Prevalence, risk factors, and clinical outcomes of vitamin C deficiency in adult hospitalized patients in high-income countries: a scoping review

BACKGROUND

Assessment for vitamin C deficiency (VCD) is rarely undertaken in an acute hospital setting in high-income countries. However, with growing interest in VCD in community settings, there is emerging evidence investigating the prevalence and impact of VCD during hospitalization.

OBJECTIVES

In this scoping review, the prevalence of VCD in adult hospitalized patients is explored, patient characteristics are described, and risk factors and clinical outcomes associated with VCD are identified.

METHODS

A systematic scoping review was conducted in accordance with the PRISMA-ScR framework. The Ovid MEDLINE, Ovid Embase, Scopus, CINAHL Plus, Allied and Complementary Medicine Database, and the Cochrane Library databases were searched for interventional, comparative, and case-series studies that met eligibility criteria, including adult hospital inpatients in high-income countries, as defined by the Organization for Economic Co-operation and Development, that reported VCD prevalence using World Health Organization reference standards. These standards define VCD deficiency as plasma or serum vitamin C level <11.4 µmol/L, wholeblood level <17 µmol/L, or leukocytes <57 nmol/108 cells.

RESULTS

Twenty-three articles were included, representing 22 studies. The cumulative prevalence of VCD was 27.7% (n = 2494; 95% confidence interval [CI], 21.3-34.0). High prevalence of VCD was observed in patients with severe acute illness and poor nutritional status. Scurvy was present in 48% to 62% of patients with VCD assessed in 2 studies (n = 71). Being retired (P = 0.015) and using excessive amounts of alcohol and tobacco (P = 0.0003) were independent risk factors for VCD (n = 184). Age was not conclusively associated with VCD (n = 631). Two studies examined nutrition associations (n = 309); results were inconsistent. Clinical outcomes for VCD included increased risk of frailty (adjusted odds ratio, 4.3; 95%CI, 1.33-13.86; P = 0.015) and cognitive impairment (adjusted odds ratio, 2.93; 95%CI, 1.05-8.19, P = 0.031) (n = 160).

CONCLUSIONS

VCD is a nutritional challenge facing the healthcare systems of high-income countries. Research focused on early identification and treatment of patients with VCD is warranted.

SYSTEMATIC REVIEW REGISTRATION

Open Science Framework ( https://doi.org/10.17605/OSF.IO/AJGHX ).

Dermatological manifestations relating to nutritional deficiencies after bariatric surgery: case report and integrative literature review

BACKGROUND

The number of bariatric surgeries performed worldwide is growing. Among the main short, medium or long-term complications after surgery are nutritional deficiencies. Many of these, such as those of Zn, Cu and vitamins A, B1, B3, B6 and B12, are manifested by dermatological lesions before potentially fatal systemic disorders occur.

OBJECTIVE

To identify the main dermatological manifestations associated with nutritional deficiencies after bariatric surgery, and the associated variables.

DESIGN AND SETTING

Integrative literature review carried out at a public university in Brazil.

METHODS

This was a case report and a review of health research portals and databases of national and international biomedical journals, without publication date limitation. The descriptors used for searches followed the ideal methodology for each database/search portal: "bariatric surgery", "skin", "skin disease", "skin manifestation", "deficiency disease" and "malnutrition".

RESULTS

A total of 59 articles were selected, among which 23 were review articles or articles that addressed specific dermatological manifestations. The other 36 articles described 41 cases, which were organized into a table with the clinical variables.

CONCLUSIONS

Although nutritional deficiencies are expected as complications after bariatric surgery, few articles relating them to their dermatological manifestations were found. It is important to recognize skin changes caused by nutritional deficiencies in patients treated via bariatric surgery, as these may occur before systemic complications appear and are easier to diagnose when the patient does not have any systemic symptoms yet. However, there is generally a delay between the appearance of skin lesions and making the diagnosis of nutritional deficiency.

Effect of Fortification with Multiple Micronutrient Powder on the Prevention and Treatment of Iron Deficiency and Anaemia in Brazilian Children: A Randomized Clinical Trial

Fortification with multiple micronutrient powder has been proposed as a public health intervention able to reduce micronutrient deficiencies in children. Our objective was to compare the effectiveness of fortification with multiple micronutrient powder with drug supplementation in the prevention and treatment of iron deficiency and anaemia. This was a cluster trial with anemic and non-anaemic children between six and 42 months old, in randomization data. Non anaemic children received fortification with multiple micronutrient powder or standard drug supplementation of ferrous sulfate associated with folic acid in a prevention dose. Anaemic children who were randomized to receive multiple micronutrient powder also received the recommended iron complementation for anaemia treatment. A total of 162 children were evaluated. The prevalence of anaemia decreased from 13.58 to 1.85%. Iron deficiency decreased from 21.74% to 7.89% (by serum ferritin) and iron deficiency decreased from 66.81 to 38.27% (by soluble transferrin receptor). No difference was identified between interventions for hemoglobin (p = 0.142), serum ferritin (p = 0.288), and soluble transferrin receptor (p = 0.156). Fortification with multiple micronutrient powder was effective in preventing iron deficiency and anaemia in children aged six to 48 months. In anaemic children; it was necessary to supplement the dose of multiple micronutrient powder with ferrous sulfate.

The Association between Dietary Inflammatory Index and Sex Hormones among Men in the United States

PURPOSE

This study investigated the association between Dietary Inflammatory Index and sex hormones in a large, nationally representative adult male sample.

MATERIALS AND METHODS

We utilized data from the 2013-2014 and 2015-2016 National Health and Nutrition Examination Survey. Males aged ≥20 years who provided a 24-hour dietary intake history and underwent serum sex hormone testing were included in analysis. Weighted proportions and multivariable analysis controlling for age, race, energy, smoking status, education level, body mass index and time of venipuncture were used to evaluate the associations between Dietary Inflammatory Index and sex hormones.

RESULTS

For 4,151 participants, Dietary Inflammatory Index ranged from -5.05 to 5.48. Mean±SD total testosterone was 419.30±176.27 ng/dl. Mean±SD total testosterone was lower among men in the highest tertile compared with men in the lowest tertile group (410.42±171.97 vs 422.71±175.69, p <0.001). A per unit increase in Dietary Inflammatory Index was related to 4.0% (95% CI 0.5-7.6) higher odds of testosterone deficiency. In the fully adjusted multivariable model, males in Dietary Inflammatory Index tertile 3 (the most pro-inflammatory) had 29.6% (3.1-63.0) higher odds of testosterone deficiency than those in tertile 1 (p trend=0.025). Interaction tests revealed no significant effect of body mass index on the association of Dietary Inflammatory Index with testosterone deficiency and all sex hormone parameters.

CONCLUSIONS

Men adhering to a more pro-inflammatory diet appear to have a higher risk of testosterone deficiency, indicating the important role of diet in male reproductive health.

Deficiency of vitamins C and E in women of childbearing age in Brazil: a systematic review and meta-analysis

BACKGROUND

Despite the several options available for supplements containing vitamins C and E, evidence regarding the prevalence of deficiency or insufficiency of these vitamins is weak.

OBJECTIVES

To estimate the prevalence of deficiency or insufficiency of vitamins C and E and associated factors among women of childbearing age, in Brazil.

DESIGN AND SETTING

Systematic review and meta-analysis conducted at a Brazilian public university.

METHODS

A search from index inception until May 2020 was conducted. Meta-analyses were performed using inverse variance for fixed models, with summary proportions calculation using Freeman-Tukey double arcsine (base case). Reporting and methodological quality were assessed using the Joanna Briggs Institute tool for prevalence studies.

RESULTS

Our review identified 12 studies, comprising 1,316 participants, especially breastfeeding women. There was at least one quality weakness in all studies, mainly regarding sampling method (i.e. convenience sampling) and small sample size. The prevalence of vitamin C deficiency ranged from 0% to 40%. Only vitamin E deficiency was synthetized in meta-analyses, with mean prevalences of 6% regardless of the alpha-tocopherol cutoff in plasma, and 5% and 16% for cutoffs of < 1.6-12.0 mmol/l and < 16.2 mmol/l, respectively. The cumulative meta-analysis suggested that a trend to lower prevalence of vitamin E deficiency occurred in recent studies.

CONCLUSIONS

Although the studies identified in this systematic review had poor methodological and reporting quality, mild-moderate vitamin C and E deficiencies were identified, especially in breastfeeding women. Thus, designing and implementing policies does not seem to be a priority, because the need has not been properly dimensioned among women of childbearing age in Brazil.

REGISTRATION NUMBER IN PROSPERO

CRD42020221605.

Trace Elements in Human Nutrition (II) - An Update

The dietary requirement for an essential trace element is an intake level which meets a specified criterion for adequacy and thereby minimizes risk of nutrient deficiency or excess. Disturbances in trace element homeostasis may result in the development of pathologic states and diseases. This article is an update of a review article “Trace Elements in Human Nutrition-A Review” previously published in 2013. The previous review was updated to emphasis in detail the importance of known trace elements so far in humans’ physiology and nutrition and also to implement the detailed information for practical and effective management of trace elements’ status in clinical diagnosis and health care situations. Although various classifications for trace elements have been proposed and may be controversial, this review will use World Health Organization( WHO) classification as previously done. For this review a traditional integrated review format was chosen and many recent medical and scientific literatures for the new findings on bioavailability, functions, and state of excess/deficiency of trace elements were assessed. The results indicated that for the known essential elements, essentiality and toxicity are unrelated and toxicity is a matter of dose or exposure. Little is known about the essentiality of some of the probably essential elements. In regard to toxic heavy metals, a toxic element may nevertheless be essential. In addition, the early pathological manifestations of trace elements deficiency or excess are difficult to detect until more specific pathologically relevant indicators become available. Discoveries and many refinements in the development of new techniques and continual improvement in laboratory methods have enabled researchers to detect the early pathological consequences of deficiency or excess of trace elements. They all are promises to fulfill the gaps in the present and future research and clinical diagnosis of trace elements deficiencies or intoxications. However, further investigations are needed to complete the important gaps in our knowledge on trace elements, especially probably essential trace elements’ role in health and disease status.

Multiple Micronutrient Powder Reduces Vitamin E Deficiency in Brazilian Children: A Pragmatic, Controlled Clinical Trial

Multiple micronutrient powder supplementation is a health promotion strategy, but data on its effectiveness regarding vitamin E are rare. The objective was to evaluate the impact of home fortification with powdered micronutrients on α-tocopherol concentrations, growth, and inflammation in Brazilian children aged 6–15 months. This is a pragmatic, controlled clinical trial, in which the intervention group received micronutrient powder sachets for up to 3 months. Vitamin E deficiency was considered when α-tocopherol was less than 11.6 µmol/L. The Poisson regression model was used to estimate adjusted values for prevalence ratios (PR) for the outcome variable. A total of 224 children participated in the study. The intervention group had a higher median α-tocopherol level (17.2 versus 3.6 µmol/L; p < 0.001) and an 82.0% reduction in the prevalence of vitamin deficiency (PR = 0.18; 95% CI 0.11–0.30) when compared with the control group. Consumption of multiple micronutrients in powder increases serum α-tocopherol concentrations, promotes better linear growth, and reduces morbidity in children.

The Evolving Role of Multivitamin/Multimineral Supplement Use among Adults in the Age of Personalized Nutrition

Micronutrient deficiencies occur in segments of the adult population in the United States. Multivitamin/multimineral supplements (MVMS) are widely used by this population, which reduces inadequacies in micronutrient intake, but the potential for exceeding tolerable upper intake levels in others should be considered. There are concerns associated with the excessive intake of certain nutrients, particularly folic acid, and potential untoward consequences. The advent of nutrigenomics and the enhanced ability to directly study the interactions between nutrition and genetic variants and expression will allow for the conduct of more targeted studies with specific endpoints and may ultimately lead to progress in the field of personalized nutrition. The role of MVMS in health maintenance and chronic disease prevention remains controversial. Conducting studies in this area has been hampered by, among other factors, inconsistent definitions of MVMS, ranging from as few as three vitamins to broad-spectrum products containing more than two dozen vitamins and minerals. Results from some observational studies and large-scale, randomized, controlled trials suggest that MVMS may reduce the risk of some forms of cancer and, potentially, cardiovascular disease. The ongoing COcoa Supplement and Multivitamin Outcomes Study (COSMOS) is expected to build on this research and provide additional insights into these areas.

Nutritional reformulation: Fortification in the factory and in the field

Deficiencies in DHA/EPA are widespread, but not widely recognised. The scale of the problem is difficult to assess, because targets for consumption vary and intakes are poorly measured, but most people in most countries eat too little. The principal policies to correct the shortfalls have been educational programmes urging people to eat more fish. Two problems limit this approach: many do not like fish; and there are not enough fish available if everyone ate recommended levels. One pragmatic alternative is to start with the popular foods people actually eat, then fortify them with DHA/EPA. The paper discusses technical options for doing this, and three problems: the scale of sales, the use of inappropriate forticants, and the costs. The key to reducing costs lies in obtaining new, larger, sustainable and cheaper sources of DHA/EPA. Major efforts to achieve this are underway the genetically modified crops and new sources of algae. The public health goal is affordable fortified foods consumed by billions, not just affluent, health-conscious minorities. It is a strategy for nutritional improvement without dietary change.

WITHDRAWN: Maternal iodine supplements in areas of deficiency

BACKGROUND

Iodine deficiency is the leading preventable cause of intellectual impairment in the world. Although iodine supplementation is generally considered to be safe, there is a possibility of high doses of iodine suppressing maternal thyroid function.

OBJECTIVES

The objective of this review was to assess the effects of iodine supplementation before or during pregnancy in areas of iodine deficiency.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group trials register.

SELECTION CRITERIA

All acceptably controlled trials of maternal iodine supplementation during pregnancy with clinical outcomes.

DATA COLLECTION AND ANALYSIS

Eligibility and trial quality were assessed by two reviewers.

MAIN RESULTS

Three trials involving 1551 women were included. In two trials, iodine supplementation was associated with a statistically significant reduction in deaths during infancy and early childhood (relative risk 0.71, 95% confidence interval 0.56 to 0.90). Iodine supplementation was associated with decreased prevalence of endemic cretinism at the age of four years (relative risk 0.27, 95% confidence interval 0.12 to 0.60) and better psychomotor development scores between four to 25 months of age.

AUTHORS' CONCLUSIONS

Iodine supplementation in a population with high levels of endemic cretinism results in an important reduction in the incidence of the condition with no apparent adverse effects.