Vitamin C: Should you take it before and after surgery? Part 1

In 2010, I read that some guy named Paul Jaminet claimed to have contracted scurvy a few years prior. My first reaction: the man is clearly on drugs. No wonder he’s causing a stir in the paleo community. Or maybe he’s watching too many episodes of House? Either way, poor Shou-Ching 🙁

Well, it turns out that Paul’s scurvy experience is not so uncommon in low-to-zero carb dieters who might otherwise appear to have adequate vitamin C intake. Vitamin C deficiency is a big deal — aside from some well-known roles (e.g. immune system, growth), it’s one of a variety of micronutrients that can be helpful when recovering from injury.

Orthopedic surgery and pain

One of the biggest injuries of them all is an intentional injury known as “surgery”. Studying chronic pain as part of a PhD thesis, I had run across instances of vitamin C being used to prevent a terrible pain condition sometimes caused by surgeries called RSD (Reflex Sympathetic Dystrophy, alternately called Complex Regional Pain Syndrome or CRPS). Being in the middle of a series of orthopedic surgeries at the time, I wanted to avoid RSD like the plague.

So what is RSD? It’s an experience that’s tough to capture with words. Like how do you explain being in love to someone who hasn’t experienced it? RSD often brings burning, constant pain, coupled with swelling and immobility. In some cases, a light gust of wind across your skin can feel like a hot poker; laying a blanket on a patient can feel like barbed wire to them. Pain levels of different conditions are compared using the McGill Pain Index, on a scale of 0 to 50. A bone fracture is 18, childbirth is in the 30s, RSD (formerly known as causalgia) is at 42 — making it one of the, if not the most, painful of chronic conditions.

What if I told you that taking 500 mg/day of vitamin C starting immediately after surgery can nearly eliminate the occurrence of RSD? The same timing and dose may apply in cases of injury (bad ankle sprain, suspected ACL tear, etc).

Aside from antioxidant mechanisms (stabilizing free radicals that would normally damage lipid membranes and microcirculation), vitamin C can help normalize pain-inhibiting pathways involving dopamine, NMDA, and other neurotransmitters, and has shown promise for a variety of pain conditions in animal models. A higher vitamin C dose of 2 grams was shown to reduce morphine use after surgery. Reducing opioid intake post-surgically should be approached with caution, and always listen to your doctor. That being said, some people can’t tolerate opioids, are at risk of addiction, or just want to avoid the constipation that often accompanies painkiller use. In the above trial, patients took it orally just before surgery, as vitamin C peaks four hours after administration which coincides with waking from surgery.

I’m no actuary, but the numbers seem to favor taking a dose of vitamin C insurance for orthopedic surgery and injury. But is this also true for other surgery-related cases? The answer is not so straight forward.

Hospital food isn’t optimally nutritious? Whaaa?

The reputation of hospital food is a tier below airline food — bland, unsatisfying, and noted for having gelatinous blobs. Aside from taste, the other thing about hospital food (along with tube feeds, and intravenous nutrition) is that it will likely deplete your micronutrient stores, including vitamin C. Not only is the food not incredibly nutritious, but hospital patients often don’t eat much. Is it because of the taste or because of being sick in the hospital? Who knows.

One of the most important times to optimize your nutrition is when in the hospital. In surgical patients, supplementing with 200 mg of vitamin C is not enough to attain adequate vitamin C levels or reduce oxidative stress.

If you can get enough vitamin C perioperatively (how much is “enough” will be explored in part 2), it may prove therapeutic to a variety of conditions. In GI surgery, 500 mg of vitamin C by IV reduced post-surgical oxidative stress. Several trials have shown that taking 1-2 grams of vitamin C before and after heart surgery prevents atrial fibrillation and reduces hospital stay.

The benefits of vitamin C extend to less critical conditions as well. After laser surgery for skin, topical vitamin C reduced skin injury and restored acidic skin pH. Acidic skin provides defense against microbes, and inflamed skin can have a higher than normal pH. Vitamin C also has anti-acne effects (possibly by lowering sebum secretion and preventing water loss from skin) and reduces pigmentation (e.g. for freckle reduction or to help remove skin marks).

Vitamin C for other serious conditions

High doses of vitamin C show promise for critical care patients such as those with major burns. Surgical patients with major infection or critical illness require tissue to be replaced at a high rate, and hence use up vitamin C quickly — 300 mg isn’t enough for repletion but 1000 mg is. If you have borderline vitamin C stores before a hospital stay, there’s a chance that vitamin C dipping further will lead to fragile capillaries, poor wound healing, and possible hemorrhage. Luckily, bleeding ceases in under 24 hours with vitamin C supplementation, and adverse skin changes are reversed in 2-3 weeks.

Even if you’re as healthy as an ox, there’s a good chance that you’re the (welcome or unwelcome) nutrition adviser among friends and family with health conditions. If grandma or grandpa is hospitalized with a respiratory infection, remember that vitamin C significantly improves respiratory function in these patients. Vitamin C combined with vitamin E also reduces oxidative damage caused by sleep apnea, which has been called an “oxidative stress disorder”.

Finally, if you fracture your wrist, that is one instance where taking vitamin C (500 mg/d for 50 days) is unequivocally and officially recommended by evidence-based guidelines.

Conclusion

In part 2, we’ll check out some reasons to be cautious when considering vitamin C intake before and after surgery.

Leave a comment ?

37 Comments.

  1. Another good one to take is Vitamin D, to prevent infection.

    Lately I’ve been curious about what can be done to minimize the impact of surgery on nerve function. From the description, it sounds like Vitamin C can help. I’ve also read of topical B12 application helping. Any thoughts?

    • There are a few interesting things that could be done to both maintain nerve health and prevent excess scar tissue formation. Most of them are already encapsulated in a healthy diet, but some are not.

      Depending on the type of surgery, post-surgical nerve issues could be in the form of obvious nerve dysfunction (e.g. loss of sensation) or chronic pain. For the latter, there was a disgraced physician at Tufts Hospital named Scott Reuben who proposed prophylactic use of painkillers plus some nerve medications (Gabapentin I think) before surgery. He’s disgraced because he fudged most of his studies, and essentially committed big time fraud. But the idea is interesting: minimize the chances of the nervous system going haywire after surgery.

      Anyway, back to non-pain-related nerve function. Adequate sulfur intake is important, as is adequate vitamin C and B12 stores along with magnesium. If someone is at particular risk for nerve issues (like a history of RSD for example) then additional supplements such as alpha-lipoic acid may be warranted. Regular meditation before surgery (especially in the sun!) is a good idea too.

      • Thanks for the tip! Is there any evidence that it works? Guidelines for how much to take and when?
        I had a little incision to my lower abdominal area a few years ago. 6mo later I developed mild allodynia on one calf. I have a few more surgeries planned.

        • Evidence for the above is pretty dependent on the specific condition/surgery.

          Have you ever tried topical ketamine for allodynia? I’ve seen a small number of people improve with it, and some people have no effect. Check it out:

          http://www.ncbi.nlm.nih.gov/pubmed/19703730

          • It comes and goes and is only a minor annoyance so I let it be. Thanks for the tip though!

            I’m looking at sinus surgery and double jaw surgery. I haven’t heard of CPRS from these procedures. Permanent numbness is what typically happens. I guess distance from the brain matters?

          • I’ve seen CRPS of the face and it is not good. Not good at all. Although I don’t know if it was from jaw/sinus surgery.

            You should be good though with even moderate vitamin C intake (sure hope I’m not jinxing you).

          • Yeah my diet was terrible when I had that surgery – strange as it may sound, I hated fruit and didn’t eat it. Relatively few veggies. I was young, stupid, and unlucky (or lucky given that’s all that happened!).

            In any case, given that this is a Paleo blog, could you provide some food equivalent recommendations? That is, suggesting consuming 3 cups of strawberries a day instead of vitamin C and magnesium or, if unrealistic, explicitly state that supplement is needed. Also useful to have suggestions for improving bioavailability along with supplement recommendations.

            Awesome and very timely post me – thanks!

          • I’ll see if I can append some food recommendations on to part 2, or at least link to something Paul or someone else has written. Vitamin C is very bioavailable at normal doses.

        • I will undergo a big surgery soon. Before that I will need to strengthen my immune system. For that I am taking Vitamin C by IV. Not pills. It must be intravenous!

  2. Hi,

    What about the types of vitamin C?
    Pill form, IV, I’ve started making Liposomal Vit C… Which is best ?

    Thanks.

    • I’m guessing that you’re making liposomal in order to avoid GI disturbances from oral and the humungo prices of store-bought liposomal.

      IV leads to around eight times higher concentration, and while I haven’t seen studies for liposomal C, I’ve seen papers for liposomal resveratrol and the theory makes sense.

      If you need big doses frequently, I guess homemade liposomal would make sense, although I haven’t tried it (although I ran across a couple threads a while back about making it and was intrigued).

      • That’s no small dose – 4G/day! I suppose there’s no practical toxic dose for it. I’ll keep it in mind though.

        Is vitamin C uniquely special here or will other antioxidants do as well or better? Green tea, curcumin, etc.

    • IV is the best.

  3. If I were preparing that pain scale I’d definitely swap toothache with nulliparas (prepared). Or maybe it just goes right between that and causalgia. I hope to never feel anything like a dying tooth ever again!

  4. Love your sense of humor, Kamal! That intro was hilarious.

    I think the requirement for Vitamin C interacts with the status of other micronutrients. In my experience, when I developed iron deficiency (no anemia), my Vitamin C requirement went way up. I now take 500 mg each day as I try to figure out the iron thing (I seem to not be absorbing much from my high-iron diet). If I lower the dose I eventually get extremely dry, flaky skin, receding gums, skin that easily blisters, etc. I don’t know if iron status is ever controlled for as an interacting factor in these studies, so I’m not sure if this is a common thing, or just me. (Though I would assume iron would affect the tissue healing part more than the pain, but just thought I’d mention it.)

  5. Hi Kamal,

    What do you think of Camu Camu powder food-grade vitamin C?

    • While camu camu has a bunch of phytochemicals that may complement vitamin C’s antioxidant role, it seems pretty expensive for what amounts to a vitamin C source.

      Vitamin C is a lot stronger in vivo antioxidant than many phytochemicals (which test better in vitro).

  6. Hi Kamal,

    How much vitamin C is necessary to combat acne?

  7. Good post….Pain is an unpleasant conscious experience that emerges from the brain when the sum of all the available information suggests that you need to protect a particular part of your body. When a health illness or condition is chronic it means it is long-lasting. Chronic pain is pain that persists or progresses over a long period of time. Chronic pain typically has persisted for at least 3 months. visit our site for good tertments for Back Pain, Diabetes, Fibromyalgia, Thyroid. http://www.drbastomski.com/

  8. Peggy Mandell

    Kamal,
    Thank you so much for your interesting and timely post about vitamin C. We have a close friend with RSD and have therefore learned a lot about it (most of it awful). Secondly, my husband, Herb, is about to undergo bilateral knee replacement surgery and the vitamin C reminder is most helpful–we already drink ascorbic acid crystals in mineral water every day, but we just ordered more! Looks like you have become a major PHD player, and Paul must be thrilled to have you on the team. Hope your first Retreat in May goes well-wish we could be there (we were in Austin Oct – Nov).
    Peggy Mandell

    • Oh yes, I remember reading your awesome review of last fall’s retreat!

      The outcome of knee replacement surgery is likely very nutrition (and sticking with PT of course). I wish your husband the best of luck, and see you around the comments sections if not in person some time!

  9. Hi Kamal,

    I had a more general question as to how you stumble upon such interesting information. Like what spurred your interest in regards to any micronutrient reducing pain, or what pointed you in this direction? I always see such great pubmed articles when reading other blog posts but seldom come across them myself.

    • Hey Lenny — I became interested in pain after having a few orthopedic surgeries (one of which involved a big surgical error which I was trying to figure out how to rectify), and since I was in a nutrition PhD program at the time, nutrition therapy was my first thought.

      This particular article stemmed from a couple friends having developed RSD. Pubmed is such a massive beast that it’s easy to get lost in the trees. I tend to do the same thing as you – see cool research in the posts of others, then start looking on my own. Every field has a few researchers or aggregaters who tend to have new stuff. In pain science, one of those people is Lorimer Moseley from Australia.

  10. I experience mild brainfog 1 hour after heavy squats. I assume this is due to post exercise endotoxemia and 1000+ mg dose of vitamin C fixes it for me. Seeing how many references comes up by googling surgery endotoxemia this could be another way vitamin C might be helpful.

  11. What are your thoughts on food-based vs synthetic vitamin C? It’s been my shopping experience that almost all vitamin C supplements are using synthetic vitamin C which is not chemically identical to the kind that occurs naturally. As a result, I’ve stopped taking my 1g Nature Way vitamin C. Currently, I’m just trying to eat lots of lemons, limes, and peppers. Any ideas?

    • Hi Ben,

      I think synthetic C is fine. If you are healthy, then vitamin C needs of ~500 mg/day can be met with food by eating sweet peppers and citrus fruits daily. But if you are stressed, which nearly everyone is as they get older, then you should supplement.

      Best, Paul

    • I’ve read somewhere that vitamin C in real foods could have a better effect than synthetic C due to the various phytochemicals present in foods, which complement vitamin C and increase its bioavailability.
      To accomplish that with synthetic C I disolve it in a glass of squeezed lemon juice and/or I eat some fruits and veggies along.

  12. thanks. although i wish i had read this tho.

  13. Hello Kama,

    Thanks for sharing this information, i didn’t know much about the benefits behind Vitamin C on sleep apnea.

  14. Friday 140418 | CrossFit NYC - pingback on April 17, 2014 at 11:01 pm
  15. HI Kamal

    So whats your, or pauls thoughts on aspirin?

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