage on Vitamin C Stability in Fruit and Vegetable Products: Critical Review and Kinetic Modelling Approaches. Foods. 2021;10(11):2630. Published 2021 Oct 29. doi:10.3390/foods10112630 
  29. Chadare FJ, Idohou R, Nago E, et al. Conventional and food-to-food fortification: An appraisal of past practices and lessons learned. Food Sci Nutr. 2019;7(9):2781-2795. Published 2019 Aug 5. doi:10.1002/fsn3.1133
  30. Gregis A, Ghisalberti C, Sciascia S, Sottile F, Peano C. Community Garden Initiatives Addressing Health and Well-Being Outcomes: A Systematic Review of Infodemiology Aspects, Outcomes, and Target Populations. Int J Environ Res Public Health. 2021;18(4):1943. Published 2021 Feb 17. doi:10.3390/ijerph18041943
  31. Idiom origins – limey – history of Limey. Origins of Idioms Archive. Accessed July 31, 2023. https://idiomorigins.org/origin/limey. 
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