Evo Terra (Host): COPD, chronic obstructive pulmonary disease, is quite common. Scurvy, on the other hand is quite rare. Did you know there was a connection? Yeah, me neither. Luckily, Dr. Robert Reed, Professor of Medicine at the University of Maryland School of Medicine and Medical Director at the University of Maryland Lung Transplant Program at University of Maryland Medical Center, is here to help square that circle.

Welcome to the Live Greater podcast series, information for a healthier you from the University of Maryland Medical System. I'm Evo Terra. Thanks for joining me, Dr. Reed.

Robert Reed, MD: Thanks for having me.

Host: So, what is scurvy? And how does it relate to COPD? We need that circle squared.

Robert Reed, MD: It does sound like it's a little bit hard to reconcile. Scurvy is a deficiency in vitamin C. It is commonly discussed when you think about pirates and ancient times, and to find it in the modern society was a little bit of a surprise to me. But it actually is part of what drew me in to be fascinated with COPD. Because in my training, I ran into a couple of patients that had advanced COPD and I ended up diagnosing them with scurvy. And so, I thought that was fascinating. And I did some additional thinking and looking into it and found that there is indeed a link.

Host: Yeah, that had to be fascinating to discover that there was a link. Why is that? What's the history of scurvy and what role do you know that vitamin C plays?

Robert Reed, MD: Well, let me start with a history lesson, if you will. Scurvy is just fascinating. The role that it's played in world history is one that deserves a little bit of conversation. It was described as early as 1550 B.C. on the Ebers Papyrus, which is a famous medical writing that was part of the ancient Egyptians' medical knowledge back then, and they described Scurvy on that papyrus.

There was a lot of issue with scurvy, particularly in sailing. Some of the stories that have filtered into literature and even into modern cinematography, like Pirates of the Caribbean, the concept of a ghost pirate ship floating around, being run by these zombie-like sailors, it actually has some bearing in reality. And the most notable example of a ship that was really overcome with scurvy and was an example of such a ghost ship was captained by a fellow named George Anson in 1743. His job was to capture a Spanish vessel called Nuestra Señora de Covadonga, and it was carrying a tremendous treasure, and he chased this ship all around the world and eventually did capture it. And it had 1.3 million pieces of eight that they captured from this ship. But the ultimate demise of that ship was due to scurvy. There were four men on that boat that died of enemy action, and there were about 1,300 that died primarily from scurvy. And the stories of that boat really paint quite a picture of a ghost ship.

In one incredible case, there was a sailor who had had a wound in 1690 at the Battle of Boyne, and he'd had a bone that broke and it healed. And when he developed scurvy, it broke back again at that exact point where it had been broken before. The word scurvy itself is actually kind of telling about the disease. The word scurvy in English comes from the French word scorbut, which comes from Latin scorbutus, which comes from Middle Low German, schorbuk, which is a combination of two words, schoren, which is break, and buk is belly, so it's break belly, that likely comes from the observation that when we develop scurvy, some of our old wounds that healed open up again. And that's right there in the name of it. So, I'll go on with the history because it continues.

The first ever randomized experiment in the history of medicine was in 1747. There was a physician named James Lind, who was treating over a dozen sailors with scurvy. And there were six different groups that he assigned different treatments ranging from just drinking salt water from the ocean to one group included treatment with fresh fruit. And lo and behold, the two sailors that were being treated with fresh fruit were fit for duty in just a matter of days. The rest of the groups didn't fare so well. And so, James Lind went on to publish a treatise on scurvy and he made mention of George Anson. He actually dedicated his treatise to George Anson, the captain of that fateful ghost ship that was so overtaken with scurvy.

And then, the history continues because it was really fascinating. The Revolutionary War was shortly after this experiment. The American Revolutionary War was between 1775 and 1783. And scurvy played a huge role. Despite James Lind already having kind of found the cure for scurvy, it wasn't implemented on the British ships. And so, the vessels were not able to blockade French ports. And so, they couldn't prevent the French from reinforcing the American colonists. They also had very long supply lines to reinforce their troops in the Americas. And they had to put their sailors on ships and cross the ocean, and those sailors were susceptible to scurvy. So, scurvy really impeded the British efforts to fight the colonists. And lo and behold, America won that war and became an independent country.

Now, in 1795, this was almost 50 years after James Lind had his experiment. There was a fellow named Gilbert Blane who implemented lemon rations on British ships. So, all of a sudden, scurvy was a thing of the past. And the British ships were revolutionized. They were able to float around blockade ports, and they were the masters of the sea. And the timing was right, because in 1803, the Napoleonic Wars broke out. And Napoleon tried to sail across the English Channel and take over England. But with a much smaller group of, Navy vessels, the British were able to repel Napoleon in the Battle of Trafalgar, and it was such a humiliating defeat that Napoleon turned tail and decided to take his troops into Russia during the winter, and that never works out well. That was the end of Napoleon. And so, there's the history of how scurvy shaped the world.

Host: That's amazing. And I've known a little bit about the history of scurvy, but not quite the details that we went into there. So, thanks for the history lesson. So, vitamin C, that's what fixes scurvy as I understand it. Is that correct?

Robert Reed, MD: That's correct. Actually, there was a scientist who discovered vitamin C, and he had a little bit of a sense of humor, and he tried to call it Godnose, or Ignose. And the reviewers thought that that wasn't very funny at all, and they refused to let him publish it calling it that. He found out that it was the cure for scurvy when he discovered this vitamin C molecule, so he named it ascorbic acid.

Host: I kind of thought scurvy was a thing of the past, but still, it must be relevant today. Risk factors for scurvy, and how are they associated with an individual with COPD?

Robert Reed, MD: Sure. Well, it's related to COPD for me because the first couple of patients I ever diagnosed with scurvy were people with COPD. And it turns out that in patients with severe COPD, about half of them are malnourished in some way. And it turns out that scurvy is going to be more common in them.

It's fascinating that modern American diet is one that is actually fairly devoid of vitamin C. If you look at some of the common sources that you would think have vitamin C in them, they're actually not so great. One of the patients that I first diagnosed with COPD was eating these little fruit cocktail cups with the little cut up fruit in a can. And if you look on the back of those cans, they have 4% of the recommended daily allowance of vitamin C, and the reason that's there is to maintain color. Actually, the original vitamin C from the fruit is all gone. They just add a little bit of vitamin C back to maintain the color of the fruit so it doesn't all look gray. If you consider the dried fruit, if you have one of those little cans of dried apricots, and you would think that that would be a good source of vitamin C, but turn it around and look on the back, zero percent. There is no vitamin C in that. Even artificial lime juice, if you get the real lime juice that has the flavor of lime juice in it, you flip that around, zero. No vitamin C in that at all. So, how about orange juice? You flip that around, oh, well that's actually 130%. That's a good source of vitamin C. And actually, the primary source of vitamin C in the American diet is orange juice.

One of the more fascinating things to me as I was learning about this is that those tubes of frozen orange juice that you squeeze out and you reconstitute with water, those are actually the best. They preserve the vitamin C content of the orange better than all the other types. That fresh squeezed orange juice, probably okay if you get it right away. But if you get the liquid orange juice in the store, It's not going to have as much bang for your buck in terms of the vitamin C content as just the reconstituted orange juice. Surprising.

Host: That's all amazing stuff that, you know, we don't think about. We assume the things that we're eating is good. But again, here's a pro tip, people, flip the can around, look at the nutritional label on the back, that's what it exists for. So, okay, we're deficient in vitamin C, I know you're connection to scurvy now with it, but how does malnutrition contribute to both of these things, scurvy and COPD?

Robert Reed, MD: Right. That's a very interesting question as well. If you look at the U.S. Recommended Daily Allowance for vitamin C, you'll see a couple of numbers there. And the way that they were generated dates back to some experiments done in the 1980s where young healthy men were given a diet devoid of vitamin C and they induced scurvy. They followed these folks over time to the point where they developed scurvy. And then, they gave them small amounts of vitamin C back in order to see what the minimum amount of vitamin C in the diet would be necessary to treat and reverse the effects of the deficiency. And they use that information to come up with a recommended daily allowance. It doesn't really incorporate in people that are older or sicker, have COPD, active smokers. So if you look at the recommended daily allowance, there's actually a little note there that says that active smokers require more vitamin C in their diet than somebody who doesn't smoke.

The reason for that is twofold, and they found out these associations through large population studies where they measured both the amount of vitamin C that was in the diet, as well as the amount of vitamin C that was in the blood of quite a number of people, and they found that smokers were much more likely to be deficient in vitamin C. And the reason for it was, one, they were eating a diet that had less vitamin C in it. They had just a taste preference that was towards other things. You can kind of think, well, these folks with a cigarette in hand probably have a coffee in the other hand instead of an orange juice.

The other factor was that for any given amount of nutritional intake of vitamin C, smokers actually had lower levels of vitamin C in their blood. And so, it shows that not only are they eating less vitamin C-rich foods, but for any amount of the foods that they do eat, they require more vitamin C. And vitamin C is integral to a lot of different functions of the body. Normal lung function is one of them. And I think that it is an antioxidant and the oxidizing effects of smoking and behaviors that get you into a position of having COPD are the same behaviors that put you at risk for developing scurvy.

Host: I want to ask you a question about nutrition in a moment. But before I do that, for the individuals who might have COPD, what are the early signs of scurvy? What should they be looking out for?

Robert Reed, MD: What does scurvy look like? Well, we'll go back to the history lesson again. There have been a lot of discussions around what scurvy looks like in the literature. A young medical student back in the beginning of World War II decided he would look into, and he got a couple of his med student friends to be involved in an experiment with him where they would take on a diet that was devoid of vitamin C and just cataloged what was going on as they developed scurvy and they were interested in wound healing as well.

Well, he found his buddies in the cafeteria drinking orange juice, so he kicked them out of the study, but he continued along alone. He measured levels of vitamin C in his blood. And after 44 days of level of zero, he ended up making a cut on himself of about 6 centimeters. And he biopsied it 10 days later and showed that it was healing normally. So, he did have some symptoms at that time, but he went on to continue the diet without any vitamin C in it. And he continued for another 100 days. And after about 140 days of having a vitamin C level of zero, he repeated that cut. And 10 days later, there was no healing at all. That was informative of what vitamin C was like. And he did also describe some of the issues that he developed over time, but there was actually a repeated experiment in the 1980s where they took a young man and gave him a diet devoid of vitamin C and followed him over time. And they really documented the onset and progression of scurvy symptoms.

So at about a month, you start to develop these things called petechiae that are really like very small bruises. And they're mostly around the hairs on your body. Easy bruising also develops. There are some characteristic changes to the hairs themselves. They'll come out of the skin in a coiled way that looks really unusual and it's very characteristic of scurvy to have those coiled hairs, and the hair follicles themselves will have a little bit of extra skin around them that's adherent. It's all called hyperkeratosis and congested follicles. The gums will become a little bit abnormal, although I've found that that's a little hard to really hang my head on and identify. And if the scurvy progresses, the teeth can actually fall out. And that's the most irreversible of the symptoms of scurvy. There can be manifestations like bleeding around nerves and even passing out when it gets very extreme. Ultimately, it can lead to death.

Host: Wow. Okay. So, we don't want scurvy, period. End of story. Understood. Let's talk about nutrition. And specifically for people who do have COPD, how can they ensure that they are maintaining a well-balanced diet?

Robert Reed, MD: Well, I think that it applies to everybody. It is probably more important for folks with COPD, because they do have higher nutritional requirements for some things like vitamin C, but everybody should eat a healthy diet with some fresh fruits and vegetables in it. They should avoid smoking. Smoking is bad for you. It eats up a lot of the nutrition that you're otherwise going to use for things that you'd like to do with your body, like heal and move around. So, it's just another smoking cessation ad here. Don't smoke because you'll get scurvy. There's no rocket science here. If you look at your food and it looks like food, eat it. If it looks like a fried piece of whatever, then it's probably not all that nutritionally valuable.

Host: Yeah. That makes sense. You know, we're talking about scurvy and vitamin C and COPD. I'll ask you kind of a technical question here. What's the role vitamin C plays in respiratory health specifically?

Robert Reed, MD: The link is a bit indirect, to be honest. It is something that can certainly make respiratory health worse. It can affect the function of the surfactant in the airways and the lungs themselves. It can change the way that the fluid is handled by your body so that you retain fluid, and that can make you short of breath. It can cause a lot of problems, but really the primary issue is that of the patients that develop these problems are ones that are smokers. Those again are the folks that are less likely to have a good nutritious diet and less likely to get as much of the nutrition out of their diet, as they would if they weren't smokers. So, that's really the link right there.

Host: Individuals who have COPD, how can they work with their health care providers to prevent and address any nutritional deficiencies? Is it all on them? Or is it something that they can do, that COPD patient can do in conjunction with their healthcare provider?  

Robert Reed, MD: It's certainly something that they can engage their healthcare provider in a conversation around. The studies on folks with COPD who were nutritionally deficient found that there were two different flavors. There was COPD cachexia, which is an irreversible condition. It doesn't matter how much they eat. They aren't going to gain weight. They aren't going to put on muscle. And then, there's malnutrition. And those folks do better if they eat more and put on muscle and put on strength. So, working to find a way to optimize your nutrition and to quit smoking and to dedicate yourself to health is important.

I think that one of the other factors that is more of a function of our modern society is that you can be nutritionally deficient and be overweight. And that is something that is appreciated by physicians, for sure. And I think that just understanding what constitutes good, healthy nutrition that is offering an appropriate amount of calories versus a high caloric, low nutritional value diet is important for people to have conversations around. Sometimes I've had patients that were so severely limited by their lung disease, it's just hard for them to go out and get good nutritious food. They can't get to the store that often. It's a chore. And finding clever ways to get around that, asking for input from social work, meals on wheels, just other ways to get access to good nutritional food is one way to engage with a healthcare provider if getting access to food is a barrier?

Host: And for those who've already been diagnosed with scurvy or, I guess, are at risk for scurvy, what treatment options are available and specifically how can they integrate those treatment options into their overall COPD management plan?

Robert Reed, MD: Well, I think that if you've been diagnosed with scurvy, then it's possible that you could have another nutritional deficiency. Treating scurvy is easy. If you take a vitamin C pill, it can replete your body's supply of vitamin C very quickly. It's important to recognize that if you have any vitamin deficiency, it's a reflection of a diet that isn't meeting your needs and you really ought to just look at what you're eating and think about whether you can do better.

Host: Well, Dr. Reed, thank you very much for all of the information today. It was very, very fantastic. I want to thank my guest, Dr. Robert Reed. He's the Professor of Medicine at the University of Maryland School of Medicine and Medical Director of the University of Maryland Lung Transplant Program at University of Maryland Medical Center. For more episodes just like this one, you can find them at umms.org/podcast and on the University of Maryland Medical System's YouTube channel. If you found this episode helpful, please share it on your social channels and check out the full podcast library for topics of interest to you. I'm Evo Terra. Thank you for listening to Live Greater, a health and wellness podcast brought to you by the University of Maryland Medical System. We look forward to you joining us again.