Pellagra: Interesting Alert-NIH

WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite the treatable dementia and psychosis, pellagra is often under-diagnosed, especially in developed countries and alcoholic patients. Pellagra should be routinely suspected in alcoholic patients because the response to appropriate treatment is typically dramatic.

Alcoholic Pellagra as a Cause of Altered Mental Status in the Emergency Department ~ Source-NIH


Pellagra, which is caused by a deficiency of niacin and tryptophan, the precursor of niacin, is a rare disease in developed countries where alcoholism is a major risk factor due to malnutrition and lack of B vitamins. Although pellagra involves treatable dementia and psychosis, it is often underdiagnosed, especially in developed countries.


In Japan, a 37-year-old man presented to the emergency department with altered mental status and seizures. Wernicke encephalopathy and alcohol withdrawal were suspected. The patient was treated with multivitamins, which did not include nicotinic acid amide, and oral diazepam. Despite medical treatment, his cognitive impairment progressively worsened, and eventually, pellagra was suspected. His response to treatment with nicotinic acid amide was substantial, and he was discharged without any long-term sequelae. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Despite the treatable dementia and psychosis, pellagra is often underdiagnosed, especially in developed countries and alcoholic patients. Pellagra should be routinely suspected in alcoholic patients because the response to appropriate treatment is typically dramatic.

Niacin: No flush, No good.

More on niacin: No flush, no good

Several readers wrote in wanting to know more about why we don’t recommend no-flush niacin products. A little bit of background will help us explain.

The term niacin comes from nicotinic acid vitamin, but it’s used to refer to both nicotinic acid and a closely related molecule, nicotinamide. Both nicotinic acid and nicotinamide are necessary to prevent pellagra, a disease that causes skin inflammation, diarrhea, and dementia. After they were first discovered in the 1930s, nicotinic acid and nicotinamide were known for a time as the pellagra-preventing vitamins.

In the mid-1950s, researchers discovered that nicotinic acid — but not nicotinamide — was remarkably effective at lowering cholesterol and triglyceride levels. We talk about niacin having these good effects, partly because niacin appears on ingredient and nutrition labels, but strictly speaking, it’s just nicotinic acid that does.

Nicotinic acid — but again, not nicotinamide — also triggers the release of prostaglandins that cause flushing, a more severe and sometimes uncomfortable form of the blushing that occurs when we’re embarrassed. So researchers have looked for ways to chemically package nicotinic acid so it retains its cholesterol- and triglyceride-lowering effects but doesn’t turn people red-faced.

Inositol hexaniacinate looked like it might be the answer. It’s a combination of six molecules of nicotinic acid (thus hexaniacinate) and one molecule of inositol. The hope was that it would break down slowly so the nicotinic acid would hit the bloodstream gradually and not cause flushing.

Results in rabbits were promising. But in a number of trials conducted in people in the late 1970s, the compound had little, if any, effect on cholesterol. Other research has shown peak levels of nicotinic acid in the blood from inositol hexaniacinate were a tiny fraction of those seen after a person took crystalline or sustained-release forms of niacin.

The niacin in every no-flush product we’ve seen comes as inositol hexaniacinate. The no-flush claim is true enough, but the credible evidence we know of suggests that you aren’t likely to see the cholesterol or triglyceride benefits, either. For a niacin product to have an effect on cholesterol and triglyceride levels, the niacin must be in the form of nicotinic acid — not inositol hexaniacinate or nicotinamide.

Nicotine, Niacin and Double Vision

A cursory study into tobacco use by teenagers appears to have discovered a new door into the causes of teenage smoking.  Nicotine has long been accepted as the addictive portion of tobacco products, but what is apparently little known is that nicotine and niacin (vitamin B3) are analogues.  An examination into this previously untrod avenue may yield significant new data into the treatment of teenage tobacco use.

Much research has been done establishing that teenagers do use tobacco, but very little has looked into the actual causes and none could be found on E.R.I.C. that has been done from the aspect that tobacco may fulfill a nutritional need.

As a parent of six children and a non-traditional graduate student, adolescent smoking is something I have had to deal with at least six times. As a graduate student with a grounding in communication, it is of primary concern to me, with all the information targeting teen smoking, that there has not been a more significant effect on the target audience — adolescents.

The Federal Interagency Forum on Child and Family Statistics (1998) shows a steady increase in smoking in that while 9% of the children in the 8th grade surveyed admitted to smoking every day, 24.6% of the 12th graders smoke daily.

The Federal Interagency Forum offered no answers but did recommend more study.

The statistics would seem to show that Festinger’s Theory of  Cognitive Dissonance (Festinger, L. 1957) does not apply to smoking.  Applying  Festinger’s theory, a greater amount of resources dedicated to preventing teen smoking should have led to a greater decrease in teen smoking, but that does not seem to be the case.  In fact, the opposite seems to have occurred. The teenagers exposed to the larger amount of anti-smoking information (the 12th Graders) were almost 3 times as likely to be smokers. This led me to ask whether the addictiveness of nicotine might have some influence on why a theory like Festinger’s, so well grounded in other areas, did not seem to work here.

Teenagers use tobacco.  That is an established fact.  What is up for contention is why do teenagers use tobacco, in spite of all the propaganda cultural pressure aimed at telling them not to. Many court cases have been fought on this issue but there is still little current information due to the mutability of the subject matter, children.

If teenager’s diets are niacin deficient and their bodies know what their minds don’t ( and their teachers won’t tell them), that niacin and nicotine are the same thing, their bodies would make them crave tobacco as the source of a necessary nutrient, but being a matter of taste, they would not be able to describe it scientifically.  An anecdotal reply might be — “I don’t know why I like it; I just do,”  with no understanding that it’s fulfilling necessary needs of the nervous system, like orange juice provides antioxidants for the body..  B Complex vitamins are just as important as vitamin C.  A lack of vitamin C compromises the immune system; a lack of B vitamins compromises the nervous system.

Another example is Iodine. Iodine is a poison but it is also a necessary nutrient. The body only needs a thimble full of Iodine for a lifetime but without that thimble full a lifetime is only a few years. The endocrine system self destructs without it. A smoker may only get a thimble full of Niacin from a lifetime of smoking (10-20mcg per cigarette), but at least they have that lifetime to discover and correct the problem (poor diet, alcoholism or malabsorptive bowel), which is how to get the Niacin without the other 43 carcinogenic substances the American Cancer Society has identified in Tobacco smoke.

The intention of this study is to discover if teenage tobacco use, smoking and other, may be the result of a niacin deficient diet, not tobacco advertising.  There may appear to have been an intentional deception in hiding the fact that niacin and nicotine are basically the same thing, but simply put, it’s because until now there has been no funding to look at tobacco from the point of view of a nutritional function. Tobacco has been used for a wide range of other maladies from Asthma ( Niacin prevents Histamine release Robert Thompson to Bowel obstruction (A Modern Herbal guide 1931).

My argument is that the real cause has been overlooked in the “rush to judgment” and nutritional deficiencies have been misdiagnosed as mere addictions, subject to whim and will. The body needs niacin and it knows nicotine will work if niacin isn’t available. This is not a conscious function.

The objective is to decrease adolescent smoking by removing the dietary deficiency, hence the body’s need for the nicotine. The U.S. RDA for niacin ranges from about 15mg to about 20mg per day, but to get that much a person needs to eat a serving of chicken , a serving of turkey, a serving of Spinach and a bowl of fortified cereal each day or smoke 2 packs of cigarettes.

This shed an entirely new light on the problem of teen smoking. It meant that teens might not be smoking because it was “cool” or because the nicotine was addictive; it might be because tobacco was fulfilling a nutritional deficiency in their diets.  Niacin deficiency is common outside the United States and, in its severest form, Pellagra, it can kill.  It is rare in this country because since Dr Goldberger discovered niacin as a nutrient in 1895, corn meal and wheat flour have been fortified much the same way as salt is fortified with iodine.

Iodine, as a substance, is a poison, but in very small amounts, it is required by the body for thyroid function and preventing unwanted growths like goiters. A body requires less than a thimbleful of iodine for a lifetime, but without that thimbleful, it doesn’t have a life. Niacin is similar in that it doesn’t take a lot (20 mg RDA) and too much is toxic. A single gram of niacin is toxic to most humans.

Niacin, like iodine, is hard to find in the diet without supplementing it somewhere.  For example, to receive the Recommended Daily Allowance (RDA) of niacin (20 mg), a person would need to eat 3 servings of poultry, 3 servings of pork and a baked potato with skin to get 20 mg of natural niacin. Other alternatives would include 5 bowls of fortified cereal or 15 servings of french fries. Another problem is that some people with gastrointestinal problems have trouble absorbing niacin, even if it is in the diet.

I realized that there was nothing wrong with Festinger’s Theory; what was wrong was the current view of nicotine as a cultural or behavioral symptom. A person has only 2 choices when it comes to oxygen, do it or die. The same choice applies to niacin and iodine. Without it we die.  Lack of niacin or iodine may not be as quick a death as a lack of oxygen, but the results are just as certain.

The result of this information was the formulation of a theory that teenagers may be smoking to fulfill the nutritional need for niacin. In order to test this, a comparison will be done comparing teen smoking and diet. The best way to do this is with a controlled survey of the high schools. If the information from the survey supports that teen smoking has a dietary link, then efforts will be made to improve the nutritional levels of that segment of our society that seems to have the least concern for nutrition, teenagers.