Chemical pathology| Volume 50, ISSUE 6, P654-658, October 2018

Vitamin C deficiency in an Australian cohort of metropolitan surgical patients


      Vitamin C is an essential micronutrient in the human diet. While large population studies measuring vitamin C have been performed in other countries, there are few studies of deficiency in the Australian population. This study aimed to quantify vitamin C deficiency, identify scorbutic symptoms and examine dietary associations in a cohort of preoperative general surgical patients.
      Vitamin C levels were determined in a cohort of patients referred to a single surgeon between January 2011 and December 2013. Baseline data were collected along with data on fruit consumption, weekly citrus fruit intake and presence of scorbutic symptoms.
      A total of 309 patients were included in the study and 21.4% of our cohort showed a vitamin C level ≤11.4 μmol/L (deficient). Mean citrus fruit intake was significantly higher in the normal vitamin C groups (>28.4 μmol/L) and patients with vitamin C levels ≤28.4 were more likely to consume no fruit (p=0.0004) which was also significant on multivariate analysis. Neither age nor gender appeared predictive of suboptimal vitamin C levels. No symptoms were significantly related to vitamin C levels on multivariate analysis.
      Vitamin C deficiency was common in Australian adults attending a surgical practice within south western Sydney. Review of the Australian recommended daily allowance for vitamin C is suggested, not only in clinically well patients but particularly in ICU and hospital inpatients. Larger studies examining the prevalence and impact of vitamin C deficiency in the Australian population are required to further investigate these findings.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Pathology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Schleicher R.L.
        • Carroll M.D.
        • Ford E.S.
        • et al.
        Serum vitamin C and the prevalence of vitamin C deficiency in the United States: 2003–2004 National Health and Nutrition Examination Survey (NHANES).
        Am J Clin Nutr. 2009; 90: 1252-1263
        • Huang A.
        • Vita J.A.
        • Venema R.C.
        • et al.
        Ascorbic acid enhances endothelial nitric-oxide synthase activity by increasing intracellular tetrahydrobiopterin.
        J Biol Chem. 2000; 275: 17399-17406
        • Chatterjee I.B.
        • Kar N.C.
        • Ghosh N.C.
        • et al.
        Aspects of ascorbic acid biosynthesis in animals.
        Ann N Y Acad Sci. 1961; 92: 36-56
        • Gluecksohn-Waelsch S.
        Lethal genes and analysis of differentiation.
        Science. 1963; 142: 1269-1276
        • Delanghe J.R.
        • Langlois M.R.
        • De Buyzere M.L.
        • et al.
        Vitamin C deficiency: more than just a nutritional disorder.
        Genes Nutr. 2011; 6: 341-346
        • Leger D.
        Scurvy: reemergence of nutritional deficiencies.
        Can Fam Physician. 2008; 54: 1403-1406
        • Mayberry J.
        Scurvy and vitamin C.
        (Third year food and drug law paper.) Harvard Law School, Cambridge, MA2004
        • Cahill L.
        • Corey P.N.
        • El-Sohemy A.
        Vitamin C deficiency in a population of young Canadian adults.
        Am J Epidemiol. 2009; 170: 464-471
        • Clase C.M.
        • Ki V.
        • Holden R.M.
        Water-soluble vitamins in people with low glomerular filtration rate or on dialysis: a review.
        Semin Dial. 2013; 26: 546-567
        • Gabb G.
        • Gabb B.
        Scurvy not rare.
        Aust Fam Physician. 2015; 44: 438-440
        • Lykkesfeldt J.
        • Christen S.
        • Wallock L.M.
        • et al.
        Ascorbate is depleted by smoking and repleted by moderate supplementation: a study in male smokers and nonsmokers with matched dietary antioxidant intakes.
        Am J Clin Nutr. 2000; 71: 530-536
        • Olmedo J.M.
        • Yiannias J.A.
        • Windgassen E.B.
        • et al.
        Scurvy: a disease almost forgotten.
        Int J Dermatol. 2006; 45: 909-913
        • Riess K.P.
        • Farnen J.P.
        • Lambert P.J.
        • et al.
        Ascorbic acid deficiency in bariatric surgical population.
        Surg Obes Relat Dis. 2009; 5: 81-86
        • Singer R.
        • Rhodes H.C.
        • Chin G.
        • et al.
        High prevalence of ascorbate deficiency in an Australian peritoneal dialysis population.
        Nephrology. 2008; 13: 17-22
        • Raynaud-Simon A.
        • Cohen-Bittan J.
        • Gouronnec A.
        • et al.
        Scurvy in hospitalized elderly patients.
        J Nutr Health Aging. 2010; 14: 407-410
        • Carr A.C.
        • Pullar J.M.
        • Bozonet S.M.
        • et al.
        Marginal ascorbate status (hypovitaminosis C) results in an attenuated response to vitamin C supplementation.
        Nutrients. 2016; 8: E341
        • Perret J.L.
        • Lagauche D.
        • Favier J.C.
        • et al.
        Scurvy in intensive care despite vitamin supplementation.
        Presse Med. 2004; 33 (French.): 170-171
        • Blee T.H.
        • Cogbill T.H.
        • Lambert P.J.
        Hemorrhage associated with vitamin C deficiency in surgical patients.
        Surgery. 2002; 131: 408-412
        • Langlois K.
        • Cooper M.
        • Colapinto C.K.
        Vitamin C status of Canadian adults: findings from the 2012/2013 Canadian Health Measures Survey.
        Health Rep. 2016; 27: 3-10
        • Lykkesfeldt J.
        • Poulsen H.E.
        Is vitamin C supplementation beneficial? Lessons learned from randomised controlled trials.
        Br J Nutr. 2010; 103: 1251-1259
        • Robitaille L.
        • Hoffer L.J.
        A simple method for plasma total vitamin C analysis suitable for routine clinical laboratory use.
        Nutr J. 2016; 15: 40
        • Ruston D.
        • Hoare J.
        • Henderson L.
        The National Diet & Nutrition Survey: Adults Aged 19 to 64 Years. Vol. 4: Nutritional Status (Anthropometry and Blood Analytes), Blood Pressure and Physical Activity.
        TSO, London2004
        • Wrieden W.L.
        • Hannah M.K.
        • Bolton-Smith C.
        • et al.
        Plasma vitamin C and food choice in the third Glasgow MONICA population survey.
        J Epidemiol Commun Health. 2000; 54: 355-360
        • He E.Y.
        • Wang L.W.
        • Kiernan M.C.
        Scurvy and stroke – is there an association?.
        Med J Aust. 2010; 193: 555-556
        • Taylor C.A.
        • Hampl J.S.
        • Johnston C.S.
        Low intakes of vegetables and fruits, especially citrus fruits, lead to inadequate vitamin C intakes among adults.
        Eur J Clin Nutr. 2000; 54: 573-578
        • Golriz F.
        • Donnelly L.F.
        • Devaraj S.
        • et al.
        Modern American scurvy – experience with vitamin C deficiency at a large children's hospital.
        Pediatr Radiol. 2017; 47: 214-220
        • Mapp S.J.
        • Coughlin P.B.
        Scurvy in an otherwise well young man.
        Med J Aust. 2006; 185: 331-332
        • Smith A.
        • Di Primio G.
        • Humphrey-Murto S.
        Scurvy in the developed world.
        CMAJ. 2011; 183: E752-E755
        • Hansen E.P.
        • Metzsche C.
        • Henningsen E.
        • et al.
        Severe scurvy after gastric bypass surgery and a poor postoperative diet.
        J Clin Med Res. 2012; 4: 135-137
        • Elia M.
        • Stratton R.J.
        Geographical inequalities in nutrient status and risk of malnutrition among English people aged 65 y and older.
        Nutrition. 2005; 21: 1100-1106
        • Hagel A.F.
        • Albrecht H.
        • Dauth W.
        • et al.
        Plasma concentrations of ascorbic acid in a cross section of the German population.
        J Int Med Res. 2018; 46: 168-174
        • Mosdol A.
        • Erens B.
        • Brunner E.J.
        Estimated prevalence and predictors of vitamin C deficiency within UK's low-income population.
        J Public Health. 2008; 30: 456-460
        • Christie-David D.J.
        • Gunton J.E.
        Vitamin C deficiency and diabetes mellitus – easily missed?.
        Diabet Med. 2017; 34: 294-296
        • Kotze V.
        Perioperative nutrition: What do we know?.
        S Afr J Clin Nutr. 2011; 24: 19-22
        • Akbarshahi H.
        • Andersson B.
        • Norden M.
        • et al.
        Perioperative nutrition in elective gastrointestinal surgery–potential for improvement?.
        Dig Surg. 2008; 25: 165-174
        • Giladi A.M.
        • Dossett L.A.
        • Fleming S.B.
        • et al.
        High-dose antioxidant administration is associated with a reduction in post-injury complications in critically ill trauma patients.
        Injury. 2011; 42: 78-82
        • Oudeman-van Straaten H.M.
        • Man A.M.S.
        • de Waard M.C.
        Vitamin C revisited.
        Crit Care. 2014; 18: 460
        • Nathens A.B.
        • Neff M.J.
        • Jurkovich G.J.
        • et al.
        Randomized, prospective trial of antioxidant supplementation in critically ill surgical patients.
        Ann Surg. 2002; 236: 814-822
        • Bikker A.
        • Wielders J.
        • van Loo R.
        • et al.
        Ascorbic acid deficiency impairs wound healing in surgical patients: four case reports.
        Int J Surg Open. 2016; 2: 15-18
        • Ellinger S.
        • Stehle P.
        Efficacy of vitamin supplementation in situations with wound healing disorders: results from clinical intervention studies.
        Curr Opin Clin Nutr Metab Care. 2009; 12: 588-595
        • Fukushima R.
        • Yamazaki E.
        Vitamin C requirement in surgical patients.
        Curr Opin Clin Nutr Metab Care. 2010; 13: 669-676
        • Cevikel M.H.
        • Tuncyurek P.
        • Ceylan F.
        • et al.
        Supplementation with high-dose ascorbic acid improves intestinal anastomotic healing.
        Eur Surg Res. 2008; 40: 29-33
        • Carr A.C.
        • Rosengrave P.C.
        • Bayer S.
        • et al.
        Hypovitaminosis C and vitamin C deficiency in critically ill patients despite recommended enteral and parenteral intakes.
        Crit Care. 2017; 21: 300
        • Australian Bureau of Statistics
        National Nutrition Survey Nutrient Intakes and Physical Measurement Australia 1995. Cat no. 48050.
        Australian Bureau of Statistics, Canberra1998
        • Hodges R.E.
        • Baker E.M.
        • Hood J.
        • et al.
        Experimental scurvy in man.
        Am J Clin Nutr. 1969; 22: 535-548
        • Delanghe J.R.
        • Langlois M.R.
        • De Buyzere M.L.
        • et al.
        Vitamin C deficiency and scurvy are not only a dietary problem but are codetermined by the haptoglobin polymorphism.
        Clin Chem. 2007; 53: 1397-1400
        • Benzie I.F.
        Vitamin C: prospective functional markers for defining optimal nutritional status.
        Proc Nutr Soc. 1999; 58: 469-476
        • Hasselholt S.
        • Tveden-Nyborg P.
        • Lykkesfeldt J.
        Distribution of vitamin C is tissue specific with early saturation of the brain and adrenal glands following differential oral dose regimens in Guinea pigs.
        Br J Nutr. 2015; 113: 1539-1549
        • Hughes R.E.
        • Hurley R.J.
        • Jones E.
        Dietary ascorbic acid and muscle carnitine (beta-OH-gamma-(trimethylamino) butyric acid) in Guinea-pigs.
        Br J Nutr. 1980; 43: 385-387

      Linked Article