Niacin Deficiency

What is Niacin Deficiency?

Niacin, also known as vitamin B3, is a name that represents two similar substances, nicotinic acid and nicotinamide (also known as niacinamide). Originally, it was called the anti-black tongue factor because it helped dogs with this condition. Niacin became known to us through a disease caused by its deficiency, known as pellagra. Pellagra first came to light in Italy in the 1700s. The name ‘Pellagra’ comes from ‘pella’, meaning skin, and ‘agra’, meaning rough.

In the early 1900s, many people in the southern U.S. were affected by pellagra due to a low amount of corn, which is a key food source of niacin, in their diets. In 1937, a scientist by the name of Elvehjem and his team identified the substance and showed that pure nicotinic acid and nicotinic acid amide could cure black tongue and pellagra.

Nowadays, it’s uncommon to see niacin deficiency in industrialized countries. This is mainly because people in these countries get enough niacin through their diets. However, some people are still at risk.

In the past, pellagra in the world was mostly caused by not getting enough niacin in the diet. However, in developed nations, this is no longer the case. Pellagra is almost nonexistent due to dietary improvements. Now, when we see instances of pellagra, it’s usually linked to chronic alcoholism, conditions that impede nutrient absorption from food, certain medications’ side effects, or anorexia.

What Causes Niacin Deficiency?

Niacin, an important nutrient for your body, can be found in several foods like fish, meats, and fortified grains such as cereals and bread as well as in legumes, coffee, tea, and nuts. However, certain foods like corn, can hold onto niacin making it hard for your body to access. As a result, if your diet relies heavily on corn, you might develop a niacin deficiency, called pellagra. Your liver can also create niacin from a substance called tryptophan, so it’s important to have a diet that contains both niacin and tryptophan to maintain healthy niacin levels.

On the other hand, pellagra can also be caused by medication, excessive drinking, diseases in the digestive system, and cancers. Overconsumption of alcohol can bring about pellagra by hindering your body’s absorption of niacin. Chronic alcohol use can also interfere with your body’s ability to turn tryptophan into niacin. Since niacin is mostly absorbed in the small intestine, any disease that obstructs the absorption of nutrients there, such as chronic diarrhea, inflammatory bowel disease, and cancer, can lead to pellagra. Additionally, a disease called Hartnup results in difficulty in absorbing tryptophan, further hindering the production of niacin.

A medication called isoniazid, used in tuberculosis treatment, can increase the risk of niacin deficiency. It decreases niacin levels by inhibiting its absorption in the intestine and the production from tryptophan. There are also other tuberculosis drugs and certain cancer treatment drugs that can lead to niacin deficiency.

Furthermore, carcinoid tumors, that produce an excess of serotonin, can result in niacin deficiency. This happens because the process of creating serotonin uses up tryptophan, leaving less available for the production of niacin.

Risk Factors and Frequency for Niacin Deficiency

Niacin deficiency leads to a condition called pellagra. Although rare in industrialized nations, it can still be found in people living in poverty or those eating diets extremely low in both niacin and protein. This includes individuals who are homeless, malnourished, struggling with disorders like anorexia nervosa, suffering from malabsorption, using alcohol excessively, or taking certain medications.

• Pellagra was prevalent in African countries, even though corn, a niacin-rich food, was a staple. For example, in 1990, 6.3% of refugees in Malawi from Mozambique had pellagra.
• In about nine months, 691 people in Kasese, Malawi developed pellagra, largely because of a niacin-deficient diet.
• In Angola, approximately one-third of 723 women and 6% of 690 infants and children between 6 months and 5 years had pellagra.
• Only 0.7% of 142 Tanzanian patients aged 55 to 99 years with skin diseases were diagnosed with pellagra.

In the United States, pellagra is uncommon due to the fortification of processed flour with B vitamins. Native people in North, Central, and South America used to consume maize treated with lime or wood ashes, which enhanced the bioavailability of niacin. Pellagra is still seen in countries like African nations, India, and parts of China, despite enriched foods and less nutritional deficiency-related diseases in industrialized nations.

• In India, about 13% of 34 adolescent girls aged 10 to 13 years were deficient in niacin, but boys were not affected.
• In Thailand, a traditional meal consisted of canned fish, stir-fried roselle, ivy gourd omelettes, mung bean noodle soup, or canned fish curry with chili paste and pumpkin – this provided around 13% of the recommended niacin intake.
• Compared to vegetarian and vegan adults in Switzerland, omnivores had a low intake of niacin. However, blood tests showed that it was vegetarians who were actually deficient in this vitamin.

Signs and Symptoms of Niacin Deficiency

Pellagra is a health issue caused by a lack of niacin or tryptophan. Niacin deficiency leads to pellagra, which comes with three main symptoms: dermatitis, dementia, and diarrhea. If not addressed, it can be fatal. It often shows signs like discolored skin and sores in parts of the body that are frequently exposed to the sun, specifically the hands, elbows, knees, and feet. Other signs can range from anxiety, difficulty focusing, fatigue, and depression, to more severe conditions like dementia and delirium if the disease progresses. Pellagra can also cause complications in the digestive system, including glossitis, cheilosis, stomatitis, nausea, vomiting, and variations in bowel movements.

There are several signs and symptoms of niacin deficiency grouped into three main categories:

• Gastrointestinal Findings:
• Poor appetite, nausea, discomfort in the upper part of the abdomen, excessive saliva, and abdominal pain
• Gastritis and lack of stomach acid
• Glossitis, mouth soreness and difficulty swallowing
• The tongue may become bright red and raw-looking due to the shrinking of the papillae
• Diarrhea is often watery, but can sometimes be bloody and mucus-filled
• Skin Findings:
• Red skin with a burning sensation
• The distribution is usually symmetrical and bilateral on sun-exposed parts of the body. There can also be blisters, termed wet pellagra.
• Common areas for this rash include the cheeks, back of the hands and feet, and neck
• The skin symptoms of niacin deficiency, which improve with niacin treatment, are described as an early sign of Crohn’s disease
• Neuropsychiatric Findings:
• Fatigue, lack of interest, depression, anxiety, difficulty concentrating, and irritability
• Disorientation, confusion, and delirium
• In severe cases, the patient can become stuporous and comatose
• Muscle weakness and strange sensations might be evident upon clinical examination
• Death:
• Death can occur due to a lack of coenzymes needed to produce sufficient energy to maintain essential body functions

Testing for Niacin Deficiency

If your doctor suspects you might have a niacin deficiency, they may order several laboratory tests to confirm their suspicions. These tests include checking the levels of tryptophan, NAD, NADP, and niacin in your body. Tryptophan and NAD are types of proteins, NADP is a type of molecule that plays an essential role in our metabolism, and niacin is a type of vitamin – specifically Vitamin B3.

If your urine contains less than 5.8 micromols of a substance called N1-methylnicotinamide (NMN) per day, this could suggest you have a niacin deficiency. Another sign of potential niacin deficiency is low levels of a substance called nicotinamide adenine dinucleotide (NAD) in your red blood cells, also known as erythrocytes.

Your doctor may also opt to perform a more specialized test called high-pressure liquid chromatography (HPLC) of niacin metabolites in your urine. This test can be particularly effective at identifying a niacin deficiency.

Lastly, one of the most definitive ways to diagnose niacin deficiency is to see how you respond to niacin treatment. If your symptoms improve after being given niacin, and your other test results suggest a deficiency, then this will confirm that you have been suffering from niacin deficiency.

Treatment Options for Niacin Deficiency

Treating an insufficient levels of niacin, a critical nutrient for the body, hinges on two things. First, it’s important to address any underlying causes that might be leading to the deficiency. Second, it’s crucial to replenish the body’s stores of niacin. That’s often done through nicotinamide, a type of niacin that doesn’t cause side effects like itching or a flushed face.

Prevention is also a top priority, especially for people who may be at higher risk of developing the illness. Those measures often include adding niacin supplements to their daily routine.

Deficiencies in niacin often go hand-in-hand with other nutritional gaps, so eating a balanced diet rich in various nutrients can also go a long way in helping keep your niacin levels in the healthy range. In terms of how much niacin you need per day, it varies by age and gender. For children aged 1-8, the daily recommended amount is between 6-8 milligrams (mg) of niacin equivalents (NE), a unit of measurements that’s used for this nutrient. For boys and girls aged 9-13, it’s 12 mg/NE, and for those aged above 14, it’s 16 mg/NE for males and 14 mg/NE for females. Nursing mothers need about 17 mg/NE daily.

If a patient is being treated for tuberculosis and using isoniazid, it often makes sense to also supplement with B complex vitamins or nicotinamide. Doing so will help prevent niacin deficiency. But keep in mind, patients with alcohol consumption issues who have multiple vitamin B deficiencies should be treated carefully. If they’re given B complex that contains too little niacin or treated with pyridoxine and thiamine without also including niacin, it could worsen their neurological conditions, or even contribute to the development of a condition known as alcoholic pellagra encephalopathy.

What else can Niacin Deficiency be?

Pellagra is a medical condition that sometimes can be confused with more common skin problems caused by sunlight. Moreover, the lack of a nutrient called niacin in the body (which causes Pellagra) needs to be distinguished from general undernourishment conditions like anorexia nervosa and kwashiorkor. Kwashiorkor is a serious form of malnutrition usually associated with a swollen liver and water retention, typically seen during periods of severe food shortage. It’s also important to note that niacin deficiency can be missed in cases related to excessive alcohol use and during the process of withdrawal from alcohol.

When a patient shows signs of niacin deficiency, the doctor should consider several other conditions that could present with similar symptoms. These include:

• Acute cutaneous lupus erythematosus (a form of lupus affecting the skin)
• Crohn disease (an inflammatory bowel disease)
• Discoid lupus erythematosus (another form of lupus primarily affecting the skin)
• Drug eruptions (skin rash caused by a drug reaction)
• Drug-induced lupus erythematosus (a lupus-like disease caused by certain medications)
• Drug-induced photosensitivity (skin reaction to sunlight caused by drugs)
• Drug-induced pemphigus (a rare, blistering skin condition triggered by medications)
• Porphyria cutanea tarda (a disorder that affects the skin and nervous system)
• Ulcerative colitis (a type of inflammatory bowel disease)

What to expect with Niacin Deficiency

If pellagra is left untreated, it can become worse and even lead to death. Death can occur as a result of severe malnutrition. This malnutrition can be caused either by not eating enough, ongoing diarrhea, infections, or neurological (brain or nerve-related) factors. Without treatment for pellagra, a person may die within 4 to 5 years.

Until the early 20th century, pellagra was a common cause of death. But once food manufacturers began adding niacin to flour – a process known as fortification – the number of people suffering from pellagra (niacin deficiency) decreased dramatically in developed countries. Despite this, recent reports suggest that pellagra might still be going undiagnosed in some cases.

Possible Complications When Diagnosed with Niacin Deficiency

Niacin deficiency can lead to several complications, including a condition called pellagra. Pellagra symptoms may include mental confusion, tongue inflammation (glossitis), hair loss (alopecia), skin inflammation (dermatitis), sensitivity to sunlight, enlarged heart, peripheral nerve damage (neuritis), and memory disorder (dementia). Here’s a simple list of complications that could follow a deficiency of niacin:

• Poor nutrition and severe weight loss
• Secondary infection from skin rashes
• Mental health symptoms
• Coma
• Death

Preventing Niacin Deficiency

A lack of niacin, a type of vitamin, can be prevented by eating a diet that’s high in protein. Therefore, knowing about proper nutrition and having access to the right kinds of food is very important for prevention. Some individuals may have health conditions that prevent them from absorbing niacin properly, or they may be on medications that limit their body’s access to niacin. In these cases, a vitamin supplement might be helpful.

In areas where starvation is a high risk or where the diet is mainly corn-based and low in protein, often seen in tribal communities, it’s particularly important for food to be fortified or enriched with additional nutrients, like niacin.

Encouraging the consumption of food like milk, meat, peanuts, whole grains or grains that have been enriched with vitamins, as well as green leafy vegetables and a yeast used in brewing known as ‘brewers’ dry yeast’, can help people get more niacin in their diet. For those who have trouble swallowing food due to inflammation of the tongue (‘glossitis’), they may need to consume a diet that’s mostly semi-solid or liquid. To help with recovery, incorporating long-term foods like meat, milk and eggs can provide the protein that’s needed.