The populations at risk of vitamin C deficiency are those for whom the fruit and vegetable supply is minimal. Epidemics of scurvy are associated with famine and war, when people are forced to become refugees and food supply is small and irregular. Persons in whom the total body vitamin C content is saturated can subsist without vitamin C for approximately 2 months before the appearance of clinical signs, and as little as 6.5–10 mg/day vitamin C will prevent the appearance of scurvy. In general, vitamin C status will reflect the regularity of fruit and vegetable consumption but also socio-economic conditions, because intake is determined not just by availability, but by cultural preferences and cost.
In Europe and the United States an adequate intake of vitamin C is indicated by the results of various national surveys. In the United Kingdom and Germany, the mean dietary intakes of vitamin C in adult men and women were 87 and 76 and 75 and 72 mg/day, respectively. In addition, a recent survey of elderly men and women in the United Kingdom reported vitamin C intakes of 72 (SD 61) and 68 (SD 60) mg/day, respectively.
In the United States, in the National Health and Nutrition Examination Survey, the median consumption of vitamin C from foods during the years 1988–91 was 73 and 84 mg/day in men and women, respectively. In all these studies there was a wide variation in vitamin C intake and 25–30 percent of the US population consumed less than 2.5 servings of fruit and vegetables daily. Likewise a survey of Latin American children in the United States suggested that less than 15 percent consumed the recommended intake of fruits and vegetables. It is not possible to relate servings of fruits and vegetables to an exact amount of vitamin C, but the World Health Organization (WHO) dietary goal of 400 g aimed to provide sufficient vitamin C to meet the 1970 Food and Agriculture Organization of the United Nations (FAO)/WHO guidelines – that is, approximately 20–30 mg/day – and lower the risk of chronic disease. The WHO goal has been roughly translated into the recommendation of five portions per day.
Reports from India show that the available supply of vitamin C is 43 mg/capita/day, and in the different states of India it ranges from 27 to 66 mg/day. In one study, low-income children consumed as little as 8.2 mg/day of vitamin C in contrast to a well-to-do group of children where the intake was 35.4 mg/day. Other studies done in developing countries found plasma vitamin C concentrations lower than those reported for developed countries, for example, 20–27 μmol/l for apparently healthy adolescent boys and girls in China and 3–54 μmol/l (median 14 μmol/l) for similarly aged Gambian nurses (44, 45), although values obtained in a group of adults from a rural district in Northern Thailand were quite acceptable (17–118 μmol/l, median 44 μmol/l) (46). However, it is difficult to assess the extent to which sub-clinical infections are lowering the plasma vitamin C concentrations seen in such countries.
Data describing a positive association between vitamin C consumption and health status are frequently reported, but intervention studies do not support the observations. Low plasma concentrations are reported in patients with diabetes and infections and in smokers, but the relative contribution of diet and stress to these situations is uncertain. Epidemiologic studies indicate that diets with a high vitamin C content have been associated with lower cancer risk, especially for cancers of the oral cavity, oesophagus, stomach, colon, and lung. However, there appears to be no effect of consumption of vitamin C supplements on the development of colorectal adenoma and stomach cancer, and data on the effect of vitamin C supplementation on coronary heart disease and cataract development are conflicting.
Currently there is no consistent evidence from population studies that heart disease, cancers, or cataract development are specifically associated with vitamin C status. This of course does not preclude the possibility that other components in vitamin C – rich fruits and vegetables provide health benefits, but it is not yet possible to separate such an effect from other factors such as lifestyle patterns of people who have a high vitamin C intake.
References:
Arab, L., Schellenberg, B. & Schlierf, G. 1982. Nutrition and health. A survey of young men and women in Heidelberg. Ann. Nutr. Metab., 26: 1-77.
Gregory, J.R., Foster, K., Tyler, H. & Wiseman, M. 1990. The dietary and nutritional survey of British adults. London: HMSO.
Life Sciences Research Office, Interagency Board for Nutrition Monitoring and Related Research. 1995. Third Report on Nutrition Monitoring in the United States. Washington, D.C. U. S. Government Printing Office.
Finch, S., Doyle, W., Bates, C.J. Prentice, A., Smithers, G. & Clarke, P.C. 1998. National diet and nutrition survey: people aged 65 years and over. Volume 1: Report of the diet and nutrition survey. London: The Stationery Office.
Basch, C.E., Syber, P. & Shea, S. 5-a-day:dietary behavior and the fruit and vegetable intake of Latino children. Am. J. Public Health 1994; 84:814-818.
WHO. 1990. Diet, Nutrition and the Prevention of Chronic Diseases. WHO Technical Report Series 797. Geneva: World Health Organization.
Williams, C. 1995. Healthy eating: clarifying advice about fruit and vegetables. BMJ, 310: 1453-55.
Narasinga Rao, B.S. 1995. Dietary intake of antioxidants in relation to nutrition profiles of Indian population groups. Nutrition, lipids, health and disease, p.343-353 [A.S.H. Ong, E. Niki, and L. Packer editors]. Champaign Illinois: AOCS Press.
Chang-Claude, J.C. 1990. Epidemiologic study of precancerous lesions of the oesophagus in young persons in a high-incidence area for the oesophageal cancer in China. Heidelberg: Heidelberg University.
Knowles, J., Thurnham, D.I., Hill, A.V.S., Tang, C. & Greenwood, B.M. 1991. Plasma ascorbate concentrations in Human malaria. Proc. Nutr. Soc., 50: 66A.
Thurnham, D.I., Singkamani, R., Kaewichit, R. & Wongworapat, K. 1990. Influence of malaria infection on peroxyl-radical trapping capacity in plasma from rural and urban Thai adults. Br. J. Nutr., 64: 257-271.
Jennings, P.E., Chiroco, S., Jones, A.F., Lunec, J. & Barnett, A.H. 1987. Vitamin C metabolites and microangiography in diabetes mellitis. Diab. Res., 6: 151-154
Thurnham, D.I. 1994. b-Carotene, are we misreading the signals in risk groups? Some
analogies with vitamin C. Proc. Nutr. Soc., 53: 557-569
Faruque, O., Rahman Khan, M., Rahman M. & Ahmed F. 1995. Relationship between smoking and antioxidant status. Br. J. Nutr., 73: 625-632.
Yong, L., Brown, C.C., Schatzkin, A., Dresser, C.M., Slesinski, M.J., Cox, C.S., & Taylor P.R. 1997. Intake of vitamins E, C, and A and risk of lung cancer. Am. J. Epidemiol.,146: 231-243.
Byers, T. & Mouchawar, J. 1998. Antioxidants and cancer prevention in 1997. In: Paoletti R, Sies H, Bug J., Grossi E, Poli A, eds. Vitamin C: the state of the art in disease
prevention 60 years after the Nobel Prize. ,p. 29-40. Milan: Springer.
Schorah, C.J. 1998. Vitamin C and gastric cancer prevention. In: Paoletti R, Sies H, Bug J., Grossi E, Poli A, eds. Vitamin C: the state of the art in disease prevention sixty years after the Nobel Prize. p. 41-49. Milan: Springer,
Blot ,W.J., Li, J., Taylor, P.R., Guo, W., Dawsey, S., Wang, G.Q., Yang, C.S., Zheng, S.F., Gail, M. & Li G.Y. 1993. Nutrition intervention trials in Linxian, China: supplementation with specific vitamin/mineral combinations, cancer incidence, and disease-specific mortality in the general population. J. Natl. Cancer. Instit., 85: 1483-1492.
Greenberg, E.R., Baron, J.A. Tosteson, T.D., et al. 1994. A clinical trial of antioxidant
vitamins to prevent colorectal adenoma. Polyp Prevention Study Group. N. Engl. J. Med., 331: 141-147.
Rimm, E.B., Stampfer, M.J., Ascherio, A., Giovannucci, E., Colditz, G.A. & Willett, W.C. 1993. Vitamin E consumption and the risk of coronary heart disease in men. N. Engl. J. Med., 328: 1450-1456.
Sahyoun, N.R., Jacques, P.F. & Russell, R.M. 1994. Carotenoids, vitamins C and E, and mortality in an elderly population. Am. J. Epidemiol., 144: 501-511.
Jha P., Flather, M., Lonn, E., Farkouh, M. & Yusuf, S. 1995. The antioxidant vitamins and cardiovascular disease: a critical review of the epidemiologic and clinical trial data. Ann. Intern. Med., 123: 860-872.
Losonczy, K.G., Harris, T.B. & Havlik, RJ. 1996. Vitamin E and vitamin C supplement
use and risk of all cause and coronary heart disease mortality in older persons: the established populations for epidemiologic studies of the elderly. Am. J. Clin. Nutr., 64: 190-196.
Enstrom, J.E., Kanim, L.E. & Klein, M.A. 1992. Vitamin C intake and mortality among
a sample of the United States population [see comments]. Epidemiology, 3: 194-202.
Enstrom, J.E., Kanim, L.E., & Breslow, L. 1986. The relationship between vitamin C
intake, general health practices, and mortality in Alameda County, California. Am. J. Public Health, 76: 1124-1130.
Seddon, J.M., Ajani, U.A., Sperduto, R.D., et al. 1995. Dietary carotenoids, vitamins A, C, and E, and advanced age-related macular degeneration. Eye Disease Case-Control Study Group [see comments] [published erratum appears in JAMA 1995 Feb 22;273(8):622]. JAMA, 272: 1413-1420.
Riemersma, R.A., Wood, D.A., Macintyre, C.C., Elton, R.A., Gey, K.F. & Oliver M.F. 1991. Risk of angina pectoris and plasma concentrations of vitamins A, C, and E and carotene [see comments]. Lancet, 337:1-5.
Gey, K.F., Moser, U.K., Jordan, P., Stahelin, H.B., Eichholzer, M. & Ludin, E. 1993. Increased risk of cardiovascular disease at suboptimal plasma concentrations of essential antioxidants: an epidemiological update with special attention to carotene and vitamin C. Am. J. Clin. Nutr., 57:787S-797S.
Kushi, L.H., Folsom, A.R., Princas R.J., Mink, P.J., Wu, Y. & Bostick, R.M. 1996.
Dietary antioxidant vitamins and death from coronary heart disease in postmenopausal women. N. Engl. J. Med., 334: 1156-1162.
Simon, J.A., Hudes, E.S. & Browner, W.S. 1998. Serum ascorbic acid and cardiovascular disease prevalence in US adults. Epidemiology, 9: 316-321.
Jacques, P.F., Chylack, L.T., Jr., McGandy, R.B. & Hartz, S.C. 1988. Antioxidant status in persons with and without senile cataract. Arch. Ophthalmol., 106: 337-340.
Robertson, J.M., Donner, A.P. & Trevithick, J.R. 1991. A possible role for vitamins C and E in cataract prevention. Am. J. Clin. Nutr., 53:346S-351S.
Leske, M.C., Chylack, L.T. & Wu, S. 1991. The lens opacities case/control study: risk factors for cataract. Arch. Opthalmol., 109: 144-251.
Italian-American Cataract Study Group. 1991. Risk factors for age-related cortical, nuclear, and posterior sub-capsular cataracts. Am. J. Epidemiol., 133: 541-553.
Goldberg, J., Flowerdew, G., Smith, E., Brody, J.A. & Tso, M.O. 1988. Factors associated with age-related macular degeneration. An analysis of data from the first National Health and Nutrition Examination Survey. Am. J. Epidemiol.,128: 700-710.
Vitale, S., West, S., Hallfrisch, J., et al. 1993. Plasma antioxidants and risk of cortical and nuclear cataract. Epidemiology, 4: 195-203.
Hankinson, S.E., Stampfer, M.J., Seddon, J.M., et al. 1992. Nutrient intake and cataract extraction in women: a prospective study. BMJ, 305: 335-339.
Mares-Perlman, J.A. 1997. Contribution of epidemiology to understanding relationships
of diet to age-related cataract. Am. J. Clin. Nutr., 66: 739-740.
Jacques, P.F., Taylor, A., Hankinson, S.E., Willett, W.C., Mahnken B., Lee, Y., Vaid, k. & Lahav, M. 1997. Long-term vitamin C supplement use and prevalence of early
age-related lens opacities. Am. J. Clin. Nutr., 66: 911-916.
Haytowitz, D. 1995. Information from USDA's Nutrient Data Book. J. Nutr., 125: 1952-1955.
References:
Arab, L., Schellenberg, B. & Schlierf, G. 1982. Nutrition and health. A survey of young men and women in Heidelberg. Ann. Nutr. Metab., 26: 1-77.
Gregory, J.R., Foster, K., Tyler, H. & Wiseman, M. 1990. The dietary and nutritional survey of British adults. London: HMSO.
Life Sciences Research Office, Interagency Board for Nutrition Monitoring and Related Research. 1995. Third Report on Nutrition Monitoring in the United States. Washington, D.C. U. S. Government Printing Office.
Finch, S., Doyle, W., Bates, C.J. Prentice, A., Smithers, G. & Clarke, P.C. 1998. National diet and nutrition survey: people aged 65 years and over. Volume 1: Report of the diet and nutrition survey. London: The Stationery Office.
Basch, C.E., Syber, P. & Shea, S. 5-a-day:dietary behavior and the fruit and vegetable intake of Latino children. Am. J. Public Health 1994; 84:814-818.
WHO. 1990. Diet, Nutrition and the Prevention of Chronic Diseases. WHO Technical Report Series 797. Geneva: World Health Organization.
Williams, C. 1995. Healthy eating: clarifying advice about fruit and vegetables. BMJ, 310: 1453-55.
Narasinga Rao, B.S. 1995. Dietary intake of antioxidants in relation to nutrition profiles of Indian population groups. Nutrition, lipids, health and disease, p.343-353 [A.S.H. Ong, E. Niki, and L. Packer editors]. Champaign Illinois: AOCS Press.
Chang-Claude, J.C. 1990. Epidemiologic study of precancerous lesions of the oesophagus in young persons in a high-incidence area for the oesophageal cancer in China. Heidelberg: Heidelberg University.
Knowles, J., Thurnham, D.I., Hill, A.V.S., Tang, C. & Greenwood, B.M. 1991. Plasma ascorbate concentrations in Human malaria. Proc. Nutr. Soc., 50: 66A.
Thurnham, D.I., Singkamani, R., Kaewichit, R. & Wongworapat, K. 1990. Influence of malaria infection on peroxyl-radical trapping capacity in plasma from rural and urban Thai adults. Br. J. Nutr., 64: 257-271.
Jennings, P.E., Chiroco, S., Jones, A.F., Lunec, J. & Barnett, A.H. 1987. Vitamin C metabolites and microangiography in diabetes mellitis. Diab. Res., 6: 151-154
Thurnham, D.I. 1994. b-Carotene, are we misreading the signals in risk groups? Some
analogies with vitamin C. Proc. Nutr. Soc., 53: 557-569
Faruque, O., Rahman Khan, M., Rahman M. & Ahmed F. 1995. Relationship between smoking and antioxidant status. Br. J. Nutr., 73: 625-632.
Yong, L., Brown, C.C., Schatzkin, A., Dresser, C.M., Slesinski, M.J., Cox, C.S., & Taylor P.R. 1997. Intake of vitamins E, C, and A and risk of lung cancer. Am. J. Epidemiol.,146: 231-243.
Byers, T. & Mouchawar, J. 1998. Antioxidants and cancer prevention in 1997. In: Paoletti R, Sies H, Bug J., Grossi E, Poli A, eds. Vitamin C: the state of the art in disease
prevention 60 years after the Nobel Prize. ,p. 29-40. Milan: Springer.
Schorah, C.J. 1998. Vitamin C and gastric cancer prevention. In: Paoletti R, Sies H, Bug J., Grossi E, Poli A, eds. Vitamin C: the state of the art in disease prevention sixty years after the Nobel Prize. p. 41-49. Milan: Springer,
Blot ,W.J., Li, J., Taylor, P.R., Guo, W., Dawsey, S., Wang, G.Q., Yang, C.S., Zheng, S.F., Gail, M. & Li G.Y. 1993. Nutrition intervention trials in Linxian, China: supplementation with specific vitamin/mineral combinations, cancer incidence, and disease-specific mortality in the general population. J. Natl. Cancer. Instit., 85: 1483-1492.
Greenberg, E.R., Baron, J.A. Tosteson, T.D., et al. 1994. A clinical trial of antioxidant
vitamins to prevent colorectal adenoma. Polyp Prevention Study Group. N. Engl. J. Med., 331: 141-147.
Rimm, E.B., Stampfer, M.J., Ascherio, A., Giovannucci, E., Colditz, G.A. & Willett, W.C. 1993. Vitamin E consumption and the risk of coronary heart disease in men. N. Engl. J. Med., 328: 1450-1456.
Sahyoun, N.R., Jacques, P.F. & Russell, R.M. 1994. Carotenoids, vitamins C and E, and mortality in an elderly population. Am. J. Epidemiol., 144: 501-511.
Jha P., Flather, M., Lonn, E., Farkouh, M. & Yusuf, S. 1995. The antioxidant vitamins and cardiovascular disease: a critical review of the epidemiologic and clinical trial data. Ann. Intern. Med., 123: 860-872.
Losonczy, K.G., Harris, T.B. & Havlik, RJ. 1996. Vitamin E and vitamin C supplement
use and risk of all cause and coronary heart disease mortality in older persons: the established populations for epidemiologic studies of the elderly. Am. J. Clin. Nutr., 64: 190-196.
Enstrom, J.E., Kanim, L.E. & Klein, M.A. 1992. Vitamin C intake and mortality among
a sample of the United States population [see comments]. Epidemiology, 3: 194-202.
Enstrom, J.E., Kanim, L.E., & Breslow, L. 1986. The relationship between vitamin C
intake, general health practices, and mortality in Alameda County, California. Am. J. Public Health, 76: 1124-1130.
Seddon, J.M., Ajani, U.A., Sperduto, R.D., et al. 1995. Dietary carotenoids, vitamins A, C, and E, and advanced age-related macular degeneration. Eye Disease Case-Control Study Group [see comments] [published erratum appears in JAMA 1995 Feb 22;273(8):622]. JAMA, 272: 1413-1420.
Riemersma, R.A., Wood, D.A., Macintyre, C.C., Elton, R.A., Gey, K.F. & Oliver M.F. 1991. Risk of angina pectoris and plasma concentrations of vitamins A, C, and E and carotene [see comments]. Lancet, 337:1-5.
Gey, K.F., Moser, U.K., Jordan, P., Stahelin, H.B., Eichholzer, M. & Ludin, E. 1993. Increased risk of cardiovascular disease at suboptimal plasma concentrations of essential antioxidants: an epidemiological update with special attention to carotene and vitamin C. Am. J. Clin. Nutr., 57:787S-797S.
Kushi, L.H., Folsom, A.R., Princas R.J., Mink, P.J., Wu, Y. & Bostick, R.M. 1996.
Dietary antioxidant vitamins and death from coronary heart disease in postmenopausal women. N. Engl. J. Med., 334: 1156-1162.
Simon, J.A., Hudes, E.S. & Browner, W.S. 1998. Serum ascorbic acid and cardiovascular disease prevalence in US adults. Epidemiology, 9: 316-321.
Jacques, P.F., Chylack, L.T., Jr., McGandy, R.B. & Hartz, S.C. 1988. Antioxidant status in persons with and without senile cataract. Arch. Ophthalmol., 106: 337-340.
Robertson, J.M., Donner, A.P. & Trevithick, J.R. 1991. A possible role for vitamins C and E in cataract prevention. Am. J. Clin. Nutr., 53:346S-351S.
Leske, M.C., Chylack, L.T. & Wu, S. 1991. The lens opacities case/control study: risk factors for cataract. Arch. Opthalmol., 109: 144-251.
Italian-American Cataract Study Group. 1991. Risk factors for age-related cortical, nuclear, and posterior sub-capsular cataracts. Am. J. Epidemiol., 133: 541-553.
Goldberg, J., Flowerdew, G., Smith, E., Brody, J.A. & Tso, M.O. 1988. Factors associated with age-related macular degeneration. An analysis of data from the first National Health and Nutrition Examination Survey. Am. J. Epidemiol.,128: 700-710.
Vitale, S., West, S., Hallfrisch, J., et al. 1993. Plasma antioxidants and risk of cortical and nuclear cataract. Epidemiology, 4: 195-203.
Hankinson, S.E., Stampfer, M.J., Seddon, J.M., et al. 1992. Nutrient intake and cataract extraction in women: a prospective study. BMJ, 305: 335-339.
Mares-Perlman, J.A. 1997. Contribution of epidemiology to understanding relationships
of diet to age-related cataract. Am. J. Clin. Nutr., 66: 739-740.
Jacques, P.F., Taylor, A., Hankinson, S.E., Willett, W.C., Mahnken B., Lee, Y., Vaid, k. & Lahav, M. 1997. Long-term vitamin C supplement use and prevalence of early
age-related lens opacities. Am. J. Clin. Nutr., 66: 911-916.
Haytowitz, D. 1995. Information from USDA's Nutrient Data Book. J. Nutr., 125: 1952-1955.
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