Determination of plasma and leukocyte vitamin C concentrations in a randomized, double-blind, placebo-controlled trial with Ester-C(®)

Micronutrient status in children aged 6-59 months with severe wasting and/or nutritional edema: implications for nutritional rehabilitation formulations

Undernutrition remains a global struggle and is associated with almost 45% of deaths in children younger than 5 years. Despite advances in management of severe wasting (though less so for nutritional edema), full and sustained recovery remains elusive. Children with severe wasting and/or nutritional edema (also commonly referred to as severe acute malnutrition and part of the umbrella term "severe malnutrition") continue to have a high mortality rate. This suggests a likely multifactorial etiology that may include micronutrient deficiency. Micronutrients are currently provided in therapeutic foods at levels based on expert opinion, with few supportive studies of high quality having been conducted. This narrative review looks at the knowledge base on micronutrient deficiencies in children aged 6-59 months who have severe wasting and/or nutritional edema, in addition to highlighting areas where further research is warranted (See "Future Directions" section).

Reversible right-sided heart failure and pulmonary hypertension caused by scurvy in a 7-year-old boy with autism spectrum disorder and a review of the literature

Scurvy, a condition caused by vitamin C deficiency, is rare, especially in high-income countries. Symptoms of scurvy are typically characterised by dermatological disorders such as poor wound healing and tooth loss, but there is not usually cardiac involvement. A case of reversible pulmonary hypertension and right-sided heart failure owing to scurvy in a 7-year-old boy with autism spectrum disorder is reported. He had a very restricted diet and presented with polyarthralgia, gingival hyperplasia with ecchymosis, and fatigue. His condition, including pulmonary hypertension and right-sided heart failure, completely resolved with vitamin C supplementation. Paediatricians should have a high index of suspicion for scurvy in children with nutritional selectivity and be aware that it can manifest with cardiac symptoms. Scurvy may be life-threatening if not treated, but the symptoms can improve rapidly with vitamin C supplementation.

Abdominal Ecchymosis: Emergency, or Urgen-C?

Scurvy is a multisystem disease caused by vitamin C deficiency, historically associated with lethargy, gingivitis, ecchymosis, edema, and death if left untreated. Contemporary socioeconomic risk factors for scurvy include smoking, alcohol abuse, fad diets, mental health conditions, social isolation, and economic marginalization. Food insecurity is also a risk factor. This report describes a case of a man in his 70s who presented with unexplained dyspnea, abdominal pain, and abdominal ecchymosis. His plasma vitamin C level was undetectable, and he improved with vitamin C supplementation. This case highlights the significance of awareness of these risk factors and emphasizes the need for a comprehensive social and dietary history to enable the timely treatment of this rare but potentially fatal disease.

Gene expression profiling in Rosa roxburghii fruit and overexpressing RrGGP2 in tobacco and tomato indicates the key control point of AsA biosynthesis

Rosa roxburghii Tratt. is an important commercial horticultural crop endemic to China, which is recognized for its extremely high content of L-ascorbic acid (AsA). To understand the mechanisms underlying AsA overproduction in fruit of R. roxburghii, content levels, accumulation rate, and the expression of genes putatively in the biosynthesis of AsA during fruit development have been characterized. The content of AsA increased with fruit weight during development, and AsA accumulation rate was found to be highest between 60 and 90 days after anthesis (DAA), with approximately 60% of the total amount being accumulated during this period. In vitro incubating analysis of 70DAA fruit flesh tissues confirmed that AsA was synthesized mainly via the L-galactose pathway although L-Gulono-1, 4-lactone was also an effective precursor elevating AsA biosynthesis. Furthermore, in transcript level, AsA content was significantly associated with GDP-L-galactose phosphorylase (RrGGP2) gene expression. Virus-induced RrGGP2 silencing reduced the AsA content in R. roxburghii fruit by 28.9%. Overexpressing RrGGP2 increased AsA content by 8-12-fold in tobacco leaves and 2.33-3.11-fold in tomato fruit, respectively, and it showed enhanced resistance to oxidative stress caused by paraquat in transformed tobacco. These results further justified the importance of RrGGP2 as a major control step to AsA biosynthesis in R. roxburghii fruit.

Pharmacokinetics of a Novel Sustained-Release Vitamin C Oral Tablet: A Single Dose, Randomized, Double-Blind, Placebo-Controlled Trial

Introduction

Vitamin C is available in various oral formulations for dietary supplementation and for use in deficiency. However, because of the saturable active transport mechanisms in the absorption, distribution, and excretion of vitamin C, oral doses above 400 mg/day are not effectively absorbed. This may be overcome by employing slow-release delivery systems. We tested this by evaluating the pharmacokinetics of a novel sustained-release oral tablet (C-Fence, Inventia Healthcare Limited, Mumbai, India).

Methods

We conducted a randomized, placebo-controlled, parallel-design, 500 mg single-dose pharmacokinetic study of this new preparation in 18 healthy, adult, human subjects (nine in each group) under fasting conditions. The concentration-time profile and pharmacokinetic parameters of L-ascorbic acid, including Cmax (maximum plasma concentration), Tmax (time to reach Cmax), and AUC0-24h (area under the plasma concentration versus time curve from time 0 h to 24 h) were calculated using baseline-corrected values.

Results

The sustained-release tablets resulted in mean Cmax and AUC0-24h, respectively, of 1.39 ± 1.21 µg/mL and 11.72 ± 10.73 µg.h/mL against 0.18 ± 0.10 µg/mL and 0.89 ± 0.27 µg.h/mL, respectively, in the placebo group. The mean Tmax with the sustained release tablets was 4.3 ± 2.5 h. At 12, 16, and 24 h from dosing, the concentrations were 0.6, 0.4, and 0.3 µg/mL, respectively, above baseline values.

Conclusion

Novel sustained-release formulations of vitamin C are expected to help achieve plasma vitamin C values above the homeostatic saturation level and result in higher steady-state plasma concentration, which might result in better cellular uptake.

A pilot study on the effect of formulation and individual muscle mass on vitamin C absorption in randomized clinical study

The current study investigated that the vitamin C absorption in plasma depends on the individual muscle mass and the formulation including drinks (Vita 500), capsules, and tablets by using a randomized and double-blind clinical study. The volunteers were divided into two groups that depended on their muscle mass, including those whose muscle mass was greater than 40% ( ≥ $ \ge $ 40%) and less than 40% muscle mass (<40%). Levels of vitamin C in blood plasma was analyzed by high-performance liquid chromatography by ultraviolet detection (HPLC-UV). The existing HPLC method was modified according to lab conditions but maintained a constantly low pH sample reduction procedure. The analytical method validated stability, linearity, recovery, reliability, and accuracy. The vitamin C absorption was the highest at 120 min after ingesting Vita 500 (21.47 ± 15.99 µmol/L). It was higher in the group that has more than 40% muscle mass compared to other formulations, such as tablets and capsules. The results from the current study indicate that vitamin C formulations differently affect the vitamin C absorption, and its effect depends on the muscle mass. As the results, liquid type vitamin C formulations could enhance vitamin C absorption, which resulted in an improvement of vitamin C absorption according to muscle mass. PRACTICAL APPLICATION: The results of this study may recommend using vitamin C supplementation as liquid type. It may also provide evidence that people with higher muscle mass can absorb vitamin C more efficiently.

Metabolic engineering in food crops to enhance ascorbic acid production: crop biofortification perspectives for human health

Ascorbic acid (AsA) also known as vitamin C is considered as an essential micronutrient in the diet of humans. The human body is unable to synthesize AsA, thus solely dependent on exogenous sources to accomplish the nutritional requirement. AsA plays a crucial role in different physiological aspects of human health like bone formation, iron absorption, maintenance and development of connective tissues, conversion of cholesterol to bile acid and production of serotonin. It carries antioxidant properties and is involved in curing various clinical disorders such as scurvy, viral infection, neurodegenerative diseases, cardiovascular diseases, anemia, and diabetes. It also plays a significant role in COVID-19 prevention and recovery by improving the oxygen index and enhancing the production of natural killer cells and T-lymphocytes. In plants, AsA plays important role in floral induction, seed germination, senescence, ROS regulation and photosynthesis. AsA is an essential counterpart of the antioxidant system and helps to defend the plants against abiotic and biotic stresses. Surprisingly, the deficiencies of AsA are spreading in both developed and developing countries. The amount of AsA in the major food crops such as wheat, rice, maize, and other raw natural plant foods is inadequate to fulfill its dietary requirements. Hence, the biofortification of AsA in staple crops would be feasible and cost-effective means of delivering AsA to populations that may have limited access to diverse diets and other interventions. In this review, we endeavor to provide information on the role of AsA in plants and human health, and also perused various biotechnological and agronomical approaches for elevating AsA content in food crops.

Relationship between Vitamin C Deficiency and Cognitive Impairment in Older Hospitalised Patients: A Cross-Sectional Study

Vitamin C is a powerful antioxidant and facilitates neurotransmission. This study explored association between vitamin C deficiency and cognitive impairment in older hospitalised patients. This prospective study recruited 160 patients ≥ 75 years admitted under a Geriatric Unit in Australia. Cognitive assessment was performed by use of the Mini-Mental-State-Examination (MMSE) and patients with MMSE scores <24 were classified as cognitively-impaired. Fasting plasma vitamin C levels were determined using high-performance-liquid-chromatography. Patients were classified as vitamin C deficient if their levels were below 11 micromol/L. Logistic regression analysis was used to determine whether vitamin C deficiency was associated with cognitive impairment after adjustment for various covariates. The mean (SD) age was 84.4 (6.4) years and 60% were females. A total of 91 (56.9%) were found to have cognitive impairment, while 42 (26.3%) were found to be vitamin C deficient. The mean (SD) MMSE scores were significantly lower among patients who were vitamin C deficient (24.9 (3.3) vs. 23.6 (3.4), p-value = 0.03). Logistic regression analysis suggested that vitamin C deficiency was 2.9-fold more likely to be associated with cognitive impairment after adjustment for covariates (aOR 2.93, 95% CI 1.05−8.19, p-value = 0.031). Vitamin C deficiency is common and is associated with cognitive impairment in older hospitalised patients.

Stress amelioration potential of vitamin C in ruminants: a review

Ruminants, as well as other livestock, can synthesize vitamin C (VC) in their liver, and therefore, dietary requirements from exogenous supplementation are often ignored. However, metabolic demand may be exceeded, leading to a decreased endogenous synthetic capacity of VC following exposure to stressful conditions. Such conditions include high thermal load, limited water intake (induced by water scarcity), physiological status and infectious diseases. The obvious consequences are decreased performance, susceptibility to infections and increased mortality. This review discusses the potential role of vitamin C in ruminants' stress management and summarizes the in vitro and in vivo research to date. The different administration routes, comparative advantages and supplementation outcomes on growth, production parameters and physiological status were also identified. Also, areas where there was a lack of evidence or controversy, including critical literature research gaps, were identified, while the mechanism of VC's actions on significant outcomes was explained.

Prevalence of Hypovitaminosis C and its Relationship with Frailty in Older Hospitalised Patients: A Cross-Sectional Study

Frailty is common in older hospitalised patients and may be associated with micronutrient malnutrition. Only limited studies have explored the relationship between frailty and vitamin C deficiency. This study investigated the prevalence of vitamin C deficiency and its association with frailty severity in patients ≥75 years admitted under a geriatric unit. Patients (n = 160) with a mean age of 84.4 ± 6.4 years were recruited and underwent frailty assessment by use of the Edmonton Frail Scale (EFS). Patients with an EFS score <10 were classified as non-frail/vulnerable/mildly frail and those with ≥10 as moderate–severely frail. Patients with vitamin C levels between 11–28 μmol/L were classified as vitamin C depleted while those with levels <11 μmol/L were classified as vitamin C deficient. A multivariate logistic regression model determined the relationship between vitamin C deficiency and frailty severity after adjustment for various co-variates. Fifty-seven (35.6%) patients were vitamin C depleted, while 42 (26.3%) had vitamin C deficiency. Vitamin C levels were significantly lower among patients who were moderate–severely frail when compared to those who were non-frail/vulnerable/mildly frail (p < 0.05). After adjusted analysis, vitamin C deficiency was 4.3-fold more likely to be associated with moderate–severe frailty (aOR 4.30, 95% CI 1.33-13.86, p = 0.015). Vitamin C deficiency is common and is associated with a greater severity of frailty in older hospitalised patients.

Surface-engineered liposomal particles of calcium ascorbate with fenugreek galactomannan enhanced the oral bioavailability of ascorbic acid: a randomized, double-blinded, 3-sequence, crossover study

The antioxidant, anti-inflammatory, immunomodulating, anti-thrombotic, and antiviral effects along with its protective effects against respiratory infections have generated a great interest in vitamin C (vitC) as an attractive functional/nutraceutical ingredient for the management of COVID-19. However, the oral bioavailability and pharmacokinetics of vitC have been shown to be complex and exhibit dose-dependent non-linear kinetics. Though sustained-release forms and liquid liposomal formulations have been developed, only marginal enhancement was observed in bioavailability. Here we report a novel surface-engineered liposomal formulation of calcium ascorbate (CAAS), using fenugreek galactomannan hydrogel in powder form, and its pharmacokinetics following a randomized, double-blinded, single-dose, 3-way crossover study on healthy human volunteers (n = 14). The physicochemical characterization and in vitro release studies revealed the uniform impregnation of CAAS liposomes within the pockets created by the sterically hindered galactomannan network as multilaminar liposomal vesicles with good encapsulation efficiency (>90%) and their stability and sustained-release under gastrointestinal pH conditions. Further human studies demonstrated >7-fold enhancement in the oral bioavailability of ascorbate with a significant improvement in pharmacokinetic properties (C_max, T_max, T_1/2, and AUC), compared to the unformulated counterpart (UF-CAAS) when supplemented at an equivalent dose of 400 mg of CAAS as tablets and capsules.

A green process to modulate the surface properties of liposome was reported using fenugreek galactomannan hydrogel and successfully applied to vitamin C with significant enhancement in human oral bioavailability.

Multiple Effects of Ascorbic Acid against Chronic Diseases: Updated Evidence from Preclinical and Clinical Studies

Severe disease commonly manifests as a systemic inflammatory process. Inflammation is associated withthe enhanced production of reactive oxygen and nitrogen species and with a marked reduction in the plasma concentrations of protective antioxidant molecules. This imbalance gives rise to oxidative stress, which is greater in patients with more severe conditions such as sepsis, cancer, cardiovascular disease, acute respiratory distress syndrome, and burns. In these patients, oxidative stress can trigger cell, tissue, and organ damage, thus increasing morbidity and mortality. Ascorbic acid (ASC) is a key nutrient thatserves as an antioxidant and a cofactor for numerous enzymatic reactions. However, humans, unlike most mammals, are unable to synthesize it. Consequently, ASC must be obtained through dietary sources, especially fresh fruit and vegetables. The value of administering exogenous micronutrients, to reestablish antioxidant concentrations in patients with severe disease, has been recognized for decades. Despite the suggestion that ASC supplementation may reduce oxidative stress and prevent several chronic conditions, few large, randomized clinical trials have tested it in patients with severe illness. This article reviews the recent literature on the pharmacological profile of ASC and the role of its supplementation in critically ill patients.

The effect of dietary nitrate and vitamin C on endothelial function, oxidative stress and blood lipids in untreated hypercholesterolemic subjects: A randomized double-blind crossover study

BACKGROUND

Vitamin C may enhance nitric oxide (NO) production through stepwise reduction of dietary nitrate (NO₃) to nitrite (NO₂) to NO. The combined effect of vitamin C and NO₃ supplementation is relatively unexplored in untreated hypercholesterolemia.

AIMS

We aimed to examine whether co-administration of vitamin C and nitrate for 4-weeks would improve endothelial function (primary outcome), plasma NO metabolites, oxidative stress, and blood lipids (secondary outcomes).

METHODS

Subjects 50-70 years of age with low density lipoprotein (LDL) > 130 mg/dL and RHI ≤2 were enrolled in this randomized double-blind crossover study. Subjects were assigned to two 4-week supplementation treatments starting with 70 ml of concentrated beetroot juice (CBJ) with 1000 mg of vitamin C (NC) or CBJ with matched placebo (N), then switched to alternate treatment following 2-week washout. The change in reactive hyperemia index (RHI), sum of plasma NO metabolites (NO₂ + NO₃ (NOx)), oxidized LDL (oxLDL), and serum lipids were assessed at baseline and at 4-weeks of each treatment period.

RESULTS

Eighteen subjects (11M:7F) completed all study visits. No significant treatment differences were observed in RHI change (N: 0.21 ± 0.12; NC: 0.20 ± 0.17; p = 0.99). Secondary analysis revealed that a subgroup of NC subjects who started with a baseline RHI of <1.67 (threshold value for ED) had greater improvements in RHI compared to subjects with RHI >1.67 (1.23 ± 0.15 to 1.96 ± 0.19; n = 8 vs. 1.75 ± 0.11 to 1.43 ± 0.10; n = 8; p = 0.02). Compared to N, NC experienced a significant increase in plasma NOx (N: 94.2 ± 15.5 μmol/L; NC: 128.7 ± 29.1 μmol/L; p = 0.01). Although there was no significant difference in oxLDL change between treatments (N: -1.08 ± 9.8 U/L; NC: -6.07 ± 9.14 U/L; p = 0.19), NC elicited significant reductions in LDL (N: 2.2 ± 2; NC: -10.7 ± 23; p = 0.049), triglycerides (N: 14.6 ± 43; NC: -43.7 ± 45; p = 0.03), and no change in serum high density lipoprotein. Within treatment group comparisons showed that only NC reduced oxLDL significantly from baseline to 4 weeks (p = 0.01).

CONCLUSIONS

No between intervention differences were observed in RHI. RHI only improved in NC subjects with ED at intervention baseline. Four weeks of NC enriched the NO pool and promoted reduction of blood lipids and oxidative stress in subjects with hypercholesterolemia. These preliminary findings highlight a supplementation strategy that may reduce the progression of atherosclerotic disease and deserves further attention in studies using flow mediated dilation methods.

CLINICAL TRIAL REGISTRATION

www.clinicaltrials.gov (NCT04283630).

LED&Paper-based analytical device for phosphatemia/calcemia diagnostics☆

In this communication a prototype of paper-based analytical device designed for simultaneous determination of orthophosphate and calcium ions, which levels are significant for hyperphosphatemia diagnostics, is presented. The laboratory-on-paper structure for two analytes detection was wax-printed on the surface of filter paper. These two-analyte disposable paper strips are combined with two paired LED-based fluorescence detectors and simple voltmeter used as recorder of analytical signal, what makes the developed device miniature, extremely low-cost, portable and user-friendly. Thus the developed device allows usage outside of specialized clinical laboratory. Moreover, each paper strip is disposable and its utilization is easy and fast and, additionally, burnt strip tests ensure waste non-infectious. The presented LED&Paper-based analytical device provides low detection limits: 1.4 μmol L^-1 and 7.4 μmol L^-1 for orthophosphate and calcium ions, respectively. The practical utility of the developed device for calcemia/phosphatemia diagnostics is demonstrated using control serum standards and real human serum.