Danger of Zero-Carb Diets III: Scurvy

I started low-carb Paleo dieting in late 2005. I ate a lot of vegetables but no starches and hardly any fruit. In retrospect, I would call it a near zero-carb diet. At that time I was 12 years into a chronic illness that got a little worse each year and was quite mysterious to me. Adopting a low-carb diet brought immediate changes: it made what I would much later recognize as a chronic bacterial infection better (in parts of the body, not the brain) and made a chronic fungal infection worse.

Within about a year I had developed scurvy. It took me an embarrassingly long time to figure out what it was. By the time knew what it was, I had 3 cavities; had lost 25 pounds; had developed diverticulitis and an abdominal aorta that visibly swelled with every heartbeat; and had minor skin wounds – scrapes and scratches – that hadn’t healed in 6 months.

Developing scurvy was a surprise, because I was eating many vegetables plus taking a multivitamin containing 90 mg of vitamin C. I had never had any signs of vitamin C deficiency before adopting a low-carb diet.

Four grams a day of vitamin C for two months cured all the scurvy symptoms. It would be several more years before I figured out the infections, but this experience taught me the importance of micronutrition. The experience persuaded me that I needed to research diets and nutrition closely, and started us down the path of writing Perfect Health Diet.

Scurvy on a Ketogenic Diet

My experience is not unique. Here’s one case we mention in the book: the story of a young girl with epilepsy.

KM was a 9-year old girl … diagnosed with epilepsy at six months old. She started a ketogenic diet in October 2003, as her multiple antiepileptic drugs were proving to be less than effective; indeed she was having as many as 12 tonic seizures per day with prolonged periods of non-convulsive status epilepticus. After the diet was prescribed the seizure frequency reduced markedly and there were a number of long periods of time in which she had no seizures.

KM’s mother gave a history of her daughter having had bleeding gums since the beginning of September 2006; she described them as being very dark red, swollen and bleeding. In addition, she explained that her daughter had dry, crusted blood peri-orally. The family’s general dental practitioner had explained that this was probably caused by erupting teeth and instructed her to use 0.2% chlorhexidine gluconate gel and to continue her regular oral hygiene regimen; however this had no effect. About a month later the patient’s right arm became swollen. It was thought that she had sustained a fracture or a dislocation; however she was discharged from the local hospital’s fracture clinic because there was clinical improvement and radiographs showed no callus formation.

In early November KM inhaled a primary molar tooth while she was having her teeth cleaned (Fig. 1). This required an emergency bronchoscopy to retrieve it; at the same time the surgeons extracted her remaining primary teeth in order to avoid a recurrence of the problem….

At that time an appointment was made to attend a paediatric dentistry consultant clinic at the Leeds Dental Institute; however this was never kept as about three weeks after the extractions the patient was admitted to hospital with low grade fever, persistently bleeding gums, oedema of her hands and feet and a petechial rash on her legs. [1]

This girl was eating a typical amount of vitamin C: her dietary intake was calculated at 73 mg/day, well above the US RDA for 9-13 year olds of 45 mg/day. Yet her blood level was only 0.7 µmol/l. Scurvy is diagnosed at levels below 11 µmol/l.

The symptoms of scurvy are sufficiently insidious that it is easy to miss the diagnosis. In KM’s case, it happened that a “senior house officer” – a junior doctor in training – from India recognized the symptoms of scurvy. Otherwise, it might have never have occurred to the doctors to test her vitamin C level. [2]

What Is the Cause of Low-Carb Scurvy?

So what causes scurvy to develop on low-carb diets even with vitamin C intake well above the US RDA?

It seems to be a confluence of two factors:

  • An infection or some other stress (e.g. injury, cancer) leads to the oxidation of extracellular vitamin C; and
  • On a low-insulin or glutathione-deficiency-inducing diet, oxidized vitamin C is not recycled.

Infection and Vitamin C

The immune response to infections generates reactive oxygen species, which oxidize vitamin C. Oxidation removes a hydrogen atom from vitamin C, turning it into “dehydroascorbic acid,” or DHAA. If DHAA remains in the blood, it degrades with a half-life of 6 minutes. [3]

Infections can cause vitamin C deficiency on any diet. During the “acute phase response” to infection or injury, vitamin C often becomes deficient. Here is a nice paper in which French doctors surveyed their hospital patients for scurvy:

We determined serum ascorbic acid level (SAAL) and searched for clinical and biological signs of scurvy in 184 patients hospitalized during a 2-month period.

RESULTS: The prevalence of hypovitaminosis C (depletion: SAAL<5 mg/l or deficiency: SAAL<2 mg/l) was 47.3%. Some 16.9% of the patients had vitamin C deficiency. There was a strong association between hypovitaminosis C and the presence of an acute phase response (p=0.002). [4]

So half were at least depleted in vitamin C and 17% had outright deficiency, which if it persisted would produce scurvy.

We’ve previously written of how important it is to supplement with vitamin C during infections:

I might add here that in sepsis, an extremely dangerous inflammatory state brought on by bacterial infections, intravenous vitamin C reverses some of the worst symptoms. [5] If you have a loved one suffering from a dangerous infection, it might not be a bad idea to get them some vitamin C.

Insulin Dependence of Vitamin C Recycling

DHAA can be recycled back into vitamin C, but only inside cells.

In order to enter cells, DHAA needs to be transported by glucose transporters. GLUT1, GLUT3, and GLUT4 are the three human DHAA transporters; GLUT1 does most of the work. [6]

DHAA transport is crucial for brain vitamin C status. There is no direct transport of vitamin C into the brain, yet the brain is one of the most vitamin C-dependent tissues in the body. The brain relies entirely on GLUT1-mediated transport of DHAA from the blood for its vitamin C supply. Within the brain, DHAA is restored to vitamin C by glutathione.

Supplying DHAA to stroke victims (of the mouse persuasion) as late as 3 hours after the stroke can reduce the stroke-damaged volume by up to 95%:

DHA (250 mg/kg or 500 mg/kg) administered at 3 h postischemia reduced infarct volume by 6- to 9-fold, to only 5% with the highest DHA dose (P < 0.05). [7]

This is a fascinating reminder of the importance of vitamin C for wound repair and protection from injury.

Glucose transporters are activated by insulin. Thus, DHAA import into cells is increased by insulin, leading to more effective recycling of vitamin C [8]:

Insulin and IGF-1 promote recycling of DHAA into ascorbate. Source.

Confirming the role of insulin in promoting vitamin C recycling, Type I diabetics (who lack insulin) have lower blood levels of vitamin C, higher blood levels of DHAA, increased urinary loss of vitamin C metabolites, and greater need for dietary vitamin C. [9, 10]

Now we have a mechanism by which zero-carb diets reduce vitamin C recycling: by lowering insulin levels they inhibit the transport of DHAA into cells, preventing its recycling into vitamin C. Instead, DHAA is degraded and excreted. As a result, vitamin C is lost from the body.

Glutathione and Vitamin C Recycling

Once inside the cell, DHAA is recycled back to ascorbate, mainly by glutathione inside mitochondria:

Dehydroascorbate, the fully oxidized form of vitamin C, is reduced spontaneously by glutathione, as well as enzymatically in reactions using glutathione or NADPH. [11]

A GLUT1 transporter on the mitochondrial membrane is needed to bring DHAA into mitochondria, possibly squaring the effect of insulin on vitamin C recycling.

Since glutathione recycles vitamin C, glutathione deficiency is another possible cause of vitamin C deficiency.

Glutathione is recycled by the enzyme glutathione peroxidase, a selenium-containing enzyme whose abundance is sensitive to selenium status. One difficulty with zero-carb diets is that they seem to deplete selenium levels.

Selenium deficiency is a common side effect of ketogenic diets. Some epileptic children on ketogenic diets have died from selenium deficiency! [12]

So here we have a second mechanism contributing to the development of scurvy on a zero-carb diet. The diet produces a selenium deficiency, which produces a glutathione deficiency, which prevents DHAA from being recycled into vitamin C, which leads to DHAA degradation and permanent loss of vitamin C.

Conclusion

Zero-carb dieters are at high risk for vitamin C deficiency, glutathione deficiency, and selenium deficiency. Anyone on a zero-carb diet should remedy these by supplementation.

These deficiencies are exacerbated by chronically low insulin levels. Insulin helps recycle vitamin C, which supports glutathione status. Lack of insulin increases vitamin C degradation and loss.

The failure of the body to efficiently recycle vitamin C and maintain antioxidant stores on a zero-carb diet is evidence of an evolutionary maladaption to the zero-carb diet.

There was no reason why our ancestors should have become adapted to a zero-carb diet; after, all they’ve been eating starches for at least 2 million years. It seems a risky step to try to live this way.

Related Posts

Other posts in this series:

  1. Dangers of Zero-Carb Diets, I: Can There Be a Carbohydrate Deficiency? Nov 10, 2010.
  2. Dangers of Zero-Carb Diets, II: Mucus Deficiency and Gastrointestinal Cancers A Nov 15, 2010.
  3. Dangers of Zero-Carb Diets, IV: Kidney Stones Nov 23, 2010.

References

[1] Willmott NS, Bryan RA. Case report: Scurvy in an epileptic child on a ketogenic diet with oral complications.  Eur Arch Paediatr Dent. 2008 Sep;9(3):148-52. http://pmid.us/18793598.

[2] Willmott NS, personal communication.

[3] “Dehydroascorbate,” Wikipedia, http://en.wikipedia.org/wiki/Dehydroascorbate.

[4] Fain O et al. Hypovitaminosis C in hospitalized patients. Eur J Intern Med. 2003 Nov;14(7):419-425. http://pmid.us/14614974.

[5] Tyml K et al. Delayed ascorbate bolus protects against maldistribution of microvascular blood flow in septic rat skeletal muscle. Crit Care Med. 2005 Aug;33(8):1823-8. http://pmid.us/16096461.

[6] Rivas CI et al. Vitamin C transporters. J Physiol Biochem. 2008 Dec;64(4):357-75. http://pmid.us/19391462.

[7] Huang J et al. Dehydroascorbic acid, a blood-brain barrier transportable form of vitamin C, mediates potent cerebroprotection in experimental stroke. Proc Natl Acad Sci U S A. 2001 Sep 25;98(20):11720-4. http://pmid.us/11573006.

[8] Qutob S et al. Insulin stimulates vitamin C recycling and ascorbate accumulation in osteoblastic cells. Endocrinology. 1998 Jan;139(1):51-6. http://pmid.us/9421397.

[9] Will JC, Byers T. Does diabetes mellitus increase the requirement for vitamin C? Nutr Rev. 1996 Jul;54(7):193-202. http://pmid.us/8918139.

[10] Seghieri G et al. Renal excretion of ascorbic acid in insulin dependent diabetes mellitus. Int J Vitam Nutr Res. 1994;64(2):119-24. http://pmid.us/7960490.

[11] Linster CL, Van Schaftingen E. Vitamin C. Biosynthesis, recycling and degradation in mammals. FEBS J. 2007 Jan;274(1):1-22. http://pmid.us/17222174.

[12] Bank IM et al. Sudden cardiac death in association with the ketogenic diet. Pediatr Neurol. 2008 Dec;39(6):429-31. http://pmid.us/19027591. (Hat tip Dr. Deans.)

Leave a comment ?

205 Comments.

  1. good read, appreciating this series as someone who spent a year on a zero carb diet… glad i started to follow and listen to my body

  2. Can I ask for a sample meal plan for 2-3 days? I’m a bit lost in the carb-fear zone and need some specific ideas. Thanks.

  3. This is my favorite post in your series. How did you end up ridding yourself of your infection?

  4. Hi Danny,

    That’s coming! A series on chronic bacterial infections will be the next major series. Basically, the book is a summary of how I did it – diet, nutrition, plus some antibiotics. The fungal infection may not be completely gone, but it’s confined to the colon and fading.

  5. Thanks for your reply Paul, I can’t wait.

    Stop me if this is in your book, but are large doses of iodine not enough when it comes to antibiotics?

    Where you originally on a zero-carb diet to kill your fungal infection?

  6. No, I went on the zero-carb diet hoping to improve my health. I didn’t know I had a fungal infection then, but it became obvious after I went zero-carb. I think zero-carb diets promote fungal infections.

    No, iodine is not sufficient as an antibiotic. Iodine supplementation will improve immune function, but by itself it won’t eradicate infections.

  7. Thank you for answering my questions Paul,

    Looking forward to your future posts.

  8. Anon –

    We’ll be posting a recipe a week from here forward. Also, there are some ideas in the “Color Companion,” which you can download from the sidebar.

    More detailed meal plans are a good idea, we’ll see what we can put together after we’ve posted a bunch of recipes.

  9. Could you state your thoughts on glutathione supplementation?

  10. Thanks – fascinating post. I’ve always been wary of zero carb diets from a personal experience perspective. I changed my own diet from high carb to moderate (40% carbs) and had a massive improvement in health. I tried very low carb briefly but never felt good. 18 months ago I cut grains, legumes and dairy (paleo) and without realising went to about 20% carbs, where I feel great, lower and I don’t feel good.

    A few years ago I started taking a high dose of Omega 3, because of joint inflammation, and other issues. This made big difference for about 3 months, then seemed to not work any more. I talked to a nutritionist friend and she pointed out that according to Andrew Stoll (The Omega 3 Connection) you must take 1000mg vit C and 500iu vit E daily or the omega 3 becomes oxidised in your body (cell membranes) and ineffective. I started taking both and in days was back to the original anti-inflammatory effectiveness of omega 3. I have since talked to others about this – for example a psychiatrist whose clients did well on omega 3 for 3 months and then it became ineffective.

    Paleo advice from many is to consume a high dose of omega 3, and at the same time reduce carbs. I am wondering if there are people suffering vit C depletion as a result of increased omega 3 consumption as well as too low carbs?

  11. My experience with going very low carb seems to agree with what you’re talking about. I need to supplement Selenium(600mcg) + vit C, or else I get a headache. Thanks for confirming my observation from theory.

    I wonder if we did adapt to a zero-carb diet, and then lose the adaptation (perhaps it was expensive?) over say the last 10k years.

  12. Do you count the fructose in fruit as a protective carb or must it be a starch.

  13. A number of people have reported a flare of auto-immune thyroid disease with going low carb – I wonder if selenium depletion has anything to do with it? T4 to T3 conversion.

  14. What effect does insulin sensitivity have upon Vit C status? I would assume that the more sensitive receptor sites are to insulins action the more DHAA transport into the cells.

    I don’t necessarily think that these things are due to being on a zero/low carb diet. The selenium and glutathione issue can be sorted on zero/low carb by eating a few brazil nuts and consuming raw milk. If these are taken care of then I wonder whether the insluin/vit C relationship will ever actually be a problem as per the above comment. I vaguely remember hearing that scurvy was almost non-existent in the inuit, so I don’t think it is low carb per se. More that people on low carb miss out on eating certain things.

  15. If you follow paleo nutrition closely you should also include offal, which is abundant in Vit C and minerals (Selenium amongst others).

    I think everyone has a fungal infection to some degree and it should not be a problem with good bacteria in your body keeping them in check.

    Did you have a mercury issue (fish or dental fillings) ? It seems that larger (then usual) amounts of selenium are needed to counteract the toxic effects of mercury.

    I do think you can go to zero carb for months on end (if one includes offall) but probably not years on end.

  16. Thanks for a very interesting article. I recently found your website and will have to go through your back articles. You do bring a very different perspective to the Paleo diet. One which resonates with me.

  17. I too am looking forward to your series on infections. I hope you can include things like fungus, Candida, viruses, etc. along with bacteria.

    I would like to find the best way to go about testing for these infections, as I have a long history of antibiotic use from my childhood, as well as heavy steroid bursts on a few occasions, and suspect I could have any number of infections at this point.

    Thanks for another informative post!

  18. Hi Jeremy,

    Glutathione interacts with and is maintained by vitamin C and selenium, so these two are essential for glutathione support. Raw materials for glutathione manufacture — cysteine and glycine — may be helpful; cysteine, a sulfur-containing amino acid, is the one most likely to be deficient. N-acetylcysteine is therefore a helpful supplement. You can also take glutathione directly, this needs to be taken on an empty stomach with a full glass of water because it is destroyed by stomach acid. Indirectly, a little B6, which helps recycle homocysteine to cysteine, may also improve glutathione status.

    Glutathione supplements are essential during infections and on very low carb / ketogenic diets I think. On mid-range Perfect Health Diet macronutrient ratios, 400 carb calories from starches and 300 protein calories, I don’t think they’re necessary, just the vitamin C and selenium should be satisfactory. But there’s no harm in taking NAC or glutathione if you wish.

  19. Hi julianne,

    Fascinating experience, thanks for sharing.

    Vitamin C deficiency tends to develop slowly over months, losing a little every day, so it’s quite plausible that a deficiency could develop over 3 months and lead to those changes in omega-3 oxidation. Still, it’s startling to see such a strong effect.

    It is possible that extra lipid peroxidation on a high-PUFA diet could help deplete vitamin C faster.

    By the way, I may conclude the Zero-Carb Series with a post on the diagnostic value of zero-carb diets. Since the presence of chronic infections makes zero-carb diets intolerable, and different infections produce different symptoms, the particular symptoms that develop on a zero-carb diet can be a diagnostic tool. Your “joint inflammation” is suggestive of some kind of chronic infection, as is your low-carb intolerance.

  20. Hi Kiran,

    I think every low-carber will do better with selenium and vitamin C. 600 mcg may be a little high for selenium though. Be careful.

    I doubt we were ever adapted to a zero-carb diet. If there are people adapted to it, the adaptation probably happened in the last 20,000 years. The Inuit would be good candidates. Before fishing and other modern technologies, no one could have survived in Arctic conditions where plant foods are scarce.

  21. Hi Jake,

    Fructose can act as a carb on low-carb diets, as it can be converted to glycogen in the liver. However, I consider it an inferior / toxic carb and would recommend safe starches.

    We eat typically a banana and some berries daily, and that is the extent of our fructose intake, save for some occasional sugar in, say, ice cream.

    Hi julianne,

    Autoimmune conditions seem to be common on zero-carb diets, I might discuss that briefly toward the end of this series.

    Hi James,

    I do think it’s probably true that we can eventually figure out how to supply extra micronutrients and make a zero-carb diet reasonably healthful. But I doubt it will ever be optimal. I don’t believe it’s robust to infections. And having to follow a rigorous supplementation schedule to make a diet healthful is a problem for practical living.

    Hi Ahrand,

    Agreed, offal is nutritious and healthful.

    I had no mercury issue that I’m aware of.

  22. Hi Rodney,

    Unfortunately there aren’t really good diagnostic methods for chronic infections, this is one reason doctors are so poor at treating chronic disease. It’s more art than science at this point.

    There are various diagnostic tests, but all require interpretation and can be misleading / produce false negatives (or false positives). Also, there are generally co-infections that are fellow travelers with disease, due to suppressed immunity, and they may be present but not be causing your health issues. So doctors may be reluctant to treat even infections that are known to be present.

    Some of the best ways to diagnose these issues are to eat and supplement in ways that promote immunity and reduce pathogen growth, and see if you get better.

  23. Dr. Jaminet, this is an interesting counterpoint to the argument advanced by Taubes in GCBC that starches and refined carbs in the diet flush vitamin C out of our systems.

    To summarize:
    According to Julie Will and Jim Byers of the Centers for Disease Control and the University of Colorado respectively, one potential explanation for the fact that people with metabolic syndrome have reduced circulating vitamin C is that high blood sugar and/or high levels of insulin work to increase the body’s requirement for vitamin C. It is pointed out that glucose and vitamin C compete for cellular uptake, so that the more glucose there is, the less vitamin C taken up by the cells, and moreover that glucose impairs the reabsorption of vitamin C by the kidneys. Infusing insulin into experimental subjects has been shown to cause a “marked fall” in circulating vitamin C levels.

    Ketosis actually seems to increase the activity of glutathione, at least in these studies:
    http://www.springerlink.com/content/r8lt796017t41jg1/
    http://cat.inist.fr/?aModele=afficheN&cpsidt=20525389
    http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6SYR-4WM0JCP-6&_user=10&_coverDate=08%2F25%2F2009&_rdoc=1&_fmt=high&_orig=search&_origin=search&_sort=d&_docanchor=&view=c&_searchStrId=1549788571&_rerunOrigin=scholar.google&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=567ad57581494ef4611cfa58e2a9f856&searchtype=a , though I admit I have only the most superficial of understanding of the relevance of those studies to your argument.

    I do see a paper that details that many children on the KD experienced selenium deficiency (http://onlinelibrary.wiley.com/doi/10.1046/j.1528-1157.2003.26102.x/full), though in that same paper, it states that “Dietary selenium is found in the highest concentrations in meat and seafood”, which makes me wonder if the problem stemmed from protein restriction. Once again, I am concluding that the potential problems can be avoided by eating sufficient quantities of meat.

    I’m very glad you are bringing these potential problems to my attention, because the health benefits I have gained from reducing my carbohydrates from very low to zero are so drastic and important to me, that I want to make every attempt to avoid any pitfalls. I’m still open to the idea of experimenting with adding safe starches.

  24. Great article. I’ve been following your posts for the past month and started eating starch again with great results so far. I was too thin and my gums were always bleeding but i’ve recently gained 5 lbs and gums are in better shape now.
    I started giving my boyfriend vit c after your previous posts and his allergy symptoms have decreased enough for him to be able to function normally. He’s sold on the benefits of vit c and is religious about taking it because he does not want to go back to allergy meds.
    It’s interesting that someone brought up iodine because I remember my grandmother saying she cured my dad’s malaria with rosehip tea and warm raw milk with iodine drops. Maybe to vit c + iodine combo was very effective.
    Anyway, I’m looking forward to the next series.

  25. Interesting hypothesis. Many carb-bashers like to point out that carbs could competitively inhibit vitamin c transport but never mention that without insulin those transporters take a vacation.

    I got your book in the mail, thank you so much! I will probably wind up reading it embarassingly late, but I can’t wait to get around to it.

    And thank you for the gentleman/scholar comments.

    Also saw your recent post on choline. I have a choline post in the queue, probably coming out in the next couple of days. I’m not sure if it will mention that particular study yet but the research you reviewed has been important to the continued development of my ideas about the potential role of choline in leptin resistance and selective hepatic insulin resistance.

    Keep up the good work!

    Chris

  26. Hi Amber,

    Thank you for a very interesting comment.

    I disagree with the assertion that starches “flush vitamin C out of the system.” Insulin doesn’t drive DHAA/C into the urine, it drives it into cells. Thus, even though serum vitamin C is lower, the body’s vitamin C status is improved. Lower serum vitamin C means less DHAA/C is being excreted, so over time C levels build up.

    True, the glucose pathways do impair vitamin C status. BUT – higher carb consumption tends to lower blood glucose levels, as Stephan points out in yesterday’s post (http://wholehealthsource.blogspot.com/2010/11/glucose-tolerance-in-non-industrial.html), so only the higher insulin pathway is obviously relevant.

    So it may be that only hyperglycemia induced by toxic foods / malnutrition / metabolic syndrome causes the vitamin C loss.

    Now, we are open to the idea that high-carb intakes can cause problems. Our diet is low-to-moderate carb, we recommend 200 to 600 calories per day (10% to 30% calories), with the low end our ketogenic diet which is therapeutic for various conditions, the upper range of 20% to 30% a good range for healthy people.

    But it’s hard to make strong assertions about what would happen in a high-carb 50% of calories “safe starch” Perfect Health Diet variant. It could be that the problems on high-carb diets are due to toxic plant foods like grains and legumes. High-carb “safe starch” only cultures like the Kitavans seem to be healthy. Has anyone checked their vitamin C status?

    The ketogenic diet / glutathione links are very interesting. They mostly tell us that the body needs much more antioxidant activity on the ketogenic diet, so it produces a lot more glutathione / glutathione peroxidase. This confirms that KDers need more selenium / C.

    It is possible that a high-protein, high-nutrient diet ameliorates most or all of the problems on zero-carb diets. We still believe in the therapeutic value of appropriate ketogenic diets. But we need to know the pitfalls in order to make them healthy, as you say.

    Again, thanks for the very interesting comment.

  27. Hi Violette,

    I’m glad you and your boyfriend are benefiting!

    If he hasn’t already, he should optimize his vitamin D status, since that’s also important for allergies.

    I do think that immune function is strongly affected by diet and nutrition, so cumulatively optimizing everything has a powerful effect. Vitamin C and iodine are both important pieces to the puzzle.

    Hi Chris,

    Thanks much!

    I’m very interested in your choline posts. I liked your previous one on choline, I’d been wondering what was causing the trouble on high-fat lard diets in rats and choline deficiency makes a lot of sense.

    Best, Paul

  28. Great series, I’m gaining new insights with every installment.

    I do wonder though: a post about zero-carb and scurvy, but no mention of Vilhjalmur Stefansson? He used a zero-carb diet to cure scurvy. Stefansson provided boiled and raw (frozen) caribou meat (head, brisket, rib, pelvis, and bone marrow) to colleagues who developed scurvy on one of their expeditions. Within days their joint pains were gone, and in two weeks they were able to start traveling again. [1] Also, during the Bellevue one year meat diet, neither Stefansson nor Andersen developed scurvy. [2]

    It is concluded that the failure of the body to efficiently recycle vitamin C and maintain antioxidant stores on a zero-carb diet is evidence of an evolutionary maladaption to the zero-carb diet, mainly based on the idea that there would be a lack of insulin on a zero-carb diet.
    However, insulin secretion is not exclusively stimulated by carbohydrates: protein stimulates it too. [3] Amino acids, like for example leucine, directly stimulate pancreatic cells to secrete insulin. [4] (Note: protein also stimulates glucagon in order to keep the blood glucose from dropping due to insulin.)
    In other words: if there is enough protein in a zero-carb diet, there should be enough insulin for proper vitamin C recycling, thus reducing scurvy risk. Stefansson’s experience (and that of scurvy-free carnivore Inuit sub-groups) might be explained by this.
    By the way: James Krieger did a very extensive series on insulin (I got the leucine reference from it). [5]

    My conclusion based on the zero-carb dangers posts up until now is that zero-carb diets mainly seem to cause problems when they lack protein and/or vitamins and minerals. This could to lead to glucose deficiency and scurvy. So, going zero-carb in a healthy way is less trivial than just removing all carbs from an average diet.
    What puzzles me is that some people conclude that the problems are caused by a lack of carbs, simply because the problems go away when carbs are added to the diet. To me this is a bit like saying that depression is caused by a lack of Prozac…

    I’m curious if there will be a post about zero-carb and cortisol.

    Keep up the good work.

    John

    References:
    [1] Stefansson, V. Adventures in Diet. Harper’s Monthly Magazine. 1935 November. Online version (3 parts): http://www.biblelife.org/stefansson1.htm (Note: the scurvy cure information can be found in part 3.)
    [2] McClellan W.S., Du Bois E.F. Clinical calorimetry. XLV. Prolonged meat diets with a study on kidney function and ketosis. J. Biol. Chem. 1930;87:651-668. http://www.jbc.org/cgi/reprint/87/3/651
    [3] Holt, S.H., Miller, J.C., Petocz, P. An insulin index of foods: The insulin demand generated by 1000-kJ portions of common foods. Am. J. Clin. Nutr. 1997;66:1264-1276. http://pmid.us/9356547
    [4] Yang J., Chi Y., Burkhardt B.R., Guan Y., Wolf B.A. Leucine metabolism in regulation of insulin secretion from pancreatic beta cells. Nutr. Rev. 2010 May;68(5):270-9. http://pmid.us/20500788
    [5] Krieger, J. http://weightology.net

  29. Hi John,

    Great points all, thanks for the links!

    I do think that high protein and micronutrient intakes will rescue most — but perhaps not all — the problems on a zero-carb diet. At the end of this series I’ll do a summing up of the evidence and see where we stand.

    I am a supporter of low-carb ketogenic diets as therapies for certain conditions. Thus, it’s important to learn how to rescue them from these problems. That way we can use these diets to treat epilepsy, other mental health conditions, cancer, diabetes, etc. without worrying about scurvy etc.

    That said, I think a “perfect” diet for busy people should be robust to minor variations. If a little loss of protein, or a deficiency of a micronutrient, can lead to serious problems, then I question the suitability of a zero-carb diet for routine use.

    If either (carbs) or (protein+C+selenium+N-acetylcysteine+salt+water+???) rescues a zero-carb diet, isn’t it reasonable to say the simpler solution (carbs) is the best fix?

    I’m planning a post in this series on circadian rhythms which might mention cortisol, I’ll figure that out when I write it.

    Thanks for the links and comment!

    Best, Paul

  30. Hi Paul,
    When I took the high dose fish oil, I was on a moderate carb diet (approx 30 – 40% cal from carbs, about 100grams day). I took the fish oil for menstrual pain and joints. The joint swelling I’ve had since I was 18 and was auto-immune related (a mild lupus, same symptoms as my mother)
    What ‘cured’ the joint swelling was Paleo eating – cutting grains and legumes. My mother has also had fantastic improvements in her small airways disease (also auto-immune related) from cutting grains, a massive decrease in mucous, and improved lung capacity. I have not had any joint problems since I switched to paleo eating 18 months ago. Nor have I needed much omega 3 to control menstrual pain, so no need to overload my system with Pufa’s. (at least n-3 ones) I already did low n-6’s.

  31. Hi julianne,

    Grains and legumes are really good at causing autoimmune disease! It’s great that Paleo eating cured your lupus symptoms.

  32. I found this fascinating. My son is 9 and has been on the Specific Carbohydrate Diet since he was 2.5. He’s on the autism spectrum and was truly a different child in 5 days of changing his diet. However his health has never been “perfect”. I can’t seem to find just what I need to do for him.

    He has had tooth decay since his baby teeth came in. The adult teeth seem better thank goodness and he has no cavities in those so far. He seemed to do better to me with more meat and fat and less carbs in the form of honey and fruit.

    However I’d noticed the last few months that his fingers seemed almost swollen to me. They looked different to me. He’s had a lot of teeth problems lately. He had to have a baby tooth pulled with a crown on it. It had gotten an infection underneath the tooth. Honestly his health seemed to go down hill after he got crowns nearly 2 years ago. I tried diet as long as I could and just could not improve his baby teeth significantly. I naively thought crowns would be better than fillings.

    But he’s also had a lot of gum bleeding as well. I wonder if I’ve restricted his diet too much and he might have low levels of vit C causing the swelling in his fingers and increased gum bleeding? He had a fever this weekend and it was gone within just a few hours of getting about 5 grams of Vit C.

    I’m going to go ahead and try really increasing his Vit C. What do you recommend? To bowel tolerance? Should I try adding selenium? He eats plenty of meat though and raw dairy. His diet consists of large amounts of meat, fat, vegetables, fermented raw dairy and some coconut oil. His Vit D levels were 42 a month ago and I’m upping his D intake.

  33. Hi Beet,

    It’s possible that vitamin C can cause the swelling and gum bleeding.

    Also, vitamin C, vitamin D, vitamin K2 and magnesium are critical for teeth. Vitamin C, vitamin D, selenium and magnesium are important for immunity to infections.

    I think vitamin C to a slight feeling of queasiness on the first day – stop at the first hint of queasiness – then 2 g/day thereafter would be the quickest reasonably safe way to fix any scurvy.

    His vitamin D levels were good, but now it’s winter so he may need slightly more.

    Selenium about 100 mcg/day would be good. We say 200 for adults and at his age half the dose would be about right.

    Magnesium chelate or citrate 200 mg/day. Vitamin K2 100 mcg/day. I would also add copper, maybe 1 mg/day.

    I might experiment also with a bit of rice in the diet. It doesn’t have the toxicity of other grains, gets well digested by humans so there’s not a lot of fiber for gut pathogens. I doubt it would contribute to autism the way other starches might, and might ease some of these issues.

    Let us know how it goes!

    Best, Paul

  34. Fresh meat cures scurvy. Did you eat some? Then that’s your problem.

  35. By the way, fresh meat cures scurvy in four (that’s 4) days. Quite a difference to your 4 months on loads of vitamin C. Maybe scurvy isn’t caused by a vitamin C deficiency, but by a fresh meat deficiency?

  36. Oh, and another thing. When cutting out all carbs, insulin doesn’t get low, it gets normal. But then, if you start calling it “normal”, you can’t make a point about everything else, can you.

  37. My comment is probably not going to add much to this very informative discussion, but apparently there is an episode of the tv series “House” dealing with scurvy and low-carb diets. I haven’t seen it but now I’m curious. “House” is supposed to be very accurate in its portrayal of diseases. It would be interesting to see what the docs on the show diagnosed the patient with before coming to the correct conclusion that s/he suffered from scurvy. Your article is showing me that scurvy not always so easy to recognize.

    Thank you for the time and effort you are putting into this series of articles. I have learned a lot.

  38. You’re welcome, LynMarie!

    I also would love to see that episode. I guess from googling that he only mentioned low-carb diets in a single throw-away line.

    Hi Martin,

    Raw, freshly killed meat can prevent scurvy in healthy people, but in people with infections the rate of vitamin C degradation can increase from <50 mg/day in the healthy to as high as 100 g/day. There's no way anyone will get 100 g/day ascorbate from raw meat.

    In any case, most people would prefer to get their vitamin C from a pill than from raw fresh meat.

  39. Hi Paul,
    I have been visiting your blog here for the past two months.In this post you mentioned–“an
    abdominal aorta that visibly swelled with every
    heartbeat;”.
    My mother recently passed away of a “dissected
    aorta” that burst a hole in the aorta.It seems to me
    that for the inner lining of the aorta to degrade is
    some kind of connective tissue pathology.
    What is your best guess as to the nutritional
    cause of this i.e. autoimmune related or could this be an infection causing the inner lining to degrade??
    Thanks in advance.
    Mark J. Cooper

  40. Hi Mark,

    Very sorry about your mom.

    In my case it was scurvy causing a loss of collagen. The extracellular matrix that backs the aorta was gradually disintegrating and not being replaced.

    I think in most cases it’s due to vascular infection, but I haven’t really studied aortic dissections. Of course malnutrition would exacerbate the problem. I think vitamin D and vitamin K2 deficiencies (along with C if that was deficient) would probably be the biggest factors.

  41. Sorry, I wasn’t clear enough. If you want the information regarding fresh meat and scurvy, look up the Bellevue all-meat trial with Stefansson. It’s not about freshly killed vs old, it’s about fresh vs cooked. Pemmican can be stored for years yet maintain its anti-scorbutic properties. But once you cook it too much, there goes your health.

    Anyway, you’re talking about infections, not a zero carb diet.

    But wait, are you saying that since people would prefer to get their C from a pill rather than from fresh raw meat, it’s OK to conclude that scurvy is a vitamin C deficiency? What you prefer in this case has exactly nothing to do with what your physiology requires. If indeed scurvy was a vitamin C deficiency, then why did it take you 4 months and 480g of pure vitamin C to cure it when it would have taken you 4 days and just fresh meat? Something’s not right.

    I believe you when you say that you ate that diet, and that you suffered scurvy, and that you cured it that way, but when it comes to why, you’re just trying to rationalize it. Why don’t you reason it out instead? Start with the thing about “low” insulin and go on from there. So, it’s not low insulin, it’s normal insulin, therefore, if we blame this level of insulin, we are in fact blaming normal insulin level for scurvy. Is that even reasonable? It’s like blaming good health for the disease. As if…

  42. In another reply just above my last one, you talk about vitamin D deficiency. Well, vitamin D requires dietary fat to be absorbed. It might require dietary fat to be metabolized even when produced through sun exposure, I’m not sure. The point is that you should question whether you were eating enough fat during your stint with the your so-called “near zero carb” diet.

    Besides, why don’t you question the nutritive value of all the vegetables you ate during that time? Is it because of the aura of good that surrounds them therefore they are immune to your questioning? Did you also supplement with something at any time then? Tsk tsk, bad reasoning that is.

  43. Hi Martin,

    I disagree with many of your assertions, especially the notion that 4 days of fresh meat would have fixed my scurvy, or that scurvy is not a vitamin C deficiency, or that it’s “normal” to maintain basal insulin levels 24 hours a day.

    You seem to be combative, and yet unaware of much of the content on our blog and in our book. We recommend a high-fat, low-to-moderate carb diet. So you don’t need to persuade me to eat fat. We discuss the Bellevue trial in our book, and mention it in this post: http://perfecthealthdiet.com/?p=1077.

    As for questioning the nutritive value of vegetables, this post is not about the nutritive value of vegetables. It is about why zero-carb and ketogenic dieters are more prone to scurvy than the general public.

    Please, if you want me to reply to your comments in future, adopt a more conversational and less belligerent tone.

  44. How was your scurvy diagnosed? Was this a self-diagnosis or did some medical tests point it out?

  45. It was self-diagnosed, but I got obviously better in the first day of vitamin C supplementation, and improved rapidly from there, so it was very clear. In retrospect, the symptoms were clear too.

    The only symptom I didn’t have was bleeding. I’m guessing my nutrition was good enough that I could make some kind of fibrin-based matrix to prevent bleeding.

    My doctor was as baffled as I was. We did ultrasounds and other tests but never a vitamin C test.

    Remember, I had chronic infections and other symptoms that were not scurvy-related. The scurvy symptoms weren’t the ones I was most concerned about until the very late stages when I started losing weight rapidly and fearing an aortic dissection. Once I focused on those issues it led me toward vitamin C.

  46. Paul: An aside to post or not as you see fit.
    Martin Levac is a well-known gadfly at low carb sites. He is unfailingly rude, somehow confusing a superior attitude with superior information. You would do well to ignore him, as Eades, Harris, and others have learned to do.

  47. This is an awesome post but I have a few issues with it.

    1. Ketogenic diet does not = zero-carb diet. When you go back and forth interchanging the terms it looks like you are equating them. You can induce ketosis at as high of an intake as 40g a day, depending on your individual situation.

    2. Protein induces insulin release just like sugar (starch is a sugar) intake does. Also, you can make glucose from protein, which is why you can maintain a fasting sugar level even though you haven’t eaten in twelve hours. I’m confused why we must eat starches in order to keep insulin levels up.

    3. You honestly can’t think of any circumstances under which human beings would have lived without starch-containing foods? Seriously? Does the phrase “Ice Age” mean anything to you?

    OK, that last one was snarky. Seriously though, I understand being so excited about a finding that you overlook important details, but that’s a big one. Not all human groups were affected by the Ice Age, mind you, but some definitely were. And until the late 1800s or early 1900s, some of them were still living in one. The traditional Inuit come immediately to mind. And it’s interesting that white explorers living among them could avoid scurvy on the Inuit diet but not the white-man-explorer diet that included vitamin-C-containing fruits.

    (Yes, I’ve heard that bit about them eating the contents of the guts of the animals they hunted. I’ve also heard that that was told to the white explorers as a practical joke. I’m more inclined to believe the latter.)

    I’ve run into some info over the years that tells me that you’re just as likely to get scurvy on a high-starch diet as on a low-starch one, possibly because vitamin C and glucose utilize the same cell receptors in the body. It’s more important in the immediate sense to clear excess glucose from the bloodstream than it is to absorb vitamin C, so guess which substance would take precedence. Probably one of the reasons diabetics age so quickly, along with the formation of AGEs.

    In any case it doesn’t seem to be zero-carbing in and of itself that is the problem, according to your own information here. Sounds like a perfect storm of undiagnosed infection and glutathione deficiency. Maybe it’d be best if someone attempting to embark on a new way of eating gets their health checked out first to make sure they aren’t putting themselves at extra risk of a a problem, rather than tell people to avoid a dietary approach entirely.

    And if you’re going to up your starch intake because of the information presented here, my suggestion is get your starch from root vegetables rather than from grains. Whole Health Source had a fabulous post about this recently. Starchy tubers are lower in phytates than seeds are, and tend to be higher in micronutrient content without all the rancid polyunsaturated oils and such getting in the way.

  48. My apology Paul, but you did not eat a zero carb diet, you ate a diet full of vegetables. Zero carbers don’t eat vegetables, they don’t eat plants of any kind except as spices. Your experience does not reflect the reality of those you try to warn: It doesn’t apply to them.

    I was merely pointing out glaring errors in _your_ assertions.

    Furthermore, it’s not my assertions, it’s the Bellevue experiment’s findings. Those findings are matter of record. You could argue against that but I advise against it. Indeed, it was supposed to answer all kinds of questions regarding an all-meat diet including the claim that fresh meat would cure scurvy in short order.

    I did not say it was alright to maintain basal insulin for 24 hours. I was merely pointing out that cutting out carbs does not lead to low insulin, but to normal insulin. When we eat meat, insulin rises and falls as it should normally. Accordingly, arguing that this level of insulin leads to scurvy is like arguing that normal insulin leads to scurvy. You did not develop scurvy because of normal insulin.

    It just occurred to me that my tone could prevent you from seeing the facts as they are. I’m sorry for that. It’s not my intention to provoke you, but to point out the errors in your thinking. Thinking, which, if maintained, can lead right back where you started: Scurvy. If you believe that scurvy is a vitamin C deficiency or the result of normal insulin level or anything else that isn’t actually true, you might continue to over-cook your meat, eat lots of vegetables, and generally continue to do whatever brought you here in the first place. After all, you are mistaken in what a zero carb diet really is.

    Look at what you did based on what you believe, and what you could have done based on actual fact. The two are worlds apart.

  49. Kathy, thank you for the warning, but my own actions will speak for themselves, as yours will too no doubt. If you have nothing else to contribute, farewell.

  50. Hi Dana,

    1) Yes … We recommend a ketogenic diet for certain conditions, and advocate a 50 g / 200 carb calorie version with coconut oil. We’re using the ketogenic diet for clues to problems that can arise on very low-carb or zero-carb diets, since ketogenic diets for epilepsy are well-documented clinically.

    2) Yes … But starches produce twice as much insulin per calorie as protein. Also, one can only eat so much protein, so in general diets containing starches will release more insulin over the course of a day.

    3) I don’t believe I said that no one has ever lived on zero-carb diets – I’m well aware of the Inuit – but rather that there has never been a time when our evolutionary ancestors lived on zero carbs. The contribution of Inuits to modern genomes is infinitesimal. The Ice Age was no different – the population center of humanity was in the tropics throughout the Last Glacial Maximum.

    4) Yes, it’s quite possible that high-carb diets promote scurvy as well. I’m considering a post on that, since so many people in this comment thread have brought it up. I suspect the carb intake that optimizes vitamin C status is around 600 calories per day.

    5) I agree that zero-carb diets have diagnostic value. Also, as many have pointed out, it may be that most problems of zero-carb diets can be fixed with high protein and micronutrient intake. Right now we’re mainly exploring issues and trying to generate hypotheses to explain them.

    6) Re starches, we’re big fans of tubers here. See http://perfecthealthdiet.com/?p=788.

    However, I think there are situations when rice (a grain, but very low in toxins) is superior to tubers. These include some colonic infections in which starving the colon of fiber, but providing glucose to the immune system, is beneficial.

    Thanks for your comment!

    Best, Paul

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