Helicobacter pylori infection reduces systemic availability of dietary vitamin C

Association between dietary antioxidant index and risk of Helicobacter pylori infection among adults: a case-control study

Backgrounds and aims

One of the most important risk factors for Helicobacter pylori (H. pylori) infection is nutrition. Balanced diets with high antioxidant properties may have protective effects against the consequences of this infection. In the current study, we aimed to investigate the association between the dietary antioxidant index and the risk of H. pylori infection among adults.

Methods

In a case–control study the dietary intake of patients with H. pylori infection was compared with healthy subjects. The dietary antioxidant index (DAI) was calculated using dietary intakes derived from a validated food frequency questionnaire (FFQ). Demographic information was obtained by a related questionnaire and Physical Activity was measured by International Physical Activity Questionnaire (IPAQ) were used to obtain information. Using logistic regression models, we evaluated the association between the DAI and H. pylori infection risk. The significance level was determined as P < 0.05.

Results

Finally, dietary data of 148 cases and 302 controls (mean age: 38.72 ± 10.61 (were analyzed. The mean of total DAI was significantly higher in controls (7.67) when compared with H. pylori cases (3.57) (P < 0.001). After adjustment for covariates, participants with less than median DAI values had an increased risk of H. pylori onset (adjusted OR 1.08, 95% CI: 1.02–1.12, P < 0.001).

Conclusions

Appropriate intake of nutrient antioxidants may have a role in decreasing the likelihood of H. pylori infection risk.

The Effects of Vitamins and Micronutrients on Helicobacter pylori Pathogenicity, Survival, and Eradication: A Crosstalk between Micronutrients and Immune System

Helicobacter pylori as a class I carcinogen is correlated with a variety of severe gastroduodenal diseases; therefore, H. pylori eradication has become a priority to prevent gastric carcinogenesis. However, due to the emergence and spread of multidrug and single drug resistance mechanisms in H. pylori, as well as serious side effects of currently used antibiotic interventions, achieving successful H. pylori eradication has become exceedingly difficult. Recent studies expressed the intention of seeking novel strategies to improve H. pylori management and reduce the risk of H. pylori-associated intestinal and extragastrointestinal disorders. For which, vitamin supplementation has been demonstrated in many studies to have a tight interaction with H. pylori infection, either directly through the regulation of the host inflammatory pathways or indirectly by promoting the host immune response. On the other hand, H. pylori infection is reported to result in micronutrient malabsorption or deficiency. Furthermore, serum levels of particular micronutrients, especially vitamin D, are inversely correlated to the risk of H. pylori infection and eradication failure. Accordingly, vitamin supplementation might increase the efficiency of H. pylori eradication and reduce the risk of drug-related adverse effects. Therefore, this review aims at highlighting the regulatory role of micronutrients in H. pylori-induced host immune response and their potential capacity, as intrinsic antioxidants, for reducing oxidative stress and inflammation. We also discuss the uncovered mechanisms underlying the molecular and serological interactions between micronutrients and H. pylori infection to present a perspective for innovative in vitro investigations, as well as novel clinical implications.

Vitamins and Helicobacter pylori: An Updated Comprehensive Meta-Analysis and Systematic Review

Background

Over recent decades, epidemiological studies have shown relationships between vitamins and Helicobacter pylori (H. pylori) infection and eradication, but the results are controversial.

Methods

A comprehensive meta-analysis and systematic review were conducted to clarify the relationships between common types of vitamins and H. pylori. We applied meta-regression, subgroup analysis and sensitivity analysis to obtain available evidence. Articles published from January 1991 to June 2021 in PubMed, EMBASE, and the Cochrane Library were searched.

Results

In total, we identified 48 studies. The results indicate that H. pylori -positive patients had lower serum vitamin B₁₂ [standardized mean difference (SMD) = −0.30; 95% confidence interval (CI): −0.53 – −0.08], folate (SMD = −0.69; 95% CI: −1.34 – −0.04), vitamin C (SMD = −0.37; 95%CI: −0.57 – −0.18) and vitamin D (SMD = −0.34; 95% CI: −0.49 – −0.18) levels than H. pylori-negative patients. Patients in which H. pylori had been successfully eradicated had higher serum vitamin D levels (SMD = 1.37; 95% CI: 0.37–2.38) than in patients in which eradication had been unsuccessful. The serum vitamin B₁₂ levels of H. pylori-positive patients improved after successful H. pylori eradication therapy (SMD = 1.85; 95% CI: 0.81–2.90), and antioxidant vitamin supplementation to an H. pylori eradication regimen improved the eradication rate (risk ratio = 1.22; 95% CI: 1.02–1.44 for per-protocol analysis; risk ratio = 1.25; 95% CI: 1.06–1.47 for intention-to-treat analysis).

Conclusions

H. pylori infections decrease the serum levels of several types of vitamins, eradication of H. pylori could rescue its adverse effects, and antioxidant vitamin supplementation may improve the H. pylori eradication rate.

Systematic Review Registration

identifier: CRD42021268127.

Overview of Helicobacter pylori Infection: Clinical Features, Treatment, and Nutritional Aspects

Helicobacter pylori (H. pylori) is a 0.5-1 µm wide, 2-4 µm long, short helical, S-shaped Gram-negative microorganism. It is mostly found in the pyloric region of the stomach and causes chronic gastric infection. It is estimated that these bacteria infect more than half of the world's population. The mode of transmission and infection of H. pylori is still not known exactly, but the faecal-oral and oral-oral routes via water or food consumption are thought to be a very common cause. In the last three decades, research interest has increased regarding the pathogenicity, microbial activity, genetic predisposition, and clinical treatments to understand the severity of gastric atrophy and gastric cancer caused by H. pylori. Studies have suggested a relationship between H. pylori infection and malabsorption of essential micronutrients, and noted that H. pylori infection may affect the prevalence of malnutrition in some risk groups. On the other hand, dietary factors may play a considerably important role in H. pylori infection, and it has been reported that an adequate and balanced diet, especially high fruit and vegetable consumption and low processed salty food consumption, has a protective effect against the outcomes of H. pylori infection. The present review provides an overview of all aspects of H. pylori infection, such as clinical features, treatment, and nutrition.

Common Pitfalls in the Management of Patients with Micronutrient Deficiency: Keep in Mind the Stomach

Micronutrient deficiencies are relatively common, in particular iron and cobalamin deficiency, and may potentially lead to life-threatening clinical consequences when not promptly recognized and treated, especially in elderly patients. The stomach plays an important role in the homeostasis of some important hematopoietic micronutrients like iron and cobalamin, and probably in others equally important such as ascorbic acid, calcium, and magnesium. A key role is played by the corpus oxyntic mucosa composed of parietal cells whose main function is gastric acid secretion and intrinsic factor production. Gastric acid secretion is necessary for the digestion and absorption of cobalamin and the absorption of iron, calcium, and probably magnesium, and is also essential for the absorption, secretion, and activation of ascorbic acid. Several pathological conditions such as Helicobacter pylori-related gastritis, corpus atrophic gastritis, as well as antisecretory drugs, and gastric surgery may interfere with the normal functioning of gastric oxyntic mucosa and micronutrients homeostasis. Investigation of the stomach by gastroscopy plus biopsies should always be considered in the management of patients with micronutrient deficiencies. The current review focuses on the physiological and pathophysiological aspects of gastric acid secretion and the role of the stomach in iron, cobalamin, calcium, and magnesium deficiency and ascorbate homeostasis.

Attenuated Total Reflectance Fourier Transform Infrared Spectroscopy (FTIR) and Artificial Neural Networks Applied to Investigate Quantitative Changes of Selected Soluble Biomarkers, Correlated with H. pylori Infection in Children and Presumable Consequent Delayed Growth

Helicobacter pylori infections causing gastroduodenal disorders are a common medical problem. The aim of this study was to determine the specific motives of infrared spectroscopy (IR) spectra of sera from H. pylori-infected and uninfected children applied to investigate quantitatively-selected soluble biomarkers correlated with H. pylori infection in children and presumable consequent delayed growth. Sera from 41 children infected with H. pylori (Hp(+)) and 43 uninfected (Hp(-)) under the care of the Polish Mother's Hospital in Lodz, Poland, were analyzed. The H. pylori status was confirmed by gastroscopy, ¹³C urea breath testing, and anti-H. pylori IgG antibodies. Infrared spectra were measured using an FTIR/FT-NIR Spectrum 400 spectrometer (PerkinElmer). The IR spectrum was measured in the wavenumber range 3000-750 cm^-1 and subjected to mathematical calculation of the first derivative. Based on the chi-square test, 10 wavenumbers of spectra correlating with H. pylori infection were selected for use in designing an artificial neural network. Ten parts of the IR spectra correlating with H. pylori infection were identified in the W2 and W3 windows associated mainly with proteins and the W4 window related to nucleic acids and hydrocarbons. Artificial neural networks for H. pylori infection were developed based on chemometric data. By mathematical modeling, children were classified towards H. pylori infection in conjunction with elevated levels of selected biomarkers in serum potentially related to growth retardation. The study concludes that IR spectroscopy and artificial neural networks may help to confirm H. pylori-driven growth disorders in children.

Plasma Vitamin C Concentrations Were Negatively Associated with Tingling, Prickling or Pins and Needles Sensation in Patients with Postherpetic Neuralgia

Vitamin C deficiency increases the risk of postherpetic neuralgia (PHN). In this cross-sectional study, the relationships among plasma vitamin C concentrations, pain and Leeds assessment of neuropathic symptoms and signs (LANSS) items were investigated during their first pain clinic visit of 120 PHN patients. The factors associated with vitamin C deficiency were determined. Independent predictors of vitamin C deficiency were presented as adjusted odds ratios (AOR) and 95% confidence intervals (CI). The patients had a high prevalence (52.5%) of vitamin C deficiency. Their plasma vitamin C concentrations were negatively associated with spontaneous pain and tingling, prickling or pins and needles sensation according to the LANSS questionnaire. Based on the receiver operator characteristic curve, the cutoffs for plasma vitamin C to predict moderate-to-severe and severe symptoms of sharp sensation were <7.05 and <5.68 mg/L, respectively. By comparison, the patients well-nourished with vitamin C had lower incidences of sharp sensations, sharp pain, and reddish skin. Multivariate analyses revealed that vitamin C deficiency was associated with the low intake of fruit/vegetables (AOR 2.66, 95% CI 1.09–6.48, p = 0.032), peptic ulcer disease (AOR 3.25, 95% CI 1.28–8.28, p = 0.014), and smoking (AOR 3.60, 95% CI 1.33–9.77, p = 0.010). Future studies are needed to substantiate these findings.

Association Between Lifestyle Factors, Vitamin and Garlic Supplementation, and Gastric Cancer Outcomes: A Secondary Analysis of a Randomized Clinical Trial

IMPORTANCE

The associations of lifestyle factors with gastric cancer (GC) are still underexplored in populations in China. Long-term nutritional supplementation may prevent GC in high-risk populations, but the possible effect modification by lifestyle factors remains unknown.

OBJECTIVE

To evaluate how lifestyle factors, including smoking, alcohol intake, and diet, may change the risk of GC incidence and mortality and whether the effects of vitamin and garlic supplementation on GC are associated with major lifestyle factors.

DESIGN, SETTING, AND PARTICIPANTS

This is a secondary analysis of the Shandong Intervention Trial, a masked, randomized, placebo-controlled trial that aimed to assess the effect of vitamin and garlic supplementations and Helicobacter pylori treatment on GC in a factorial design with 22.3 years of follow-up. The study took place in Linqu County, Shandong province, China, a high-risk area for GC. Data were collected from Jully 1995 to December 2017. Overall, 3365 participants aged 35 to 64 years identified in 13 randomly selected villages who agreed to undergo gastroscopy were invited to participate in the trial and were included in the analysis. Data analysis was conducted from March to May 2019.

INTERVENTIONS

Participants received vitamin and garlic supplementation for 7.3 years, H pylori treatment for 2 weeks (among participants with H pylori ), or placebo.

MAIN OUTCOMES AND MEASURES

The primary outcomes were GC incidence and GC mortality (1995-2017). We also examined the progression of gastric lesions (1995-2003) as a secondary outcome.

RESULTS

Of the 3365 participants (mean [SD] age, 47.1 [9.2] years; 1639 [48.7%] women), 1677 (49.8%) were randomized to receive active vitamin supplementation, with 1688 (50.2%) receiving placebo, and 1678 (49.9%) receiving active garlic supplementation, with 1687 (50.1%) receiving placebo. Overall, 151 GC cases (4.5%) and 94 GC deaths (2.8%) were identified. Smoking was associated with increased risk of GC incidence (odds ratio, 1.72; 95% CI, 1.003-2.93) and mortality (hazard ratio [HR], 2.01; 95% CI, 1.01-3.98). Smoking was not associated with changes to the effects of vitamin or garlic supplementation. The protective effect on GC mortality associated with garlic supplementation was observed only among those not drinking alcohol (never drank alcohol: HR, 0.33; 95% CI, 0.15-0.75; ever drank alcohol: HR, 0.92; 95% CI, 0.55-1.54; P for interaction = .03), and significant interactions were only seen among participants with H pylori (never drank alcohol: HR, 0.31; 95% CI, 0.12-0.78; ever drank alcohol: HR, 0.91; 95% CI, 0.52-1.60; P for interaction = .04). No significant interactions between vitamin supplementation and lifestyle factors were found.

CONCLUSIONS AND RELEVANCE

In this secondary analysis of a randomized clinical trial, smoking was associated with an increased risk of GC incidence and mortality. Not drinking alcohol was associated with a stronger beneficial effect of garlic supplementation on GC prevention. Our findings provide new insights into lifestyle intervention for GC prevention, suggesting that mass GC prevention strategies may need to be tailored to specific population subgroups to maximize the potential beneficial effect.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00339768.

Unraveling the factors and mechanism involved in persistence: Host-pathogen interactions in Helicobacter pylori

Helicobacter pylori and humans have one of the most complex relationships in nature. How a bacterium manages to live in one of the harshest and hostile environments is a topic of unraveling mysteries. H. pylori is a prevalent species and it colonizes the human gut of more than 50% of the world population. It infects the epithelial region of antrum and persists there for a long period. Over the time of evolution, H. pylori has developed complex strategies to extend the degree of inflammation in gastric mucosa. H. pylori needs specific adaptations for initial colonization into the host environment like helical shape, flagellar movement, chemotaxis, and the production of urease enzyme that neutralizes acidic environment of the stomach. There are several factors from the bacterium as well as from the host that participate in these complex interactions. On the other hand, to establish the persistent infection, H. pylori escapes the immune system by mimicking the host antigens. This pathogen has the ability to dodge the immune system and then persist there in the form of host cell, which leads to immune tolerance. H. pylori has an ability to manipulate its own pathogen-associated molecular patterns, which leads to an inhibition in the binding with specific pattern recognition receptors of the host to avoid immune cell detection. Also, it manipulates the host metabolic homeostasis in the gastric epithelium. Besides, it has several genes, which may get involved in the acquisition of nutrition from the host to survive longer in the host. Due to the persistence of H. pylori, it causes chronic inflammation and raises the chances of gastric cancer. This review highlights the important elements, which are certainly responsible for the persistence of H. pylori in the human host.

The effect of antioxidants on Helicobacter pylori eradication: A systematic review with meta-analysis

BACKGROUND

The efficacy and safety of the addition of antioxidants to triple or quadruple therapy were unclear.

MATERIALS AND METHODS

This systematic review was performed in accordance with the PRISMA 2009 guidelines. A systematic search of PubMed, EMBASE, and the Cochrane Library databases was conducted to identify potentially relevant publications using the following keywords: ([Helicobacter pylori] or [H. pylori] or [Hp]) and ([antioxidant] or [vitamin] or [N-acetylcysteine] or [curcumin] or [cranberry]). The primary end-point of this study was to evaluate the efficacy of the addition of antioxidants to triple or quadruple therapy according to ITT and PP analysis. The second end-points were side effects and the comparative efficacy in terms of H. pylori eradication according to different antioxidant and antibiotic combinations.

RESULTS

We included 9 studies with 1260 participants. The total eradication rate of H. pylori in the group combining eradication therapy with antioxidants was not superior to that without antioxidants according to the ITT (pooled RR [95% CI] = 1.17 [0.99-1.38]; P = 0.07) and PP analysis (pooled RR [95% CI] = 1.15 [0.99-1.34; P = 0.07]. There were no differences regarding side effects between the two groups (pooled RR [95% CI], 1.36 [0.81-2.28]; P = 0.24). However, the eradication regimen with vitamin supplementation (1400 mg/day) showed a significant, superior efficacy in eradication relative to those without supplementation (pooled RR [95% CI] = 1.57 [1.35, 1.84]; P < 0.01). In particular, in the amoxicillin-clarithromycin-based subgroup, the crude H. pylori eradication rate determined by ITT analysis was 81.3% and 68.6% for eradication therapy with and without antioxidant supplementation, respectively, which was a statistically significant difference (pooled RR [95% CI] = 1.23 [1.02-1.49]; P = 0.03).

CONCLUSIONS

The addition of antioxidants (vitamin, N-acetylcysteine, curcumin, cranberry) to amoxicillin-clarithromycin-based therapy could improve the eradication rate, and vitamin supplementation might be effective at a high dosage. However, antioxidant supplements have no impact on improving side effects.

Juvenile scurvy from Late Medieval Knin, Croatia

In this study, we examine the scurvy associated skeletal lesions among juveniles from the late Medieval site Uzdolje-Grablje in Croatia. The study aims to establish a demographic pattern of scurvy using existing diagnostic criteria. The sample consists of 16 well-preserved and fairly complete juveniles, excavated from a cemetery dating to 1420-1920. Skeletal remains were analyzed macroscopically for signs of porosity and new bone formation. Scurvy is diagnosed using the "Ortner criteria" of cranial and postcranial lesions. Depending on the location of the lesions, individuals were diagnosed with either scurvy or possible scurvy. Half of the individuals in our sample are diagnosed with scurvy, with additional 25% being diagnosed with possible scurvy. Along with porotic lesions, all individuals diagnosed with scurvy/possible scurvy showed new bone formation on at least one skeletal element. The occurrence of lesions associated with scurvy in our sample is unusually high. Instead of focusing solely on diet and insufficient intake of the vitamin C, a more likely explanation lies in the synergy between diet, exposure to infections, and the environment.

Vitamin C and Helicobacter pylori Infection: Current Knowledge and Future Prospects

The gram-negative bacterium, Helicobacter pylori (H. pylori), infection is predominantly known for its strong association with development of gastric diseases, including gastritis, peptic ulcers, and stomach cancer. Numerous clinical reports show that ascorbic acid deficiency has been connect with gastritis. Vitamin C levels both in gastric acid and serum have constantly been affirmed to be low in subjects with H. pylori infected gastritis and peptic ulcers. Ascorbic acid supplementation likely relates to reduced incidences of bleeding from peptic ulcers and gastric cancer. H. pylori eradication is shown to increase vitamin C levels, while the benefits of ascorbic acid oral intake to increase the effectiveness of H. pylori-eradication therapy are controversial. Recent studies suggest that ascorbate intake intravenously, but not orally; pharmacologic ascorbate concentrations up to 30 mmol/L in blood, several millimolar in tissues as well as in interstitial fluid, are easily and safely achieved. Pharmacologic ascorbate can exert pro-oxidant effects locally as a drug by mediating hydrogen peroxide (H₂O₂) formation, which was applied to animal and clinical trials of cancer, sepsis, and severe burns etc. In this review, we summarize current understanding of the associations of vitamin C and H. pylori infection, and outline some potential strategies for H. pylori intervention from emerging advances on ascorbic acid physiology and pharmacology.

Evidence of Drug-Nutrient Interactions with Chronic Use of Commonly Prescribed Medications: An Update

The long-term use of prescription and over-the-counter drugs can induce subclinical and clinically relevant micronutrient deficiencies, which may develop gradually over months or even years. Given the large number of medications currently available, the number of research studies examining potential drug-nutrient interactions is quite limited. A comprehensive, updated review of the potential drug-nutrient interactions with chronic use of the most often prescribed medications for commonly diagnosed conditions among the general U.S. adult population is presented. For the majority of the interactions described in this paper, more high-quality intervention trials are needed to better understand their clinical importance and potential consequences. A number of these studies have identified potential risk factors that may make certain populations more susceptible, but guidelines on how to best manage and/or prevent drug-induced nutrient inadequacies are lacking. Although widespread supplementation is not currently recommended, it is important to ensure at-risk patients reach their recommended intakes for vitamins and minerals. In conjunction with an overall healthy diet, appropriate dietary supplementation may be a practical and efficacious way to maintain or improve micronutrient status in patients at risk of deficiencies, such as those taking medications known to compromise nutritional status. The summary evidence presented in this review will help inform future research efforts and, ultimately, guide recommendations for patient care.

Role of Helicobacter pylori infection on nutrition and metabolism

Helicobacter pylori (H. pylori) is a gram-negative pathogen that is widespread all over the world, infecting more than 50% of the world’s population. It is etiologically associated with non-atrophic and atrophic gastritis, peptic ulcer and shows a deep association with primary gastric B-cell lymphoma and gastric adenocarcinoma. Recently, the medical research focused on the modification of the gastric environment induced by H. pylori infection, possibly affecting the absorption of nutrients and drugs as well as the production of hormones strongly implicated in the regulation of appetite and growth. Interestingly, the absorption of iron and vitamin B12 is impaired by H. pylori infection, while infected subjects have lower basal and fasting serum levels of ghrelin and higher concentration of leptin compared to controls. Since leptin is an anorexigenic hormone, and ghrelin stimulates powerfully the release of growth hormone in humans, H. pylori infection may finally induce growth retardation if acquired very early in the childhood and in malnourished children. This review is focused on the nutritional effects of H. pylori infection, such as the reduced bioavailability or the malabsorbption of essential nutrients, and of gastrointestinal hormones, as well as on the relationship between H. pylori and the metabolic syndrome.

A likely case of scurvy in a rural Early Classic Maya burial from Actun Uayazba Kab, Belize

A Maya burial of a late adolescent (Burial 98-3) found in the rockshelter entrance of Actun Uayazba Kab (AUK), Belize, displays a combination of lesions that is consistent with scurvy. Signs include large, active lesions on the posterior surfaces of maxilla; relatively mild porotic hyperostosis along the midline of the skull on the parietals and occipital; cribra orbitalia; potential pinprick lesions on the greater wings of sphenoid and temporal; reactive lesions on the palate, temporal lines of frontal and parietals, and external and internal surfaces of zygomatics; small lesions on the popliteal surfaces of both femora; and periodontal disease. Identification of scurvy at AUK potentially informs the analysis of other primary burials and scattered bone found there and at other nearby sites, which often reveal evidence of nonspecific lesions that are usually attributed to anemia and infection, but that are also consistent with scurvy. The social and ecological context of this Protoclassic (0-AD 300) individual, who lived in a rural agricultural community with no evidence of complex social hierarchy, contrasts with typical discussions of disease among the Maya, which tend to focus on the degrading effects of overcrowding and resource deficiencies. While scurvy has been largely overlooked in the Maya area, this study supports earlier arguments for its presence that were based largely on clinical and ethnographic analogies and suggests the need to incorporate scurvy into broader synergistic models of ancient health.

Helicobacter pylori and gastric cancer

Infection with Helicobacter pylori is established as the major risk factor for gastric cancer development. Damage of the mucosal barrier due to H. pylori-induced inflammation enhances the carcinogenic effect of other risk factors such as salt intake or tobacco smoking. The genetic disposition of both the bacterial strain and the host can increase the potential towards gastric cancer formation. Genetic variance of the bacterial proteins CagA and VacA is associated with a higher gastric cancer risk, as are polymorphisms and epigenetic changes in host gene coding for interleukins (IL1β, IL8), transcription factors (CDX2, RUNX3) and DNA repair enzymes. Application of high-throughput assays for genome-wide assessment of either genetic structural variance or gene expression patterns may lead to a better understanding of the pathobiological background of these processes, including the underlying signaling pathways. Understanding of the stepwise alterations that take place in the transition from chronic atrophic gastritis, via metaplastic changes, to invasive neoplasia is vital to define the 'point of no return' before which eradication of H. pylori has the potential to prevent gastric cancer. Currently, eradication as preventive strategy is only recommended for high-incidence regions in Asia; large population studies with an adequate follow-up are required to demonstrate the effectiveness of such an approach in Western populations.

Effects of widely used drugs on micronutrients: a story rarely told

Vitamins and trace elements are essential to the body, however, deficiencies are frequently observed in the general population. Diet is mostly responsible for these deficiencies but drugs also may play a significant role by influencing their metabolism. These effects are rarely assessed in clinical practice, in part because of limited data available in the literature. Drug-induced micronutrient depletions, however, may be the origin of otherwise unexplained symptoms that might sometimes influence medication compliance. We present various examples of widely prescribed drugs that can precipitate micronutrient deficiencies. This review aims at sensitizing physicians on drug-micronutrient interactions. High-risk population groups also are presented and supplementation protocols are suggested.

Vitamin C, gastritis, and gastric disease: a historical review and update

The discovery of Helicobacter pylori as the cause of gastritis and peptic ulcers ushered in the modern era of research into gastritis and into acid-peptic diseases and rekindled interest in the role of ascorbic acid in the pathophysiology and treatment of gastritis and peptic ulcer disease. Here, we review historic and modern studies on ascorbic acid and gastric diseases with an emphasis on H. pylori gastritis and its sequelae. The relationship of ascorbic acid and gastritis and peptic ulcer and its complications was extensively studied during the 1930s through the 1950s. Much of this extensive literature has been effectively "lost." Ascorbic acid deficiency was associated with all forms of gastritis (e.g., autoimmune, chemical, and infectious) due in varying degrees to insufficient intake, increased metabolic requirements, and destruction within the GI tract. Importantly, gastritis-associated abnormalities in gastric ascorbic acid metabolism are reversed by H. pylori-eradication and potentially worsened by proton pump inhibitor therapy. Diets rich in naturally occurring ascorbic acid are associated with protection of the gastric corpus from atrophy and a reduction in the incidence of gastric cancer possibly through the ability of ascorbic acid to reduce oxidative damage to the gastric mucosa by scavenging carcinogenic N-nitroso compounds and free radicals and attenuating the H. pylori-induced inflammatory cascade. Ascorbic acid supplementation was possibly associated with a decreased incidence of bleeding from peptic ulcer disease. Pharmacologic doses of ascorbic acid also may improve the effectiveness of H. pylori-eradication therapy. Occasionally, looking back can help plot the way forward.

Micronutrients (Other than iron) and Helicobacter pylori infection: a systematic review

BACKGROUND

Many micronutrients depend on a healthy stomach for absorption. Helicobacter pylori chronic gastritis may alter gastric physiology affecting homeostasis of vitamins and minerals.

OBJECTIVES

Systematic review to assess whether H. pylori infection is associated with reduced micronutrient levels (other than iron) in the plasma or gastric juice and whether low micronutrient levels are modified by eradication treatment.

METHOD

Medline was searched for relevant publications from inception to June 2010. Studies describing micronutrient levels in H. pylori-infected and not-infected adults and/or the effect of eradication treatment on micronutrient levels were included.

FINDINGS

Fifty-two publications were selected: 46 investigated the association between H. pylori infection and reduced micronutrient levels and 14 the effect of eradication treatment on micronutrient levels. Sixty-four studies investigated vitamins (23 ascorbic acid, four ß-carotene, 21 cobalamin, 11 folate, and five α-tocopherol) and 10 addressed minerals (one calcium, one copper, one magnesium, one phosphorus, three selenium, and three zinc). Pooled standardized mean differences in micronutrient levels showed positive associations with H. pylori infection for ascorbic acid (gastric juice, -1.087) and cobalamin (-0.744), and a positive effect of eradication treatment, which increased ascorbic acid in the gastric juice (-1.408) and serum cobalamin (-1.910). No significant association between infection and low folate levels was observed. Meta-analyses for other micronutrients were not performed owing to insufficient data.

CONCLUSIONS

Meta-analyses indicate that H. pylori infection is associated with reduced levels of ascorbic acid and cobalamin, supported by the positive effect of eradication treatment. For other micronutrients, further studies are needed.

Gastric carcinogenesis

INTRODUCTION

In most patients, gastric cancer is diagnosed in advanced stage. Curative treatment options are limited and the mortality is high. The process of gastric carcinogenesis is triggered by Helicobacter pylori-driven gastritis and is further characterized by its complexity of interaction with other risk factors. Health care systems are challenged for the improvement of prevention, early diagnosis, and effective treatments.

METHODS

An extensive literature research has been performed to elucidate the interplay between etiological factors involved in gastric carcinogenesis.

RESULTS

H. pylori is the most important carcinogen for gastric adenocarcinoma. Evidence is provided by experiments including animal studies as well as clinical observational and interventional studies in humans. Eradication has the potential to prevent gastric cancer and offers the greatest benefit if performed before premalignant changes of the gastric mucosa have occurred. Bacterial virulence factors are essential players in modulating the immune response involved in the initiation of the carcinogenesis in the stomach. Host genetic factors contribute to the regulation of the inflammatory response and in the aggravation of mucosal damage. The harmful role of environmental factors is restricted to salt intake and smoking of tobacco. The ingestion of fruit and vegetables has some protective effect.

CONCLUSION

Infection with H. pylori is the major risk factor for gastric cancer development, and thus, eradication of the Helicobacter offers a promising best option for prevention of the disease. Bacterial virulence, host genetic factors, and environmental influences are interacting in the multifactorial process of gastric carcinogenesis.

Essential role of vitamin C and zinc in child immunity and health

With the progressive elimination of dietary protein-energy deficits, deficiencies of micronutrients are emerging as the limiting factors in ensuring children's optimal health. Data from several countries in Asia and Latin America indicate that deficiencies of vitamin C and zinc continue to be at alarming levels. This article reviews the roles of vitamin C and zinc in supporting children's growth and development, with a particular focus on the complementary roles they play in supporting immune functions and combating infections. The contemporary relevance of vitamin C and zinc deficiency in the Asian and Latin American regions, both undergoing a rapid nutritional transition, are also discussed. Overall, there is increasing evidence that deficiency of vitamin C and zinc adversely affects the physical and mental growth of children and can impair their immune defences. Nutrition should be the main vehicle for providing these essential nutrients; however, supplementation can represent a valid support method, especially in developing regions.

Helicobacter pylori, nutrition and smoking interactions: their impact in gastric carcinogenesis

Gastric cancer (GC) is the result of a long multi-step and multifactorial process involving possible interactions between Helicobacter pylori infection, environmental exposures and host genetic susceptibility. Interactions between H. pylori infection, tobacco smoking and dietary antioxidants are biologically plausible. Positive interactions between risk factors imply that, in certain subgroups of the population, the risk of GC associated with simultaneous exposure to these factors is higher than that in the rest of the population, and these subgroups have to be the target for preventive measures. Using PubMed, we reviewed all studies published in English up to December 2008 carried out in humans on interactions between H. pylori infection and smoking exposure and between H. pylori infection and dietary factors in gastric carcinogenesis. Although relatively few epidemiological studies have evaluated the effect of the interaction between smoking and H. pylori infection on GC risk, there is a suggestion of a positive interaction between the two factors. In contrast, evidence suggests a negative interaction between dietary antioxidants and H. pylori infections on GC risk. The potential protective effect of dietary antioxidants such as vitamins C and E and beta-carotene seems to be stronger in those infected by H. pylori, even though results are inconsistent. In Asian populations, subjects infected by H. pylori and with high dietary salt intake may have a higher risk of GC than subjects without H. pylori infection and with a low salt intake. The risk of GC associated with red meat, processed meat or endogenous formation of nitrosamines appears to only be observed in subjects infected by H. pylori. More and larger epidemiological studies, mainly prospective studies, are necessary to reach a more definitive conclusion on these interactions.

Role of Helicobacter pylori infection in gastric cancer pathogenesis: a chance for prevention

Gastric cancer in the absence of strategies implemented for early detection continues to have a dismal prognosis. There are limited options for a curative therapy once patients present with clinical manifestations of this malignant disease. Helicobacter pylori (H. pylori) infection plays a key role in gastric carcinogenesis, supported by epidemiological, preclinical and clinical studies. The recognition of H. pylori infection as a critical risk factor in the development of gastric cancer opens the chance for new venues in prevention strategies.

Effect of proton pump inhibitors on vitamins and iron

Vitamin C is actively secreted in human gastric juice. Proton pump inhibitor therapy lowers the concentration of vitamin C in gastric juice and the proportion of the vitamin in its active antioxidant form i.e., ascorbic acid. This has secondary effects on intragastric nitrite chemistry, resulting in a rise in gastric juice nitrite levels. There is also some evidence that proton pump inhibitors may reduce the bioavailability of ingested vitamin C. The effect of proton pump inhibitors on vitamin C and nitrite chemistry is more marked in Helicobacter pylori-infected subjects. Proton pump inhibitors also reduce the absorption of vitamin B(12) probably by inhibiting intragastric proteolysis and, thus, its release from food required prior to binding to R-proteins and gastric intrinsic factor. Under certain circumstances, the treatment may lower serum vitamin B(12) levels. Proton pump inhibitor therapy reduces the absorption of non-heme iron and this effect has been employed in the management of hemochromatosis. It may also retard clinical response to iron supplementation.

Java project on periodontal diseases: the relationship between vitamin C and the severity of periodontitis

OBJECTIVE

To study the relationship between vitamin C and the severity of periodontitis.

MATERIAL AND METHODS

The study population consisted of subjects from the Malabar/Purbasari tea estate on West Java, Indonesia. In 2002, clinical measurements were performed in 128 subjects, including evaluation of plaque, bleeding on probing, pocket depth and attachment loss. In 2005, 123 out of 128 subjects could be retrieved who were present at the examination of 2002. Blood samples were taken to measure plasma vitamin C levels. Information about the subject's dietary habit was obtained by means of a personal interview guided by a questionnaire.

RESULTS

Plasma levels of vitamin C ranged from 0.02 to 34.45 mg/l with a mean of 7.90 mg/l (+/-5.35). The correlation coefficient between plasma vitamin C level and periodontal attachment loss was -0.199 (p<0.05); stepwise linear regression revealed that vitamin C levels explained 3.9% of the variance in periodontal attachment loss. Subjects with vitamin C deficiency (14.7% of the study population) had more attachment loss compared with those with depletion or normal plasma vitamin C values.

CONCLUSION

The negative association between plasma vitamin C levels and periodontal attachment loss suggests that vitamin C deficiency may contribute to the severity of periodontal breakdown.

Plasma and dietary carotenoid, retinol and tocopherol levels and the risk of gastric adenocarcinomas in the European prospective investigation into cancer and nutrition

Despite declining incidence rates, gastric cancer (GC) is a major cause of death worldwide. Its aetiology may involve dietary antioxidant micronutrients such as carotenoids and tocopherols. The objective of this study was to determine the association of plasma levels of seven common carotenoids, their total plasma concentration, retinol and α- and γ-tocopherol, with the risk of gastric adenocarcinoma in a case–control study nested within the European Prospective Investigation into Cancer and Nutrition (EPIC), a large cohort involving 10 countries. A secondary objective was to determine the association of total sum of carotenoids, retinol and α-tocopherol on GCs by anatomical subsite (cardia/noncardia) and histological subtype (diffuse/intestinal). Analytes were measured by high-performance liquid chromatography in prediagnostic plasma from 244 GC cases and 645 controls matched by age, gender, study centre and date of blood donation. Conditional logistic regression models adjusted by body mass index, total energy intake, smoking and Helicobacter pylori infection status were used to estimate relative cancer risks. After an average 3.2 years of follow-up, a negative association with GC risk was observed in the highest vs the lowest quartiles of plasma β-cryptoxanthin (odds ratio (OR)=0.53, 95% confidence intervals (CI)=0.30–0.94, P_trend=0.006), zeaxanthin (OR=0.39, 95% CI=0.22–0.69, P_trend=0.005), retinol (OR=0.55, 95% CI=0.33–0.93, P_trend=0.005) and lipid-unadjusted α-tocopherol (OR=0.59, 95% CI=0.37–0.94, P_trend=0.022). For all analytes, no heterogeneity of risk estimates or significant associations were observed by anatomical subsite. In the diffuse histological subtype, an inverse association was observed with the highest vs lowest quartile of lipid-unadjusted α-tocopherol (OR=0.26, 95% CI=0.11–0.65, P_trend=0.003). These results show that higher plasma concentrations of some carotenoids, retinol and α-tocopherol are associated with reduced risk of GC.

Effect of nutrient intake and Helicobacter pylori infection on gastric cancer in Korea: a case-control study

To examine the effects of dietary factor and Helicobacter pylori (H. pylori) infection with emphasis on vitamin intake on the risk of gastric cancer (GC), we conducted a case-control study in South Korea, a high-risk area for GC. Trained dietitians interviewed 136 cases histologically diagnosed with GC. An equal number of hospital controls was selected by matching sex and age. High dietary intakes of vegetable fat [odds ratio (OR) = 0.35; 95% confidence interval (CI) = 0.15-0.83], folate (OR = 0.35; 95% CI = 0.13-0.96), and antioxidants, such as vitamin A (OR = 0.34; 95% CI = 0.13-0.83), beta-carotene (OR = 0.33; 95% CI = 0.13-0.82), vitamin C (OR = 0.26; 95% CI = 0.09-0.72), and vitamin E (OR = 0.41; 95% CI = 0.17-1.01), were shown to have a protective effect on GC risk using a multivariate model adjusting for foods significantly related to GC in our previous study (charcoal grilled beef, spinach, garlic, mushroom, and a number of types of kimchi) and supplement use. When stratified according to H. pylori infection, high intakes of vitamin C (OR = 0.10; 95% CI = 0.02-0.63) and vitamin E (OR = 0.16; 95% CI = 0.03-0.83) exhibited highly significant inverse associations with GC among the H. pylori-infected subjects compared with noninfected individuals. GC risk was significantly decreased only when consumption levels for two of these vitamins were high. Our findings suggest that high intake of antioxidant vitamins contribute to the reduction of GC risk and that GC risk in Korea may be decreased by encouraging those with H. pylori infection to increase their intake of antioxidant vitamins.

Gastric cancer: global pattern of the disease and an overview of environmental risk factors

This first part of this chapter looks at the worldwide burden of gastric cancer at the beginning of the 21st century and summarises available population-based routine data that describes the variation in incidence of the disease in relation to age, sex, geography and time period. Consideration is also given to the differences in the descriptive epidemiology of gastric cancer arising in the proximal cardia region of the stomach. In the second part of the chapter, a brief review of the main identified environmental risk factors is conducted drawing, where available, on published systematic literature overviews and meta-analyses. Evidence relating the aetiology of gastric cancer to Helicobacter pylori infection, dietary factors, smoking, occupation, physical activity and anthropometry is presented.

Effect of Aloe vera preparations on the human bioavailability of vitamins C and E

There are no literature references describing the effect of consumption of Aloe vera liquid preparations on the absorption of water- or fat-soluble vitamins. There is a very large population worldwide which consume vitamins and many people also consume Aloe. Thus we report the effect of Aloe on the human absorption of vitamins C and E, the most popular vitamin supplements. The plasma bioavailability of vitamins C and E were determined in normal fasting subjects, with eight subjects for vitamin C and ten subjects for vitamin E. In a random crossover design, the subjects consumed either 500 mg of ascorbic acid or 420 mg of vitamin E acetate alone (control), or combined with 2 oz of two different Aloe preparations (a whole leaf extract, or an inner fillet gel). Blood was collected periodically up to 24 h after consumption. Plasma was analyzed for ascorbate and tocopherol by-HPLC with UV detection. There was no significant difference in the areas under the plasma ascorbate-time curves among the groups sincerely due to large differences within the groups. For comparative purposes the control area was 100%. The Aloe Gel area was 304%, and Aloe Whole Leaf 80%. Only Aloe Gel caused a significant increase in plasma ascorbate after 8 and 24 h. For vitamin E, the results for the relative areas were control 100%, Gel 369%, and Leaf (198%). Only the Aloes produced a significant increase in plasma tocopherol after 6 and 8 h. Both Aloes were significantly different from the control after 8 h. Aloe Gel was significantly different from the baseline after 24 h. The Aloes slowed down the absorption of both vitamins with maximum concentrations 2-4 h later than the control. There was no difference between the two types of Aloe. The results indicate that the Aloes improve the absorption of both vitamins C and E. The absorption is slower and the vitamins last longer in the plasma with the Aloes. Aloe is the only known supplement to increase the absorption of both of these vitamins and should be considered as a complement to them.

Proton pump inhibitors reduce the bioavailability of dietary vitamin C

BACKGROUND

The gastric juice concentration of vitamin C is reduced in subjects with elevated intragastric pH. This is probably because of the fact that the vitamin is unstable at non-acidic pH and undergoes irreversible denaturation.

AIM

To determine whether elevation of intragastric pH reduces the bioavailability of dietary vitamin C.

METHODS

Plasma vitamin C was measured before and after a course of omeprazole 40 mg/day for 4 weeks in 14 Helicobacter pylori positive and 15 H. pylori negative subjects. Dietary intake of vitamin C was measured and intragastric pH monitored.

RESULTS

Compared with the H. pylori negative subjects, H. pylori positive subjects had a lower mean daily vitamin C intake (141.7 mg vs. 41.5 mg, P < 0.01) and also lower plasma vitamin C concentration (25.1 microg/mL vs. 17.4 microg/mL, P < 0.0001). After 28 days of 40 mg/day of omeprazole the mean plasma vitamin C level had fallen by 12.3% (P = 0.04). This fall affected both the H. pylori positive and negative subjects.

CONCLUSIONS

We have shown that a short course of omeprazole will cause a reduction in the plasma vitamin C level of healthy volunteers. This decrease in plasma vitamin C is independent of dietary intake of the vitamin and indicates reduced bioavailability. The clinical significance of this is unclear but any adverse effects will be most apparent in H. pylori infected subjects who have a low pre-treatment vitamin C status.

The effect of Helicobacter pylori infection and dietary iron deficiency on host iron homeostasis: a study in mice

BACKGROUND

Helicobacter pylori, which requires iron to survive, may cause host iron deficiency by directly competing with the host for available iron or by impairing iron uptake as a consequence of atrophy-associated gastric hypochlorhydria. The aim of this study was to examine the effect of H. pylori infection and dietary iron deficiency on host iron homeostasis in a mouse model.

MATERIALS AND METHODS

H. pylori SS1-infected and uninfected C57BL/6 mice, fed either a normal diet or an iron-deficient diet, were assessed for iron status and infection-associated gastritis over a 30-week period.

RESULTS

After 10 weeks, serum ferritin values were higher in H. pylori-infected mice than in uninfected controls, irrespective of dietary iron intake (p = .04). The infection-related increase in body iron stores persisted in the iron-replete mice but diminished over time in mice with restricted dietary iron intake (p < .0001). At 30 weeks serum ferritin levels were lower in these animals (p = .063). No significant difference in bacterial numbers was detected at the 30-week time point (p > .05) and the histological changes observed were consistently associated with infection (p < .01) and not with the iron status of the mice (p = .771).

CONCLUSIONS

Infection with H. pylori did not cause iron deficiency in iron-replete mice. However, diminished iron stores in mice as a result of limited dietary iron intake were further lowered by concurrent infection, thus indicating that H. pylori competes successfully with the host for available iron.

Review article: is there a link between micronutrient malnutrition and Helicobacter pylori infection?

Helicobacter pylori causes a chronic gastric infection, which is usually life-long. Many epidemiological studies have shown that this is probably one of the most common bacterial infections throughout the world involving 30% of the population living in developed countries and up to 80-90% of the population in developing regions. Concomitantly, developing regions also have high prevalence of micronutrient malnutrition. In the last few years, some studies have suggested that H. pylori infection may affect the homeostasis of different micronutrients including iron, vitamin B12, folic acid, alpha-tocopherol, vitamin C and beta-carotene. In this article, we discuss the current scientific information of the effect that H. pylori infection may produce on micronutrient malnutrition.

Helicobacter pylori-CagA seropositivity and nitrite and ascorbic acid food intake as predictors for Gastric Cancer

A hospital-based case-control study was carried out between 1994 and 1996 to evaluate the risk of gastric cancer (GC) according to Helicobacter pylori-CagA (+) seropositivity, nitrite and ascorbic acid intake. Three geographical areas of Mexico were selected on the basis of their contrasting dietary patterns and H. pylori seroprevalence. Nitrite and ascorbic acid consumption were estimated by interview among 211 cases and 454 matched controls. Serum antibodies against IgG H. pylori and CagA were detected by immunosorbent assays. The adjusted risk for GC was significantly higher among CagA+ subjects compared with those that were CagA negative (Odds Ratio (OR)=2.04 95% Confidence Interval (CI) 1.37-3.02 P for trend P < 0.001), this effect remained significant among diffuse GC cases (OR 2.05 95% CI 1.25-3-36). No significant effects due to nitrite and ascorbic consumption or interactions of these nutrients with CagA seropositivity were detected. Seropositivity to H. pylori CagA+ strains may be an independent factor for diffuse GC in Mexico.

Plasma reactive oxygen species activity and antioxidant potential levels in rosacea patients: correlation with seropositivity to Helicobacter pylori

BACKGROUND

Recent studies have suggested that there might be an etiologic role for Helicobacter pylori (HP) in rosacea. HP is a Gram-negative bacterium that colonizes the gastric mucosa, increases the generation of reactive oxygen species (ROS), and decreases plasma antioxidants such as ascorbic acid.

AIM

To investigate plasma ROS activities and antioxidant status, and their relationship with HP infection, in rosacea patients.

METHODS

Twenty-nine rosacea patients and 20 age- and sex-matched healthy controls were examined for specific immunoglobulin G (IgG) and IgM against HP, plasma malondialdehyde (MDA), and antioxidant potential (AOP) levels.

RESULTS

Compared with controls, the seropositivity of HP for IgM was significantly higher (P = 0.03) and the seropositivity of HP for IgG was significantly lower (P = 0.0001) in patients with rosacea. Plasma MDA levels were higher (P = 0.0001) and AOP levels were lower (P = 0.019) in patients than in controls, regardless of the severity of the disease. Plasma MDA and AOP levels were not affected by the seropositivity of HP for IgM and/or IgG in either group.

CONCLUSION

Our results suggest that rosacea is an oxidative stress condition, as reflected by the increased ROS activity and decreased AOP, regardless of HP infection.

Amelioration of oxidative stress with ensuing inflammation contributes to chemoprevention of H. pylori-associated gastric carcinogenesis

The gastric inflammatory response provoked by Helicobacter pylori (H. pylori) consists of infiltrations by neutrophils, lymphocytes, and macrophages, resulting in varying degrees of epithelial cell damage. H. pylori-associated inflammation not only activates various oxidant-producing enzymes such as NADPH oxidase and inducible nitric oxide synthase, but also lowers the antioxidant ascorbic acid in the stomach. Reactive oxygen metabolites and nitrogen metabolites generated by these enzymes react with each other to generate new or more potent reactive species. The specific types of cellular damage resulting from reactive oxygen metabolites include lipid peroxidation, protein oxidation, and oxidative DNA damage. All of these oxidative products can result in biochemical changes leading to cancer. A positive association has been demonstrated between H. pylori infection and gastric adenocarcinoma with increased oxidative stress. Therefore, appropriate treatment to reduce oxidative stress would be expected to prevent subsequent gastric carcinogenesis through lessening of H. pylori-associated inflammation. This review will provide evidence that antiinflammatory regimens can decrease the development of tumors and the amelioration of gastric inflammation might lead to chemoprevention strategies by the attenuation of oxidative stress.

Gastric histopathology, iron status and iron deficiency anemia in children with Helicobacter pylori infection

OBJECTIVES

Helicobacter pylori has been established as a major cause of gastritis and peptic ulcer disease in adults and children. H. pylori infection may also have a role in the development of some extra-gastrointestinal diseases, including iron deficiency anemia. The aim of this study is to investigate H. pylori-related changes in gastric physiology and histology and the relationship of these changes to iron deficiency anemia in children.

METHODS

Fifty-two patients with gastrointestinal complaints were studied. Hematologic parameters, 3-day vitamin C and iron consumption, serum gastrin levels, and gastric juice ascorbic acid levels were compared in patients with and without H. pylori infection. Dietary intake of vitamin C and iron, serum gastrin, gastric juice ascorbic acid content, and gastric histology were compared in patients with H. pylori infection and anemia and in patients with H pylori infection and no anemia. The CagA status of the H. pylori organisms was evaluated.

RESULTS

Twenty-eight of 52 patients had H. pylori. Thirty-one patients had iron deficiency anemia. H. pylori infection was associated with low serum iron levels. H. pylori gastritis was associated with a decrease in the gastric juice ascorbic acid level. Infection with CagA-positive strains was associated with a greater decrease in gastric juice ascorbic acid than infection with CagA-negative strains. However, the gastric juice ascorbic acid levels of patients with H. pylori and anemia were not different from those of non-anemic patients with H. pylori. Among patients with H. pylori infection, pangastritis was twice as common in those with anemia than in those without anemia.

CONCLUSIONS

H. pylori infection was associated with a decrease in gastric juice ascorbic acid concentration, and this effect was more pronounced in patients with the CagA-positive strain. Pangastritis was more common in patients whose H. pylori.infection was accompanied by anemia.

Helicobacter pylori infection and micronutrient deficiencies

It is known that deficiencies of micronutrients due to infections increase morbidity and mortality. This phenomenon depicts itself conspicuously in developing countries. Deficiencies of iron, vitamins A, E, C, B12, etc are widely prevalent among populations living in the third world countries. Helicobacter pylori (H pylori) infection has a high prevalence throughout the world. Deficiencies of several micronutrients due to H pylori infection may be concomitantly present and vary from subtle sub-clinical states to severe clinical disorders. These essential trace elements/micronutrients are involved in host defense mechanisms, maintaining epithelial cell integrity, glycoprotein synthesis, transport mechanisms, myocardial contractility, brain development, cholesterol and glucose metabolism. In this paper H pylori infection in associaed with various micronutrients deficiencies is briefly reviewed.

Relation of serum ascorbic acid to Helicobacter pylori serology in US adults: the Third National Health and Nutrition Examination Survey

PURPOSE

To examine the relation between serum ascorbic acid and Helicobacter pylori serology from a probability sample of US adults.

SUBJECTS AND METHODS

Data from 6,746 adults (ages 20 to 90 years) enrolled in the Third National Health and Nutrition Examination Survey (NHANES III), 1988-1994 were analyzed. Multiple logistic regression models were examined taking into account sample weights and the complex survey design of NHANES III, and controlling for the effects of potential confounders. Because race appeared to modify the association between serum ascorbic acid and seropositivity to H. pylori, we conducted the analyses stratified by race.

RESULTS

A total of 2,189 adults (32%) had a positive serology for H. pylori, and, of these, 1,175 (54%) were positive for the CagA antigen. Among whites, a 0.50 mg/dL increase in serum ascorbic acid level was associated with decreased seroprevalence of H. pylori (Odds Ratio (OR) = 0.89, 95% confidence interval (CI) CI 0.82-0.96, p < 0.01). In analyses that controlled for seroprevalence of H. pylori, a 0.50 mg/dL increase in serum ascorbic acid level among whites was independently associated with a decreased seroprevalence of the pathogenic cagA-positive strain of H. pylori (OR = 0.31, 95% CI 0.12-0.79, p < 0.05). Serum ascorbic acid levels were not significantly associated with H. pylori serology among non-whites (all p > 0.05).

CONCLUSIONS

Higher serum levels of ascorbic acid were associated with a decreased seroprevalence of H. pylori and of the pathogenic cagA-positive strain of H. pylori among whites. If these associations are related causally and are not the result of residual confounding by factors such as socioeconomic status, ascorbic acid may affect the risk of H. pylori infection and in turn, the risk for peptic ulcer disease and gastric cancer among white Americans.

Gastric cancer

The past decade has seen many advances in knowledge about gastric cancer. Notably, tumour biology and lymphatic spread are now better understood, and treatment by surgical and medical oncologists has become more standardised. Since refrigerators have replaced other methods of food conservation, Helicobacter pylori has become a factor in the cause of gastric cancer. Cancers that arise at the oesophagogastric junction might be further examples of wealth-associated disease. To tailor treatment better, the western hemisphere needs to borrow from the East by establishing screening programmes for early diagnosis, through careful surgical resection, and through detailed analysis of tumour spread. In Europe and the USA, most patients reach treatment with cancers already at an advanced stage. For these patients, three important randomised trials are underway that evaluate combined therapy. Cytostatic drugs, especially angiogenesis inhibitors have proved disappointing; however, basic research efforts to detect familial gastric cancers and to assess minimally residual disease look more hopeful.

Correlation between Helicobacter pylori infection and vitamin C levels in whole blood, plasma, and gastric juice, and the pH of gastric juice in Korean children

BACKGROUND

It is well known that chronic gastritis induced by Helicobacter pylori may be associated with hypochlorhydria and may also be accompanied by low levels of vitamin C in plasma and gastric juice in adults. This study investigates the relationship between H. pylori infection and vitamin C levels in the blood, plasma and gastric juice and the gastric juice pH of Korean children.

METHODS

During a 5-year period, multiple gastric antral biopsies were taken from 452 children who underwent gastroduodenoscopy. The biopsy specimen was inoculated into phenol red buffered urea broth and incubated for 48 hours to detect color changes. The histopathologic findings were evaluated using the Sydney System. Concentrations of vitamin C in whole blood, plasma, and gastric juice aspirate were measured using the 2,4-dinitrophenylhydrazine method.

RESULTS

Four hundred fifty-two patients (228 boys, 224 girls) aged 1 to 15 years were enrolled in this study. H. pylori was detected in 112 patients (24.8%) using histology, whereas it was found in 204 patients (45.1%) using the urease test. One hundred seven patients (23.7%) had active gastritis, and 421 patients (93.1%) had chronic gastritis. Vitamin C levels in whole blood, plasma, and gastric juice exhibited significant negative correlation with the age of patients, the histologic density of H. pylori, the degree of active and chronic gastritis, and the severity of H. pylori infection (based on urease positivity and histologic density of H. pylori). Gastric juice pH was correlated with the degree of chronic gastritis and was significantly higher in urease-positive patients.

CONCLUSIONS

The data demonstrate that vitamin C levels in whole blood, plasma, and gastric juice and the gastric juice pH in Korean children are closely related to the severity of H. pylori infection and the histologic changes in the stomach. These data suggest that vitamin C may play a role in determining infection and progression, and vitamin C supplementation may be an important axis for the management of H. pylori infection in children.

Increased risk of noncardia gastric cancer associated with proinflammatory cytokine gene polymorphisms

BACKGROUND & AIMS

Genetic variations in proinflammatory and anti-inflammatory cytokine genes influence individual response to carcinogenic exposures. Polymorphisms in interleukin (IL)-1 beta and its endogenous receptor antagonist are associated with risk of Helicobacter pylori-related gastric cancer. The aim of this study was to evaluate the role of proinflammatory cytokine gene polymorphisms in gastric and esophageal cancers defined by anatomic subsite.

METHODS

We assessed polymorphisms of the IL-1 gene cluster and 4 other cytokine genes in a population-based case-control study of upper gastrointestinal cancers, including gastric cardia (n = 126) and noncardia adenocarcinoma (n = 188), esophageal squamous cell carcinoma (n = 53), and adenocarcinoma (n = 108), and frequency-matched controls (n = 212). ORs for the different cancers were computed from logistic regression models adjusted for potential confounding factors.

RESULTS

Proinflammatory genotypes of tumor necrosis factor alpha and IL-10 were each associated with more than doubling of the risk of noncardia gastric cancer. Carriage of multiple proinflammatory polymorphisms of IL-1B(o) IL-1 receptor antagonist, tumor necrosis factor A, and IL-10 conferred greater risk, with ORs (and 95% confidence intervals) of 2.8 (1.6-5.1) for one, 5.4 (2.7-10.6) for 2, and 27.3 (7.4-99.8) for 3 or 4 high-risk genotypes. In contrast, these polymorphisms were not consistently related to the risks of esophageal or gastric cardia cancers. Polymorphisms in IL-4 and IL-6 were not associated with any of the cancers studied.

CONCLUSIONS

A proinflammatory cytokine genetic profile increases the risk of noncardia gastric adenocarcinoma but not other upper gastrointestinal cancers, possibly by inducing a hypochlorhydric and atrophic response to gastric H. pylori infection.

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Consequences of Helicobacter pylori infection on the absorption of micronutrients

Recent studies have suggested a relationship between Helicobacter pylori infection and various important micronutrients, including iron and vitamin B12, suggesting likely biological factors in the association between Helicobacter pylori and microcytic or macrocytic anaemia. There is some evidence that direct or indirect consequences of Helicobacter pylori gastritis on acid secretion account for the role of the bacterium in the absorption process of iron and Vitamin B12. The plasma, intragastric and mucosal concentration of different antioxidant compounds such as ascorbic acid, a-tocopherol and beta-carotene is also affected by Helicobacter pylori gastritis supporting the possible role of Helicobacter pylori in the multistep cascade leading to gastric carcinogenesis. The relationship between Helicobacter pylori infection and micronutrients is, therefore, a promising and, until now, poorly investigated field of research.